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YOUR ONE STOP SAR SHOP Commercial Helicopter Operators, Para public Safety Agencies, and Defense Forces need proven, cost effective, and innovative training capabilities that are speciically relevant to performing their mission mandates. Training thousands of Search & Rescue and Tactical students worldwide, on 26 different aircraft types, and having experience operating in diverse environments around the globe, Priority 1 Air Rescue meets the demands of our customers by offering the most comprehensive mission training solutions in the industry. O ur Search & Rescue and Tactical Training Academy (SART/TAC) is setting a new standard for mission training performance and safety by employing synthetic hoist/aerial gunnery virtual simulators, hoist and fast-rope training towers, and modern classrooms that utilize cutting edge technology to provide our universally adaptable and standardized multi-mission training and operational SAR programs. Whether you are looking for Civil Aviation Authority (CAA) compliant and certiied basic to advanced hoist mission training, new aircraft type SAR role conversion, or complete turn-key Air Ambulance/HEMS and SAR/LIMSAR program implementation with operational Paramedic and Rescue Specialist Aircrew staffing, we deliver proven solutions. Priority 1 Air Rescue is dedicated to providing unparalleled capability, safety, and service to perform lifesaving missions.

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YOUR ONE STOP SAR SHOP Commercial Helicopter Operators, Para public Safety Agencies, and Defense Forces need proven, cost effective, and innovative training capabilities that are speciically relevant to performing their mission mandates. Training thousands of Search & Rescue and Tactical students worldwide, on 26 different aircraft types, and having experience operating in diverse environments around the globe, Priority 1 Air Rescue meets the demands of our customers by offering the most comprehensive mission training solutions in the industry. O ur Search & Rescue and Tactical Training Academy (SART/TAC) is setting a new standard for mission training performance and safety by employing synthetic hoist/aerial gunnery virtual simulators, hoist and fast-rope training towers, and modern classrooms that utilize cutting edge technology to provide our universally adaptable and standardized multi-mission training and operational SAR programs. Whether you are looking for Civil Aviation Authority (CAA) compliant and certiied basic to advanced hoist mission training, new aircraft type SAR role conversion, or complete turn-key Air Ambulance/HEMS and SAR/LIMSAR program implementation with operational Paramedic and Rescue Specialist Aircrew staffing, we deliver proven solutions. Priority 1 Air Rescue is dedicated to providing unparalleled capability, safety, and service to perform lifesaving missions.

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AIRMED&RESCUE MAGAZINE

POLICE AVIATION EDITION

Insights into medical interiors Is a modular solution the answer for an aircraft performing many roles?

Profile: South Africa Police Service Insights into the operations of the Air Wing

magazine ISSUE 90 | JUNE / JULY 2018

ISSUE 90 JUNE / JULY 2018


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In this issue

Editor-in-chief: Ian Cameron Editor: Mandy Langfield Sub-editors: Christian Northwood, Lauren Haigh, Stefan Mohamed, Sarah Watson

News Analysis: Crash-resistant fire systems Are regulations going to be enough?

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Advertising Sales: James Miller, Mike Forster, Becky Payne, Kathryn Zerboni

What if … the pilot falls ill in flight? Lessons to be learned from recent events

14

Profile: South Africa Police Service – Insights into the operations of the Air Wing

24

Feature: Flood water rescues Tried and tested techniques

28

Design: Tommy Baker, Will McClelland Marketing: Isabel Sturgess, Kate Knowles Finance: Elspeth Reid, Alex Rogers, Kirstin Reid Contact Information: Editorial: tel: +44 (0)117 922 6600 (Ext. 3) email: editorial@airmedandrescue.com

Police Aviation: Police helicopter medical interiors Is a modular solution the answer for an aircraft performing many roles?

Advertising: tel: +44 (0)117 922 6600 (Ext. 1) email: jamesm@airmedandrescue.com Online: www.airmedandrescue.com @airmedandrescue www.airmedandrescue.com/facebook www.airmedandrescue.com/linkedin www.vimeo.com/airmedandrescue

20 Feature: US Air Force aeromedical evacuation research – Preventing the second hit to patients

Subscriptions: www.airmedandrescue.com/subscribe subscriptions@voyageur.co.uk

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CONTRIBUTORS

Published on behalf of Voyageur Publishing & Events Ltd Voyageur Buildings, 19 Lower Park Row, Bristol, BS1 5BN, UK The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. The views expressed do not necessarily reflect those of the publisher. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned, is hereby excluded.

Printed by Pensord Press Limited © Voyageur Publishing & Events 2018

magazine AIRMED & RESCUE ISSUE 90 ISSN 2059-0822 (Print) ISSN 2059-0830 (Online) Materials in this publication may not be reproduced in any form without permission.

Amy Gallagher Amy Gallagher is an internationally published journalist covering aviation, rescue, medical and military topics, including evidence-based research articles. Amy has worked in both agency and corporate communications for aviation companies such as SimuFlite Training International, K-C Aviation, Chrysler Pentastar Aviation, and McKinney Aerospace. Dr Philip Lucas BSc(Hons) MB ChB MRCGP DipIMC RAF Philip Lucas is a Medical Officer and BASICS Doctor who also volunteers with Wiltshire Air Ambulance as a medical passenger. He is a qualified military aviation medical examiner who has previously worked as a pilot, accruing 2,000 hours flying, predominately on multiengine platforms. Dino Marcellino Known around the world for his aviation photography and reports, Dino Marcellino has been fascinated by aircraft since his childhood, and has spent his life combining his passion for aircraft with that of photography. Flying on more than 25 different types of helicopters, he has worked with the Italian Navy, Army and Air Force, as well as police and rescue organisations. Barry Smith Barry Smith has been a published author for 35 years with over 300 magazine articles and six books to his credit. He has been involved in emergency services for 40 years as a member of a search and rescue team, a volunteer firefighter, and a paramedic on ground ambulances. He resides in Reno, Nevada, in the US. James Paul Wallis Previously editor of AirMed & Rescue Magazine from launch up till issue 87, James Paul Wallis continues to write on air medical matters. He also contributes to AirMed&Rescue’s sister publication the International Travel & Health Insurance Journal.


NEWS

Air Zermatt takes delivery of Bell 429 Swiss air ambulance operator Air Zermatt has celebrated its 50th year of operation with the delivery of a brand new Bell 429 helicopter. Gerold Biner, CEO of Air Zermatt, said that taking delivery of the new aircraft is the perfect way to celebrate the organisation’s 50 years of operation. He praised the new chopper: “This Bell 429 is truly customer designed and has incredible performance, especially in the tough terrain of the Swiss Alps. Bell continuously surpasses our expectations in terms of products and customer care, and we are thrilled to receive another beautiful aircraft.” The twin-engine Bell 429 operated by Air Zermatt has cabin space for two litter

carriers, plus 60-inch-wide side doors and optional rear clam-shell doors allowing for quick and easy passenger and patient ingress and egress. It also features a fully integrated glass cockpit, advanced drive system, WAAS/ SBAS navigation and IFR capability. “We are delighted that after five years of Bell 429 operations, where the aircraft proved its incredible performance in one of the most demanding missions in the world, Air Zermatt chose the aircraft again for its long-term twin-engine needs,” said Patrick Moulay, Senior Vice-President, Commercial Business – International, Bell. “This speaks to the incredible trust our customers have in Bell aircraft performance and customer support.”

US Coast Guard Academy cadets have put their mechanical engineering training into practice, designing and prototyping a new and improved rescue basket model, which the US Department of Defence says could ‘revolutionise the way the Coast Guard conducts search and rescue missions with MH-60 Jayhawk helicopters’. The cadets, Christian Breviario, Riely Brande, Benjamin Crutchfield, Nolan Richerson and Spencer Smith, spent a year working closely with the US Coast Guard Research and Development Center (RDC) when designing the new rescue basket. It came about after a Coast Guard study found that the Coast Guard’s ability to respond to mass rescue incidents was limited by the methods and equipment employed. In response to these findings, the new basket can carry two people, which could reduce the amount of time needed to make evacuations. “We have added a means of entry that is easier for people who may be injured or have limited mobility,” Breviario said. “We have also maximised the space dimensions of the basket, given the dimensions of the MH-60 Jayhawk cabin. With these modifications we have made the basket more accessible, decreased the amount of time needed per hoisting evolution, 44

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Petty Officer 3rd Class Nicole Foguth

Cadets design improved basket for hoist rescues

and improved upon the effectiveness of the Coast Guard during mass rescue incidents.” The flotation system in the basket has also been reconfigured, increasing the buoyancy of the basket by up to 79 pounds (35 kg). “Their [the cadets’] project absolutely showcases what they’ve learned during their four years as engineering students, as well as pushed them to go beyond what we taught them and learn new topics and techniques on their own,” said Coast Guard Cmdr. Matthew Walker, a pilot and mechanical engineering instructor at the academy. “I am intrigued by the team’s approach to this project and to see where it goes from here.”

Editor’s comment Safety is on the agenda this month – well, isn’t it always? But this issue of AirMed&Rescue analyses the next moves from the Federal Aviation Administration with regards to crash resistant fuel tank regulation. The loophole in the current regulation that allows older type certified helicopters to be delivered to operators without crash-resistant fuel tanks has resulted in serious injuries and even fatalities, and enough is enough. While there is inevitably a cost associated with increased safety, and perhaps a lower maximum load capacity due to the additional weight of safer seat structures and fuel tanks, isn’t this a price worth paying when lives could be saved? Elsewhere, we analyse what kind of flight training the medical crew onboard helicopters undertake – the majority of air medical flights are undertaken in a single pilot configuration, and what should happen in the event that a pilot is medically incapacitated should give many pause for thought. And when it comes to the health of the team working on the helicopter, Dr Philip Lucas of Wiltshire Air Ambulance in the UK shares his thoughts on when medical crews might need to examine their own health more closely. Features in the magazine this month focus on research undertaken by the US Air Force to examine aeromedical evacuation in-flight stressors, the findings of which may alleviate a ‘second hit’ to patients. On the topic of aeromedical research, we interviewed Colonel Elizabeth Mann-Salinas, who, with her team, has examined the outcomes of critical care transfers to determine ways in which to maximise resources and skillsets. As it is our Police Focus issue, we’ve included an interview with Brigadier Mahlangu of the South African Police Service Air Wing, as well as taking a look at the interior options for police services whose helicopters are often called into action as air ambulances as well. Safe flying all.

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NEWS

Life Flight Network launches helicopter call-out app US-based air medical transport service Life Flight Network has announced the launch of a new app, LFN Respond, aimed at hospitals and first responders. It will allow those responding to an emergency to call for one of the service’s air ambulances with ‘the touch of a button’, according to Life Flight Network. The app has been created in partnership

with software developer Flight Vector, and aims to save valuable seconds. It will be free for healthcare agencies approved by Life Flight Network. This includes hospitals, first responders, fire departments, EMS, law enforcement, search and rescue, ski patrols, and other qualified agencies working in the Oregon, Washington, Idaho and Montana areas. “With LFN Respond, approved hospital and emergency responders can instantly request a Life Flight Network aircraft by tapping the flight call button in the app, sending vital information and GPS location directly to dispatch personnel at our communications center,” said Life Flight Network CEO Michael Griffiths. “LFN Respond saves precious seconds and makes calling for air ambulance transport easier for hospitals and

first responder teams working to save lives.” Users can also use the app to track the incoming aircraft’s location after it has been called out, and view when it is estimated to arrive on scene. The app also features a number of other functions, including a searchable hospital directory, a landing zone guide, access to Life Flight Network’s calendar of outreach education trainings, and push notifications from Life Flight Network on education and training events. “Life Flight Network’s investment in this technology will help us work together better and more efficiently to get people the emergency care they need, as quickly as possible,” said South Lane County Fire & Rescue Fire Chief John Wooten. “Especially in rural parts of our state, air medical transport is critical to saving lives and being able to communicate with Life Flight Network through LFN Respond will improve the process.”

GNAAS trialing tech that streams incidents to first responders The Great North Air Ambulance Service (GNAAS) has announced that it has been trialing the GoodSAM emergency response app service, which will allow emergency responders to view an accident scene by sending a text to a 999 caller’s phone. Responders will then be able to use the respondent’s camera on their smartphone to view the scene. Chris Smith, GNAAS aircrew Doctor, was key in getting the scheme implemented and says that the service has already seen positive results, with members of the public embracing the technology. “We frequently ring people back on scene to get more information about an incident. But that can be problematic in that we are asking members of the public to identify often complex medical issues,” he said. “This development gives us eyes on the ground so we can see for ourselves if our team is needed on scene or not. In terms of information gathering, it’s a significant step forward and we are pleased with the results so far.” Several incidents have already benefitted 66

AIRMED&RESCUE

from the tech, with one incident showing that a helicopter was not needed at all, whilst another showed a car crash that was far more serious than first though. Being able to see a scene before a team enters ‘dramatically improves remote assessment of illness’ says GoodSAM’s Medical Director, Professor Mark Wilson. “This information

can radically improve resource management – prioritising patients who otherwise might not have been thought of as that urgent,” he added. GNAAS is one of two organisations currently using the GoodSAM emergency response app, and if successful, it may be rolled out to others across the UK.


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NEWS

The Pennsylvania Helicopter Aquatic Rescue Team (PA-HART) in the US recently took part in a complex search and rescue land exercise, with more than 50 civilian and military personnel gathering at Gilbert Airfield in York, Pennsylvania for the exercise. The exercise used one CH-47F Chinook, three UH-60 A/L Black Hawks and one LUH-72 Lakota helicopter to simulate search and rescue operations to hoist simulated patients and rescue divers/ technicians. “The primary goal is to conduct realistic search and rescue operations training safely,” said Ryan Walt, Programme Manager for PA-HART and Pennsylvania Fish and Boat Commission Swift Water Rescue Program. “Our main focus is to conduct training iterations proficiently and mitigate risk to participants.” PA-HART is a joint multi-agency partnership between the Pennsylvania Army National Guard, the Pennsylvania Fish and Boat Commission, the Pennsylvania Emergency Management Agency and credentialed civilian expert

PA-HART

PA-HART completes complex exercise

rescue specialists. The partnership’s air-ground team is trained to respond to natural and man-made disaster incidents. The initiative mirrors the National Incident Management System. “The joint planning makes such training appear seamless and simple, but it is

the unique team we have that allows us to execute training safely that will save time, money and most importantly lives when we get [the] actual call to go,” said Lt Col. Michael Girvin, Commander of the 2-104th General Support Aviation Battalion.

Swiss Air-Rescue Rega has taken delivery of the first of its three new Bombardier Challenger 650 air ambulance jets. The new Rega jet is an enhanced version of those the organisation has in its current fleet, offering various improvements for both patients and crews. According to 88

AIRMED&RESCUE

Rega, the interior and medical equipment are custom-made: a project team comprising Rega pilots, medics and engineers, in collaboration with external specialists, has spent the last four years designing the new cabin fit-out. Patients are set to benefit not just from wider, multifunctional stretchers and reduced cabin noise, but also from the fact that pilots are now permitted to use higher altitude flight routes across the Atlantic, and due to the lower air resistance at higher altitudes, REGA

REGA

New air ambulance jet arrives in Switzerland for Rega the new jet uses less fuel on these routes, which in turn means fewer refuelling stops on long-distance flights. Urs Nagel, Chief Pilot at Rega, explains: “As a result, particularly with long-haul operations, we will be able to fly our patients home faster and in a more cost-effective manner in future.”


NEWS

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ENHANCED SAFETY TANGLED IN RED TAPE Crash-resistant fire system regulation: a collective cycle of compromises

Amy Gallagher explains the current status of crash resistant fire system regulations, and the possible outcome of the final ruling on the helicopter industry, while providing some of the updates and opinions of operators, manufacturers, associations, and industry experts In the 5 November 2015 US Department of Transportation (USDOT) Federal Aviation Administration (FAA) Federal Register, Vol. 80, No. 214, the FAA published the results of an in-depth study of helicopter accidents involving post-crash fire and blunt force trauma, in response to the ‘unacceptably high’ fatal accident rates, notably two fatal accidents in July 2015 just 20 days apart. The study revealed only 16 per cent of the US helicopter fleet complied with the crash-resistant fuel system (CRFS) (14 CFR §27/29.952; Parts 27 and 29 of the Federal Aviation Regulation) required in 1994. Results from the same study showed that only 10 per cent met the emergency landing certification requirements of 1989, according to the Federal Register. Finally, the FAA study further concluded that 80 per cent of accident fatalities were caused by blunt force trauma; 20 per cent were caused by post-crash fires. A fatal accident study showed both measures would have been effective in saving lives (Federal Register Vol 80 no 214). Weight, power, cost, market, payload, makes and models, performance, fuel requirements, the helicopter is a matrix of variables that depend on the other to function. Increasing the weight of any aircraft will potentially reduce its useful payload; any impact this has on performance must be compared to the

CRFS are only a part of general aviation safety benefits provided by implementing increased safety measures. “A helicopter is a ‘system of compromises’,” said Alan Syslo, President, S.A.F.E. International, Inc. of Fort Worth. “CRFS are only a part of general aviation safety.” Timeline for regulation change The timeline to review and revise the 1994 CRFS certification is an example of how long the regulatory process can take. Syslo said that the initial recommendation from the National Transportation Safety Board (NTSB) to change the certification process for helicopter fuel systems was recorded in October 1985; however, it did not produce a rule change and briefing back to the board until June 1995, noting the rule change took place 10 10

AIRMED&RESCUE

September 1994. According to Syslo, the collaborative communications between the FAA and the NTSB show how seriously the FAA takes recommendations from the NTSB. “I believe that the fact that we may be seeing a rule change in the near future on Recommendation A-15-012 that was issued as a result of an accident on 4 October 2014 shows that the FAA is definitely fast-tracking this issue as a priority,” he stated. The principal challenge is the timeline within which the industry can make this

The principal challenge is the timeline within which the industry can make this transition transition, which may be more difficult for some models than with others, according to Airbus. “The long-term benefit is to ensure that all newly manufactured helicopters, regardless of the original certification date, are equipped with modern CRFS,” noted an Airbus spokesperson. FAA-ARAC-ROPWG recommendations In 2015, the FAA assigned the Aviation Rulemaking Advisory Committee (ARAC) to form a Rotorcraft Occupant Protection Working Group (ROPWG) to provide recommendations regarding occupant protection rulemaking in normal and transport category rotorcraft for older certification basis type designs that are still in production. The ROPWG is comprised of 22 technical experts with a wide range of industry experience (normal category rotorcraft manufacturers, transport category, rotorcraft manufacturers, and rotorcraft operators from various segments of the industry such as oil and gas exploration, emergency medical services, and air tour operators) who have been completing a series of tasks since 2015 required by the FAA to ensure all aspects of the tasks are considered in development of the recommendations. After a nearly three-year study examining the factors affecting full or partial compliance of the CRFS in Civil Part 27 and Part 29 helicopters, the FAA is scheduled to brief the NTSB on 31 July on the recommendations resulting from the ARAC-ROPWG report. Impending FAA decision According to written responses from the FAA, the agency has not yet decided


NEWS ANALYSIS

Standard Aero

ROPWG ‘Partial Compliance’ report to FAA In March 2018, the ROPWG report submitted to the FAA containing CRFS and CRSS includes the industry analysis of partial implementation of the relevant regulations. The Working Group determined that a subset of the regulations is nearly as effective as a mandate of full compliance to the regulations, and at a much-reduced price. The crash data for the current study was extracted from the NTSB Microsoft Access Accident Database and included the last 20 years of accidents involving US registered helicopters equipped with partially compliant CRFS at the time of the accident. In a comparative analysis of Part 27 and Part 29 helicopters, the ROPWG’s

research was based on 1,182 partially compliant and non-compliant accidents individually reviewed to determine the following: • Whether or not there was a postcrash fire (PCF), and if so, the cause of the fire • The severity (survivability) of the accident • The number of occupants that sustained thermal injuries after surviving the accident impact. The data show that the crash performance of the partially-compliant Part 27 helicopters, regarding the prevention of post-crash fires, is far superior to that of non-compliant helicopters and, for most partially compliant models studied, equally effective as fully compliant models.

Standard Aero

on potential CRFS and CRSS rulemaking for newly manufactured rotorcraft. Before the FAA issues any final regulations, a notice will be issued to allow the public to comment on any proposed regulations, including comments on the FAA’s economic analysis. The FAA will review the recommendations to prepare a proposal for rulemaking package after the Working Group completes its final report. The public will have an opportunity to review and comment on the FAA’s economic analysis. Any impact that new proposed CRFS and CRSS (crash resistant seats and structures) regulations might have on current models in production would be considered in the FAA’s economic analysis, which would accompany the regulatory notices in rulemaking publications. The economic analysis will address cost and benefits associated with new proposed regulations. Before the FAA issues any final regulations, a notice will be issued to allow the public to comment on any proposed regulations, including comments on the FAA’s economic analysis.

NTSB response The October 2017 letter from the Honorable NTSB Chairman Robert Sumwalt addressed the safety recommendation A-15-12, which the ARAC subcommittee presented to the FAA with responses from the NTSB. According to Syslo, the letter is an indication of a compromise that will likely be a way to improve the current system without grounding entire models of helicopters. “However, what is missing from the discussion appears to be any reference to existing or ‘legacy’ aircraft that do not comply with CRFS,” explained Syslo. “These helicopters can fly effectively forever as long as there are parts available to continue maintenance. This is the only real hole I find in the current rulemaking; however, we have yet to know if there will be any acknowledgement of this in the final rule.” A collaborative commitment “It’s important to note that the recommendations of the ROPWG were not developed in isolation, but with input from operators as well as from OEMs,” said Airbus, which participated in the ROPWG. “Operators have also been very welcoming to the idea of CRFS retrofits on their aircraft that are not already equipped.” Since 2016, all new Airbus helicopters delivered to the US market have been equipped with modern crashworthy fuel systems as standard equipment, and any helicopter that is not currently equipped can be retrofitted with a modern CRFS, said Airbus. According to the manufacturer: “We expect that the industry will continue to be deeply invested in finding ways of improving safety, and will address these issues collaboratively with operators and OEMs for the greater good of our industry and the flying public.” StandardAero has received significant interest from both small and large fleet operators, said Rick Stine, President, StandardAero Components, Helicopters & Accessories. “We’ve been actively engaged with customers interested in enhancing their fleet with this new technology,” he said. The StandardAero/Robertson Fuel Systems CRFT is the only FAA-approved retrofit solution designed as a direct replacement for legacy AS350 models, including the AS350 D, AS350 B/B1/B2/BA/B3 and AS350 B3e (H125), as well as for the EC130 B4, according to Stine. “Our CRFT (crash-resistant fuel tank) kit solution is field replaceable, with a design that features a robust crash-resistant fuel bladder, slightly greater >>

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NEWS ANALYSIS

INDUSTRY OPINIONS Mike Allen, President and Chief Operating Officer, Air Methods “We are grateful that this day has finally come. More than two years ago, we publicly committed to retrofitting every one of our aircraft in need of this safety enhancement as soon as a product was available, certified and ready to go. We are excited that the FAA has provided certification for a viable solution and our crash resistant fuel system programme is leading the way for the entire air medical transportation industry. We want to recognise our partners, StandardAero and Robertson Fuel Systems, for helping us get to this point. At Air Methods, we continue to raise the bar to ensure the safe return of our crews and patients to their loved ones. For us, it’s always been about doing the right thing.” Kurt Robinson, President & CEO, Robinson Helicopter Company Robinson Helicopter Company participated in the FAA’s study of crash-resistant fuel tanks and seats. “What we determined on our aircraft is that bladder fuel tanks do improve the fuel system’s resistance to a post-accident fuel leak, which is why we install them in all new aircraft and require they be retrofitted in older aircraft that were originally manufactured without bladder tanks,” he said. Robinson added that the company’s R66 was certified to the current FAA regulations and has always been manufactured with a fully compliant fuel system and seats. “While the costs of complying with all of the current regulations regarding fuel tanks and seats may not be feasible for every aircraft, we do believe requiring bladder tanks (or a comparable crash-resistant fuel tank) in all helicopters makes sense.” Randy Rowles, HAI Board Member, Director of Training, EPIC Helicopters “With the impending FAA ruling, a dynamic cultural shift will emerge and permeate the entire helicopter industry impacting all personnel and all providers, indirectly or directly,” stated Randy Rowles. Advances in electronic technology have also impacted the industry. “Capturing a video with social media takes minutes, while uploading that video to the news media even faster. Technology expedites the speed at which humans operate.” The speed at which social media technology captures an unexpected event in the public and private domain generates those affected to respond faster as well, he added. “While the legal ramifications of those responsible must also expedite their timelines,” said Rowles. “Notably, regulator of government agencies, such as the FAA which has taken on a faster timeline. The discussion point now is the FAA’s decision to ‘hammer down’ on the impending 31July ruling on the CRFS certification requirements for Part 25 and Part 29 operators.” The cultural shift of installing CRFS, is similar to the legal requirements of using a car seat belt in the 1970s and 80s, explained Rowles. “The outcome of a major cultural change at which one law exponentially impacts the life and work of many, demanded by the masses, the question then becomes: who is responsible for the expense?” Seth Myers, President, Air Evac Lifeteam “The kits were just made available to us in November 2017 for the Bell 206 that needed the CRFS. We have been taking delivery of them as soon as they can be completed. Our Bell fleet, the majority of our fleet, in June this year,” Myers told AirMed&Rescue. In the meantime, the organisation is awaiting on a delivery date to retrofit its fleet of six Airbus B2 A-Stars, as well as a kit for the B3. “We will be systemwide complete for Air Evac this year,” said Myers. “Based on availability of them getting through the approval process and the availability, we’ll have six remaining after June.”

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fuel capacity than the legacy tank, and introduces magnetic field sensor fuel gauging technology, a recessed sump drain valve, quick-change cartridge fuel pump design and vent system roll-over protection,” said Stine. Following the delivery of multiple CRFT kits to launch StandardAero’s customer Air Methods, and a separate Memorandum of Understanding (MOU) with Papillon Airways, Stine also said that StandardAero submitted its application for EASA approval of the CRFT-STC pursuant to the FAA and EASA bilateral agreement. “With Air Methods and Papillon investing in our CRFT, the launch of the programme is just the ‘tip of the iceberg’ when it comes to the overall safety-minded landscape,” said Stine. EASA rulemaking task The European Aviation Safety Agency (EASA) participated in the FAA-initiated ARAC working group tasked with assessing the options for the retrospective application of design changes for CRFS for rotorcraft, according to David Solar, Acting Head of Rotorcraft Department, EASA. “In parallel, EASA has included a dedicated Rulemaking Task (RMT) 0710 in the European Plan for Aviation Safety (EPAS) to consider the way forward for the retrospective application of CRFS based upon the recommendations of the ARAC working

Any impact that any new proposed CRFS and CRSS regulations might have on current models in production would be considered in the FAA’s economic analysis group,” Solar explained. “This RMT has not yet been initiated and the next step will be to prepare and approve the Terms of Reference (ToRs) in order to agree the scope of this activity.” During this RMT, a Regulatory Impact Assessment (RIA) will be conducted to consider the effect of the proposed regulatory changes using different factors including safety, economic, harmonisation, social and proportionality, Solar further explained. “The different options will be considered against these factors in order to establish the most viable options,” he said. In addition, Solar said the ARAC working group recommendations will need to be reevaluated in a European context based upon the use of European safety and economic data. The RIA would be included in a Notice of Proposed Amendment (NPA) which will contain the regulatory changes, and then consulted with the public. “Only if the expected safety benefit of a new certification specification (standard) outweighs the grandfathering rights, then the aircraft manufacturer (type certificate holder), or operator/owner of aircraft could be required to comply with the latest certification specifications (standards),” he said. This decision needs to consider the impact to operators of the aircraft and to the aircraft manufacturer (type certificate holder), whether the required changes are technically viable and what expected costs will be, Solar concluded. So, much has still to be decided. Cost, of course, is a significant factor in the decision-making process. The data is clear, though – CRFS, even if partially implemented, can save lives in the event of a crash. It is now up to the FAA and EASA to decide how far new regulations will go to force operators and manufacturers to step up their safety levels.


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NEWS ANALYSIS

WHAT IF…? The vast majority of HEMS flights are performed in a single pilot configuration, which begs the question: what happens if the pilot suddenly becomes unwell during a flight? When this exact situation arose for Air Evac Lifeteam in January of this year, thankfully the helicopter was landed safely by the pilot, and the medical team performed an emergency shutdown of the aircraft. This prompted the company to take further action with regards to the training of its medical crew members, so that they are better able to cope with such a situation should it ever happen again. Original incident report from the CONCERN Network At approximately 16:28 hrs CDT, on 12 January 2018, an Air Evac Lifeteam flight crew was transporting a patient from a scene flight when the pilot suffered a medical emergency that impaired his ability to operate the aircraft. The pilot had engaged the stability augmentation system and autopilot systems (HeliSAS) after departure from the scene and moments later stopped responding to the medical crew over the ICS. After several attempts to elicit a response from the pilot, the flight paramedic accessed the cockpit and assisted the pilot, who landed the 14 14

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aircraft safely in a rice field while the flight nurse contacted the company’s operations control center. The flight paramedic and nurse performed an emergency shutdown of the aircraft and removed the pilot. Additional resources were dispatched to transport the patient and the pilot to appropriate medical facilities. Action taken Following the incident, Air Evac Lifeteam is now developing revised cockpit orientation and HeliSAS autopilot familiarisation training for medical crew members, and additional procedural guidance for use by company operations control specialists during in-flight emergencies is being developed. Tom Baldwin, the company’s Director of Safety, explained in more detail the training that crew members will undergo: “All company medical crew members receive both initial and recurrent training relevant to their duties on and around the aircraft. This training covers a series of modules that includes in-flight emergency procedures, Air Medical Resource Management (AMRM), aircraft performance and limitations, fuelling operations, survival training, and hot and cold climate operations.” He then went on to share more information about what the company has done to


NEWS ANALYSIS

take action following the incident in January: “In accordance with our SMS, a thorough review of this event was conducted and additional training has been developed and tested in our in-house simulators that increases the medical crew members’ awareness and understanding of the Autopilot/Stability Augmentation System (SAS) platform. Working in conjunction with our operations control center, this training allows a medical crew member to quickly determine the status of the Autopilot/SAS and establish an approach to the closest airport if necessary.” Industry opinion AirMed&Rescue spoke to Stacy Fiscus, NRP, CCP-C, FP-C, MTSP-C, who currently works on an air ambulance helicopter in Haiti, about her experience as a flight medic with regards to how much she knows about the aircraft on which she flies. “Personally,” she said, “I’ve been given very little training in regard to operating a helicopter other than how to perform an emergency shutdown while it is on the ground.” While this may be the industry standard, there are exceptions. “There are some public service programmes that allow for the medical crew members to have more advanced aviation training, which allows them to land the aircraft on a set of dual controls in the event of an emergency or act as a pseudo second-in-command as far as navigation and radios go. Once, I even visited a programme that offered pilot training to its medics, but this is rare,” she added. Baldwin of Air Evac Lifeteam is not aware of any US operators that offer to train their medical crews as pilots. However, in a single engine, single pilot helicopter not configured for dual operations, such training would be moot anyway, as the medical crew member would likely not be able to just slip into the pilot’s seat. Fiscus points out: “If, due to the incapacitation of the pilot, the helicopter became unstable it would be that much harder, if not impossible, to even get a hand on the cyclic and collective, let alone the pedals.” Are medics better off just doing what they should do, then, instead of trying to fly the helicopter? Maybe. They could try to treat the pilot, getting them into a state of health whereby they are able to safely land the helicopter, and then the medics can perform an emergency shutdown. Fiscus said: “Training is always a good thing; but for now, staying in our own lanes and

mastering our own trades while learning to bring it all together as a team is one of the most important things we can do.” Fiscus also noted a trend towards better aviation terminology knowledge and education efforts, related to other safety movements. She added: “I think medical crews are asking more questions of their pilots and pilots are taking an active role in ensuring they understand their responsibilities in the aircraft. Stateside, associations like NEMSPA and AAMS are ensuring there is more aviation-related safety training at national conferences and available online to anyone interested. So, while training on the rare instance of operating an aircraft for an incapacitated pilot may not be occurring, I think safety training and general aviation awareness has increased exponentially.” A prime example of flight and medical crews working together in an emergency was exemplified by another CONCERN Network report early this year, in which a US-based medevac company reported that a paramedic assisted a pilot in reviewing the aircraft emergency checklist when the #2 Engine Chip Light illuminated; the pilot landed the aircraft without an issue, but the paramedic did state that it was difficult to locate the emergency procedure in the checklist. The operator, in its ‘after-action items’ report, noted: “The pilot handing a clinical team member the aircraft checklist is probably a foreign process. In an emergency, we know we should use all resources when necessary. We are exploring and discussing future education for team members regarding the use of checklists as well as other situational awareness items in the aircraft. The entire process worked very well with all involved, as did the communication among disciplines – great AMRM. This is a testament to processes, training, and education.” Safety first There is little doubt – thankfully – that flying in an air ambulance has become safer in the last decade. It’s a risky business, but through a combination of regulation and independent industry efforts, the number of crashes involving air ambulances has dropped significantly. This shouldn’t mean, though, that there should be any kind of complacency. Education of the flight medics about the workings of the helicopters on which they are placed could save their own lives, and those of the pilots and patients onboard. A little bit of knowledge can go a long way. Keeping an eye on pilot health For US part 135 air medical operations the Federal Aviation Administration requires an annual class II flight physical. Tom Baldwin told AirMed&Rescue: “In addition, all of our employees are given the opportunity to undergo a biometric screening annually. If they do so, they increase their short-term disability coverage from 50 to 70 per cent. This screening includes a variety of medical tests. While the company does not have access to the results of these screenings, the employees do, and may choose to follow up with their personal doctors to correct potential health issues.”

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SPECIAL REPORT

FIT TO OPERATE? In this article, Dr Philip Lucas shares his personal thoughts on the health and fitness to fly of Technical Crew Members, based on his experience of working alongside Wiltshire Air Ambulance (WAA)

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SPECIAL REPORT

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f you are a paramedic in the front seat of an air ambulance, are you fit and healthy enough to safely fulfil this role? What are the consequences of a sudden incapacitation while in the front seat at a critical stage of flight?

Risky business HEMS operations are by their nature, hazardous from an aviation point of view. The flights are unscheduled, often carried out in restricted airspace with frequent landings in unprepared areas with the pressure of knowing that you are potentially delivering life-saving care to the scene. To add to the hazards, the recent development of night flights present the additional challenges of disorientation, low-light and easily concealed obstructions. Such a flying regimen demands a high degree of flying skills and airmanship. A lot of air ambulances employ aircrew with experience in military flying operations, which have similar demands. However, these military operations are mainly conducted on platforms that have two pilots in the front seat. A lot of air ambulance operations have a pilot/paramedic combination as an alternative. Air ambulances currently operate with either two pilots (mostly this is only during darkness) or a single pilot, teamed with a paramedic in the front seat operating as a technical crew member (TCM). The latter combination applies to the majority of UK air ambulances1. As defined by the European Aviation Safety Agency (EASA)2, the role of the paramedic is to assist the pilot ‘during HEMS operations which may require the operation of specialised onboard equipment’3. The TCM is providing a regulated, flight safetycritical role and therefore their actions should not be mitigated by their general health. While paramedics are trained to a good standard of airmanship through their crew training courses, the health dimension also requires consideration. Helimed operations are inherently demanding and call on a high standard of medical fitness. Current state The current standard of health monitoring practice at air ambulance units is for crew members to verbally declare themselves ‘fit’ at the daily brief. While this is always needed to cover acute illness, self-declared fitness is not against an agreed standard and also puts the onus on individuals where there may be self-induced pressure to ensure that they are able to fly that day. It could be argued that if this is the only form of health monitoring for TCMs within a unit, then this would be insufficient to ensure an individual is fit to fly. The UK Civil Aviation Authority (CAA) demands that airline cabin crew, who occupy no front-seat role, but nonetheless perform safety-related tasks, undergo medical assessments4. However, there are no such CAA-led standards for HEMS crewmembers. Each air ambulance operator has to interpret itself what the medical standards should be for

their HEMS crew. Wiltshire Air Ambulance has taken steps to meet this challenge and this may be a benchmark to consider as good practice. The regulatory framework EASA has published the requirements for operators with TCMs in HEMS and NVIS (night vision imaging system) operations. Regulation ORO. TC.105 sets down the conditions for assignment to duties where TCMs can only start duties if they ‘are physically and mentally fit to safely discharge assigned duties and responsibilities’. The guidance material for this EASA order is adopted by the British Helicopter Association (BHA) in its HEMS Guidelines, Number 11 as follows: • The technical crewmember in HEMS, HHO or NVIS operations should undergo an initial medical examination or assessment and, if applicable, a re-assessment before undertaking duties • Any medical assessment or reassessment should be carried out

according to best aeromedical practice by a medical practitioner who has sufficiently detailed knowledge of the applicant’s medical history • The operator should maintain a record of medical fitness for each technical crew member. • Technical crew members should: • Be in good health • Be free from any physical or mental illness that might lead to incapacitation or inability to perform crew duties • Have normal cardiorespiratory function • Have normal central nervous system • Have adequate visual acuity 6/9 with or without glasses • Have adequate hearing, and • Have normal function of ear, nose and throat. In Wiltshire Within this framework, WAA has developed its own health monitoring for TCMs, and has set medical standards which are described below. First, a medical passenger5 such as a doctor or non-TCM paramedic who >>

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works solely with the patient and not in the front seat, signs their own declaration of fitness every 90 days. These medical passengers are, as such, not crucial to flight safety and therefore not subject to health monitoring. Pilots are required to undertake annual medical assessments in accordance with their licensing requirements, and they are also not monitored. TCMs who operate in the front seat, next to the pilot, are subject to the medical assessment. When paramedics join WAA as TCMs, they complete a detailed health form, adapted from the CAA Light Aircraft Pilot Licence (LAPL) medical standard. GP clinical summaries are obtained. The flight medical doctor then undertakes an evaluation that includes a look at their medical history, basic observations, ECG, eyesight, hearing and a clinical examination. For medical standards, the BHA guidance is that an individual is assessed to the equivalent standard of a DVLA Group 2/Light-Aircraft Pilot’s License/Class 2 Private Pilot Medical. WAA sets the standard as appropriate to the work the paramedic is carrying out in the aviation environment. For example, as all front seat paramedics employ NVIS, eyesight requirements are much more stringent, approaching military standards. Once working on the unit, TCMs are encouraged to declare any problems to the flight medical doctor. Any condition is assessed in the context of their flying role. Confidentiality is paramount, of course, so any condition that affects flying is passed onto the management purely in the context of restrictions in practice. For example, ‘Unfit front seat one month, but fit to work as a medical passenger, medical assessment required before return to full duties’, or ‘Unfit flying two weeks, fit for base work’. Health is monitored on a yearly basis, through either a self-declaration

or further examination, depending on age or risk factors. A health certificate is then renewed for a further 12 months. If a paramedic has a clinical problem that can affect work, a letter can be written to a consultant or GP explaining the paramedic’s occupational role and how it is affected. This helps provide guidance for the clinician on how to test for, or manage, a condition. The flight medical doctor is also available as a ‘reach-back’ to deal with any medical problems a paramedic may present with. Case Studies Below are a couple of case studies which are theoretical, but illustrate the thinking behind aircraft medical standards and how guidance from other organisations can assist in balanced decision making and understanding of risk. Case One History: On yearly monitoring, a middle-aged paramedic with a family history of cardiovascular disease is found to have an incidental high blood pressure reading. The Flight Medical Doctor gave him an automatic cuff and sent him away to complete a week of home BP monitoring in accordance with National Institute of Clinical Excellence guidance. When these figures were returned, it was found that the readings were consistently high. A clinical examination revealed no cardiac abnormalities or retinal changes. Guidance: There is CAA guidance for pilots with hypertension that dictates which anti-hypertensives are acceptable and which are not. A pilot can continue flying on these

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medications once shown to be stable with no side effects. Furthermore, cabin crew are also temporarily grounded until they are stable on antihypertensive medication. It could be considered reasonable that a paramedic in this case follows this guidance. Decision: The paramedic is sent to his GP with a covering letter explaining the occupational background and which medications are acceptable. While he is stabilising on the medications at work, he is declared unfit to fly until it was determined there were no side effects. However, he is fit to carry out all other medical duties on base and on the response car, with a discussion about side effects he may experience. In future, at his annual medical, the medication is reviewed and a 12-lead ECG is taken. Case Two History: A paramedic has sustained a cycling injury resulting in an isolated fractured clavicle, for which conservative treatment was indicated. He is initially provided with Ibuprofen and co-codamol for analgesia and is fitted with a sling. Decision: This injury will be incompatible with flying for the duration of time that the clavicle is healing. However, you would be looking to assess the paramedic once he has been discharged from the fracture clinic. Before returning to flying duties, you would complete a cockpit assessment. This would cover fitting and removing the helmet, strapping in, reaching everything in the cockpit and most importantly, effecting a rapid evacuation of the aircraft and moving quickly to safety. Given the need to carry heavy medical bags, often on the shoulder, an assessment of carrying representative loads would be also carried out. While there are ways to compensate for the injury while it is healing, care has to be taken that other compensatory muscle groups not being overstrained. The flight medical doctor can also ensure that a timely referral can be made to any available physiotherapy service. Codeine would not be compatible with flying duties, but simple analgesia is fine, as long as it is well tolerated. It is important that the TCMs do not self-medicate, in line with other aircrew. The way ahead I would suggest that air ambulance units consider the following measures to ensure the occupational health of those paramedics who are working as front seat crew in a helicopter, in order to ensure aviation safety and meet the EASA TCM Medical Standards requirement: Appointment of a Flight Medical Doctor A flight medical doctor should be a primary care physician. They would ideally work in pre-Hospital Emergency Medicine (PHEM) themselves, to help understand the working environment. They also need experience and/or a qualification in aviation medicine or occupational health. They should not be involved in base management or clinical governance as this would mean a conflict of interest in maintaining confidentiality and independence. Such a doctor can also look at occupational health patterns to identify where the working environment can be improved. Provision of periodic medical assessments The chance to talk in an informal, one-to-one environment about any work or health concerns is important for the wellbeing of the HEMS crew members. It is important to ensure that eyesight and hearing

standards are also maintained, and crews have appropriate equipment for their protection, such as adequate hearing protection. Ensuring speedy referrals If a paramedic is off sick, it is important that secondary care services understand how to manage a condition in the context of the individual working in the aviation environment. A letter to their GP can provide information to add to this dimension. The Doctor can ensure any referrals are rapidly made to ambulance service occupational services such as physiotherapy or mental health with minimal delays. With thanks to Richard Miller, Georgio Bendoni and Jill Crooks from Wiltshire Air Ambulance for their assistance in preparing this article.

Further reading on medical standards To determine an appropriate medical standard for paramedics with a particular condition, the following guidance is consulted and interpretation can be made with application to the air ambulance front seat environment. 1 – CAA. There is extensive guidance on medical standards for cabin crew and Light aircraft pilots. This can be found at www.caa.co.uk/Aeromedical-Examiners/ Medical-standards 2 – DVLA. Group 2 (Lorries/buses) medical standards can be accessed at www.gov.uk/guidance/general-information-assessing-fitness-todrive

Dr Philip Lucas BSc(Hons) MB ChB MRCGP DipIMC RAF Philip Lucas is a Medical Officer and BASICS Doctor who also volunteers with Wiltshire Air Ambulance as a medical passenger. He is a qualified military aviation medical examiner who has previously worked as a pilot, accruing 2,000 hours flying, predominately on multi-engine platforms. All correspondence to Philip.lucas@swast.nhs.uk

References 1. Air Ambulance Association, Operational Characteristics of UK Air Ambulances, 2015. 2. In accordance with SPA.HEMS.130.(e) and Definition (115) in Annex 1 to CR (EU) 965/2012 3. Commission Regulation (EU) No 965/2012 amended as of 22/3/2017 4. Implementation of EASA Part-MED requirements, MED.C.005 (www. caa.co.uk/Aeromedical-Examiners/Medical-standards/Cabin-Crew/CabinCrew-Medical-Report/) 5. A medical person carried in a helicopter during a HEMS flight, including but not limited to doctors, nurses and paramedics [CR (EU) 965/2012, Annex 1, (78)]

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INSIGHTS INTOÂ

INTERIORS

Aerolite

How are police helicopters adapted for medical care?

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POLICE FOCUS

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aw enforcement aviation divisions were at the forefront of the development of air medical services in the 20th Century, and police agencies around the world continue to fly patients by helicopter, whether as a primary role or on an occasional basis. The equipment carried and the extent to which the interior is adapted for medical use depends not least on the mission mix the agency sees, but also on the size of the helicopters used. Hans Bretscher, Vice-President/General Manager at interior manufacturer Aerolite, has seen how varied a police operator’s requirements for a medical interior can be: “We found that the various law enforcement operators have different requirements. This ranges from a single-stretcher capability, up to full EMS capability that are the same as are on a dedicated EMS helicopter.”

Aerolite

Same but different For a police helicopter configured as a dedicated medical aircraft, the considerations for the design of the interior are identical to those of any other air ambulance helicopter. Alex Hudson, who handles marketing at interior maker Air Ambulance Technology (AAT), highlighted that police services have to follow the same regulations as other providers: “As far as the aerospace rules and regulations go (whether they are from the European Aviation Safety Agency (EASA) or the Federal Aviation Administration (FAA)), the police forces have to go by the civilian regulations as they fly civilians and not military staff. This means that they need a supplemental type certificate just like any other private operator.” Any differences in interiors therefore come not from the police status, but the particular requirements of the operator – Hudson commented that AAT’s interiors are all custom built. Wiltshire Air Ambulance (WAA), a UK HEMS charity, has experience working on both sides of the ‘blue line’. The service now flies its own helicopter, but used to partner with the Wiltshire Police and conduct joint missions on the law enforcement agency’s aircraft. Jill Crooks, Media and Communications Co-ordinator for WAA, commented on the parity of the regulatory regimes: “From an operational point of view, there haven’t been major regulatory differences between the shared and the stand-alone operation: HEMS tasking from the Ambulance Service remains the main trigger of any missions and they enjoy the same HEMS privileges accorded by the [UK] Civil Aviation Authority.” The interior layout and equipment demands of a law-enforcementorientated helicopter and a machine dedicated to patient care are, of course, different. Gustavo Romero, Director, Europe Region at aircraft interior maker Bucher Aerospace Corp., commented: “There are limited possibilities to reasonably adapt (in terms of cost and time) a pure police helicopter for medical use.” Where a helicopter’s main mission is observation from the air, the cabin configuration design has to bear in mind that overall weight should be minimised to allow the aircraft to stay in the air as long as possible, said Romero. In contrast, for air ambulance missions, ‘flight autonomy and duration play a secondary role compared with the medical support tools in the cabin’, he said, adding that space, cabin layout and access have to be optimised for loading and unloading a patient on

a stretcher. Where a helicopter serves dual (or multiple) roles, however, the interior design can help to promote flexibility, said Hudson: “We designed our equipment to be compatible with rappelling systems, hoists and tactical operator stations (FLIR and surveillance equipment). The seat the operator sits in is also used as a caretaker seat in the EMS role of the interior. At the same time, this is all compatible with the stretcher installation.” Broadly speaking, a police aviation division developing a new helicopter interior to include medical capability faces three options: to make use of quick-change installations to reconfigure the cabin ad-hoc according to the demands of each tasking; to opt for a compromise design, fitting in whatever law enforcement and air ambulance equipment is most needed; or to set up the helicopter with a full EMS interior. Of course, if the helicopter is large enough, then the operator has the luxury of having space for a full medical fit-out not instead of, but alongside, the law enforcement gear (such as a tactical station with camera and searchlight controls).

No compromise In 1948, the New York Police Department’s Air Support Unit received its first Bell 47 helicopter, although it was operating a fixed wing division from 1929. In 1954, the fixed-wing unit was abandoned, and the department operated solely with rotor wing aircraft with a variety of mission profiles. Let’s consider what is (in the US at least) the ‘original’ police medical helicopter service – the Maryland State Police (MSP). Following a mission in March 1970, the agency staked its claim as being the first civilian service in the US to transport a critically injured patient by helicopter. The organisation purchased its first helicopters, Bell Jet Rangers, specifically to fly patients such as injured traffic accident victims to hospital. In 1989, the Jet Rangers began to be replaced with Dauphins, which were in turn succeeded by AW139s from 2013 onwards. The two main considerations that have dictated the cabin layouts were the size of the aircraft and the roles the helicopter crews are charged with performing. While the helicopters’ role began as a medical service, it has expanded to ‘law enforcement and homeland security support, search and >>

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Aerolite

BUCHER

rescue, aerial rescue and disaster assessment’ – all performed by the same aircraft and crew. This multifunctional approach is advantageous when the character of a tasking changes mid-mission, such as when a high-speed vehicle pursuit ends with an accident and the crew transitions from assisting in tracking the vehicle to transporting injured drivers or passengers. Bearing the above in mind, it’s clear that the optimum approach is for the helicopter to be set up for both EMS and law enforcement operations at all times, which is possible thanks to the size of the AW139s the agency now uses. Discussing Maryland MSP’s fleet replacement programme after the order for the new aircraft was placed, helicopter manufacturer Leonardo (then known as AgustaWestland) noted that the new machines’ cabins are getting on for two-thirds (57-per-cent) larger than the Dauphins they replaced. The New York Police Department currently operates, among other aircraft, four Bell 429s, for a variety of missions including search and rescue at sea, patient transport, intelligence gathering and combating terrorism. Aerolite equipped these aircraft, the fourth of which was delivered in 2015, with stretcher capability, thus meeting New York state regulations that allow it to serve as a certified air ambulance. For search and rescue missions, the current MSP AW139s are fitted with rescue hoists and rescue baskets to bring injured victims onboard from locations where the aircraft is unable to land, and the organisation lists the standard medical crew as one flight paramedic/crew chief and one rescue technician. On the law enforcement side, the helicopters include tactical stations at the front of the rear cabins (aft of the pilot positions) with camera and searchlight controls, as well as moving map displays. For flights where the crew care for and transport patients, the helicopters feature customdesigned medevac interiors from Aerolite, which include flight crew seats that provide fore and aft movement, as well as full rotation, enabling the crew to either operate the tactical station or provide patient care during flight. The stretcher can also swivel, further facilitating patient access. The modular medical floors come with tracking that allows the aircraft to be set up to carry a second patient if required – the AW139s can carry one or two patients of up to 600 lbs (270 kg) each. The track system also allows for a neonatal isolette to be fitted, or for the seats and stretcher to be removed to make space for tactical cargo. The medical equipment carried includes fluid warmers and suction units, and the MSP selected +LifeBlanket all-weather patient packaging systems. The comprehensive approach to the interiors reflects the fact that ‘the airborne delivery of emergency

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medical transportation’ is the primary role listed in the Aviation Command’s mission statement. Shared aircraft In the UK, the partnership between Wiltshire Police and the WAA was pioneering in its own way, Crooks explained: “Most air ambulances use their own helicopter, but in Wiltshire the police force was the first in this country to pioneer a joint helicopter with the Ambulance Service.” Crewed by a pilot and observer from the police force, along with a paramedic from the HEMS charity, the helicopter was able to fly and make landings at unprepared landing zones at night thanks to the police equipment. In contrast to the example of MSP’s AW139s, though, the interior of the Wiltshire Police MD902 Explorer was a compromise. Critical Care Paramedic and Operations Officer Richard Miller has worked at WAA since 2001 and leads the service’s paramedics. He explained: “The interior of the MD902 had been specified for a primary law enforcement role, giving priority of installation to its core mission equipment, including the camera system and the connected recording devices. The HEMS equipment, fixed and carry-on, was accommodated in the residual space and weight capacity of the aircraft. Position and accessibility were suboptimal and required [continual] unbuckling or removal from storage. Accessibility to the patient was also limited due to cabin space constraints.” When police air coverage for the county was taken over by the National Police Air Service in 2014, WAA launched its own dedicated air ambulance helicopter, a Bell 429. The biggest change was that the entire interior in the charity’s new craft can be utilised for the medical role. Miller explained: “[It] was selected to deliver HEMS as its primary and sole mission; the interiors have therefore been designed and made to specs that have been developed by the clinical team to optimise the delivery of critical care, and the space and load capacity of this larger airframe. All equipment is custom fitted and it is ergonomically efficient in the delivery of pre-hospital care to the patient.” He added: “Becoming a stand-alone air ambulance was a radical change for the charity and has benefited patients. We now fly with two critical care trained paramedics and that is important because a lot of the extra medical treatment we can give to patients, such as sedation and pre-hospital blood transfusions, requires two clinicians.”


POLICE FOCUS

It’s important to point out though that the Bell 429 cabin has a larger volume than the MD902s – large enough that Delaware State Police adopted the Bell 429 in 2014 for an upgrade to its multi-role fleet. Like MSP, the Delaware Aviation Section has medevac as a primary mission, operating patient flights as well as performing search and rescue and law enforcement roles. The service’s helicopters can even accommodate two patients and two medical crew. And, as has been mentioned with the MSP example, there are benefits to having both law enforcement and medical staff onboard, as Crooks of WAA acknowledged: “Operational tasking which began as a police incident could become a medical incident. For example, a search for a missing person who, when found, needed urgent medical treatment, and this could include being airlifted to hospital.”

process, Bucher’s Romero noted: “Unless the original police helicopter was designed for multi-purpose mission profiles and equipped with the necessary fixed provisions (e.g., pipe connectors, brackets, hooks, etc.), it is unlikely that the police helicopter can be quickly and inexpensively reconfigured for medical use. Retrofit with the usual long downtime and costs would be necessary.” It’s a different story with quick-change systems. Hudson of AAT said: “As our interiors can be installed and removed within a few minutes, when a helicopter goes into maintenance (for example) the interior is removed and installed in the next helicopter … the policing equipment doesn’t have to be removed – in fact in one of the Arabic countries, they change the interiors from one helicopter to the next quite often.”

Quick change So far, we’ve considered larger helicopters that can accommodate a multi-role interior, and smaller helicopters where the police-plus-medical interior may equal compromise. The third option, of course, is to make use of quick-change systems to swiftly adapt the helicopter to either lawenforcement or medical-only use at the start of each mission. Bretscher of Aerolite shared his experience: “[Police operators] all want to be able to reconfigure these helicopters from EMS to a strictly [passenger] configuration within minutes … for police or VIP missions.” Interiors such as Aerolite’s allow for swift swap-outs without tools. Such adaptations are essential, as without them reconfiguring the aircraft would be a lengthy

Ongoing demand Although solutions may vary, it’s clear that there’s a continuing demand from law enforcement agencies for helicopters adapted to provide medical care. Just last year, for example, AAT modernised a number of Czech Police helicopter medical interiors, said Hudson: “They now have the newest medical devices (ventilator, monitor etc). We have designed new holders for these devices and installed them in the helicopter.” The decision on how to modify a police helicopter for medical use is always going to be based on mission profiles, but there is undoubtedly huge benefit in having the different options available on how far a police helicopter can be adapted for optimal patient transports.

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Profile: South African Police Service Air Wing The South African Police Service has operated an Air Wing for 33 years, since 1985. The Air Wing operates a variety of aircraft, fixed-wing as well as helicopters, which are based at airports around the country. They are used in many policing operations such as crime prevention, vehicle tracking and pursuit, dagga plantation spraying, crowd control and monitoring, VIP transport and search and rescue operations. The current fleet consists of 36 aircraft: • • • • • • • •

15 x H125 helicopters 6 x Robinson R44 helicopters 2 x MacDonnell Douglas 500 helicopters 1 x BK 117 helicopter 9 x Pilatus PC 6 aeroplanes 1 x Pilatus PC12 aeroplane 1 x King Air 90 aeroplane 1x Cessna Citation Sovereign Jet

The aircraft are strategically placed in different regions (see fig.1)

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All the helicopters are single pilot operated, together with a crew of airborne Law Enforcement Officers. The primary missions undertaken are airborne law enforcement missions such as crime prevention, as well as responding to call-outs for armed robberies, cash-in transit heists, and, of course, search and rescue operations. There is no set configuration for mission type, really, except where relevant mission equipment is required, such as a hoist, camera, or slings. Responding to emergencies is outside the Air Wing’s responsibilities, except for search and rescue operations, which are minimal in number. The bulk of Air Wing responsibilities entail responding to crime callouts. The Air Wing also provides air support during the monitoring of public protests and major events, including support to specialised units such as the Special Task Force, National Intervention Unit and Tactical Response Teams. A total of 2,695 airborne law enforcement operations were conducted during the 2017/2018 financial year (April 2017 to April 2018), which translates to an average of seven operations/events per day. In terms of the breakdown per type, 2,238 of the operations/events were conducted by helicopters and 465 by aeroplanes.


[fig.1]

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AIRCRAFT TYPE

PROVINCE

TOTAL AIRCRFT

H125 HELICOPTERS X 2 ROBINSON R44 X 2 PILATUS PORTER PC 6X1

EASTERN CAPE

5

H125 HELICOPTERS X 5 MD 500 HELICOPTERS X 2 PILATUS PORTER PC 6 X 3 BK 117 HELICOPTERS X1 PILATUS PC 12 X 1 CESSNA CITATION x 1 KING AIR 90 X 1

GAUTENG

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H125 HELICOPTER X 1 ROBINSON R44 X 1 PILATUS PORTER PC X 1

FREE STATE

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H125 HELICOPTER X 1 ROBINSON R44 X 1 PILATUS PORTER PC 6 X 1

POLOKWANE

3

H125 HELICOPTER X 1

MPUMALANGA

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H125 HELICOPTERS X 2 ROBINSON R44 X 1 PILATUS PORTER PC 6X 1

KWAZULU NATAL

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H125 HELICOPTER X 1 PILATUS PORTER PC 6 X 1

NORTHERN CAPE

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H125 HELICOPTER X 1 ROBINSON R44 X 1

NORTH WEST

2

H125 HELICOPTER X 1 PILATUS PORTER PC 6 X 1

WESTERN CAPE

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AirMed&Rescue had a brief word with Brigadier Mahlangu of the Air Wing For how long have you worked in the SAPS, and the Air Wing? I have been with the SAPS for 27 years, with five years in the Air Wing. What do you enjoy most about the job? The environment is highly specialised, technical and regulated which requires absolute focus and keeping up with the ever-changing dynamics. Its speciality and challenges make one derive more pleasure and motivation from the work. It’s one environment where safety is an apex priority, and thus as a manager it gives you powers which you will not have in an ordinary environment. Responsibility and accountability are the order of the day. What is the most challenging aspect of your role? My ultimate everyday goal is to ensure availability of serviceable, airworthy and well-equipped aircraft, proficient and well-trained pilots and crew for deployment at any given time. Should I not be able to provide such, it poses a challenge for me. However, with the support I get from everybody challenges are handled.

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SPECIAL REPORT

THE ARMIES THAT TRAIN TOGETHER...

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very year, the Italian Army’s Mountain Troops organise a skiing championship called CaSTA, which is now in its 70th year. The event takes place over the course of one week, during which the soldiers undertake a range of races in different disciplines – giant slalom, biathlon, cross-country skiing – as well as military activities. Sounds fun, right? Well, yes, but in fact, CaSTA is actually organised to test the operational capabilities of the Mountain Troops, and the stimulation of the competitive challenges pushes the soldiers to try their hardest, even though the aim of the event is training for military activity. More than 1,500 soldiers took part in the most recent CaSTA, in which 10 other nations participated, thus offering a training opportunity to increase cooperation and interoperability between elite units of allied armies.

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Mountain Troops The Mountain Troops (or Alpine Troops), constitute a significant part of the Italian Army, deployed throughout the northern Alpine arc of the country, as well as in the central Abruzzo region. Each Department, at a regimental level, has an alpine rescue team made up of at least eight people who are trained specifically for mountain operations – as experienced with skis as they are with snowshoes. The members of the team are qualified to provide first aid, holding BLS-D and BTLS licences; there are dog drivers, plus at least one radio player to guarantee connection with other teams and helicopters. The rescue teams are dedicated to the recovery of Alpine Troops and military departments in general, and are trained and equipped to that effect; this makes them suitable for use even at night and in particular emergency situations, such as when normal communication systems cannot be used. These skills, though, can also be used for civil emergencies, where the prefecture or the national civil protection system may request their involvement in a rescue scenario. Thus, in 2017, a historic battalion was recreated – the Vicenza – whose configuration is specifically adapted for intervention in the event of natural disasters when the civilian population needs them. With the challenge of a new mission profile, and working in collaboration with other civil organisations, the Army identified the need for targeted training for the integration of their respective skills, knowledge and operating methods. For this reason, CaSTA 2018 included an avalanche rescue exercise, conducted in co-operation with Army helicopters,


SPECIAL REPORT

the CNSAS National Alpine and Speleological Rescue Corps, the rescue teams of the Guardia di Finanza (Italian Treasury and border police), and units and staff of the Carabinieri (Military Police). Chaberton 2018 rescue scenario In the small village of Monte Rotta, consisting of huts scattered on a plateau at an altitude of 2,100 meters, there are some families, mainly elderly people, who have been isolated as a result of recent heavy snowfall. An Alpine Troop rescue team approached at night, with the help of night vision goggles and moving on fresh snow, reaching the first homes early in the day. Via radio, the rescue team communicated to the operations room that the residents needed to be evacuated due to their dangerous situation and their poor health status. Other rescue teams were sent in using Army and Carabinieri snowmobiles, and BV-206 tracked vehicles of the Army moved in a medevac configuration, towing a team of CNSAS using the skijoring technique (skijoring is a winter sport where a person on skis is pulled by a horse, a dog (or dogs) or a motor vehicle). The vehicles also carried a DRASH (Deployable Rapid Assembly Shelter) tent, which was used as an advanced rescue station. However, as that rescue was in progress, an avalanche overwhelmed a group of tourists who were skiing off-piste nearby. In order to cope with the new emergency, other rescue teams were needed, and the intervention of the Army Aviation helicopters became essential. A CH-47F Chinook of the 1st AVES Regiment (Army Aviation) ‘Antares’ was the first to arrive in the avalanche zone, deploying two army rescue teams using the fast-rope technique – a rapid deployment and retrieval method, carried out at a maximum height of 20 metres. Staff descend on

the rope without constraints, and two or more ropes can be used at the same time, and more people, spaced at least three metres apart from each other, can fall in sequence. It is a technique that requires specific training and physical training, and in Italy at least, it is implemented only by military personnel. The first teams arranged themselves in orderly rows in order to probe the avalanche in search of the missing, while at the same time, a second CH-47F reached the area with other rescue teams, and an AB-205 of the 4th AVES Altair Regiment / 34th Squadrons Group Toro landed two K9 units of the Guardia di Finanza and of the CNSAS. Dogs that are trained for avalanche research are still the most effective tool if people who are buried do not have an emergency rescue beacon on them. An operations director managed the influx of personnel throughout the morning, dividing them between the surveyors and the diggers, and placing them in the correct position on the avalanche so as to maximise the safety of the personnel as well as give them the best chance of locating the missing people. The first people extracted from the avalanche were taken to first level tactical triage, then depending on the severity of their health condition, an evacuation was arranged with the helicopter or with the BV-206, or even on a stretcher pulled by snowmobile. Co-operative working environment The training event was a complex exercise that saw the use of various structures and techniques for transport and research, and put to the test the logistical, communication and co-ordination skills of the various operators. For the Army and its Alpine Troops, meanwhile, this was a first step towards the realisation of a new project, in which at least eight rescue teams will become part of the national civil protection system, with full integration and operational readiness 24/7. All images by Dino Marcellino

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FEATURE

RISING WATERS Rescuing victims from floods with helicopters is a complex and dangerous business, but when performed correctly, it can save lives without risking those of the crew, or the aircraft in which they carry out their vital work. Barry Smith details the challenges for the crews performing these types of missions

Arizona DPS uses Bell 407s for flood rescues

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umans can’t live without water. They also can’t live very long with too much water. A report by the UN stated that, in the last 20 years, over two billion (yes, billion) people have been affected by floods. Rescue by helicopter during flooding is a very dynamic and often unpredictable process. It is an environment that can kill otherwise healthy people quickly by hypothermia and drowning, which can severely limit the amount of time given to perform a rescue. In addition, there are a wide variety of possible scenarios with floods that demand different techniques and equipment. Tried and tested techniques “Our flood rescues typically take place in our monsoon season, which is late spring to summer when moist air from the south is pushed into Arizona,” stated Dan Millon, Jr, Chief Paramedic with the Arizona Department of Public Safety (AZDPS). “These tend to be flash flood events where people try to cross flooded roads in their vehicles and get stuck.” The AZDPS has four single-engine Bell 407 helicopters that are used for flood rescue events. It also has one twin-engine Bell 429 equipped with a hoist, although it is not yet used for water rescues. One of the AZDPS’s basic techniques is to hover with one skid about a foot above the roof of a vehicle to remove passengers. The crew wears inflatable flotation devices as well as being secured by a full-body harness. Being this close to the water, a serious issue that the crew must watch out for is debris washing down and possibly hitting the tail rotor. They will

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then put a rescuer out onto the vehicle, who puts a personal flotation device (PFD) on the victim and gets them into the helicopter. One of the dangers at this particular moment, according to experts, is that as you remove the weight of the vehicle’s passengers, the car gets lighter and might begin to be pushed downstream. The team cannot put the skid on the roof of the vehicle in an effort to hold it steady, as by doing so

as you remove the weight of the vehicle’s passengers, the car gets lighter and might begin to be pushed downstream they could possibly dislodge it from whatever is holding it in place in the moving water. The AZDPS is also trained to use a short-haul rope system to place the rescuer in the eddy of the vehicle on the downstream side. In this scenario, the rescuer then moves onto the vehicle and disconnects from the line. He then secures the victims in a harness, and they are


FEATURE

all short hauled to a safe location on the bank. The short-haul rope for water rescues is attached directly to the cargo hook of the helicopter so the pilot can release it if it gets entangled and endangers the ship. The helicopter is flown at a very low level with the rescuers and victims on the short haul rope. In case the pilot does have to release the line, the fall is short and not lethal. The state of Texas can see a wide variety of flood events – thunderstorms, for example, can produce flash floods or inundate a few neighbourhoods over a small area. Hurricanes, meanwhile, can

The short-haul rope for water rescues is attached directly to the cargo hook of the helicopter so the pilot can release it if it gets entangled produce widespread flooding as happened in Houston, Texas, during Hurricane Harvey in 2017. During prolonged inclement weather, flood rescues become even more challenging. One of the most experienced rescue organisations in the state is Travis County STAR Flight, a civilian EMS and rescue helicopter agency with three hoist-equipped Airbus H145 helicopters. “Weather can be a huge factor in flood rescue events,” explained Mike Summers, a flight medic and Crew Chief with STAR Flight. “Low clouds, rain, wind gusts, and lightning can interfere with flight operations. With land rescues, the patient may be in an area difficult to access, but they aren’t moving. In water rescues, they can be moving, which increases the difficulty and danger to the rescuers and victims. If they are holding onto an object, such as a tree or vehicle, fatigue and hypothermia can cause them to lose their grip and get carried away by the moving water. So, a helicopter rescue team must act quickly.” Danger to life Assessing the scene requires considering the risks to the victims and the rescuers. Any time a rescuer is put into moving water, the AZDPS has to consider moving debris such as propane tanks, pieces of homes, furniture, and refrigerators, as well as fixed obstacles such as barbed wire fences and water features, which can suck a rescuer and their victim underwater. All of our rescue swimmers and crew chiefs, said Summers, maintain their hepatitis A vaccinations due to raw sewage often being in the water in wide area floods. In addition, there are often fertilisers, pesticides, petroleum products and other pollutants in the water. So, the rescue swimmers always wear a dry suit for flood events. Another very real danger is wildlife. In central Texas, water moccasins (a poisonous snake) and fire ants will gather in balls for safety as they get pushed through moving water. As soon as they encounter something stable, they will latch on to it, which might be a rescue swimmer. Other places in the southern US have alligators that end up in neighbourhoods due to flooding. Since many of the flood events occur in the hotter months of the year, the rescue swimmers must be monitored for heat illness due to being

in a dry suit. They have to stay hydrated and eat often as well as take regular breaks during long-lasting flood events so they can do their job and not end up as a victim. Victim prioritisation In a wide-area event, such as a hurricane, there can be many victims that need to be rescued. There may be entire neighbourhoods that are flooded, with hundreds of people either stranded inside flooded homes or on the roofs. In these situations, say experts, you have to determine who needs to be rescued first and who can wait. You also have to predict how long the event will last to determine fuel needs, crew rest, and whether or not there is a need to obtain more rescue resources, etc. The water may rise and fall quickly, in a matter of hours, or the water level may stay high for days. If the water is receding rapidly, the victims on the roofs may be safe until ground units can reach them. Then, the air resources can concentrate on the victims in higher risk locations or those who have been swept away. “The height of the buildings is important when assessing the risk to victims,” Mike Summers said. “With a two-storey house, the residents may only have to go to the second floor to reach safety. With a single storey home, they may have to go into the attic or onto the roof. If they go into the attic and the water continues to rise, they are at much higher risk. So, it is important to have information about what the water level is going to do in the next several hours when assessing a situation. In addition, you have to be flexible when developing a rescue plan because things can change quickly. If an otherwise safe building with victims on the roof suddenly collapses and dumps people into moving >>

A short haul system can quickly shuttle multiple victims to shore www.airmedandrescue.com

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victim – easily done in a large grove of trees. Next, they assess exactly where the victim is located in the tree. They might be secure, sitting in a fork of the tree well above the water. In that case, the helicopter can be brought in directly over the victim and use the rotor wash to blow apart the tree limbs, making the hoist relatively straightforward. However, if the victim is lower down or partially in the water, the rotor wash might end up dislodging them into the moving water. In this situation, the crew must lower the rescue swimmer outside the canopy of the tree to the altitude of the victim. The helicopter will then move the rescuer into the tree using radio directions from the rescuer. The highest-risk part of this rescue evolution is the extraction after the rescuer has reached the victim, as this is when the chance of cable entanglement is greatest. Good communication among the entire team is crucial, especially at night. “One of the key training points for us with flood rescue events is to minimise time of exposure for the victims and the rescuers,” Summers emphasised. “The quicker we are able extract the victim from the water, the less exposure to hazards for both the rescuer and the victim. It also reduces the risk to the helicopter and crew.” A huge issue that must be addressed is the fact that many victims in a wide area flood event may be elderly, have medical conditions, or are very young infants and toddlers, and thus may be much more difficult to fit into rescue devices and be safety hoisted into the helicopters.

Since many of the flood events occur in the hotter months of the year, the rescue swimmers must be monitored for heat illness due to being in a dry suit

US Army National Guard helicopters, such as this UH-60 Black Hawk, are frequently involved in large scale flood events

water, everything changes.” Summers continued: “We have a breaching kit if we have to get through a roof to victims in an attic. We try to use a vent as a breaching point because it can be difficult to cut through a roof. Here in Texas, many roofs are metal. The kit includes a battery-operated reciprocating saw with multiple blade types as well as hand tools for cutting and prying.” STAR Flight also trains its crews to access and remove victims through windows. During this training, they are taught about the different types of windows found in residential and commercial buildings, and how to insert a rescuer through the window. This type of hoist rescue requires a high level of skill and communication between the pilot and hoist operator as well as the rescuer on the hoist. Windows are typically no more than three feet by four feet, which is a very small target for rescuers to hit to achieve a successful hoist operation. Many of STAR Flight’s rescues, said Summers, occur in swift water events such as flash floods with the victims situated in trees. The technique in this situation is that once a victim has been identified in a tree, the team try to mark their location with a lightstick so they don’t lose track of the 3030

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Another issue is that many people will not leave their pets behind, say the experts. Many times, the people who do not evacuate when told are those who are infirm and have mobility issues. STAR Flight carries some rescue devices that work well for these kind of patients. One wraps around the victim’s back and upper legs with straps that come up between their legs and under their arms to cradle them like a large diaper, keeping the person in a seated position so they can be safely hoisted. They also have devices that can hold small children and infants. Sometimes, the rescue swimmer has to be creative to safely secure victims with special needs or those who are very small – they will take pets and have hoist harnesses for dogs, as well as enclosed devices for smaller animals to protect the animal and rescuers. Another option for rescuers who are tasked with saving lives in flood waters is the Airborne Tactical Extraction Platform (AirTEP), manufactured by Capewell. The AirTEP device itself was developed in France by Escape International, and it is engineered to be versatile and straightforward to use. It is lightweight and simple to deploy via helicopter cargo hook, and it collapses for easy transportation and storage. The device is built around a centre post that connects via 80’ line to the cargo hook. Five hinged ‘ribs’ fold out from the centre post to form the structure for the pentagonal platform made of heavy duty Kevlar webbing. The webbing is thermal, abrasion and chemical


FEATURE

resistant, which allows AirTEP to be used in harsh conditions on land or at sea. There are ten integrated personnel tethers that allow passengers to secure themselves directly to the centre post. Inexperienced passengers are usually seated with their backs to the centre post, while rescue personnel often prefer to clip in and stand. “The real beauty of the AirTEP is its versatility,” Capewell’s President and CEO John Marcaccio told AirMed&Rescue. “It’s a huge asset in many

One of the key training points with flood rescue events is to minimise time of exposure for the victims and the rescuers rescue situations. The floods following Hurricane Harvey in Texas are a good example. Hundreds of victims were rescued by helicopters oneby-one. With the AirTEP, multiple people could have been rescued in a single trip. That means a lot when whole families are stranded in yards or on rooftops in the middle of raging flood waters.” A joined-up approach Flood events can be very sudden or be anticipated several days ahead of time. They may involve a small dry wash or hundreds of square kilometers. Victims are of all ages, sizes, and physical capabilities. The key to successful helicopter rescue during these events is skill, the proper equipment, and the ability to quickly assess each situation and minimise risks of danger to the crew and the helicopter. All images by Barry Smith

www.airmedandrescue.com

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PROVIDER PROFILE

Airlec Ambulance Group Medical Director Dr Yann Rouaud introduced Airlec Ambulance’s blood carrying capacity to the travel insurance and assistance community at the ITIC Global event in November last year. AirMed&Rescue found out more about the French fixed-wing international air medical service The Airlec Group we know today dates back to 1997, when Patrick Tiba bought the rights to the name of what had been a major firm and France’s oldest business aviation company. He decided at that time to specialise in air ambulance flights, which now account for some 80 per cent of Airlec’s work. The company flies more than 1,000 patients each year. Patrick Tiba continues to serve as President and Chief Pilot – he is qualified as a Captain on the service’s Merlin IIIB and Citation planes. It’s a family concern, with son Paul Tiba in the role of Managing Director. Like his father, Paul is also a pilot, flying as captain on the Hawkers; both father and son still fly air ambulance missions alongside their leadership roles. Paul completed an aeronautical degree before working in every department at Airlec, an experience that he says gave him a deep understanding of every position in the company. He has served as managing director since 2011. Headquartered in Bordeaux, southwest France, the overall Airlec Air Espace group employs 35 staff, comprising pilots, engineers

and technicians. The firm also has a presence at Paris-Le Bourget Airport, including a permanent logistics replenishment base and a supplementary pharmacy. The group includes the Airlec Medical division, which provides international medical escort services onboard commercial flights and ground ambulances, and Airlec Ambulance, which flies patients onboard fixed-wing aircraft. Airlec Medical has 55 doctors and nurses at its disposal, who are called on for the medical evacuations carried out by Airlec Ambulance. Structure The current fleet, split between Bordeaux Aiport and Paris-Le Bourget Airport, comprises three turboprops (Merlin IIIBs) and three jets (a Citation Eagle II and two Hawker 1000B Elixirs). At least one aircraft (usually two) is on stand-by in Paris, along with four pilots. Each of the jets can accomodate two stretchers. For long-range missions, the Hawker 1000Bs offer a range of 3,000 nm, along with a standup cabin, a toilet, generous luggage bays and a loading ramp. When the second Hawker joined the fleet in summer 2017, Airlec highlighted its capabilities by listing the journey times possible, such as Paris to New York in eight hours, or Paris to Tokyo in 15 hours. As an example of actual missions, in March 2017, Airlec flew a patient from Montreal to Paris non-stop, and in May 2017, the firm completed a successful medevac from Iran to Belgium in one flight. Airlec says it only uses experienced pilots, with its captains having an average of 8,000 flight hours under their belts. Regular flight simulator >>

www.airmedandrescue.com

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training affords ‘the ability to perform any kind of flight to any destination’. The planes are maintained by Airlec’s team of in-house tehnicians in Bordeaux, supplemented by manufacturer service centres. Medical specialities The medical side of the business is headed up by Dr Hamida Chaouky (scientific and human resources) and Dr Yann Rouaud (communications and corporate side), who was appointed as Group Medical Director in August 2017. Dr Rouaud specialises in emergency medicince and disaster medicine, and has advanced cardiac life support (ACLS) and PALS certifications. As well as his hospital roles as an emergency physician, he worked as a flight doctor for a medical assistance company, performing medical evaucations, and has held senior positions with assistance companies around the world. A standard flight medical team comprises of a nurse and a doctor, and Airlec can dispatch paediatricians, gynaecologists, obstetricians and surgeons for difficult cases. All medical crew have an emergency care background, enabling them to repatriate patients in need of intensive care. The team also undergoes continuous training in medical aviation to keep abreast of the latest methods and technologies, and to guarantee the best

During the Ebola crisis, we instinctively knew we had to act and were confident that our aircraft and team were equipped to carry out the flights

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care possible. Airlec’s medical specialities include neonatal and paediatric intensive care. The service accepts bariatric patients weighing up to 168 kg, using loading ramps to board patients through the 92-cm wide door of a Citation Super II plane. Airlec can also conduct extracorporeal membrane oxygenation (ECMO) flights, and a surgical team consisting of a heart surgeon, a perfusionist, an anaesthetist and an intensive care nurse is operational for repatriation of patients with acute respiratory distress syndrome (ARDS) or cardiogenic shock. More unusually, perhaps, are the service’s history of flying patients infected with Ebola, and its recent adoption of a blood-carrying protocol. Airlec


PROVIDER PROFILE

has transported infectious patients using a negative-pressure isolation stretcher, and says it transferred the majority of European patients during the Ebola disease crisis in the winter of 2014-15 – one mission in October 2014 saw it become the first European aviation company to repatriate a confirmed Ebola patient, says the firm. The pilots and plane were supplied by Airlec, joined by a doctor, nurse and medical equipment from Medic’Air International. In October the following year, Airlec was awarded the Baltic Air Charter Association’s (BACA) Humanitarian Award for its Ebola work. Speaking at the time, Paul Tiba, who received the award at a ceromony in London, said: “During the Ebola crisis, we instinctively knew we had to act and were confident that our aircraft and team were equipped to carry out the flights.” BACA noted that while global advice was against flying into the region, Airlec created plans in co-ordination with the French government. BACA said: “The whole mission lasted only 42 hours, between the alert from the NGO and the return of the patient from Sierra Leone to Norway. The flight was conducted on Airlec’s Citation Super IIXR aircraft, (fitted with a cargo door) with most flying taking place at night. The most challenging part of the mission was to obtain landing permits for technical stops (refuelling). In total, Airlec safely performed eight repatriations of aid workers who were suspected or infected by the Ebola virus.” The company now uses its own medical team for cases involving infectious diseases, including Ebola, and last month successfully flew a patient with suspected Lassa fever. In July 2017, Airlec Ambulance announced that it had developed a medevac blood transfusion protocol after signing an agreement with the Etablissement Français du Sang (EFS), the French national blood service, which gave it access to plasma and red blood cell concentrate. The firm said it was taking the initiative to respond to the need for blood transfusions on medevac missions, putting an end to dramatic situations where patients could not be rescued due to blood needed for transfusion being either unavailable or unsafe where they were being treated. Dr Rouaud, in presenting the new protocol to the audience at the International Travel & Health Insurance Conference (ITIC) in Barcelona, Spain, last November, gave road traffic accidents and gastrointestinal bleeding as examples of situations where the ability to fly

blood to patients would be advantageous, and detailed the company’s first use of blood products on a live mission: a patient with malaria was successfully flown from Abidjan, Côte d’Ivoire, to Paris, France. Ethics Something emphsasised in Airlec’s marketing is its pride in French medical culture and strong belief in ethics. Dr Yann Rouaud explained: “Airlec Ambulance, a state-of-the-art air ambulance company, is first of all a family business with genuine human values and truthful leadership. By experience, we know that urgent evacuation/repatriation situations carry many

we know that urgent evacuation/repatriation situations carry many challenges with a lot of emotion for patients, families and clients challenges with a lot of emotion for patients, families and clients. Therefore, we proudly commit to keep all stakeholders at the centre of everything we are doing. Top technology, [high] performing jets as well as highly skilled medical teams is one thing, but a benevolent and empathetic relationship is a must through hard times. Trust has to be well deserved. Our philosophy is, and will always be, to offer efficient solutions and make a positive difference in people’s lives.” Looking forward As for the future, a representative told AirMed&Rescue that Airlec is constantly on the move. The company acquired two more jets, a Hawker 1000B and a Hawker 9000XP, in late February. They are now being modified to air ambulance configuration and will be integrated into the fleet this summer. Airlec said that the purchase was made ‘in order to respond to an increasing number of requests’. For Airlec, it seems, the only way is up.

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Members of the of the 455th Expeditionary Aeromedical Evacuation Squadron assist patients on a C-17 Globemaster III medical transport flight out of Bagram Air Field, Afghanistan, March 21, 2013. With help from the Critical Care Air Transport Team, the crew can turn a regular medical transport aircraft into a flying intensive care unit, making it possible to move severely injured or gravely ill servicemembers by air. (US Air Force photo/Senior Airman Chris Willis)

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TAKING ALL THE EVIDENCE INTO ACCOUNT Amy Gallagher reports on new US Air Force evidence-based research on aeromedical evacuation in-flight stressors, the findings of which may alleviate a ‘second hit’ to patients Preface The US Air Force (USAF) Aeromedical Evacuation (AE) System is a significant part of the nation’s primary mode of patient movement within the theatre of operations (intra-theatre) or between two theatres (inter-theatre) to medical treatment facilities (MTF) where essential and/ or definitive care can be administered. Through AE crews and Critical Care Air Transport Teams (CCATT), the AE force provides missioncritical en route patient care, scalable En Route Patient Staging Systems (ERPSS), and transport of contaminated and contagious patients using the Transport Isolation System. Air Force AE clinical protocols are guided by Air Mobility Command, the lead command responsible for clinical and operational policy, organising, training and equipping AE forces and CCATT. The Air Force AE department charged with improving En Route Care (EC) for the Joint Force is the 711th Human Performance Wing, Division of EC, USAF School of Aerospace Medicine (USAFSAM) Aeromedical Research Department at Wright-Patterson Air Force Base (AFB) in Dayton, Ohio.

EVIDENCE-BASED SCIENCE EXPLAINING HOW AND WHY IN-FLIGHT PHYSIOLOGICAL STRESSORS AFFECT THE HUMAN SYSTEM HAS REMAINED A MYSTERY

From the EC Research Division, USAF Colonel Nicole H. Armitage, NC, PhD, Chief; Tami Averett-Brauer, MN, RN, Colonel, (Retired) USAF, NC, CFN, Core Research Competency Lead (CRCL); and David Burch, PhD, Research Biomedical Engineer, and William Butler, PhD, Colonel (Retired), contributed to the investigation of the first ever evidencebased research (EBR) on in-flight physiological stressors of AE transport on patients who were prescribed a Cabin Altitude Restriction (CAR) by the Theatre Validating Flight Surgeon (TVFS) and those who were not. This article further explains the research results, as well as the post-hoc salutary clinical effect for CAR patients, which may reduce potential postflight complications and procedures. Clear evidence at last Although substantial research on the science of flight stressors on aircraft and medical equipment has been widely published, the evidence>>

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based science explaining how and why in-flight physiological stressors affect the human system has remained a mystery, until now. Understanding the science of how flight stressors can ‘add insult to injury’ to an AE patient is explained in the research study, Assessment of Aeromedical Evacuation Transport Patient Outcomes with and without Cabin Altitude Restriction, August 2017 Final Report as researched and published by the 711th Human Performance Wing USAFSAM, EC Research Division, which produces knowledge and technologies to improve EC for the Joint Force. The three-year evidence-based research (EBR) report showed patient outcomes that were impacted by a ‘second hit’, during aeromedical transport, with the ‘first hit’ incurred on the battlefield.

Master Sgt. Zachary Johnson cares for a patient during an aeromedical evacuation mission to transport patients July 19 from Kandahar Airfield, Afghanistan, to Bagram Airfield, Afghanistan. Sergeant Johnson is a 451st Expeditionary Aeromedical Evacuation Flight aeromedical technician. (US Air Force photo/ Staff Sgt. Shawn Weismiller)

Practicing EBR to ‘close the gap’ AE is the ‘means of moving patients from one level of care to the next, always bringing the patient to a higher level of care’, explained Averett-Brauer. “We focus on the evacuation and in-

WE KNOW AEROMEDICAL EVACUATION IS NOT WITHOUT RISKS

flight phases and transitions of care, and the austere environment within the transport aircraft,” she said. “At the same time, we now know AE patients are exposed to a number of in-flight stressors. Unfortunately, we also know AE is not without risks.” The practice of conducting EBR is designed to open doors to greater

understanding in all areas of medicine while closing the ‘theory-practice gap’, according to Averett-Brauer. More specifically, the multi-phased, retrospective matched case control study investigated whether there were differences in the clinical outcomes, in-flight status, and mission costs between CAR and non-CAR patients as prescribed by the TVFS, she added. “Although guidelines for the use of CAR exist, those guidelines are not necessarily supported with EBR,” explained AverettBrauer. “This study followed the EBR protocols to identify if a patient receives any clinical benefits with a CAR.” Prescription: CAR It is current practice that the TVFS makes the flight prescription for a CAR based on the potential negative impacts of flight on the patient’s clinical condition, said Dr Burch. One example is determining whether or not the patient will have adequate haemoglobin saturation throughout the transport. “This can be impacted by the patient’s haemoglobin levels, cardiac output, lung shunt ratios, and the TVFS determination of whether the patient will have adequate tissue oxygen delivery,” explained Dr Burch. “Our research aims to expand and validate the paradigm of this tissue oxygen delivery to account for more variables that may influence patient outcomes and provide decision support for the TVFS and the in flight clinical team. We are contributing to the evidence base needed to make changes to the TVFS Primer, which is a clinical guide used within the patient movement system,” he added. “CAR is but one of several prescriptions available to the TVFS, such as supplemental oxygen, more gradual ascent/descent profiles, and blood transfusions, to name a few.”

Aeromedical evacuation and critical care air transport team members prepare Army Spc. Dustin Morrison, an Iowa Army National Guardsman severely wounded by an improvised explosive device attack in Afghanistan, for an April 26, 2011, flight from Ramstein Air Base, Germany, to Washington, D.C., for treatment at Walter Reed Army Medical Center. (Defense Department photo/Donna Miles )

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Paradigm of tissue oxygen delivery Traumatic brain injury (TBI) research conducted by the Air Force and US Department of Defense (DoD) has been instrumental in


FEATURE

the development of various breakthroughs that are improving the lives of airmen and all other service members who have sustained a TBI, explained Averett-Brauer. “Research and studies examining the interactions between TBI and low-pressure aeromedical conditions, the impact of hypobaric environment, and understanding of how TBI is

RESEARCH AND STUDIES … HELP GUIDE THE WAY THE AIR FORCE TREATS TBI RECEIVED ON THE BATTLEFIELD

impacted by the aeromedical environment help guide the way the Air Force treats TBI received on the battlefield,” she added. The research lines of inquiry included understanding the impact of transport on patients and providers; improving operational clinical care and patient safety; developing medical technology solutions; and simulation, education and training research, said Averett-Brauer. “We use a variety of research approaches including quantitative and qualitative methods; retrospective and prospective studies; interventional studies; and clinical trials,” she added. “We also evaluate medical technologies for use in the EC environment.” Research approaches include explorations surrounding the stresses of flight, including hypobaria, hypoxia, vibration and the biodynamics of the environment, noise, temperature changes, and humidity changes; all of these stresses of flight culminate in fatigue. “Well-established research has demonstrated reductions in tissue health associated with acute high-altitude exposure due to hypoxic hypoxemia,” said Dr Burch. “However, at much lower altitudes, including those common for patient transport (8,000 feet or below), we are seeing some changes in oxygen saturation.” However, lower partial pressure of oxygen alone cannot fully explain the effects observed in controlled studies, he added. “We are still investigating the mechanisms to ascertain if they are more dependent on hypoxia, hypobaria, or interaction effects of both factors,” said Averett-Brauer. “Once we better understand the stresses of flight on the patients, our research can better focus on identifying mechanisms that may cause secondary insults due to transport, so that we can then focus on determining optimal mitigating strategies to improve patient outcomes. This is only the beginning.” Potential outcome for the soldier The goal is to maintain and improve patient status during the transport, using the transport time for therapeutic gains, according to Colonel Nicole Armitage, Chief EC Research Division. “All this feeds into improved patient outcomes, facilitates return to duty and improved quality of life, or improved transition to civilian life,” she added.

Consolidating electronic and handwritten documentation into the full implementation of the electronic health record (EHR) also leads to improved patient outcomes, said Averett-Brauer. “The vision is that the EC EHR will be part of the entire health record continuum,” she said. “Access to improved patient care data will translate into higherquality evidence and analyses.” With the continued development of retrospective and prospective research capabilities, the team will be able to provide stronger evidence to inform clinical protocols, according to Averett-Brauer. Physiological phenomena from additional altitude The AE flight has a number of physiological stressors that could potentially cause a ‘second hit’ to the patient, said Averett-Brauer. The research concluded that hypoxia and hypobaria are the most prominent features associated with the cabin environment. “As a result, CAR is often prescribed to counter the effects of hypoxia and hypobaria on such patients,” she said. As explained in the research report, the pressurisation imposes both hypoxia (reduced oxygen availability) and hypobaria (reduced barometric pressure that has a physiologic effect of shifting intravascular fluid into

RESEARCH APPROACHES INCLUDE EXPLORATIONS SURROUNDING THE STRESSES OF FLIGHT, INCLUDING HYPOBARIA, HYPOXIA, VIBRATION AND THE BIODYNAMICS OF THE ENVIRONMENT

the extravascular space) upon patients. The research further stated that the two physiological phenomena can have an adverse impact on tissue oxygen delivery (DO2), particularly critical to patients’ compromised physiology (eg. massive transfusions, significant trauma). “The results suggest that the AE flight may not be innocuous,” said Dr Burch. “Indeed, it may pose a ‘second hit’ risk to our patients, resulting >>

Medical personnel prepare to transfer patients from a KC-135R Stratotanker to an ambulance after arriving on an aeromedical evacuation flight to Hickam Air Force Base, Hawaii on Feb. 23, 2017. (US Air National Guard photo by Tech. Sgt. Annie Edwards)

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FEATURE

in both devitalised and compromised tissue.” As explained by Dr Burch, the CAR is generally accompanied by a drop in the cruising altitude. “Normally, the cabin is pressurised around 8,000 feet,” he said. “In an already compromised patient, this lower cabin altitude (CAR) can potentially benefit the patient in a number of ways.”

IN AN ALREADY COMPROMISED PATIENT … LOWER CABIN ALTITUDE CAN POTENTIALLY BENEFIT THE PATIENT IN A NUMBER OF WAYS

Post-flight: the clinical effect of CAR The salutary clinical effect of CAR might well alleviate the ‘second hit’ based on our understanding of the DO2 paradigm, said Dr Burch, citing his mentor and the study’s author Dr William Butler. In addition to hypoxia and hypobaria, the research indicated other stressors including acceleration forces, vibration, noise, thermal instability and reduced humidity. “These flight stressors can ‘add insult to injury’, including multiple organ system post-flight complications,” said Averett-Brauer. “Knowing the cabin altitude consequences, we can expect a physiological milieu in which oxygen diffusion into tissues is impaired,” she said. “This can cause a potential drop in oxygen delivery to the tissue or DO2.” However, the CAR is a prescription that can enhance DO2 by bringing the patient ‘closer to the ground level’, which would lessen the impact of hypoxia and hypobaria, Averett-Brauer said. Additionally, the findings revealed that those patients who were transported with a CAR had a significantly lower systolic blood pressure

and a statistically higher 24-hour fluid intake. The most significant finding was in post-flight procedures with the CAR group, which experienced fewer major and minor procedures, according to Dr Burch. “The study, however, did not find a significant difference in length of stay, days in the ICU, post-flight transfusions, or discharge status,” he said. More to be done Investigations into the uses of CAR and the impact on patient outcome will continue, Averett-Brauer said: “One special means through which the TVFS can mitigate clinical impact is the CAR. The effect is most likely a consequence of improved DO2, making a ‘second hit’ to already compromised tissues less likely. Thus, these results suggest a CAR benefit. This study is just the beginning.” Dr Burch concluded: “We anticipate closing more of the gaps in knowledge between patients with survivable injuries, and those that ultimately survive and thrive.”

Sources Fouts, Brittany; Butler, William; Connor, Susan; Smith, Danny; Maupin, Genny; Greenwell, Brandon; Serres, Jennifer; Dukes, Susan. Final Report Aug 2017, March 2014 to August 2017; Assessment of Aeromedical Evacuation Transport Patient Outcomes with and without Cabin Altitude Restriction, [Online] REPORT DOCUMENTATION PAGE.1-4; 8; 22-23. Interview 15 Feb 2018; Armitage, Nicole H.; Averett-Brauer, Tamara; Burch, David. Air Force Research Laboratory, 711th Human Performance Wing, U.S. Air Force School of Aerospace Medicine, Aeromedical Research Department, Wright-Patterson AFB, OH. Available from: http://www.dtic.mil/dtic/tr/fulltext/u2/1039508.pdf Access: 28 Jan 2018.

Tami Averett-Brauer,

Nicole H. Armitage,

David Burch,

MN, RN, DR-III (GS-14), DAF Civilian Colonel,USAF, NC, CFN (Retired) Core Research Competency Lead (CRCL) -- En Route Care (EC)/Expeditionary Medicine (EM) En Route Care Research Division, Department of Aeromedical Research USAF School of Aerospace Medicine, 711th Human Performance Wing

Colonel, USAF, NC, PhD Chief, En Route Care Research Division

PhD, Research Biomedical Engineer, En Route Care Research Division, USAF School of Aerospace Medicine, 711th Human Performance Wing

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m am ll gr e Fu Pro labl p ai ho av ks w o r no W FEATURE

e

RCN Critical Care and In-Flight Nursing Forum

Fit to fly: complex care in the air RCN Flight Nursing Workshop Fees t jus from £

82s.V5AT0 plu

Join us for this workshop as we expand your knowledge and skills in flight nursing. If you are a medical professional working in or with an interest in aviation medicine this workshop is your invaluable learning opportunity to develop your confidence and competence in delivering challenging medical care in the air. • Discover the changing face of global health and how this impacts patients requiring care abroad • Explore factors affecting medical decision making in regards to what is medically appropriate vs medically necessary • Learn how airlines accommodate passengers requiring special assistance and determine who is fit to fly • Understand the commercial pilot and crew perspective on human factors and teamwork in flight • Reflect on complex cases from military, commercial flight nursing and air ambulance transfers

Timings Registration and networking: Workshop:

9am

9.30am-4.30pm

Planned topics include: • Travel trends – what’s new this year • Special assistance and disabled travellers • We will be joined by speakers from major commercial airlines • Human factors and communication within the aviation industry • Complex care in the air: case studies

Really enjoy these workshops to network with others in the industry and gain bespoke CPD opportunities for flight nursing RCN Flight Nursing Workshop Delegate, October 2017

For further information and to book, visit www.rcn.org.uk/FN18

Saturday 6 October 2018

RCN HQ, 20 Cavendish Square, London W1G 0RN Accrue up to 7.5 hours of CPD

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PROFILE

DAVID LOCKEY

AirMed&Rescue spoke to Professor David Lockey, the new National Director of the Welsh Flying Medics, about his experience in the charity air ambulance sector, and how he sees the future of the organisation developing Why did you decide to take on the role of National Director of the Welsh Flying Medics? For those who may not be aware, the Welsh Flying Medics (also known as EMRTS Cymru) refers to the NHS medical provision on board the Wales Air Ambulance (WAA) Charity helicopters. In this unique partnership, the Welsh Flying Medics supply the medical teams and equipment while the WAA raise the funds required to run the helicopter operation. I have been involved in many UK air ambulance operations in my career.

“The Service is ... looking to broaden its research portfolio, and this may lead to opportunities to introduce innovative technologies across the medical and operational spectrum” This Service has been set up from scratch in a short period of time and has learned many lessons from the successes and problems in long-established services. It is a young, highly professional organisation with excellent governance serving a population with a fascinating mixture of trauma and medical emergencies in a mixed rural and urban environment. The 42 42

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National Director role was a rare opportunity to lead a great organisation and one I could not miss. What are the primary challenges the organisation faces at the moment? The major current challenge is developing a service configuration that delivers critical care to the highest possible proportion of the population when they need it. This means expansion of the service into night hours, which will be a major undertaking. How do you see the Service model developing in the future with regards to the Major Trauma Network, and the effect that its introduction will have on delivery of urgent medical services? The Service is already delivering high-quality trauma care in Wales. Approximately half of the current case mix is trauma. When a trauma network is developed, high-quality pre-hospital care is an essential component of the trauma patient journey. We look forward to working with the ambulance service to develop even better early trauma care and transfer to appropriate receiving hospitals as part of trauma network development. We are currently engaged with the development of a major trauma network in South Wales and South Powys, while already contributing to the existing trauma network that covers North Wales. Any developments in our service will enhance patient care the whole county.


PROFILE

What innovations has WAA been coming up with to improve the care on offer to patients, and are there any more in the pipeline? We are one of the first services in the UK to carry blood products on board its helicopters, and we have developed a comprehensive range of blood products to treat haemorrhage and patients on anticoagulation drugs (e.g. Warfarin). The organisation is looking at innovative ways to improve service delivery. One of these ideas has already been rolled out, in the form of an app, which has been produced for staff and provides the ability to have a huge amount of information about hospitals, staff and major incidents to hand when working on scene. The Service is also looking to broaden its research portfolio, and this may lead to opportunities to introduce innovative technologies across the medical and operational spectrum. However, in the shorter term, we have plans to introduce telemedicine capabilities from the aircraft and we are exploring body-worn video cameras to enhance clinical audit and learning. In addition, the Service has strong links with Swansea University and is continuing to link data to allow longitudinal follow up of patients through their world-class SAIL database. This data is used to quality assure and examine the impact that the Service is having. Our Charity partners have introduced, and are fully funding, the Children’s Wales Air Ambulance. This aircraft, currently being trailed, is dedicated to the inter-hospital transfer of neonates and paediatrics, and when required adult patients. This specialist service has also prompted the introduction of a new role, Helicopter Transfer Practitioner (HTP). Continuing professional development of the medics onboard the helicopter is key to their ability to deliver the best pre-hospital care; how does the Service make certain that all its medics are gaining sufficient knowledge and experience? The Service runs a comprehensive selection, training and continual professional development programme to ensure that our doctors and critical care practitioners (CCPs) are well placed to utilise best practice and new developments in pre-hospital care. All full-time medics have access to a generous package of protected training time and study budget. This not only includes access to standard life support courses, but extended skills such as ultrasound use. In addition, CCPs undertake an MSc in critical care from one of a number of providers and we are currently developing a bespoke course with academic partners. This is overseen by consultant and CCP leads for training

and education who regularly review portfolios, as well as named supervisors for each member of staff. In addition to developing our own staff, we deliver a large number of CPD events and observer opportunities to partner organisations and individuals every year. This ensures that we meet one of our aims of supporting clinical and skills sustainability. Previously, you were a consultant and research lead at London’s Air Ambulance, and are a trustee of that charity. How has your role there helped you to prepare for your new job in Wales? Although the two services are very different, many of the challenges (e.g.

“System design is the key component of improved outcomes” 24-hour working, meeting the specific needs of the population and the introduction of new interventions) is common to both. This, and exposure to a huge number of trauma patients over 20 years, has made London a great preparation for this Service. Working as a charity trustee has also given me a valuable perspective into some of the challenges and successes of our key operational partner – the Wales Air Ambulance Charity. The Welsh Flying Medics also has a great deal of potential as a research organisation – and this is an area in which we are keen to deliver. You also have military experience of pre-hospital care. In what capacity did you serve? I have served in pre-hospital and in-hospital military roles in several recent conflicts. It has been a privilege to be involved in a system that has evolved so quickly to deliver amazing outcomes to the seriously injured in very difficult operating conditions. In what ways do you think that civilian air ambulance organisations can learn from the military medical evacuation service? System design is the key component of improved outcomes. In common with military medical evacuation services, we need to adapt our service to the needs of our population, the geography and the other services that we interact with. Although specific interventions and medical advances are important, the overall performance of a good system is what really delivers results. There has been international interest in medical innovations used by the Welsh Flying Medics from Northern Ireland, New Zealand and America; what were these medical innovations, and did new practices get introduced in services in other countries as a result of those being undertaken by your teams? Whilst many of the innovations were relatively new in 2014 when the Service was being developed, these are rapidly becoming standard practice across the sector. One aspect that still stands out, though, is the workforce model that has many advantages to the Welsh NHS, clinicians and, of course, patients. Our consultants already hold permanent contracts within the NHS in Wales and England. In the majority of cases, their sessions with us are done in addition to their standard NHS sessions, so hospitals are not being denuded of consultant cover. This model has acted as a blueprint for other new services who are in the process of setting up.

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INTERVIEW

Undertaking critical research Gathering sufficient data in order to reach viable conclusions is an issue that many in the air rescue community face. For air medical crews in the military seeking to ensure they maximise resources and skillsets, though, this is increasingly vital Colonel (Ret.) Elizabeth Mann-Salinas, PhD, RN, FCCM, Senior Nurse Scientist Department of Trauma Outcomes and Systems Research Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research Army Burn Center, spoke to AirMed&Rescue about the research into en-route critical care transfers she and her team have undertaken recently. In terms of your background and experience in the military, where did you serve, and in what capacity? I joined the Army in 1994 directly from my baccalaureate nursing programme and was assigned to a hospital in Georgia, US for four years. During that time, I spent four months training as a critical care nurse and worked in the Medical Intensive Care Unit (ICU). I then moved to Heidelberg, Germany, for three years, where I was assigned to the 212th Mobile Army Surgical Hospital (MASH) as an ICU nurse and deployed to Kosovo as part of the NATO mission. Then I moved to New Orleans, Louisiana, and served as a healthcare recruiter for two years and before going to Denver, Colorado for graduate school. I received a Master of Science as a Critical Care Clinical Nurse Specialist (CNS) and moved to San Antonio, Texas to be the Burn ICU Head Nurse and then the CNS. The Army offered to fund me to obtain my PhD in Nursing at the University of Texas in Houston, after which I returned to work at the Army Burn Center and Institute of Surgical Research to conduct combat casualty care research. During this assignment, I deployed to Afghanistan as a research co-ordinator and was located at Camp Bastion with the UK combat support hospital (CSH). I recently retired from the Army last year and am continuing my research in a civilian capacity at the ISR. What prompted you to carry the En Route Critical Care Transfer From a Role 2 (R2) to a Role 3 (R3) Medical Treatment Facility in Afghanistan research? During the 2013 deployment at Camp Bastion, we initiated a working group of military US and UK tri-service members (Army, Navy, Air Force) to understand the effect the UK MERT (Medical Emergency Response Team) had on transport of patients from point of injury to the role 3 CSH. The hypothesis was that with the physician and enhanced team on a large airframe, with blood products and advanced airway management, the MERT would ‘overfly’ the small austere R2 team and take the extra time to travel to definitive surgical capability at the R3. During this process, we realised that no review of any aggregated R2 work had been done and there were a myriad of unanswered questions relating to the utilisation of the R2 capability. As a result, two years later, about $3.8 million of research funding was received to perform a comprehensive investigation of how R2 was utilised and to inform best 4444

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practices for training deploying personnel. We have published a series of manuscripts to date regarding our analyses of the R2 data set maintained by the US Joint Trauma System. During the same time, I had been an active member in the Triservice Nursing Research Program (TSNRP) En Route Care (ERC) Research Interest Group. When we had the opportunity to contribute to an ERC special edition of Critical Care Nurse, this project was perfect because of the utilisation of critical care nurses for post-surgical transport from the R2 to R3. Your team involved representatives from many different military organisations, how did you co-ordinate everyone and your findings? Our institute is unique in that we have Army, Navy, Air Force combat casualty care research colocated within the same organisation. Additionally, the Joint Trauma System is located here. Therefore, it is possible to align research efforts among different services. We have been able to closely collaborate with the US Air Force research team, led by MAJ (Dr) Maddry, and the Joint Trauma System surgeons oversee the registry where the data were retrieved. Colonel Biever is the Consultant to the Surgeon General for En Route Critical Care Nurse (ECCN) programme and is the expert in this area. We remain in close contact with her through our professional network. It is exceptionally easy to co-ordinate and collaborate when everyone (except Colonel Biever)


INTERVIEW

is literally in the same building, all pursuing improvement in delivery of combat casualty care. What are the main insights from the En Route Critical Care Transfer study? Probably the most important finding is the lack of documentation of what happens during en route care. This is an identified problem on all levels because we cannot monitor and improve a system without information/data. Many teams are working on technological solutions to overcome this shortcoming, but solutions are complex and won’t be available any time soon. We can strive to hold individuals accountable for clear documentation, but currently there is no mandate to hold unit commanders accountable for ensuring this is accomplished. Another critical element is understanding what provider capability is required for various patient types. For example, the ECCN programme came about because it was recognised that a medic, or even paramedic, lacks the critical care experience to care for post-operative patients requiring transport following damage control surgery. Our next challenge will be to determine the ideal provider skill sets for various transports. How might these insights help to inform decisions on team composition, staff training and the ideal skill mix of a team on the battlefield and in the air? Identifying the ideal team composition and skill mix is the ultimate goal of this work. We have much to learn from our colleagues in the UK with

the MERT teams in the far-forward environment. However, physicians and ECCNs are a commodity that must be carefully employed. A project we are now working on is the concept of ‘intelligent tasking’ – basically sending the right capability to the right place in an efficient manner to safely move that patient to higher levels of care. We can utilise machine learning, decision support technologies to assist the dispatchers and medical planners, but we need data to inform the algorithms. Back to problem number one… What research are you currently working on, and can you share any insights about this with AirMed&Rescue? We hope to develop a medical operation center, similar to the one in Texas, to execute the intelligent tasking of resources, create seamless communications across the battlespace, offer virtual/telesupport, and provide situational awareness of all stakeholders. Our other main effort is to develop a comprehensive and standardised training programme to ensure all providers have basic competency in deployment-related knowledge, skills and abilities. First, we had to define what the core competencies are in the deployed environment, and then determine optimal training platforms, and finally, document that each individual is ready and validated for deployment. There is much more to be done, but we are making improvements incrementally and the future is bright. Contact: Elizabeth.a.mannsalinas.ctr@mail.mil for additional information.

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COMPANY PROFILE

Kopter Company Profile

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COMPANY PROFILE

E

ntering the headquarters of Kopter in Wetzikon, Switzerland, what immediately strikes you is the air of quiet excitement; as well as the large helicopter placed in the middle of the open plan office – the first prototype of the SH09 has been given pride of place in the building. The team at Kopter is right now working steadily towards its goal of certification of its SH09 helicopter, which will happen during the second half of 2019, with P3 (the third prototype) to head into flight testing in the coming weeks. For CEO Andreas Löwenstein, the ramp up towards delivery of the helicopters to the first customers is an exciting time, and one he has been working towards since he joined the company some 18 months ago. With more than 28 years of experience in the aerospace and defence industry, having worked at EADS and Eurocopter in the past, there is little doubting the fact that he knows what the market needs, and for him, the opportunity to be at the helm of a company that is delivering a brand-new helicopter to the market was one that he couldn’t pass up. “I’ve always been a builder,” he told AirMed&Rescue, “whether that is building a company or building a team. To bring together the team and knowledge that inspires the spirit of innovation is a very enjoyable experience.” A costly one though – CHF300 million (€253,670,343) has been spent so far, and certification has still to come. In a move new to the industry, Kopter is aiming for dual accreditation from the European Aviation Safety Agency and US Federal Aviation Administration at approximately the same time – ambitious, for sure, but achievable, said Löwenstein, depending on how the two agencies will work together, which seems to be going very well today.

Fresh approach Designed originally in 2009 by Martin Stucki from scratch, with large rearopening cargo doors and no separation between the cockpit and the cabin, the spacious interior of the SH09 allows for a wide range of configurations – emergency medical transport, surveillance and law enforcement, utility, and passenger transport. Its modular design means that the change from one mission profile to another can be effected quickly and easily – from adding another stretcher, to moving the pedals from the second pilot’s seat in order to allow an additional passenger to sit safely in that seat without risking an accidental movement of the pedals by that passenger. Löwenstein used the term ‘a flying Swiss Pocket knife’. Löwenstein has mentioned in the past that innovation in the helicopter market is notable by its absence – ‘it’s easier for manufacturers to stick with what has been tried and proven’, he said.

So, what is different about the SH09 to other aircraft? “New technology has allowed for a change in fundamentals – the helicopter architecture being one,” he said. “Being made from composite materials means it is both light and crash resistant. The second revolution is the additional safety features that we have put on the aircraft as part of the initial design – these (such as many dual systems) are often optional extras [on other aircraft]. Finally, the cost of maintenance and operation will be lower.” There was mention too of linking the digital systems of the aircraft and some more sensors with an app on the customer’s mobile device, which would allow connected services, enabling for more efficient maintenance processes. The cabin of the SH09 will come equipped with a full glass cockpit, with an avionics suite from Garmin – the newly launched G3000H. “The G3000H will ease the workload of SH09 pilots while providing best-in-class situational awareness. This will enable a higher level of safety for every mission, the core principle behind the design of our helicopter,” noted Michele Riccobono, Kopter Executive Vice-President Technology. Safety has been at the heart of the helicopter’s development from its inception. The air medical industry will without doubt be a key customer segment for Kopter – for the past 18 months, it has been working on the interior cabin design with Metro Aviation, one of the largest providers of air medical services in the US. This has resulted in more space for stretchers, better access to the patient (s) for the medics, and more space made available for medical kit thanks to the movement of a fuel tank from the cabin wall into the cabin floor. Kopter’s manufacturing and flight testing departments are in the dramatic landscape of a valley near Mollis, not far from its headquarters in Wetzikon, and although currently it only has the one hangar, plans are afoot to build a 16,000m2 facility in 2019. Production of certain parts of the SH09 – such as the five rotor blades – are done in-house. Most, though, are sourced from third party suppliers. While every effort has been made to ensure the finest quality for each of the thousands of components from which a helicopter is built, there are almost inevitably some teething problems. One such issue has been with the dynamic components provided by a supplier in the third prototype (PS03), which will (once fixed!) be off to Sicily for three quarters of intense testing, where it will be put through its paces and pushed to – and past – its operational limits. The small delay in getting the P3 to Sicily for testing has actually had a beneficial side too – the company is taking advantage of the schedule shift to refine a number of subsystems where areas of further optimisation were identified during ground testing. While these refinements were meant to be phased into the PS4 (Pre-Series 4) aircraft, by putting them onto the P3, >>

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diary dates

COMPANY PROFILE

the development programme can be accelerated. The PS4 will be the aircraft submitted for certification, which Kopter expects will be achieved next year, ensuring the first aircraft can be delivered to customers before the end of 2019. While currently the plan is to build the helicopters in the facility in Switzerland, there will be a time in the near future, according to Löwenstein, when this will not be the case: “The SH09 has been built in the knowledge that parts can be made here, and tested here, but can ultimately be put together in other countries.” There will be a manufacturing facility in the US before long, he said, and there are also plans to expand to the Asia Pacific region. Assembly facilities around the world are a sensible move – not only to ensure compliance with local laws and regulations, but lso because it is a much more cost effective way of doing business, he explained, as Kopter will be able to meet local operator requirements for customisation of the helicopter. Market opportunity The belief in the product among the Kopter employees to whom AirMed&Rescue spoke for this article was infectious. Christian Gras, Executive Vice President of Customers, has lengthy experience in the industry, and is passionate in his belief that strong, adaptable singleengine helicopters such as the SH09 are the future of the industry. “Kopter,” he said, “is going to shake up the hierarchy of the helicopter manufacturing sector.” Having worked in the US, Europe and South America, Gras’s understanding of market dynamics is impressive. Identifying gaps in the market and being able to exploit them is key to success in any business, but in the relatively dense aircraft manufacturing business, it is more important than ever. The growth of the helicopter emergency medical services

sector in the US will continue, he says, and through a close strategic co-operation with Metro Aviation, Kopter is planning on holding a strong position in this area in years to come: “We are going to aim to take a significant per cent of the market in the next 10 years,” he told AirMed&Rescue. With many operators in the US still using the AS350 Ecureuil, the time will soon be nigh for these helicopters to be put out to pasture, and thus comes the opportunity for the SH09 to potentially become the aircraft of choice. While it is possible that other manufacturers could downgrade a twin-engine aircraft into a single-engine one, question marks hang over whether or not this would be a profitable move for them. Kopter’s first customers of the SH09 ‘will be partners’, said Jan Nowacki, Executive Vice-President of Operations. Kopter isn’t going to deliver hundreds of helicopters in the first few years. There will be time for feedback from these initial customers, with the opportunity to improve and streamline processes and services. Without data from these customers, the company is unable to progress further. “It is normal in a complex technical development process that unforeseen circumstances will appear,” said Löwenstein, “and we have mitigation processes in place for when that happens.” A passion for what they are doing is apparent throughout the layers of the company, from the CEO to the Chief Safety Officer, who explained in detail the inner workings of the helicopter prototypes and the testing that was going to be taking place. Kopter is not innovating for the sake of it – the team has the experience to know what can be improved upon, and is taking the opportunity to do just that, with new technology allowing for the introduction of an aircraft that offers real mission versatility and enhanced safety features. The EMS helicopter of the future? Maybe.

Send your diary dates to: info@airmedandrescue.com

12-14 June AIRMED World Congress Warsaw, Poland

18-24 June 50th Annual Washington States Search and Rescue Conference Ellensburg, Washington, US

9-14 July ALEA Expo 2018 Airborne Law Enforcement Association Louisville, Kentucky, US

10-12 July International Search & Rescue Conference 2018 Kuala Lumpur, Malaysia

7-9 September SAREX 2018 El Dorado, California, US

19-20 September The Emergency Services Show 2018 Birmingham, UK

1-4 October American College of Emergency Physicians Annual Meeting San Diego, California, US

19-20 October The Pittman Course: Flight & Critical Care Paramedic Review Phoenix, Arizona, US

22-24 October Air Medical Transport Conference Phoenix, Arizona, US

29 October EMS World Expo Nashville, Tennessee, US

12 November Association of Air Ambulances Air Ambulance Conference London, UK

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Medic’Air International

Ace Air & Ambulance (Pvt) Ltd. 2 Mount Road, Avondale, Harare, ZIMBABWE

+263 (4) 302 141

AMREF Flying Doctors Dr Bettina Vadera Medical Director

Wilson Airport, Langata Road, PO Box 18617, Nairobi, KENYA tel: +254

20 6000 090 fax: +254 20 344 170

email: emergency@flydoc.org website: www.flydoc.org

medic-air.com

+212 5 24 38 13 88

Asia Air Ambulance Asia Air Ambulance Co. Ltd., Bangkok599/59 Ratchadaphisek Road, Jatujak, Bangkok 10900, THAILAND

+668 9896 9000

asiaairambulance.com

EDS AVIATION PTE LTD 33 Ubi Avenue, #08-13, Vertex Tower B, SINGAPORE, 408868

+65 9836 3265

eds-aviation.com

+65 6483 5412

flyingdoctorsasia.com

Flying Doctors Asia A’Posh Bizhub, 1 Yishun Industrial St 1, #08-03, SINGAPORE, 768160

LifeFlight

Awesome Air Evac Hanger 104C, Gate C, Lanseria Airport, Lanseria, SOUTH AFRICA

Dar El Bacha - Tizougarine 5, 40000 Marrakech Medina, MOROCCO

ace-ambulance.com

(ASIA-PACIFIC)

AIR AMBULANCE (AFRICA)

SERVICE DIRECTORY

+27 11 430 1777

awesomeairevac.com

+61 7 5553 5955

LifeFlight.org.au

Medic’Air International 每递安国际

ER24 Cambridge Manor Office Park, Manor 1, Stone Haven Road, C/o Witkoppen & Stone Haven Roads, Sandton, Paulshof, SOUTH AFRICA

PO Box 15166, City East, QLD 4002, AUSTRALIA

+27 (0) 10 205 3100 er24.co.za

885 Renmin Road, Huaihai China Building, Room 808, 200010 Shanghai, CHINA

+86 2163 558289

medic-air.com

www.airmedandrescue.com

49 49

>>


Medical Wings 222 Don Mueang International Airport Office Building 3rd Floor, Vibhavadi Rangsit Road, Sanambin, Don Mueang, Bangkok 10210, THAILAND

+662 247 3392

medicalwings.com

To have your company listed in our service directory contact the sales department now: sales@airmedandrescue.com +44 (0)117 925 51 51 (opt.1)

(EUROPE)

AIR AMBULANCE (EUROPE) (ASIA-PACIFIC)

SERVICE DIRECTORY

+49 170 366 4933

+335 56 34 02 14

+356 2703 4129

+41 44 654 33 11

Rega-Center, PO Box 1414, CH-8058 Zurich, SWITZERLAND

airlecairespace.com

rega.ch

+49 7007 3010

drf-luftrettung.de/air-ambulance

EURO LINK GmbH +49 89 6137 2103

Allgemeine Luftfahrt, D -85356 München Flughafen, GERMANY

FlyEuroLink.de

European Air Ambulance Luxembourg Airport, B.P.24, L-5201, Sandweiler, LUXEMBOURG

+352 26 26 00

air-ambulance.com

taa.at

+43 512 22422 100

Fuerstenweg 180, A-6026 Innsbruck-Airport, AUSTRIA

capitalairambulance.co.uk

AIR AMBULANCE (NORTH AMERICA)

+44 845 055 2828

DRF Luftrettung / German Air Rescue

Aeromedevac Air Ambulance Gillespie Field Airport, 681 Kenney Street, El Cajon, CA 92020,USA

+(800) 462 0911 eromedevac.com

AirEvac International 8001 South InterPort Blvd., Suite 150, Englewood, CO 80112, USA

aeiamericas.com

+1 619 754-6755

AMR Air Ambulance 001 South InterPort Blvd., Suite 150, Englewood, CO 80112, USA

+1 720 875 9182

AMRAirAmbulance.com

Global Jetcare, Inc.

FAI – rent-a-jet AG Flughafenstasse. 124; 90411 Nuremberg; GERMANY

+49 911 36009 31

fai.ag

+212 5 24 38 13 88

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

medic-air.com

+1 352 799 7771

globaljetcare.com

+49 211 602 7775

2561 Rescue Way, Brooksville, FL 34604, USA

+1 352 796 2540

jeticu.com

Jet-Rescue Air Ambulance

Jet Executive International Charter Mündelheimer Weg 50, D-40472, Düsseldorf, GERMANY

15421 Technology Dr. Brooksville, FL 34604, USA

JET ICU

GlobalMed International

jetexecutive.com

Suite 100, 7777 Glades Road, Boca Raton, Florida 33434, USA

+1 786 619 1268

medjetsUSA.com

REVA Inc

Malteser Service Center +49 221 98 22 333

malteser-service-center.de

2101 W. Commercial Blvd., Suite 1500, Fort Lauderdale, Florida 33309, USA

+1 954 730 9300

flyreva.com

Skyservice Air Ambulance

Medic’Air International

AIRMED&RESCUE

quickair.de

+49 2203 955 700

Tyrol Air Ambulance

Airport House, Exeter International Airport, EX5 2BD, UK

50 50

Quick Air Jet Charter GmbH

186 Ix Xatt Santa Maria Estate Mellieha MLH 2771, MALTA

air-alliance.de

Capital Air Ambulance

35 rue Jules Ferry, 93170 Bagnolet, Paris, FRANCE

northflying.com

Swiss Air-Rescue (Rega)

Zone Aviation Générale, 33700 Mérignac Cidex 05 FRANCE

Malteser Service Center Kalker Hauptstr. 22-2, 51103 Köln, GERMANY

+45 9632 2900

Rescue Wings Malta

AIRLEC Air Espace

Rita-Maiburg-Str. 2, D-70794 Filderstadt, GERMANY

North Flying Terminal, Aalborg Airport, DK-9400, Nørresundby, DENMARK

Hangar 3, Cologne Airport, 51147 Cologne, GERMANY

Air Alliance Medflight GmbH SIEGERLAND AIRPORT, Werfthalle G1, 57299 Burbach, GERMANY

North Flying a/s

+33 141 72 1414

medic-air.com

Montreal/PE Trudeau Int Airport, 9785 Avenue Ryan, MONTREAL (Quebec), H9P 1A2, CANADA

+1 514 497 7000

skyserviceairambulance.com


AAMS 909 N. Washington Street, Suite 410, Alexandria, VA 22314, USA

tel: +(703) fax: +(703)

836-8732 836-8920

website: www.aams.org

IAFCCP Monica Newman Executive Director

4835 Riveredge Cove, Snellville, GA 30039, USA tel: +770-979-6372

website: www.iafccp.org

fax: +770-979-6500

MEDICAL ESCORT ON COMMERCIAL AIRLINES

ASSOCIATIONS

SERVICE DIRECTORY

AMREF Flying Doctors Dr Bettina Vadera Medical Director

Wilson Airport, Langata Road, PO Box 18617, Nairobi, KENYA tel: +254 fax: +254

20 6000 090 20 344 170

email: emergency@flydoc.org website: www.flydoc.org

European Air Ambulance Luxembourg Airport, B.P.24, L-5201, Sandweiler, LUXEMBOURG

GROUND TRANSPORT - MEDICAL

Gateway International EMS 600 Pennsylvania Ave SE, Washington DC, 20003, USA

+1-202-499-2294

+49 6742 897 425

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

globalmed-international.com

LIFESUPPORT Patient Transport Graham Williamson CEO

VANCOUVER – TORONTO – HONOLULU tel: +1 fax: +1

250 947 9641 877 288 2908

email: graham.williamson@LifeSupportTransport.com

website: www.LifeSupportTransport.com

Medical Wings gateway-ems.com

LifeMed Worldwide 990 Biscayne Blvd. Suite 502 Miami, FL 33132, USA

air-ambulance.com

GlobalMed International

To have your company listed in our service directory contact the sales department now: sales@airmedandrescue.com +44 (0)117 925 51 51 (opt.1)

+352 26 26 00

222 Don Mueang International Airport Office Building 3rd Floor, Vibhavadi Rangsit Road, Sanambin, Don Mueang, Bangkok 10210, THAILAND

+662 247 3392

medicalwings.com

Prime Nursing Care, Inc. +1-305-501-2009 lifemedworldwide.com

1918 Harrison Street, Suite 215, Hollywood, Florida, 33020, USA

+1 754 999 0460

primenursingcare.com

One Call Medical Transport 24hr Worldwide Ground Transports 3815 E Main St., Suite C St. Charles, IL 60174, USA tel: +1 fax: +1

630 444 2100 630 823 2900

To have your company listed in our service directory contact the sales department now: sales@airmedandrescue.com +44 (0)117 925 51 51 (opt.1)

email: ops@ocmt.com website: www.ocmt.com

www.airmedandrescue.com

51 51


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AirMed Rescue June / July 2018  
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