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Prehospital care

Should helicopters have a hoist or long-line

capability to perform mountain rescue in the UK?
John Ellerton,1 Hannah Gilbert2
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1

Medical Officer Mountain

Rescue (England and Wales),
member and vice president of
ICAR Medcom, Penrith, UK
2
Penninsula Medical School,
Plymouth, UK
Correspondence to
Dr John Ellerton, Pinfold,
Nicholson Lane, Penrith,
Cumbria CA11 7UL, UK;
ellerton@enterprise.net
Accepted 28 September 2010
Published Online First
28 October 2010

ABSTRACT
Objectives To determine how far mountain rescue
casualties in the UK have to be carried and the impact of
adding a hoist or long-line to helicopters operating in
this environment.
Design Retrospective analysis of mountain rescue
incidents.
Setting Pre-hospital, mountain rescue service based in
Patterdale, English Lake District.
Participants Casualties between 1 January 2006 and
31 December 2008 that required stretcher evacuation.
Casualties directly accessible by a road ambulance were
excluded.
Main outcome The horizontal and vertical distance of
the evacuation route to an agreed helicopter-landing site,
and its technical character. Direct access to the incident
site by a helicopter with a hoist or long-line capability
was determined.
Results 119 casualties were identified. The median
horizontal and vertical evacuation distances were 250 m
and
30 m respectively. The proposed manual carrying
distances were #100 m in 33/119 (28%), between 101
and 400 m in 60/119 (50%) and >400 m in 26/119
(22%) of casualties. 13/119 (11%) casualties were in
a position where direct access to the incident site would
not have been possible with a helicopter equipped with
a hoist or long-line. 31/119 (26%) casualties required
a technical evacuation with the use of ropes.
Conclusions Using the criteria that all casualties
requiring a technical rescue or >400 m evacuation route
to an appropriate helicopter-landing site, 34% of
casualties could have been rescued using a hoist or
long-line with an expected reduction in the pre-hospital
time. Helicopters working in UK mountain rescue should
be equipped to international standards.

developed by consensus within the International

Commission for Alpine Rescue (ICAR) and its
medical commission (ICAR Medcom), they have
not been adopted in the UK.8
In mountainous terrain, a suitable helicopterlanding site may not be close to the incident site.
Thus the transfer from incident site to helicopter
usually involves either:
1. Carrying the casualty on a stretcher. This is time
consuming and requires a team to carry the
stretcher; or
2. Using a hoist or long-line to directly bring rescue
personnel and equipment to the incident site
and then evacuate the casualty.
(Note that the term hoist is used instead of the
more commonly used UK term winch, as it is
more internationally accepted for a vertical motion;
images of deploying a rescuer using a hoist, the
helicopter attachment for a long-line and use of
a long-line are available as online supplementary
les at http://emj.bmj.com.)
Search and Rescue (SAR) helicopters in the UK
and some HEMS helicopters in other areas of the
world use a hoist. Long-line rescue, where a xed
rope is slung from the underside of the helicopter, is
used in many countries where smaller rescue helicopters are the norm. In the UK, HEMS helicopters
are not equipped with either hoist or long-line.
This paper addresses the question: Should helicopters have a hoist or long-line capability to
perform mountain rescue in the UK? by analysing
the evacuation routes of casualties rescued from the
140 km2 area of the English Lake District that
forms the primary operational area of the Patterdale
Mountain Rescue Team (PMRT).

METHODS
INTRODUCTION
In the UK, volunteer teams carry out inland
mountain rescue under the auspices of the police.
The teams are well organised, equipped and
trained.1 They attend approximately 950 incidents
a year; in 32% assistance from a helicopter is
received.2 3 Though the majority of injuries and
illnesses are non-life threatening, 3.6% of casualties
have major trauma (Injury Severity Score >15).4 In
the last 5 years, there has been an expansion of the
helicopter emergency medical services (HEMS) into
upland areas. This new asset has been used by
mountain rescue and effective working relationships have subsequently formed in some regions.
The safety of HEMS and the medical benet it
affords to patients have been studied but assessing
their value and suitability in mountain rescue has
not.5e7 Though international guidelines for the
use of helicopters in mountain rescue have been
56

A retrospective analysis of all PMRTs callouts

between 1 January 2006 and 31 December 2008
(3 years) was carried out. The data was sourced
from the Mountain Rescue (England and Wales)
incident log and PMRT annual reports. Callouts
outside of PMRTs primary area of operation,
casualties directly accessible by road ambulance or
who self-evacuated and searches for missing
persons who where either never found or escorted
from the fell without the need for medical assistance, were excluded. In incidents where multiple
casualties required medical attention, each casualty
was analysed independently. An appropriate evacuation route to a helicopter-landing site was agreed
between the authors and members of PMRT, and
plotted on the map. Helicopter-landing sites were
dened as areas of >50 m diameter at <158 declination with no overhead hazards and having
a suitable at rm surface for landing. The
Emerg Med J 2012;29:56e59. doi:10.1136/emj.2010.105403

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Prehospital care
majority of sites had previously been used for helicopter landing;
the remaining ones were checked by direct observation for suitability by the authors. The authors and members of PMRT
reviewed each incident site to assess: (a) whether extricating the
casualty with a hoist or long-line was possible taking into
account the local topography and overhead hazards such as trees,
power cables, and so on; and (b) whether technical assistance
using ropes to safe guard the evacuation would have been needed
in summer conditions. Results were calculated using Microsoft
Excel 2004 for Mac, and are given as median values in metres with
the minimum (Q0), 1st quartile (Q1), 3rd quartile (Q3) and
maximum (Q4) in parentheses and mean value (if appropriate).

RESULTS
In all, 166 casualties were identied. The following casualties
were excluded from the analysis: four were outside PMRTs
primary area of operation; three were accessible to a road
ambulance; 34 were found uninjured after a ground search and
six self-evacuated. Thus the number of casualties that could
potentially have required helicopter evacuation was 119. HEMS
were involved during the rescue of 32 of the casualties and SAR
helicopters in 29, of which 22 were hoisted. The role (uplifting
rescuers and equipment, medical treatment, evacuation, etc)
fullled by HEMS could not be accurately determined from the
incident reports.
The horizontal and vertical distances from the casualty site to
the proposed helicopter-landing sites are shown in a scatter
plot (gure 1). The median horizontal and vertical distances
were 250 m (Q050; Q1150; Q3550 and Q41500) and

30 mdminus gures represent descent from the incident site
(Q0
550; Q1
105; Q30 and Q4+45) respectively. Those
casualties whose proposed evacuation route involved using the
rescue teams boat or Land Rover ambulance for all or part of it
are indicated. The proposed manual carrying distances were
#100 m in 33/119 (28%), between 101 and 400 m in 60/119
(50%) and >400 m in 26/119 (22%) of casualties.
Of the 119 casualties, 13 (11%) were assessed as being in a
position where, because of tree cover, it was unlikely that a hoist
or long-line rescue from the incident site could be used. However,
nine were by the lake and evacuation by rescue team boat or road
ambulance could have been carried out without introducing
signicant time delays. Obligatory delays from stretcher carrying
would have been unavoidable in 4/119 (3.4%) casualties.
In all, 31/119 (26%) casualties were assessed as requiring
a technical evacuation with the use of ropes under summer
conditions. Only one of these casualties was not in a position
100

directly accessible by hoist or long-line. The median distance of

stretcher carrying in casualties requiring a technical evacuation
was 500 m, (Q00, Q1300, Q3600, Q41300). By comparison, the median distance for those evacuated from non-technical ground was 150 m, (Q00, Q1100, Q3300, Q4900). A
histogram showing the distribution of technical and non-technical rescues with distance from the proposed helicopter-landing
site is shown in gure 2.

DISCUSSION
A casualty injured on the mountains can be accessed and evacuated in a number of ways depending on a wide range of factors
as listed in table 1. When the speed of evacuation is paramount,
manual carrying of a stretcher over signicant distances introduces large time delays, particularly when technical ground has
to be negotiated.
The deployment of HEMS helicopters in UK mountain rescue
over the last few years has reduced access and evacuation times
but effectiveness is limited by their need to land for rescue
personnel to embark/disembark. Frequently the landing site is
a signicant distance from the casualty. In this study, we have
taken one of the busiest mountain rescue teams and assessed
how far the casualty has to be manually carried to a realistic
helicopter-landing site. At rst glance, the median horizontal
distance of 250 m does not seem too onerous but there is a large
distribution with 22% (29/119) of casualties being over 400 m
from the proposed landing site. Carrying a casualty (weighing
60e100 kg) packaged in a vacuum mattress (7.5 kg) and rigid
stretcher (8 kg) is hard work on all but the smoothest terrain. In
addition, a casualty sleeping bag, splints, oxygen cylinders and
monitors may be added, giving a realistic load of 80e120 kg.
Traditionally in terrestrial mountain rescue, six or eight persons
rotating regularly do this task, while a HEMS crew consists of
a maximum of four persons. How far is it reasonable to carry
a stretcher? Using HSE manual handling assessment charts, only
casualties weighing <70 kg would be suitable for a two person
team, making a four person team preferable for almost all
casualties.9 The US Army Research Institute of Environmental
Medicine study recommended that a 4-person male team should
carry a similar load for no more than 5 min.10 At an average
walking speed of 4.5 km/h, this equates to 375 m. Over uneven
ground the distance would be considerably reduced. In addition,
in the US Army study, ne motor skills (shooting at a target)
deteriorated after stretcher carrying; perhaps this activity is also
not ideal for a helicopter pilot.
In many places in the world, where distances to and from the
incident site can measure tens of kilometres and thousands of
vertical metres, mountain rescue is carried out almost exclusively
by HEMS-type helicopters using a hoist or long-line. Would such

-100

35

-200

30

Non-technical rescue (n = 88)

25

Technical rescue (n = 31)

Number of casualties

Vertical distance (m)

-300
-400
-500
-600
200

400

600

800

1000

1200

1400

1600

20
15
10
5

Horizontal distance (m)

0

Manual carrying

Mountain Rescue Ambulance

Boat

101-200

201-300

301-400

401-500

501-600

601-700

701-800

>801

Distance (m)

Figure 1 Scatter plot of the horizontal and vertical distance from

incident site to the proposed helicopter-landing site (n119; area of dot
proportionate to number of casualties).
Emerg Med J 2012;29:56e59. doi:10.1136/emj.2010.105403

Figure 2 Histogram of manual carrying distances to proposed

helicopter-landing site (n119).
57

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Prehospital care
Table 1 Factors influencing the method of access and evacuation of
mountain rescue casualties
Location

Environmental
Casualty
Operational

Distance from a road including terrain of access and egress routes

(ie, water hazards, technical ground requiring ropes)
Local terrain including dangers (ie, avalanche, rock fall)
Weather (cloud base, wind, precipitation, altitude)
Daylight/night
Life- or limb-threatening injuries or illness
Availability and capability of a search and rescue resource

an asset be useful in the less mountainous UK? As shown in

gure 2, many of proposed evacuation routes involve an element
of technical rescue where ropes are used to protect the casualty on
the stretcher and the rescue team from danger. Such techniques
require additional skilled personnel and inevitably increase the
evacuation time.
Our analysis shows that 13/119 (11%) casualties were in
a location where direct access to the incident site was unlikely
even if the helicopter was equipped with a hoist or long-line. Of
these, nine were close to the lakeshore, and a timely rescue could
have been carried out by use of the rescue boat or mountain
rescue ambulance. In addition, one casualty could have accessed
quicker by lifting the rescue team to within 20 m of the casualty.
Thus only three (2.5%) casualties would not have beneted
from acquisition of a hoist/long-line should its use have been
appropriate.
Using a long-line introduces a number of delays. Initially the
helicopter has to land to rig the long-line, the helicopter then
takes off and the rescue personnel are suspended from the longline and own to the casualty. During evacuation, the reverse
occurs. A minimum of two landings at an appropriate site has to
be made before the casualty is inside the helicopter. If a hoist is
used on a small HEMS helicopter, it is very difcult to safely
transfer a casualty on a stretcher directly into the helicopter
when airborne; the helicopter frequently lands at an appropriate
site having picked up the casualty to allow the casualtys transfer
from hoist to on-board. From our analysis, if evacuation routes
with technical difculty and/or >400 m horizontal stretcher
carry were considered appropriate for use of a hoist or long-line
then 41/119 (34%) of casualties would have used this technique.
Reducing the maximum horizontal carrying distance to 200 m
would increase the number of casualties to 60/119 (50%).
Is the cost of equipping the helicopter and training its staff in
the use of hoist/long-line realistic? HEMS in the UK are largely
funded by charitable donations and pilots are less familiar to
external load carrying than their European colleagues. Even in
the most mountainous areas, the proportion of mountain rescue
to total HEMS ights is small and the number of casualties with
time critical injuries or illnesses is even smaller. In the UK, only
a handful of HEMS operate in the mountains; expertise will
need to come from abroad. The obligatory extra weight of
a hoist or long-line will have implications to the performance
and load capacity of the helicopter during all missions.
In this analysis, hoists and long-lines have been considered as
equally applicable in terms of accessing the casualty. However,
many factors such as helicopter type, door opening mechanisms,
weather conditions, as well as pilot and HEMS crewmember
experience will inuence which would be the preferred method.
Some countries, for example Austria, exclusively use long-line
techniques. These have the advantage of central loading
allowing the helicopter to maintain full manoeuvrability and the
load carrying capacity can be up to six persons. In additional, no
additional HEMS crew is needed and the time (if any) in hover
is minimised. The latter is often the deciding factor in a mission
58

as safety margins are greatly reduced when helicopters are

hovering. Hoists are favoured when the helicopter is bigger (eg,
EC145), for rescues on less steep ground and where the load is
relatively small (eg, rescuer and casualty only). However, to
operate the hoist either an extra HEMS crewmember has to be
carried taking the staff compliment to four, or the medical team
at the incident site is reduced to one, impacting on casualty care.
In addition, the effect of increased helicopter rescue on the
current UK mountain rescue service is difcult to quantify. Its
volunteers may become deskilled and less motivated should
smaller HEMS units located at fewer bases become the norm.
Like HEMS, mountain rescue is funded by charitable donations
largely triggered by rescues; a fall in funding may result. This
may be detrimental to casualties trapped in the mountains in
poor weather.
HEMS has extended in to mountain rescue at a local and
regional level without critical national oversight giving rise to
concerns that mirror those expressed by Nicholl et al and Black
et al in 2003 and 2004.5 6 The expansion of HEMS, its accident
rate and associated high mortality have been recently highlighted.11 The mountain environment is characterised by many
of the factors (wind, cloud, remote landing sites) associated with
these accidents. A non-systematic dataset of 130 rescuers deaths
in countries belonging to the International Commission for
Alpine Rescue showed that 29% occurred in helicopter accidents.12 There is no evidence that hoist or long-line procedures
increase risk, indeed by reducing impetuous to land as close to
the casualty as possible, risk may be reduced.
Multiple agencies, both statutory and voluntary, are involved in
Search and Rescue. Coordinating an emergency response
and deploying the most appropriate asset maybe hampered by the
many pathways available to the statutory agencies and their
knowledge of mountain rescue. The UK SAR Strategic Committee
has recently updated agreed standard operating procedures for the
deployment of air assets that recognise the limitations of HEMS
helicopters. These were implemented on 1 of April 2010; all
services must follow these to ensure an effective service.13
By using a combination of both HEMS and SAR helicopters
and terrestrial mountain rescue teams, the UK may have achieved
a safe, appropriate and cost effective model for rescue from
remote places without the need to duplicate hoist techniques.
However competitiveness between organisations and failure
to recognise limitations can compromise the service provided
to the casualty. Robust inter-agency clinical and operational
governance procedures are needed.

Limitations
Our analysis is based on a number of premises. These are that
the:
< Weather is suitable for the helicopter to y to the incident
site. This is often not the case; not infrequently, the
helicopter cannot proceed into the high mountain areas
because of cloud cover. In addition, HEMS helicopters in the
UK are rarely equipped with night-ying aids and so are
limited to daytime hours.
< Helicopter landing sites were appropriate. Helicopters can
land in smaller areas than our denition of a landing site
particularly if rotor blades are kept turning and the casualty
hot-loaded. However the inherent risks are increased.
< Medical condition of the casualty warrants the use of
a helicopter.8 In the PMRT area, casualties falling from the
Helvellyn edges are likely to have the most severe injuries but
in the absence of an accurate diagnosis this could not be
factored into the analysis.
Emerg Med J 2012;29:56e59. doi:10.1136/emj.2010.105403

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Prehospital care
< SAR helicopters are equipped with hoists and meet all the

Competing interests None.

International Commission for Alpine Rescue recommendations for helicopters in mountain rescue. However, they are
a limited resource and are stationed over 30 min ying time
from Patterdale. In contrast, the HEMS base is within 10 min
ying time of the casualty sites. SAR helicopters in the UK
are currently undergoing a harmonisation and replacement
programme. This may impact upon service provision in the
future.14
< Findings may be limited to the PMRT area. Similar
topography exists in the central Lake District but in other
areas, such as the Pennines and the Peak District, available
landing sites may be much nearer the incident site. In North
Wales, a SAR helicopter base is within 10 min of ying time
of the Snowdonia National Park.

Provenance and peer review Not commissioned; externally peer reviewed.

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CONCLUSION
In the PMRT area, it would appear advantageous to rescue
34e50% of casualties directly from the incident site using a hoist
or long-line. Only a few casualties are in positions where the
technique would not be possible. A hoist/long-line capability can
be expected to signicantly shorten many rescues, resulting in
casualties arriving in hospital quicker. If this conclusion can be
generalised, helicopters working in UK mountain rescue should
be equipped with such a capability in line with international
recommendations. Both the suitability and effectiveness of
HEMS-type helicopters would be enhanced if either technique
were available. This study cannot quantify how many casualties
and what time saving would accrue, but it highlights the issues
around using helicopters in mountain rescue, which should be
considered as the service develops.
Acknowledgements The authors acknowledge the help of members of Patterdale
Mountain Rescue Team, Ged Feeney (Mountain Rescue England and Wales
Statistics Officer) and Robin Harvey of Harvey Maps and thank Dr Stephen Hearns,
Consultant in Emergency and Retrieval Medicine, Glasgow and Dr Olivier Reisten,
Alpine Rescue Center, Zermatt, Switzerland for their comments.

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59

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Should helicopters have a hoist or 'long-line'

capability to perform mountain rescue in the
UK?
John Ellerton and Hannah Gilbert
Emerg Med J 2012 29: 56-59 originally published online October 28,
2010

doi: 10.1136/emj.2010.105403

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