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AMTC 2011

Human Factors in HEMS

ISSUE 3 | Vol. 1 | 2011


C-MAC® – Pocket Monitor Mobility is our Passion… …and Highest Requirements of Hygiene our Standard!

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KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: info@karlstorz.de KARL STORZ Endoscopy America, Inc, 2151 E. Grand Avenue, El Segundo, CA 90245-5017, USA, Phone: +1 424 218-8100, Fax: +1 800 321-1304, E-Mail: info@ksea.com KARL STORZ Endoscopia Latino-America, 815 N. W. 57 Av., Suite No. 480, Miami, FL 33126-2042, USA, Phone: +1 305 262-8980, Fax: +1 305 262-89 86, E-Mail: info@ksela.com KARL STORZ Endoscopy Canada Ltd., 2345 Argentia Road, Suite 100, Mississauga, Ontario L5N 8K4, Phone: +1 905 816-8100, Fax: +1 905 858-0933, E-Mail: info@karlstorz.ca www.karlstorz.com

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EHAC

E di tori a l Dear Reader, “Just culture” is a term that is currently resounding throughout the world. From Perth, Australia, and Shanghai, China, to St. Louis and Dallas in the USA and all the way to Europe, experts are talking about just culture and recommending its implementation in modern flight operations. As representatives of Europe’s professional air rescue providers, EHAC experts have been invited to several international conferences by organisations like the Aeromedical Society of Australasia (ASA), the Association of Air Medical Services (AAMS), the European Aviation Safety Agency (EASA) and the International Helicopter Safety Team (IHST). We have taken advantage of these opportunities to spread the word, but have also been listening carefully to learn how our operations could be improved further. EHAC was actively involved in the regional AirMed congress in Shanghai for the first time and we believe that co-organising even more regional conferences to foster the exchange of expertise would improve the final outcome for patients and enhance flight safety. Safety, be it patient safety or flight safety, must always be at the forefront of our activities. And we have been exchanging ideas on how to improve safety with professional organisations outside the realm of pure air rescue. Alongside the new EHA, for example, we participated in a high-level technical meeting with EASA officials.

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As we are not as powerful as the fixed-wing industry, players within the rotorcraft industry must work together to tackle risks. In the end, it is up to every pilot and every crew member to raise awareness of safety issues. An important prerequisite for that is the establishment of a just culture, which is the responsibility of the management, who also need to set a good example. If we want to improve safety, mere words are not enough – we need a just culture, too. EHAC’s Aeromedical Crew Resource Management (ACRM) training courses also address the topic of just culture. If you have not yet participated in one of the courses or have not heard about the exclusive discounts available to you as an EHAC member, send us an e-mail and we will inform you about upcoming courses. In any case, we would like to know what you think of our work. Please send any comments to feedback@ehac.eu Yours sincerely,

Christoph Breitenbach President of the European HEMS & Air Ambulance Committee


4 | CONTENTS

AirRescue International Air Rescue & Air Ambulance

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ISSN: 2192-3167 Publisher: L. Kossendey Verlagsgesellschaft Stumpf & Kossendey mbH Rathausstraße 1 26188 Edewecht | Germany service@skverlag.de Tel.: +49 (0)4405 9181-0 Fax: +49 (0)4405 9181-33 www.airrescue-magazine.eu Medical Advisor: Dr Erwin Stolpe Medical Director EHAC

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Human factors in HEMS – the EHAC‘s ACRM B. Lang

Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: poguntke@airrescue-magazine.eu Editors: Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: bader@skverlag.de Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: frieling@skverlag.de Christoph Kossendey Tel.: +49 (0)4405 9181-14 E-Mail: cko@skverlag.de Marketing · Advertising · Subscription Ch. Niemann Tel.: +49 (0) 4405 9181-16 Fax: +49 (0) 4405 9181-33 E-Mail: sales@airrescue-magazine.eu

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LAR-fleet: next generation airborne A. Planer-Nonnweiler

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Gällivare Rescue Service B. Ulmer, A. Larsson et al.

Subscription Rate: Europe: 35  (Shipping included) World: 40  Price per Issue:   9  (Shipping not included) Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF Production and Design: Bürger Verlag Oldenburg GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany

AirRescue ist the offical publication of the European HEMS & Air Ambulance Committee (EHAC)

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Helipad at the new Royal London Hospital – part of UK‘s biggest building project

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CONTENTS | 5

42

London‘s Air Ambulance

06 11  12 22

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P. Permien

News

Functional and symbolic: new helipad at UK Aachen T. Bader

30  32  38  50  52 60 64 

Case Report: Geocaching – a modern treasure hunt with risks

Events AMTC 2011 in St. Louis

J. Gollwitzer

Interview with Dr. M. Sax on psycho­­­logical aspects of air ambulance operations

E. Timm, P. Knacke et al.

Repatriation missions by DRF Luftrettung E. Baumann

 ow Kugler-san contributed to H the birth of the Doctor-Heli system W. Nishikawa

 ew landing information system: N improving helipad safety T. Wysk Rega completes first GPS approach

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STEMI – can we reach the catheter suite in time? Á. Sóti

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Air safety at hospital landing pads G. König

 ir rescue in court – A forced rescue by helicopter M. Ufer

Major incident patient evacuation: feasibility study M. Rehn, T. Vigerust et al.

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Cover Image: P. Permien


6 | NEWS First mission for AirMed’s perinatal service Air Medical Ltd. (AirMed) of UK recently announced the operational launch of their new perinatal service. The new service follows a long consultation period with clients regarding their requirements and continues AirMed’s close collaboration with the Oxford Radcliffe Hospital NHS Trust and its renowned Obstetric Department (including the Fetal Medicine Unit). The perinatal service has already completed its first successful mission: It involved a mother-to-be who had gone into premature labour at 29 weeks whilst travelling abroad. Following comprehensive planning (both, medically and operationally) and after close consultation with the treating physician, a combined neonatal and obstetric senior specialist-led team was dispatched on board of a Learjet 35AS. All eventualities had been planned for, including the necessity to deliver the baby. AirMed’s Learjet 35AS was equipped with double stretchers, including a BabyPod, enabling the carriage of both, mother and baby, post delivery if required. After the mother was assessed by AirMed’s team, it was agreed that the best course of action was to deliver the baby on site prior to the air ambulance flight home due to the onset of acute sepsis. With close co-operation from the treating facility, baby Max, all 3lbs of him, was delivered successfully and subsequently resuscitated and intubated. The appropriate travel documents were sourced as quickly as possible and mum and baby were repatriated back to the UK where Max is continuing his care in a specialist neonatal unit. For more information, visit: ››› www.airmed.co.uk

United Rotorcraft designs air ambulance interior concept for the AW169

M. Mennie

AgustaWestland (AW), a Finmeccanica company, announced the signing of a non-exclusive agreement with United Rotorcraft, an Air Methods division, to design an air ambulance interior concept for the AW169 helicopter. The agreement includes AW providing United Rotorcraft a full-scale cabin Mock-up of the AW169 aircraft for design and full integration of the EMS interior. The concept will include several design features, including a next-generation machined aluminium floor and modular litter kits. Furthermore, it will include medical equipment racks that will be wall mounted in an effort to keep the ceiling unobstructed from head strikes. The modular approach for the EMS interior ensures that the

aircraft keeps its multi-mission capabilities and ensures the ability to rapidly re-configurate the interior if needed. The spacious, unobstructed cabin space with constant section geometry can accommodate two longitudinally or transversally mounted stretchers for EMS applications. A wide range of equipments will be available so that each AW169 can be customized to respective requirements. First flight of the AW169 is scheduled to take place in 2012. For more information, visit: ››› www.agustawestland.com ››› www.unitedrotorcraft.com

Ten years of ARA-Flugrettungs GmbH and the RK-1 in Fresach

Air Medical

Austrian air rescue company ARA-Flugrettungs GmbH recently celebrated its tenth birthday with an open day attended by a variety of honorary guests. The event also marked the tenth anniversary of the inauguration of ARA’s Fresach-based air ambulance helicopter RK-1. The festivities were hosted in collaboration with the Austrian Red Cross in Spittal an der Drau. ARA is a member of the DRF Luftrettung Group and operates air ambulances from two locations in Austria. Its head office is in Klagenfurt. At the event, CEO Steffen Lutz was keen to point out ARA’s excellent performance record: “For over ten years our air ambulance helicopters have played an important part in providing emergency medical care to people in Carinthia and Tyrol. We have helped skiers, mountaineers and swimmers in trouble as well as assisting in internal or neurological emergencies. The past decade has shown us that the helicopter is essential for ensuring local people and visitors to the area receive speedy medical attention in all kinds

of emergencies.” The crew of the RK-1 helicopter, which is equipped with a winch, has undertaken around 8,000 life-saving missions to date. While in 2007 the Fresach team went out on 659 missions, in 2010 the figure rose to 832. For more information, visit: ››› www.drf-luftrettung.de

DRF Luftrettung

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NEWS | 7 New hoist harness

EC145 simulator “takes off” After gaining authorisation from the Federal Aviation Office on 7 September 2011, the second simulator at the German ADAC HEMS Academy in Sankt Augustin near Bonn is now ready for action. At present, it is the only full flight simulator in the world authorised for EC145 type helicopters. This ultra-modern piece of technology completes the ADAC HEMS Academy’s training centre for pilots working on EC135 and EC145 helicopters. The simulator cockpit is equipped just as it would be in real life and, thanks to the full-screen display, it offers an extremely realistic flight simulation. The new EC145 simulator, which also offers multi

ADAC HEMS Academy

crew cockpit training (MCC), is now open and available to all training organisations and pilots. For more information, visit: ››› www.hems-academy.de

DLR

Helicopters are not only suited to transporting unwieldy or heavy loads; they are also perfectly adapted to rescuing people, for example at sea. During these missions it is crucial that the helicopter remains stable and manoeuvrable even with an external load. The German Aerospace Center (DLR) is developing a pilot assistance system to automatically stabilise and accurately position this external load – without the pilot having to do anything. A DLR research helicopter officially known as ACT/FHS (Active Control Technology/

Flying Helicopter Simulator), which is a modified Eurocopter EC135, is currently being equipped with the appropriate hardware for this purpose. When the rescue winch is in use, the pilot has to concentrate on controlling both the aircraft and the person, or “load”, on the end of the winch. To complicate things further, the pilot cannot see this external load and is therefore reliant on information from someone else. This creates an enormous amount of workload for the pilot. This is where HALAS comes in – a helicopter assistance system for controlling external loads currently being developed by DLR and iMAR GmbH within the Federal Ministry of Economics and Technology (BMWi) aeronautics research programme. HALAS is intended to work within the flight control system, automatically stabilising the external load by taking into account the adjustable cable length and – also automatically – positioning the “load” at the end of the cable. After successfully carrying out test flights to check the external winch, the researchers are pressing on with the project and the first flights with the pilot assistance system are planned for next year. AirRescue Magazine will report on the HALAS project in detail in the next issue (1/2012). For more information, visit: ››› www.dlr.de

Corpuls3 Smart Metronome improves therapy GS Stemple recently updated the software on its Corpuls3 and introduced a new Smart Metronome function at the same time. The Smart Metronome supports rescue workers in cardiopulmonary resuscitation by indicating the optimal compression frequency and ventilation intervals with different acoustic signals so that the rescue team can focus solely on the resuscitation itself. This reduces intervals without therapy and maximises the number of thorax compressions during cardio­ pulmonary resuscitation. There are five different modes for compressions and for frequency and duration of ventilation intervals (different ones for children and adults). Smart Metronome complies with ERC 2010 guidelines.

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Lite Flite

Safe rescue missions with pilot assistance systems

Lite Flite, the Danish company specialised in helicopter rescue equipment, has released its new helicopter hoist harness (part no. 60081453) that comes without shoulder straps. Due to the special design of the front part, the waist belt “locks” itself on to the hips in case of a head-down position and thus prevents the winchman from sliding out of the harness. The harness features alpine style, fully padded, open leg straps and elastic suspensions facilitating walking and swimming. In addition, the harness has D-rings for auxiliary equipment and a strap to secure a radio. To provide added safety for winchmen returning from the water with cold hands, a click-lock tang and a D-ring serve as lanyard attachment points at the rear of the harness. According to Lite Flite, it is a very versatile harness specifically designed for demanding helicopter SAR crews. Lite Flite designs, produces and maintains helicopter rescue equipment, i.e. hoist harnesses, rescue sling strops and the famous QRB. For more information, visit: ››› www.lite-flite.aero

Corpuls

For more information, visit: ››› www.corpuls.com

Lite Flite


8 | NEWS Hamilton Medical and Rega are partners in intensive care Hamilton Medical recently launched the HamiltonT1, a new ventilator for use in mobile IC units. Rega, also of Switzerland, is the first air rescue service to equip its fleet with this solution for mobile intensive care ventilation. The company claims that its compact design increases the availability of appropriate modes of therapy for ventilation of intensive care patients outside the hospital. It covers the full range of clinical requirements: invasive ventilation, automated ventilation with Adaptive Support Ventilation (ASV®) and noninvasive ventilation (NIV). Rega chose Hamilton’s T1 as it provides ventilation on a transportable platform that’s appropriate for all patients, from children to adults. It is made for extreme environments where ICU ventilation is a must. As ventilators also have to deliver reliable data and easy-to-follow user guidance for better clinical decisions and improved patient outcomes, while also keeping operating costs low, the Hamilton-T1 was regarded as the right choice. For more information, visit: ››› www.hamilton-medical.com ››› www.rega.ch

DRF Luftrettung

DRF Luftrettung and Pratt & Whitney sign agreement Pratt & Whitney Canada Customer Service Centre Europe GmbH (CSC Europe) signed a 13-year Fleet Management Program (FMP®) agreement with DRF Luftrettung of Germany for comprehensive maintenance support of its PW206B2 engines. This long-term agreement with CSC Europe provides DRF with expanded coverage until 2024. CSC Europe is a joint-venture between Pratt & Whitney Canada (P&WC) and MTU Aero Engines. “The long term cooperation with Pratt & Whitney Canada has influenced our decision to renew the FMP agreement with the CSC in the long run”, said Juergen Zoller, Director Technical Operations, DRF Luftrettung. “We are pleased to

continue with our reliable partner and consider both the product and the service as an important contribution to keep our aircraft flying.” P&WC has produced more than 12,000 engines for the helicopter market since the 1970s, accumulating more than 43 million flying hours. The company has certified 31 models for more than 25 applications and engines destined for the helicopter industry. For more information, visit: ››› www.drf-luftrettung.de ››› www.mtu.de

1,000th EC135 with Becker’s DVCS-6100

Rega

NEMSPA pilots survey of heliports now available for download The National EMS Pilots Association (NEMPSA) of the USA has conducted a survey to gather opinion on heliport design and safety from those who are most affected by the design and management of heliport facilities – the helicopter pilots. NEMPSA sought input from all pilots involved in any form of helicopter operations. Now the initial analysis of the data gathered has been completed. The survey garnered over 1,300 responses from heli pilots with opinions and suggestions regarding the design and the safety of the heliport facilities that they typically use in their daily flying duties. The detailed results of the survey can be accessed through the NEMPSA-website.

Eurocopter recently delivered the 1,000th EC135 to ADAC Air Rescue Germany. It’s equipped with a Becker Avionics Digital Voice Communication System DVCS-6100 digital audio and intercom system. The EC135 light twin-engine multi-purpose helicopter – along with the Becker DVCS – have been very successful products over the last decade. Becker explains that the DVCS-6100 is the “ideal system for HEMS operations due to the excellent man-machine-interface, outstanding field reliability, and its crystal-clear audio quality.” The DVCS system is comprised of one Remote Electronic Unit (REU) 6100, two Audio Control Panel (ACU) 6100’s for pilot and co-pilot, and one ACU6101 Audio Control Panel for the medical cabin. Through software programming options, the DVCS-6100 is quickly configurable to individ-

ual customer requirements. It has been designed for both, rotary and fixed-wing applications. Since market introduction of the 1st DVCS generation, over 800 systems have been delivered. The product offers up to 8 communication transmit (TX) and up to 8 receiver (RX) channels, an integrated warning tone generator for up to 8 different signals, an amplifier for 2 cockpit speakers, as well as interfaces for 2 Cockpit Voice Recorders (CVR), and a Public Address Amplifier (PA). The ACU6100 is available with NVIS green (MIL-STD 3009 Green B) and white Backlight. It offers emergency and slaved mode operation. For more information, visit: ››› www.becker-avionics.com

Eurocopter/C. Abarr

For more information, visit: ››› www.nempsa.org

3 · 2011 I Vol. 1 I AirRescue I 8


NEWS | 9 Chinese delegation visits ADAC HEMS Academy

ADAC HEMS Academy

A Chinese delegation from Huarui Xintong Network Technology Co. Ltd. in Beijing and representatives of the Nantong Development Zone recently took up an invitation from ADAC to tour the ADAC HEMS Academy GmbH in Hangelar near Bonn. On 15 August 2011 the Chinese visitors learned all about the work at the training centre and were particularly interested in the medical equipment on board the air ambulance helicopters. Thanks to interpreter Fu Franzen, Maria von Nathusius, medical director at the ADAC HEMS Academy, was able to give comprehensive and competent answers to all the delegates’ questions. They were keen to know more as China does not yet have an air rescue system in place like the one in Germany. The delegates attended talks about the ADAC organisation, its air rescue branch and the ambulance service, giving them a broad insight into the medical assistance services available here. They also visited the air rescue base in Munich to see “Christoph 1” and the base in Würselen near Aachen to get a closer look at “Christoph Europa 1”. For more information, visit: ››› www.hems-academy.de

China to install world’s largest helicopter rescue system According to Chinese news reports, China needs to spend at least 30 billion yuan (3.1 billion euros) within 15 years to establish a helicopter rescue system that covers its vast territory and serve its population of around 1.3 billion people. It would be the world’s largest helicopter rescue system consisting of at least 850 helicopter rescue bases and more than 1,000 helicopters to cover its 9.6 million square kilometres territory, said Chen Ping, deputy director-general of the emergency rescue promotion center under the Ministry of Civil Affairs, while attending the China Helicopter

Development Forum. Chen said that general aviation operations, especially helicopters, are necessary for everyday life in medical rescues and disaster relief efforts, and the helicopter emergency rescue system is needed to reduce casualties and asset losses. Although military helicopters were used for the relief work in the aftermath of the 2008 Wenchuan and 2010 Yushu earthquakes (when around 70,000 and ca. 2,800 people resp. died) as well as during the severe droughts in southwest China in recent years, a civil helicopter fleet for rescue efforts is still lacking.

Inaer-fleet with Telvent technology

AgustaWestland

Inaer Helicopteros S.A. will soon begin to utilize the MxVision AviationSentry Online® and RotorWatch™ solutions by Telvent, a real-time IT solutions and information provider. With the implementation of this technology, Inaer aims at improving safety and operational efficiency at its

operations centers around the globe and in its fleet of 298 aircraft. The platform provided by Telvent is a customized and real-time one-stop weather forecasting and positioning system for the helicopter industry. The system makes all data available on one integrated screen and will also include information generated from Inaer’s fleet management system. By heightening awareness of current and forecasted conditions, Inaer pilots and crews will have the information necessary to more safely determine the viability of a safe rescue, as well as up-to-the minute notifications to adapt to changing weather conditions more quickly. MxVision AviationSentry Online and RotorWatch meet the United States Federal Aviation Administration’s AO21 Operations Specification requirements for helicopter weather briefings as well as all Joint Aviation Requirement Operations III Specifications in Europe. For more information, visit: ››› www.telvent.com ››› www.inaer.com

DRF Luftrettung introduces Vscan ultrasound device DRF Luftrettung will soon start using a new portable ultrasound device. This will increase the examination options available to doctors in emergency accident situations and benefit seriously injured people or patients experiencing difficulty breathing or suffering from certain heart problems. The device, produced by GE Healthcare, was successfully tested at the bases in Göttingen and Freiburg on routine missions in the first half of 2011.

The portable ultrasound device allows doctors at accident sites to quickly establish whether a patient is suffering from internal bleeding. The new hand-sized device can also be used to perform heart examinations. According to DRF rescue assistants, the Vscan, which is fitted with a digital ultrasound probe, boasts several advantages over the device that has been used until now. It is handier, easier to operate and only weighs around 400 grams. The picture quality of the ultrasound images is also significantly better. The DRF crews in Friedrichshafen and Bad Saarow will soon follow Göttingen and Freiburg and start using the device in their day-to-day operations. The next issue of AirRescue Magazine will feature a more detailed report on the use of the Vscan device in air rescue missions. For more information, visit: ››› www.drf-luftrettung.de ››› www.gehealthcare.com

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10 | NEWS DRF Luftrettung sings purchase agreement for 25 type EC145 T2 helicopters Eurocopter and the German air rescue organisation DRF Luftrettung signed a purchase agreement for 25 helicopters of the newest generation – the EC145 T2. With the purchase of these aircraft, the DRF Luftrettung will successively

replace the BK 117s in its helicopter fleet. The first five aircraft will be put into operation in 24-hour service between December 2013 and end of 2015. The helicopters comprise an order volume of close to € 200 million. The remaining

20 helicopters in this order are to be delivered in phases through 2022. Eurocopter declared that it has been a part of the air rescue story from day one – starting with the Alouette III and continuing with the BO 105 and BK 117 to the EC135 and EC145. A total of 46 EC helicopters are currently in service with the DRF Luftrettung. In 2010 alone, this nonprofit organisation flew 36,900 rescue missions. Dr. Hans Joerg Eyrich, member of the Board of Directors of the DRF Luftrettung, declared that “the EC 145 T2 is excellently suited for air rescue missions thanks to its performance capability and the Fenestron. Particularly in night rescue missions, the shrouded tail rotor provides a further measure of safety.” For more information, visit: ››› www.eurocopter.com ››› www.drf-luftrettung.de Signing the agreement (from left): Thomas Hein, Eurocopter, Head of Sales Europe; Wolfgang Buchner, Eurocopter, Head of Sales Central Europe; right side (back): Steffen Lutz, DRF Luftrettung, Executive Board; Dr. Wolfgang Schoder, Eurocopter, Executive Vice President Programs; Hans Joerg Eyrich, DRF Luftrettung, Executive Board (Photograph: DRF Luftrettung)

O B I T U A R Y

A lif e in h e li c o p t e rs : S i e gfri e d S obotta His name evokes the successful development and major deals of Franco-German helicopter manufacturer Eurocopter. For many years Siegfried Sobotta was Co-President of Eurocopter and head of Eurocopter Deutschland. A native of the South German state of BadenWürttemberg, Sobotta actually started out in a different industry. For many years he worked in the vehicles division at Daimler before being made an executive at DASA, the former aerospace subsidiary of Daimler-Benz. In 1990, DASA brought together all the aerospace and defence activities of MBB, Dornier, MTU and Telefunken Systemtechnik. Two major challenges awaited newly appointed manager Sobotta. First he had to establish the helicopter business within DASA and, secondly, he had to work with his French counterparts to set up the first Franco-German joint venture in the sector – truly pioneering work! The appointment of Siegfried Sobotta was serendipitous for air rescue in Germany.

Siegfried Sobotta He was committed to maintaining on-going dialogue within the sector, and he created a permanent communication platform for the industry and air rescue services that helped foster mutual understanding for the work and needs of both groups. It is thanks to him that ideas originating from German air

rescue have been exported across the globe. His efforts found their technical expression in aircraft like the EC BK 117. When Sobotta left Eurocopter it had become the world leader in its sector. The man who had dedicated his career to helicopters remained loyal to them even during his “retirement”. In 2006, Sobotta became President of the German Helicopter Association (DHV) and was also active within international organisations, playing an important role in the founding of the new EHA (new European Helicopter Association). Despite being focused and determined in everything he did, Sobotta was always friendly and obliging. Those who knew him remember him as someone who was cooperative and accommodating, someone who sought solutions that suited everyone, not just himself. Siegfried Sobotta died on 26 October 2011 aged 72. Dr. Erwin Stolpe, Medical Director EHAC

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EVENTs | 11

International Helicopter Safety Symposium 2011: Human factors at the forefront The International Helicopter Safety Team (IHST) was founded in 2005 with the ultimate goal of reducing helicopter accident rates around the world by 80 percent by the year 2016. At IHST, global teams of analysts perform detailed studies of helicopter accidents and make recommendations for action so that implementation experts can look at ways of putting their recommendations into practice in order to reduce accident rates. At the International Helicopter Safety Symposium (IHSS) in Fort Worth, Texas this November participants from all over the world reported on results and discussed how the immense task of minimising the number of accidents can be coordinated. One of the new approaches is to incorporate maintenance personnel into efforts as their work is crucial to flight safety. Thus far, engineers and mechanics have not been involved to the same extent as mission crews. Issues such as safety culture, communication and fatigue are equally or even more important for maintenance crews as for flight crews since deficits in these areas constitute classic human factors impacting on safety. More flight training for pilots often used to be the only solution for improving flight safety, but recent findings have revealed that technical skills are only a minor issue. The individuals involved, related human factors and, in the end, human error have a much greater influence on the outcome of a rescue operation. The three most important factors that have been identified as “level 1 standard problem statements” (SPSs) are pilot judgement (affected in almost 70 percent of all accidents), safety culture (playing a role in more than 50 percent of all accidents) and situational awareness (impaired in approximately 35 percent of all accidents). These issues are being tackled with various approaches. The first of three tiers in the accident prevention strategy is the proper, professional behaviour of pilots, engineers, doctors, paramedics, etc. The next tier is adequate supervision (tier 2), followed by a just culture (tier 3), which is the responsibility of senior management. EHAC’s scientifically proven training scheme Aeromedical Crew Resource Management (ACRM) is initially targeting mission crews to address human factors within tier 1. It was revealed that accident rates are significantly worse in general aviation than in the case of commercial operators. True professionals are always enthusiastic about their work and are motivated by the desire to return safe and well to the base and to their families. They are not motivated by money alone. The reasons for crashes are pretty much the same across all industries and all around the world. Amateur pilots also need to act like professionals, as they, too, have to take direct personal responsibility for their actions. IHST aims to find better ways to target small-scale operators and general aviation and to broaden awareness of safety issues and mitigation strategies. Fatigue plays a particularly important role, not only for mission crews, but also, perhaps even more so, for technical staff. At the moment there are usually less strict limitations on the amount of time engineers and mechanics are allowed to work, despite the fact that an

3 · 2011 I Vol. 1 I AirRescue I 11

Author: Stefan Becker Managing Director EHAC, stefan.becker@ehac.eu

Fig. 1: Recent findings have shown that technical skills are only one out of many other contributing factors to safety (Photograph: ÖAMTC)

Fig. 2: Incorporating maintenance personnel into efforts as their work is crucial to flight safety, is one of the new approaches (Photograph: S. Drolshagen)

overworked, sleepy mechanic can have a dramatic impact on safety for mission crews and patients. At the IHSS, Bill Johnson, Chief Scientific and Technical Advisor for Human Factors in Aircraft Maintenance at the Federal Aviation Administration, spoke about fatigue as a key problem affecting human performance. EHAC is involved in the work of IHST in many different ways as a member of Helicopter Association International (HAI) and of IHST’s European branch, the European Helicopter Safety Team, and its specialised teams of experts representing the European HEMS industry. The IHSS takes place annually, alternately hosted by a city in the United States and one in a country on another continent. The next IHSS congress takes place in Brazil. 

Training materials are available at www.easa.eu.int/essi/ehest/ and www.ihst.org


12 | EVENTS

W elcome to S t. L ouis Fig. 1: The Gateway Arch, symbol of the city of St. Louis (Photograph: D. Schwen/ Wikipedia)

Air Medical Transport Conference 2011 St. Louis, Missouri is called the Gateway to the West because so many people migrated westward from there in the 19th century. The 192-metre-tall Gateway Arch, the centrepiece of the Jefferson National Expansion Memorial, symbolises that history. From 15 to 19 October 2011 though, St. Louis was not just the Gateway to the western United States, it was the gateway to the entire AMT world as the city hosted the annual Air Medical Transport Conference (AMTC). The congress focuses on both air rescue and air and ground medical transport and is sponsored and organised by various trade associations and special interest groups. Among them are the Association of Air Medical Services (AAMS), the Air & Surface Transport Nurses Association (ASTNA), the International Association of Flight and Critical Care Paramedics (IAFCCP), the National EMS Pilots Association (NEMSPA) and the Air Medical Physician Association (AMPA).

Author: Juergen Gollwitzer RA, CCP-C, FP-C, RN IAFCCP Germany Martinstr. 2 86368 Gersthofen iafpgerm@t-online.de

Paramedics, nurses, doctors, managers, pilots and control centre staff met at the conference to learn from each other, to network, and to find out about the industry’s newest products in an accompanying exhibition. An estimated 2,300 people attended this year. Most were from the US, but about 100 had travelled from such faraway places as Australia, Japan, Germany and the UK. Preconference sessions and numerous board meetings were held by the sponsoring organisations in the days leading up to the conference. For example, the International Association of Flight and Critical Care Paramedics (IAFCCP) held its annual board meeting during

this time. A TRACER course (Transport Certification Examination Review) was also held to get people ready for the exams for Flight Paramedic Certification (FP-C) and Critical Care Paramedic Certification (CCP-C), which were held the next day by the Board for Critical Care Transport Paramedic Certification (BCCTPC). The opening address was given by Chris Baker, Medical Program Director at TriState CareFlight and a registered nurse (RN) for neonatal transport care. This preconference session was designed for (H)EMS personnel who do not regularly deal with such patients. Baker gave lots of valuable advice gained from his many years of experience

3 · 2011 I Vol. 1 I AirRescue I 12


EVENTS | 13

in neonatal care. The subsequent session, “Rotors, Skids & Crystal Balls – What is the Future of HEMS?”, was no less interesting, but it dealt mainly with the situation in the United States. With around 150 thought-provoking talks on the programme, participants also needed some time for fun. American Eurocopter filled the bill with a Rock ’n Bowl on Sunday evening. The activity was about more than friendly competition – it was also a chance to demonstrate the kind of team spirit that is so essential to making rescue services work well. The conference itself began with a keynote address from Nick Argyres, Professor of Strategy at Olin Business School at Washington University in St. Louis, where he asked “Are we solving the right problem?”. Taking as an example the rescue efforts in New Orleans in the wake of Hurricane Katrina and the associated errors in planning and decision-making, Argyres showed how the experience, “expertise” and opinions of the personnel involved kept them from seeing the bigger picture and how that negatively affected the way they approached the problem. His insights can be transferred to any area of the job, including CRM, safety management systems and medical areas. He also explained how people can overcome this tunnel vision in their day-to-day work and drew from Albert Einstein, who said that recognising a problem is more important than resolving it, as describing the problem accurately leads almost automatically to the right solution. With such a large number of talks taking place at the same time, delegates had to plan their days very carefully. One highlight of the first day was an event called Personal Survival Kit. German air rescue personnel are not likely to know what this is; there is probably not a single rescue

3 · 2011 I Vol. 1 I AirRescue I 13

helicopter location in Germany with an aircraft survival kit, let alone a personal survival kit. But its importance is seriously underestimated. The naive assumption that “that will never happen to me” and near-blind faith in ELT technology lead people to neglect this important subject. Everyone knows that an otherwise low-risk mission can become a real challenge after just a couple of hours if the weather does not cooperate and personnel have not brought along the right clothing or equipment. It doesn’t even take that long if the aircraft crashes in a remote area. In one example, a LifeReach helicopter went down in heavy fog just 150 metres off a highway, injuring all three crew members. It took over four hours before they were found. A talk entitled “Saturday Night Special Delivery” by B. Rogge (RN, BSN) and S. Pitts (NREMT-P, RRT) from NorthWest MedStar vividly illustrated a mission that involved a breech birth at a location that was about 15 minutes by air and 45 minutes by road from the hospital. The exemplary work of everyone involved (first responders, BLS unit, rescue helicopter crew and control centre), their ability to remain calm despite the stress of the situation, and the well-considered decision to choose ground transport over air transport ultimately led to a happy ending for both mother and child. The speakers pointed out that there is an urgent need to always train regular rescue assistants and members of paediatric or neonatal transport teams side by side. The industry exhibition that opened at midday presented well-known rescue helicopters as well as a B 429 equipped for EMS. Intensive care ambulances were also on display. The vehicle used by Children’s Mercy Hospitals and Clinics in Kansas City, Missouri had a colourful

Fig. 2: Convention centre in St. Louis, Missouri, the site of AMTC 2011 (Photographs: J. Gollwitzer)


14 | EVENTS

Fig. 3: The vehicle used by Children’s Mercy Hospitals and Clinics had a colourful interior suitable for children and was equipped with a DVD player and monitor

Fig. 4: The winning team of the METI Cup

interior suitable for children and was equipped with a DVD player and monitor. The medical device area also had plenty to admire with items such as transport monitors, IABPs and a portable ECMO machine. The visit was enriched by knowledgeable exhibition personnel, and it was possible to learn something new, too. Like every year, the second day of the conference was Flight Suit Day. Most participants showed up in their flight suits or uniforms, proudly displaying which transport programme they belonged to. It was also Safety Day. The presentations showcased Vision Zero (1) and the AAMS Survivors Network programme (2). A “challenge coin” that commemorated safety work was distributed to all delegates. The opening session was also dedicated to this important subject. Randy Mains, a pilot, veteran and elder statesman in the US air rescue world, became the first person to receive the Golden Hour Award for his achieve-

ments in helping develop air rescue services in the US. He has also written a number of books on the subject. The second day also offered tips for trainers in the medical aspects of air rescue and intensive care transport. One topic the presenters addressed was how to make dry, recurring subject matter more interesting for course participants. The speakers talked about the possibility of using modern technology and game-playing, such as a Jeopardy game with PowerPoint slides. They made the point that it is a privilege, not a right, for trainers to serve as preceptors. (A preceptor is a mentor or practical guide for air rescue workers.) They said that preceptors should work to deserve their title and not simply be appointed. The final round of the METI Cup began the same day, and by late afternoon the winners were announced. The competition uses patient simulators to test participants’ real-time skills. This year’s champs were Dave Allison and Sherry Gauthier of STARS from Alberta, Canada. In the evening, the IAFCCP held its leadership reception in the jovial atmosphere of the Dubliner, an Irish pub. The event was a chance for board members, state delegates, international executives and members to meet and discuss current challenges and share their experiences. On the third and final day of the conference, one of the talks focused on human factors, which are still the root cause of 80 percent of accidents in air rescue. The speaker attempted to answer the question of how that happens and why even clearly defined regulations are often not enough. On the medical side, there was an outstanding talk about traumatic and non-traumatic aortic dissection. It emphasised that for type A dissections, the time span until clinical care is provided, has a critical influence on mortality. Another point was that it is not enough to just lower blood pressure; the heart rate also needs to be reduced to decrease the force on the damaged wall of the aorta. To treat tachycardiac patients, they recommended first lowering contractility with beta blockers and then lowering the afterload with appropriate vasodilators as this creates a reflex that in turn increases contractility. In the evening, this wonderful conference came to a close with the annual M*A*S*H Bash, where most people showed up in old army uniforms or operating room attire just like in the classic TV series. Tickets to the conference are not exactly cheap and the flight from Europe isn’t either, but the quality of the conference justifies making the trip every few years. The next AMTC conferences will be held in Seattle from 22 to 24 October 2012 and in Virginia Beach from 21 to 23 October 2013. Hope to see you there!  Notes: 1. Vision Zero is an initiative developed to lower the car accident rate in Sweden. AAMS has adapted it for air rescue. More information is available at www.aamsvisionzero.org. 2. Survivors Network was created by MedEvac Foundation International to provide psychosocial and financial support to the survivors of air accidents and to the families of people killed.

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Image depicts actual rescue Broken legs | Darkness | Hypothermia | Pilot wearing nvg’s | Man lives and sells skis on ebay |

L-3 AN/AVS-9 night vision goggles


16 | TRAINING

Human Factors in HEMS – the EHAC-Network Aeromedical CRM Author: Bernd Lang Head of AirRescueCollege, Christophorus Flugrettungsverein, Chairman of EHAC Working Group ACRM Schubertring 1-3, 1010 Vienna, Austria bernd.lang@oeamtc.at

The challenges of day-to-day air-rescue work and the various legal regulations governing it mean that a special HEMS human factors training system is required. A group within the European HEMS and Air Ambulance Committee (EHAC) pooled forces to establish an internationally standardised training concept called Aeromedical Crew Resource Management (ACRM). Human factors A large number of accident reports, incident analyses and studies have shown that human beings are a significant influencing factor on safety in highly complex areas of operations (1, 2). In this context, human factors can be defined as all our physical, psychological and social characteristics, insofar as they influence actions in or with socio-technical systems or are influenced by these systems (3). A wide range of measures has been introduced in order to respond to these findings. The gradu-

ally developed Cockpit Resource Management system, later known as Crew Resource Management (CRM), for example, represents one of the greatest success stories in aviation (4). The introduction of this training format was a milestone in target-oriented safety training for teams and crews. The evolution described by Helmreich was continued with the establishment of the EHAC training concept Aeromedical CRM, and a human factors format tailored to HEMS operations has been developed.

JAR-OPS 3.943 Initial Operator’s Crew Resource Management (CRM) training (a) When a flight crew member has not previously completed initial Operator’s Crew Resource Management (CRM) training (either new employees or existing staff), then the operator shall ensure that the flight crew member completes an initial CRM training course. New employees shall complete initial Operator’s CRM Training within their first year of joining an operator. JAR-OPS 3.965 Recurrent Training and Checking

Table 1: JAR-OPS 3 CRM requirements for flight crew members (5)

(e) An operator shall ensure that: Elements of CRM are integrated into all appropriate phases of the recurrent training, and; Each flight crew member undergoes specific modular CRM training. All major topics of the initial CRM training shall be covered over a period not exceeding 3 years.

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TRAINING | 17 Table 2: JAR-OPS 3 calls for a compulsory, modular CRM training course in various training formats

CRM items in acc. with JAR-OPS 3 (5)

Leonardo da Vinci project partners

(1)

Human error and reliability, error chain, error prevention and detection;

Austria: ÖAMTC Christophorus Flugrettungsverein

(2)

Company safety culture, Standard Operating Procedures (SOPs), organisational factors;

Luxembourg: Luxembourg Air Rescue

(3)

Stress, stress management, fatigue and vigilance;

Netherlands: ANWB Medical Air Assistance

(4)

Information acquisition and processing, situation awareness, workload management;

Switzerland: Schweizerische Rettungsflugwacht REGA

(5)

Decision making;

(6)

Communication and co-ordination inside and outside the cockpit;

(7)

Leadership and team behaviour, synergy;

(8)

Automation and philosophy of the use of Automation (if relevant to the type);

(9)

Specific type-related differences;

3 · 2011 I Vol. 1 I AirRescue I 17

Fig. 1: ACRM structure with all of the subjects taught in the training courses

COMPANY SAFETY CULTURE

Teamwork and Leadership

Communication

ACRM

Decision Making and Risk Management

CRM training is a legal requirement for pilots and crew members deployed in air rescue. JAR-OPS 3 (Joint Aviation Requirements – Operations 3) calls for a compulsory, modular CRM training course in various training formats and on various levels (see also Table 1.) The compulsory subject areas to be taught in a CRM training course in accordance with the stipulations of the Joint Aviation Authorities (JAA) are regulated at European level (5). Table 2 provides an overview of the 12 required subject areas. The fields of application for these CRM subjects can be very wide. For example, classroom-based training courses are required for initial and recurrent training. However, CRM elements must also be included in instruction on line checks, proficiency checks, upgrading to commander, and simulator training. No concrete training requirements are stipulated for aeromedical team members. Instead, the following is expected and required: “HEMS crews – including medical passengers – are also expected to operate in accordance with good CRM principles (5).” The flight and the emergency medical operation of an HEMS mission cannot be considered separately if we are to ensure an effective and safe mission. In particular, a team that has to tackle operational situations together must also cooperate in training situations, especially as the individual stages of an air-rescue operation cannot be divided into separate components. Only by involving all team members is it possible to deal with all of these stages in a training course and thus to ensure it has a positive impact on flight and patient safety. This is a goal that should be adopted by all members of an HEMS organisation. The planned implementation of the EASA (European Aviation Safety Agency) Part Operation will change the legal basis for human factor training courses in air rescue. However, all drafts clearly indicate that the value of CRM will be maintained thanks to its comprehensive integration in the wording of the law.

Situational Awareness

Legal requirements for CRM in HEMS

In 2004, representatives of five European air-rescue organisations came together in an EU-funded project to codevelop a standardised initial and further training concept for human factors in air rescue (see Table 3.) On the one hand, the aim was to comply with the legal requirements; on the other, to develop a successful and effective training format. This Leonardo da Vinci project aimed to apply insights from established aviation CRM concepts to the development of a training format especially for air rescue. The first major challenge was integrating emergency medicine into the existing concepts, although it did prove possible to apply certain previously developed human factors concepts to the field. This integration process was not merely a question of adapting psychological safety models for aviation and medicine, but rather of considering the expectations of two different cultures in the training format so as to meet the needs of the individual team members in the various professional groups. The foundations for the EHAC Working Group ACRM were laid with the launch of this project. Using many years of knowledge from aviation and initial experience from relevant medical training procedures (6), the project developers were able to adapt learning objectives and content specifically for air-rescue situations and for the people working in the different professions in this field.

Stress and Stress management

(11) Additional areas which warrant extra attention, as identified by the accident prevention and flight safety programme.

Table 3: Project partners co-developing the training concept Aeromedical CRM

Aeromedical CRM – development and history

Human Error

(10) Case based studies;

Germany: ADAC-Luftrettung GmbH


18 | TRAINING

Fig. 2: The EHAC-ACRM quality system and the agreed standards are summarised in three handbooks: Train-the-Trainer Curriculum (ensuring quality of trainers involved in initial and further training), ACRM Syllabus (ensuring quality of the training format) and Quality Manual (ensuring quality of the system and laying down cooperation requirements)

Training philosophy and concept ACRM is defined as the effective use of all available resources, hardware and software (e.g. team members, information, aircraft systems, medical systems and other technical as well as support staff), to increase flight and patient safety as well as the effectiveness and efficiency of the entire mission. This definition is close to that of the JAA for CRM. However, it refers to the entire HEMS team and the entire HEMS mission, i.e. to the medical care at the scene of the incident, as well as flight operations. Similarly, the concept of safety covers both the flight and the patient’s safety. Since ACRM refers to the entire HEMS team, cooperation between course trainees representing all professional groups in aeromedical crews is an important aspect (7). ACRM training aims to improve the aeromedical team’s non-technical skills in air rescue (8). New crew members are confronted with the topic of ACRM as soon as they start training, to enable them to learn the theoretical foundations of human factors and gain an understanding of the importance of this training format. During their first year as a crew member, the new pilots, HEMS crew members and air-rescue doctors should complete initial ACRM training totalling around 20 hours that covers all content required by aviation law. This material should then be briefly reviewed in recurrent training courses. A high standard is set for the training philosophy and the defined training objectives (8): • • • • • • • • •

Development of teams in HEMS Clarity about expectations in the team Development of a common language Development of common goals on an HEMS mission Change in perspective between self-perception and perception Raising awareness and dealing with the cultural differences Developing an understanding of the team resources Clarity on processes and procedures in HEMS Building up a common mental model

The ACRM training target group includes all active professional groups working on emergency medical and intensive care helicopters (pilots, HEMS crew members and air-rescue doctors). The composition of the participants in an ACRM training course should ideally correspond to that of the professional groups involved. It is a good idea to include participants and trainers from different organisations within the EHAC-ACRM cooperation network as this

broadens the participants’ horizons. (For example, they gain insight into other systems and have the opportunity to view problems from a different perspective.) As an overall process – the alarm, the flight, the treatment of the patient, the flight to the clinic, the patient handover, the return flight and the switch back to stand-by – an air-rescue operation is a series of rapidly altering and diverse situations. Responsibilities within the team change with each stage of the process. The whole procedure is characterised by complex, interlinked, nontransparent and quickly evolving challenges and problems – and it is only in the rarest cases that all the necessary information is available (9). The subjects tackled and their theoretical foundations consider these problems. They are taught with a focus on practice, using real-life air-rescue examples. In this way, the importance of the course contents and concepts for air-rescue work is made clearer to the participants, making it easier for them to transfer what they have learned to their own daily work. As the participants come from different organisations and hence from different structures/ cultures, it is particularly important to take this situation into account and to invest time in this element of the training courses in order to create a shared foundation for all participants. The defined training content is taught and discussed in theoretical and practical modules. The ratio of theory to practice depends on the level of knowledge of the individual course participants and the composition of the group. Theoretical foundations form the starting point for the courses. This is necessary to bring crew members with varying prior knowledge of human factors up to the same level and to allow the course to draw on more profound concepts and practical elements. Figure 2 shows an example of the structure of the ACRM subjects. The training courses use a very wide range of methods requiring active participation from all trainees to ensure that everyone gets involved. Based on Strohschneider’s breakdown (10) of training methods for human factor training, the methods used in ACRM training courses include: • Lectures, presentations and instructions in classroom training • Training material, handouts, handbooks and computer based training (cbt) • Exercises (single and group) • Case-based studies and exchange of experience • Discussion, reflection and feedback • Role plays and group-dynamic activities • Computer simulations • High-fidelity simulation

This wide range of methods provides trainers with a comprehensive set of tools to help them achieve the extensive goals of the training course. Method selection should always take into account the participants’ current learning needs, the existing learning environment, and particularly the group dynamics of the course. No two training courses are the same. Each new group follows its own process, guided and accompanied by the trainers.

3 · 2011 I Vol. 1 I AirRescue I 18


TRAINING | 19 The use of case-based studies guarantees that the ACRM subjects addressed in the course are firmly rooted in real life, thus combining theory and practice. These are frequently applied in initial training and particularly in recurrent training. These cases, which include outstanding performances as well as incidents and errors, can be used to establish links to the various ACRM subjects through investigations into the individual causal factors. The idea is to establish a direct relevance to participants’ own dayto-day work, so cases from within their own organisations are often the most suitable. Ideally, participants will make use of the safe environment of the group to speak openly about situations that they have experienced themselves. These situations will then be analysed by the group, working as a team. These types of personally experienced cases offer the greatest learning potential, as they come directly from the participants’ own environments, whereas there is a risk that participants will categorise external examples as irrelevant to their own work (11).

EHAC-ACRM network and partnership EHAC has established a permanent working group responsible for the development, implementation and monitoring of all tasks related to the ACRM project. A comprehensive quality-assurance programme laid down in the handbooks ensures that the defined quality standards are actually met and thus that the minimum requirements for a successful ACRM training system are also met internationally (see Fig. 3). The ACRM cooperation network is open to all EHAC members – provided that they meet the entry requirements – and is constantly growing. Some organisations are currently in the predefined implementation process, which ensures the smooth introduction of the ACRM philosophy and training courses with the help of experienced ACRM trainers. The network of air-rescue organisations now includes the following countries:

• • • • • • •

Fig. 3: Numerous studies have shown that human beings are a significant influencing factor on safety in highly complex areas of operations (Photographs: ÖAMTC)

Austria Czech Republic Germany Hungary Luxembourg Netherlands Switzerland

The train-the-trainer programme is the most important element in both the implementation process and the quality assurance system. This programme has a comprehensive curriculum and lays down all of the quality standards for ACRM trainers with regard to entry requirements, initial and further training, supervision and inspection (12). As

Train-the-Trainer Concept Aeromedical CRM (Vienna, 20091023) Prerequisits

Initial Training

Recurrent Training

Selection Interview

Integrated in a HEMS Team or HEMS experience of more than 3 years

Human Performance Limitation course or examination

Key Performance Competences

Human Factors – Self Study

Aeromedical CRM Training

Instructor Competences

Trainer Meetings

Educational Supervision 1. Session

CRM & Human Factor Recurrent Training (24h in 3 years)

Aeromedical CRM Trainer Course Educational Supervision 2. Session (at ACRM Training)

Annually 2 or more ACRM trainings as trainer

Educational Supervision 3. Session (at ACRM Training) ACRM Trainer Assessment (at ACRM Training)

3 · 2011 I Vol. 1 I AirRescue I 19

Assessment – (Rezertification 3 years)

Release Assessor + Supervisor

Human Factors – Self Study

Fig. 4: The initial and further training process for ACRM trainers is defined in the train-the-trainer curriculum, as are the entry requirements, the individual stages of the training course and the steps candidates need to take to obtain a qualification


Final_

20 | TRAINING ing formats for all the professions involved. But this is not enough: ACRM should also become a fixed element in the thinking of all individuals who hold responsibility, even those not directly involved in training and HEMS missions. This is not only a means of preventing active errors and their negative consequences: if ACRM-relevant aspects are included in strategic decisions that do not directly involve the actual HEMS mission, latent errors within the system can be prevented at an early stage, stopping chains of error at their source. Irrespective of the specific challenges that the partner organisations face, they know that within the strong EHAC-ACRM network they do not have to deal with them alone. And that is a very good feeling. 

For more information, visit: www.ehac.eu/acrm.html

Fig. 5: Highly complex situations always require an experienced team: As an independent complex system, patient handover – an interface with the organisational unit of a hospital – is just one of many such situations

the quality of an ACRM training course is completely dependent on the quality of the trainers deployed, this qualification process is very comprehensive, labour-intensive and detailed. The trainer candidates are prepared for their future role as experts in the human factors affecting air rescue so that they can subsequently become the person to contact about this within their own organisations. Fig. 5 provides an overview of an ACRM train-the-trainer programme (12). Over the years and during the development of the training concept, a very wide range of material has also been developed and placed on a website so that it is available to all cooperation partners and new members. Handouts and presentations on the required CRM subjects, material for individual and group exercises, case-based studies and training films are shared in this way. However, the great strength of the ACRM network is only partly to be found in the implementation process and training materials. Annual and regular meetings ensure that the exchange of experience and the further development of the entire system are driven forward by all those involved. In this way, the workload is shared among many people, while each new partner and each new trainer provides the network with new ideas and impetus.

Future challenges The greatest challenge for the future is to constantly improve the ACRM training concept and adapt it to changing working conditions. The further development of the training concept is heading towards that of a fundamental human factors concept. In this sense, ACRM should not be understood merely as an individual training module within the initial and further training system. Instead, ACRM needs to be integrated as a philosophy in all of an organisation’s operations. The improvement of human factors must be a defined learning objective of all train-

References 1. Flin R, O’Connor P, Crichton M (2008) Safety at the Sharp End – A Guide to Non-Technical Skills. Ashgate Publishing, Aldershot 2. St. Pierre M, Hofinger G, Buerschaper C (2005) Notfallmanagement – Human Factors in der Akutmedizin. Springer Medizin Verlag, Heidelberg 3. Badke-Schaub P. et al. (2008) “Human Factors”, Badke-Schaub P, Hofinger G, Lauche K (Eds.) Human Factors. Psychologie sicheren Handelns in Risikobranchen. Springer Medizin Verlag, Heidelberg, pp. 4-18 4. Helmreich RL et al. (1999) “The Evolution of Crew Resource Management Training in Commercial Aviation”, The International Journal of Aviation Psychology 9, pp. 19-32 5. Joint Aviation Authorities (2007) JAR-OPS 3: Commercial Air Transportation (Helicopters), Amdt. 5 6. Ruppert M, Lackner CK (2009) “Neue Trainingskonzepte in der Akutmedizin”, Madler C, Jauch KW, Werdan K, Siegrist J, Pajonk FG (Eds.) Akutmedizin – Die ersten 24 Stunden, 4th edition. Urban & Fischer, Munich, pp. 39-46 7. EHAC Working Group Aeromedical CRM (2011) Trainer Handbook. Munich 8. EHAC Working Group Aeromedical CRM (2006) Aeromedical CRM Syllabus. Munich 9. Lang B, Ruppert M, Schneibel W, Urban B (2010) “Teamtraining in der Luftrettung – Aeromedical Crew Resource Management – Ein europäisches Trainingsprogramm zur Optimierung der Flug- und Patientensicherheit in der Luftrettung”, Notfall und Rettungsmedizin 13, pp. 368-374 10. Strohschneider S (2008) “Human-Factors-Training”, Badke-Schaub P, Hofinger G, Lauche K (Eds.) Human Factors. Psychologie sicheren Handelns in Risikobranchen. Springer Medizin Verlag, Heidelberg, pp. 289-306 11. Lang B, Posch G, Weiermayer M (2008) “Führungsverantwortung und Leadership in der Flugrettung”, Buerschaper C, Starke S (Eds.) Führung und Teamarbeit in kritischen Situationen. Verlag für Polizeiwissenschaft, Frankfurt, pp. 156-179 12. EHAC Working Group Aeromedical CRM (2009) Trainthe-Trainer Curriculum. Munich

3 · 2011 I Vol. 1 I AirRescue I 20


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22 | INTERVIEW

“Our support begins with the first contact” – Psychological aspects of air ambulance operations A n i n t e r v i e w w i t h M a n u e l a S a x o f Ty r o l A i r A m b u l a n c e Trained clinical and emergency psychologist Dr Manuela Sax works for Tyrol Air Ambulance (TAA), where she runs courses and practical coaching sessions that focus on the psychological care of patients and their families during repatriation flights. Dr Sax has accumulated a wide range of experience in this area, including 20 years as an ICU nurse, and ten years working on ambulance flight missions and disaster missions as well as a crisis intervention trainer – while maintaining close links to academia.

Fig. 1: Manuela Sax presenting her award-winning poster on “Psychosocial Interventions in Patients and Relatives on Ambulance Flights” at the AIRMED World Congress in Brighton, 2011. (Photograph: M. Mennie)

ARM: Dr Sax, air ambulance crews often have to deal with patients in emotional distress. What are the dominant feelings that may affect the patients’ situation? Sax: On ambulance flights, patients and their companions are flown back to their home country or to a place where they can receive better medical care. During the flight, the crew is not only responsible for looking after patients’ physical health but also for providing psychosocial care to the patients and their companions. That huge challenge is too often overlooked or sidelined by medical teams. But proper psychosocial care is crucially important as it brings comfort and security to passengers after a traumatic experience abroad. And this makes a big difference to the transport situation as a whole. Acute stress reactions in emergency situations vary greatly. A crisis and the response to it are connected in Fig. 2: “The crew is not only responsible for looking after patients’ physical health but also for providing psychosocial care to the patients and their companions” (Photographs: Tyrol Air Ambulance)

a very complex way, so it’s impossible to say for sure beforehand that a specific situation will trigger a specific reaction. The effect on the persons concerned in what may appear to be a very traumatic situation is just as difficult to predict. It is also impossible to know when a reaction to a traumatic experience might surface – it may appear immediately or only at a later point. In many cases, patients and their companions will display signs of acute emotional stress during repatriation flights. These include fear, helplessness, emotional numbness, disturbed perception, hyperactivity, disturbed concentration or dissociation. Psychosocial care during an ambulance flight aims initially to create stability and then involves gently asking questions to establish traumatisation levels and possible symptoms such as intrusive memories, avoidance or hyperarousal. The crew will often have to help patients deal with acute feelings of loss and/ or guilt – particularly survivor guilt. Parents often ask a lot of questions about how they can help their children process the trauma in an age-appropriate way and when they should consult a specialist to help them. ARM: How should the crew react to that? What are your recommendations? Sax: In an emergency the people affected often put a lot of hope in the repatriation flight so it is vital that the entire crew behaves in a psychologically correct manner during the first contact and at the handover at the hospital. Patients and their families can experience the ambulance

3 · 2011 I Vol. 1 I AirRescue I 22


INTERVIEW | 23 flight as psychologically stabilising or even pleasant if they feel they are in good, i.e. competent, hands. And patients will feel that the crew is competent if their injury or illness can be named and explained in a way they can understand, if the steps that need to be taken are outlined and then quickly applied, and if they are given some idea of the effects they are likely to experience as a result of the treatment. It is also very important that the medic in charge listens attentively to what the passengers say, reacts appropriately and gives them the feeling that they have been understood. Such measures are very helpful in reducing tension. It is also essential for crew members to be able to identify an acute stress disorder when they see one, to classify the symptoms and to know how to react. They must be able to competently answer any questions passengers ask about their own reactions and to initiate conversations that might help reduce the emotional stress and tension of the situation. Holistic support – combining medical and psychosocial care – gives people involved in a crisis the reassurance that they are being looked after by competent professionals. Expanding their psychosocial skills also has a positive effect on the crew members as their own stress levels are reduced and they gain greater satisfaction from their work. ARM: In your opinion, should the whole team be responsible or just individual members that are well trained in giving psychological support? Sax: If you mention the subject of “psychological first aid” in this context, the first and possibly only thing people think of is the medical crew. But that’s not how it should be. The entire crew of an air ambulance should be in a position to provide psychological first aid. All the people affected by a disaster have been psychologically injured in some way and they require appropriate care. The sooner they receive this kind of attention the better – ideally at the scene of the accident. That substantially reduces the risk of long-term effects, or at least reduces their intensity and lessens the likelihood of their becoming chronic. A professional assistant – i.e. a psychosocial expert – at the target hospital can then provide the more differentiated and skilled care victims need in the period after an incident. Psychosocial support begins with the first contact with the patient and his or her companions. This first contact is always via the alarm centre, which is why the TAA staff here are trained in this area. The flight crew are largely responsible for making patients feel secure and in good hands during the flight. The flight crew communicate with the passengers while the patient is being loaded into and out of the plane and when caring for them during the flight. It is vital that the whole flight crew receives appropriate training in this area. Intuition is no substitute for proper training. ARM: Transparency is another essential factor: Providing the patients and their relatives with essential information regarding their transport/risks/condition, etc. is vital to

3 · 2011 I Vol. 1 I AirRescue I 23

ensure a safe and trouble-free air ambulance flight. What kind of information do you regard to be of major importance? And how should it be communicated? Sax: People who have had accidents or received an alarming diagnosis are often desperate for information that will give them a sense of orientation. The situation of being repatriated in an ambulance aircraft is new, complex and upsetting. Those affected are often unable to assess the extent of an injury or the gravity of an illness and their effects. The information they get in the first hospital they go to is often scanty or impeded by language barriers. In such a situation, even just silence on the part of doctors and nurses can be misinterpreted. Any kind of expert information that seems reliable or illuminating is therefore gratefully received. The questions asked by patients and their families vary greatly. Some people don’t want to say anything, while others fire question after question about all sorts of details in an attempt to gain a sense of control and security in this very stressful situation. The challenge is to precisely recognise the individual needs of the patient and their families and to try to react to them as sensitively as possible. Patients should always be given a general idea of their condition and be told about the next steps – the journey, the medical care they will receive, any necessary repositioning, the rough time schedule, etc. – so they know what is going on and feel that the situation is under control. This also greatly increases passengers’ willingness to cooperate. ARM: It seems that training medical crews is essential here. What kinds of training have been set up so far, at Tyrol Air Ambulance as well as in general?

Fig. 3: “The people affected often put a lot of hope in the repatriation flight so it is vital that the entire crew behaves in a psychologically correct manner”


24 | INTERVIEW Fig. 4: “Patients should be given a general idea of their condition and be told about the next steps – the journey, the medical care they will receive etc.”

Fig. 5: “The situation of being repatriated in an ambulance aircraft is often complex and upsetting for those affected”

Sax: Alarm centre and air ambulance staff have already completed a psychosocial training course that dealt with the kind of thing outlined above. The medical crew has received similar training. Naturally, the main thrust of the course is tailored to the group of professionals concerned. Our experience has shown that ongoing further training in the form of special interdisciplinary discussions of individual cases, specifically targeted courses and complementary coaching deepens and refines the knowledge gained on the course. In some cases, improved awareness in this area has led alarm centre staff to identify the need for emergency psychological care and put an expert on the flight straightaway. This expert was then able to ensure appropriate care throughout the flight. ARM: What are the basic elements of the training sessions given by your operator? What kind of exercises and theories are included and how much time is involved? Sax: The basic building blocks of a psychosocial training course are: • An introduction to psychotraumatology • Basic intervention techniques (steps to reduce stress, conversation guidelines, communication, etc.) • Emergency care of children and teenagers • Indications for transfer to specialised psychosocial care at the target hospital

This basic knowledge is then expanded on to meet the specific needs of the group concerned, as different demands are placed on different types of professionals. The basics are usually taught in evening classes or a one-day

seminar. However, ongoing reflections on the subject are also an important part of the process. This can be done in discussion groups or via written feedback from participants. On the basis of that feedback, follow-up training courses or individual coaching sessions can be offered. ARM: You carried out a study at Tyrol Air Ambulance regarding the correlation between levels of stress and information as well as between psychological support and cooperation. Could you elaborate on this? What are the results? Sax: The study enabled us to prove just how important it is to integrate psychosocial care in ambulance flights. A whole range of internationally acclaimed studies show the same results in similar areas. As a result, efforts to improve the quality of patient care have put greater emphasis on these training courses. I have also started follow-up research on the subject. Continuous feedback from flight medics and nurses at TAA showed me just how much their awareness of the issue has grown. These very positive results have enabled me to intensify my research in this field and to use the findings to improve quality – in our collaboration with other organisations, too. 

3 · 2011 I Vol. 1 I AirRescue I 24


Indonesia: Medical emergency assistance after the tsunami w© Francesco Zizola/Noor

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26 | MEDICAL CARE

Fig. 1: There are 16 PCI centres in Hungary and five of them are based in the capital city of Budapest, only five of them are equipped with a direct helipad (Photograph: Á. Sóti)

STEMI – Can we reach the catheter suite in time? Author: Ákos Sóti Medical Director Hungarian HEMS Hungarian Air Ambulance Nonprofit Ltd. akos.soti@airambulance.hu

Acute myocardial infarction with ST-segment elevation is widespread and thus also very prominent in pre-hospital care. The time factor and well-described treatment protocols are of high relevance here. The main aim of the retrospective study depicted here was to determine if patients received definitive care (through the PCI centre) within the time period recommended by the European Society of Cardiology (ESC) and the Hungarian Society of Cardiology. Factors that may have influenced this process were also examined. Methods

Fig. 2: The interval from the first call (to the dispatch centre) until the moment when the helicopter takes off (Talarm) was also being analyzed (Photograph: Á. Sóti)

Between January 2007 and June 2010, every seventh mission of the Hungarian Air Ambulance Ltd. was a primary or secondary transport of a STEMI patient. All patients whose symptoms indicated a primary percutaneous coronary intervention (PCI) were included in the study. The time examined was calculated from the earliest available time (the time of notification of need of a helicopter in the dispatch centre) to the last reliably documented time (helicopter landing time at the delivery point). This is called the time interval – Tint. This time interval consists of the following different time phases: the time from the first call (to the dispatch centre) until the moment when the helicopter takes off, called time of alarm (Talarm); the time from the take-off till the landing of the helicopter

3 · 2011 I Vol. 1 I AirRescue I 26


l ita

tio

n

ho e

fla

th

on

in

at

llo

in

Ba

riv Ar

La Tflight 2

tint – measureable in our study

unknown

g

g in nd

eTa k Tscene

sp

yp de at

ts fa of

on S M HE

Tflight 1

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ak rt te op lic He

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ym

pt

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oin

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medIcal care | 27

unknown

Tdoor-balloon Fig. 3: The time examined was calculated from the earliest available time to the last reliably documented time

Guideline: max 90 / 120 min

on scene (Tflight1); the time spent at the scene (Tscene) and the time from take-off at the scene to the landing time at the delivery point (Tflight2). Patients were divided into two groups. The members of the first group (Group A) were delivered directly to the PCI centre, whereas patients of the second group (Group B) needed further ground ambulance transfer from the nearest possible landing site around the hospital to the catheter suite (because of the lack of a direct helipad at the PCI centre). In order to get the real time frame from the diagnosis to the inflation of the balloon, some additional time (the time of the delay between the moment of the diagnosis and the dispatch of the HEMS, the time of the ground ambulance transfer where it was necessary and the hospital door-to-balloon times) should be added to the calculated time interval, but the exact data was not (yet) available to the study group. The primary care provider staff (ground ambulance, general practitioner, hospital, helicopter), the number and success rate of CPRs and thrombolytic therapies performed before and after the arrival of the helicopter and during transport, were also examined. There are 16 PCI centres in Hungary and five of them are based in the capital city of Budapest. Only five of the 16 PCI centres are equipped with a direct helipad (one in the capital). In

time limits

pCi-capable hospital

2h

4)

primary pCi

all other cases, a further ground ambulance transfer from the landing site is necessary. During the study period, only one PCI centre (in the capital – without a direct helipad) has published its door-to-balloon-times, which were 41 to 45 min (1).

Guideline It is essential to make every effort to minimize all time delays, especially within the first 2 h after specific symptoms appeared. This may also be achieved through the implementation of a system of care network (2, 3). As illustrated in Figure 4, the preferred pathway is immediate transportation of STEMI patients to a PCI-capable centre offering an uninterrupted primary PCI service by a team of high-volume operators. Patients admitted to a hospital without PCI facilities should be transferred to a PCI-capable centre and no fibrinolytics should be administered if the expected time delay between the first medical contact (FMC) and balloon inflation is < 2 h. If the expected delay is > 2 h (or > 90 min in patients < 75 years old with large anterior STEMI and recent onset of symptoms), patients admitted to a non-PCI centre should immediately receive fibrinolysis and then be transferred to a PCI-capable centre where angiography and PCI should be performed within a time window of 3 to 24 h.

ambulance

Non pCi-capable hospital

pCi < 2 h possible1) pCi < 2 h not possible2)

12 h

rescue pCi

24 h

angiography3)

1) Time from FMC to balloon inflation must be shorter than 90 min in patients presenting early (< 2 h after onset of symptoms), with a large amount of viable myocardium and low risk of bleeding.

3 · 2011 i Vol. 1 i airrescue i 27

pre-, in-hospital fibrinolysis

failed

successful

First Medical Contact (FMC) 2) If PCI is not possible < 2 h of FMC, start fibrinolytic therapy as soon as possible.

3) Not earlier than 3 h after starting fibrinolysis. 4) 24/7 service

Fig. 4: Reperfusion strategies (2): Arrow indicates the preferred strategy


28 | MEDICAL CARE

Fig. 5: Some other important circumstances that influence when a patient gets the definitive care, are the time between the set up of the diagnosis and the HEMS request as well as the doorballoon times at the PCI centres (Photograph: T. Bader)

Fig. 6: Between January 2007 and June 2010, every seventh mission of the Hungarian Air Ambulance Ltd. was a primary or secondary transport of a STEMI patient (Photograph: T. Bader)

Results In the examined time period, 1,034 patients with acute STEMI (with PCI indication) were treated and transferred. These were 14,51 % of all the patients treated (1034/7126). The average age of the patients was 59 ± 10 years. A total number of 370 (35,78 %) patients were categorized in group A (delivered directly to the PCI centre). Time data were the following: Tsumm: 68±12 min Talarm: 7±5 min, Tflight1: 18±5 min, Tscene: 23±8 min, Tflight2: 19±5 min. 652 (63,05%) patients were categorised in group B (further ground ambulance transfer needed from the landing site to the hospital) with the following time intervals: Tsumm: 63 ± 14 min, Talarm: 7 ± 4 min, Tflight1: 17 ± 5 min, Tscene: 20 ± 6 min, Tflight2: 21 ± 9 min. The alerting of the HEMS team to the scene was requested by a ground ambulance or a GP in 502 cases (48,54%). In 20 cases (1,93%) the HEMS was the first – and only – provider and 512 patients (49,51%) were transported from a hospital to a PCI centre. Eleven patients died at the scene and one during transport. 106 CPRs were performed successfully before the arrival of the helicopter. The helicopter crew performed CPR in 33 cases including 13 cases in the field (started by the first provider, successful: 2) and 20 cases (successful: 19) during transport. Seventeen patients were sent to a rescue PCI (unsuccessful thrombolysis performed by the sending hospital) and two successful thrombolyses were performed at the scene by a ground ambulance (during CPR – based on

3 · 2011 I Vol. 1 I AirRescue I 28


MEDICAL CARE | 29 Table 1: Time intervals of groups A and B

Patient number

Talarm

Tflight 1

Tscene

Tflight 2

Tint

Group A

370 (35,78 %)

7±5 min

18±5 min

23±8 min

19±5 min

68±12 min

Group B

652 (63,05 %)

7±4 min

17±5 min

20±6 mon

21±9 min

63±14 min

0,3421557 0,0458241 0,0000572 0,4950553

0,0000371

Student’s T test

(two sample)

P value

Table 2: First Observer

First observer Table 3: Number of CPRs carried out on scene and on flight

HEMS

GP / ground ambulance

Non PCI capable hospital

20

502

512

1,93 %

48,54 %

49,51 %

CPR (successful)

Thrombolysis

Before HEMS

(106)

17 – rescue PCI needed

On scene (by HEMS)

13 (2)

10 – during CPR (2 successful)

During flight

20 (19)

justified diagnosis of STEMI). The HEMS team performed thrombolysis at the scene 10 times (in all cases during cardiopulmonary resuscitation and by the evidence of diagnosis of STEMI), of which two were successful (see Table 3).

Conclusion The results are able to show an approximate reference rather than exact facts, because the time phase – measureable objectively in the study – was only a part of the time data, which has a precise definition in the guidelines. The patients of group A reached the delivery point significantly later (however the delivery point here was the PCI centre itself) than the patients of group B, where a further ground ambulance transfer was needed. This was mainly because of the significantly longer time spent at the scene in group A. There are some other important circumstances that influence when a patient gets the definitive care (balloon inflation), namely the time between the set up of the diagnosis and the HEMS request, and the door-balloon times at the PCI centres. The data and the additional estimates show that the patients probably reach the catheter suite and have balloon inflation in less than 120 min in both groups. But under current circumstances it is unlikely that the 90 min recommendation can be accomplished, especially for group B. A very large percentage of the patients were transported from a hospital and the study group assumes that most of these patients were not admitted to the hospital by coming in on foot with chest pain and STEMI was diagnosed, but that they were referred by a GP or ground ambulance to a non PCI-capable hospital. In these cases it would be desirable if patients were referred primarily to a PCI centre by the first provider and the HEMS were requested to the scene as needed. This would be a very important time asset for the patients’ heart muscle. The HEMS team should reduce the average time spent at the scene. To enable this, it would be helpful if the patient had received all of the treatment indicated by the guidelines by the time of the helicopters’ arrival. More patients should

3 · 2011 I Vol. 1 I AirRescue I 29

be transported to a PCI centre with a direct helipad (and that is why more helipads should be built in the near future). Where a ground ambulance transfer is necessary, the HEMS team should escort the patient in the ambulance to the operating room instead of the time-demanding handover to the ambulance physician/paramedic. A direct contact with the PCI centres is very important in order for them to prepare for the patient with an empty OR and completely ready staff. About one tenth of our patients received successful CPR before we arrived. Our success rate in the field is low (these CPRs were started by the first provider and the HEMS took over the care); by contrast, the cardiac arrests witnessed in-flight were treated with very high success. Only few patients were transported to rescue PCI after thrombolysis. The HEMS crew performed this therapy only in cardiac arrests with a low success rate. We did not examine the time benefit – or delay – comparing the use of the helicopter with the use of ground transfer. This factor must be examined as well in every case. In a case where the patient should reach the balloon inflation in 90 minutes, a careful individual assessment – based on a thorough consideration of the circumstances – is necessary to decide whether to deploy a helicopter or not. In these cases, if the calculated estimated time is significantly more than 90 minutes, immediate thrombolysis and subsequent coronary angiography is recommended instead of dispatching the helicopter. 

References: 1. Becker D. et al. (2009) Significance of Off-hours in Centralized Primary Percutaneous Coronary Intervention Network. Croat Med J. 5: 476-482 2. Werf F. Vd et al. (2008) Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. European Heart Journal 29: 2909-2945 3. Wijns W. et al. (2010) Guidelines on myocardial revascularization. European Heart Journal 31: 2501-2555


30 | MEDICAL CARE

Case Report Geocaching: a modern treasure hunt with risks Authors: Esther Timm HEMS crew member on the “Christoph 12“ 23623 Siblin/Ahrensbök, Germany Esther.Timm@web.de Peer G. Knacke Senior Physician Head of Department of anaesthesia, emergency medicine and pain therapy Sana Kliniken Ostholstein GmbH – Klinik Eutin p.knacke@t-online.de Petra Saur Senior Consultant Department of anaesthesia, emergency medicine and pain therapy Sana Kliniken Ostholstein GmbH – Klinik Eutin Hospitalstr. 22, 23701 Eutin, Germany

On the evening of a glorious summer’s day, emergency air ambulance helicopter “Christoph 12” and the nearest road ambulance are called into action after an electrical accident in a rural area. Situation After 13 minutes in the air, the team spots the concealed accident site in the corner of a remote field. There appears to be no direct access for road vehicles and no other rescue teams have arrived. From the air, the team can make out one person and a quad bike. After landing, they find a conscious patient lying on his back (Fig. 1) and an uninjured female friend, who made the emergency call using her mobile phone. A nearby electricity pylon does not seem to pose a risk for the rescue team as the woman is moving around between the pylon and the patient.

Case history and results According to his own statement, which was confirmed by the female friend, the 26-year-old male patient had climbed about three metres up a steel electricity pylon that was not connected to a power line (Fig. 6) in order to hide a geocache. Geocaching is a modern form

of treasure hunting using GPS devices. When he tried to climb further, the patient received an electric shock and fell backwards onto the field, where the ground was very soft. He was responsive and lucid (GCS 15) and was not suffering from any problems related to airway, breathing or circulation (ABC principle). He could not move either of his arms due to the pain this caused. His hands and the bottom third of his lower arms on both sides had suffered third-degree burns (Fig. 2) and his fingers were bent (Fig. 3). A physical examination did not reveal any further pathological problems on the rest of his body. According to the patient, he had already taken (untypical) medication – a beta-blocker and an asthma inhaler. He was not able to remember the name of the specific drugs, however. The ECG showed he had a sinus rhythm with a heart rate of 100 beats/minute, and the result of the pulse oximetry was SpO2 100% without any additional oxygen being administered. Blood pressure was measured at 170/98 mmHg.

Therapy and treatment procedure After failing to insert a line into veins on the foot, the rescue team inserted one line (G18, green) into the left arm above the patient’s injuries and connected it to 500 ml of Ringer’s acetate solution. Routine checks on blood sugar levels gave a constant figure of 90 mg/dl. To manage his pain, the patient was initially given 0.2 mg of fentanyl, and small top-up doses of 0.3 mg were administered throughout the rescue mission. While treating the patient, the team also contacted the call centre to ask whether he could be admitted to the nearest severe burns unit. He could. However, because of his fall the patient first of all had to be taken to a trauma centre. The patient was positioned on a spine board. After 17 minutes of treatment, he was ready to be transported to the hospital in the emergency air ambulance (Fig. 5). A police vehicle then arrived at the scene and a paramedic from the road ambulance. After 17 minutes in the air, the patient was handed over to the trauma centre in a conscious state with stable circulation and minimal pain (RR 150/90 mmHg, SpO2 96, pulse 100/min).

Discussion

Fig. 1: Situation upon arrival (Photographs: P. Knacke)

Air rescue has proved to be a particularly useful way to help accident victims in rural areas. In cases where no exact location can be given it is often quicker to find the site of the accident from the air (although not always in wooded areas). The air ambulance can also reach areas that are difficult to access on the ground due to a lack of paths or roads.

3 · 2011 I Vol. 1 I AirRescue I 30


MEDICAL CARE 31 Figs. 2 & 3 : Close-up of both hands with third-degree burns

Fig. 4: Close-up of back of left hand

Fig. 5: Patient in the emergency air ambulance

When dealing with electrical accidents, it is always important to consider one’s own personal safety first. Warning signs must be taken into account – as the patient neglected to do. Electrical accidents can lead to very different types of injury depending on the amount of electrical charge. All types of cardiovascular disorder right through to ventricular fibrillation might occur, and it is therefore always essential to conduct a diagnostic ECG. In general, the higher the electrical charge, the worse the thermal damage. It is important to remember that electrical accidents can cause deep tissue damage, which could lead to significant necrosis. That is why it is important for high-voltage electrical accident victims to be sent to a severe burns unit. If the transfer is likely to take less than 45 minutes, it is worth considering taking the patient straight there. In this particular case, the emergency doctor on board the helicopter had spent many years working in a severe burns unit and therefore had amassed a large amount of experience in this area. It is also always important to consider the way in which the accident happened. A three-metre fall where the patient lands on his or her back could inflict yet more injuries, even if the ground is very soft. In this case, a radiologic diagnosis showed that the patient had fractured a bone in his lumbar region, which, however, did not need to be operated on. The emergency rescue team were therefore subsequently proved to have been right to use the spine board. This mission clearly demonstrated where air rescue comes into its own: it is unbeatable when it comes to performing quick rescues in isolated, hard-to-reach areas and speedy transfers to a specialised hospital. 

3 · 2011 I Vol. 1 I AirRescue I 31

Fig. 6: The steel pylon that the patient climbed onto


32 | FIXED-WING

DRF Luftrettung repatriation missions depend on the expertise of the crew Author: Eva Baumann DRF Luftrettung eva.baumann@ drf-luftrettung.de

Twenty-four hours a day, 365 days a year, DRF Luftrettung – as many other air ambulance operators – deploys air ambulance planes to transport patients quickly and safely back to their home countries. But what do these urgent transport missions involve? How exactly are they carried out? The following examples illustrate the challenges associated with repatriation missions. To meet them, DRF relies on its expert medical, flight operations and technical teams, as well as the staff at the Alert Centre.

Fig. 1: DRF Luftrettung – under the name of European Air Ambulance – is based at Airport Baden-Baden/ Karlsruhe (Photograph: DRF Luftrettung)

From Baden-Baden to Grenoble to Durham to Gran Canaria to Stuttgart and back to Baden-Baden. What may sound like a varied holiday itinerary is actually the route taken by a DRF Luftrettung Learjet on 26 and 27 September 2011 to get two patients the medical care they needed.

Hang-glider crash near Grenoble While hang-gliding near the French city of Grenoble, a 60-year-old man crashed, suffering traumatic brain injury as well as a break in his sixth cervical vertebra. After the patient underwent neurosurgical treatment at the local hospital, it quickly became clear that he needed further medical care in his home country. His health insurer therefore commissioned DRF Luftrettung to transport him home to the UK on 26 September. As soon as it received the call, the Alert Centre sprang into action to prepare for the repatriation mission. The dispatcher responsible for the mission prepared the flight plan and ensured everyone involved had the necessary medical information. This meant obtaining the necessary patient and hospital records and contacting a consultant, who then spoke to the doctors at the hospital in Grenoble to gain precise information about the patient’s condition. The dispatcher then passed on this information to the medical crew accompanying the patient and organised the entire transfer from hospital bed to hospital bed. Within a few hours, the entire mission was fully planned and ready to begin. The Learjet 35A took off at

4 p.m. from its base at Airport Baden-Baden/Karlsruhe and an hour later the crew, comprising captain, co-pilot, emergency doctor and rescue assistant, landed on French soil. After a smooth handover at the intensive care unit and a quick transfer to the airport, the red-and-white air ambulance plane took off from Grenoble at 7 p.m. Throughout the flight, emergency doctor Florian Meister and rescue assistant Christoph Lind monitored the patient’s vital signs. Due to the break in his cervical vertebra, the patient had to be immobilised to avoid further complications. After a flight time of around 90 minutes, the air ambulance landed in Durham, and the patient was handed over to doctors at the hospital there in a stable condition at around 9 p.m.

Mission to Gran Canaria In the hours before, the central operations centre had already started preparing for the repatriation of another patient. On Gran Canaria, a 70-year-old woman had slipped on the bathroom floor in her hotel, dislocating her right knee and fracturing her ankle joint. The fracture had been reduced and surgically treated at the hospital on the island, but it was decided that all further medical care, including subsequent surgical treatment and rehabilitation measures, should be carried out in Germany to prevent any long-term damage to the musculoskeletal system. As the doctors agreed that repatriation would improve the woman’s chances of recovery, the Alert Centre quickly

3 · 2011 I Vol. 1 I AirRescue I 32


FIXED-WING | 33 made the necessary preparations, which involved obtaining the medical report from the hospital in Gran Canaria, liaising with the hospital in Stuttgart and contacting the air ambulance crew in Durham. Everything went according to plan, and the following morning, after spending the night in Durham, the crew flew directly to Gran Canaria.

Comprehensive expertise The Alert Centre at Airport Baden-Baden/Karlsruhe is staffed by skilled personnel around the clock, ensuring rapid response times whatever the time of day. To plan the flights effectively and get the necessary overflight and landing permits, the mission dispatchers require excellent foreign language skills and a good working knowledge of flight operations. They also need to have the geopolitical knowledge to accurately assess the situation in the countries the crews fly to. DRF Luftrettung transports an even mix of patients with internal, surgical, neurological and neurosurgical requirements. Around 20 percent of the patients transported on board DRF Luftrettung air ambulance planes are, as in these two instances, NACA III cases – patients with a severe though not life-threatening disorder. However, the bulk of its work is specialised transport missions for patients requiring intensive care and for high-risk patients. Around 80 percent of cases are patients whose condition could rapidly deteriorate into a life threatening condition (NACA IV) or patients suffering from acute, lifethreatening conditions (NACA V). All the doctors aboard the air ambulances need to have many years’ experience in emergency and intensive medical care. They are mainly doctors specialising in anaesthesia, although paediatric and neonatal doctors also work on these flights. This allows DRF Luftrettung to offer additional special services such as incubator transports. A fundamental part of the medical quality assurance is the programme of regular training sessions. These include medical simulator sessions and special seminars on hygiene and tropical medicine, as well as talks on the latest medical issues. In 2011 these have included new resuscitation regulations (ERC guidelines), traumatology, ventilation procedures and general anaesthetic and medical treatment during ambulance flights. DRF Luftrettung also ensures that its in-flight personnel are well trained. The captains of its air ambulances have an average 8,500 hours of flight time, while the co-pilots have around 3,500 hours.

Worldwide logistics The complex logistics involved in urgent repatriation missions have to be planned and implemented within a very short amount of time. A recent example of this was an air ambulance flight that was carried out from Dakar, the capital of Senegal, to Berlin. The message that the Alert Centre received at 4:15 a.m. was: “Patient severely injured after road accident in Dakar. Multiple trauma, intubated and ventilated. Patient to be transported to Berlin as quickly as possible.” Given the patient’s critical condition, time was of the essence. The Alert Centre took 35 minutes to check out the various criteria for the mission, includ-

3 · 2011 I Vol. 1 I AirRescue I 33

ing weather conditions, restrictions on flight operations, airfield opening times, crews’ shift and rest times, and medical criteria. After liaising with the internal medical, flight operations and technical teams, Alert Centre staff offered the client three different options. 1. Air ambulance with standard crew (captain, co-pilot, emergency doctor, medical assistant) 2. Air ambulance with additional crew members (2 captains, co-pilot, emergency doctor, medical assistant) 3. Air ambulance with a double crew (the standard crew twice over)

Given the patient’s critical condition and taking into account the crew’s shifts and rest times, performing the mission with a double crew was considered to be the quickest and best option. The Alert Centre made this recommendation to the patient’s insurance company. The insurer agreed, and at 5:10 a.m. it commissioned DRF Luftrettung to carry out the rescue mission with a double crew. The Alert Centre then started planning the mission in earnest. Its preparations included clarifying and organising the various aspects affecting the mission, such as overflight and landing permits, a detailed flight plan with a refuelling stop in Agadir (Morocco), and the patient’s transport from Dakar to Berlin. In addition, the medical team liaised with the medical team in Dakar to gain an overview of the patient’s condition. About 90 minutes after receiving confirmation from the insurance company, the ambulance plane took off from Airport Baden-Baden/Karlsruhe, heading for Africa. After a flight time of three hours 35 minutes, the first crew left the plane at Agadir and went to a hotel to rest before their next shift. The red-and-white Learjet then quickly took to the skies again and touched down in Dakar at around 2:30 p.m., two hours 50 minutes later. After a successful patient hand-over, the second crew set off again and landed at 8:45 p.m. in Agadir. The first crew climbed back on board and took the plane to Berlin. The Learjet landed at its German destination in the middle of the night, around 1:40 a.m. After the patient was handed over to doctors at the hospital in Berlin, the crew flew for 50 minutes back to its base at Airport Baden-Baden/ Karlsruhe, arriving at 3:50 a.m. 

Working in conjunction with LAR (Luxembourg Air Rescue) under the name European Air Ambulance (EAA), DRF Luftrettung and its team of experienced pilots and medical staff operate six ambulance planes used to repatriate patients across the world. Three of these air ambulances are based at Airport Baden-Baden/Karlsruhe. Their missions are coordinated by the experienced team at the Alert Centre, which is open around the clock, every single day of the year. In 2011, 892 patients were transported home from 95 different countries. For more information, visit: ››› www.drf-luftrettung.de


34 | FIXED-WING

Fig. 1: LAR decided to purchase the LearJet 45XR aircraft model for air ambulance operations (Photographs: LAR)

The next generation is airborne – renewal of the LAR-fleet Author: Alessandra PlanerNonnweiler Luxemburg Air Rescue alessandra.planernonnweiler@lar.lu

When it came to (re-)organizing its fleet, Luxembourg Air Rescue (LAR) often went its own way: In 1995, LAR chose to partner with Boeing in order to launch the MD900/MD902 type helicopter in Europe, the first one without a conventional tail rotor. Today, this helicopter is regarded as one of the most comfortable rescue helicopters in the world. In 2009, fixed-wing fleet renewal was on top of the agenda, and the LearJet 35A aircraft model that had been in operation for more than 10 years was to be replaced. For this reason, an internal expert group was commissioned to find the ideal ambulance jet that could meet the demands of a high-tech ambulance aircraft and serve LAR’s needs for at least ten to twelve years. It was the LearJet 45XR that was the first choice. In Search of a Suitable Jet

Medical Equipment

Restructuring the LAR ambulance fleet at this point in time was no coincidence. As a result of the financial crisis, aircraft with few flight hours were being offered at reasonable rates. The only problem was to find an aircraft model suitable for the requirements at LAR. Current developments in aircraft technology have been monitored for many years as well as trends in the aircraft market and, of course, developments in flight medicine. That is why the decision was taken quickly and the LearJet 45XR was chosen. It is one of the most up-to-date jets of its category in terms of technology and achieves great range while consuming a minimum amount of fuel. Another advantage is the short-landing capability as well as its speed. When choosing a suitable jet, attention was not only paid to the technical performance of the aircraft, but also and in particular to its interior. This was essential in view of the need for sufficient space for the state-of-theart equipment of the future ambulance aircraft.

On 1 May 2011, the first of the two aircraft landed at Findel Airport in Luxembourg. The jet, still in a VIP-configuration, had to be converted into an ambulance aircraft. Together with an Austrian specialist in air ambulance interior technology, a patient transport system was developed which not only had to meet certain quality standards of LAR, but also had to be quickly adjustable to particular and varied air rescue tasks and missions. Employees of LAR were able to apply their experience to create a concept for two patient stretchers and 4 seats in its double stretcher configuration. The ambulance configuration offers different variants: On the one hand, two intensive care patients – the jet offers a spacious cabin interior for the installation of two stretchers – can be transported and looked after by two medical teams. On the other hand, one patient (intensive care) and another patient (non-intensive care, for instance with a spine fracture) can be looked after by a medical

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FIXED-WING | 35

team, while the two seats are available to relatives accompanying the patient. In the single stretcher configuration, an intensive care patient can be repatriated with six available seats. On long flights, this allows taking a second crew on board. Both ambulance jets are equipped with state-of-theart medical appliances. The new interior also offers sufficient space for enough medication and medical materials even on long flights. Another innovation is the special flooring, particularly developed for LAR-purposes. It consists of so-called pallets that are made from a robust anodized aluminium alloy that provides the option to easily anchor belts and fastening systems. Because of this, humanitarian aid can also be transported in the event of a disaster. Various configurations are possible, the entire

interior room of the aircraft can be laid up with this special flooring pallets. LAR has also been operating in disaster regions in cooperation with the UN and NATO. After an earthquake in Iran for instance, two ambulance jets were deployed to evacuate patients from the region.

Fig. 2: The LearJet 45XR offers a spacious cabin interior for the installation of two stretchers

Summary Technical development of the past 20 years made a restructuring of the fleet necessary. The first missions have already shown that the LearJet 45XR aircraft can be operated in an economical, environmental and profitable way. It also offers greater patient convenience and LAR can now provide an even larger variety of tailor-made solutions to patients and customers for every emergency. LAR will continue to venture onto new paths.  Fig. 3: Both ambulance jets are equipped with state-of-the-art medical appliances and the interior offers sufficient space for enough medication as well as medical materials – even on long flights

Fig. 4: Together with an Austrian specialist in air ambulance interior technology, a distinct patient transport system was developed

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36 | IN PROFILE

Fig. 1: Primary deployment in the high mountains close to the Norwegian border on 11 August 2011 (Photographs: B. Ulmer)

Air rescue in Sweden – the Gällivare rescue service On 11 August 2011, the rescue service from Gällivare, Sweden, was called out to the high mountains on the Norwegian border. The difficult weather conditions made it impossible to touch down right next to the casualty, so the pilots decided to drop the medical crew at cloud level. The emergency doctor and HEMS crew member then had to walk around a kilometre in order to reach the casualty, who was located in the fog behind the helicopter, above the snowfield. Plexus anaesthesia (local anaesthetic) was administered for the casualty’s dislocated shoulder. The casualty and rescue team then had to walk down the mountain until they were below the cloud line and could be picked up by the Dauphin helicopter.. Authors: Bastian Ulmer Medical Director Intensive Care Unit & Emergency Physician, Gällivare Hospital, Norrbotten, Sweden bastian.ulmer@nll.se Anders Larsson Intensive Care Nurse anders.larsson@nll.se Sara Turtola Intensive Care Nurse, sara.turtola@nll.se Jan Sjödin Intensive Care Nurse jan.sjodin@nll.se

The early days Sweden’s most northerly rescue helicopter base has been using an AS 365 N3 Dauphin helicopter since 1 December 2010. The Dauphin was brought in to replace the old Sikorsky S 76 A from Norrlandsflyg AB after 12 years of service. Norrlandsflyg AB, the company that originally operated the base, was founded in 1961 by Knut Hedström, who set up the company headquarters in Gällivare in Norrbotten, Sweden’s most northerly county. At first, the Norrlandsflyg crews and their two Cessna 185 aircraft (which were fitted with floats for landing on water) flew tourists and locals to remote moutain lakes for fishing expeditions, delivered provisions to the Sami people and supported businesses and government authorities by transporting staff around Sweden’s largest and most extensive province. Thanks to the high demand for flights, the company grew rapidly. By 1969, the Nor-

rlandsflyg fleet comprised of three hydroplanes and a Bell 47J helicopter. Over the years, the fleet was called out on SAR missions in the mountains time and time again. The region offered enormous potential in terms of hydroelectric power and as more and more development work took place and more and more workers came to the region, the number of accidents increased.

Official appointment of Norrlandsflyg Norrlandsflyg was officially asked to take over the air rescue service for Norrbotten in 1970 – the same year that the ADAC Air Rescue took on its service in Germany. The first rescue missions were carried out using a Bell 206 Ranger, but at the end of the 1970s this helicopter was replaced by a Sikorsky S55T. The 1980s saw the introduction of an AS 350 followed by an AS 360, and in 1992 the first Sikorsky S76 joined the rescue fleet.

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IN PROFILE | 37 SAA in Gällivare In November 2010, Norrlandsflyg retired from its air rescue work in Norrbotten after 40 years of service, in order to concentrate its efforts on its SAR service on the Swedish coast. The Vassaraträsk heliport in Gällivare has been taken over by Scandinavian Air Ambulance (SAA), a company that has been providing a highly successful air rescue service in Sweden for the past nine years and is also active in Norway and Finland. Operating the Gällivare base is a huge challenge. The region of Norrbotten is about the same size as the northern half of Germany, however, in Germany, this same area is served by 33 emergency response and secondary transport helicopters. The population of Norrbotten is around 200,000, most of whom live in the coastal towns of Luleå and Piteå. Gällivare and Kiruna on the Norwegian border are home to extensive heavy industry due to the widespread iron ore deposits, and every year, the Sarek, Stora Sjöfallet and Padjelanta national parks in the mountainous areas to the west of the province attract large numbers of tourists, who come to walk in summer and ski in the winter.

Operations in Gällivare The diversity of the region means that the work of the Dauphin crews in Gällivare is very varied, covering accidents in heavy industry and the timber industry, skiing accidents, road traffic accidents, mountain rescue work, internal medical emergencies and emergency medical evacuations from remote areas. The teams also transport patients and those in intensive care from medical centres in small villages and the small hospitals in Kiruna and Gällivare to the specialist hospital in Luleå or university hospital in Umeå. The journeys to Luleå and Umeå are an impressive 250 km and 550 km respectively. Emergency response work takes up 40% of the teams’ time, while secondary transport makes up the remaining 60%.

Operational challenges In the summer, the teams’ task is made even harder by the very changeable local weather conditions in the mountains and the millions of midges. Midge-resistant clothing and strong insect repellent are an absolute must on board the Dauphin. Likewise, in winter, the darkness and freezing temperatures as low as minus 40°C can severely hamper air rescue efforts. A helicopter needs to be light; therefore the doors, windows and outer skin are relatively thin and have only limited insulation. The heating system on board the Dauphin is generally effective in outside temperatures down to minus 10°C. In the four coldest winter months, two additional electric heaters are also installed to try and keep the cabin warm, because between November and March it is common that temperatures fall below minus 20°C or minus 30°C. Pre-heated infusion solutions being used outside will freeze within ten minutes. Frozen infusion tubes simply snap off and battery-powered electrical devices are pushed to their limit. Intravenous lines have to be inserted while wearing thick winter gloves and there is a major risk of the patient developing hypothermia. The only option is to get the patient into the helicopter as quickly as pos-

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sible and to treat them there. This is another reason – in addition to the long distances travelled – why the teams use such large helicopters. It must be possible to lay the patient down in the centre of the aircraft and treat him from both sides. The emergency doctor and paramedic sit to the right and left of the patient. The helicopter’s standard kit includes a padded sleeping-bag-like cover to keep the patient warm, head torches, snow shoes and a winter survival pack, complete with bivi bag (bivouac sack), dried food, etc. The helicopter and two pilots are on 24-hour standby. In order to work for the Vassaraträsk heliport in Gällivare, a co-pilot must have completed 500 flying hours and a pilot must have completed 3,000 flying hours (including experience of flying in the mountains). The AS 365 N3 Dauphin helicopter of the air rescue service in Gällivare is fitted with all the necessary flying instruments. In order to enable the helicopter to operate efficiently on a 24-hour basis, it is equipped with a continuous internet connection (for accessing the latest weather reports), as well as a weather radar and night vision goggles (NVGs) for use in the dark. 

Fig. 2: Gällivare JIA rescue helicopter in deep snow in the mountains at the Norwegian border

Fig. 5: Paramedic Britta accompanies a patient on a spineboard, who is being transported to the helicopter on a snowmobile


38 | IN PROFILE

Fig. 1: The immediate objective is to complete the establishment of at least one HEMS base in each of the 47 Japanese prefectures (Photographs: W. Nishikawa)

How Kugler-san contributed to the birth of Japan’s Doctor-Heli system Author: Wataru Nishikawa Director HEM-Net, Japan

As of June 2011, the number of helicopter bases for physician-staffed helicopter ambulance operations in Japan has totalled 27 (Fig. 2). More than ten years have passed since the “Doctor-Heli” system was officially inaugurated in April 2001. The German helicopter emergency medical system (HEMS) started in 1970, thirty years earlier than in Japan. Until 1980, the number of German bases had risen to 30. The pace of progress in the Japanese system is a little slower compared to the rapid progress in the German system. However, it can be said that in Japan the speed of growth is nearly similar to that in Germany. The number of missions the Doctor-Heli carried out and the patients treated in the past 10 years are shown in Fig. XY. A total of more than 45,000 missions and 40,000 patients treated are recorded. The average number of missions per HEMS operation base per year was 400. This figure is less than half of the German equivalent, where 1,000 missions were carried out in a year per operation base. It is desirable to more than double the mission frequency, by not thinking too carefully about whether to call the Doctor-Heli, in order to make full use of this medical system effectively. Our immediate objective is to complete the establishment of at least one HEMS operating base in each of the 47 Japanese prefectures. We expect nearly 50 bases to be completely established within the next 10 years. After that, bases may be built in any remote place in mountain-

ous regions, and the number of bases may ultimately total about 70 like in Germany. Germany and Japan have an almost identical surface area and the base availability in Japan will then be the same as in Germany. However, Japan has a more mountainous terrain than Germany. For this reason, Japan may need about 100 bases to maintain equal survival chances. The parties concerned will have to exert their efforts on increasing the availability of HEMS.

Who pays the costs? Expansion of the Doctor-Heli system greatly depends on economic factors to cover activity expenditures in addition to medical and humanitarian factors for relieving patients. The operational costs of the Doctor-Heli are totally covered by public funds from local and central governments, while those of German emergency helicopters are covered

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IN PROFILE | 39 by public health insurance and the contributions of civilians and enterprises. The running costs of the ambulance, which is the conventional transport system on the ground, is financed by public funds as well as a contribution by the patient, and helicopter transport must be financed as well since it is as much a part of the emergency medical transport system as the ambulance. An annual fund of 170 million Japanese yen per HEMS-programme was distributed between the fiscal years 2001 and 2007. The fund was contributed equally by the local governments in question and the central government’s Ministry of Health, Labour and Welfare. However, only one or two HEMS programmes started per year for six years in a row following the year of the inauguration and no programme was added in the fiscal year of 2003 (see Fig. 4). Fifty percent of the share proved unaffordable for the local governments. Consequently, the Ministry of Internal Affairs and Communications decided in 2008 to cover half of the local governments’ share. The fund of 170 million for one program was also increased to 210 million yen. Five new HEMS-programmes in five different prefectures immediately started operation in the same year. Effective from fiscal 2009, the Ministry again increased the fund to subsidize HEMS operation costs, and the share of the local governments decreased to 10 percent of the total. As the result, three to five new Doctor-Heli programmes will be added every year in the future. It is likely that nationwide distribution of the Doctor-Heli HEMS operations will be implemented by 2020, after which the development of the Doctor-Heli programme will enter the next stage.

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Learning from the Munich Model We should not overlook the major contribution of Mr Gerhard Kugler to the successful development of the DoctorHeli system in Japan. He gave us useful information for many years and supported us in establishing the DoctorHeli system. It was a great loss for us as well as for the HEMS community worldwide that Mr. Kugler passed away in November 2009. The Japanese Doctor-Heli system is in fact similar to the “Munich model” set up by Mr. Kugler, although the system for financing the helicopter emergency services is different in the two countries. A Doctor-Heli, complete with medical equipment, stands ready at the hospital facilities at all times and it takes off within a few minutes after receiving an emergency call, with a doctor and a nurse on board. Immediately after landing on site, the doctor practices initial treatment. When the patient’s condition is stabilized, the patient is transported to the most suitable hospital. Currently, in Japan, a flight nurse who works at the same hospital will join the flight, while in Germany, a paramedic working for a fire department or rescue organization will get on board with the doctor. The Japanese system therefore has the advantage of collaborative medical work between a doctor and a nurse since they routinely work at the same hospital, are acquainted with each other and know each other’s character. One single pilot is responsible for the flight in Japan as well as in Germany, but a mechanic takes a seat instead of a co-pilot. One of two pilots on board in Canada and Great Britain is responsible for navigation, communication, and watching outside while in Japan the mechanic

Fig. 2: Doctor-Heli bases in Japan: There is a total number of 27 bases in 23 prefectures, with two to three bases in some cases (Image: Create 21)


40 | IN PROFILE

Fig. 3: Three to five new DoctorHeli programmes will be added every year in the future and it is likely that nationwide distribution of HEMS operations will be implemented by 2020

in the co-pilot seat takes on all co-pilot functions. With the support of the mechanic, the workload of the pilot is reduced and he can concentrate fully on the safety of the flight.

Forty years of friendship To return to Mr. Kugler: the translator of this article, Mr. Yamano, travelled from Japan to Germany to visit Mr. Kugler at his office at ADAC in the beginning of the 1970s, at a time when ADAC was extensively launching its HEMS operations. Mr. Kugler took him to Christoph 1 operation base at Harlaching Municipal Hospital to show him an actual mission and explained the details of the fundamental philosophy underlying the HEMS. At the time, Mr. Yamano was working in his Japanese trading house on marketing and sales of an MBB BO 105 helicopter that ADAC had

Fig. 4: Deployment of Doctor-Helis in Japan

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started to operate for medical service. Through his daily business activities with Messerschmitt-Boelkow-Blohm (MBB), he got to know Mr. Kugler and a friendship developed that lasted for more than 40 years. Mr. Yamano was deeply impressed with the helicopter operating system for saving lives that Mr. Kugler showed him, and was driven to exert his efforts to introducing software for a helicopter lifesaving system to Japan, in addition to importing hardware of the BO 105 helicopter, which was his primary bread-and-butter business. Along with a group that included medical doctors, he attended the first AIRMED 1980 International Congress held in Munich, organized by Mr. Kugler. After Mr. Kugler first visited Japan in 1975, he frequently visited the country, and at our request attended many meetings, including those of the Japanese Society of Aeromedical Services, took part as a panelist at symposia and gave seminars. We learned a lot from his lectures and opinions on the concept of the helicopter lifesaving system. Mr. Kugler was always very hospitable and helpful to the many Japanese HEMSinterested visitors to ADAC Air Rescue and Harlaching Municipal Hospital. These visitors came from commercial helicopter operators, medical institutions, government offices, news media, etc. He always found time to respond to every question.

Impact of the German system One of the results of a visit by the Japan Broadcasting Corporation (NHK, non-commercial national mass media) was the special TV programme “West Germany reduces traffic accident mortalities by 50 percent”, which was broadcast on Japanese television in the evening news in December 1989. A team of reporters and camera crew under the guidance of Yutaka Yamano interviewed Gerhard Kugler at Harlaching Municipal Hospital. Furthermore, a scene was filmed where an emergency medical helicopter flew to a traffic accident site on an Autobahn and a flight doctor carried out medical treatment. It was reported in the TV programme that the number of traffic deaths in West Germany in 1970, the year the German Helicopter Emergency Medical Service started, was 21,332, while it was down to 10,070 in 1985. This reduction by half during 15 years proved the success of the HEMS operations. At that time, Japan suffered from an excessive number of traffic deaths, which was 16,756 in 1970. Despite this serious situation, there was no sign that mortality numbers were decreasing in the following years. Therefore, many Japanese people were hugely impressed by the successful results of West Germany as reported in the TV programme. The programme won the Prime Minister’s Prize for its quality and constructive content. It was aired on TV three times. The telephone of NHK began to ring during broadcasting. Many viewers complained or criticized the authorities for their lack of action in dealing with the excessive amount of traffic deaths. The number of telephone calls and mails from TV audiences to NHK totalled more than 250. This also encouraged the National Police Agency to organize a delegation of 14 members to visit Munich to study HEMS operations. Yutaka Yamano again guided them.

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IN PROFILE | 41 However, the helicopter medical service in Japan has still not been developed to such an extent that it could be labelled as an all-encompassing social system in daily life. Mr. Kugler, who was aware of this situation was sad about the strangely slow development of the system in Japan and said in the interview with an NHK reporter, “Why has no helicopter emergency system materialized in spite of the many concerned Japanese people who have visited Munich to see how we actually operate?” In 2002, Japan was able to reduce the number of traffic deaths to 8,326 from the highest number of 16,765 recorded in 1970. It took 32 years for Japan to achieve a 50 percent reduction. This figure has currently decreased to around 5,000. Fig. 5: Mr Gerhard Kugler (19352009) made a major contribution to the successful development of the Doctor-Heli system in Japan

Like a father watching his son grow In 1990 Mr. Kugler, together with his close friend Dr. Erwin Stolpe, delivered a lecture to an audience of more than 100 people at the seminar over which the author presides in Tokyo. In his lecture he focused on the fundamental requirements for helicopter emergency medical services. In 1994, the Japanese Society for Aeromedical Services was founded. Mr. Kugler kindly accepted our request to be a special advisor to the Society. At long last, the Japanese government took action to officially inaugurate the DoctorHeli system. Mr. Kugler kept visiting Japan frequently and watched over the progress of the Doctor-Heli system as if he were watching his son grow. His last visit to Japan was on 27 October 2007. Mr. Takaji Kunimatsu, chairman of the Emergency Medical Network of Helicopter and Hospital (HEM-Net), a non-profit organization for promoting the expansion and improvement of the Doctor-Heli service, invited Mr. Kugler to a banquet with traditional Japanese cuisine. In the convivial conversation, Mr. Kugler recommended Mr. Kunimatsu to hold AIRMED in Japan in the near future. Mr. Kugler’s recommendation was a great honour for us, but Mr. Kunimatsu declined with thanks since the expansion of the Doctor-Heli had still stagnated and we were too busy then to set up effective measures to promote and prepare to host the AIRMED. One year later, in October 2008, Mr. Yamano and the author attended the AMTC 2008, held in Minneapolis, Minnesota. One night Mr. Kugler invited us for dinner at a “Japanized” ethnic restaurant. EHAC president Mr. Christoph Breitenbach and Dr. Stolpe were also there. Of course, we briefly reported on the current progress of the Doctor-Heli program. He listened with a radiant smile as usual. It was the very last dinner that we had with Mr. Kugler.

Deep gratitude to Kugler-san for saving lives In the following year, when the author met Dr. Stolpe at the entrance of AMTC 2009 held in San Jose, California, he immediately told him that he had paid a visit to Kugler-san just before coming to San Jose, and that he was seriously ill in bed. Kugler-san (-san is a title of respect in Japanese and Kugler-san thus an affectionate name for Mr Kugler) had asked him to look after Japan’s development of the Doctor-Heli program, and also asked Dr. Stolpe to support Mr. Yamano and the author who were ardently interested in hosting AIRMED in Japan. Later, several HEMS leaders

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who had visited Kugler-san with Dr. Stolpe reported the same things. The next day, the day of our return home to Japan, we received the most unwelcome e-mail with the greatest sadness. Kugler-san passed away on 3 November 2009. In the summer of 2010, Mr. Yamano and the author visited Munich on their way to ILA Berlin Air Show as well as to participate in the 40th Anniversary of German HEMS. Dr. Stolpe took them to Kugler-san’s grave. They also had the opportunity to express their heartfelt condolences to Mrs. Renate Kugler at the auditorium, where the 40th anniversary event was held. The seeds that Kugler-san scattered 40 years ago are growing enough to have flowers in every corner of Germany as well as Europe and in Japan too. Thus, many lives have been saved in Japan. The author and translator wish to report the current remarkable achievement of the Doctor-Heli system to the great benefactor Kugler-san and wish to express their deep gratitude to him. 

Fig. 6: The number of traffic deaths was reduced from 16,765 (recorded in 1970) down to 8,326 in 2002 and further down to around 5,000 today


42 | IN PROFILE

London’s Air Ambulance – On duty around the clock When riots and mass looting struck London recently, London’s Air Ambulance (LAA) was on normal duty. While fire fighters and police had exceptionally tough days tackling the unrest, the emergency doctors and paramedics of London’s Air Ambulance were available just like on any ordinary day. They did what they are supposed to do: provide prehospital trauma care for the most severe cases. So the riots were not a particular cause for alarm as far as LAA was concerned. About one week after the riots had died down, I visited the base of the only helicopter emergency medical service (HEMS) in the area demarcated by the M25 motorway that encircles London. The sun is shining, it is a bright and warm summer’s day, and nothing hints at the recent unrest.

Author: Patrick Permien Editor “www.rth.info” Robert-Leicht-Str. 7 70563 Stuttgart patrick.permien@rth.info

LAA is based at one of London’s major emergency and trauma centres, the Royal London Hospital (RLH). Located just east of the inner city, the hospital is easy to reach on the famous “Tube”, the London Underground. The MD 902 helicopter perches on a rooftop helipad high above the pedestrians down on busy Whitechapel Road. After I meet friendly PR manager Siobhra Murphy downstairs, we take a lift straight up to the roof. The emergency team here differs from setups in other countries – for example in Germany – in both number and roles. The two pilots are accompanied by an emergency doctor and a flight paramedic. Often a second trainee doctor or paramedic goes with them and helps out as an observer during landing and takeoff procedures in urban areas. On the base, two fire officers are ready to provide technical assistance. This includes standing by during flight operations at the helipad and helping to unload patients from the aircraft. For reasons of safety and comfort, the stretcher is always loaded and unloaded via a sliding door on the right-hand side. The fire officers come from different backgrounds. They might, for instance, have served previously as heli-

copter technicians. While working for LAA they undergo regular training which includes exercises in a helicopter mock-up. Regular training sessions are scheduled every six months – an exception to the normal requirement for training every three months. But the team fulfils the legal requirements of having two fire officers and 2,500+ litres of water available as well as foam. This law applies to all UK helipads that are more than three metres above the ground. All paramedics and doctors undergo a four-to-sixweek special training course when they join LAA. You can find an in-depth review of the emergency doctor training courses in the August issue 2011 of AirRescue Magazine. Anyone who has never visited London or has no concept of its size might have difficulties understanding the special challenges that the HEMS crews face day in, day out. The head fire officer on duty today tries to give me an

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idea of what they are dealing with. On average, the London Ambulance Service (LAS) handles more than 4,000 emergency calls every day, which adds up to an impressive 1.5 million calls per year. To prove his point, the officer picks up the phone. Around 15 seconds and two sentences later he presents me with the exact number. The worker he just spoke to was handling call 2,078 since midnight. We check the clock on the computer screen – it is not yet 3 p.m. Tea and biscuits are handed out, and the officer continues explaining how London deals with emergency calls. A trained HEMS paramedic is on duty around the clock at the London Ambulance Service NHS Trust dispatch centre. The paramedic’s main task is to screen all incoming mission requests for certain keywords that have been defined as automatic triggers for starting a HEMS mission.

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For example, the keywords cover trauma indications after criminal incidents like stabbings or shootings as well as cases where someone has fallen from a great height (e.g. two storeys or more). LAA also covers a wide range of road traffic collision (RTC) scenarios such as crashes with at least one reported fatality or a person ejected from the vehicle, or a collision between a car and a pedestrian or cyclist (often involving tourists who are unfamiliar with left-hand traffic). LAA also responds to cases of people trapped under a train, a relatively frequent reason for making an emergency call. Members of the emergency services at the scene of an accident can also call for LAA’s help if they consider it necessary, and dispatchers may send in LAA if a call back to the person who reported the incident generates suspicion of severe trauma. First aid knowledge in the

Fig. 1: When riots struck London recently, the emergency doctors and paramedics of LAA were available just like on any ordinary day (Photograph: P. Permien)


44 | IN PROFILE

Fig. 3: Anyone who has never visited London might have difficulties understanding the special challenges that the HEMS crews face (Photograph: LAA)

Fig. 6: Two fire officers are ready to provide technical assistance: this includes helping to unload patients from the aircraft (Photograph: LAA)

UK tends to be poorer than in other EU states, and LAA staff told me that dispatchers frequently have a hard time figuring out the actual scenario over the phone. In cases that dispatchers suspect may be serious it is not unusual for them to call back many times in order to gather more details. As LAA operates only in cases of severe trauma, the keywords do not include anything related to medical emergencies like myocardial infarction (as is the case in Germany). Critical illnesses of this kind are only responded to by LAS paramedics in ambulances. Compared to its German equivalent for instance, the UK healthcare system has a much more diverse spectrum of entitlement to emer-

gency paramedics while prehospital emergency doctors are generally spread more sparsely throughout the country. LAA is called out around 2,000 times a year. In 2010, the counter stopped at 1,981. A little more than half of the callouts use the helicopter; the others use an emergency vehicle. Remarkably, LAA has the only emergency doctor response team in London’s entire prehospital care system. After treatment at the scene of the accident, patients can either be flown to hospital in the helicopter or taken there by ambulance. Both variants are frequently made use of. LAA does not carry out any special operations (such as cooperations with emergency divers) other than trauma care. When LAA is at the base, alarms come in over the phone. As soon as it starts ringing, the pilot rushes to the helicopter while the fire officers get ready to supervise the start-up. In the meantime the co-pilot will check the location of the mission request. The target is identified through a combination of the address provided and the uniquely numbered ATC grid square associated with it. The flight vector can be retrieved from the GPS coordinates. On-board navigation is carried out using traditional street maps. With takeoff usually occurring two to three minutes after the alarm is sounded, response times are very similar to those in Germany. I am told that the cooperation with Heathrow ATC works excellently. Upon request, LAA receives priority treatment over even the biggest jets like the Boeing 747 or Airbus A380. And since Heathrow is one of the world’s main air traffic hubs there are many of those around. However, the controllers will nonetheless allow LAA to proceed unhindered whenever possible. Likewise, cooperation with the local police runs smoothly. In many

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places, police officers will supervise and secure the HEMS operation at the scene and might even take the medical crew closer to the site by car if needed. The LAA helicopter is an MD 902 Explorer, which has several advantages as well as some tradeoffs. The machine’s NOTAR system, for example, which replaces the use of a tail rotor, makes landing in urban areas much safer. However, LAA is dependent on spare parts delivery from American company McDonnell as the European supply is considered very unreliable. A visible consequence of this is a contrasting black tail part – this was provided by a British police unit. The MD 902’s predecessor was an AS 365 Dauphin. The first helicopter’s main sponsor was the Express newspaper group. When the Express pulled out, Virgin became a corporate sponsor – so the Dauphin had to be given a new paint job. This red colour scheme was later transferred to the MD 902 Explorer. The logos of the major sponsors feature on the helicopter’s fuselage, and the most prominent among them is still the Virgin logo. LAA has a constant struggle to raise funds, mostly because of competition from the vast number of different charities in the area, all begging for support. As LAA operates the only HEMS service in London, patients from other HEMS services are not brought in very frequently. When another service requests permission to land, LAA has to judge the urgency of the incoming case in order to decide whether to move its helicopter from the helipad to make way for the guest or to ask the other service to land in a nearby location and use a ground ambulance to take the patient the rest of the way to the hospital. LAA cannot afford a backup helicopter as it is run on donations alone. When the MD 902 Explorer helicopter is

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offline, it is replaced by an emergency rapid response vehicle. The car covers the same range the helicopter would. The same applies when the helicopter is offline during the night. It spends its nights in a hangar at a nearby airfield. But LAA has a number of emergency Skoda Octavia cars based in front of the Royal London Hospital so switching from helicopter to car takes place swiftly. In the early morning on the day of my visit the helicopter was offline for some time due to low visibility. At noon, LAA responded to a suspected severe wound caused by a dog bite but the response was cancelled by the first units arriving at the scene as the case was less severe than initially assumed. During my visit to the base there were no incoming calls to respond to, although ground ambulances were constantly entering and leaving the hospital. This callfree time gave us time to take a look at the next big step ahead: a huge, blue building – the new Royal London Hospital LAA expects to move in on top of the complex in December 2011. The rooftop helipad has already been installed (see also the article on the new helideck at the Royal London Hospital, pp. 46-47). LAA’s new home is more modern and even higher above the ground – though this does mean HEMS members will have a longer trek to reach the helicopter. If you would like to know more, visit the LAA’s informative website which features additional data and regular news. Anyone who feels a personal connection to London or to LAA specifically will also find plenty of information on how to donate to the charity. The fan shop is currently under construction but it is set to re-open very soon. 

For more information, visit: ››› www.londonsairambulance.co.uk

Fig. 4: Picadilly Circus, central London – members of the emergency services at the scene of an accident can also call for LAA’s help if they consider it necessary (Photograph: LAA) Fig. 5: Medical equipment inside the MD 902 Explorer that works with the NOTAR system (Photograph: P. Permien)


Fig. 1: The new RLH features a cluster of inter-connected contemporary glass buildings, one of the towers, 17 storeys high, is equipped with the helipad for London’s Air Ambulance (Photographs: Bayards)

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Helipad at the new Royal London Hospital: Part of the biggest building project in the UK Author(s): Editorial Team AirRescue Magazine info@airrescue-magazine.eu

The highest point even overtops the clock tower of London’s Palace of Westminster, commonly referred to as the Big Ben: At 93 metres, the helipad has been assembled on the rooftop of the compellingly large building of the new Royal London Hospital (RLH). The RLH, originally founded in 1740, is currently being rebuilt. The new hospital arises between the edifices of the old hospital. It is the biggest building project ever undertaken in the UK as well as the largest hospital redevelopment project in the world: According to RLH’s press releases, more than 4.5 million man hours were worked at the height of the construction period, 175,000 tonnes of concrete were used, 1,750 tonnes of structural steelwork has been installed and 11,000 tonnes of metal reinforcement was used in the structure. The “icing on the cake” of this building project is the new helipad. The new development will provide general hospital services for the City of London as well as Tower Hamlets and specialist tertiary care services for patients from across east London and beyond. Britain’s biggest new hospital will also include a leading trauma and emergency care centre, providing excellent trauma care through the London Trauma System. Opening ceremonies are expected to be held in December. Preparations are said to be “on track for the first clinical moves into the new hospital.”

Constructions shall be completed three years later, by 2015, although 75% of its redevelopment is planned to be ready by early 2012. Total construction costs are reported to be in the region of £1 billion UK-Pounds. The new hospital features a cluster of inter-connected contemporary glass buildings, also including two 17-storey towers. One of these towers is equipped with the helipad for the Helicopter Emergency Medical Service, carried out by London’s Air Ambulance (LAA).

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Fig. 2: The new RLH will also be home to London’s Air Ambulance which then will be accommodated below the new helipad (Photograph: P. Permien) Fig. 3: An 120m walkway leads to the top of the helipad, the bottom side of the 28m by 28m rooftop pad is completely covered with aluminium cladding

Fig. 4: The Bayards-helipad is equipped with flood and perimeter lighting; it also has a built-in fire fighting system and is equipped with drainage-piping as well as an oil separator Fig. 5: Gareth Davies, the medical director of LAA, who was involved in the planning and development, says that the most important features of a good helipad are its “accessibility and good safety features”

The 28m by 28m rooftop helipad with an 120m walkway was designed and constructed by the aluminium construction company Bayards, who specialize in aluminium helipads. The underside of the helipad is completely covered with aluminium cladding and it is equipped with flood and perimeter lighting. It also has a built-in fire fighting system and is equipped with drainage-piping as well as an oil separator. A fast elevator, taking about two minutes, moves the patient from the top of the 17-storey building to the Emergency Department that is based on the ground floor. The LAA-team is accommodated immediately below the helipad. Dr. Gareth Davies is the medical director of LAA and a senior doctor in the emergency department of the RLH. Davies was involved in the planning and development of the new helipad, a process that began ten years ago. “A helipad is essential for the RLH. The roads of London are so congested and transport times very protracted.” For patients with life-threatening conditions like trauma, heart-attacks and strokes, the RLH is an important re-

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gional centre. Most of the trauma patients are transferred to the hospital by helicopter. “Emergency medicine, fast transport and good accessibility demand a helicopter and a helipad that is safe and comfortable.” Davies states that the most important features of a good helipad are its “accessibility and good safety features”. Furthermore it has to be “usable and functional in all weather conditions and have a surface that is non-slip and not too bumpy.” After a thorough selection, RLH and Skanska, a multinational construction company based in Sweden and the builder of the gigantic project, chose a Bayards-aluminium helipad. With more than 25 years of expertise in the field, Bayards carried out the design and construction of the aluminium helipad. Aluminium requires practically no maintenance; the oxide layer protects the underlying metal itself. That is why the respective type of aluminium can last for around 30 years without any surface damage. Davies and all those involved in the project are eagerly awaiting December 15th, when the helipad will be taken into service. 


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Fig. 1: OX2architekten is responsible for the striking design of the “saving hand” (OX2architekten, Prof. M. Orawiec)

Functional and symbolic: the new helipad at University Hospital Aachen Author: Tobias Bader Editorial Team, AirRescue Magazine

Fig. 2: The new helipad has a landing- and a parking area to ensure that one heli can land even if another is waiting on the pad (UK Aachen)

It looks like an open hand with its palm facing up towards the sky: after a year of construction, the new helicopter landing pad at University Hospital Aachen (UKA) officially opened in July 2011. Named “Rettende Hand” or “saving hand”, the new landing platform for air ambulance helicopters recently held an open day where the public could come and get a closer look at the new structure. Visitors and employees could take tours and find out all there is to know about helipads and air rescue. They also had the opportunity to go on accompanied visits up to the platform, which rises 15 metres up into the air and is accessed via 102 steps. There they learnt how patients landing on the platform are transferred to the hospital via a diagonal lift. In emergency situations, the diagonal lift enables rescue crews to quickly negotiate the 22-metre height difference between the platform and the hospital. Moving at a speed of a metre a second, the lift allows patients to be transported directly into the A&E for diagnosis and to the neighbouring operating theatres, removing the need to move the patient into an ambulance car and cutting the transfer time from the helipad to the hospital down from five minutes to one. Aachen firm of architects OX2architekten is responsible for the striking design of the new pad, which was inspired by the image of the “saving hand”. This was intended to express the idea of the landing platform as a connection between the emergency rescue mission and initial hospital care. The architects wanted to ensure that the platform would encroach on the public space below as little as possible. Towering above the heads of employees, students, patients and visitors at the University Hospital Aachen, at the heart of the action, it symbolises how life-saving missions are a service needed and supported by society.

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Fig. 3a: In emergency situations, the diagonal lift enables rescue crews to quickly negotiate the 22-metre height difference between the platform and the hospital Fig. 3b: The fibreglass membrane covers a total surface area of 1,450 m² (Photographs: OX2architekten, Prof. M. Orawiec)

Fig. 4: The “Rettende Hand” will welcome many different air ambulances bringing patients from all over Germany to Aachen (Photograph: R. Mehl)

The new helicopter landing pad was necessary due to new aviation guidelines. These aim to guarantee safe landings and take-offs from helipads even when things go amiss (like if a helicopter malfunctions). This requires a shallow take-off angle that is free of obstacles. In the case of the UKA, this meant ensuring helicopters landed at least 14.5 metres above street level and taking into account the main flight approaches. The contractor for the project was the University Hospital, and Bau- und Liegenschaftsbetrieb (BLB) NRW in Aachen was responsible for managing the project. HeliportDesign Carloff GmbH carried out the expert evaluation to ensure the raised helipad complied with aviation guidelines, and also prepared the landing pad for testing and approval by the Düsseldorf borough authorities with regard to flight safety and landing angle. The Rettende Hand is a concrete platform set on top of a steel structure. Its construction comprises around 318 tonnes of steel in the support structure, around 25 tonnes of steel in the membrane substructure, and around 25 tonnes of steel parts for the diagonal structure con-

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necting the helipad to the hospital. This was constructed from four pre-fabricated parts, each weighing 45 tonnes. The Rettende Hand also features around 960 m² of aluminium panelling. The fibreglass membrane covers a total surface area of ca. 1,450 m². The entire structure weighs 880 tonnes. The new helipad has a landing area and a parking area to ensure that one helicopter can land even if another helicopter is waiting on the landing pad getting ready to transport donor organs or a patient. The project will cost €7.5 million in total and is being paid for by the state. The money has also been used to refurbish the ambulance bay and to adapt A&E itself. The Rettende Hand will welcome many different air ambulances bringing patients from all over Germany to Aachen. A frequent guest to the futuristic-looking helipad is likely to be “Christoph Europa 1”, which is stationed nearby in Würselen, near the border with Belgium and the Netherlands.  For more information, visit: ››› www.ukaachen.de and www.ox2.de


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Fig. 1: Ground-level helipads that have predominated at hospitals until now are increasingly being replaced by rooftop helipads (Photograph: DRF Luftrettung)

Improving helipad safety with a new landing information system Author: Thomas Wysk Keppel Data-Systems Thomas.Wysk@keppel.de

Even though pilots of rescue helicopters are absolute professionals, they still need reliable conditions to work in. Much remains to be done in this respect, because as far as the safety and approval of helicopter landing pads, or helipads, is concerned, very little has actually been achieved in recent years – despite the fact that this is a very important area for aviation and air rescue. Very few helipads have permanent approvals, and others are only approved in emergency situations – they have never officially been put into service and are simply operated without an official permit. EASA standards and hospital helipads

Are rooftop helipads better?

This year, however, things have really started moving regarding helipads and the legal framework for them. The problem of helipads at hospitals re-emerged as a result of efforts by EASA to achieve uniform standards in European aviation. Minimum demands for even the smallest airfields – such as being able to call up the latest data on weather conditions and landing direction – were simply not satisfied by most helipads. In view of this problem, Keppel Data-Systems has now developed a complete landing information system especially for hospital helipads. Keppel Data-Systems has been an important player in German aviation for around ten years thanks to msFIS, a landing information system for smaller airfields and landing spaces that it developed in cooperation with Markus Software. In response to a request from a customer, the company developed the Helipad-LIS landing information system using know-how gained from earlier projects. The system has already been installed in several locations. It helps ensure safety at helipads where there had previously been no radio contact with the approaching rescue helicopter.

The ground-level helipads that have predominated at hospitals until now are increasingly being replaced by rooftop helipads which – despite the higher initial investment – offer a number of benefits to hospitals. Ground-level helipads were (and still are) a world unto themselves, featuring various dangers and problems that should not be under-estimated. For example, in only a very few cases are ground helipads sufficiently protected from curious onlookers – something that can impede a safe landing. Furthermore, pilots often have to make a second landing without ground support. Although that is part and parcel of day-to-day business, it does cause unnecessary stress for crews. In addition, hospitals have had to put aside relatively large areas of their premises for their helicopter landing pad. Now, with the construction of a rooftop helipad, this area can be used for other purposes, opening up new scope for the hospital to expand.

Practical example The problem of noise pollution in the approach and landing area also makes it a good idea to move modern

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helipads to the hospital roof wherever possible. But this can create a completely new risk situation, for which a solution now has to be found. Kliniken der Stadt Köln, a group of hospitals in the city of Cologne, is a pioneer when it comes to the safety of roof-based helipads. Roman Lovenfosse-Gehrt, Commercial Director of Kliniken der Stadt Köln and himself a crew member on rescue helicopters for many years, is convinced of the advantages of Helipad-LIS, emphasising how important the system is for ensuring flight safety at hospitals. He also endorsed the installation of the system at Kliniken der Stadt Köln, to help rescue helicopters approach safely. Helipad-LIS essentially closes the communication gap between the ground (helipad) and the air (helicopter), replacing the need for the extra personnel that would otherwise be required. In other European countries, a landing deck officer (with JAR/OPS3 training in radio communications), for example, is standard at hospitals. In Germany this will continue to be a pipe dream, primarily due to limited finances. Landing on the ground is completely different to landing on a roof. In the first case the pilot can carry out the approach more or less protected by surrounding buildings, but when landing on a rooftop helipad, pilots are exposed to all the caprices of wind and weather. Furthermore, an accident on a rooftop helipad can easily go unnoticed from the ground for a relatively long time. The topic of the presence on site of a “qualified expert” is still something of a hotly debated issue, as it is well known that this expert can basically do nothing to rectify things, even if he or she manages to reach the helipad before the helicopter lands.

Data updates as and when needed The developers attached great importance to ensuring that their product requires no additional installations to be made in rescue helicopters operating in Germany. Thanks to direct cooperation with leading air navigation manufacturers, the system can transmit the very latest data updates, including warnings of possible temporary obstacles in the approach to the hospital, directly to cockpit crews as soon as the helicopter lifts off from the pickup point.

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This not only makes the roof approach far safer, it also helps to reduce noise and increase the acceptance of the helipad among the hospital’s neighbours. This indirect radio contact also activates a whole chain of functions and landing aids, ranging from automatic switching on of the landing lights through to the provision of information to all emergency staff at the hospital. Helipad-LIS also enables live monitoring of the landing by the rescue services and documents the whole procedure. During its development phase, the system was examined by the Institute of Flight Guidance at the Technical University of Braunschweig and classified as “highly recommended” for all helipads.

Ground lighting with LEDs The new rooftop helipad at Merheim, one of the three hospitals of Kliniken der Stadt Köln, is being equipped not only with a Helipad-LIS system, but with an LED stripbased ground lighting system to ensure adequate safety. Dortmund-based airport technology company DeWiTec is providing this technology. LED lighting systems have been in use for years in other European countries as they offer enormous advantages. In Germany, long-winded approval procedures lasting years have prevented their prompt introduction. This innovative ground lighting system is now to be employed for the first time (see Fig.).

Conclusion The use of Helipad-LIS has significantly increased safety for crews on hospital roofs and for landings on offshore platforms. Pilots are being provided with completely new optical landing aids alongside the novel lighting concepts. Just like Helipad-LIS, these are helping to improve safety standards at helipads for all concerned, bringing them into line with EASA’s efforts to introduce Europe-wide standards.  For more information, visit: ››› www.keppel.de ››› www.helipad-lis.de ››› www.dewitec.de ››› www. helipad-consulting.de

Figs. 2 and 3: This innovative LED strip-based ground lighting system is now to be employed for the first time (Photographs: T. Wysk)


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Fig. 1: Rega’s chief pilot Heinz Leibundgut has been campaigning intensively for the introduction of the GPS approach procedure for years (Photographs: Rega)

Rega completes first GPS approach Rescue helicopters can now land at Inselspit Having been technically feasible for years, the new approach procedure of the Swiss Air Rescue, Rega, has now received official approval from the Swiss Federal Office of Civil Aviation (BAZL). In future, Rega will be able to fly to the Inselspital hospital in Berne even when weather conditions are fairly poor and visibility is below the minimum limit – a major step towards making air rescue less dependent on the weather.

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h lspital even in bad weather Not all flight paths lead to “INSIL”. On the contrary, there is only one precisely defined path through the Berne airspace that starts at navigation point “ABNOR” or “ASBER” and ends at “INSIL”. This point is 0.65 miles or 1,200 metres before the helicopter landing pad of Bern University Hospital (one of the country’s leading hospitals), 443 feet or 135 metres above the ground. Data from satellites ensure that the rescue helicopter can follow the defined path even in heavy cloud. The helicopter’s on-board computer

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receives the data and uses them to calculate the exact position. The autopilot then takes over the GPS-aided approach. It ends at the decision point “INSIL”. Once there, the pilot must be able to clearly recognise the landing pad in order to steer the helicopter manually onto the Inselspital Berne platform. If weather conditions make landing impossible, the pilot can pull up and follow the glide path of the conventional instrument landing system (ILS) to land at Berne airport.

Fig. 2: A safe flight to this point in practically any weather: An EC145 lands at Inselspital Berne after a GPS-aided approach


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Fig. 3: If conditions do not permit visual flight, the helicopter’s approach must be coordinated with other air traffic Fig. 4: For the time being, only the EC145 Eurocopters used by Rega at its lowland bases have been approved for satellite-aided approaches

New chapter in air rescue Rega senior pilot Heinz Leibundgut has been campaigning for the establishment of this technology in the Swiss air rescue service for years. He was therefore delighted in late July 2011 when BAZL gave its approval for the procedure in day-to-day (flight) operations, opening the door for the approval of weather-independent rescue flights by the International Civil Aviation Authority (ICAO). “With this project, we have all taken a huge step forward together along the learning path,” says Leibundgut. “Just as the first direct rescue operation from the north face of the Eiger in 1977 opened up new possibilities in air rescue, this GPS approach procedure is an important step towards being able to help people in need in practically any situation.” The GPS approach procedure still needs conventional backup in Switzerland from the ILS in Belpmoos but the system proved to be very reliable during test flights. Various checks are performed during the approach. If the satellite constellation provides sufficient signal cover, the EC145’s on-board computer gives the go-ahead for the satellite-based approach and the helicopter follows the predefined path. The deviation from the defined GPS path is displayed to the pilot on a monitor. No deviation of more than 370 metres (0.2 nautical miles) was measured at any time during the test flights. The decision point at which the GPS track ends and the pilot has to be able to see the hospital’s landing pad in order to make a landing is close to the clearly visible chimney stacks of the incineration plant. Cameras are also installed there, and their images are accessible to the operations centre of Swiss Air-Rescue, Rega, in real time, allowing the prevail-

ing situation to be continually assessed. The helicopter reaches the decision point at a speed of around 70 knots (130 km/h). In the event that wind conditions necessitate a different landing direction, the pilot can line up the helicopter for landing into the wind, following a predefined visual flight circuit.

Only when the tower is active One item of important information – the local barometric pressure – cannot be provided by the satellites. This has to come from a weather station on the ground. As Inselspital is within five kilometres of Bern-Belp airport, the weather data can be taken from there in accordance with regulations of the International Civil Aviation Authority. Otherwise the system is independent of facilities on the ground. The only addition to the helicopter landing pad at Inselspital Berne has been a set of lights to ensure that pilots can clearly identify the landing area against the bright background of the city, particularly at night. If conditions do not permit visual flight, the helicopter’s approach must be coordinated with other air traffic. For this reason, Rega approaches to Bern University Hospital (Inselspital) are currently only possible when the control tower at Bern-Belp airport is staffed. The approach path based on the Global Positioning System (GPS) is within the control zone of the airport, so the air traffic controllers have to be able to direct the various aircraft past one another with a sufficient safety distance. At present no instrument flights can take place in the “Golf” airspace, which, with the exception of the control zones, extends to a height of 600 metres above the ground. However, Heinz

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Leibundgut is convinced that, with the support of signals from the European Aviation Safety Authority (EASA), instrument flights will also be permitted in this airspace in the future.

Half the minimum visibility Like many other air rescue organisations, Rega is on standby for emergencies 24 hours a day. The minimum horizontal visibility for rescue flights at night is currently 2,500 metres, with no clouds below 1,000 feet (305 metres). The GPS procedure thus halves the minimum visibility required for approaches to Inselspital Berne. This can provide a life-saving advantage for patients in a critical condition, allowing them to be transported straight to the hospital even in poor weather conditions. Until now it was frequently necessary to transfer the patient to an ambulance at a rendezvous point – in foggy weather, for example, these transfers had to take place outside the fog zone. For the time being, only the EC145 Eurocopters used by Rega at its lowland bases have been approved for satellite-aided approaches. But the AgustaWestland Da Vinci AW109SP helicopters at the mountain bases are set to be approved for approaches using this technology in the near future. “With the EC145, not a single screw had to be changed for flights using this procedure. The helicopter was equipped for it just as we purchased it,” explains Leibundgut. The pilots need to take instrument flight training courses to learn how to perform the GPS approaches, and the GPS procedures make up part of this training. Around half the pilots stationed at the lowland bases are

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to have received this training by the end of the year. The aim is for all the pilots to have this qualification by 2015.

Rega is driving development The introduction of the new procedure at Inselspital was financed directly by Rega at a cost of 100,000 Swiss francs (around €81,000 at the current exchange rate). The procedure is not public and belongs to Rega, but it is available to rescue organisations as long as they have the necessary approval from BAZL. For Rega, the new approach procedure to the Inselspital marks the beginning of a new chapter in helicopter air rescue. Both alone and within the framework of European research projects, the Rega is working on the further development and introduction of technologies to make emergency aid from the air possible in practically any weather. In Switzerland the programme that coordinates the introduction of new (satellite-based) navigation forms is known as “Chips”. The GPS approach to the Inselspital is a milestone for the Swiss air traffic control authority Skyguide, too, as it wants to play a leading role in satellite-based approaches throughout Europe. For its part, Rega continues to actively push forward the utilisation of technological possibilities. For the University Hospital and University Children’s Hospital in Zurich, for example, it is evaluating the introduction of an LPV procedure (localizer performance with vertical guidance) that permits approaches with an accuracy comparable with that of ILS systems today.  For more information, visit: ››› www.rega.ch & www.skyguide.ch

Fig. 5: The AgustaWestland Da Vinci AW109SP helicopters at the mountain bases are set to be approved for approaches using GPS technology in the near future

This article was originally published in SkyNews.ch. Used with permission.


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Fig. 1: The OPEN concept in use during the evacuation of the 22nd of July 2011 Utøya terrorist incident (Photograph: All Over Press)

Major incident patient evacuation: full-scale field exercise feasibility study Authors: Marius Rehn Norwegian Air Ambulance Foundation, Drøbak & Akershus University Hospital, Lørenskog, Norway, marius.rehn@ norskluftambulanse.no Trond Vigerust Norwegian Air Ambulance Foundation, Drøbak Jan E. Andersen Norwegian Air Ambulance Foundation, Drøbak, Norway Andreas J. Krüger Norwegian Air Ambulance Foundation, Drøbak, Norway & St. Olav University Hospital, Department of Anesthesia and Emergency Medicine, Trondheim, Norway Hans M. Lossius Norwegian Air Ambulance Foundation, Drøbak, Norway & University of Bergen, Department of Surgical Sciences, Bergen

Major incident management relies on efficient patient transportation. Prompt initiation improves patient outcome and optimizes resource expenditure (1). The evacuation of patients is the third initiative in the hierarchy of medical support at major incidents: triage, treatment, and transport (2). Casualty evacuation should be dynamic, because mode of transport, evacuation priority and final destination will be influenced by triage and treatment decisions. To ensure optimal outcomes, patients should be transported as efficiently as possible from the scene to the hospital providing definitive care. In order to avoid unnecessary delay, treatment and packaging should be limited to that necessary for transport (2). Optimal care therefore relies on a well-organized transportation chain using field-friendly evacuation equipment to ensure transport of the “Right Patient to the Right Place at the Right time.” Major incidents are infrequent, overwhelming events with a heterogeneous nature that favours the “allhazards” approach. Because rescue capacity varies between systems, an incident may be considered major by one emergency medical service (EMS) but not by another service (2). EMS systems are primarily designed to respond to the daily burden of injuries and can have delayed access to evacuation material for multiple casualties. Even when major incidents are flooded with resources, rescue workers struggle to coordinate and optimize patient evacuation (3, 4). Additionally, major incident management usually involves emergency workers from multiple rescue services. Standardizing the equipment for patient evacuation seems essential given the multitude of responders. Providing rescue workers with rapid access to a large quantity of standardized stretchers may improve patient transportation efficacy.

In the absence of a coherent and interoperable national civil system for major incident management, the Norwegian Air Ambulance Foundation developed and funded the Interdisciplinary Emergency Service Cooperation Course (TAS), a no-cost training course for all emergency services in Norway. The TAS program was established in 1998. By 2009, approximately 15,500 professionals had participated in one of more than 500 available courses. The TAS curriculum has gradually evolved, and the principles for disaster health education as proposed by World Association for Disaster and Emergency Medicine have been adapted progressively (5). Norway is a sparsely populated,

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TECHNOLOGY | 57 subarctic country with time-consuming, weather-dependent patient transport (6). Although large-scale incidents are infrequent in our region, such incidents demand advanced interdisciplinary cooperation of local EMS, fire fighters, police, rescue technicians, and air medical resources. In remote areas, single EMS units may handle multiple casualties for prolonged periods until inter disciplinary assistance arrives. In the absence of a standardized field-friendly approach to multiple casualty management, the Norwegian Air Ambulance Foundation developed “Optimal Patient Evacuation Norway” (OPEN). The OPEN concept has been incorporated as a module in the TAS courses. OPEN aims to save time, improve patient handling, prevent hypothermia, and simplify scene management. In this study, we assessed access to patient evacuation supplies among Norwegian EMS personnel participating in TAS courses. Furthermore, we assessed the feasibility of the OPEN concept for major incident patient evacuation in the extrication and triage phase of full-scale major incident field exercises.

Fig. 2: Car- and helicopterfriendly bags containing five multiple casualty stretchers, stretcher carry harnesses, and triage equipment (Photographs: Norwegian Air Ambulance Foundation)

Methods TAS course From March to May 2010, we conducted four 2-day TAS courses in mixed urban/rural and coastal/inland municipalities. The courses were free of charge for the participants. The didactic program was piloted and refined through 43 TAS courses before the study. The TAS course combines theoretical and practical didactical techniques to teach local emergency service personnel (healthcare, police, and fire and rescue technicians) major incident cooperation, triage, and patient evacuation (OPEN). The students participated in major incident field exercises, using a standardized bus collision scenario with approximately 20 patients (range, 17 to 21) and a full-size, postcollision bus. The patients were located inside the bus and were provided with standardized descriptions of injury type and physiologic parameters for triage purposes. The major incident field exercise was performed once before the OPEN lectures were given, when participants lacked formal OPEN competence and access to OPEN equipment, and once at the end of the course, when participants had formal OPEN competence and access to OPEN equipment.

The OPEN Concept We designed car- and helicopter-friendly bags (Figs. 2 and 3) containing five heavy-duty multiple-casualty stretchers (Fig. 6), stretcher carry harnesses, and triage equipment to provide EMS units with rapid access to large quantities of standardized equipment.7,8 Ideally, all units responding to the incident should carry a minimum of one stretcher bag. To save time, prevent hypothermia, and avoid patient manipulation, one standardized lightweight, insulating stretcher was allocated to each patient throughout the evacuation chain. These stretchers fit all ground and air EMS units and are radiolucent to optimize logistics during radiological evaluation at the hospital. Furthermore, we designed a fieldfriendly action card (Fig. 5) depicting the principles for scene-management organization.

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Study Design The full-scale major incident field exercise started with students receiving a dispatch call informing them of a bus accident and ended when all patients were transported to the evacuation clearing station. For practical purposes, no patients were transported to definitive care. The students answered a before-and-after questionnaire, and the instructors measured time expenditure. We linked the two questionnaires without compromising anonymity and calculated self-efficacy and reaction to patient evacuation. The Regional Committee for Medical and

Fig. 3: Stretcher bag inside a helicopter: Stretchers fit all vehicles and helicopters


58 | tecHnoloGY Fig. 4: Field-friendly stretcher design: Insulating and radiolucent stretchers (Norwegian Air Ambulance Foundation)

Health Research Ethics deemed that approval was unnecessary (2009/1390a). The Norwegian Social Science Data Services approved the study (22991/2/MAB). The SQUIRE (Standards for QUality Improvement Reporting) guidelines and the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines for reporting observational studies were used in the drafting of this article (9, 10).

Data analysis Data were collected in Excel spreadsheets (2007; Microsoft Corporation, Redmond, WA) and analyzed in STATA/SE 10.1 (Statacorp, College Station, TX). Continuous variables measured before and after the TAS course were compared using the pairedsample t-test.

results Student background and access to major incident material

Fig. 5: Principles for scenemanagement organization: Fieldfriendly action card (Norwegian Air Ambulance Foundation)

Among the 110 emergency service professionals who attended the course, 93 (84.5%) enrolled in the study. Among the study participants, 26 (28.0%) worked in health care (nurse, ambulance, other), 47 (50.5%) were firefighters, 13 (14.0%) were police officers, and 7 (7.5%) had “other” backgrounds. The mean participant age was 38.6 years (range, 20-62), with a median working experience of 8 years (range, 0–34), and 83.7% were men. Approximately half of the students (51.2%) were not aware of any stretcher storage in their coverage area. A minority (18.6%) of the learners confirmed that fewer than 16 stretchers were available, and 30.2% had access to over 15 stretchers. Thirty-one percent of the students confirmed that multiple stretchers could be available at the scene within 30 minutes in their catchment area, 26.4% would need longer than 30 minutes, and 42.5% were unable to describe stretcher delivery times.

to “How did patient evacuation work?” with mean 5.4 (95% CI, 5.2–5.6) before the course versus a mean of 5.8 (95% CI, 5.7–6.0), after the course (P ! .001). Students’ estimations of the success of interdisciplinary cooperation improved, with a mean of 5.4 (95% CI, 5.2–5.6) before the course and a mean of 5.8 (95% CI, 5.7–6.0) after the course (P ! .001). The students also described improved use of patient evacuation materials between their initial (mean, 5.3 [95% CI, 5.0–5.5]) and postcourse (mean, 6.0 [95% CI, 5.8–6.15]) evaluations (P ! .001). The mean time from “scene secured” to complete patient evacuation to the casualty clearing station was 22 minutes (range, 19–26) without and 21 minutes (range, 17–28) with TAS– OPEN training and supplies. Both the stretcher bag and the scene-management action card were reported to work adequately (median, 6 [interquartile range (IQR), 6–7] and median, 6 (IQR, 5–6), respectively).

Self-efficacy and reaction to training

discussion

Each question on the questionnaire was scored on a 7-point Likert scale, with points labeled “Did not work” (1) through “Worked excellently” (7). The students replied

We found the OPEN concept for multiple casualty evacuation to be feasible for interdisciplinary emergency service personnel participating in full-scale major incident field exercises. The students found the stretcher equipment useful in evacuating patients in a structured and fieldfriendly manner. Unnecessary patient mobilization is a time-consuming threat to patient safety, and several papers describe movement-associated adverse events (11-13). Although these studies are conducted inside the hospital, eliminating unnecessary physical movement of the patient will result in safer and more effective major incident management. Currently, the absence of standardized patient evacuation equipment increases the risk for patient manipulation both during the immediate scene management phase and during later organization of the patient evacuation clearing station. The OPEN concept stresses rapid EMS access to large number of stretchers, allowing provision of a personal stretcher to every patient in the extrication phase. Our study confirmed that Norwegian rescue workers struggle to provide all patients with rapid access to a

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tecHnoloGY | 59 stretcher. By avoiding improvised transportation methods that occur when stretchers are unavailable, OPEN reduced unnecessary physical manipulation of the injured. The OPEN stretcher fits all patient transportation units in our area, and it reduces the inherent risks of patient mobilization associated with variable stretcher types across EMS units. Efficient patient evacuation relies on interdisciplinary cooperation from all emergency services managing the scene. We found high interdisciplinary satisfaction with both the equipment and the principles. The OPEN concept introduced standardized handling of patient evacuation from scene extrication through patient evacuation clearing station without increasing onscene time expenditure. We believe the time required for complete evacuation and transport to definitive care will most likely be reduced. However, we acknowledge that this study did not evaluate the entire evacuation chain, and we plan to address this question in a future study. We intended to ensure the appropriateness of the OPEN concept for safe implementation in our vehicle and helicopter EMS units. Optimally, the stretcher material and scene-management principles would have been evaluated in real multiple-casualty incidents to avoid the unrealistic aspects of exercises. However, research on major incident management is mostly observational, because disasters are difficult to study via interventional study designs. Furthermore, this study relied on self-reported variables as measures of effect, although they may vary in accuracy (14). To address this limitation, the instructors measured time consumption objectively. Major incidents are infrequent in our area, and EMS providers have little experience handling multiple casual-

ties. The low incidence of large accidents favours systems that allow providers to follow their daily routine. We found that Norwegian EMS providers have reduced access to field-friendly patient evacuation equipment. Delayed access to stretchers combined with absence of interdisciplinary routines for patient evacuation remains a gap in Norwegian preparedness for major incidents.

Conclusions Efficient and structured patient evacuation can be taught effectively to multidisciplinary emergency service professionals attending a 2-day major incident course. The OPEN concept provides rapid access to standardized, field-friendly patient evacuation equipment in a feasible and time-efficient manner. 

references: 1. Aylwin CJ, Konig TC, Brennan NW et al.(2006) Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 368: 2219-2225 2. Advanced Life Support Group (2002) Major incident medical management and support, the practical approach at the scene. 2nd ed. BMJ Publishing Group, Plymouth 3. Romundstad L, Sundnes KO, Pillgram-Larsen J, Roste GK, Gilbert M (2004) Challenges of major incident management when excess resources are allocated: experiences from a mass casualty incident after roof collapse of a military command center. Prehospital Disaster Med 19: 179-184 4. Simon R, Teperman S (2001) The World Trade Center attack: lessons for disaster management. Crit Care 5: 318-320 5. Seynaeve G, Archer F, Fisher J et al. (2004) International standards and guidelines on education and training for the multi-disciplinary health response to major events that threaten the health status of a community. Prehosp Disaster Med 19: 17-30 6. Kruger AJ, Skogvoll E, Castren M et al. (2010) Scandinavian pre-hospital physician-manned Emergency Medical Services: same concept across borders? Resuscitation 81: 427-433 7. Rehn M, Andersen JE, Vigerust T, et al. (2010) A concept for major incident triage: full-scaled simulation feasibility study. BMC Emerg Med 10: 17 8. Rehn M, Vigerust T, Kruger AJ et al. (2010) Paediatric vital sign tape on stretchers: a field-friendly triage tool? Emerg Med J 27: 412 9. Davidoff F, Batalden P, Stevens D, et al. (2008) Publication guidelines for quality improvement in health care: evolution of the SQUIRE project. Qual Saf Health Care 17 (Suppl 1): i3-9 10. von Elm E, Altman DG, Egger M et al. (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Bull World Health Organ 85: 867-872 11. Indeck M, Peterson S, Smith J, et al. (1988) Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma 28: 1020-1025 12. Smith I, Fleming S, Cernaianu A (1990) Mishaps during transport from the intensive care unit. Crit Care Med 18: 278-281 13. Stearley HE (1998) Patients’ outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. Am J Crit Care 7: 282-287 14. Weller JM, Robinson BJ, Jolly B (2005) Psychometric characteristics of simulation-based assessment in anaesthesia and accuracy of self-assessed scores. Anaesthesia 60: 245-50

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Fig. 6: Providing rescue workers with rapid access to a large quantity of standardized stretchers may improve patient transportation efficacy

An earlier version of this article appeared in the Air Medical Journal, May-June 2011: 153-157. Reprinted with permission of the publisher.


60 | RULES AND LAWS

Fig. 1: “Maybe instead of introducing new regulations we could ensure that the existing rules for safety at hospital landing pads are adhered to more rigorously and consistently” (Photograph: J. Osnabrügge)

Air safety at hospital landing pads Author: Günter König Safety Manager and Head of Project Development, HDM Luftrettung gGmbH

In AirRescue Magazine 1/2011 (pp. 33-36), Jochen Decher, Assistant Ministerial Counsellor, describes how a planned revision of Germany’s Air Traffic Act (Luftverkehrsgesetz, LuftVG) could have “grave consequences for the country’s air ambulance services.” Decher reports that the “amendment envisions only permitting regular air ambulance operations on hospitals’ permanent landing pads or open spaces that have been approved in line with Section 6 of the LuftVG.” In practice, he says, “this would make it almost impossible to operate flights to or from hospitals without LuftVG-approved landing pads.” Air operations are said to be “regular” when there are more than four flights per month – and that means just two flights, because take-off and landing are counted in each case. The goal of the LuftVG revision is, of course, to improve (flight) safety at hospital landing pads. And in order to achieve that we do need rules, regulations and laws. But there is already an abundance of these. Maybe instead of introducing new regulations we could ensure that the existing rules are adhered to more rigorously and consistently. If we really do end up with a situation where all hospitals with more than four flights per month (that’s just two missions!) are forced to have a Section 6-approved landing pad, then it is true what Decher says – around 88 percent of the landing pads in Hesse would no longer be accessible to air ambulances. And the figure would not be much different in the rest of the country. The regulatory authorities have largely ignored hospital landing pads for years (Section 25[2.2] of the LuftVG) and now they are suddenly trying to impose “maximum demands”(Section 6 of the LuftVG) that are completely

unfeasible in many cases. In 2000 Konsensgruppe Luftrettung mentioned changes to EU regulations in its final report, but this alone was clearly not enough, as for a long time no one knew exactly what had been changed and the uncertainty persists to this day. One cannot help wondering if these “maximum demands” (should there be no transitional regulation for a longer period of time) might not be responsible for many more deaths than potential helicopter crashes at hospital landing pads. If 88 percent of all hospital landing pads can suddenly no longer be used, how many patients might be denied prompt medical attention and either die or sustain serious bodily injury because the journey to hospital took longer than necessary? The problem is that most hospitals are not even capable of fulfilling the requirements laid down in Section 6 due to their location in built-up areas, which feature many

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RULES AND LAWS | 61 obstacles. In most cases, it is also not possible to retrofit the hospitals to ensure compliance as existing hospital buildings are not physically able to support the additional weight of, for example, a rooftop landing pad. On top of that, within built-up areas it is not possible to simply create the approach conditions dictated by Section 6 of the LuftVG, which specifies certain requirements for helicopter landing pads that actually come closer to those for an airfield. It should not be forgotten that helicopters fly in a completely different way to aeroplanes. The “maximum demands” of Section 6 of the LuftVG are, in many cases, simply not the appropriate way to improve flight safety. I would propose the following more feasible regulations: 1. Both Section 6 and Section 25(2.2) of the LuftVG should remain in place as they have proved their merit. 2. New hospital buildings should only receive planning permission if they include the (re-)construction of a helicopter landing pad, preferably on the roof, that complies with Section 6 of the LuftVG. However, economic viability must be taken into account, especially for smaller hospitals. 3. If a hospital is not able to fulfil the regulations of Section 6 of the LuftVG or if the number of flights is too small to justify investing in a rooftop landing pad (setting the limit at just four flights a month is simply absurd), it must initiate measures to improve flight safety so that it meets a minimum standard. These measures must be based on the standards laid down in Section 6 of the LuftVG and must implement these as far as possible. In particular, the approach and take-off areas and the area around the landing pad must be freed from obstacles. The TLOF (touchdown and liftoff area), the wind direction indicator, and all other relevant obstacles around the landing pad must be clearly marked and illuminated for night-flight operations. In

other words, if the landing pad is optimised as far as possible in line with Section 6 of the LuftVG, it should then be able to keep operating, in accordance with Section 25(2.2) of the LuftVG. 4. These measures can often achieve sustainable improvements for flight safety with relatively little effort and at a relatively low cost. Regular checks by the responsible Regional Commissioner’s Offices or other authorised experts could help ensure adherence to safety criteria at landing pads. 5. Approval should only be granted for a limited period. This would mean that hospitals risk losing permission to use their landing pads if they neglect to maintain them.

Fig. 2: “The regulatory authorities have largely ignored hospital landing pads for years and now they are suddenly trying to impose ‘maximum demands’ that are unfeasible in many cases” (Photograph: ADAC Air Rescue)

Fig. 3: Do inexpensive solutions always ensure adequate safety? Helipad on a 75m high hill in Tønsberg, Vestfold (Norway) with the hospital’s emergency helicopter landing pad in the foreground (Photograph: P. Fiskerstrand/Wikipedia)

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Helicopter landing pad

LED-illuminated wind director indicator

Section 25 (2.2) LuftVG Complete with LED lighting and a remote control device for switching lights on from the cockpit

lights@night remote control switching device for controlling the entire lighting system via the aircraft’s radio system

LED obstacle lighting, illumination of surrounding trees

LED obstacle warning lights Fully visible from all angles

TLOF markings (touchdown area) LED lines and spots (green marks the safe area)

TLOF markings (touchdown area) LED lines and spots (red signifies a warning − do not fly into this area) Fig. 4: Helicopter landing pad equipped with LEDs according to Section 25(2.2) of the LuftVG; total cost are around €25,000 (Photograph: G. König)

The opinions expressed in this article reflect the views of the author and do not represent the views of HDM Luftrettung or DRF Luftrettung.

6. If the hospital is not able to optimise its landing pad to comply with Section 25, meaning that the risks of operating it are too high, the landing pad should be closed. The hospital would then have to find or create an alternative landing space. If the hospital management refuses to take the appropriate safety measures, approval should not be granted until an acceptable solution has been found.

How might hospitals be able to optimise their landing pads (in accordance with Section 25[2.2] of the LuftVG) in practice? Are there any inexpensive solutions that would still ensure adequate safety? Let’s look at the example of a hospital in Upper Franconia. This hospital is situated on the crest of a hill, so there are often strong winds in the area that come predominantly from the west. Within the hospital grounds is an open space that was used as a landing pad for helicopters (in accordance with Section 25[2.2]). The space was clearly marked for daytime landings. During night-flight operations, obstacles were illuminated by floodlights. During one approach in strong winds, the area around the landing pad was battered by heavy turbulence due to the presence of nearby trees and buildings over 20 metres high. The landing had to be aborted. I subsequently received a safety report from the pilot in charge of the mission and then immediately arranged a meeting with the hospital’s management and senior technician.

They were very cooperative and understanding and my discussions with them were insightful and constructive. Working together and in consultation with our pilots and air operations management, we were able to find a suitable location for a new landing pad. After performing a thorough examination and weighing all the considerations, we decided on a section of a private road within the hospital grounds. The space is situated at the highest point in the grounds, and the approach from east and west is largely free of obstacles, which means there is a relatively smooth flow of air during strong winds, so heavy turbulence can be avoided. The hospital’s own fire brigade is present at every landing at the hospital. It also ensures that no vehicles enter the area around the landing pad when air ambulance helicopters and intensive-care helicopters are touching down or lifting off. Additional traffic safety precautions include a barrier system and large warning signs. A further requirement was a remote switching device to allow the pilots in approaching helicopters to activate the lighting system themselves. The hospital in Upper Franconia opted for a lights@night device, which can be activated by pressing the PTT button several times at a frequency of 129.90 MHz (the frequency of the Rescue Coordination Centre), meaning that no additional equipment is required in the cockpit. The device only has a receiver so it does not affect flight security and therefore does not need any special legal clearance. We also decid-

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RULES AND LAWS | 63 ed to mark the TLOF, wind direction indicator, potentially obstructive trees, nearby hospital buildings and a church with waterproof LEDs suitable for outdoor use. LEDs are long-lasting, use very little electricity and require barely any maintenance. Their colour can also be determined by a central controller. That does, however, mean that no one is quite sure whether the TLOF markings should remain green as they are now or change to orange (as is common elsewhere), or whether different colours should be used for night-flight operations with night vision goggles (NVG) as NVG do not render all light frequencies with equal clarity. But it is possible to easily adapt the colours should this be deemed necessary. Due to the specific conditions of the location, the size of the TLOF had to be kept down to just 10.80 m x 10.80 m, which I believe constitutes the minimum space required to land a helicopter and load/unload a patient. For night-flight operations the TLOF was marked with LED lines at the corners and with three ground-recessed luminaires between each of the LED lines. The illuminated TLOF can be seen very clearly at night. The strip lights in particular ensure that the touchdown zone is very clearly marked. To the south of the TLOF the terrain rises relatively sharply and at the top of the elevation is a power supply line. Therefore this side of the TLOF is marked with red lights as an optical warning to not fly over this line. All the other lights are green. Information including a map and precise description of the landing area has been sent to all the major helicopter operators. The responsible regulatory authorities were kept informed during every phase of the project. The assessment at the final inspection was very positive and ended with the remark that this landing area could certainly be ap-

proved in line with Section 6. The total cost of the remote switching device and complete lighting system for the TLOF, wind direction indicator and all obstructions was around €25,000. This should be an entirely manageable sum for most clinics.

Summary The revision of the Air Traffic Act (LuftVG) is, in principle, correct and desirable. However, it should not automatically outlaw helicopter landing pads that do not comply with Section 6 of the act. If existing landing areas that comply with Section 25(2.2) are optimised and adapted to the actual needs of helicopter crews, we could quickly ensure a large number of eminently usable and safe helicopter landing pads within a short space of time. Regular inspections combined with time-restricted approvals would ensure landing pads stay in relatively good condition, thus guaranteeing a high level of flight safety. This would be a fairly quick way to counter the risk of around 88 percent of all hospital landing pads in Germany having to close. It would be possible without much political intervention, civic involvement or press scrutiny and without hospitals having to invest large sums, and a high degree of safety could be achieved within a short time. Hospitals, particularly those with a high patient transfer rate, that decide to construct new buildings should take advantage of the opportunity to install new landing pads that are compliant with Section 6 of the LuftVG on the roof (e.g. on top of a multi-storey car park). This would mean that helicopter landing pads at hospitals would gradually evolve from simply being compliant with Section 25(2.2) of the LuftVG to becoming fully-fledged Section 6-approved landing pads.  Fig. 5: LEDs are long-lasting, use very little electricity and require barely any maintenance (Photograph: DRF Luftrettung)

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64 | RULES AND LAWS

Air rescue in court – forced rescue by helicopter Hiking requires a certain level of fitness. People who have circulatory problems can quickly run out of energy, and this often means they are no longer able to make the descent. In one such instance, a witness who saw a female hiker in trouble informed the emergency dispatch centre, which sent out a rescue helicopter. Although the hiker refused transportation, the helicopter flew her to a hospital, which she then left immediately. She refused to pay for the rescue helicopter mission. The court found in her favour. In this article, AirRescue Magazine reports on the initial appeal at the district court and the further appeal at the state court. was already present at the site. Her husband, the other hiker, was also present. The court records reveal that the patient was given a sedative and hoisted into the helicopter. Once she had been delivered to the hospital she immediately left. The plaintiff charged the defendant €4,419.60 for the air ambulance operation. It reports that the defendant had collapsed and was completely exhausted; she had pale, clammy skin and had vomited. The rescue helicopter was the only way, the plaintiff contends, to bring the emergency doctor to the site on time. At the time when the call to the emergency dispatch centre was made it could not be determined whether or not the defendant was in a life-threatening condition. Because it has had to take legal action in this case the plaintiff is seeking additional payment of €2,721.55 plus interest.

Fig. 1: A hiker gave her agreement for another hiker to call the mountain rescue service and the emergency dispatch centre sent out a rescue helicopter with an emergency doctor on board (Photograph: ADAC Air Rescue) The images shown here bear no relation to the case under discussion.

District court ruling: Claim dismissed (Munich district court, decision of 6 August 2010 – 281 C 22204/09). Non-official guiding principle:

Information on legal rulings provided by: Michael R. Ufer Presiding Judge at Hanover Administrative Court, Schliekumer Str. 33 B, 31157 Sarstedt, Germany The following German court decisions were provided by a translation agency working in collaboration with Alexandra Ufer law student, University of Hanover, Annenstr. 10, 30171 Hanover, Germany

Forced rescue by helicopter The case: As a result of overexerting herself, a hiker (the defendant) was suffering from circulatory problems. On her own admission, she would have needed help to descend. This would have taken at least 20 minutes on foot. She gave her agreement for another hiker to call the mountain rescue service. The emergency dispatch centre sent out a rescue helicopter (belonging to the plaintiff) with an emergency doctor on board. According to the state court records, the rescue helicopter was not able to land on the ground, but instead lowered down the emergency doctor on a rescue hoist. Once at the site, the emergency doctor noted that the patient was suffering from hypertension and needed to be examined in a hospital. The defendant, whom the doctor reports was lucid, refused both transportation with the helicopter and hospital treatment. She wanted to be carried down by the mountain rescue service, of which at least one member

1. The principal’s interest in a certain rescue mission (here: an air ambulance operation) should be denied when other, equivalent, i.e. equally promising, rescue options are available that are, moreover, less expensive (here: mountain rescue service) than the chosen method. 2. Cases where simple clarification rather than treatment of a medical condition is required do not constitute a need for helicopter transport.

Preliminary remark: The court always checks in advance whether the parties concluded a contract. If not, under Section 677 ff. of the BGB, a legal claim for the reimbursement of expenses can be made according to the rules of agency without specific authorisation. From the court’s decision (edited): “The charge is baseless. The plaintiff can make no claims against the defendant. Since no contract was concluded, the plaintiff has no valid contractual claim. The defendant gave her agreement to an emergency call being made, but never asked for a helicopter to be sent. She only intended the mountain rescue service to come.

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RULES AND LAWS | 65 Neither can the plaintiff make a claim on the basis of agency without specific authorisation. According to Section 683 of the BGB, the voluntary agent may demand reimbursement of expenses like an authorised service provider if agency is assumed in the interest of or based on the actual or presumed will of the principal. After looking at the evidence, it cannot be held that the assumption of agency was in the interest of the principal. According to the emergency doctor’s description, the defendant’s condition was not life-threatening. In this case, the crucial factor for the emergency doctor was that the defendant was not able to descend on her own. According to the statement of witness E, whose credibility is not in doubt – although he is the defendant’s husband – there was another way to bring the defendant down. The witness credibly reported that a member of the mountain rescue service stated that four men could carry her down and that this could have been organised. Moreover, the witness stated that it would have only taken 20 minutes to make the descent and that the mountain rescue service member’s Volkswagen van was waiting at the bottom. Given a non-life-threatening condition, a walking distance of just 20 minutes to a point accessible by car, and the possibility of transportation assistance by the mountain rescue service, the use of a helicopter – incurring costs amounting to €4,000 – was objectively not necessary and, moreover, did not correspond with the expressed will of the person who had to be rescued. A rescue by the mountain rescue service would have been sufficient and was possible. The principal’s interest in a certain rescue mission (here: an air ambulance operation) should be denied when other, equivalent, i.e. equally promising, rescue options are available that are, moreover, less expensive than the method chosen by the principal (OLG Frankfurt NJW-RR 1996, p. 1,337 f.). The emergency doctor’s statement, too, gives no reason to doubt the mountain rescue service’s equal capability to carry the patient down. Although this witness stated that the patient had hypertension of unknown causes, her medical condition did not require treatment, only clarification; the witness did not regard the patient’s condition as life-threatening. The need for clarification does not provide adequate justification for an air ambulance operation. Furthermore, it is uncertain whether the patient’s blood pressure was already high when the emergency call was made or if it only increased when she was put in the stressful situation of being flown by helicopter against her will – especially since she is also afraid of flying. Witness S, who is trained as an emergency medical technician, stated that the defendant’s pulse felt normal when he took it. Even if the plaintiff believed, until arrival at the site, that the air ambulance mission reflected the defendant’s will, this assumption cannot have persisted once the defendant clearly stated her desire not to be flown by helicopter. According to the emergency doctor, the defendant was not disorientated in any way, but was lucid and responsive. In cases where a patient’s capacity to make decisions is not impaired, it is the patient’s will that is decisive, not the doctor’s, even if the doctor consid-

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ers the patient’s decision to be unreasonable. The court was astonished by the emergency doctor’s statement that she was afraid of being made liable for failure to render assistance to a person in danger if she did not take the patient to a hospital for examination, even though she was not in a life-threatening condition and had expressly stated that she did not want this. The situation becomes particularly absurd when we learn that the patient saw a doctor in the hospital who clearly did know about the right of self-determination and who allowed her to leave the hospital immediately. It is unacceptable to suggest that a patient should have to pay for a transportation that was against her will and deprived her of her freedom. Witness K was working in the hospital when the defendant was brought in but cannot remember the specific case. However, he clearly stated that he cannot force a patient to stay in the hospital. In light of that, it is not only unlawful but also senseless to take a fully lucid patient to hospital against her will. The plaintiff is wrong to state that the patient’s will cannot be taken seriously. In actual fact, in cases of agency without specific authorisation it is precisely the will of the principal that the voluntary agent’s decisions should be based on. From a legal point of view the plaintiff is also wrong in contending that the interests of the patient are being upheld when, in the moment that it assumes agency, it is not yet sure whether it is a life-or-death situation. There are situations when the plaintiff performs an air ambulance operation in the belief that it is necessary where it is initially not possible to objectively determine that this is not the case, such as when a third party wilfully triggers a false alarm. Even if the plaintiff believes it has done everything correctly, this does not automatically mean that it is entitled to reimbursement of expenses. It is not relevant whether the plaintiff refuses to accept that the mission was unnecessary – all that matters is determining whether the operation was objectively necessary. Only an objectively necessary operation is in the principal’s interest. The agent bears the risk that an operation may not be necessary even if there are good reasons for assuming such a necessity. It is not enough when the agent wrongly assumes an interest, even if it is not to blame (Palandt, Section 683[4] BGB, 70th ed.). The agent bears the risk of an erroneous evaluation of the principal’s circumstances (Munich commentary on the BGB, Vol. IV, Section 683[12]). The case is different if agency proves not to have been necessary after the event. In the current case, the air ambulance operation was objectively not necessary from the beginning, although this may not have been clear to the plaintiff from the beginning. Even when the alarm was raised, the defendant’s condition was objectively not life threatening and a rescue by the mountain rescue service was possible and sufficient.” State court ruling: The plaintiff’s appeal against the aforementioned district court ruling is also dismissed (Munich state court I, decision of 8 Feb. 2011 – 13 S 17056/10). Non-official guiding principle: 1. The single fact that the patient allowed herself to be


66 | RULES AND LAWS lifted into the helicopter without resistance cannot be seen as (implicit) agreement to a transportation contract. 2. In cases where a rescue service’s organisation is based on work-sharing, meaning that operations are not controlled by the same instance that implements them, the responsibility for checking the need for a mission is transferred to the work-sharing partner (in this case the emergency dispatch centre).

From the court’s decision (edited): “The appeal was unsuccessful.

Fig. 2: The rescue helicopter was the only way, the plaintiff contends, to bring the emergency doctor to the site on time (Photograph: DRF Luftrettung)

1. Contrary to the contention made by the plaintiff in its appeal, there are no grounds to consider that a contract was concluded between the two parties. Accepting another hiker’s offer to call the emergency dispatch centre cannot be regarded as a declaration of intent to enter into a legal contract (Sections 130, 145 of the BGB) concerning the call-out of a rescue helicopter carrying an emergency doctor. Under these circumstances, the patient’s silence cannot be deemed to imply consent, especially since no message had been agreed upon with the other hiker and it is not known what message he did actually convey. Thus, this cannot be considered as the patient giving her (implicit) authorisation to the other hiker to call out a rescue helicopter. Air ambulance operations are not part of the phenomenon of modern mass transportation, where services are used without express prior agreement (cf. Palandt/ Ellenberger, BGB, 70th ed., before Section 145[25]).

In particular, given that the defendant refused to be transported in the helicopter until she was sedated, the fact that she offered no resistance when being winched up to the helicopter cannot constitute implicit agreement to a transportation contract. Finally, allowing the helicopter to approach does not constitute a declaration of intent on the part of the defendant either, although it is doubtful whether there was any way of hindering the helicopter’s approach. 2. Furthermore, it is not necessary to decide whether there was express authorisation (communicated via the other hiker) for the plaintiff to provide help or if there was a need for agency without specific authorisation (after all, the defendant did ask for and need help) because in either case the defendant is making a claim for the reimbursement of expenses according to Section 670 of the BGB and the preconditions for such reimbursement are in any case not fulfilled. The air ambulance operation cannot in any case be deemed necessary. The plaintiff’s objection that it was obliged to fly the mission as it was ordered to do so by the emergency dispatch centre cannot be considered, since in cases where a rescue service’s organisation is based on work-sharing, meaning that operations are not controlled by the same instance that implements them, the responsibility for checking the need for a mission is transferred to the work-sharing partner. The plaintiff bears the burden of proof and of producing evidence to fulfil the preconditions of Section 670 of the BGB (Palandt/Sprau, BGB, 70th ed., Section 670[5]). However the plaintiff has not submitted any information on what the basis was for making decisions during the air ambulance operation. The abstract possibility of a serious health risk is not sufficient grounds. Therefore, the validity of the medical opinion verbally expressed during the hearing cannot be established. The emergency doctor stated that the situation was not life threatening. She also stated that the defendant was not able to descend alone; she might have been able to get up and walk but would probably have had to sit down again. The witness was obviously no longer concerned about hypertension. The emergency doctor’s concrete diagnosis might have made the air ambulance operation an appropriate way to help the defendant, but since she was within a half-hour’s walk of a parking area and there was no actual serious health hazard, the operation cannot be considered as having been necessary. Given the short distance, the defendant could have been carried by the mountain rescue service (whereas the helicopter could not land at the site) (cf. Staudinger/Martinek, BGB, ed. 2006, Section 670[13]). The use of subjective criteria (“considered necessary”) does not lead us to a different finding. Due to inadequate statements of fact, it cannot be determined what the emergency dispatch centre based its decision on. If no documentation of this phase of the event can be presented to the court then this is the fault of the plaintiff, who bears the burden of producing evidence.“ 

3 · 2011 I Vol. 1 I AirRescue I 66


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AirRescue Magazine 3-2011