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Edward Griffiths, search and rescue paramedic-winchman, NorthWestWales.
Email for correspondence: edward.griffiths@go.edgehill.ac.uk
Abstract
Despite its decline in recent years, coronary heart disease remains the UKs
single biggest killer. When someone suffers a heart attack on a mountainside
in the UK, they often need a search and rescue (SAR) helicopter to provide
them with timely emergency care and to transport them to a suitable hospital.
The early diagnosis of an ST-elevation myocardial infarction (STEMI) from a
12-lead electrocardiogram facilitates timely initiation of reperfusion therapy,
but obtaining one in the mountain rescue environment is challenging and
sometimes impossible.
Although primary percutaneous coronary intervention for STEMI patients is
the treatment of choice, facilitating it renders the SAR aircraft unavailable for
greater periods of time and requires the relevant, supporting infrastructure to
be in place. The SAR paramedic must assess the suitability, validity and usability
of clinical guidelines and pathways on a case-by-case basis, then integrate
them into the demands of each particular SAR mission. Although cardiac
rehabilitation has not traditionally been within the remit of the pre-hospital
clinician, responding to the psychological needs of the heart-attack victim in the
aircraft may be a significant determinant to their participation in rehabilitation
programmes.
Key words
lCardiac care facilities lElectrocardiography lMyocardial infarction
lPercutaneous coronary intervention lRehabilitation lThrombolytic therapy
Accepted for publication 28 March 2016
Cardiac care in SAR helicopter
paramedic practice:
from mountainside to
rehabilitation
Search and Rescue (SAR) helicopter paramedic
winchmen are part of a four person crew
manning SAR helicopters around the world.
When casualties find themselves inaccessible to
land or air ambulances, SAR helicopter (SARH)
crews are called upon to care for, extricate and
rapidly transport patients to places of definitive
care or safety (Howes et al, 2011). While the
majority (around 80%) of their patients are
victims of traumatic injury (Dykes et al, 2009;
Sherren et al, 2013; Meadley et al, 2015), they are
also called upon to assist those presenting with
acute coronary syndromes. Despite the recent
recognition of the search and rescue technical
crewmember role by the College of Paramedics
(2015: 36), the specifics of the profession remain
unfamiliar to most.
Each SARH mission presents its own unique
challenges due to numerous dynamic aviation,
rescue and clinical considerations. The aim
of this article is to provide an insight into
the emerging role of the SARH paramedic
by highlighting and critically analysing the
considerations they are faced with when called
to a cardiac patient on the mountainside. It will
begin by revising the pathophysiology of acute
myocardial infarctions and the importance of
timely reperfusion. The article will then progress
by highlighting and discussing the merits of,
and the barriers to, the available cardiac care
investigations and recommended treatment
pathways in paramedic practice. The final section
will explore an aspect previously considered
outside the remit of the SARH paramedic:
healthcare promotion and the rehabilitations
process.

2. Journal of Paramedic Practice • Vol 8 No 5 3
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Background: the pathophysiology
of myocardial infarctions
Cardiovascular disease (CVD) is a non-specific
phrase used to describe diseases of the heart and
circulation. The World Health Organization (WHO)
estimates that CVD is the leading cause of death in
the world, responsible for over 17.5 million deaths
each year (WHO, 2015). According to the British
Heart Foundation (BHF), around half of the deaths
from CVD in the UK can be attributed to coronary
heart disease (CHD) (BHF, 2015). Despite the
number of deaths from CVD in the UK reducing
by half between 1961 and 2009 (Scarborough et al,
2011), CHD remains the UKs single biggest killer
(BHF, 2015).
The underlying disease process responsible for
the majority of CVDs is atherosclerosis (WHO,
2011). Atherosclerosis is a generic term for the
progressive and degenerative thickening of the
arteries (see Figure 1). There are several risk-factors
that promote atherosclerosis. Some of the significant
contributors include smoking, an unhealthy diet
and physical inactivity (BHF, 2015; WHO, 2015)—
all of which appear to be behavioural choices.
The National Institute for Health and Care
Excellence (NICE) (2013) describes coronary
atherosclerosis in more detail as the accumulation
of protruding, elevated white lesions (plaques)
within the relatively small bores of the coronary
arteries. These plaques consist of a fibrous outer
layer surrounding a lipid core. Blood flow over
a plaque with a high lipid concentration and an
unstable (thinner) cap can cause it to rupture.
Platelets now accumulate around the newly
exposed cholesterol core and a thrombus is formed.
When a persistent and complete occlusion of a
coronary artery by a thrombus occurs, blood flow
and thus the delivery of oxygen to the myocardium
distal to the blockage is impeded. Failure to resolve
a blockage results in necrosis of the affected
myocardium. This pathophysiology is referred to as
a myocardial infarction (MI). Following complete
occlusion of a coronary artery, an abnormality seen
on the electrocardiogram (ECG) is elevation of the
ST-segment. Hence, it is referred to as an
ST-segment elevation myocardial infarction
(STEMI).
The 12-lead ECG in SAR paramedic
practice
Most deaths from CHD are caused by an acute MI
(BHF, 2015). When one strikes, 50% of potentially
salvageable myocardium is lost within 1 hour, two
thirds is lost within 3 hours (NICE, 2013). ‘Time is
muscle’ and muscle is life (NICE, 2013)—for both
the SARH paramedic and their patient, the clock
is ticking! Other than resuscitation from cardiac
arrest, the most significant determinant in reducing
mortality is the speed at which coronary blood
flow can be re-established (Smith et al, 2010; NICE,
2013). Early reperfusion depends on a timely
diagnosis, the cornerstone of which is the 12-lead
ECG. The recent transition from a predominantly
military SAR service to a civilian contracted one
in the UK has brought with it the acquisition of
a 12-lead ECG capability on SAR helicopters. The
pre-hospital 12-lead ECGs role in the diagnosis of
an acute STEMI is vital in enabling timely access to
the preferred reperfusion treatments: percutaneous
coronary intervention (PCI) and thrombolysis (TL)
(NICE, 2013).
PCI is only available in specialist, tertiary centres
and involves the introduction of a fine, guide-
wire into an occluded coronary artery via the
patients groin or wrist. A thrombectomy device
is then advanced over the wire and the thrombus
is mechanically aspirated. The device is removed
and a balloon/stent is advanced and left in place
to open up the artery (Figure 2). When this
procedure is performed as the initial reperfusion
Healthy
artery
Build-up
begins
Plaque
forms
Plaque
ruptures;
blood clot
forms
Figure 1. Stages of atherosclerosis
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reduced (Figgis et al, 2010). Pre-hospital ECGs
can also provide evidence of the evolutionary
patterns indicative of MIs (College of Paramedics
and American Academy of Orthopaedic Surgeons,
2014), they are also useful for pre- and post-
reperfusion therapy analysis.
But, performing a 12-lead ECG in the SAR
environment has its difficulties. SARH paramedic
practice is unforgiving, conducted in a context
fraught with chaos, danger and uncontrollable
elements. During a SARH mission (by definition)
injured or ill patients need treating and rescuing
from austere, inaccessible locations. In extremis,
taking time to perform a 12-lead ECG on scene
may result in a missed opportunity for rescue due
to aircraft, weather or fuel limitations. Ironically
in these circumstances, focusing purely on clinical
considerations may prove detrimental to casualty
care. The urge to do so must be resisted, otherwise
the patient may face a lengthy carry down the
mountain by ground parties. If this occurs, by
the time they reach a hospital, the window for
timely reperfusion treatment may have passed
and the SARH paramedic may themselves require
assistance, calling on ground parties to escort them
safely down the mountain. Overall mission success
demands a holistic approach to the management of
the clinical, aviation and rescue considerations.
The skill of performing and interpreting an ECG
also presents significant challenges during rescue
missions. Procedural guidelines suggest that the ECG
is a simple investigation during which the patient
should be relaxed and comfortable to reduce artefact
(Gregory and Mursell, 2010). During a mountain
rescue mission this is often challenging and not
always possible. Casualties may be in precarious
positions, wearing saturated clothing in gale force
winds, shivering in temperatures below freezing.
The prospect of being winched up around 300 ft to
a hovering helicopter only exacerbates the situation
for the already anxious, fearful patient. Sometimes
just getting the ECG machine to the patient is
challenging on the mountain. Winching down with
a portable (yet still cumbersome) ECG machine can
be impossible in hazardous conditions. Although
in-flight ECGs are possible, a SAR helicopter is a
turbulent, vibrating platform which is not conducive
to obtaining an accurate ECG trace.
Patients not presenting with typical retrosternal
chest pain make up around 30% of STEMI cases
(Steg et al, 2012). These are typically older patients,
women and diabetics (Steg et al, 2012; AACE,
2013). Thygesen et al (2007) describe common ECG
pitfalls which mimic ischaemia or infarction, such
as a left bundle branch block or pericarditis. These
factors compound to further exacerbate difficulties
in making a pre-hospital diagnosis of a STEMI.
treatment, it is referred to as a primary PCI (pPCI).
Due to its high success rate and low risk rate in
comparison to TL, pPCI is the treatment of choice
for those diagnosed with a STEMI (NICE, 2013).
The Association of Ambulance Chief Executives
(AACE) (2013) have embraced the NICE (2013)
guidelines and empowered paramedics to bypass
local emergency departments (EDs) in favour of
direct transportation to PCI centres. This enables
timelier access to pPCI for those meeting a certain
criteria. To facilitate this the pre-hospital 12-lead
ECG is imperative.
If bypass to a PCI centre from scene is not
possible, an alternative reperfusion method for the
STEMI patient is TL. This involves the introduction
of a thrombolytic agent to pharmacologically
break down the offending thrombus. At the time
of writing the SAR paramedics’ formulary in the
UK does not contain TL drugs. When bypass is not
possible, SARH paramedics employ a ‘scoop and
run’ strategy to rapidly transport their patients to
the nearest ED for TL. In these circumstances the
pre-hospital ECG could be misconceived as an
unnecessary waste of time as it does not directly
alter the SARH paramedic’s immediate provision
of care. But this is certainly not the case, the
additional time spent on scene is justifiable. A
pre-hospital STEMI diagnosis combined with a
hospital pre-alert enables the ED staff to prepare
for the arrival of the STEMI patient and administer
timelier TL (Figgis et al, 2010). In comparison, the
additional on-scene time is rendered insignificant
as the overall onset-to-reperfusion time is still
Figure 2. Balloon angioplasty and stenting
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These difficulties can be overcome with training
and regular exposure to ECG mimics (Huitema et
al, 2014). But the predominantly trauma orientated-
role of the SARH paramedic makes this challenging.
Technological advances on modern helicopters
offer an alternative solution. The advent of a data
transmission capability via Bluetooth and a Wi-Fi
‘hotspot’ enables ECG telemetry from the aircraft.
Already pioneered by their domestic paramedic
colleagues, this provides the ability to collaborate
with other healthcare professionals who posess a
more advanced ECG diagnostic skillset.
Utilising this option not only promotes
identification of those patients requiring
reperfusion, but significantly in the case of the
STEMI mimic, it reduces the number of false-
positives (Davis et al, 2007; McLean et al, 2008).
However, using this capability requires further
consideration of the time constraints imposed
by weather or fuel restrictions. Additionally, high
cruising speeds of modern helicopters mean that
the aircraft may be capable or reaching several
appropriate hospitals (including pPCI centres)
before the data can be transmitted, analysed and an
answer communicated.
An investigation by Figgis et al (2010) concluded
that only 20% of patients presenting to UK
ambulance paramedics with chest pain had a pre-
hospital 12-lead ECG recorded. Of the paramedics
surveyed, 27.6% stated they had received
insufficient training to perform and interpret a
12-lead ECG; 64% cited the same reason for their
inability to interpret ECG abnormalities. This study
had a small sample size taken from one region
rendering its external validity compromised. It is
not necessarily a true reflection of UK paramedic
practice as a whole, but it does reemphasise the
training implications already highlighted. Beygui
et al (2015) recommend that specific training
in ECG interpretation should be mandatory for
those involved in the care of STEMI patients.
Whitbread et al (2002) concluded that with
sufficient training, UK paramedics are comparable
to emergency department doctors in diagnosing
STEMIs from a 12-lead ECG. They are able to
diagnose with a sensitivity of 97% and a specificity
of 91% (Whitbread et al, 2002). Provided they are
adequately trained, SARH paramedics, like their
domestic counterparts, can act as a vital timely filter
for the activation of reperfusion pathways.
Thrombolysis in local EDs versus
bypass to a PCI centre
Ultimately, the reperfusion strategies available to
the STEMI patient on the mountain are determined
by the SAR paramedic’s choice of destination
hospital. The complexities and dynamics of a SAR
mission often hinder strict adherence to clinical
guidelines. But this does not excuse guideline non-
adherence as the default option, the decision not to
bypass to a PCI centre must be justifiable and on a
case-by-case basis.
Once a STEMI diagnosis has been obtained, the
greatest barriers to the SARH paramedic adhering
to the AACE (2013) PCI centre bypass guidelines
are the aviation and strategic considerations. The
primary role of a SAR helicopter is to rescue those
SARH paramedic practice is unforgiving, conducted in a context
fraught with chaos, danger and uncontrollable elements
During a SARH mission injured or ill patients need treating and
rescuing from austere, inaccessible locations

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in urgent need that other agencies cannot reach
within the required timescale; clinical care can
often be relegated to an ancillary consideration.
Bypass to a PCI centre may result in a significant,
additional delay (over an hour) in the asset being
available for re-tasking. Unlike the ambulance
service, the nearest comparable, covering asset is
often the neighbouring SAR base over 100 miles
away. For some casualties (such as those
drowning), timely rescue by a SAR helicopter
makes the difference between life and death. SARH
paramedics may be asked to conduct rapid, in-
flight triage when information about other, life-
saving tasking is received. They must weigh up
the benefits gained through facilitating pPCI in
preference to TL for one patient, against the odds
of other persons requiring timely rescue by a SAR
helicopter.
While weather and fuel restrictions also hamper
the ability to bypass, infrastructure can also be
limiting. Many PCI centres do not have a dedicated
helicopter landing site (HLS) suitable for a SAR
aircraft on-site. A recent review estimated that 60%
of hospitals in the UK have inadequate helicopter
landing facilities (Association of Air Ambulances,
2014). The subsequent secondary ambulance
transfer from a nearby ‘field’ HLS can incur
significant delays. Although pPCI is the preferred
reperfusion method, TL at local EDs can offer a
more favourable alternative from purely an aviation
perspective.
To produce their STEMI guideline, the NICE
(2013) conducted a clinical review comparing
the incremental benefits of pPCI over TL. They
concluded that, despite pPCI related time delays, it
is both cost effective and feasible; it is the preferred
treatment for those meeting its criteria and should
be administered in a timely manner (NICE, 2013).
But the evidence is not unanimous for this ‘one-
size-fits-all’ guideline, a detailed review suggests
no single pathway is optimal for all patients, in all
situations.
Defining the equipoise for pPCI and TL is
complex. One determinant appears to be patient
age and profile risk (Pinto et al, 2006; Tarantini et
al, 2009). A review of the evidence conducted by
Widimsky (2009) suggests that patients older than
65 years of age, or with a higher Killip class (higher
mortality risk), should be treated with pPCI. But
those younger than 65 years, with a low Killip class,
only appear to gain significant benefits from pPCI
if the related time delay is less than 35 minutes
(Widimsky, 2009). For this subgroup presenting
on the mountain, where pPCI related time
delays may be significant, TL appears a suitable
alterative. However, Widimsky (2009) admits the
small numbers in this subgroup cast doubts on
his conclusions. The NICE (2013) acknowledge
this and recommend further investigation
through a randomised controlled trial to compare
the outcomes between TL and pPCI for those
presenting within 1 hour of symptoms.
Although TL at the nearest ED is favourable from
purely an aviation perspective, when compared
to pPCI, it is blighted by clinical contraindications
and complications. While TL usually dissolves
the thrombus, the underlying atherosclerotic
plaque often remains and reocclusion is common
(Schofield, 2011). In around 5% of cases this leads to
reinfarction and a poor associated outcome (Gibson
et al, 2003). It is also less successful in sufficiently
opening the effected artery (Schofield, 2011).
Widimsky et al (2009) state that mechanical (pPCI)
reperfusion rates are circa 90% in comparison to a
pharmacological (TL) reperfusion rate of circa 50%.
The AACE (2013) re-iterates this difference in success
rates in its TL guideline. It states that TL in the field
should not be considered the end of emergency
care, as these patients still require rapid transfer to
an appropriate hospital to prevent re-infarction and
assess the need for rescue PCI.
As a non-specific treatment, TL also predisposes
patients to a higher risk of haemorrhagic stroke
and bleeding (Schofield, 2011; Beygui et al, 2015).
Some patients are exposed to an increased risk
of intracranial haemorrhage (0.2–1%) (Califf et al,
1992) without gaining significant benefit. When
this risk overbalances the expected benefit, TL is
contraindicated (Beygui et al., 2015). For these
Key points
ll [AQ: please add 3–4 key points]

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patients, any apparent initial benefit gained from
rapid transportation from mountainside to a local
ED is no longer applicable. These patients attract
a high mortality rate, the AACE (2013) specifically
emphasises the need for direct transportation to a
pPCI centre for this subgroup, whenever possible.
From a purely clinical perspective, timely pPCI is
the treatment of choice.
Rehabilitation
Regardless of reperfusion therapy, cardiac
rehabilitation (CR) is crucial to restoring cardiac
patients to optimal health and psychosocial
function; it begins from the point of first medical
contact and can continue for the rest of the person’s
life (Grove, 2011).
Life-threatening cardiac events induce feelings
of fear, hopelessness, anxiety and ultimately
depression. Approximately 39% of cardiac
patients cite ‘a lack of interest’ or ‘refusal’ as
their main reason for not participating in CR
programmes (Doherty et al, 2014). The National
Service Framework for Coronary Heart Disease
recommends that a patient’s psychological needs
are assessed and addressed throughout the four
stages of CR (Department of Health, 2000). The
ability of patients to manage these psychological
difficulties induced by life-threatening cardiac
events remains vital to the success of CR (Doherty
et al, 2014). This is a multidisciplinary responsibility
and should begin early for all patient groups
(Doherty et al, 2014).
The evolving role of the paramedic now extends
beyond that of a purely reactive profession that
provides care and transportation. The paramedics’
registering body, the Health and Care Professions
Council (HCPC), now embraces the concept of
healthcare promotion for paramedics (HCPC,
2014). While the back of a SAR helicopter is not
traditionally regarded as a suitable venue for the
promotion of health care and the rehabilitations
process, meeting the psychological needs of the
patient in the pre-hospital setting might be crucial
to their subsequent perception of the emergency.
The rehabilitation process can begin on the way to
hospital by reassuring the casualty that although
the situation is serious, it is not hopeless and that
with optimism, determination and adherence to
the CR programme there is no reason they will not
make a full recovery. Assessing and addressing a
patient’s psychological needs immediately may be
relevant to the likelihood of the patient attending
rehabilitation.
Conclusions
CHD is the UKs single biggest killer. When a
person falls victim of a STEMI on the mountainside,
timely reperfusion is imperative. But for the
SARH paramedic, the patients’ immediate clinical
requirements are not the only consideration. One
of the most highly prized attributes of the SARH
paramedic is not their abilities as a clinician, but
their ability to manage the competing, cumulative
considerations during a SARH mission. It is often
challenging, sometimes impossible, to comply with
the recommended clinical guidelines.
Cardiac care on the mountainside demands that
practitioners are neither uncompromising slaves
to clinical protocol, nor do they ignore guidelines
without justification. SAR clinicians must evaluate
the evidence behind clinical guidelines for validity,
applicability and usability, while concurrently
considering the aviation and rescue implications of
each SARH mission on a case-by-case basis. Only
after considering these elements can they make
informed decisions on ‘what, when and where’ with
regards to investigations, treatments and destination
hospitals for the cardiac patient. Although
healthcare promotion and CR has not traditionally
been within the SAR paramedics remit, addressing
a patient’s psychological needs early, increases
their likelihood of participating in rehabilitation
programmes.
Conflict of interest: none declared
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