Exploring of Offshore Medical Emergency Response System Challenges in Oil and Gas Environment

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

J. Environ. Treat. Tech.

ISSN: 2309-1185

Journal web link: http://www.jett.dormaj.com

Exploring of Offshore Medical Emergency Response

System Challenges in Oil and Gas Environment

Ahmad Sufian Bin Huzaini, Roslina Mohammad*, Norazli Othman and Zuritah A.Kadir

Razak Faculty of Technology and Informatics, Universiti Teknologi Malaysia, 54100, Jalan Sultan Yahya Petra, Kuala Lumpur, Malaysia

Received: 29/07/2019

Accepted: 10/12/2019

Published: 20/02/2020

Abstract

This paper explored the challenges present in the offshore medical emergency response (MER) system from the perspective of offshore

medics by reflecting on their experiences in handling delays in emergency medical evacuation cases. We conducted qualitative interviews

using the critical incident technique method. The participants recruited using the purposive sampling method comprise of 8 experienced

offshore medics working on various types of oil and gas offshore facilities across the Malaysian Offshore. Data analysis was performed using

qualitative content analysis. The in-depth individual interviews have resulted in the identification of 114 critical incidents for analysis. Seven

themes emerged on MER system challenges including communication, decision making, facility layout, logistics problems, offshore medic

responds, SOP and protocols as well as weather conditions. Decision-making was found to be one of the major challenges. The results suggest

that the MER system needs to be revised in its current practice and we have proposed revisions to the industrial guidelines on response time

tiers. This study has added a new understanding on the challenges found in the MER system from a different perspective.

Keywords: Abrasive blasting, Control measures, HIRARC, Pressure vessel fabrication plant, Risk assessment

Introduction¹

The necessity of the Medical Emergency Response (MER)

system across the world, the current MER system practiced in

Malaysian Offshore is similar to the reported literature [5, 6]. The

process of evacuating the injured/ill person (IP) in emergencies

system in reducing health, safety and environment risks in the

offshore work environment has been highlighted. The offshore

work environment is categorized as a high risk to the health,

safety and environment of workers due to the nature of this

environment as it is located at remote areas and has dynamically

hazardous operations [1,2]. These mean that offshore workers do

not have immediate access to healthcare facilities especially in

medical emergencies while the risks of injury and illness are well

known. Therefore, it is an expectation in the offshore oil and gas

industry that each operation site should have a MER system in

accordance to industry guidelines regardless of whether specific

country legislation requirements exist [3,4]. However, having a

MER system in place is futile without effective implementation.

Thus, the major players in the global oil and gas industry have

continuously improved their MER system to ensure system

effectiveness. The changing trends of injuries and illnesses,

advances in medical treatment and delays in emergency medical

evacuation (medevac) have urged the revision of the MER system

for continuous improvement [5, 6, 7, 8]. The revision lead to the

identification of challenges in implementing the MER system that

were categorized as communication, personnel skills and

competency, decision making, logistics problem, equipment and

clinic facility; standard of procedure (SOP) and protocols.

(

medevac) is outlined by a tiered response time starting from the

medical event occurring at an offshore facility until the IP arrives

at a shore-based medical facility.

Delays in emergency medevacs from the standard expected

response time remains a concern especially for companies

operating in the Malaysian Offshore. The delay in medevacs not

only reflects on the ineffective system in place, it also indirectly

incurs high costs to the operations due to a possible decrease in

survival rates as well as longer recovery times and high

compensations. Even if studies on indirect cost are difficult to

conduct, a few studies on the direct cost of medevacs have been

reported. Based on cases that were collected retrospectively

between 2008 and 2012 from 102 oil rigs and platforms operating

in the US Gulf Coast, it was revealed that an average cost of

4,333 to 54,167USD has been charged by three different

helicopter providers per medevac (2 to 3 hours flight) [8]. On the

other hand, a total of 2.81 million in cost was involved for 2982

medevac cases that were recorded between 1989 and 1992 [9]. Of

that total cost, musculoskeletal (1,251,020USD), respiratory

(399,730USD) and injury (268,380USD) cases were the top three

highest costs incurred by the company. It is expected that the

higher costs will be revealed if indirect costs such as the

replacement of the medevaced worker, lost man-hours and

compensation were included in the calculation.

Fig 1 illustrates the general MER system practiced by oil and

gas companies operating in the Malaysian Offshore. Since the

international oil and gas companies standardized their MER

Corresponding author: Roslina Mohammad, Razak Faculty of Technology and Informatics, Universiti Teknologi Malaysia, 54100, Jalan

Sultan Yahya Petra, Kuala Lumpur. Email: mroslina.kl@utm.my.

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

The challenges of the MER system have been investigated

from an administrative perspective, but little is known regarding

the experience of offshore medics in MER system challenges

when handling delayed emergency medevacs. As primary

healthcare providers in the field, offshore medics are in a unique

position in the MER system [3]. Hence, they are an important

source of information in understanding the challenges of the MER

system that leads to delays in medevac.

We used semi-structured questions to collect the critical

incidents experienced by the participants. This will allow

participants to provide information as detailed as possible. The

limitation in semi-structured interviews is the difficulty to code

the transcript, but this will able to reduce researcher bias [14]. We

constructed the questions based on relevant literature and the

researcher’s experiences in the field.

To draw out the participant’s focus and encourage them to

express a detailed description of the topic, we asked questions as

follows; ‘In this interview, please assume that I am not an offshore

medic and I do not know anything regarding your job. Think of

recent emergency medevac cases in which you handled the case

and it resulted in delayed evacuation.’ Then we proceed by

addressing the pre-constructed questions as follow:

Choose one of the cases and describe the event in as

much detail as you can recall.

Based on this case, what are the complaints raised by

the client or other related parties post-medevac, if

any?

What are the other delayed emergency medevac cases

within the past 3 years that you are willing to share?

(Back to question 1).

Consequently, we asked careful probing questions to

encourage the participants to express in-depth and recall the

critical incident event but we did not ask leading questions. For

example ‘what time did the case happen?’ and ‘please describe

more on...?’ Yet, the participants were not asked to interpret the

situation but only to tell the whole story.

.1 Participants

We recruited the participants using a purposive sampling

strategy. Offshore medics with at least three year working

experience with experience in handling delayed emergency

medevacs were considered to be eligible to participate in this

study. The potential participants were extracted from email and

telephone contacts known to the researcher. According to Burns

et al.[15], participants in CIT studies are more willing to share

information with people who are familiar with them compared to

strangers. Then, we sent them an email of invitation with the

inclusion and exclusion criteria. A returned signed consent form

was considered as volunteering to participate in the study. The

participants who volunteered were asked to choose the date, time

and the preferred method of interview (telephone or face-to-face).

Eight offshore medics volunteered to participate in this study.

The participants consisted of five medical assistants and three

registered nurses, all of whom had diploma qualifications. All

participants possessed valid skills-competency certificates in

Advanced Cardiac Life Support and International Trauma Life

Support as a standard work requirement. Three participants were

working on production platforms, four on drilling rigs and one on

the work barge. The maximum population on board (POB) for

these facilities ranged between 60 and 148 (mean=106,

mode=110). The participants were all male with ages ranging

between 28 and 40 years old (mean=34). Additionally, the

participants’ working experiences as offshore medics were varied

between 4 and 10 years (mean= 6).

Fig. 1: MER System

This study aims to explore the challenges of the MER system

from the perspective of offshore medics’ through reflections of

their experiences in handling delayed emergency medevac cases.

We gained a new understanding of the MER system challenges

from the study findings and it can be useful for improving the

industry practice in MER system implementation.

. Methodology

In this research, qualitative interviews were conducted using

the critical incidence technique (CIT) to collect retrospective

cases from experienced offshore medics. Since it was introduced

in 1954, CIT is widely used in service research and health care

especially to improve systems and solve practical problems [11,

2].The principle of CIT is to capture stories from the participants

who have experienced or observed the events in search of the

essence of the problems to be solved [13].

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

.2 Ethical Considerations

This study gained ethical approval from the Ministry of

their current practice. This initial finding has established two

points. First, it confirms that the current MER system practiced in

Malaysian offshore is primarily identified from literature. Second,

it can reduce bias in analysing data collected from participants as

differences in the MER system practiced can offer alternative

explanations on the critical events being investigated.

Health Malaysia, Medical Research and Ethics Committee. The

participants involved in this study were informed regarding the

purpose of the study and their confidentiality were assured. Cases

were identified using code numbers (e.g., C5).

.3 Data collection

2.4 Data Analysis

The data collection was conducted between December 2015

We conducted data analysis using a conventional content

analysis approach [16]. Initially, we determined that the unit of

analysis is the critical incident itself. In this study, critical incident

means any event or combination of events that contributes to the

delay in emergency medevac. This is appropriate in keeping with

the current concept of risk management as placing emphasis on

shared responsibilities towards improvement instead of the

culture of blame [17]. Therefore, it is believed that multi-factors

instead of a single factor contribute to the occurrence of any

incident.

Next, the interview transcripts were read through repeatedly

to get a sense of the whole data with an open mind. Then, the

critical incidents that are the units of analysis were selected from

the interview transcripts to be included for analysis. To do that,

the first author (ASH) independently coded the interview

transcripts by repeated and careful reading. Finally, 114 critical

incidents were found for analysis. Examples of data analysis are

illustrated in Table 2. After completing the coding process, the

first author reviews the existing codes to reflect on the developing

ideas.

and March 2016. We conducted 5 face-to-face interviews and 3

telephone interviews. The critical incidents we enquired about

were the most recent and happened within the past 3 years.

However, the accuracy of the critical incidents reported did not

only depend on the time they happened but also depends on the

level of detail in the information being offered [13]. In this study,

the first author (ASH) who is a registered nurse and experienced

offshore medic was the interviewer. The data collected were

recorded using either an audio recording device or telephone call

recorder application as well as note taking.

The interviews have resulted in a collection of 11 delayed

emergency medevac cases that met the study criteria for analysis.

The cases did not involve non-routine activities (e.g., confined

space victim, man overboard) which add an extra 20 minutes

response time for off shore medics. The information in Table 1

presents the case characteristics.

Table 1: Case characteristics

Case

Types

Type of

Facility

No.

Offshore Location

Table 2: Example of data analysis

Heart

Drilling

Kerteh

Miri

Critical Incident

At 1500 hours, almost 2 Delay

hours from the case client

Code

Category

Stakeholders Decision

decision making

Theme

Platform

starts,

I asked OIM decision

Neurology Platform

Neurology Drilling

Kota Kinabalu

Kerteh

regarding the status of

medevac. So, waiting for

medevac confirmation

from town. They still not

giving the confirmation

yet. (C4)

Injury

Heart

Injury

Drilling

Miri

Work

barge

Kuala Terengganu

Kota Kinabalu

Kerteh

Drilling

Platform

Subsequently, the data analysis proceeds by sorting the 114

critical incidents into sub-categories and categories, which

constitute the manifest content. This was done by comparing the

critical incidents based on differences and similarities. At this

point, both authors (ASH, RM) revised the tentative categories

before the confirmed categories were sorted into themes. We used

NVivo 10 software to aid the data analysis process and facilitate

in tracking the original data.

Kerteh

Drilling

barge

Bintulu

Drilling

Labuan

Finally, we conducted a second round of interviews with the

participants to validate the relevancy of tentative categories and

themes generated from interview transcripts on the first interview.

This was done by randomly selecting 3 participants from the first

interview. The participants agreed on the accuracy of the

information provided from the first interview and the critical

incidents identified by the researcher. Furthermore, they did not

find any missing information and did not offer additional

information. Lastly, the participants agreed on the relevancy of

the critical incidents categorization and themes emerged which

represented their experiences. Therefore, no amendments were

required after the second interview.

The 11 cases are classified into 5 medical emergency cases

and 6 injury cases. To maintain confidentiality, the information

provided in Table 1 is purposely organized without synchronizing

the information between the different columns. The cases that had

happened at various offshore locations are representative enough

of the Malaysian offshore in which the oil and gas exploitation

activities are being carried out.

During the interview session, we showed the participants the

general MER system in Fig 1. Then, they were required to reflect

whether they are practicing a similar MER system. All

participants confirmed that the general MER system is similar to

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

(

TMS) and prepare the paperwork. One of the participants

Results and Discussion

The MER system challenges experienced by offshore medics

described:

elicited through reflections on their experience in handling

delayed emergency medevac cases were developed into seven

themes. The themes were communication, decision making,

facility layout, logistics problem, medic response, SOP and

Protocols; and weather conditions.

‘

After I have completed the dressing, then only OIM [offshore

installation manager] and safety officer came. They insist want to

see the wound. What a nonsense work like that. They want me to

remove the dressing…I told them that I have took the photos and

they can look at it. Nope, they still want to see the wound. So, I

remove it.’ (C9)

The case rate was calculated and we used a rate of 25percent

to determine the significant themes as previously recommended

[

17]. The rate was calculated by identifying the total number of

cases citing the particular theme, and then it was divided with the

total number of cases. Based on case rates in Table 3, it was

revealed that six themes are significant except for the theme

‘weather condition’. The model of MER system challenges was

developed and illustrated in Fig 2.

Table 3: MER system Challenges Themes, Case Rates and

Critical Incidents

Case N of

Rates Critical

MER System

Challenges Themes

N of Cases

Incidents

Communication

Decision Making

Facility Layout

Logistics Problem

45.5

100

36.4

81.8

Offshore Medic

Responds

54.5

SOP and Protocols

Weather Condition

45.5

18.2

Total Critical Incidents

114

*Significant rates at 25%

.1 Communication

The communication theme covers all critical incidents related

to instructions, changes, telephone, email, and radio and

communication system. When there were changes in the MER

system, the changes were ineffectively communicated or not

communicated before the emergency medical event happened.

The changes were only informed when the event happened, right

at the moment when the medics were handling the case. One of

the participants reflected.

Fig. 2: MER system challenges model

Additionally, there were times when the communication

system at the facility failed entirely or the telephone connection

was interrupted during conversation with TMS. However, critical

incidents involving communication systems in this study only

happened on mobile offshore facilities such as drilling rigs and

barges. One of the participants reflected:

‘

After I called topside, then company man [operator company

representative] came. He said I have to call Clinic Y… By right,

I don’t have to call Clinic Y according to MERP.’ (C8)

Another communication issue was inappropriate instructions.

Critical incidents include, when there were unnecessary and

irrelevant instructions given, resulting in the delay of the

emergency response. In one occasion, the offshore medics

received inappropriate instructions from the onsite supervisors.

For example, the OIM asked the medic to expose the injured limb

after it was treated. That meant that the procedure to had to be

repeated, to re-dress the injured limb while the offshore medic

was supposed to communicate with Topside Medical Support

‘Half way conversation with topside, the line broken…Again the

line was unclear and broken.’ (C6)

3.2 Decision making

Decision making forms the major theme in offshore MER

system challenges. Critical incidents in this theme were found in

all 11 cases (100% case rate). The theme was divided into two

main categories; stakeholders’ decision and TMS decision.

The stakeholders’ decision category emerged from cases that

revealed factors such as avoiding recordable cases, bureaucracy,

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

confirmation time and IP employment category; that has delayed

the final decision time in activating the emergency medevac.

Stakeholders consist of the operator companies, contractor

companies and the IP’s employer. Especially when the emergency

medical event involved workers who were on duty, the

stakeholders were careful in making the decision to approve the

treatment and emergency medevac decision made by TMS. The

bureaucracy was demonstrated when multiple stages of

confirmation are required to activate the emergency medevac. For

example, in the drilling facility case, once the TMS doctor has

made a decision, it needs to be confirmed by the client medical

advisor (drilling contractor company), rig manager, OIM and

company man.

The limited facilities at the offshore clinic impose challenges

for offshore medics to respond to medical emergencies in an

efficient manner. Described as congested with clinic items and

equipment, the medics had trouble moving and allocating

equipment even at the best-organized clinics. Some of the clinics

were set up by separating the sick bay with the clinic’s

administrative facilities. In this situation, the medic needed to

leave the IP to complete paperwork in the room next door which

surely consumed time. One of the participants described:

‘The sickbay and office is separate. After attending to the patient,

I have to leave for paperwork in the next room. Definitely not in

the same room. That’s the problem.’ (C1)

The stakeholders’ decisions were influenced by the IP

employment status as well. The status of the IP who are contractor

employees or employees in lower positions might negatively

affect the stakeholders’ decision-making time. According to one

of the participating offshore medics:

3.4 Logistics problems

Logistics problems form the second largest theme (81.8%

case rate). The logistic coordination is outsourced to agent

companies and therefore, it depends on the capacity of the agent

company to respond to emergency medevac cases. There were

delays in logistics arrangements which were considered as critical

incidents. This was determined by the timeline provided from

participants’ accounts or directly mentioned by the participants.

One of the participants reflected on the case:

‘

Moreover, he is floor man. Not important position, though. So

they took it for granted.’ (C10)

Furthermore, TMS was found uncertain in making decisions

for emergency medevacs. The medical information provided by

offshore medics was repeatedly requested. Additionally, the TMS

doctor asked to provide more information even though it was not

essential information needed to determine the emergency status.

With the time running, the offshore medic was trying to convince

the TMS on the emergency of the situation. On the other hand, the

TMS asks the offshore medics to wait for their feedback while the

case is discussed with the medical specialist team. One of the

participants reflected:

‘At around 1630 hours, which is ETD [expected time departure]

on earlier plan, received call from medevac team. They update

new ETD time around 1730 hours.’ (C4)

In this theme, helicopter delays are the most frequent critical

incidents identified (n=13). It means that the helicopter did not

arrive to the offshore facility according to its expected time of

arrival. The delays ranged from several hours to almost 24 hours.

Additionally, when the helicopter transporting the IP arrived at

the helibase, there were occasions when there was no ground

transportation arranged to transport the IP to the hospital.

Conversely, boat limitations in high wave conditions delayed the

arrangement of emergency medevac for facilities that use boats as

primary transportation. This is because the IP was unable to be

transferred from the facility onto the boat safely.

‘

The next day early in the morning around 0730H, I update the

Topside doctor with all the information required. Heart rate is

still high around 130/minutes. I spoke with another doctor again

and after waiting for quite sometimes, they only decided at 1120H

…

. It takes almost 4 hours.’ (C2)

The offshore medics viewed the TMS doctor’s decision as not

the ultimate decision but one that is influenced by the

stakeholders. The TMS needs to inform, discuss and seek

agreement with the stakeholders, specifically the client’s medical

advisor and facility manager for the decision to be made.

Therefore, the decision that is made is based on business interests

superseding the medical perspective. While the offshore medic is

handling the IP at the facility clinic, extensive discussions are

going on to reach a final decision.

3.5 Offshore medic response

The critical incidents in this theme were categorized into

inexperience, workload and poor reporting skills. Offshore

medics were inexperienced in managing emergency cases in an

offshore environment. This had hindered prompt decision making

and lead to discussions with the facility supervisor on the best

action appropriate for handling the IP. One of the participants

reflected:

.3 Facility layout

The offshore facility clinic is located at a distance from the

‘I discussed with OIM on how to transport the IP from clinic to

helideck. At last, we decided to transport the IP using crane to

helideck, using transfer basket with stretcher.’ (C5)

helideck. Whilst the clinic is commonly located at the deck

lower) level, the helideck is located on the top (3 to 4 levels from

(

the clinic) of the accommodation. Critical incidents were

considered to have occurred when time was consumed when

deciding on the best way of transporting the IP from the clinic to

helideck. The risks of carrying the IP on a stretcher while

climbing the multi-level narrow stairways up to the helideck were

deliberated. When a decision was made to use a crane to transport

the IP, a work permit needed be issued with a careful plan to

execute the task safely.

Next, offshore medics have a heavy workload to complete

within a short period and thus fail to achieve tier 2 response times.

One of the participants described:

‘I took 2 hours before I called topside because I need to take full

history. I need to do ECG as well and the documentation took

quite sometimes. There were forms to fill up before I get it

scanned and emailed it to topside.’ (C2)

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

challenges in Fig 2 was developed to enhance our understanding

of the phenomena under study.

The critical incidents did not only happen when the targeted

response time was not achieved, but were also considered to have

happened when unnecessary tasks or interferences were

introduced from the start of the medical event until the IP left the

facility. This is because if the offshore medic delays in providing

ongoing feedback to the TMS doctor, there will be delays in other

responses. For example, the helibase personnel will call the medic

to provide updates on logistic arrangements. In this situation, they

should be aware that communications on logistics should occur

between the helibase personnel and the facility’s radio operator.

Another issue is that offshore medics demonstrate poor

reporting skills when escalating the case to TMS especially when

the photos provided to topside did not represent the actual IP’s

condition. It leads to arguments and finally, the medic needs to

repeat the same process (taking photos, transferring it onto

computer and email) to allow the TMS to make the right decision.

The strengths and limitations of this study should be

considered. This study was conducted through independent

academic research from the university without preserving any

company’s interest, which could have been a source of bias. Next,

this study explores the challenges of the MER system from the

offshore medic’s perspectives which have never been investigated

before. Thus, it brings a new understanding to the complex

phenomena of which little is known. Moreover, the fact that this

study was conducted by experienced researchers in the field who

are familiar with the nature of offshore medical services helped in

the analysis of data that required a deeper understanding of the

participant accounts.

Even though researcher familiarity in the field helps in data

analysis, the familiarity may also have introduced bias in data

analysis as the researchers may have preconceived ideas. This

might affect the credibility of the findings. However, the second

round of interviews that were conducted to get the participants’

confirmation may have reduced the elements of researcher bias.

Also, the small sample size in this study may affect the

trustworthiness of the findings. Therefore, the MER system

challenges model developed in this study is immature. Further

study is required to confirm the findings using a larger sample

size with a comprehensive list of critical incidents to achieve data

saturation. However, it can be argued that having more critical

incidents is not likely to add new important themes to the current

themes about MER system challenges in this study.

Whilst Ponsonby et al. [6] found personnel skills and

competency to be the major MER system challenges, our study

found decision making to be the major challenge. This difference

may be caused by continuous improvements of the system over

time. The results of this study regarding decision making are

similar to Singh’s [8] report. However, the report is only limited

to the topside decision, which were delayed and not always

conclusive. Even though aspects of the TMS doctor’s decision

making were identified in our study, the stakeholders’ decision

making is the major challenge identified.

In oil and gas industry, companies are competing based on

performance indicators that aims for zero recordable injury/illness

for their operations [19]. Although the management of

occupational injury/illness today is more advanced and

comprehensive than before [20], the negative effects of having

zero recorded injury/illness as a goal cannot be denied when

recordable injury/illness are under reported to maintain the clean

records of companies [21]. Therefore, it is logical in the current

context for this study to find that stakeholders delay decision

making to avoid recordable cases.

.6 SOP and protocols

There were three issues emerging from the data regarding

SOP and protocols. Firstly, there is a redundancy in SOP. This

became apparent when offshore medics needed to carry out the

same flow of procedure or part of the procedure repetitively,

involving separate SOPs being used by the operator company and

the main contractor company. This situation creates a dilemma

for the offshore medic to either attend to the IP’s medical

emergency needs or to carry out repetitive tasks to satisfy both

companies requirement within a limited period of time. One of

the participants expressed it as follows:

‘

I am managing the heart case and suddenly I have to inform

another party. I took time to call the operator company… seems

like repeating the same task. What Ihave reported to topside,

needs to be reported to operator company doctor too. Meaning it

wasted of time at this point.’ (C7)

Secondly, there were recent changes in the MER procedures

prior to the medical event occurring. It was revealed that the

changes were either not documented yet or all key personnel were

in the process of understanding the new written changes when the

emergency medical event happened. Lastly, when the

management decided to deviate from protocol, the alternative

decision was contemplated from every aspect. It shows that a

deviation from protocol would consume more time in coming to

a final decision.

.7 Weather conditions

Weather conditions only appeared in two cases thus it is not a

significant theme based on case rates (18.2%). Bad weather was

mentioned when medical emergency events happened and it

affected the emergency medevac response. Because of bad

weather, there were changes in the logistics arrangements for

evacuation transportation. For example, the helicopter was

activated when the boat was not appropriate and vice versa.

Moreover, communication systems failed in bad weather but the

medics claim that it seldom happened.

The communication challenges identified in this study were

consistent with the reported literature. The similar aspects of our

findings were on communication system interruptions and failure

during emergency medevac arrangement [3,5]. However, this

study uncovered the communication behaviour category as a new

aspect of communication challenges that consists of inappropriate

instructions and ineffective communicating changes.

Although logistics problems found in this study are consistent

with the previous studies, all studies address different aspects of

the problem. The early studies highlighted the ineffective logistics

coordination specifically on helicopter activations [7] and the

later studies revealed the inappropriate ground transportation used

Discussion

This study explores the MER system challenges from the

offshore medic perspective through their experiences in handling

delayed emergency medevac cases. The model of MER system

[

6]. Unexpectedly, this study uncovered a wide range of logistics

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

problem not only pertaining to coordination but also including air,

sea, and ground transportation. Another unexpected finding is the

MER challenge about facility layout that involves clinic design

and accommodation design which have not been reported in

previous literature.

The findings of this study on medic response are similar to the

personnel skills and competencies issues in previous studies.

However, previous studies merely revealed the inadequacy of

personnel’s medical skills and competencies both to meet the

basic requirements and increasing demands of advanced

treatment [6, 7]. Conversely, the offshore medic response theme

in our study was developed from the inexperience, reporting skills

and workload categories.

The SOP and protocols theme found in this study is similar

with the Sande [7] report but involves a different aspect. In the

Sande report [7], the challenges mainly involved SOP and

protocols that were unclear and no standardized across the

company operations facility. Conversely, the findings of our

study uncovered the redundancy of SOP and protocols, deviation

from protocols and MER system changes. Surprisingly, MER

system challenges about equipment and clinic facilities did not

emerge from the data analysed in our study. It may be possible

that the challenges have been adequately addressed following the

maturity of the MER system currently practiced.

In brief, most the findings in this study are supported by

previous literature even though there are certain differences in the

aspects of MER system challenges within the same factors.

Nevertheless, this study has added facility layout as a new factor

for MER system challenges. Finally, the findings that lack

literature support indicate that our study has discovered new

aspects of the challenges in the MER system as a result of using

different research approaches and contexts.

Table 4: Implications to oil and gas industry managers and HSE

personnel

MER

challenges

system

Implication to managers and HSE personnel

Communication

Assess communication system reliability to find

the root causes and best solutions that balance

the cost-benefits of the operations.

Consider the potential to use advanced

telemedicine technology system with cost-

benefit assessment.

Decision making

Communication

behaviour

SOP and protocols

Managers and HSE personnel should incorporate

the management of change (MOC) when

managing the MER system that incorporate

points below:

Logistics problems

Facility design

▪

Reduce numbers of decision maker

personnel for medevac

▪

Reduce bureaucracy

Ensure

effective

efficient

Offshore medic

responds

communication of changes

Manage changes in MER system

effectively

▪

Need to assess the current logistics resources,

capability and coordination system that may

cause delays in medevac.

Consider area based cooperation [20]

Revise risks assessment on accommodation design

Consider to redesign the facility if appropriate to

meet the industry standard:

▪

Clinic size >5x7m for POB >100, [23]

Escape route width for stretcher 48in.[24]

Ensure the effectiveness of the existing system

such as continuous learning, offshore induction

programme and onsite specific facility

orientation.

Need to revise paperwork required for medevac

that may contribute to workload and delaying

response. However, any efforts to reduce or

simplify the paperwork should not jeopardise

the legislation requirements.

.1 Implications for practice

The findings of this study in the form of MER system

challenges model offers implications that can be categorized into

two parts. There are implications for the oil and gas industry

managers and Health, Safety & Environment (HSE) personnel; as

well as implications on industrial guidelines on tier response time.

Firstly, it is important for industry managers and HSE personnel

to understand the nature of MER system challenges found in our

study. Obviously, all the six significant factors of MER system

challenges that were found are controllable. Furthermore, the

delays in emergency medevac cases investigated in our study

were caused by multiple factors that are interrelated. Therefore, it

suggests that the managers and HSE personnel need to revise the

existing MER system and take the necessary actions for system

improvement (refer Table 4). On the other hand, the MER system

challenges factors identified can be included for consideration to

develop a MER system for a new project. This can ensure that the

MER system in place is effective in reducing health and safety

risks.

The second implication for practice is on the industrial

guidelines regarding tier response times. Table 5 compares the

tier response times reported across oils and gas industry.

Generally, the tier response time was set from the start of medical

event until the IP reached the tertiary medical facility. However,

when applying this tier response time to the MER system, there is

a gap in the time for decision making.

Table 5: Tier response time comparison

OGP

BP Company

Tier Response

Description

Shell

Guideline

International[6] [25]

[26]

Tier 0

Bystander

(

immediate)

First Aider/

Responder

Advanced First

Aider

Tier 1 (4min) Tier 1 (4min)

Tier 0 (4min)

Tier 1 (10min)

Tier 2

(20min)

Offshore

Medic, Site

clinic,

Tier 3

Tier 2 (1hour)

(1hour)

Tier 2 (1hour)

Tier 3 (6hour)

Tier 3

Medevac

preparation

Evacuation to

shore/

admission to

local hospital

Specialist

medical care/

Tertiary

Tier 4

(6hour),

secondary

and tertiary

Tier 3 (4hour)

Tier 4

Tier 4 (varied)

medical

facility

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

While the results of our study indicate that decision making is

the major challenge of an effective MER system implementation,

it also gives a sense that the existing tier response times need to

be revised. Indeed, it was suggested that another tier response

time needs to be added for decision making. Referring to the Oil

and Gas Producer (OGP) guidelines [26], the tier response time

for decision making should be added between Tier 3 and 4. Fig 3

illustrates the proposed additional tier response times when it is

applied to the MER system practiced in the Malaysian offshore.

However, it is beyond the scope of our study to determine the

duration of decision making tier response times. Further study

should be conducted to address the appropriate maximum

decision making time in the MER system.

Fig. 3: Proposed offshore MER system revision

Journal of Environmental Treatment Techniques

2020, Volume 8, Issue 1, Pages: 364-373

Although some might argue that the need to add a tier

response time for decision making is trivial, we justified its

practicality on the basis of the MER system challenges revealed

by first-hand experiences in the field. By having tier response

time for decision making, the gap in the MER system that was

previously unmeasured can now be monitored. The principle is

clear as what has been emphasized is that “you cannot manage

what you cannot measure” [27]. Moreover, the key personnel in

the MER system who are involved in decision making will take

responsibility to act promptly according to what is appropriate to

the situations need. Thus, the proposition to add another tier

response time in industry guidelines has a strong basis and it

should be seriously considered by the industry.

Authors’ contribution

All authors of this study have a complete contribution for data

collection, data analyses and manuscript writing

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