Bush Medicine 101: Ship Rescue Mission In Madagascar

The cost of saving a life, limbs, and a spine.

Dear Readers, dear Jane-Your-Younger-Self,

I hope you are well. We are well.

This week we rescued a crewman who fell 10 meters while cleaning the hold of his vessel (ship) and fractured his spine and his ankles.

I received the message via WhatsApp last Sunday evening - “Disembarkation of injured crewman, please check your mail asap”.

As soon as I receive these types of messages I tell my family I’m off parenting and other routine duties for 48 hours, because 48 hours is usually the time it takes to disembark, assess and refer the patient.

These vessel disembarkation cases are all-consuming and extremely exhausting, requiring late nights for logistics and requests for authorizations, and on the day for the actual disembarkation.

From the time I receive The Email until the time that the patient leaves Madagascar, literally hundreds of emails are sent around the world just for this one patient.

Disembarking a sick or injured crewman requires hundreds of hours of administration time from all the people involved, when all is said and done.

I love disembarking patients off vessels, BTW, for a couple of reasons. But for this particular case, and unusually so, I didn’t get a good feeling. Fortunately all’s well that ends well.

Firstly, vessel crewmen are hardcore, they do call foul or sick, so when they get sick they get REALLY sick, or REALLY injured. Not that I ever want anyone to get sick or injured, but these cases tend to be be above average medically, and they test my knowledge and 25 years of experience as a former paramedic, and a doctor.

Secondly, the actual disembarkation is technical and dynamic, using all of my former Rescue Paramedic skills.

I consider this disembarkation as one of my top 2 (of 30-50?) vessel disembarkations of my Emergency Medicine career to date.

The patient had a fractured spine, we had to move him VERY carefully.

And…..

ABOVE: Monday’s unsuccessful attempted disembarkation off the coast of Fort Dauphin Madagascar.

The sea swell last Monday was causing the vessel and our rescue tug boat to lurch and sway uncontrollably despite the best piloting by both vessel captains when they tried to hoist our patient with the vessel crane and gently lower him onto the deck of the Rescue Tug.

After 3 attempts by our rescue tug boat to come along side the patient’s vessel where we could gently land the patient on the deck of the tug boat, we took the decision to abort the rescue operation and request authorization to enter the port / harbor.

The reason why vessels don’t routinely come into port is because it is three times more expensive to berth a vessel than to do the disembarkation out at sea.

Considering that the cost of disembarking a patient at sea, never mind in the port, amounts to THOUSANDS of US dollars, triple this cost and your eyes water from the epigastric pains, nausea and chest pains caused by the cost of it all.

Remembering that I am working in one of the poorest countries in the world where poverty, malnutrition and preventable deaths are rife, and thanks to an angel donor-investor - Professor Ulrich & JOACHIM KUHLMANN STIFTUNG - we are saving lives by treating malaria for free for under $10 a patient.

The amount of patients we could treat with the money spent on one disembarkation for one patient is unthinkable.

Well, the epigastric pains, nausea and chest pains is what I felt when I asked both vessel captains to abort our rescue mission and ask authorization to disembark in the port for triple the $ amount.

The risk to our patient’s spinal fractures was too great and the sea swell too chaotic and energetic to allow for a safe lowering of our scoop (medical) stretcher, with our patient firmly strapped down by a Velcro spider harness, swaying airborne over the open sea between the two vessels in a net basket while I radioed them both from the open windy and salty vessel deck watching the dramatic situation unfold in front of me, to ask them both to abort our rescue mission.

ABOVE: Swaying between the tug and the vessel over the Madagascan waters.

We started our operation at 12h30, it was now fast approaching 16h00 and Port d’Ehoala, the port in Fort Dauphin on the south east coast of Madagascar, is only authorized and resourced for daylight operations, meaning we all had to get back to port before sundown around 17h00.

ABOVE: Heading to the vessel on the motorized Pilot Boat.

ABOVE: Testing our hand-grip strength (which is a sign of longevity btw - certainly for this case for all of us!). The strangest things come to mind in situations like these - on my way up I was asking myself, audibly, until what age I thought I could continue this job? Until I can’t hold my own body weight plus PPE I guess!

“We all” being a smaller motorized pilot boat, our rescue tug boat, and our medical team consisting of 3 doctors.

We winched our patient back to the vessel deck, unclipped him from the netting, and returned our patient to his room, making sure he had enough painkillers for the night, and left very reluctantly having not been successful at disembarking our patient with his fractured spine and limbs.

ABOVE: Our medical team all safely disembarked and heading back to Port d’Ehoala before sunset. We were all disappointed we were unsuccessful.

Sometime during Monday night we received authorization for us to allow the vessel into the port.

In parallel UNIVERSAL AIR EVAC Air Ambulance company were working throughout Monday to obtain the necessary Civil Aviation Authorizations to allow their Air Ambulance to enter Madagascan airspace to fetch our patient.

Coming back to why this disembarkation is one of my top 2 disembarkations of my medical career to date.

Firstly, this disembarkation was for a severely injured patient who required spinal immobilization and the risk of dropping him hard onto the deck of the receiving tug boat due to the chaotic swell, causing further harm and subsequently our patient never to walk again, was a real concern.

Secondly, it was technical requiring us to use the crane, medical stretcher, net, rope attachments, two vessels, two captains skillfully piloting their vessels next to each other in constant aqua chaos.

I am the first to admit that when I started doing vessel disembarkations in Fort Dauphin Madagascar 13 years ago, I was ignorant of the dangers.

Now I am wiser, purposefully slower, and calculated, during the rescue operations.

Having almost dropped my patient overboard a few years ago on my stretcher due to an error of attachment points to the scoop stretcher and trauma board, I now take the time before hoisting the patient to ANY height, to review EVERY point of the operation VERY VERY slowly, even if it slows our operation down to a halt, and I consider all worst cases scenarios, imagining myself in the stretcher, before giving the go-ahead to lift.

ABOVE: Lifting our patient for our first attempt at disembarkation. All points of attachment checked and re-checked, together with the hook which is the lifeline for our patient.

Thirdly, we managed, for the 2nd time only in my career, to do a port-to-airport transfer, with UNIVERSAL AIR EVAC Air Ambulance who’d landed 40 minutes before while we were disembarking our patient off the vessel in the port, giving their Air Ambulance time to refuel and be ready for take off shortly after handing over our patient to their awaiting Medical Team.

ABOVE: Berthing the vessel in Port d’Ehoala Fort Dauphin Madagascar on Tuesday morning.

Tuesday’s disembarkation worked

like

clockwork!

And anyone who has been involved in emergency medi-vacs can say that there are those transfers which go….not like clockwork, and those that go….

AWESOMELY.

This one -

WAS AWESOME!

There are so many points where it could have gone very VERY wrong and this should never be underestimated.

A big thanks to all those directly involved, which included the CAPTAINS and the CREWS of the vessel and the tug for all their effort and hard work.

Thank you to the OWNERS, P&I CLUB and ELTVEDT & O’SULLIVAN for being reactive and obtaining and giving the authorizations promptly - I am sincerely sorry (with associated epigastric pains, nausea and chest pains on all your behalves) for the cost of this operation, but it could not be avoided.

Thank you to our MADAGASCAN AUTHORITIES (Ministry of Health, Civil Aviation Authorities, Port Authorities and anyone I may have accidently left out) for giving their authorizations for the disembarkation and subsequent Air Ambulance medi-vac directly to South Africa, and for not having to fly via Antananarivo, which has been the law ever since the smuggling-gold-incident during Covid.

Thank you to PORT D’EHOALA, QMM RIO TINTO & STRANG who tirelessly assisted with both operations on Monday and Tuesday.

Thank you to the TOLAGNARO (Fort Dauphin) AIRPORT STAFF (below) who assisted the Air Ambulance with the necessary.

Thank you to UNIVERSAL AIR EVAC and the MEDICAL TEAM for your reactivity, efficiency and professionalism.

Thank you to our FORT DAUPHIN FIRE DEPARTMENT for their Ambulance (which was donated from France).

ABOVE: Loading the patient from our FORT DAUPHIN FIRE DEPARTMENT ambulance to the UNIVERSAL AIR EVAC Air Ambulance - Port-to-Airport transfer!

ABOVE: UNIVERSAL AIR EVAC Air Ambulance, patient handed over, loaded and ready for take-off (BEST FEELING EVER - usually after this I need to sleep for 12 hours!)

To ALL THOSE UNSEEN who worked tirelessly through Sunday and Monday night and day behind their computers in Europe, the East and beyond to make this rescue mission possible, THANK YOU, we could not have done it without you.

Last but certainly not least, thank you to DR ROLLAND, DR HIGOR and our CENTRE MEDICAL DE TAOLAGNARO Team for your huge efforts, risking your own safety to disembark our patient.

ABOVE (left to right): Dr Higor, Dr Rolland and I heading to the vessel on Monday to disembark the patient.

Our patient landed safely in Johannesburg South Africa, he was operated the following day and the prognosis is hopeful!

It took international team work, logistics and coordination to make this happen.

Kind and mad regards,

Mad Madagascan Mum & Medic,

Jane