Patient-centred team-based critical care in austere environments

The 20-hour rescue of a trapped paddler on the Franklin River. Critical care as a team sport in a tight spot.

By Rob Brittle and Mitch Parkinson (Intensive Care Flight Paramedics with Ambulance Tasmania)

Valdas Bieliauskas is a 65-year-old Lithuanian national, and the trip leader of a team paddling the Franklin River in remote Southwest Tasmania. It’s a weeklong trip requiring paddling groups to be both self-sufficient and experienced in paddling whitewater. Valdas and his group are lining their boats through the Great Ravine at a Grade 4-5 rapid known as Coruscades. He slips on a wet rock and falls feet first into a rapid, with his left leg becoming trapped underwater between two large boulders at the knee. Its early afternoon 22nd November 2024.

At 1519hrs the Bat Phone rings at the helicopter base in Hobart. The duty crew stand listening to the control room operator, who gives an economical description of the case details that comes via a satellite two-way messaging device- Garmin InReach: ‘call came in around 30 minutes ago, person has their leg trapped in water, been there an hour……Franklin River one foot of the man blocked under water by Coruscades Rapid’. As the duty helicopter rescue team try to piece together a solid picture of the environmental, clinical, logistical and communications aspects of the tasking, it becomes very clear that a multi-disciplinary team-based approach will be required to locate, access, stabilise and transport this man to safety.

Team 1. Helicopter SAR Duty Crew

At 1617hrs, the SAR helicopter (BK117) departs for the Great Ravine 85 nautical miles away with the aim of locating, then accessing the patient. Drawing upon previous rescue knowledge of the Franklin River the team know there will be nowhere to land and limited choice for a hover exit, leaving winching as the probable insertion option. At around 1723hrs, an Ambulance Tasmania Intensive Care Flight Paramedic (ICFP) and Tasmania Police Rescue Crewman (RCO) are winched to the scene. With them is standard SAR equipment including an ICFP level medical pack, overnight SAR pack (shelters, food, headtorches, stove, sleeping systems, and communication devices- GRN radio, PLB, Garmin Montana™), oxysock, plus standard flight PPE.

This team of two perform a series of tasks to establish some situational awareness: sight the patient in the river, establish access and egress, check communications viability, set safety lines around the scene, and assess group wellbeing. They make a kit dump, then get a detailed story from the paddling group including what attempts have been made to rescue Valdas, the patient.

The scene assessment reveals the patient is trapped at the knee in a hole with water at chest height, surrounded by large, wet, slippery boulders, with around 18 cubic metres of water rushing past him every second. He’s wearing a 7mm wetsuit and personal floatation device.

Communications in remote Tasmania can be challenging on a good day. In the bottom of the Franklin River, that difficulty increases significantly. Due to the steepness of terrain, the trunked digital radio network (GRN) is ineffective, radio capability is reduced to ‘line-of-sight’ simplex channels with aircraft overhead, and the satellite phone is unable to achieve a sustained signal. To overcome this, a Garmin Montana™ with InReach messaging services is used to communicate with our coordination centres. As a redundancy, the aircraft are requested to overfly at nominated intervals to utilise the line-of-sight radio channels.

Recognising the complexity of the case, the initial SAR team quickly identified that two more specialist teams will be required: an Ambulance Tasmania HEMS team consisting of a second flight paramedic and a retrieval doctor (in anticipation of the critical care interventions that may be required during the night), and more pressingly, a specialist Technical Swift Water Rescue team to attempt to free Valdas from the entrapment.

Team 2. Swift Water Rescue Team

Some Ambulance Tasmania clinicians – both flight paramedics and retrieval doctors - are trained in formal swift water rescue, however there is a patient-focused critical decision made by the first SAR team that this rescue requires a highly specialised, technical swift water team. The police SAR Controller does a ring around, and the two swift water rescue technicians that answer the phone are Tasmania’s leading operators. They teach swift water and flood rescue courses across the country and the world. Categorically, no team is more experienced and qualified for this job. By chance, both were available at short notice to provide technical rescue support for the extrication efforts.

They are winch inserted by helicopter at 2029hrs and begin by trying to understand how and why Valdas got himself into this particular spot as a way of initially attempting to simply reverse the process to rescue him. For the next 12 hours this team systematically work their way through every conceivable rescue option; simple and complex hauling systems, hydraulic airbags, cutters and spreaders. Later in the night attempts were made with Valdas in a sit harness and hauling systems with artificial high directionals established with a rescue frame. There is no measurable success.

Team 3. HEMS Team

A second pivotal decision made by the initial SAR team is to request a HEMS team. There is a good chance this case will be protracted, and the patient may need simultaneous therapies to manage hypothermia plus traumatic injuries including, but not limited to, fractures, degloving, amputation, crush, life-threatening haemorrhage, and cardiac arrest. The HEMS team (flight paramedic and doctor) is inserted by helicopter at 2041hrs with two HEMS-specific medical packs, a vacuum mattress, dry suits, an additional overnight SAR pack, the 406 winching stretcher and 3 units of blood (PRCs). Critical to the ultimate success of the case- the team bring a LUCUS 3™ mechanical CPR device with 3 batteries.

Under headtorches the HEMS team work with the initial SAR team and swift water rescue technicians to monitor and assess, gain IV access and administer a range of analgesic/sedation options to support the patient while simultaneously, efforts are made to extract him from the rapid. They relieve the other clinicians, document discussions and technical attempts at rescue and keep the patient hydrated, fed, and emotionally supported.

By 0325hours Valdas has been trapped for over 13 hours. There are two brutal realities that the whole team can begin to realise: 1). that Valdas may need surgical amputation to free him from the river to prevent hypothermic cardiac arrest in situ; and 2). that this intervention would likely lead to a cascade of other clinical and logistical challenges. The paramedics and doctor have a transparent and deliberate conversation with Valdas about what is anticipated. They gain verbal consent to amputate if required. The teams share their separate interdisciplinary mental models and develop multiple plans.

Team 4. AMSA Rescue 550

With ongoing communications challenges in the river, Rescue 550, the AMSA Challenger jet based out of Essendon, Victoria, is deployed to provide overwatch and increase both communications capabilities and situational awareness for all the teams now involved. For the teams on the ground, line of sight communication and forward relay from the aircraft is now a reality which allows real-time communication of the rescue attempts underway, the patient’s clinical condition, and also enhances awareness around the timings of inbound aircraft bringing crucial rescue equipment and personnel to the scene.

A new challenge

At 0651hrs, one of the HEMS team slip on the wet rock and fall, fracturing their arm. This leads to a change of plans and a request for a fresh HEMS team. While this is an unfortunate setback, the team member is treated, and the teams pivot to refocus on solutions to new problems plus continue planning for deterioration once Valdas is removed from the river.

The teams plan a technical approach to surgical amputation that will be underwater in a fast-flowing current, with improvised equipment and modified torniquet application. They rehearse the post procedure extrication, blood administration, hypothermia management and possible pre-hospital emergency anesthetic.

Team 5. HEMS Day crew

At 1023hrs on the second day, a new HEMS team is winched in, and the injured team member plus an ICFP are winched out. A handover is given, and a patient re-assessment is performed. This reveals an altered conscious state, weakening respiratory effort and bradycardia. The doctor listens carefully to the exhaustive attempts made overnight by the swift water rescue team to extricate the patient. The trust and belief the clinicians have in the swift water rescue team is absolute, leaving surgical amputation as the only viable option given the predicted timeline of survival. The doctor performing the procedure wears a full drysuit, PFD and helmet. He enters the water level with the patient.

The typical approach is to use a Size 21 scalpel, designed for procedures in operating theaters, not swift water. For greater control and precision in the turbulent water, the doctor elects to use a Petzl Spatha™ rescue knife. A sedating dose of Ketamine is administered IV and at 1109hrs he performs a soft tissue cut down through wetsuit, skin and muscle to the bone just above the left knee. A flexible wire saw (Gigli Saw™) is then used to cut through the bone, but this fails and separates mid-procedure due to the acute angle necessitated by the confined space. Some external pressure is applied to the amputation site until the femur fractures at the saw cut. At 1115hrs Valdas is hauled from the river by the teams using the preset mechanical advantage system. He has been in 14°C water for over 20 hours.

As anticipated, he deteriorates and becomes bradycardic with intermittent apnea. This triggers a set of pre-planned and pre-rehearsed clinical interventions. A push dose of adrenaline and warm IV fluid is administered, a chemical warming blanket applied, the team performs a modified Ketamine and Rocuronium anesthetic, and he is intubated. The femoral stump is re-checked for bleeding. There is none. No blood products are administered, and he’s placed on the Meduvent™ transport ventilator.

At 1150hrs the patient loses cardiac output and arrests with hypothermia being the primary cause. He is placed on the LUCUS 3™ mCPR device device. EtCo2 is noted to be 30-38mmHg. At 1210hrs, he is winched to the helicopter (Bell 412) with the doctor attending the stretcher, in hypothermic VF cardiac arrest, intubated, ventilated, and mechanical CPR ongoing. He is refractory to DCCS and adrenaline in flight and his EtCo2 gradually reduces to 15-20mmHg, pupils reactive. His core temperature is 26°C. The HEMS team provides a sitrep and specific request for ECMO on arrival at the hospital. It’s a 55-minute flight to the Royal Hobart Hospital helipad.

Team 6. Royal Hobart Hospital

On arrival at the resuscitation bay in ED it’s 1305hrs. There are teams from ICU (ECMO), surgical, anesthetics, trauma and ED. Before the handover is finished the patient is prepped for ECMO. At 1310hrs his right femoral vein and artery are cannulated and transitioned to ECMO, his core temperature is 26.3°C, by 1320hrs he gets 1 x shock at 200j and ROSC - sinus rhythm and systolic pressure of 90mmHg.

The next day Valdas was alive. His initial blood gas indicated metabolic acidosis and acute kidney injury (AKI) plus poor gut perfusion. With echocardiogram his myocardial performance was near normal. He was extubated a week later revealing a witty and perceptive personality. His AKI and gut dysfunction resolved after 2 weeks. He was transferred to rehab and then repatriated on 22nd January 2025 with no neurological deficit- largely due to the neuroprotection of severe hypothermia.

This was a case involving luck, but its successful outcome came mainly because of multi-disciplinary flash teams working together in challenging conditions and employing adaptive problem solving to a range of environmental, logistical and clinical obstacles. In essence it was a case about small groups of humans working together to care for another human.

ABC's Australian Story, will be running a two part series on this remarkable rescue operation. Part one is due to air on Monday 30 June at 20:00 AEST, with Part two scheduled for Monday 7 July 2025. These episodes will also be available on ABC iview and YouTube.