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IntroductiondAlthough bear attacks on humans are uncommon, the incidence has slowly risen as human populations increasingly encroach on wilderness habitat. In the Kingdom of Bhutan, Himalayan black bear attacks occur regularly. Bears preferentially attack the face, often causing injuries that require surgical airway management. We sought to determine how often patients injured by Himalayan black bears required airway management during initial resuscitation.MethodsdWe conducted a retrospective review of emergency department and admission records of the 3 referral hospitals in Bhutan. We identified all victims of bear attacks in Bhutan who received emergency airway management, including surgical airway management during the period from August 2013 to December 2017.ResultsdThere were 21 patients who were treated for injuries from bear attacks during the study period. Of these, 12 required emergency airway management. Three patients who required emergency airways (2 intubations, 1 surgical airway) were attacked near a regional referral hospital and received care at that hospital. The remaining 9 patients received care from the helicopter emergency medical services (HEMS) retrieval team (1 intubation, 8 surgical airways).ConclusionsdThe use of highly trained HEMS critical care retrieval teams may improve outcomes in critically injured patients who require time-critical airway management in remote areas. Countries such as Bhutan with populations far from emergency and critical care might benefit from the establishment of HEMS critical care retrieval services. HEMS teams providing care while retrieving patients from austere environments should be expert in emergency airway management.

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The population of the Kingdom of Bhutan is scattered in small villages throughout the eastern Himalaya. Infants born prematurely in villages have no access to neonatal intensive care until they are transported to the national referral hospital, a process that once took hours, if not days. After the introduction of a helicopter critical-care retrieval team, we were able to send a trained team to a remote location that successfully administered surfactant and initiated critical care to a premature, extreme low birth weight infant in severe respiratory distress in the first hour of life. Although the infant was in shock and in a near-arrest state at the time the team arrived, he made an excellent recovery after resuscitation by the team.

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