To medevac or not to medevac? That is the question.

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Physicians often choose to use Latin to express themselves, in keeping with their training. Dr. Benjamin Shore went right for it when asked how the decision is made to airlift a sick or injured guest from a Royal Caribbean cruise ship.

The extreme measure generally is reserved for people who are “in extremis” – translated by Merriam-Webster as “at the point of death” – said Shore, chief medical consultant for Royal Caribbean International, Celebrity Cruises and Azamara Club Cruises.

“That would include things like unstable angina, heart attacks, hemorrhaging or if they have a major trauma, where we can stabilize them onboard but then we need to get the assistance of a shoreside medical facility.” – said Shore, chief medical consultant for Royal Caribbean International, Celebrity Cruises and Azamara Club Cruises.

Stabilizing the patient is particularly important because the available space inside the rescue helicopter is tight.

“It’s a very, very narrow, extraordinarily noisy environment,” Shore said. “So the ability to try to measure blood pressures or hear heartbeats is a losing proposition.”

No single person has the authority to order a medical evacuation at sea.

The onboard physician declares the medical emergency with the ship’s captain, who provides strategic information to the Coast Guard, whether U.S. or that of another country. From that point, the Coast Guard either approves the airlift based on a review of the patient’s condition or such strategic factors as weather, or denies the request.

“The flight surgeon for the Coast Guard can make a decision that the patient either is so unwell that they can’t survive and it’s a waste of resources, or the patient is well enough that it’s an abuse of the resource and they don’t want to take the risk involved in getting the patient off the ship,” Shore explained.

That procedure is carefully orchestrated in a three-part, 23-point USCG directive beginning with how to properly request helicopter assistance to preparing the patient for hoisting from ship’s deck to chopper.

By that point, the captain will have taken the ship as close to shore and a hospital as possible within the time available.

“The helicopters can generally go out about 150 to 200 (nautical) miles, they can hover briefly for 15 to 20 minutes and then get back on fumes,” Shore said.

Once the chopper reaches the ship, which ideally will be maintaining an easy speed with any wind on the port bow, it approaches from behind on the port side.

“In a helicopter the pilot sits on the right seat, so his best visibility is if the ship is in front of him and to the right,” Shore continued. “They hover on the aft port side, and that way also if there’s any problem and they lose lift, they can always veer to the left and get away from the scene quickly without any damage to the ship.”

Shore said that while medical evacuation at sea is not easy, “It’s pretty non-hair-raising for us. We have a good grasp on what we can and can’t do; we have great cooperation from the Coast Guard. It’s nothing remarkable or new.”