Remote Medicine Remote Paramedics Have High Level Of Training

Highly trained paramedics with baggage containing a couple hundred pounds of drugs, medicines, disposables, and portable medical instruments are as essential for exploration and production ventures in Russia and other medically remote regions as are drilling and seismic crews.

Such paramedics are generally better trained than the emergency medical technician paramedics (EMT paramedics) that accompany street ambulances in major cities. Such field medics are now being designated by some in the industry as "remote paramedics" (RPs) to make the distinction in training. This article, for sake of convenience, will use the term RP even though it may not be used in some countries.

RPs have many responsibilities concerning health at remote locations, but the most critical is that of stabilizing patients suffering from major trauma or medical problems. Because they are far from reliable medical help, this first care in severe cases lasts much longer than a typical ambulance trip to a hospital.

There have been paramedics on offshore drilling rigs and production platforms in the North Sea and the Gulf of Mexico for years. But both these major oil arenas are near advanced medical care onshore. Facilities there are easily accessible by helicopter. In fact, a physician can quickly fly out to a rig or platform in the North Sea or Gulf of Mexico if necessary.

The type and number of medical personnel that North Sea operators and contractors must provide to their workers, many of whom are unionized, has been defined by British and Norwegian regulations. As a result of some 2 decades of ever-increasing offshore activity, the first firms providing paramedics in the North Sea have expanded worldwide offering a variety of medical services, including clinics. Aberdeen, Britain's offshore oil staging center, has spawned two major players, OMS and RGIT Medic International, both of which make use of advanced telemedicine techniques to link their far flung paramedics with their physicians. RGIT is a commercial, for profit company, owned by Robert Gordon University in Aberdeen.

The development of formal paramedic programs initially proceeded more slowly in the Gulf but in recent years has picked up speed. Factors that pushed the introduction of more formal programs offshore were economics, a more demanding workforce, government regulations, and the legions of lawyers in the U.S. looking for personal injury law suits to file. The increase in oil projects in distant regions also catalyzed development.

A pioneer in introducing standardized paramedics programs and defining and instituting a training program to meet RP standards has been Medic Systems of Houston. This company too has moved beyond the Gulf of Mexico and serviced some of the earliest Russian projects.

RPs in Russia

Charlie Harrington, a remote paramedic for Medic Systems, tells the Journal that in his 21/2 years at a western Siberia oil project near Niznevartovsk, he and a colleague treated more than 8,000 patients. This was from early 1993 through the autumn of 1995. Many of these were Russians who chose an oil company clinic over their local hospital. Harrington, a former U.S. Army medic, says that even though they grew up under the Russian medical system they recognize its deficiencies.

Harrington, a 31 year old native Texan who learned Russian, did something perhaps unprecedented for an American during his tour in Russia. He took and passed the examination that all Russians must pass to become physicians. He is now a certified physician licensed to practice in Russia.

Harrington's case load covered sicknesses and injuries, ranging from the minor to major. Examples are a nearly successful suicide by hanging, resuscitations from cardiac arrest, cocaine and heroin overdoses, drownings, and deliveries of babies. His work took him to local hospitals for lab tests and X-rays. There he eventually became friendly with Russian doctors, who initially seemed to resent his presence. But familiarity bred understanding.

He says many of the Russian doctors blame the desperate situation on the breakup of communism. During that era they had child immunization programs. Now there is no money for that and many children are getting whooping cough and diphtheria.

Harrington also had the responsibility of overseeing the camp's kitchen and its sanitation facilities.

Another remote paramedic in the same region where Harrington was working is Alan White of OMS, Aberdeen. White and another RP run a well-equipped clinic for a joint venture of Amoco Corp. and the Russian company Yuganskneftegas (Yukos). The venture is developing the north Priobskoye field, which is 400 miles south of the Arctic Circle near the Ob River. The nearest large town is Nefteyugansk, a city of some 100,000 that is 1,300 miles east of Moscow. There are about 25 expatriates at the site at any given time. White and his colleague, who also treat the Russian staff involved in the venture, do alternate 28 day tours.

White says OMS keeps physicians on duty around the clock in Scotland should he need consultation. In one case, he faxed an electrocardiogram there and had a diagnosis back within minutes.

Amoco's Dr. Bruce Keneamore, medical director for Russia, says that if a severe injury occurred requiring immediate stabilization or surgery the patient would be taken to a hospital in Nefteyugansk.

He says the physicians there are well qualified to handle this. The next step would be evacuation to Moscow on a Tupelov 134 aircraft chartered from an Aeroflot subsidiary. The plane is on hand at all times, normally to service the venture's business needs.

In most cases the first stop for Amoco employees would be the American Medical Center in Moscow. If more treatment is necessary the patient is transferred to the Zil Hospital, also in Moscow (see p. 35).

Keneamore says it is possible in some cases to get all the care needed for recovery at AMC and the Zil Hospital. However, the company is prepared to medically evacuate patients to Helsinki, even going directly there from Nefteyugansk. Amoco has an agreement with International SOS to make such arrangements. As mentioned earlier, evacuations are rare.

White, a former British military medic, is also responsible for the camp's hygiene, supervision of the kitchen staff, and safety. One element of his routine is breathalyzer tests for alcohol that he gives the company drivers daily.

White says drinking is not a problem among the Priobskoye drivers.

"Good jobs are too hard to get," he says.

White says he is not allowed to treat locals not working for the joint venture. He does get numerous requests, which he can't satisfy, from outsiders who want to buy medicines and medical supplies.

White also checks frequently with the local hospital about any new disease flare-ups such as food poisoning, hepatitis, and diphtheria. Concerning the latter, he says, "Any sore throat is grounds for a swab and diphtheria test."

This part of Russia also has a tick-borne disease, similar to Lyme disease found in the U.S.

Worldwide drillers

There is no set formula for meeting medical needs on offshore rigs working around the world. A lot depends on the rig's location.

Marine Drilling Cos. of Sugar Land, Tex., has a certified local physician on an offshore rig it has working off India. If an expatriate needs hospitalization, he would be air evacuated to Singapore, which, like Hong Kong, is a destination of choice for serious problems in Southeast Asia.

In the Gulf of Mexico, the company cross trains its managers in cardiopulmionary resuscitation (CPR) and first aid. Marine Drilling says the availability of all weather helicopters means in most cases the injured or sick employee can get to one of the many first class hospitals on the coast in about the same time it would take an ambulance on land to take a patient to a hospital.

Global Marine Inc., Houston, one of the world's major offshore drilling contractors, has rigs in the Gulf of Mexico, the North Sea, off West Africa, and in the Caribbean. It also operates a mobile drillship that was off Yemen earlier this month.

Daniel C. Hansen, the company's manager of employee relations, says the periodic movements around the world and off West Africa demand constant assessment of local health conditions and facilities. He stresses that detailed planning and advance arrangements are absolutely essential.

Hansen says the company employs either a certified physician or a paramedic on each of its rigs. The company uses an agent, P.O.C. International Ltd., St. John's, Newf., to recruit third-country paramedics and physicians for locations outside the U.S. Most of the physicians are direct hires.

Presently, they come from the Philippines, Croatia, and the U.K. The treatment they provide is in the realm of what a paramedic would handle on the rig; however, these physicians do stabilize patients if necessary and accompany them to shore.

Hansen says there are some onshore medical clinics run by oil operators in West Africa that can provide medical care. However, in severe cases, the company would have International SOS arrange an evacuation. Blood transfusions in Africa could pose major risks. The rigs carry blood expanders for emergency cases until safe blood is available.

All crew members carry cards listing the diseases that are prevalent in the regions where they are working and precautions they should take. The company also stays in contact with the U.S. Centers for Disease Control.

In the Gulf of Mexico where a dozen Global Marine rigs work, the company uses paramedics from Acadian Ambulance, Lafayette, La..

North Sea

Statoil, Norway's state-owned oil company and the North Sea's largest oil producer, has an elaborate offshore medical system. It is deceptively simple because there are only two registered nurses on each of the six production complexes Statoil operates.

But they are part of a sophisticated emergency care system. Physicians are on duty around the clock in Stavanger or Bergen. The nurses all have advanced specialties, such as surgery or anesthesiology, and have taken a company course in emergency care. They can consult company physicians via telephone onshore at Bergen or Stavanger and dispense medicine and perform stabilization procedures under their direction.

"They are working on the doctor's license," a Statoil spokesman says.

There is a dedicated helicopter available for evacuations, but the normal traffic to and from these major complexes with their offshore "hotels" is so frequent, a regular flight is almost always available. The doctors themselves can, of course, hop a helicopter and be on location in an hour or so.

RGIT Ltd., a major provider of paramedics in the British sector, also has medical teams around the world. It provides care for a British Antarctic research project.

Frances Dey, RGIT's manager of medics, says British law requires one medic for every 25 workers in the North Sea. The medics also devote a great deal of time to occupational health matters. The company trains its own medics, who must have certification equivalent to that of a registered nurse before starting the 4-week training program.

Southeast Asia

The situation is more difficult in Viet Nam where Statoil is in an alliance with BP. BP has let a contract to AEA International, Singapore, to cover its medical needs. AEA is a big player in that part of the world. It furnishes paramedics for remote locations and has organized and staffed several outpatient clinics in Viet Nam. It also provides paramedics to companies exploring China's Tarim basin.

In recent years it has arranged on average two air ambulance evacuations per month from Ho Chi Minh City, Hanoi, and Da Nang primarily to Singapore. The company has offices, clinics, or affiliates in 25 cities around the world.

Chevron study

Even though paramedics aren't mandatory on rigs in U.S. waters, there are some solid economic reasons for having them even on locations as near good hospitals as those on the U.S. Gulf Coast.

Oil industry managers noted that helicopter flights, costing $500 during the day to perhaps $5,000 at night, were carrying workers to shore who could be treated on the rig or platform by a remote paramedic. Flights also mean lost time, with the evacuated worker being gone for at least 24 hr. However, lost time due to accident (LTDA) has much more serious implications than just a loss of productivity.

LTDAs must be reported to the U.S. Occupational Safety and Health Administration. LTDAs can increase workman's compensation premiums. A remote paramedic could treat the patient, who could then be temporarily assigned some light work, if necessary, avoiding an LTDA on the record.

Chevron U.S.A. Production Co. is one company that looked at the cost/benefit ratio of using remote paramedics. It presented the results in 1992 of a study it did to assess the legal ramifications and costs it would face in using platform-based RPs in its operations off Louisiana. Although the costs may have changed since then, the methodology can serve as a model for other companies wishing to conduct a similar assessment anywhere.

Chevron hired Houston-based Medic Systems to furnish the RPs, onshore physician support, medicines, supplies, and equipment. A condition of the contract required by Chevron was that the paramedic consult a shore-based physician on all injuries.

Concerning the legal aspects, Chevron concluded that making use of the paramedic services by the employee voluntary would lessen the company's chance for a lawsuit. In other words, the afflicted employee could opt for transport to land. Medic Systems says it has not been sued in over 10 years of operations in the Gulf.

Medic Systems estimates that only 5% of an RP's time is actually spent treating patients. Therefore, Chevron replaced an existing dispatcher/office assistant and assigned his duties to the RP. This provided an immediate saving.

Experience

After 9 months on a drilling rig, the Chevron pilot program was transferred to a manned production facility for an additional 6 months. During the total 15 month program, the RP treated 143 patients that required 157 follow up visits. Following are the numbers of patients treated or stabilized and the specific reasons:

Major trauma (head, chest, and back injuries; multiple fractures; burns; etc.)-8

Major medical (heart attack, internal bleeding, high blood pressure, cases requiring advanced life support, etc.)-12

Minor medical (colds, flu, sore throats, ear aches, infections, body pains, diseases, etc.)-42

Minor trauma (cuts, sprains, bruises, eye injuries, etc.)-81.

Tangible cost savings

For Chevron's pilot project, the cost for the Medic System EMT paramedic program in 1993 dollars ran $110,000/year, including medicine and equipment rental. Chevron used the paramedic, as mentioned, to replace a dispatcher/office assistant costing about $80,000/year. Chevron, therefore, figured the extra cost for medical care ran only $30,000/year.

Chevron's calculated cost savings came from savings in the following four categories: emergency transportation, emergency medical services, lost time, and charges from claims carrier. Chevron, which is self insured, is charged $50 for each first aid or medical incident that reaches medical services other than the paramedic.

The company conservatively estimated it saved $4,500/year with the RP. Medic Systems, using another analysis, estimated savings of $74,000/year. Chevron, therefore, split the difference and came to the conclusion that savings of $40,000/year were realistic.

The company also identified some intangible benefits. One is the peace of mind that personnel and their families have from knowing RPs are on board. Others are reduction in lost man hours and in workman's compensation. RPs are also qualified to give physicals and draw blood on site for drug testing if a company desires.

Statistics

Dr. Michael Stafford, medical director of Medic Systems, has extensively analyzed the types and number of accidents and sicknesses that occur in remote medical environments. Fig. 1 shows these percentages for domestic and international operations.

He notes that though the percentage of major medical and trauma is small, some of these patients would probably have died without treatment by an RP.

An RP can also make important contributions in the area of minor trauma. The percentages included 88 cases of laceration. Of these 60 were successfully sutured offshore by an RP. RPs were also able to treat 80% of the 362 eye injuries that occurred offshore in that period. Numerous trips to the beach were therefore avoided.

Internationally, Medic Systems statistics are quite different, as Fig. 1b shows. The international figures are influenced by treatment of not just expatriates but local workers and even the indigenous population. Stafford says it is a fact of life that land operators and contractors in many undeveloped regions must be prepared to treat locals.

Training

Using such statistics and calling on his own experience in emergency medicine, Stafford has identified the skills a remote paramedic should acquire to work in remote environments. The skills are shown in the far right hand column of Fig. 2.

To get Medic System paramedics to this level he has written a 200 page training manual. It also covers a complete list of the equipment and medicines the RP, who will be trained in pharmacology, will need. Stafford says to reach the level of EMT paramedic shown on the chart requires 800 class room hr. This is the highest level of prehospital care provider the National Registry of EMT Paramedics certifies. Medic Systems requires an additional 88 hr to reach the remote paramedic level.

To reach this level, Stafford holds 10 hr/day training sessions for 5 days to go through the training books. The remaining hours are done in the emergency room. He said only two thirds of the candidates pass the course.

The problem for RPs is maintaining proficiency, just as it is for the flying evacuation physicians of Helsinki (p. 37), who solve this problem by also serving as life flight physicians.

Stafford is affiliated with St. Elizabeth hospital in Beaumont, Tex. There, Medic System RPs do periodic tours in the emergency room to maintain their skills.

Staffing

One RP can adequately care for some 200 expatriates or offshore workers, Stafford says. It is rare to find that many people in one location. The solution offshore is to put an RP on a mother platform. The RP can then cover more platforms or rigs that are no farther than 30 min away by boat.

In remote overseas locations such options may not be possible. But as noted, in a destitute area the local population may need very basic care.

There are indeed unofficial oil industry "medical ambassadors" at work around the world donating care and supplies as big as an ambulance or as small as their personal medical travel kit with syringes and antibiotics.