Ultrasound in hems
AirRescue International Air Rescue & Air Ambul ance
M a g a zine
NVIS in Dutch HEMS
New Learjets for LAR
ISSUE 1 | Vol. 2 | 2012
Coping With Any Situation!* Even in extreme conditions – Airway Management by KARL STORZ
*Photo taken during the Fulda Challenge 2012 at the Yukon River/Dawson City, Canada at –47°C by Prof. Christian Byhahn, M.D.
KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: firstname.lastname@example.org 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: email@example.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: firstname.lastname@example.org KARL STORZ Endoscopy Canada Ltd., 7171 Millcreek Drive, Mississauga, ON L5N 3R3, Phone: +1 905 816-4500, Fax: +1 905 858-4599, E-Mail: email@example.com www.karlstorz.com
E di tori a l Dear Reader, Welcome to this new edition of AirRescue. On 29 February 2012 the EHAC Annual General Meeting took place in Munich, elections were also held and a new EHAC President and Board were officially elected.
I would like to offer my thanks here for the support given to me. I accept the confidence shown in me with both humility and a sense of great responsibility. I would also like to publicly thank my predecessor, Christoph Breitenbach, for everything he accomplished during the many years he actively chaired EHAC. I would also like to congratulate all the elected Board members and assure them that I look forward to our future cooperation. To our members leaving the Board; I thank you for your cooperation to date and I know that we can count on your continued loyalty in the future. An important task now lies in front of us. Above all, we have to recognise the needs of our community – your needs. At the earliest opportunity together with my colleagues on the Board, we will create a list of immediate tasks and also focus on setting long-term targets. We will inform all EHAC members of our approaches, and we would also welcome any suggestions from your side. Increasing the effectivity of the Board’s work and improving the management and activities of the EHAC working groups are both of paramount importance for the future.
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In more general matters, I would like to emphasise that I view patient care and safety as the highest priorities of our service. This direction will lead to a major work effort for the new EHAC leadership. We will also rely on our cooperation with other associations in the fields of medicine, medical transport and aviation around the world. Finally, we want to ensure good communication between experts and supporters within the international HEMS and Air Ambulance community. This very magazine that you hold in your hands is one of these good ways. I would like to thank the team of S&K Publishing for their highquality work, and to the new EHAC management, I pledge my support to ensuring the utmost quality in content in future AirRescue issues. I wish you all a wonderful spring. Respectfully yours,
Pavel Müller President of the European HEMS & Air Ambulance Committee
4 | CONTENTS
International Air Rescue & Air Ambulance
ISSN: 2192-3167 Publisher: L. Kossendey Verlagsgesellschaft Stumpf & Kossendey mbH Rathausstraße 1 26188 Edewecht | Germany firstname.lastname@example.org Tel.: +49 (0)4405 9181-0 Fax: +49 (0)4405 9181-33 www.airrescue-magazine.eu Medical Advisor: Dr Erwin Stolpe Medical Director EHAC
Night vision imaging systems in Dutch HEMS – and beyond
Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: email@example.com Editors: Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: firstname.lastname@example.org Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: email@example.com Christoph Kossendey Tel.: +49 (0)4405 9181-14 E-Mail: firstname.lastname@example.org Marketing · Advertising · Subscription Ch. Niemann Tel.: +49 (0) 4405 9181-16 Fax: +49 (0) 4405 9181-33 E-Mail: email@example.com
HALAS – stabilisation and positioning system for rescue hoist operations D. Nonnenmacher, H.-M. Kim, J. Götz, M. Gestwa
Is silence really golden? Non-punitive safety management at DRF Luftrettung K.-H. Heitmüller
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 GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany
AirRescue ist the offical publication of the European HEMS & Air Ambulance Committee (EHAC)
Ultrasonography in Air Ambulance Services L. P. Bjornsen, S. Einvik, L. Jacobsen, N. P. Oveland
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CONTENTS | 5
Case Report Hungarian HEMS and the new SOPs in trauma patient care A. Pertoczy
News An Interview with Christoph Breitenbach
Instrument-flying to hospitals: NLA presents a new project E. Normann, L.-E. Vollebæk
Mechanical chest compression devices in HEMS – blessing or curse? A. Truhlar
Multiple patient configurations put to the test: Luxembourg Air Rescue’s new ambulance jet A. Planer-Nonnweiler
An interview with René Closter of Luxembourg Air Rescue (LAR) K.-H. Heitmüller
HEMS operations in Japan – the mechanic as a crucial safety feature R. Ogino, K. Suzuki, A. Kohama, M. Tabata, N. Nakatani
Situational awareness – staying ahead of the aircraft S. Burigana
IN PROFILE MEDICAL CARE
Therapeutic hypothermia in HEMS operations J. M. Gutiérrez Rubio, J. A. Sinisterra, P. Gómez-Calcerrada
Intensive-care and air ambulance transport around the world: Advanced training in repatriating patients
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Guaranteeing the highest safety standards The corporate philosophy of Swiss firm Bucher Leichtbau P. Poguntke
Cover Image: Svein G. Lunde
6 | NEWS Community-funded HEMS in Ireland In Ireland, the only country in the EU without an air ambulance service, the Air Ambulance Ireland (AAI) has now formally submitted a proposal to the Minister for Health, Dr. James Reilly, to provide a communityfunded HEMS. The move follows a number W. Murphy/Wikipedia of meetings with Minister Reilly. AAI plans to launch the air ambulance very soon, subject to ministerial approval, using pilots and helicopters provided by Bond Air Services Ireland and paramedics of the Irish Health Service Executive (HSE). Given the reconfiguration of the health service around major centres of excellence and changes to the road ambulance service in rural Ireland, AAI believes that air ambulances have a vital role to play in the provision of medical services in Ireland. The Minister has been updated on AAI’s structure and fundraising strategy, the proposed operating base and the approvals by the Irish Aviation Authority as well as air operator’s certification for HEMS operations by Bond Air Services in Ireland. AAI general manager Ellen Miller said: “To keep helicopters in the air, the charity is totally reliant on community funding. I would appeal to people throughout the country to volunteer and raise funds for this much-needed service.” For more information, visit: ››› www.airambulanceireland.net
Doctor Heli system – GrandNew for HEMS missions
AgustaWestland and Kaigai Aviotech Corporation announced that Kagoshima International Aviation of Japan has taken a GrandNew light twin helicopter into service. This aircraft will be used to perform HEMS-missions in the Kagoshima Prefecture, southern Japan. A ceremony was held on 26 December 2011 – in the presence of the Governor of Kagoshima Prefecture and the Mayor of Kagoshima City – celebrating the handover that marks the entrance of the first EMS-configured GrandNew helicopter into the Japanese Doctor Heli system. Kagoshima International Aviation’s GrandNew features a comprehensive EMS configuration with a cabin layout able to accommodate two stretchers plus medical staff. Additionally, an AW109
Power in the same EMS cabin configuration will serve as a back up for the GrandNew’s operation. The GrandNew is said to feature the most modern developments in avionics while retaining the Grand’s outstanding performance and features. According to AW, the GrandNew is the first type certified light twin (CS/JAR/FAR 27) that fully complies with the latest advanced GPSbased navigation requirements for all weather operations. AW also announced that more than 300 orders (Grand Series) by over 180 customers from almost 40 different countries have been placed. For more information, visit: ››› www. agustawestland.com
Air Evac Lifeteam with one million members Air Evac Lifeteam (Missouri, USA) announced that it reached the one million member landmark. The company is the largest independently owned air
medical service in the USA, operating more than 105 bases in 15 states, and providing employment to more than 2,200 people. The air am-
Air Evac Lifeteam
bulance operator was founded in 1985 in West Plains (southern Missouri) at that time, when air ambulances were typically based in metropolitan areas. The company founders believed that the people who need air ambulance transport the most, are the ones who live in rural areas, often far away from a hospital that provides critical trauma care. In order for the service to survive in this rural setting, they knew they would need other sources of funding besides the traditional fee-for-service billing. They learned about the Rega Foundation in Switzerland, which supports a country-wide air medical service through a membership program, and adopted a similar program. In its first year of operation, the company signed up more than 5,000 members who wanted to help support the service in their community and the surrounding area. For more information, visit: ››› www.lifeteam.net
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NEWS | 7 Image depicts actual rescue What does UMS mean? The EASA’s coming OPS contains the abbreviation UMS. These three letters stand for usage monitoring system, a system that helps HEMS helicopters to reach extended performance class 2 and therefore the same safety level as helicopters in performance class 1. In future, EASA guidelines will stipulate that only this performance class can fly on air rescue missions. However, as no helicopter currently fulfils all the necessary requirements, UMS has been developed to bridge the gap. The system guarantees increased flight safety by continually monitoring all parts subject to wear and tear. DRF Luftrettung decided to implement an extended version, known as HUMS. As well as storing data, this system documents and evaluates the information to ensure, for example, that it is possible to immediately react to any changes in operating parameters. The first HUMSs were developed in 1991 to increase the safety of large cargo helicopters flying supplies to offshore oil platforms, as emergency landings are almost out of the question on such missions. Since then, HUMSs have been continually updated. You can read more about UMS in the following issue of AirRescue Magazine. (POG) For more information, visit: ››› www.easa.europa.eu
Aerolite signs medical completion agreement over 4 EMS aircraft Aerolite recently signed an agreement with an undisclosed Canadian customer for the design, production and completions of two Bombardier Challenger CL601 and two Dash-8 Emergency Medical Interiors. Design of the medical interior will commence in February with the first aircraft completion scheduled for late Summer 2012. Aerolite, one of the leading companies in design, engineering, production and installation of state-of-the-art Air Medical interiors for the major OEM’s and scene rescue-, intensive care- as well as SAR providers, worked in close collaboration with the Medical Operator to learn about their requirement in order to assure that the customized medical interior will meet all aspects of airborne medical service as well as operational and technical needs. The spacious cabin interiors of the Challenger CL601 as well as Dash-8 are well suited for medical repatriation. Each aircraft will be equipped with a tailored medical interior, optimized for the intended medical mission. The company holds EASA DOA, POA and MOA approvals and is ISO 9001, EN9100 and ISO 13485 certified. For more information, visit: ››› www.aerolite.ch
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Hiking accident | Weather moving in | Light from cell phone | Pilot wearing NVGs | Man trades hiking boots for golf shoes |
8 | NEWS Sullenberger Keynote Speaker at 8th CHC Safety & Quality Summit
„Sully“ Sullenberger, who once masterfully landed an Airbus A320 passenger plane on the Hudson River and saving the lives of all 155 people aboard the aircraft, will be the principal speaker at the CHC Safety & Quality Summit Gala Dinner in Vancouver. Capt. Chesley Sullenberger is an airline transport pilot, internationally recognized safety expert and accident investigator as well as a New York Times bestselling author. This year’s summit will be held at the Westin Bayshore Resort & Marina in Vancouver, Canada, from 26 to 28 March. The CHC Summit is an internationally recognized aviation-safety conference aimed at improving safety through excellence in human factors. The summit will explore the theme “Improving Safety Culture Through Talent, Training and Trust”. Capt. Sullenberger will share his experiences and discuss how talent, training and trust together make the difference when confronting a challenge. Featured speakers at the summit also include Stephen M.R. Covey, renowned lecturer and author of the bestselling book „Speed of Trust“, Tom Casey, author of „Talent Readiness – The Future is Now: Leading a Multi-Generational Workforce“; and Tony Kern, who has written many bestselling books, including „Going Pro: The Deliberate Practice of Professionalism“. For more information, visit: ››› www.chcsafetyqualitysummit.com
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The ALLFlight project: fully automatic landings In its ALLFlight Assisted Low Level Flight and Landing on Unprepared Landing Sites project, the German Aerospace Center (DLR) is conducting research into a system that produces a digital map of the surrounding area for the cockpit and supports pilots in difficult situations – which could include carrying out a fully automatic landing. The last successful test of 2011, held on 5 December, was a test flight in the DLR’s ACT/FHS (Active Control Technology/ Flying Helicopter Simulator) research helicopter. Project leader Robin Lantzsch of the DLR Institute of Flight Systems is enthusiastic about the project: “We are developing various levels of assistance for take-off, low flying among obstacles, and landing. Our software presents pilots with a range of suggested landing approaches or trajectories, and the autopilot helps pilots to manoeuvre the helicopter. By the time the project phase concludes, the Flying Helicopter
Simulator should be able to carry out fully automatic landings.” The 3D trajectories factor in time and adapt to conditions in the surrounding area. For example, they consider whether it is hilly, whether there is fog, whether there are electricity cables nearby and what direction the wind is blowing in. Four different pieces of equipment − a TV camera, an infra-red camera, a laser and radar − work in unison to create the digital map of the area. The research team have carried out 14 test flights to date. After each one, they analyse the huge amount of data collected back at the lab and adjust the algorithms accordingly. These will be tested further in more test flights this year. You can read more about the ALLFlight project in the September issue of AirRescue Magazine. For more information, visit: ››› www. dlr.de
ADAC-Luftrettung: NVGs in pilot training In late September 2011 the EASA approved ADAC-Luftrettung to start carrying out night-time air rescue missions and thereby authorised the air rescue service to reequip its EC 135 helicopters with night vision devices. Pilots have already started training with night-vision goggles in a first round of sessions at Senftenberg air rescue base in the state of Brandenburg. There, pilots will be trying out night vision goggles for the first time. Once they have completed the training course, the pilots will be entitled to fly with NVGs, using them , for example, to land at the scene of an accident during the night. A total of eleven ADAC-Luftrettung pilots will receive NVG training at three different air rescue bases. The use of these new technologies will significantly increase the safety of air rescue missions in low-light conditions as pilots will be able to recognise landforms, topographical features and obstacles not visible to the naked eye plus flood-
lights. The NVGs will also make it possible to carry out air rescue missions at night, heralding a new era of air rescue at ADAC. (Scholl) For more information, visit: ››› www.adac.de/luftrettung
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NEWS | 9 Night Vision Awards 2012
New SAR-contractors in the UK
gratitude as the program “recognized early on how important NVGs could be” for their area of operations. “There were a lot of great nominees,” said ASU’s Marketing Director Hannah Gordon prior to the event. “All the nominees are a tribute to the many operators proudly serving their communities through EMS, Law Enforcement, SAR and Fire Fighting operations. There are countless stories of saved lives and successful missions made possibly with night vision systems.” The Night Vision Awards were established in 2011 to recognize operations using night vision systems to safely protect and serve communities while championing the call for safe night flights.
The UK Ministry of Defence announced last year that it withdraws the Royal Air Force from SARservice and retires the fleet of yellow Sea King helicopters by March 2016. The move will mean the end to 60 years of military search and rescue. According to the Department for Transport in London, the aim is to introduce “a modern fleet of fast, reliable helicopters” that will improve capability. The procurement process has been concluded last month and the Parliamentary Under-Secretary of State for Transport, Mike Penning, informed that “a contract has been signed to operate search and rescue services from Stornoway and Shetland with Bristow Helicopters Ltd. A separate contract has been signed with CHC Scotia Ltd. to operate search and rescue services from the Maritime and Coastguard Agency bases at Portland and Lee on the Solent. Operations under both contracts will commence by the time the existing MCA service contract expires, and will continue until June 2017.” Both contracts will be managed by the Maritime and Coastguard Agency (MCA). Penning went on saying that “procurement is now under way for longer term arrangements which will see search and rescue contracted nationally.”
For more information, visit: ››› www. asu-nvg.com
For more information, visit: ››› www.dft.gov.uk
Aviation Specialties Unlimited (ASU) announced the award winners of the Second Annual Night Vision Awards during the Heli-Expo 2012 in Dallas. Among the award winners were REACH Air Medical Services, STAT MedEvac and Collier County MedFlight, which were given the 5-Year Service Award. STAT MedEvac pilots accumulated more than 5.000 flight hours last year while transporting more than 3,300 patients at night. Many of these patient transports were from unprepared landing zones, in remote, mountainous locations, that the pilot flying would have been encountering for the first time. “The ability to turn night into day utilizing NVG technology allows STAT MedEvac to conduct these transports in the safest manner possible”, said STAT MedEvac Director of Operations, John Kenny. Steve Adams from Collier County MedFlight also expressed his
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CH-8117 Fällanden Phone +41 44 806 24 24
10 | NEWS “Christoph Hessen” moves to university clinic in Giessen The only intensive care helicopter in Hesse, the “Christoph Hessen”, is moving to the Giessen university clinic. The move was announced by Hesse’s minister of social affairs Stefan Grüttner, Johanniter-Unfall-Hilfe Hessen (which operates the intensive care helicopter on behalf of the state of Hesse) and the Giessen university clinic. “To ensure smooth and optimal medical service, it was vital for us to link the intensive care helicopter to a large clinic,” said minister Grüttner. The “Christoph Hessen” has been moved in order to improve emergency care and better equip air rescue for the future. The craft is used to transport emergency care patients who need to be taken to another medical centre for further diagnosis or treatment, or to transport intensive care patients who need to be taken to another hospital without any interruption in care. The “Christoph Hessen” is the only rescue helicopter in the state that had not been stationed at a hospital, but rather at the airfield in Reichelsheim (Wetterau). The ministry says that the decision to move the aircraft fills in the last little gap on Hesse’s air rescue map. For more information, visit: ››› www.hsm.hessen.de
New EC135 for HEMS missions in Romania A ceremony was held in Bucharest mid December for the delivery by Eurocopter Romania of an EC135 helicopter to Romania’s Ministry of Health. The ceremony was attended by the Romanian Minister of Health Ladislau Ritli, the Secretary of State in the Romanian Ministry of Administration and Interior Mihai Capra, His Excellence Henri Paul from the French Embassy in Romania, His Excellence Andreas von Mettenheim from the German Embassy in Romania, as well as by JeanLouis Mascle, CEO of Eurocopter Romania and
Xavier Poupardin, Vice President Eurocopter for the EC135 program. This is the first delivery following a contract that was awarded to Eurocopter Romania last august. The framework contract foresees the purchase of up to six helicopters by the Ministry of Health. The EC135 will be used for emergency medical missions to assist the general population in Romania. This delivery is part of a wide-scale program launched by the government to develop its medical evacuation capabilities, which includes plans to enlarge its existing fleet. Eurocopter Romania was founded over a decade ago, and is a key player in helicopter overhaul, repair and retrofit activities. Other keys to the EC135’s success are its low operating and maintenance costs. In compliance with international aviation safety regulations, the helicopter is fitted with a dual-engine and can obtain speeds of up to 254 km/h, with an average range of approximately 635 kilometres. For more information, visit: ››› www.eads.com
SkyTrac ISAT system at Polish Medical Air Rescue
INAER: New HEMS base in Chile An emergency helicopter operations centre has been installed in the city of Puerto Varas (southern Chile). At the base, a Bell 212 helicopter will be operational from now onwards. It is equipped with a mobile ICU and medical equipment for the patient to receive immediate medical care, stabilization at the accident site and care during transport. “The use of helicopters can make the difference between life and death,” said the Managing Director of INAER Chile, Rodrigo Lizasoain. The areas of operations in southern Chile are characterized by its difficult access, for example in Palena, Futaleufú and Chaitén as well as on the islands of Chiloé, to which this HEMS service can access without complications. Especially during the summer months, the number of traffic accidents in this area increases dramatically.
SkyTrac Systems announced a combined integration with EuroAvionics and the Rescue Track monitoring and dispatch software produced by Convexis GmbH of Germany. This management solution is being used by German air rescue DRF Luftrettung in its fleet of approximately 50 helicopters that operate in Europe and has most recently been implemented for the Polish Medical Air Rescue (SP ZOZ Lotnicze Pogotowie Ratunkowe). The SkyTrac ISAT system is installed on the aircraft in conjunction with the EuroAvionics EuroNav Situational Awareness system. The EuroNav system is integrated with the on-board radar altimeter and the ISAT, which then sends GPS position data via the Iridium satellite network to be viewed in the Rescue Track software. The dispatch centers monitor the real-time position and mission status of the aircraft on a secure website.
Dispatchers can see where the helicopters are located at all times and are able to plan missions accordingly. This helps to ensure faster medical care for the population, even in remote regions. For more information, visit: ››› www.skytrac.ca ››› www.lpr.com.pl
New Upgrade for Latitude WebSentinel iOS App
For more information, visit: ››› www.inaer.com
Latitude Technologies, headquartered in Victoria, British Columbia (Canada), global provider of Satellite-based communication, tracking and on-board aircraft data systems, announced the release of an updated version of their popular Latitude WebSentinel iOS App. Registered users of Latitude’s SkyNode® satcom products who have a WebSentinel service account, can now view live and historic flight tracking data, adjust reporting parameters and do two-way text messaging using the intuitive interface and high-resolution image quality that Apple® products are known for.
Tim Curtis, vice president of information services, said: “Similar programs are also available for other smartphones and tablet computers, including electronic flight bag (EFB) products.” The App is freely available in the iTunes® App Store and functions on the iPad®, iPhone®, and iPod Touch® products by Apple®. For users of Latitude’s existing iOS App, the new version is available as an update. For more information, visit: ››› www.latitudetech.com
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He caught the air rescue bug early on − outgoing EHAC President Christoph Breitenbach looks back over his time in office. When we take up a new office we ideally have a clear vision of our goals. When we leave office we have the opportunity to look back over all that has been achieved. After seven years at the head of EHAC, Christoph Breitenbach is handing over the reins to his successor − a good time for AirRescue Magazine to talk to him about his time in office. An interview with Peter Poguntke ARM: What drew a qualified lawyer like yourself to air rescue? Breitenbach: I joined the ADAC to head up its legal team on 1 March 1985. That post also put me in charge of ADAC Luftrettung’s legal affairs, so I have actually been involved with air rescue for around 27 years. Right from the very beginning, I was fascinated by the technical and medical advances that allow helicopters to rescue patients in almost every type of terrain. As I spend a lot of my free time in the great outdoors − cycling, hiking or skiing − I have always been aware of the challenges of rescuing people out in the wilds.
ARM: We’ve heard that you were particularly influenced by Gerhard Kugler, the long-time head of ADAC Luftrettung and pioneer of air rescue in Germany. Is that true? Breitenbach: I was influenced by Gerhard Kugler as we were good friends right from the very beginning. We had to collaborate very closely so we always had a very close professional relationship. That, of course, meant that I couldn’t help but catch his infectious enthusiasm. I think if you worked with Gerhard that intimately, you either got the air rescue bug or, if you weren’t interested, you looked for another job.
ARM: What would you say have been the highlights of your career in HEMS business? Breitenbach: As a lawyer, I tend always to remember the things that were legally significant. In that sense – and I think Gerhard Kugler would agree – the biggest highlight of my time
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at ADAC had to be when the first air rescue helicopter started operations in West Berlin. Back then, Berlin was still divided and subject to the Four Power Agreement. Legally speaking, it was impossible for a German company to use aircraft in West Berlin. But after long negotiations and a whole host of international agreements, it was finally possible to station an ADAC air rescue helicopter in West Berlin.
ARM: Why didn’t you present yourself as a candidate this time round? Breitenbach: After seven years in office, I thought it was time for a new president and a bit of a shake-up on the board. Every association has different development stages, and the conditions that our members operate under are also changing all the time. This state of constant flux should also be reflected in an organisation’s leadership. Keeping up with the times means constantly evolving and introducing new ideas and new approaches to problem solving.
ARM: What hopes do you have for your successor? Breitenbach: First and foremost, I wish my successor all the best and every success. I hope that the newly elected board, with four new members out of seven, will also enjoy a successful working relationship. They face a range of challenges including constant new EASA regulations, which threaten to restrict companies’ operational scope and affect the way they do business. I also hope it will be possible to establish and build up a relationship with new EHA once again.
ARM: How do you think air rescue will develop in future? Breitenbach: In my opinion, air rescue is a successful sector that works well but that faces a range of problems – problems that I think politicians often underestimate. On the one hand, we have to implement a constant flow of costly new EASA regulations. On the other, despite the fact that air rescue is now regarded as necessary – not only in Germany – and is becoming increasingly important due to the closure of hospitals and the associated demand for more patient transportations and transfer flights, these services are becoming more and more difficult for individual companies to finance due to the need to keep down costs in the healthcare business. I think there needs to be more political awareness of this and perhaps a complete policy rethink.
12 | TECHNOLOGY
Night in Du
Fig. 1: Proper integration of NVIS in combination with SOPs and a sound crew concept allows for additional safety (Photograph: ANWB MAA) 1 路 2012 I Vol. 2 I AirRescue I 12
TECHNOLOGY | 13
t vision imaging systems utch HEMS â€“ and beyond Night vision imaging systems (NVIS) are not the latest technology in aviation; they have been around for quite some time. And although some operators in Europe, especially Swiss Air Rescue (Rega), have a long history of safely operating NVIS with night vision goggles (NVG), it seems European operators and regulators are being rather slow to adopt this safety-enhancing technology in civil Helicopter Emergency Service (HEMS) operations. NVIS are an aid to night VFR flight and they improve safety by adding to the situational awareness of the crew. Although NVIS are most often used by military and law enforcement agencies, they are not new to civil HEMS operations. Swiss Air Rescue (Rega) has been operating an NVIS with NVGs in its HEMS operations since 1987. Image-intensifying NVGs improve the ability to see and avoid obstacles at night. This ability adds to the safety of the flight and, especially in HEMS operations, to the safety of the landing and consecutive take-off at an unsurveyed HEMS operating site by night. As the use of an NVIS is considered a safety adding feature, normal Night-VFR limits for HEMS apply. This ensures recovery during a mission in the (unlikely) case that the NVGs fail.
NVGs and NVIS A night vision imaging system is an integrated system that consists of NVGs, NVG-compatible aircraft lighting and systems as well as training and other measures to ensure continued airworthiness (JAA TGL-34). Proper integration of these elements in combination with standard operating procedures (SOP) and a sound crew concept allows for additional safety. Unfortunately, every element of the system is associated with challenges for the operator.
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Author: Daan Remie Flight Operations Manager ANWB Medical Air Assistance
14 | TECHNOLOGY
Fig. 2: Radboud Universiteit Nijmegen Medical Centre recently opened a new rooftop helipad (Photograph: R. Eijk)
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TECHNOLOGY | 15
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16 | TECHNOLOGY
Fig. 3: Luckily, the availability of NVGs for civil operators has improved over the years, but delivery and repair times are something that have to be taken into account (Photograph: ANWB MAA)
Fig. 4a & Fig. 4b: Some NAAs still require operators to adhere to military training programmes, which usually require more training because of their tactical “nap of the earth” operations (Photograph: ANWB MAA)
NVGs are developed as military technology and require export licences and end-user statements. Luckily, their availability for civil operators has improved over the years, but delivery and repair times are something that have to be taken into account, as they are usually significant. A pair of NVGs must be certified within the NVIS and changing to another type of NVG requires certification.
Transition period Compatibility of aircraft lighting and systems is another issue. Before EASA took on responsibilities for (continued) airworthiness, some national aviation authorities (NAA) allowed installation of NVG lighting kits – classified as a minor change – while others allowed operations with NVG-compatible aircraft instead of NVIS certified aircraft. EASA is very clear about the requirement for NVIS certification, but in the transition period after NVIS certification procedures were initiated some NAAs allowed continued NVIS operation (under a 14.4 exemption), whereas other NAAs did not. This put ANVIS operations on hold, at least temporarily. Configuration management for an NVIScertified helicopter is also more important, as changes to instruments might entail the need for recertification of the NVIS. Although JAA guidelines for NVG training exist, some NAAs still require operators to adhere to military training programmes, which usually require more training because of their tactical “nap of the earth” operations. Most NAAs lack expertise with NVIS operations in the civil environment and rely on (past) military expertise. The additional training requirements increase the initial costs for pilot training. The costs associated with an NVIS operation are another hurdle to its implementation. NVIS operations do not come cheaply; they require large initial investments for NVGs, aircraft certification, training and ensuring continued airworthiness. The operator’s business model must, of course, plan for all these extra costs. Despite all the hur-
dles, successful implementation of NVIS is possible. ANWB Medical Air Assistance B.V. (ANWB MAA), a Dutch HEMS operator that provides HEMS on behalf of four trauma centres in the Netherlands, managed to implement NVIS operations in HEMS over a five-year period.
NVIS in Dutch HEMS In April 2011 the last of four HEMS bases in the Netherlands became available 24/7. This event marked the end of a project that took six years to finish. It all started in 2005 when the Dutch Ministry of Health assigned funds to the trauma department of Raboud University Nijmegen Medical Centre for a one-year trial. The trial was intended to investigate the use of 24/7 HEMS to see if its existence was justified and to answer the question of whether the helicopter added value as a means of transportation after sunset. It took a year of preparation and implementation before “Lifeliner 3” was able to take on the first NVIS HEMS mission in the Netherlands in November 2006. Implementing NVIS in HEMS was a process that required careful planning and decision-making. It also revealed a number of challenges, some of which have not yet been resolved. They extended beyond the NVIS itself to include regulatory, logistical and environmental issues. Before that time, national regulations dictated that landings at the HEMS operating site had to be completed by civil twilight at the latest, and only allowed continuation outside UDP if the flight was to a hospital, refuel location or back to the HEMS operating base. Until then nightVFR flight in the Netherlands was restricted to state and military operators. A special exception would have to be made to allow HEMS to operate 24/7, and because there was little NVIS experience within the NAA, it was considered of utmost importance to get the NAA connected to the project as soon as possible. This proved to be a great help because it created a common understanding of the planned NVISHEMS operation. As a result, most of the issues identified
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TECHNOLOGY | 17 by the NAA were resolved early on in the project, eliminating regulatory showstoppers early in the process. Help was sought from outside the company for the design and installation of NVG-compatible lighting and equipment and for the development of standard operating procedures, a crew concept and a training programme. Outside assistance was needed because the NVIS expertise available within the company was limited to military operations. Acquiring an NVIS is a time-consuming process. There are many choices to make with regard to NVGs and NVIS lighting inside and outside the helicopter. After the right equipment and suppliers were identified, long delivery times had to be taken in account. These long delivery times for NVIS components prevail today.
NVIS concept and training With the kind help of Swiss Air Ambulance (Rega) and Norwegian Air Ambulance (Norsk Luftambulanse S.A.), a crew concept and a training programme tailored to the Dutch HEMS operation were developed. The NVIS crew concept is based on one pilot and one HEMS crew member, both of whom use NVGs. Assistance was also provided to train the company’s NVIS instructors for operations involving lots of white light – quite different from covert military operations. Training was an issue in other ways as well. One question was where and when to train. None of the civil airfields were available for training purposes. Most of them close at night because night VFR is not allowed anyway. Therefore a military airbase was used. For environmental reasons (noise pollution), training needed to finish no later than 23:00 hours local time, which limited the opportunities for NVIS training to the time between September and March. After a year of theoretical study, all of the HEMS
Fig. 5: At the end of the trial period, it was decided to extend the use of 24/7 HEMS to the whole country (Photograph: ANWB MAA)
crew members had obtained a theoretical PPL and an RT license, and the NVIS training could finally begin. During the training period, the NAA lifted the ban on landings at unsurveyed HEMS operating sites. So when “Lifeliner 3” became operational 24/7 on 1 November 2006, it was able to take on HEMS missions to unsurveyed HEMS operating sites outside congested areas and to surveyed ones inside congested areas. There were operational issues then, and some still exist today. A lack of NVIS weather forecasts, a limited number of night-VFR landing sites at hospitals, and most importantly, the limited number of refuelling stations after dark all posed challenges for operations. At the end of the one-year trial period, it was decided to extend the use of 24/7 HEMS to the whole country. Slow decision-making, the above-mentioned problems with NVIS implementation, discussions with regulators on the use of an elevated heliport at a hospital as an HEMS operating base, and debates on alternative options all slowed the implementation of NVIS at the other three HEMS operations in the Netherlands. Finally, in April 2011, the last of the four “Lifeliners” became operational. Fig. 6: Implementing NVIS in HEMS was a process that required careful planning and decisionmaking (Photograph: ANWB MAA)
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Fig. 1: ACT/FHS pilot checking the rescue hoist (Photographs: DLR)
Authors: Daniel Nonnenmacher Aerospace Engineer, Project Manager HALAS firstname.lastname@example.org Hyun-Min Kim Aerospace Engineer email@example.com Joachim Götz Dr Eng., Group Leader Flight Mechanics and Handling Qualities firstname.lastname@example.org Martin Gestwa Aerospace Engineer, Head of the FHS-Board email@example.com Lilienthalplatz 7 38108 Braunschweig Germany
HALAS – stabilisation and positioning system for rescue hoist operations Carrying an external load with a helicopter decreases flight safety. The helicopter‘s handling qualities are reduced and, at the same time, pilot workload is increased. In certain circumstances the external load could start to swing. Such instances of a swinging load are extremely challenging for the pilot as it is particularly difficult to regain “balance” and maintain the desired positioning of the load. In many cases the swinging load is hardly controllable and, considering the worst case, excessive motion can result in a damage of the helicopter or it might force the pilot to abandon the load in order to protect helicopter and crew. Stabilising and positioning external load is not only restricted to cargo handling; missions with rescue hoist operation – the handling of human external load – means a high workload for pilot and crew in a very special way. In SAR missions for example, the rescue hoist has to pick up people in hazardous situations. Therefore, the pilot has to position a rescuer right next to the person in danger – often under demanding environmental conditions. In the future, both tasks, load stabilisation and precise positioning, which are crucial for rescue hoist operation, could be done automatically by an assistance system called HALAS (“Hubschrauber-Außenlast-Assistenz-System”, helicopter assistance system for controlling external loads). HALAS is currently being developed by Deutsches Zentrum für Luft- und Raumfahrt e. V. (DLR) in cooperation with iMAR GmbH, a company specialized in inertial navigation, stabilisation and control systems. The project is funded by the German Federal Ministry of Economics and Technology (BMWi, Bundesministerium für Wirtschaft und
Technologie). This article gives an insight into the design of the system called HALAS and presents DLR’s research helicopter ACT/FHS (Active Control Technology/Flying Helicopter Simulator). Flight tests were carried out last year with the FHS – equipped with a rescue hoist – in order to demonstrate the pilot assistance system.
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TECHNOLOGY | 19 Flying a helicopter with a slung load – as described above – can be a complex and dangerous task for the pilot and crew members. The objective of the pilot assistance system HALAS is to reduce the pilot workload and to increase flight safety for cargo handling as well as rescue hoist operations by automatic slung load stabilisation and positioning. Furthermore, the HALAS is expected to improve the helicopter’s handling qualities and to ensure a higher availability of the rescue hoist under poor environmental conditions, e.g. gusty wind. In the past, a system for manual slung load stabilisation, the “Flight Director”, has been developed by DLR and iMAR GmbH. This system uses an additional and modified artificial horizon, which can easily be mounted in any helicopter cockpit. If the pilot uses this modified display to stabilise the helicopter, he or she intuitionally makes the right control inputs to damp the pendulum motion of the slung load. This system has been successfully demonstrated in flight tests on two different helicopters. The very agile BO 105 (1) and the medium-heavy transport helicopter CH53G (2). In both cases the external load was suspended centrally below the helicopter by a harness with a fixed cable length and the pilot, in both cases, was flying the helicopter manually. Simulations with fixed cable length also demonstrated that automatic slung load damping and positioning can be achieved by measuring and feeding back the slung load motion (3). The cable length has significant influence on the stability of the overall system, consisting of the helicopter and the slung load. One objective in the development of the HALAS flight control laws is that the system can handle the variable cable length in rescue hoist operations. The slung load stabilisation and positioning will be realised as additional automatic control modes of the helicopter’s automatic flight control system (AFCS). The pilot assistance system will be demonstrated in flight tests with the ACT/FHS.
Flying Helicopter Simulator ACT/FHS DLR is operating a unique airborne research rotorcraft, the ACT/FHS (4). It is based on an EC135 helicopter (see Fig. 1) and was designed and developed jointly by Eurocopter Germany (ECD), Liebherr Aerospace Lindenberg
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(LLI), the German Federal Office for Defense Technology and Procurement BWB (Bundesamt für Wehrtechnik und Beschaffung) as well as DLR. The main feature is a combination of a full-authority, quadruplex fly-by-wire/light control system with smart actuators and a simplex experimental system. It completely replaces the original flight control system and provides a high degree of flexibility. The safety-critical part of the new control system – called core system – meets the high civil aviation safety requirements with a catastrophic failure probability of 10-9 per flight hour. If the experimental system is engaged, it has full authority over all control surfaces, but is monitored by the safety pilot. He can immediately regain full control of the FHS by switching back to the certified fly-by-wire/light control system. The experimental system offers unique capabilities to the researcher. Either software-based experiments are implemented (no certification required) or the experimental system is used as an interface to integrate external hardware, like sensors, active inceptors, and display systems.
Fig. 2: Structure of the ACT/FHS core and experimental system
Fig. 3a-3c: Last preparations on ground (4a) for the first flight of the ACT/FHS (side views, 4b and 4c) with rescue hoist
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Fig. 4: ACT/FHS with rescue hoist system
Fig. 5: HALAS system components
The ACT/FHS is equipped with a hierarchical flight control system (see Fig. 2). The core system consists of the active control technology for the pilots (upper part of Fig. 2). All components – hardware and software – are four times redundant (quadruplex). The connections between the pilot controls and the core interface computer are by wire and between the core interface computer and the actuator units by light. The functionality of the core system is as follows: The command inputs of the pilot (safety or evaluation pilot) are measured and transmitted as digital signals to the core interface computer. This computer monitors the control activities and the data communication, performs the safety analysis, and limits safety critical control commands before these signals are transferred to the smart actuators. Additionally, the ACT/FHS has a mechanical backup control system for the safety pilot. If the experimental system is engaged, the controls of the evaluation pilot are fed through the experimental system (lower part of Fig. 2) and fed back to the core system with full authority.
The experimental setting consists of three computer systems, additional sensors and two stations, one for the evaluation pilot and one for the flight test engineer (see Fig. 3). The first computer system is needed for data management, for acquiring and storing data, distributing them to the other computer systems and transmitting them to the ground via telemetry. The second computer system is the experiment computer that offers several interfaces and mounting options for experiment hardware devices e.g. an optical-inertial sensor for the load dynamics measurement for HALAS. The third computer system is the graphics computer, which drives two freely programmable displays for the evaluation pilot and the flight test engineer. The data management computer accesses two attitude and heading reference systems, two air data systems, two full authority digital engine controls and a radar altimeter. In addition to these sensors of the basic helicopter, the experimental system contains further sensors: an inertial navigation system, a differential global positioning system, nose boom air data sensors, accelerometers, rotor data sensors as well as main rotor and tail boom load sensors.
HALAS System Design The ACT/FHS has been equipped with a rescue hoist system in September 2011 by Eurocopter Germany (see Fig. 4). After getting the airworthiness certification for this modification and a successful first flight with the hoist system, the ACT/FHS is now prepared for the planned flight tests to demonstrate the pilot assistance system HALAS. In order to damp the slung load pendulum motion and to position the slung load accurately, the load motion has to be measured during flight. Therefore, an optical-inertial sensor is mounted under the boom of the rescue hoist (see Fig. 5) and connected to the experimental computer. The optical-inertial sensor, developed by iMAR GmbH, consists of a camera, a control unit, and a MEMS (Mirco Electro Mechanical System) based inertial measurement unit (IMU). All parts are integrated into one single device. The camera is looking downwards. An active marker is placed above the bumper of the cargo hook. Its upper surface consists of several LEDs. These are emitting infrared light. In every picture taken by the camera, the active marker can be detected by a special image data processing algorithm. The software running on the control unit determines the slung load motion. In case the load is outside the camera’s field of view or the active marker cannot be detected with sufficient accuracy, the pendulum motion is estimated by the control unit giving an approximation of the factual pendulum motion. The IMU is used to measure the helicopter motion. Based on both measurements, it is possible to design a flight control law that is able to automatically damp the slung load oscillation. This is achieved by a feedback of the slung load motion into the AFCS, which is running as an application on the experiment computer of the ACT/ FHS. The slung load stabilisation controller is part of the AFCS and creates additional actuator commands that are overlaid with limited authority to the pilot’s manual control inputs in such a way that the helicopter automatically
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TECHNOLOGY | 21 executes small correction manoeuvres to minimize the slung load oscillations. Thus, the pilot can fully concentrate on the mission.
Outlook Two different positioning strategies will be tested for the precise positioning of the slung load. The first strategy will use (D)GPS coordinates to define the desired position of the slung load on the ground. The second strategy is more flexible and does not depend on a person on the ground and on previously determined position information. This strategy allows the pilot to set the desired slung load position with respect to the actual load position by a four-way switch on the cyclic stick. The information about the offset between the actual and the desired slung load position as well as the measured slung load motion data is used by the flight control law to create the appropriate actuator commands to position the slung load automatically with the helicopter. The control law is developed with the focus on minimal overshoots when the load is placed on the final position. For the automatic slung load positioning, no manual pilot control inputs are needed. Furthermore, the system automatically reacts to external disturbances like wind gusts and holds the desired position of the slung load. The researchers have already implemented a slung load model into the system simulator of the ACT/FHS. This model allows for simulation of slung load operations in
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the ground-based simulator. Current flight control laws for automatic slung load stabilisation and positioning can be tested (for feasibility) in this environment. For that purpose, a close cooperation between researchers, flight test engineers and test pilots is necessary. When all tests in the ground-based system simulator have successfully passed, the pilot assistance system HALAS will make its first flight this year.
For more information, visit: ››› www.dlr.de ››› www.imar-navigation.de References: 1. Hamers,M, Bouwer G (2004) Flight Director for Helicopter with Slung Load, 30th Annual European Rotorcraft Forum, Marseille, France, September 14-16 2. Hamers M, von Hinüber E, Richter A (2008) CH53G – Experiences with a Flight Director for Slung Load Handling, 64th Annual Forum of the American Helicopter Society, Montreal, Canada, April 29-May 1 3. Brenner H (2009) Automatische Pendeldämpfung und Positionierung von Hubschrauber-Außenlasten, DLRForschungsbericht 2009-27, Braunschweig, Germany 4. Kaletka J, Kurscheid H, Butter U (2003) FHS, the New Research Helicopter: Ready for Service, 29th Annual European Rotorcraft Forum, Friedrichshafen, Germany, September 16-18
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Fig. 1: Poor visibility and heavy rain – the GPS-system permits for flights to the hospital even in IFR conditions (Photographs: Lars-Erik Vollebæk)
Authors: Erik Normann and Lars-Erik Vollebæk Norsk Luftambulanse AS, P.O. Box 39, 1441 Drøbak, Norway lars-erik.vollebaek@ norskluftambulanse.no
Instrument-flying to hospitals: NLA presents a new project Some patients to be transported by helicopter cannot wait. Why should seriously ill or injured persons have to wait for treatment – even if weather conditions do not seem to permit transport? Norsk Luftambulanse (NLA) has initiated a project to surmount the difficulties of flying in inclement weather. As the first air ambulance operator in Europe, NLA has been given approval to design and implement procedures which make it possible to fly to hospitals on instruments only. This took place in September 2006 when the approach procedure to Stavanger University Hospital was approved by the authorities. The system makes it possible for the helicopter to undertake flights to the hospital even in IFR conditions. Flying seriously ill patients and persons with life-threatening injuries to a hospital – even in bad weather – can save lives. East of Oslo. Visibility is poor and there is heavy rain. The ambulance helicopter is on a training flight. Flight Ops Manager Erik Normann downloads a pre-defined route from the helicopter’s satellite navigation system. The route comprises of five points that must be passed on the way to Ullevål Oslo University Hospital. At each point there is a pre-defined altitude. The autopilot system is then switched on. The idea of designing GPS-based approaches to hospitals and other key positions emerged in 2004. Flight Ops Manager Erik Normann and his colleagues experienced frustration over having to cancel flights due to the weather. Approximately 10 percent of all flights get cancelled due to poor weather conditions. Weather conditions vary greatly in Norway, depending very much on the region of
the country. The crew often experience that a flight starts in good VFR conditions only to see that the designated hospital is covered with clouds. This results in the use of alternative transportation and a significantly increased spending of the patient’s time – time the patient actually does not have.
More lifes to be saved Passenger traffic continues to arrive and depart from airports around the world even on days when visibility is poor. But if a person has a life-threatening injury and needs to be flown to a hospital by an ambulance helicopter as quickly as possible, visibility must be acceptable before it can take off. Is this reasonable? Not so in the opinion of NLA, initiator of the project PinS (Point in Space). The Norsk Luftambulanse foundation has contributed finan-
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TECHNOLOGY | 23 cially to this project. The object of the foundation is to further develop the air ambulance service also by spreading instrument flying so that more lives can be saved. We pass the first waypoint at an altitude of 2,300 feet. The GPS lines up a course to the next waypoint and the autopilot makes small adjustments so that we keep on course. We are gradually approaching waypoint No. 2. Pilot Erik Normann sits with his hands in his lap. We pass waypoint No. 2 and the helicopter turns right 90 degrees. Erik gradually reduces altitude. At waypoint No. 3 our altitude is 1,800 feet. We can now make out the silhouette of Ullevål Hospital building.
The Norwegian context Ambulance helicopters in Norway mainly fly according to VFR-rules. All regular air traffic is in accordance with instrument flight rules (IFR). The instruments that make IFR-approaches possible are installed at airports. Norwegian air ambulance helicopters can also make instrument based approaches to airports, but patients usually need to go to hospital, not to an airport. There are no navigation instruments at hospitals and frequently there is hardly enough space to land. Installing conventional navigational aids at hospitals would be far too expensive and complicated. The solution is satellite navigation (GPS), a technology that is also used in navigation for road vehicles and has an accuracy margin of a few metres.
The Norwegian Air Ambulance helicopters are equipped with dual Garmin GNS 430A installations, certified for precision RNAV operations. This means that approval is given by the aviation authorities to use the GPS system for very accurate navigation procedures. The EC 135s have an Automatic Flight Control System certified for single pilot IFR operation, allowing automatic coupled precision approaches down to a minimum decision height of 200 feet, in visibility down to 500 meters. The autopilot will even continue to fly the helicopter overhead the runway and level off at a height of 65 feet. For the PinS approaches, the minimum decision height can be as low as 250 feet, terrain and obstacles permitting. A great advantage with these approaches in participating in the construction process is the opportunity to select a final approach track that gives the lowest possible minimum height. In cockpit, the flight route, including the PinS approach, is depicted on the navigation display, allowing for great situational awareness. It can even be shown as an overlay on the installed, excellent digital electronic map, providing an extra assurance for keeping sufficient altitude above terrain and obstacles. Incorporated in the Garmin GNS 430 is also an excellent safety function called TCAS, which stands for Traffic Collision Avoidance System, and gives the flight crew an on-screen-display of other aircrafts in the vicinity as well as acoustic guidance to avoid the traffic. Another feature utilized for safety is the combined weather and ground
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Fig. 2: Flight Ops Manager Erik Normann can sit with his hands in his lap while the helicopter finds its way to Ullevål University Hospital by means of GPS and the autopilot
Fig. 3: NLA-helicopters are equipped with dual Garmin GNS 430A installations, certified for precision RNAV operations
mapping radar installed. It gives information of temporary obstacles, in the shape of moving ships, as well as showing shore-lines. For some approaches the use of radar permits special, lower minimum height. Even though single pilot IFR flights are allowed, the operations include a HEMS crew member occupying the left seat. The crew member is specially trained and carries out different tasks during the flights, performing the duties of a nonflying copilot. The main task however is to act as a safety guard, supervising and supporting the commander. In a true CRM environment this crew composition is also tested during proficiency flight checks and simulator training. All PinS approaches include a contingency plan to be put in force in case of GPS malfunctions. This provides for an easy transition to conventional instrument flight for these very unlikely occasions.
To land or not to land We are now approaching the fourth point at an altitude of 900 feet (300 metres). We can now see the helipad. If this had been a real assignment, we could have continued to the hospital despite the fact that it is covered in cloud. We are now approaching the final point. Erik Normann must decide whether we are to continue towards the helipad or if we should abort. We have now arrived at a point where the pre-defined route takes us no further. Unlike an airport, a GPS-based approach to hospitals ends at a point in space. If we are to land now, we must have good visibility. Otherwise we must increase altitude and abort. As this is a training flight we do not wish to cause a disturbance through unnecessary noise and we therefore increase altitude and turn home.
With paper and pencil About 10% of all air ambulance assignments in Norway are cancelled due to inclement weather. This project is aimed at reducing this percentage. Ullevål University Hospital is the largest hospital in the country and more than one million people can be treated here if they are seriously injured. It was therefore natural to prepare one of the first instrument approach procedure to this destination. The job started with a map, a pencil and a trip to town. “The aim is to come in as low and as close to the helipad as possible while maintaining required safety margins,” says Erik Normann. We must therefore go out and inspect the terrain and plot a course where there are fewest possible hindrances.
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TECHNOLOGY | 25 In the case of Ullevål Hospital this means that the course is defined from east to west. Pen and paper are gradually exchanged for computer technology. A comprehensive set of digital terrain and obstacle data is put together by the charting expert of NLA and sent to the procedure designers. The final procedure is plotted into the GPS onboard the helicopter. A comprehensive approval routine then follows before any procedure can be taken into use. NLA has cooperated with the Norwegian consultancy Aurinko for this project, and is using ASAP Ltd. in Slovakia for the computer-based construction and charting.
Many new opportunities NLA has given priority to the major hospitals and now has eighteen procedures approved for operation. As more experience is gained with the systems, there is nothing technical to prevent NLA from introducing the same procedure at a large number of hospitals and other landing sites in the country. The first route was approved in 2006. This year, NLA starts a full scale production. During this summer, 18 routes will be operational and more than 25 will be put into operation till the end of the year. There are plans to introduce 40 to 50 procedures at different locations. However, it is a question of resources. “Planning these approaches costs money”, says Erik Normann. He also envisages preparing procedures which make it possible to penetrate areas of poor weather conditions
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into an area where the weather is such that the flight can be completed VFR. With the service of life capability of EGNOS now operational, Norsk Luftambulanse is looking forward to cooperate with authorities and helicopter manufacturers to implement more sophisticated procedures with reduced minimas like PinS LPV (Localizer performance with Vertical guidance). Aborted assignments due to inclement weather affect about 700 patients each year. If this percentage can be reduced, more patients can be helped and lives can be saved.
Fig. 4: As more experience is gained with the system, there is nothing technical to prevent NLA from introducing the same procedure at a large number of hospitals
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Fig. 1: The Doctor-Heli System was established in 2001, with five bases being set up in the first year (Photograph: W. Nishikawa)
Authors: Ryukoh Ogino Koichiroh Suzuki Akitsugu Kohama Department of Emergency and Critical Care Medicine Kawasaki Medical School Hospital Masahiro Tabata Naritoo Nakatani Department of Emergency and Critical Care Medicine Central Helicopter Service
HEMS operations in Japan – the mechanic as a crucial safety feature Helicopter Emergency Medical Services (HEMS) in Japan, the so-called Doctor-Heli system, started in 2001, with five HEMS bases being set up in the first year. In April that year, Kawasaki Medical School Hospital was the first hospital to launch the Doctor-Heli service in Okayama prefecture. The number of Doctor-Heli bases and flight missions has been steadily increasing since. Now there are 27 bases (Fig. 2), and the number of flight missions reached more than 50,000 by the end of 2011 (Fig. 3). There have been no fatal accidents in the last ten years. Japanese HEMS professionals believe that one of the main factors preventing fatal injuries during HEMS operations in Japan has been the early integration of flight mechanics. The standard flight crew on a Doctor-Heli consists of one pilot, one or two physicians, one nurse and (ever since the service was introduced) one rotorcraft mechanic. This presence of a mechanic in the front cabin is unique –
something that is unknown in any other country. Yet the presence of a rotorcraft mechanic next to the pilot seems to play a very important role in ensuring the safety of the Doctor-Heli crew. In order to establish the truth of this,
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TECHNOLOGY | 27 the authors of this report designed questionnaires, which were distributed to Japanese helicopter bases, to allow us to get their staff’s opinion on the value of the mechanics’ presence during HEMS operations. The results of the survey are given below.
Results A total of 59 staff members at five HEMS operators completed the questionnaires. The respondents included 16 pilots, 23 rotorcraft mechanics, 17 communication specialists and three business managers. A majority of 91.5% (54 respondents) thinks that the presence of a rotorcraft mechanic on board is necessary for Doctor-Heli operations. The reasons given for this are: 1. Aircraft mechanics can assist the pilot to ensure safe operations (92.6%) 2. Aircraft mechanics can assist medical crews (37.0%) 3. Aircraft mechanics can carry out radio communications with ground rescue teams (53.7%) 4. In case of a mechanical failure, mechanics can immediately deal with problems (90.3%) 5. Others comments generally in favour of the presence of a mechanic (53.7%)
Only five respondents (8.5%) stated that it is not necessary to have a mechanic on board. And all of these only believe it is not necessary when there are other crew members on board who can do the mechanic’s job without the assistance of a “real” mechanic. But 44 respondents (74.6%) indicated that other crew members cannot substitute for a mechanic if safe Doctor-Heli operations are to be guaranteed. Only 13 respondents (22.0%) stated that new crew members, such as paramedics, may be a suitable substitute for a rotorcraft mechanic if they receive training in this area on top of their flight nurse training. As far as funding for on-board mechanics was concerned, 43 respondents (72.9%) stated that the deployment of mechanics at each Doctor-Heli base is not an economic burden. Only seven respondents (11.9%) felt that the deployment of mechanics at Doctor-Heli bases did represent a financial burden for their companies.
Features of the Doctor-Heli system: • Hospital-based helicopter, used only for (H)EMS • Emergency doctor as integral part of the crew • Base hospital of the highest standard (a beacon hospital for the region with a trauma centre that can care for critically ill and major trauma patients) • Financial support from the Japanese national government and the local prefectures
Discussion To the authors’ knowledge, there is no comparable survey verifying that the presence of a mechanic on board is crucial for safe HEMS operations. Japan is the only country where the benefits of having a mechanic on board can be evaluated, as flight crews are not joined by mechanics on
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No. of missions 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 year
Fig. 2: Annual flight missions
missions in any other country. This is, therefore, the first analysis of the contribution on-board mechanics make towards guaranteeing safe HEMS operations. Flight crew configuration varies from country to country. In the US, for example, HEMS operations are usually carried out with a single pilot. This is probably for financial reasons. Recently there has been a significant increase in the number of fatal accidents in the US. The authors suspect that the lack of someone assisting the pilot with navigation during HEMS missions may be one of the reasons for this. European countries do have such “assistants”. In Germany, for example, paramedics assist the pilot with navigation. In London (UK) there are co-pilots for HEMS operations. Fatal accidents during HEMS operation are very rare in Europe, and the presence of an “assistant” to the pilot may be the reason for this – although there is no reliable evidence to substantiate this claim. Two pilots may be ideal for safe HEMS operation. However, the pilot may not be able to help medical crews at the scene and with loading or unloading the patients. Also, staffing each Doctor-Heli craft with two pilots may be too costly for operators. In Japan, mechanics not only assist
Fig. 3: In April 2001, Kawasaki Medical School Hospital was the first hospital to start the DoctorHelicopter service in Okayama prefecture (Photograph: Setouchi/ Wikipedia)
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Fig. 4: In Japan, mechanics not only assist pilots with navigation, they also help medical crews with medical care and loading/ unloading of patients (Photograph: K. Omori)
pilots with navigation, they also help medical crews to provide medical care and to load and unload patients. Furthermore, the mechanic communicates with the ground rescue team to ensure safe take-off and landing. Onboard mechanics have had this multi-tasking role since the very beginning of air rescue in Japan. A rotorcraft mechanic has to check the helicopter before and after each operation and thus one is always present at each base. So, almost inevitably, mechanics became the appropriate crew member to perform additional duties such as assisting the pilot, helping the medical crew during operations, or, in some cases, even offering support to TV broadcasting teams and journalists.
Fig. 5: Annual changes in the number of Doctor-Heli bases
The results of the survey indicate that the respondents are aware that mechanics handle multiple jobs during DoctorHeli operations. The majority of the respondents therefore agreed that a mechanic on board a Doctor-Heli is indispensable. There are no data to prove for certain that the
No. of base 30 25 20 15 10
presence of a mechanic during HEMS operations is the only factor preventing fatal accidents. But there have been no fatal accidents during Doctor-Heli operations in Japan for the past ten years, so this may be read as an indication that the presence of a rotorcraft mechanic on board has contributed to safer Doctor-Heli operations. Some people in Japan believe that a paramedic can substitute not only for a mechanic but also for a flight nurse. But in order to be able to do both these specialist jobs, paramedics would need extensive education and training, something that would probably not be cost effective for operators. Also, Japanese law does not permit paramedics to carry out certain medical procedures that nurses are authorised to perform – even under a doctor’s supervision. Therefore, at present a paramedic cannot be considered as a suitable substitute for both specialists. As for the financial aspect, the findings suggest that most operators do not regard the provision of mechanics at each HEMS base as an economic burden. However, the respondents to this survey included just three business managers. If more business managers were included, the percentage of respondents indicating that an aircraft mechanic is an economic burden would probably be higher. Additionally, the recent rapid increase in the number of Doctor-Heli bases (Fig. 4) may result in a shortage of mechanics in the near future. Subsequently, training of new mechanics will be essential for operators. On the basis of this survey, the authors conclude that having a mechanic on board a Doctor-Heli is crucial for ensuring safety, at least in Japan. The findings of this study also suggest that in other countries, e.g. in the US, the presence of a pilot’s “assistant” – such as a mechanic – may be helpful in preventing serious accidents during HEMS operations.
5 0 year
Address for reprint: Matsushima, Kurashiki, Okayama, 701-0192 Japan firstname.lastname@example.org
1 · 2012 I Vol. 2 I AirRescue I 28
32nd Myron B. Laver International Postgraduate Course
“The Risk of Fatigue” 30-31 March 2012, Basel Convention Center, Switzerland Fatigue is dangerous – and mostly underestimated. International experts discuss the backgrounds and impact of fatigue on safety and security and how these risks can be mitigated. Prof. Scheidegger, Medical Director of Anaesthesia & Intensive Care at University Hospital Basel, SWISS International Airline and Swiss Air-Rescue (Rega) have organised a high-level scientific symposium for physicians, pilots, managers, regulators, paramedics, maintenance staff and also customers. It does not matter whether one sits in a cockpit or stands in an OP theatre or repairs aircrafts. All have to deal with the same problem: Working under fatigue is dangerous – and mostly underestimated. Learn how you can intervene and discuss the latest results and solutions. For your registration please visit the official website www.anaesthesia.ch/mbl www.rega.ch
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30 | SAFETY
Is silence really golden? Non-punitive safety management at DRF Luftrettung Author: Karl-Heinz Heitmüller Safety manager station superintendent and pilot DRF HEMS base Bremen
Flight safety programmes and safety management systems (SMS) became mandatory for all air rescue companies in Europe at the start of 2009. Of course, everyone was already well aware that it makes more sense for organisations and staff to learn from errors during flight operations than to keep quiet about them for fear of sanctions – and run the risk of having those same errors happen again and again. That is precisely why DRF Luftrettung has been championing the further development of an open, non-punitive reporting culture. The goal is to avoid critical incidents and accidents. Such a system requires that staff feel able to openly report things that go wrong. No members of staff who report potential safety risks or their own inadvertent errors should have to fear disciplinary action.
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SAFETY | 31 Training courses can make helicopter and aeroplane crews aware of incidents without exposing the identity of those who made the errors. The point is to prevent past errors from happening again. As human rights activist and former first lady Eleanor Roosevelt once said, “Learn from the mistakes of others. You can’t live long enough to make them all yourself.” Yet air rescue crews are not the only ones who need to be more aware of air safety; safety management is an important issue for the people down on the ground, as well. That is why DRF Luftrettung requires its entire staff to take part in regular safety management training. The open reporting culture at DRF Luftrettung has led staff to report not only errors but also problematic processes that could have negative consequences for entire workflows and the entire operation. This is a proactive aspect of SMS, something that can actually be more important than simply reacting to incidents. The proactive
approach encourages staff to bring in their own ideas on how to improve flight safety, to formulate them appropriately and to communicate them to others. This requires them to look beyond their normal everyday working environment and can only happen if there is a reporting culture that allows them to communicate circumstances that may be confidential and to make reports anonymously. The safety management system must also ensure that reports are taken seriously, that the persons responsible make a real effort to deal with the issues in question, and that staff receive feedback. Here is a specific example. A large number of different audits are regularly carried out at air rescue stations. The pharmacist checks the anaesthetics, then the occupational safety representative comes and makes various checks, and then it’s time for a line check. It is entirely possible for the team to get called out on an emergency rescue mission during these checks – in a matter of seconds, they have to switch gears and focus on their core task. One staff member recently brought this problem to our attention, saying that a disagreement during one such audit resulted in him not being able to fully concentrate on the mission that followed. How paradoxical! Checks are meant to standardise the station’s workflows and make them safer and more orderly, yet these same checks can also jeopardise the safe execution of a mission! Fortunately, the staff member who experienced this problem did not keep it to himself; he took the time to report it to the safety manager using the company’s reporting system.
Fig. 1: All staff, not just the flight crews, take part in regular safety management training (Photographs: DRF Luftrettung) 1 · 2012 I Vol. 2 I AirRescue I 31
Fig. 2: Initial steps have already been taken to reduce the burden on crew members: the number of annual audits has been halved, and line checks and internal audits are now often conducted together
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Fig. 3: The goal of this training is to get crews prepared for future missions and to improve team communication – ultimately, both – crew safety and patient safety – benefit from this
Fig. 4: DRF Luftrettung’s air rescue stations have been providing medical simulation training for several years now and the training courses use high-tech human patient simulators as well as realistic emergency scenarios to train rescue workers
What happens when a report like that is made? Around once every quarter, safety managers chair a meeting of the safety panel where they review all the reports received, both proactive and reactive. The panel is made up of DRF Luftrettung executives and the heads of the flight operations, technology and medicine departments, who all consult with the safety managers. In the specific area of checks, initial steps have already been taken to reduce the burden on crew members. The number of annual checks has been halved, and line checks and internal checks are now often conducted together. At its last meeting, the panel also discussed the report described above and found a more complete solution: wherever possible, future checks will be moved to the winter and done at the end of shifts. When this is not possible, additional personnel will be on hand at the station during the check. Staff members can use the same reporting system that they used to make their report to find out the outcome of the safety panel’s evaluation. A database lists all the incidents that the panel has considered, along with their risk assessments and agreed corrective measures. Any member of staff can access this database. The reporting system itself, called Air Safety Reporting (ASR), can be
accessed via a central portal. The goal here is for staff to learn from past mistakes and to avoid them in the future. Transparency is a two-way street. Management expects it of staff and, in turn, staff expect the management to openly report on their decisions and plans. But this process does not happen on its own. It is driven by annual training sessions for both pilots and rescue workers (HCM), where important safety topics are taught and reviewed. These sessions hone staff members’ awareness of various flight safety issues and enable them to incorporate this knowledge into their everyday work. One stumbling block to transparency can be the fact that each department has its own set of rules and its own safety areas. When workflows need to be modified, these changes are usually communicated only within that specific department; staff in other departments often never hear about them. We need to ensure that information flows across departments, in the area of safety management, too. In the future, the flight safety database will include not only flight-relevant topics but also information about related medical and technical issues, something that should improve the flow of information among DRF Luftrettung’s 500 staff members. This positive outcome is also thanks to the safety panel’s proactive work. These measures fulfil the legal requirements for setting up a safety management programme. But DRF Luftrettung wants to go further. For DRF Luftrettung, there is more to safety culture than proactive and reactive error reporting – it also includes patient safety. The company’s air rescue stations have been providing medical simulation training for several years now. The training courses use high-tech human patient simulators and realistic emergency scenarios to train rescue workers. The decentralised training concept enables crews that actually go out on missions together to practice together beforehand. The goal is to get crews prepared as well as possible for future missions and to improve team communication. Ultimately, both – crew safety and patient safety – benefit from this.
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SAFETY | 33
Fig. 1: A major aspect of Situational Awareness (SA) is the perception of elements in the environment within a certain volume of time and space (Photograph: Elilombarda)
Situational awareness – staying ahead of the aircraft Do you sometimes find yourself in situations where suddenly you don’t know what to do or what decision to take? Well, maybe it’s time to stop for a moment and ask yourself “Do I really know what’s going on around me?” Let’s analyse for a moment the Schweizer 300C/Huges 269C accident that occurred on 25 May 2002 in Frassineto Po (Province of Alessandria), Italy, when the helicopter crashed after hitting a power line (15,000 Volts). The pilot had inspected the area before starting to spread fertilizer at low altitude, yet he only saw the wires at the last minute. You wonder if the pilot was aware of the high voltage line before starting his work above the rice fields or if he only noticed the wires when they suddenly appeared in front of him during the flight. Both cases imply a lack of situational awareness. The wires may not have been identified during the inspection, indicating a lack of knowledge of the dangers, or the high voltage line was spotted but not sufficiently taken into account for the low-altitude job. Situational awareness (SA) may be defined as (Endsley, 1988): • The perception of elements in the environment within a certain volume of time and space • The comprehension of their meaning • The projection of their status in the near future
In other words, the detailed and continuous knowledge of what has happened before, what’s happening now and what I expect will happen in the future. It’s nothing much, just a mental exercise that we are used to doing every
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day. Take a wet floor in a shopping centre, for example. We see the warning sign, we notice that someone has slipped, we analyse that the floor really is slippery, we consider the fact that if we continue walking there we will probably slip. So we walk more slowly and take shorter steps. It’s a banal situation, but it contains all the features of situational awareness: observation of what has happened (the person who slipped), assessment of the situation (warning signs, visual verification) and a projection of what will happen (“If I continue I might slip but if I choose another way the danger diminishes.”). The ability
Author: Stefano Burigana Elilombarda Safety Manager EASA-EHSAT and EHSIT member EASA-EHSIT ST Ops & SMS Team Leader
34 | SAFETY Factor
% of Events
Inadequate decision making
Omission of action or inappropriate action
Non-adherence to criteria for stabilized approach
Inadequate crew coordination, cross-check and back-up
Insufficient horizontal or vertical situational awareness
Inadequate or insufficient understanding of prevailing conditions
Slow or delayed action
Flight handling difficulties
Deliberate non-adherence to procedures
Incorrect or incomplete pilot/controller communication
Interaction with automation
Table 1: Causal Factors in Approach and Landing Accidents (Source: Flight Safety Foundation, Flight Safety Digest, Volume 17 & 18; Nov. 1998/February 1999)
to understand what is happening around us allows us to make appropriate decisions – whether to accept the risk (“I’ll go along anyway, but I’ll walk more slowly and with shorter steps”) or not (“I’ll choose an alternative route”).
How does SA affect incidents? Situational awareness is not just a theoretical notion; it is pertinent to most accident or incident cases. It is real, and its absence causes accidents. Research from the Australian Transportation Safety Board (ATSB) indicates that human factors are a contributing cause in around 70 percent of all incidents and accidents. Approximately 85 percent of incident reports include a mention of loss of situational awareness. Degraded situational awareness can lead to inadequate decision-making and inappropriate actions. This is illustrated in Tabble 1, which identifies causal factors involved in approach and landing accidents. As part of the study and analysis of European helicopter incidents (EHSAT), as many as 84 cases out of 202 (41 percent) were linked to a lack of adequate SA by the pilot. And studies of all origins have revealed that a high percentage of incidents have as a causal element a partial or total lack of situational awareness. Therefore, paying proper attention to what is happening around us triggers a mental process that can put a stop to a detrimental chain of events.
Gaining and maintaining situational awareness Situational awareness means having an accurate understanding of what is happening around you and what is likely to happen in the near future. As shown on the following page, situational awareness includes three processes: • Perception of what is happening (Level 1) • Understanding of what has been perceived (Level 2) • Use of what has been understood to think ahead (Level 3)
Level 1 – Perception: scanning, gathering data In order to create a mental model of the environment, we have to gather sufficient and useful data by using our senses (vision, hearing, touch) to scan the environment. We must direct our attention to the most important and relevant aspects of our surroundings and then compare what we sense with the experience and knowledge in our memory. It is an active process that requires significant discipline as well as knowing what to look for, when to look for it and why.
Level 2 – Representation: understanding, creating our mental model Our understanding is built by combining observations from the real world with knowledge and experience recalled from memory. If we successfully match observations with knowledge and experience, we develop an accurate mental model of our environment. This mental model is kept updated with input from the real world when we pay attention to a wide range of information.
Level 3 – Projection: thinking ahead, updating the model Our understanding enables us to think ahead and project the future state of our environment. This step is crucial in the pilot’s decision-making process and requires that our understanding, based on careful data gathering, is as accurate as possible. It is simply “flying ahead of the aircraft”.
Situational awareness and the decision-making process
Fig. 2: Events related to situational awareness (Source: European Safety Analysis Team)
External Environment Awareness 25 % Other 59 %
VisibilityWeather 15 %
Internal Aircraft Awareness 1 %
Situational awareness is strongly related to the decisionmaking process. Fig. 4 shows a simple model of the tight coupling between situational awareness and decisionmaking. Situational awareness must precede decisionmaking because the operator has to perceive a situation in order to have a goal. Our actions are driven by goals. To help us act in a way conducive to achieving our goals, we use our mental models to anticipate the outcome of our action. This can be thought of as a “feed forward” process. The more accurately we anticipate, the more efficient we become in our tasks, the more energy we save, and the more we can conserve resources for unexpected situations. Conversely, by comparing the results of our actions with set goals, we can modify our actions or, if neces-
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SAFETY | 35 sary, our goals. This feedback is vital to the success of the process. Feedback and anticipation help us keep our mental picture of the world aligned with the real world. A major loss of situational awareness occurs when inappropriate mental representations are activated in spite of real-world evidence. People then act within “the wrong scene”, seeking cues that confirm their expectations – a mode of behaviour known as confirmation bias. In other words, situational awareness influences our decision-making and allows us to stay ahead of the aircraft: 1. It helps us to develop a mental picture of the world around us and use that mental picture to anticipate the future – or to “feed forward”. 2. Because of the close coupling of real-world feedback, mental anticipation and adaptation of actions, we adjust our mental picture and modify our actions. If what we expect to happen and what is really happening do not coincide, we may even adjust our goals. This is often coupled with a feeling that we have lost “control”.
• Ask “What if?” • Manage workload • Shift tasks away from busy times, delegate, anticipate
Fig. 3: The use of NVGs is a way to gather more information during a mission, thus increasing situational awareness
Losing situational awareness Many factors can cause a loss of situational awareness. Errors can occur at each level of the process described above. Table 2 contains a non-exhaustive list of factors related to the loss of situational awareness and conditions contributing to these errors.
Best practices, prevention strategies and lines of defence Building situational awareness • • • • • • •
Set specific objectives Define flight targets and gather data Set priorities Follow SOPs Prepare for anomalies Consider optical illusions, missing information, etc. Make risk assessments
Maintaining situational awareness • Communicate • Keep all crew members and external participants (e.g. company flight dispatch / flight watch office) in the loop • Manage attention • Set priorities, avoid distraction, adjust monitoring to flight phase urgency • Seek information • Use your senses • Know what is important, when to seek for it and where to find it • Validate your data • Cross check • Use multiple sources of information when available; use rules of thumb when data are not available • Check your understanding
Internal attention Memory Recall
External attention Real World Searching
Training Knowledge Experiences
Plane, Path, People What, When, Where, Why (importance)
Our understanding of the situation
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Fig. 4: Feedback and anticipation help to keep the mental picture of the world aligned with the real world
36 | SAFETY Fig. 5: Situational awareness and decision making (Source: Endsley, 1995)
Task / System Factors • System Capability • Interface Design • Stress & Workload • Complexity • Automation
SITUATION AWARENESS State of the Environment
Perception of Elements in Current Situation
Comprehension of Current Situation
Projection of Future Status
Performance of Actions
Information Processing Mechanisms
• Goals and Objectives • Preconceptions (Expectations)
Long Team Memory Stores
• Abilities • Experience • Training
Example: Focusing on recapturing the LOC and not monitoring the G/S
Check for contradictory elements in the real world Apply experience and lessons learned Think ahead Brief others on what you expect Compare projected state with objectives Set markers for confirmation and information (define “next targets” at each point of the whole flight and “approach gates” during descent/approach) • Compare actual state with expectations and objectives • Readjust your plan if required
Level 2: Understanding
Detecting loss of situational awareness
1. Use of a poor or incomplete mental model due to: • Deficient observations (Level 1 problem) • Poor knowledge / experience 2. Use of a wrong or inappropriate mental model 3. Confirmation bias: perceived information is misunderstood. Expecting to observe something and focusing our attention on this belief can cause seeing what you expect rather than what is actually happening
• Look for hints of degraded situational awareness: • Ambiguity – unclear flight plans or ATC instructions • Fixation – focusing on one thing to the exclusion of everything else • Confusion – uncertainty or misunderstanding a situation or piece of information • Preoccupation – everyone focusing on non-flying activities; nobody flying the aircraft • Unresolved discrepancies – contradictory data or personal conflicts • Expected checkpoints not met – flight plan, profile, time, fuel burn • Poor communications – vague or incomplete statements • Broken rules – limitations, minimums, regulatory requirements, failure to follow SOPs
Level 1: Perception 1. Data is not observed, either because it is difficult to observe or because the observer’s scanning is deficient due to: • Tunnel vision • Passive, complacent behavior • High workload • Distractions and interruptions 2. Visual Illusions
Example: A pplying a fuel imbalance procedure without realizing that it is an engine fuel leakage Level 3: Thinking Ahead 1. Over-reliance on the mental model and failing to recognize that the mental model needs to be changed Example: Expecting an approach on a particular runway after having received ATIS information and being surprised to be vectored for another runway
• • • • • •
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SAFETY | 37 Recovering situational awareness • Go to the nearest STABLE, SIMPLE and SAFE situation • Follow rules, procedures and SOPs • Change automation level (user a lower level of automation or revert to hand-flying) • Buy time (request delaying radar vectors, a hold or an extended downwind leg)
Communicate – asking for help is not a sign of weakness • Restore the big picture • Go back to the last thing you were sure of • Assess the situation from different perspectives, with different sources • Expand your focus to avoid fixation and tunnel vision • Manage stress and distraction • Take time to think, use that time, be willing to delay flight progress
Summary of key points • Situational awareness is essential for flight safety, its influence and impact are pervasive • Situational awareness is gained by using the senses to scan the environment and compare the results with mental models • Planning, communication and coordination on upcoming flight phases, goal setting and feedback are essential ingredients of situational awareness and decisionmaking
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• Inattention, distraction and high workload threatens situational awareness • To prevent the loss of situational awareness, implement proven best practices: sterile flight deck, standard calls, CRM, golden rules, instrument scan, etc. • Strictly follow company SOPs (Source: Airbus Flight Operations Briefing Notes)
Situational Awareness – either during a flight or in every day world – is a condition, where we can feel as being “part of the world”, i.e. we understand our environment. This condition will eventually “project” us into the future, anticipating and preventing problems before they happen. This mental exercise is a practical procedure that we, unconsciously, execute in all our decisions. Nevertheless, this procedure must be continuously improved to better cope with high-demand tasks like in traffic-congested areas or during emergencies. This can make the difference between a well-executed flight and a bad mishap.
References: 1. Endsley, M.R. (1988) Situation Awareness Global Assessment Technique (SAGAT). Proceedings of the National Aerospace and Electronics Conference (NAECON): 789-795. New York: IEEE 2. Endsley, M.R. (1995) Toward a theory of situation awareness in dynamic systems. Human Factors 37: 32-64
Fig. 6: Situational awareness is gained by using the senses to scan the environment and compare the results with mental models (Photograph: Elilombarda)
Authors: Lars Petter Bjornsen Steinar Einvik Emergency Department Clinic of Anaesthesia Intensive Care and Emergency Medicine St. Olav’s University Hospital Trondheim, Norway Lars Jacobsen Dpt. of Anaesthesiology and Intensive Care & Air Ambulance Department Sorlandet Hospital Arendal, Norway Nils Petter Oveland Norwegian Air Ambulance Foundation, Dpt. of R&D Droebak, Norway and Dpt. of Anaesthesiology & Intensive Care Stavanger University Hospital Stavanger, Norway nils.petter.oveland@ norskluftambulanse.no
Emergency ultrasound (US) is used for the diagnostic evaluation of acute medical conditions, resuscitation of critically ill or injured patients, guidance of high risk or difficult procedures, monitoring certain pathological states, for triage and as an adjunct to therapy. We refer to point-of-care US when clinicians try to answer a specific clinical question at the patient’s bedside by carrying out a targeted US examination (1). The goal is to diagnose life-threatening conditions as early as possible, because the prognosis of patients with severe injuries often depends on time to treatment (Fig. 1). Ultrasound examinations – known as Focused Assessment with Sonography for Trauma, or FAST (2) – have been used in emergency departments (ED) to evaluate trauma patients for many years. US in the emergency department The FAST protocol is performed as part of the primary survey of trauma patients, with the aim of detecting blood in the abdomen or pericardial space (3). An extended version of FAST (E-FAST), which includes the chest, allows the diagnosis of air (pneumothorax) and blood (haemothorax) in the chest cavity (3). The use of US in emergency departments has been shown to reduce morbidity and mortality in critically ill patients, and the point-of-care approach reduces time to diagnosis and improves outcome. US can also be used as an aid in treatment procedures such as central and peripheral vascular access and nerve blocks (1) or to distinguish various forms of circulatory failure and detect pleural effusion in ICU patients (4). Assess-
ment with US has also been included in the updated CPR guidelines from 2010.
Pre-hospital ultrasound The development of small, mobile, battery-powered machines has made it possible to perform high-quality US evaluations outside hospitals (5). This article describes the use of US in pre-hospital settings and how it has gradually become more helpful in diagnosing and monitoring patients. The scientific data and documentation on the use and effects of pre-hospital US are sparse. A recent review article concluded that there is little reliable data on the use of pre-hospital US (6) and that the studies conducted are
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Ultrasonography in Air Ambulance Services
Fig. 1: Point-of-care ultrasonography (Photographs: N. Oveland)
often of poor quality, not randomised, and not comparable in terms of their focus and the populations studied. The use of US in pre-hospital settings has been described previously (6, 7, 8, 9) and has been found to improve the assessment, treatment and monitoring of patients suffering from trauma, cardiac complications or circulatory shock, as well as of pregnant women. An increasing number of ambulance services in Europe, Australia and the United States are using pre-hospital US. Studies have reported that US affects the choice of treatment in more than 30% of patients and the choice of receiving hospital in 22% of cases. So far no studies have unambiguously demonstrated that pre-hospital US increases survival among trauma patients (6), although it appears to have a positive effect. The FAST examination has been conducted outside hospitals (pre-hospital FAST) with good results and with a specificity and sensitivity of 93% and 99% respectively (5). FAST and abdominal US examination for aortic aneurysm can be performed in ambulances with similar results as in the emergency room. Pre-hospital FAST is more reliable when it comes to detecting blood in the abdominal and pericardial cavities compared to clinical examination (5), which can be normal in 20% to 43% of trauma patients. There are few studies addressing the use of pre-hospital
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US to evaluate medical patients, but some studies show benefit in the diagnosis of patients with dyspnea. Pre-hospital E-FAST may detect pneumothorax with a sensitivity and specificity of up to 100%. Other lung pathology with acute respiratory failure may be diagnosed quickly with 90.5% certainty. As technology improves and US devices provide better images, applications will increase further.
Ultrasound in the air ambulance service Use of pre-hospital US is widespread in Scandinavia (7) and has gradually expanded to include the air ambulance services in Norway, Sweden and Denmark as well (Fig. 2). A number of air ambulance services in the United States and Europe have already started using pre-hospital US (9), and a pilot project has been conducted in Norway with good results (5). Hand-held devices of robust quality allow US devices to be taken on board helicopters and out to the patients (Fig. 3). Life-threatening conditions commonly encountered in an air ambulance service are cardiac arrest (19%), airway obstruction (5%), cardiac tamponade (3%) and pneumothorax (2%). This means that there is potential for a wide range of US examinations during helicopter transport (3).
40 | MEDICAL CARE
Fig. 2: The Norwegian Air Ambulance Service responded to 18,000 calls in 2010; this number included 7,500 helicopter missions. The image shows an EC 135 helicopter in action during mountain rescue
Treating patients inside a helicopter is challenging, but it is possible to employ US despite environmental disturbances and constricting factors. In a cramped helicopter with a lot of noise, it is impossible to detect a pneumothorax by auscultation. In-flight detection of pneumothorax using US has shown to be a sensitive and specific method (Fig. 4). US has also proven to be useful for monitoring the foetus during helicopter transport of pregnant patients. There are no studies evaluating the use of US by air ambulance services in cases of different types of shock, abdominal aortic aneurysm, cardiac arrest or intravenous access. Most studies deal with trauma patients and FAST, which can be performed quickly and easily on board the helicopter – almost as efficiently as in the emergency department.
Experiences of the Norwegian Air Ambulance Service In Norway, a previous pilot project looked at the feasibility of US during helicopter transport (5), and a new project is currently trying to implement US technology in the air ambulance service. It is still unclear which US device is best suited for Norwegian conditions, and no US devices currently meet the European standard for medical equipment inside helicopters (NS-EN13718-1: 2008). Some manufacturers are working to meet this standard, and this may eliminate the flight safety issues the new technology can potentially have. The Norwegian Air Ambulance Foundation has recently launched a trial in which multiple helicopters were equipped with hand-held GE Vscan™ US machines.
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MEDICAL CARE | 41
Fig. 3: Focus Assessed Transthoracic Echocardiography (FATE protocol) examination using the hand-held Vscan™
Fig. 4: Extended Focused Assessment with Sonography for Trauma (E-FAST) examination using a high-frequency linear probe to exclude pneumothorax in a positive-pressure-ventilated patient during helicopter transport
Fig. 5: Dilatation of the aortic outlet in a patient with dissecting aneurysm; pericardial effusion is visible as a black rim covering the heart
There have also been some local experiences with the use of pre-hospital US at the air ambulance stations in Trondheim and Stavanger. The Sonosite NanoMaxx™ and M-Turbo™ machines have been used in about 5 % of the completed missions so far, including in both trauma and medical emergencies. Due to the limitations of in-flight use, the devices have proved most useful on scene in resuscitation of patients with cardiac arrest (Fig. 6). On the missions completed so far, the flight physicians have diagnosed cases of: • • • • •
Pneumothorax Pericardial effusion (Fig. 5) Pleural effusion Severe hypovolaemic shock Cardiac failure
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• Aortic aneurysm (Fig. 5) • Foetus in cardiac arrest • Right ventricle enlargement due to pulmonary embolism
Further, US has been used to monitor the evolution of a bilateral pneumothorax in-flight and in obtaining intravascular access. The focus has been on point-of-care examinations and limiting the time spent on scene. Challenges faced so far include scanning in sunlight, getting the device authorised for in-flight use and how to best improve the skills of flight physicians.
Discussion To ensure the correct use of pre-hospital US, more experience and high-quality studies are needed (6). When
42 | MEDICAL CARE
Fig. 6: Focused ultrasound scanning with NanoMaxxâ„˘ during cardiac arrest with pulseless electrical activity (PEA)
Fig. 7: Invitation to WINFOCUS, the Scandinavian course in pre-hospital ultrasound
implementing it, the question is whether its use should be limited to standardised, focused protocols such as E-FAST and FATE (Focus Assessed Transthoracic Echocardiography), or if the repertoire should be expanded to include a wider range of applications. Although many studies involving the use of pre-hospital US have methodological shortcomings, they all conclude that US performed outside hospitals is feasible and beneficial (6). Two disadvantages of US are that it is user dependent and that it may increase the time spent at the scene. It takes
between two and six minutes for an experienced user to perform a FAST examination at the accident scene; however, if the examination is performed in-flight it will not increase time spent at the scene (5), so this would seem the most pragmatic method for decreasing time to definitive treatment for the patient. Because the time spent on the US examination decreases with increasing experience, the emphasis should be on the necessary training to achieve an acceptable level of skill. Clinicians with different backgrounds can all perform and benefit from several US examinations, even after only brief focused training (1). The importance of knowing both the possibilities and limitations of pre-hospital US cannot be stressed enough. If the E-FAST is positive for pneumothorax, haemothorax or cardiac tamponade, it is possible to intervene by placing a chest tube or performing pericardiocentesis. In cases of abdominal bleeding, there is less that can be done outside the hospital, but choosing the right receiving hospital, activating the trauma team early on, and preparing for damage-control surgery and damage-control resuscitation with blood products can still affect patient outcome. Positive results provide diagnostic and clinical information, but negative results must be interpreted with caution â€“ they do not necessarily mean that there is no pathology. If the FATE protocol (4) is used with hypotensive patients, positive findings indicative of left ventricular failure, hypovolaemia, cardiac tamponade, pleural effusion, pulmonary embolism or cardiac arrest might trigger very different interventions, such as the administration of inotropic drugs, fluid resuscitation, drainage, thrombolysis or CPR. It is possible to conduct a variety of US examinations for the purposes of diagnosis and intervention, but we recommend initially taking a protocol-based approach and considering adding more procedures after adequate skills have been developed. Additional relevant US examinations are evaluations of
1 Âˇ 2012 I Vol. 2 I AirRescue I 42
MEDICAL CARE | 43 increased intracerebral pressure, brain hemisphere lateralisation , confirmation of correct tracheal tube placement and bladder fullness.
Conclusion There is growing interest in the use of pre-hospital US as an aid in diagnosing and monitoring critically ill and injured patients. In the last decade US has become a recognised in-hospital standard of care, and it has the potential to become the same outside hospitals. The goal of the Norwegian Air Ambulance is to “take the hospital out to the patient” and to act as a pioneer in promoting References: 1. Moore CL, Copel JA (2011), “Point-of-care ultrasonography”, New England Journal of Medicine 364 (8): 749-57 2. Gillman LM, Ball CG, Panebianco N et al. (2009), “Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma”, Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine 17: 34 3. Kirkpatrick AW, Breeck K, Wong J, Hamilton DR et al. (2005), “The potential of handheld trauma sonography in the air medical transport of the trauma victim”, Air Medical Journal 24 (1): 34-9 4. Jensen MB, Sloth E, Larsen KM, Schmidt MB (2004), “Transthoracic echocardiography for cardiopulmonary monitoring in intensive care”, Eur J Anaesthesiol 21 (9): 700-7, Epub 2004/12/15
the use of pre-hospital US in Norway as well as the rest of Scandinavia and Europe. In 2011, an educational and research network was established along with the Scandinavian WINFOCUS group USabcd in Aarhus, Denmark. The Norwegian Air Ambulance Foundation developed a basic pre-hospital US course (Fig. 7). Aimed at anaesthesiologists and emergency physicians as well as flight physicians, the course is held biannually in Norway and will become a mandatory part of training for physicians. Medical HEMS crew members from all over Europe are invited to attend these courses in the beautiful city of Stavanger (Fig. 7).
Acknowledgements The authors would like to thank the National Air Ambulance Service in Norway for its permission to use pictures in this article. Furthermore, we thank all members of the Norwegian Air Ambulance Foundation for their financial support that enabled us to implement ultrasound in the air ambulance system.
5. Busch M (2006), “Portable ultrasound in pre-hospital emergencies: a feasibility study”, Acta Anaesthesiol Scand 50 (6): 754-8, Epub 2006/09/22 6. Jorgensen H, Jensen CH, Dirks J (2010), “Does prehospital ultrasound improve treatment of the trauma patient? A systematic review”, Eur J Emerg Med 17(5): 249-53, Epub 2010/02/04 7. Rognas LK, Christensen EF, Sloth E (2009) [Prehospital ultrasound], Ugeskrift for Laeger 171 (36): 2545-7 8. Knudsen L, Sandberg M (2011), “Ultrasound in prehospital care”, Acta Anaesthesiolo Scand 55: 377-8 9. Nelson BP, Melnick ER, Li J (2011), “Portable ultrasound for remote environments, part II: current indications”, J Emerg Med 40 (3): 313-21, Epub 2010/01/26 Complete reference list is with the authors. Please contact the relevant author.
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Case Report Hungarian HEMS and the new SOPs in trauma patient care Author: Andras Pertoczy HEMS Doctor, Consultant Anaesthetist Hungarian Air Ambulance Nonprofit Ltd. Budaörs
Fig. 1: The fire truck was lying on its right side, the fire had already been put out and no one was inside the fire engine anymore
The call came in to Hungarian Air Ambulance Nonprofit Ltd (Hungarian HEMS) at 12:40 p.m. on 30 September 2011. A fire engine had overturned on a small country road while responding to a fire. The Hungarian HEMS coordination desk dispatched a Budaörs helicopter (EC 135 T2) based on the location of the accident, the estimated number of casualties and the available land ambulance resources. It took the helicopter ten minutes to fly the 30 kilometres in favourable weather conditions with one pilot, one doctor and one HEMS paramedic on board. Thanks to excellent visibility and the crew’s familiarity with the locale, finding the site wasn’t a problem with the exact information, i.e. bearing, distance, and GPS coordinates, provided by the coordination desk. The terrain allowed the helicopter to land next to the scene of the accident (12:55). An initial survey of the accident site was conducted from the air by the HEMS crew member (doctor) occupying the left front seat. The fire truck (Mercedes 1234 Rosenbauer 4000 TLF AT) was lying on its right side in the ditch and had sustained significant damage. The fire that had broken out in the engine compartment had already been put out. There were numerous firefighters and police officers at the scene, along with one mobile intensive care unit and two ambulances. An assessment of the site after landing showed that no one was inside the fire engine. According to the handover report by the paramedic of the mobile intensive care unit, there were six fire-fighters in the truck, four of whom were injured when the truck veered off a bend in the road and turned over in the ditch, and no other vehicle was involved. The land ambulance teams didn’t require any assistance with the treatment and transport of three of the patients, who were in a stable condition, but handed over care of the most seriously injured firefighter to the HEMS crew.
The injured man (age 43, weighing approx. 90 kg) had been moved inside one of the Ford Transit ambulances. He was responsive (AVPU: V) and had been placed in a vacuum mattress and fitted with a cervical collar. He complained of severe chest pain on the right side and difficulty in breathing despite the care that had been administered by the ambulance crew (oxygen via a mask, 16 G IV access, 200 ml Hartmann’s solution and 75 micrograms of fentanyl). An initial examination performed once the patient’s clothes had been removed showed a patent airway, shallow breathing with a respiratory rate of around 30 breaths/min., and diminished breath sounds on the right. The right side of the chest was sensitive to pressure; and breathing was painful and chest wall movement was reduced on the right side, as well. The patient was switched to a non-rebreathing oxygen mask delivering pure oxygen, partially because the SpO2 monitor indicated a blood oxygen saturation of 88%. A check of the patient’s blood pressure and pulse showed no cause for concern (NIBP: 130/80 mmHg; pulse: 90 bpm). No neurological deficit was found; the patient was assigned a GCS of 13/15 (E:3; V:5; M:5). While the patient had partial recollection of events and responded appropriately to questions, according to witnesses he was unconscious for about five minutes after the accident and regained consciousness only after being extricated from the wreck. There was a 4 cm laceration on the right side of his forehead, and his skin was slightly pale, damp and warm. The patient mentioned no significant past medical history, medication or allergies. Because of the patient’s persisting pain, further doses of an opioid analgesic were administered (a total of 125 micrograms of fentanyl in two fractions), with unsatisfactory effect. SpO2 did not exceed 90-91% despite the FiO2 of 1.0. The reasons for the ventilatory failure and the poor response to oxygen therapy were identified as right-sided chest trauma, with a possible flail chest and pneumothorax, with or without haemothorax, or pulmonary contusion. While preparations for further treatment were being made, the HEMS doctor phoned the on-call consultant to request advice following a protocol established in 2011. During the consultation, a Rapid Sequence Induction (RSI)
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was identified as the best course of action in view of the indication of ventilatory failure and the very likely need for a right-sided thoracostomy. The on-call consultant considered the possibility of chest drain insertion while the patient was awake, but left the decision to the doctor on site. The conversation was also cut short because of a poor signal. While the phone call was being made, the patient was positioned outside the ambulance with 360-degree access and left on the ambulance trolley for ideal height. An ideal location for intubation was found in the shade of a fire engine. Monitoring was switched to the Argus Pro LifeCare of the HEMS team, and a second IV line was secured with a 16 G cannula, flushed and closed. During the preparations for RSI, the right side of the chest wall was disinfected using Betadine solution at the site of the thoracostomy (fourth intercostal space, mid-axillary line). All this was done in order to optimise time and meant that a lot of procedures had to be carried out simultaneously. Based on the right-sided chest trauma, it was initially planned to insert a chest drain while the patient was awake, and the site of the thoracostomy was infiltrated with a local anaesthetic (lidocaine 1%) to prepare for this scenario. Had the physician known that an RSI had been performed initially, the local anaesthetic would not have been given. Meanwhile, because the clinical course indicated ventilatory failure with no significant haemodynamic compromise, the decision to ventilate (RSI) first and decompress the chest afterwards was overruled. Since the patient’s condition had deteriorated to the point of severe respiratory failure, general anaesthesia was performed. This meant the local anaesthetic would have been unnecessary, but lidocaine had already been administered. Following the Standard Operating Procedure established in 2011, standard preparations and an equipment check using a challenge and response checklist were performed. A standard induction was performed using 20 mg of etomidate and 200 mg of suxamethonium, followed by a laryngoscopy (Cormack-Lehane Grade I view). Swift insertion of an 8.5 mm endotracheal tube was successful on the first attempt over a 15 G bougie. There was a period of significant desaturation from the pre-induction SpO2 of 91% to 45%, but it lasted for no longer than one minute, after which time SpO2 returned to 91% after positive-pressure ventilation with 100% O2 via a bag-valve mask. Proper tube placement was confirmed by direct visualisation of the vocal cords and by immediate capnography and auscultation over the typical sites. While securing the tube, a decision was made to perform a simple thoracostomy on the injured side immediately, based on the unchanged saturation despite IPPV. The HEMS doctor put on sterile gloves and made a 4 cm incision parallel to the ribs in the fourth intercostal space, mid/axillary line. The chest cavity was entered using blunt dissection, and the pleura was penetrated using a Spencer Wells forceps. No major discharge of air or blood was witnessed during decompression, but exploration revealed a partially collapsed lung. The patient’s saturation quickly increased to 100% after the intervention.
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Fig. 2: The reasons for the poor response to oxygen therapy were identified as right-sided chest trauma with a possible flail chest and pneumothorax, with or without haemothorax, or pulmonary contusion
For the maintenance of anaesthesia the patient was given 90 mg of rocuronium and boluses of 1 mg of midazolam and 50 micrograms of fentanyl. Since the patient had been placed in a vacuum mattress and properly positioned, to minimise further trauma it was decided not to transfer him to the orthopaedic scoop stretcher (Ferno 65 EXL) normally used; stabilisation of the cervical spine was ensured by the collar and the vac-mat. The helicopter lifted off from the scene 40 minutes after landing. During transfer, the FiO2 ventilator was reduced from 1.0 to 0.6. During the seven-minute flight to the regional trauma centre, haemodynamic parameters were within the normal range (NIBP: 120/70 mmHg; pulse: 70 bpm; SpO2: 100%; and CO2: 35 mmHg). The patient was handed over to the trauma unit staff at 1:50 p.m. A hospital follow-up revealed the following injuries: • Rib fractures on the right (I, IV-VI.) • A fractured right scapula • Spinal fractures (transverse processes of the fifth to tenth thoracic vertebrae) • Right-sided haemo- and pneumothorax • Pulmonary contusions on both sides • A parietal lobe contusion (7 mm)
The patient was mechanically ventilated for four days, and had a hospital stay of 13 days before being discharged. He is expected to have a full recovery. This case study aimed at demonstrating the positive impact of the new SOPs used by the Hungarian HEMS in its trauma patient care. Fig. 3: A hospital follow-up also revealed a parietal lobe contusion (7 mm)
This case report relates to an actual incident. It is intended to provide a basis for further discussion of the issues. If you have any comments, please write to us at: firstname.lastname@example.org
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Fig. 1: It has been suggested that hypothermia causes a reduction in cerebral oxygen demand, slowing harmful enzymatic reactions, decreasing free radical production and limiting the release of excitatory neurotransmitters (Photographs: E. Garrido Abia)
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Therapeutic hypothermia in HEMS operations After a cardiac arrest, patients usually lose consciousness within seconds, and the majority of survivors do not show any symptoms prior to the event. Of those treated by emergency medical services, only about 8% survive to hospital discharge. Patients with an initial rhythm of ventricular tachycardia or ventricular fibrillation have a somewhat better prognosis (21% survive to hospital discharge). Once circulation has been restored after cardiac arrest, the primary aim of treatment is to maximise the chances for recovery by minimising damage to the brain and other organ systems. This is chiefly effected by providing supportive treatment and careful monitoring in the intensive care unit (ICU), but steps can already be taken towards this goal at the EMS/HEMS stage of care. One such measure can be inducing therapeutic hypothermia (TH). In 2002, two randomised trials were published in the New England Journal of Medicine (NEJM) assessing the evidence supporting the use of mild TH in comatose patients after cardiac arrest. Since then, the use of TH has steadily increased in emergency rooms and intensive care units around the world, but the technique has been employed inconsistently. Three recent randomised trials have evaluated the impact of pre-hospital initiation of hypothermia in shortening the time from return of spontaneous circulation (ROSC) to achieving hypothermia. Animal model data suggested that such early initiation of hypothermia should improve clinical outcomes. However, the clinical trials were not all of the same quality and a double-blind design was not possible in any of them. Of the three trials, the one conducted by Bernard et al. was of the highest quality and included the largest number of patients. In all three trials, two litres of intravenous fluids chilled to 4°C (normal saline or Ringer’s solution) were used to induce hypothermia. Recent studies that compared outcomes in survivors of cardiac arrest treated with hypothermia to historical or contemporary controls reported improvements in survival of a similar magnitude to the initial randomised trials. They also suggest that TH provides the largest benefit to the subgroup of patients presenting with VF or pulseless VT in which ROSC occurs more than 15 minutes after the initial cardiac arrest. Patients who survive cardiac arrest often have significant neurological deficits. Most patients are in a coma for at least one hour and less than half have a good neurological recovery. Outcomes are primarily assessed using the Glasgow-Pittsburgh CPC. The five-point scale is generally dichotomised, with categories one and two representing a good outcome and categories three through five representing a poor outcome.
Risks Nonetheless, hypothermia is not without risk. When core temperature drops below 32°C, there is a significant increase in the risk of bradycardia and ventricular arrhythmias.
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Hypothermia is associated with thrombocytopenia, interference with clotting factors and thus an increased risk of bleeding. Additionally, hypothermia suppresses the immune system, raising the risk of systemic infections including sepsis and pneumonia.
Authors: José Manuel Gutiérrez Rubio Medical Director, INAER Spain Juan Antonio Sinisterra Pablo Gómez-Calcerrada INAER Spain
Fig. 2: Patients who survive cardiac arrest often have significant neurological deficits: Most patients are in a coma for at least one hour after cardiac arrest and less than half have a good neurological recovery
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Fig. 3: In the summer of 2009 INAER developed an in-flight cooling protocol using intravenous (IV) cold normal saline solution and chemical cooling packs to be used during HEMS operations
Possible mechanisms of action The biological mechanisms underlying the beneficial effects of hypothermia are not completely understood. It has been suggested that hypothermia causes a reduction in cerebral oxygen demand, slowing harmful enzymatic reactions, decreasing free radical production and limiting the release of excitatory neurotransmitters. This, in turn, should help to maintain the integrity of the blood-brain barrier, maintain the supply of adenosine triphosphate, and decrease intracranial pressure.
Procedural considerations There are many approaches to cooling the patient and maintaining hypothermia, and there is disagreement on the optimal rate and method of cooling. Patients who are treated with therapeutic hypothermia are generally paralysed with neuromuscular blocking drugs to suppress the shivering response and must therefore be Table 1: Inclusion criteria (all essential)
Inclusion criteria (all essential) Cardiac arrest (CA) caused by ventricular fibrillation without pulse with ROSC and CA of non-traumatic origin. Best scientific evidence for these rhythms but application in cases of other rhythms, non-shockable rhythms, or in patients suffering from shock should not be ruled out. Cardiopulmonary resuscitation (CPR) initiated (ideally) within 15 minutes after cardiovascular collapse; longer delays in CPR after cardiopulmonary resuscitation (CPR) initiated (ideally!) within 15 minutes after cardiovascular collapse and other intervals of CPR after cardiac arrest depending on patient characteristics and the specific event should not be ruled out ROSC within 50 minutes after identifying CA Patient is younger than 85 and older than 16; pregnancy must be ruled out in women Persistence of coma after ROSC; Glasgow Coma Scale < 8 or 5t; need for mechanical ventilation after ROSC
intubated and sedated. Core body temperature also needs to be monitored to ensure that it does not drop below the target temperature. Esophageal or bladder temperature monitors are commonly used, as patients are usually intubated and have Foley catheters in place. Both approaches to core temperature monitoring all have limitations, but are appropriate measures under the circumstances.
Therapeutic hypothermia and Helicopter Emergency Medical Services Based on the various experiences reported in the literature, in the summer of 2009 INAER developed an inflight cooling protocol using intravenous (IV) cold normal saline solution and chemical cooling packs to be used during HEMS operations. Medical crew members began taking along a portable cooler with three litres of normal saline solution (0.9%) cooled to 4°C on every flight, along with the regular supplies and medication. In the HEMS environment, care is provided by emergency doctors (who routinely anaesthetise patients with ROSC), and they are the ones who initiate the cooling treatment in such cases. Currently, INAER’s TH protocol can be applied to patients between the ages of 16 and 85 with documented out-of-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) arrest who are comatose after return of spontaneous circulation (ROSC) and have a Glasgow Coma Score < 8, in the absence of certain exclusion criteria (see Tables 1 & 2). Before beginning with the induction of TH, it should be ensured that: • A functioning transport refrigerator with three litres of normal saline or Ringer’s solution cooled to 4ºC is on hand • In cases of STEMI, consideration should have been given to thrombolysis or other reperfusion techniques according to the local protocol
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MEDICAL CARE | 49 Procedure Once return of spontaneous circulation (ROSC) has been achieved, it is essential to provide high-quality critical care, including: • Nursing care: Two large-bore peripheral lines or femoral access; nasogastric tube; urinary catheter; monitoring of vital signs every 15 minutes • General care: Mechanical ventilation; sedation, analgesia and muscle relaxation; haemodynamic support
Once these have been established, the HT protocol is followed as outlined below:
Table 2: Exclusion criteria (optional)
Exclusion criteria (optional) “Do Not Resuscitate” order (DNR), bad previous baseline or terminal illness It is probable that the coma is not associated with cardiac arrest (e.g. is due to intoxication, alterations in electrolytes, CET or intracranial abnormalities, stroke) More than six hours have passed since ROSC Active bleeding due to trauma or anticoagulants (if values available: INR > 3; APTT > 1.5 x normal; platelets < 50,000/ mcl) SAP < 90 or MAP < 60 mmHg after resuscitation with fluids and/or vasopressor agents for more than 30 min.
Multimodal monitoring of vital parameters
SpO2 < 85% for more than 25 min.
This includes the following:
Uncontrolled arrhythmia inducing and perpetuating haemodynamic instability after ROSC. If the HT protocol has already been started, it should be maintained while treating arrhythmia.
• Cardiovascular: Continuous cardiac rhythm trace; continuous oesophageal temperature monitoring • Respiratory: SpO2 by pulse oximetry; capnometry • Neurological: BIS to monitor sedation (target ~ 40-60); hourly neurological examination (in paralysed patients, essentially pupil assessment) • Renal (diuresis) and biochemical (CBC, ABG and biochemical profiles, if available) • Additional monitoring and tracking: E-FAST to rule out PEA, tamponade, abdominal haemorrhage, etc.
Once multimodal monitoring is underway, resuscitation should be maintained with a focus on haemodynamic goals (target MAP between 80 and 100 mmHg).
Initial body temperature below 32°C History of cryoglobulinaemia; pregnancy
• Administer fluids to maintain MAP around 90-100 mmHg unless there are signs of congestive heart failure or if fluid replacement exceeds five litres. If urine flow is adequate (> 1ml/kg/h) and there is no hypotension or shock, administering fluids is unnecessary. • Administer vasoactive drugs if required (after adequate volume replacement)
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50 | MEDICAL CARE Table 3: Guidelines: Steps in therapeutic hypothermia treatment
Fig. 4: It is essential to maintain adequate sedation and analgesia throughout the procedure
Guidelines: Steps in therapeutic hypothermia treatment 1
Undress the patient if this has not been done already and prepare the ice packs.
Place core temperature sensor in the patient’s rectum/ oesophagus or in urinary catheter with thermistor.
If temperature drops below ≤ 30°C, allow it to rise to 32°C. If temperature exceeds > 34°C, administer a 500 ml bolus of saline solution at 4°C every 10 minutes via the peripheral or central line catheter, aiming to reach 30 ml/kg in the shortest time possible. If possible, give the desired volume of iced saline solution at a flow of ~ 100 ml/min.
Watch for signs of pulmonary congestion: crackles, jugular venous distension, hepatomegaly, hepatojugular reflex, oliguria, third heart sound (“gallop rhythm”), pulsus alternans, tachycardia
Do not stop implementation of the protocol if signs of haemodynamic instability appear; reduce the infusion rate and/or consider vasoactive drugs.
If possible, soak towels in cold saline solution and apply iced towels to the patient’s axillae, around the neck and over the groin, abdomen, pelvis, and thighs; the patient must then be covered with thermal foil blankets.
Stop infusion when the patient reaches 34.5°C and allow temperature to drop to 34°C.
• Administer noradrenaline, if required, to achieve MAP > 70-80 mmHg • If MAP remains low, administer dobutamine (2.5-20 mcg/kg/min) until target MAP is reached • BP: If MAP > 100 mmHg, reduce volume input. If necessary and if not using vasoactive amines, administer nitroglycerin (NTG) by continuous IV and increase progressively until MAP < 100 mmHg.
It is essential to maintain adequate sedation and analgesia throughout the procedure: • Fentanyl (50 to 100 mcg IV bolus, followed by infusion at 50-100 mcg/h) • Propofol (infusion at 5-10 mcg/kg/min) • Midazolam: Initial dose 5 mg IV, followed by infusion at ~10 mg/h. In cases of unexplained tachycardia and/ or hypertension and/or if the patient is shivering and/or agitated, administer 5-10 mg midazolam IV every 15 minutes and increase the infusion by 2 mg/h every 15 minutes. • Titrate sedation based on BIS monitoring to achieve BIS target values of 40-60 Administer cisatracurium (0.150.2 mg/kg iv bolus followed by infusion of 1-3 mcg/
kg/min IV) to induce muscle relaxation. Finally, in treating these patients, we must not forget: • Treatment of ACS: Reperfusion according to local protocol. In cases of STEMI or new a LBBB and if CPR was initiated without delay, consider urgent PCI. • Treatment of hyperglycaemia: Blood glucose target level 140-180 mg/dl • Fever prophylaxis: Consider acetaminophen (paracetamol) 500-1000 mg IV. • Magnesium sulfate: While no benefit has been conclusively proved for these patients, it seems to play a role in neuroprotection (hypomagnesaemia has a deleterious effect) and in helping avoid the shivering response in the induction phase.
Conclusion After years of development, TH has proved to have clear neuroprotective benefits to those suffering out-of-hospital cardiac arrest. Patients have better neurologic outcomes with hypothermic treatment. The literature shows that the earlier the cooling process is initiated, the greater and longer lasting the benefit is. Results clearly show that therapeutic hypothermia can be applied in all settings, from pre-hospital HEMS to ICUs, to treat patients who are haemodynamically unstable and those requiring emergency cardiac revascularisation. In light of the knowledge and expertise of the personnel involved in critical care transport, therapeutic hypothermia should be initiated as soon as is possible and feasible. It is a low-cost, high-yield intervention that can be easily implemented on the scene and in an inter-facility environment. Neurological outcomes are extremely promising, as seen in most of the papers reviewed and also in our own experience. Air medical service providers should implement TH as a standard of care for patients who remain comatose after out-of-hospital cardiac arrest.
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Fig. 1: The dispatch criteria for HEMS missions may vary in different European countries, depending on local policies, environmental factors, and on how the system is funded (Photograph: M. Fanta)
Mechanical chest compression devices in HEMS – blessing or curse? Providing high-quality, uninterrupted chest compression is the most important task for healthcare professionals working in advanced life support. Mechanical resuscitation devices have been used for several years as adjuncts to manual chest compression, and they continue to grow in popularity. These devices open up new possibilities for performing high-quality cardiopulmonary resuscitation (CPR) with two-member emergency teams during various diagnostic and therapeutic procedures or while patients are being transported to a hospital. They also work in confined spaces, including helicopter cabins. However, there is evidence that their use is associated with adverse effects. Because of increased risk of CPR-related injuries, the most important concern is patients’ safety. In helicopter emergency medical service (HEMS) operations, the weight and dimensions of currently available devices may also complicate their regular use. This short review will consider the evidence and indications for use of mechanical resuscitation devices in HEMS as well as some potential complications. Cardiac arrests in HEMS The major advantage of rescue helicopters is their speed, i.e. the reduction of pre-hospital time in cases where lifesaving treatment is time-dependent (e.g. internal bleeding control in severe injuries, early reperfusion after myocardial infarction or stroke). Another advantage of HEMS is that it offers the possibility of fast and direct transport of patients to highly specialised medical facilities where they can receive appropriate treatment (e.g. trauma centre, cardiac surgery, extracorporeal membrane oxygenation, catheterization laboratory). The dispatch criteria for HEMS missions may vary in different European countries depending on local policies,
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environmental factors and on how the system is funded. Generally, a physician-staffed helicopter is deployed in the most urgent (cardiac arrests, drowning, paediatric emergencies), and/or the most serious cases (high-energy injuries, severe burns, vital organ failures). In the Czech Republic, 70% of the patients treated by HEMS suffer from injuries (see Fig. 2). The incidence of cardiac arrest increases with the severity of illness or trauma. In 2010, the incidence of CPR initiated by HEMS was 7% compared to less than 1% in ground ambulance services, and on-going CPR was also needed more frequently during helicopter transports. Six patients (12.5%) out of the 48 resuscitated by HEMS were discharged from hospital,
Author: Anatolij Truhlar HEMS “Christoph 6”, Hradec Kralove, Czech Republic Dpt. of Anaesthesiology and Intensive Care Medicine Charles University Prague Faculty of Medicine and University Hospital Hradec Kralove, Czech Republic Czech Resuscitation Council email@example.com
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10% Road traffic accidents = 162 Other injuries = 179 Acute coronary syndromes = 46 Other internal emergencies = 79 Strokes = 15 37% Fig. 2: HEMS “Christoph 6” primary missions in 2010 by aetiology (n = 482)
Other missions = 4
although there was a high incidence of traumatic arrest (Fig. 3).
free, allowing them to focus on additional procedures that (may) need to be carried out within a short space of time (airway management, rhythm analysis, defibrillation, ensuring intravenous/intraosseous access, etc.). This is very important, especially in two-member teams, which are the norm for rescue helicopters, whether they consist of a physician and a paramedic or flight nurses. The HEMS teams must be trained to perform CPR independently because ground ambulances are not always able to support them if emergencies occur in mountainous or remote rural areas.
An overview of mechanical resuscitation devices There are two types of chest compression technologies available today (Fig. 3). Piston-driven devices, which were developed in the 1970s, are designed to provide anteroposterior sternal compression following well-recognised global guidelines. More recently, a load-distributing band (LDB) system was introduced that employs thoracic compressions to produce higher blood flow.
AutoPulse® Do we really need to replace manual chest compressions?
Fig. 3: HEMS “Christoph 6”-treated cases of cardiac arrest in 2010 – an Utsteinstyle report
Delivering high-quality chest compressions is the key recommendation of the new 2010 European Resuscitation Council (ERC) Guidelines for CPR. These guidelines for basic and advanced life support emphasise the importance of chest compression depth and rate, of allowing full chest recoil between compressions, and of minimising interruptions. This key recommendation was largely based on previously published clinical and simulation studies, which consistently demonstrated that resuscitation performed in real-life situations by both laypeople and healthcare professionals is often of poor quality (1, 2). During CPR, the chest should be compressed by at least 5 cm at least 100 times per minute, allowing full chest recoil between compressions, and “no-flow” (“hands-off”) time should be minimised. Mechanical resuscitation devices meet all these important criteria. Furthermore, they leave at least one member of a response team with two hands
Absence of signs of circulation and/or considered for CPR n = 98
CPR not attempted All cases = 50 DNAR = 0 Considered futile = 50
CPR attempted All cases = 48
First monitored rhythm Shockable = 13 Non-shockable = 35 Unknown = 0
Aetiology Presumed cardiac = 23 Trauma = 14 Submersion = 1 Respiratory = 0 Other non-cardiac (e. g. toxins, hypothermia) = 10
The AutoPulse® (Zoll® Medical Corporation, Chelmsford, MA, USA) is a portable chest compression device constructed around a backboard that contains a motor to retract an LDB under microprocessor control. The band is connected to a shaft in the board. The band is tightened and loosened around the chest by a motor, which alternates rotation of the shaft in both directions. The patient is positioned on the board, the two broad endings of the band are placed around the patient’s chest and connected to each other. The length of the band automatically adjusts to the size and the shape of the patient. The microprocessor is programmed to provide a constant 20% reduction in the anterior-posterior dimension of the individual patients’ chest during the compression phase. The compression rate is 80 per minute with equal periods of compression and unloading (3). Although the use of LDB systems improves haemodynamics, results of clinical trials have been conflicting. Evidence from one multicentre randomised control trial in over 1,000 adults documented no improvement in four-hour survival and worse neurological outcome when LDB was used. A non-randomised human study reported increased survival to discharge following out-of-hospital cardiac arrest, OHCA (1, 2). The results of the last randomised controlled CIRC trial (Circulation Improving Resuscitation Care) presented by Wik et al. in Orlando in November 2011 did not prove better outcome if an integrated AutoPulse® CPR was used. Although the study had a unique design reducing all potential biases, it is questionable whether its finding that “mechanical CPR is at least as good as manual CPR” is conclusive enough to warrant changing our practice.
Lucas™ I and II Outcome (all categories) Survived event = 13 Discharged alive = 6
The Lund University cardiac arrest system (Lucas™; Jolife, Lund, Sweden) is a piston compression device that incorporates a suction cup for active decompression. The device compresses the chest between 4 and 5 cm at
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a rate of 100 compressions per minute, with an equal amount of time being spent in compression and decompression (2). The Lucas™ II is a battery-operated device, while the older Lucas™ I was powered by compressed oxygen and later by compressed air because an increased oxygen concentration around the patient’s chest was considered too dangerous. Although animal studies showed that Lucas™-CPR improves haemodynamics and short-term survival com-
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pared with standard CPR, no randomised human studies comparing Lucas™-CPR with standard CPR (1, 2) have been published. A previous meta-analysis of studies comparing manual CPR to active compression-decompression CPR using a cardiopump did not prove that active decompression had any positive effect on survival (4). No large prospective randomised controlled trials with the Lucas™ device have been reported to date, but two are currently underway: a LINC trial and a PARAMEDIC trial (Prehospital
Fig. 4a-4c: Different types of mechanical chest compression devices: a LucasTM II (left), a piston-driven Life-Stat® (middle) and the AutoPulse® (right) with a load-distributing band (Photographs: Physio-Control, Michigan Instruments and Zoll®)
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Fig. 5a: An AutoPulse® resuscitation system was used for CPR (lasting 180 min.) on a young woman with accidental hypothermia Fig. 5b: HEMS transported her directly from the site of an avalanche accident to the operating room for extracorporeal rewarming; no adverse effects of mechanical CPR were observed (Photographs: “Christoph 6”)
Randomised Assessment of a Mechanical Compression Device In Cardiac Arrest) (2).
Other compression devices In addition to the AutoPulse® and Lucas™, there are other devices available in selected markets, such as the Life-Stat® (Michigan Instruments, MI, USA) or the X-CPR (Humed, China). The first European device is currently being developed by Corpuls and should be launched in 2012.
Advantages of mechanical devices in HEMS Mechanical CPR devices offer the following advantages: • Mechanical devices can be used effectively for prolonged resuscitation attempts, especially in cases where potentially reversible causes of cardiac arrest are suspected (e.g. accidental hypothermia, poisoning, pulmonary embolism, acute coronary syndromes) and specific in-hospital treatment is available (Figs. 4a-4c). • They offer consistent, high-quality CPR and preclude the problem of rescuer fatigue, which negatively impairs survival rates during manual CPR.
• They allow CPR to be performed in confined spaces, where effective manual compression is often impossible. In some types of helicopters, it is impossible for HEMS crew members to position themselves over the patient’s chest during the flight; mechanical devices can be positioned properly before take-off. • CPR using mechanical devices is much safer for the helicopter crew. In all helicopters, it is impossible to perform manual compression while seated with correctly fastened seat belts. • Mechanical devices allow defibrillation without the necessity of interrupting chest compression. A shorter pre-shock pause is associated with higher rates of return of spontaneous circulation (ROSC). • In some countries, CPR devices could help shorten the warm ischaemia times when HEMS teams transport non-heart-beating donors for organ transplan tations. • Mechanical devices probably improve myocardial flow, blood pressure, coronary perfusion pressure and cerebral blood flow during CPR.
Fig. 6: Helicopters are located at ten bases and operated by four organisations: DSA, Alfa Helicopter, the Czech Police and the Czech Army (Photograph: M. Fanta)
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MEDICAL CARE | 55 Potential risks and adverse effects It is known that various injuries can occur during delivery of CPR. Injuries to the ribs, sternum, liver, and spleen have been reported. It is unclear whether piston-driven systems or LDB technology lead to higher rates of injury. However, there are a growing number of case reports on skeletal, soft-tissue and organ damage in association with mechanical chest compression devices (5, 6). The contact surface area is 23 times greater for the LDB system than for the piston-driven system. The pressure delivered to the chest at the point of maximum compression is only 2.80 pounds per square inch (psi) for the LDB, compared to 25.45 psi in piston-driven systems (7), which may explain why more injuries have been reported in connection with the latter. However, the incidence of injuries alone is not the sole factor that needs to be taken into account; the severity of such injuries should be evaluated as well. Serious CPR-related injuries have been observed both when Lucas™ and when AutoPulse® systems were used. The possibility of mechanical chest compressions interfering with artificial ventilation should also be considered due to the risk of barotrauma. Finally, the dimensions and weight of currently available devices may cause logistical and safety problems when used inside helicopters.
Experiences with the AutoPulse® resuscitation system The Czech Republic has full HEMS coverage. The helicopters are located at ten bases and operated by four organisations: DSA (4), Alfa Helicopter (4), the Czech Police (1) and the Czech Army (1). The AutoPulse® device has been in use as optional equipment on the HEMS helicopter Christoph 6 in Hradec Kralove (100 km east of Prague) since 2006. As many cases of cardiac arrest are not immediately recognised as such by dispatchers, the best results can be achieved if the device is placed permanently on board a response vehicle. If used selectively, it should always be taken on board when a helicopter is dispatched to any medical emergencies that could potentially be or might develop into cardiac arrest. In a small prospective study including non-traumatic cardiac arrests, we compared the adverse effects of two mechanical devices used simultaneously in the same EMS system. The AutoPulse was employed in a helicopter, while a physician response unit used the Lucas™ II. Manual CPR was performed when an ambulance not equipped with a mechanical CPR device arrived at the scene. All survivors underwent physical examination and a thoracic X-ray, while non-survivors were autopsied. Both mechanical devices were associated with an increased incidence of injuries compared to manual CPR, with no significant difference between the two mechanical systems. Pericardial effusions, haematomas of the aortic adventitia, and mediastinal haematomas were found more frequently in the AutoPulse group (8). It is unclear whether these injuries were actually caused by mechanical CPR itself or if patients were previously injured during manual CPR before the initiation of mechanical CPR.
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Conclusion There is insufficient evidence to support recommending the routine use of mechanical chest compression devices in pre-hospital settings, but there are specific circumstances that make performing manual CPR difficult or even impossible. Mechanical devices should be used whenever there is at least a potential survival benefit or the need to maintain circulation during prolonged CPR or helicopter transport.
References: 1. Deakin CD, Nolan JP, Soar J et al. (2010), European Resuscitation Council Guidelines for Resuscitation 2010, Section 4: “Adult advanced life support”, Resuscitation 81: 1,305-1,352 2. Perkins GD, Brace S, Gates S (2010), “Mechanical chest-compression devices: current and future roles”, Curr Opin Crit Care 16: 203-10 3. Krep H, Mamier M, Breil M et al (2007), “Out-of-hospital cardiopulmonary resuscitation with the AutoPulse system: A prospective observational study with a new load-distributing band chest compression device”, Resuscitation 73: 86-95 4. Lafuente-Lafuente C, Melero-Bascones M (2001), “Active chest compression-decompression for cardiopulmonary resuscitation”, Cochrane Database Syst Rev 3: CD002751 5. de Rooij PP, Wiendels DR, Snellen JP (2009), “Fatal complication secondary to mechanical chest compression device”, Resuscitation 80: 1,214-1,215 6. Wind J, Bekkers SC, van Hooren LJ, van Heurn LW (2009), “Extensive injury after use of a mechanical cardiopulmonary resuscitation device”, Am J Emerg Med 27: 1017.e1-2. 7. “Potential Chest Compression Injury Mechanism from Mechanical CPR Systems (2011)”, “Comparison of Load-Distributing Band versus Piston-Driven Systems”, Zoll Medical Corporation Technical Reports 2011, available at www.zoll.com 8. Truhlar A, Hejna P, Zatopkova L et al. (2010), “Injuries caused by the AutoPulse and LUCAS II resuscitation systems compared to manual chest compressions”, Resuscitation 81 (Suppl): 62
Fig. 7: AutoPulse® has been in use since 2006 as optional equipment on the HEMS helicopter Christoph 6 in Hradec Kralove, 100 km east of Prague
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Fig. 1: The Patient Transport Compartment (PTC) can be installed in many of Lufthansa’s long-haul aircraft – here an A340 – within an hour (Photograph: Lufthansa)
Intensive-care and air ambulance transport around the world: Advanced training in repatriating patients Author: Marion Günther Team Leader, Paramedic Medical Operation Centre, Passenger Medical Care, Deutsche Lufthansa AG, firstname.lastname@example.org
These days people love to travel to exotic places far from home. Every year, Lufthansa, Germany’s biggest airline, flies over 55.5 million passengers to more than 200 destinations worldwide, for both business and pleasure. But what happens if something unexpected occurs, like a swimming mishap in Florida, a stroke in Thailand or a car accident in South Africa? A blissful holiday can quickly turn into a nightmare thousands of miles from home. Lufthansa’s medical department in Frankfurt has many years of experience dealing with passenger health, as well as with patient transport and repatriation. In summer 2009 it passed an important milestone in the improvement of its services by establishing the Medical Operation Centre (MOC), which now coordinates over 7,000 ambulance and intensive-care transports on board Lufthansa aircraft every year. The team at the Medical Operation Centre is made up of experienced rescue paramedics, nurses, midwives and emergency medical technicians (EMTs). All the staff also have years of experience in ticket sales and Lufthansa flight operation. The centre coordinates the quality control
Fig. 2: The MOC team is comprised of experienced rescue paramedics, nurses, midwives and EMTs (Photograph: I. Friedel)
of medical products and first-aid training for flight assistants. With its pioneering Patient Transport Compartment (PTC), Lufthansa is the only airline worldwide to offer international intensive-care transports on its scheduled flights. The cabin was jointly developed by the Lufthansa technical and medical department and can be installed in many of Lufthansa’s long-haul aircraft (Boeing 747, Airbus A330 and A340) within an hour. The 6 m² sealed cabin has all the necessary fittings and equipment for transporting patients in need of intensive care or artificial respiration home safely. The PTC contains the following equipment: • Oxylog® 3000 • Breas LTV 1000 ventilator • Propaq® CS • Defibrillator, Zoll M Series® • Injectomat® IV system and other perfusion pumps
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Mobile blood gas analyser Suction pump Vacuum mattress Scoop stretcher Medication Medical supplies 13,000 litres of oxygen
The transports are mainly requested by assistance ser vices or insurance companies coordinating repatriation operations. These “travel assistance” agents also provide qualified and experienced paramedics, emergency physicians or nurses, who are also required to be confident and fluent in their use of English. This kind of secondary transport varies in a number of ways from conventional transports in intensive-care ambulances and ambulance flights. One difference is that the patient is kept in spatial isolation on board the aircraft, another is that flight times can be up to 13 hours (e.g. from Buenos Aires to Frankfurt). These transports therefore have to be meticulously planned by both the contractor and Lufthansa to ensure that there are no disruptions during the flight and that other passengers are not inconvenienced. Modern medicine knows almost no limits. Or at least it doesn’t if personnel receive the necessary specialist training. To bring staff up to speed with the latest developments in repatriation missions, in September 2010, Clemens Kill MD from UKGM university hospital and Prof Jürgen Graf MD from Lufthansa ran a special four-day course following the guidelines issued by the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI). During the first two days the 24 participants met in Marburg, where they attended lectures given by different speakers, all professionals in their fields, as well as several workshops covering various aspects of monitoring patients in intensive-care stations, practical hands-on training sessions in mobile intensivecare ambulances and in ambulances specialising in the care of newborns, and training sessions in the hospital’s ultra-modern patient simulator. Examples of topics covered during the course: • Monitoring intensive-care patients during transport • Treating circulatory collapse • Respiratory failure • High-altitude and in-flight medical care • Types of artificial respiration • On-board medical emergencies • Transporting patients on scheduled flights
During the next two days at Lufthansa in Frankfurt the workshop participants focused on the organisational, logistical and medical aspects of transporting patients on board civilian aircraft. Participants were also given the opportunity to familiarise themselves with the emergency equipment on the Lufthansa fleet and to act out emergency scenarios. Participants had the opportunity to put their newfound knowledge into practice under realistic conditions
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Fig. 3: Interior of the Patient Transport Compartment, PTC (Photograph: I. Friedel)
Fig. 4: Case studies of serious internal complaints are explained in the Airbus A340 mock-up
during training sessions in the mock-ups of the Airbus and Boeing fleet (A340/B737) used for flight-assistant training at Lufthansa Flight Training. This session focused on the general management of in-flight medical emergencies. Operational reports and case studies by experienced medical flight crews showed participants how to deal with real-life situations. Different countries have different rules, so the lectures also discussed in some depth infection risks abroad, legal considerations, vaccinations and general travel information. At the end of their visit, participants headed to Lufthansa’s technical division, where they had the chance to explore a Boeing 747 (jumbo jet) and to sit in the cockpit. The four-day DIVI course closed with a written exam. This collaboration – the first of its kind – between Lufthansa, UKGM and Red Cross Mittelhessen (central Hesse) was a great success. Participants’ positive feedback and the large number of requests prompted the decision to repeat the course in the future.
For more information, visit: www.ukgm.de www.lufthansa.com www.flugmed.org
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Authors: David A. Sinclair, MD Luxembourg Air Rescue Medical Supervisor Consultant in Anesthesiology, Critical Care and Emergency Medicine email@example.com Jörn Adler, MD Luxembourg Air Rescue Medical Supervisor Consultant in Anesthesiology, Critical Care and Emergency Medicine firstname.lastname@example.org
Multiple patient configurations put to the test: Luxembourg Air Rescue’s new ambulance jet Luxembourg Air Rescue (LAR) introduced two new 45XR Learjets to its fleet in late 2011. These jets are one of the most advanced aircraft in its category, especially in terms of technology: it has long range (1,971 NM or 3,650 km) while consuming a minimum of fuel. Furthermore, it boasts outstanding performance, with a maximum speed of 465 kt (860 km/h), a take-off distance of 5,040 ft. and a landing distance of 2,660 ft. Its maximum operating altitude is 51,000 ft. These technical features make it ideal for air ambulance services. In terms of medical equipment, both jets are outfitted with two corpuls3 monitors, two LTV® 1,200 ventilators with external displays as well as six syringe pumps, an aspiration kit and a point-of-care blood gas analyser.
Fig. 1: The new 45XR Learjets are fully equipped for ICU repatriation, even when the double-stretcher configuration is used (Photographs: LAR) 1 · 2012 I Vol. 2 I AirRescue I 58
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Based on its 24 years of experience in air rescue, LAR developed – in collaboration with AAT (Air Ambulance Technology) – a concept allowing for various multiple-use, multiple-patient configurations. Offering configurations like two ICU units or one ICU unit and six passengers, it is extremely versatile and allows services (this even includes a separate lavatory) to be tailored to the needs of its members and patients, as is illustrated by the following case reports in which a double-stretcher mission was carried out. Patient A was a 61-year-old French male who was hospitalised in Muscat, Oman, and had to be repatriated to Lille, France. He had suffered an intracerebral stroke two weeks earlier; his initial GCS was seven and he was immediately taken to Royal University Hospital in Muscat. The patient was intubated and ventilated and underwent hemicraniectomy after ischemic swelling of the brain. Due to nosocomial pneumonia, several attempts to extubate him had failed. The medical report contained the following information: • Airway management: endotracheal intubation with a size-nine cannula • Breathing: spontaneous breathing with 4 L/min of oxygen and intermittent pressure support ventilation, by which satisfactory oxygenation was achieved, with pO2 around 95 mmHg and CO2 around 40 mmHg • Haemodynamics: stable without catecholamines • Impairments: right-sided hemiplegia; patient did not respond coherently to questions • Environment: the patient was in an ICU and a central venous line, an arterial line, a gastric tube, and a Foley catheter were in place. The past medical history revealed arterial hypertension as well as non-insulindependent diabetes mellitus. The patient was fit to fly, but needed intensive care treatment.
Patient B was a NACA 3 52-year-old male who was hospitalised in Crete with a broken leg and had to be repatriated from Greece to Nuremberg, Germany. The medical report showed no significant A (Airway), B (Breathing), C (circulation), or D (Drug) problems. The patient was on a surgical ward and unable to walk since he had not yet undergone surgery. His past medical history was unre-
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markable except for arterial hypertension. This patient was obviously fit to fly, but he needed pain management and wished to be accompanied by his wife. Our client wanted a bed-to-bed transfer for this patient, as well, and repatriation of such patients with a medical crew (consisting of two ICU nurses and one ICU physician) is possible in accordance with LAR’s policies. Thanks to the additional space and comfort offered by the new Learjet 45XR, it was also possible to take the patient’s wife along. The Luxembourg Control Centre (LCC) of the LAR planned the mission so that the team flew to Muscat one day prior to the patient’s repatriation, allowing international crew rest regulations to be met and the actual repatriation to be completed in one go on the following day. Early the next morning, the medical crew drove directly
Fig. 2 & Fig. 3: Medical Supervisor Dr Joern Adler and Dr David Sinclair are part of the LAR team; the crew usually consists of two ICU nurses and one ICU physician
Fig. 4: Both jets are also equipped with two corpuls3 monitors, two LTV® 1200 ventilators with external displays as well as with six syringe pumps, an aspiration kit and a point-of-care blood gas analyser
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Fig. 5: The new Learjet has an advanced patient loading system, enabling the crew to lift the patients easily into the air ambulance
from the hotel to the hospital, taking all the necessary equipment and materials with them. The LCC is managed by a specially-trained intensive care nurse who collects all relevant medical information necessary for appropriate planning. If medical limitations (as defined by SOPs) are exceeded, one of the medical supervisors and/or the escorting physician is called to clarify any uncertainties. A thorough examination of the patient revealed no further problems and the patient was considered fit to fly. After a detailed handover with the local physicians, the patient was mildly sedated with intermittent boli of morphine. All medication was administered during the flight as prescribed by the discharging physician; however, administration was slightly delayed due to the shift from Gulf Standard Time (UTC+4 hours) to Central European Time (CET). Enteral nutrition via nasogastric tube was interrupted to avoid gastric reflux. In order to avoid respiratory distress, the ICU ventilator was set up for assisted spontaneous breathing with low peak pressures. The patient was mildly sedated with boli of morphine and midazolam to avoid stress response to transport. On the second leg of the mission, landing in Crete was on schedule, and the ambulance arrived ten minutes later. Patient B was accompanied by his wife and a nurse. The LAR physician examined the patient in the ambulance and deemed him fit to fly. The patient complained of having had severe pain while being moved onto the stretcher in the hospital. To avoid further pain, the patient received analgosedation with S-ketamine and midazolam. Thanks to the well organised logistical operations, it was possible to complete handover with minimal time loss. During the short transit time in Crete, one nurse remained on board to monitor Patient A, while the physician took over Patient B. During the flight, Patient B was comfortable and received pain killers (NSAID and narcotics). This treatment relieved his pain, which decreased from 6/10 to 2/10 on the numeric rating scale. The landing in Nuremberg, Germany, was 15 minutes prior to schedule, but fortunately the ground ambulance was already on site.
Patient B was handed over to the staff of the ambulance and one LAR nurse accompanied him and his wife to the admitting hospital. Transit time in Nuremberg was no longer than 45 minutes, including refuelling. Patient A remained on board, attended by the second nurse. Treatment and monitoring were not interrupted. Here, another advantage of the new jets came into play: the internal power unit ensures air conditioning and medical power supply during the stopover. As the team was now about 45 minutes ahead of schedule, the LCC in Luxembourg was called to notify the ambulance in France so that the ground ambulance was already on site when the jet landed in Lille. Although the ambulance was well equipped, the LAR crew took all their medical equipment and supplies along. Indeed, it is one of LAR’s policies not to rely on foreign medical equipment. All LAR equipment is checked prior to every mission and the medical staff receives special training in using it, and LAR stocks different adaptor sockets for electricity and oxygen supply to guarantee full function of respirators, syringe pumps and monitors abroad. Finally, the patient, who had remained stable during the entire flight, was handed over to the ICU physician in Lille and the LCC was informed of the successful completion of this mission.
Discussion The new 45XR Learjets with double-stretcher configuration are fully equipped for ICU repatriation, offering LAR new possibilities when it comes to repatriation, in terms of comfort, safety and effectiveness. Nevertheless, thorough planning and medical clearing is essential in order to perform effective double-stretcher missions and minimising risks. The size and composition of the medical team must be adapted to the severity of patients’ illnesses/injuries. In order to repatriate two ICU patients in two separate compartments of the cabin (separated by curtains), two physicians and two ICU nurses are needed on board. This underlines the importance of having clear SOPs to provide safe and effective service.
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The Global Show for General Aviation EDNY: N 47 40.3
E 009 30.7
Wed. 18. – Sat. 21. April 2012 Friedrichshafen, Germany
www.aero-expo.com 1 · 2012 I Vol. 2 I AirRescue I 61
62 | INTERVIEW
An interview with René Closter of L u x e m b o u r g A i r R e s c u e ( LAR ) :
“What’s so great about the Learjet 45XR?” Luxembourg Air Rescue (LAR) has never been afraid to follow new paths. It was the first air rescue service in Europe to use the MD900/ MD902 and also the first to introduce the Learjet 35A. Now the Learjet 45XR forms the backbone of its blue and white fleet. ARM’s editor-in-chief, Peter Poguntke, met the President and CEO of LAR, René Closter, and asked him what impressed him so much about the aircraft. René Closter
ARM: You said that your purchasing decision was based on years of observing the aviation and aviation medicine sectors. What precise trends did you observe and analyse? Closter: Yes, we looked back on our years of experience and the thousands of rescue missions we have carried out with conventional air ambulance planes, such as the Learjet 35A. In jets like that it’s not possible to transport Fig. 1: Thanks to the new Learjet 45XR, two intensive care patients and up to four family members can be repatriated at one time (Photographs: LAR)
two intensive care patients simultaneously while providing them both with an optimum level of medical care. We observed that our members and our customers worldwide – that is, travel assistance companies – were tending more and more to require repatriation services for two intensive care patients at once. For example, perhaps a family has been involved in an accident while on holiday together and then need to be brought home. Thanks to this new machine we can now transport two intensive care patients and up to four family members at one time. Most of our competitors fly a lot of planes that are quite old, like the Learjet 35A, and it’s just very expensive to keep these machines running. It’s also getting more and more difficult to find spare parts. For that reason, and because we also like to always be one step ahead, we decided to use the Learjet 45XR for the whole fleet. We worked with Air Ambulance Technology (AAT) in Austria and used our years of experience in aviation medicine to develop a design that is currently one of the most advanced in the global air rescue sector. ARM: The importance you attach to flexible transport capabilities implies that you expect increasing demand for air rescue services in future. Is that right? Closter: In our opinion, the demand for multiple patient capabilities – transporting two patients along with family members – over long distances will increase in the near future. And this must be provided at a reasonable cost, because it has to be economical for our customers, the travel assistance companies. Factors governing the
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INTERVIEW | 63 repatriation sector in future will be cost-effectiveness, speed and the ability to transport more patients over longer distances. This will only be possible with the latest generation of air ambulance planes, which consume less fuel and require less maintenance. ARM: So you think that the number of long-distance flights will increase? Closter: Where we operate depends on the season. In the summer we usually spend a lot of time in the Mediterranean. Off season, there do tend to be more long-distance repatriation missions. How this develops will also depend on the global economy, though. For example, a lot of business travel has now been cut back and replaced with telephone conferences. ARM: One of the special technical features of your new plane is the flooring. Can you tell us a bit about its advantages? Closter: One very special thing about these air ambulance planes is the fact that they are “multiple use jets”. For years, LAR has been deployed by the state of Luxembourg, the United Nations and NATO in disasters and crisis situations all over the world, both with our rescue helicopters and our air ambulance planes. This led us to develop special cargo flooring for our planes in cooperation with the company Air Ambulance Technology (AAT). This enables us to use either the whole plane or parts of it for all kinds of transportations. The plane can be modified from an air ambulance plane to a transporter by just two people within half an hour. ARM: Can the Learjet 45XR also be used for international disaster relief? Closter: Yes, our new Learjet 45XR can be deployed at any time on those types of missions, which have always been a part of our job. Since the end of last year we’ve also been working in a partnership with the state of Luxembourg, HITEC Luxembourg S.A., SES Astra TechCom S.A. and Luxembourg Air Ambulance S.A. – a Luxembourg Air Rescue subsidiary. This partnership has enabled the government of Luxembourg to conclude a contract for the provision of rescue services and emergency humanitarian aid across the globe. This contract includes the installation and operation of a global satellite communication system. This system combines a number of unique competences and innovative technology that is already available in Luxembourg within the IT and communications sectors, global satellite services and airfreight logistics. This project makes it possible for Luxembourg to provide the global humanitarian aid community with a complete, immediately deployable solution for disaster relief and emergency rescue missions. The emergency.lu initiative can also permanently improve network infrastructures in crisis zones in order to support long-term humanitarian missions. It offers the
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Emergency.lu: a new communications solution for disaster relief The emergency.lu communications service first went into operation in southern Sudan in early 2011. The system was installed by the Luxembourg civil defence forces, the UN World Food Programme and volunteers from the Ericsson Response Volunteer Programme in Bentiu and Maban in South Sudan. Emergency.lu is a grouping of different organisations that provides a “rapid response solution for international disaster relief and humanitarian operations.” It was developed and implemented as part of a public-private partnership (PPP) between the Ministry of Foreign Affairs in Luxembourg and a consortium of Luxembourgish companies and organisations. These include SES TechCom, Hitec and Luxembourg Air Rescue. The system can be used in order to establish or reestablish telecommunications services and to enable effective communication between and coordination of aid workers. Emergency.lu provides satellite infrastructure and capacity as well as communications and coordination services and terrestrial satellite terminals. The quick provision of broadband connectivity can greatly improve the coordination of crisis management and developmental aid in places all over the world. international disaster relief and humanitarian aid community a communications system that can be employed globally and enhanced with specific additional features. Thanks to the round-the-clock service provided by Luxembourg Air Ambulance at Luxembourg International Airport, the emergency.lu technical infrastructure can be in the air within two hours. This rapid availability enables NGOs and other rescue services working in crisis zones to quickly set up a communications and information system at almost any point on the planet.
Fig. 2: The crew is preparing the advanced loading system for an easy lift of the patient(s) into the cabin
64 | IN PROFILE
Fig. 1: Bucher Leichtbau EC135 EMS Equipment in new design (Photos: Bucher Leichtbau)
”Guaranteeing the highest safety standards“ The corporate philosophy of Swiss firm Bucher Leichtbau Author: Peter Poguntke Editor-in-chief, AirRescue Magazine
Gentle transport for air rescue patients is Bucher Leichtbau’s speciality. The Swiss company is a leading provider of stretchers for air ambulances and passenger aircraft. Over 700 of its stretchers are currently in use around the world. Bucher Group is made up of two companies – one in Fällanden, Switzerland with 220 staff members and one in Everett, Washington with 50 members of staff. The group is a supplier for Airbus and Boeing. The Swiss side develops and manufactures things like galleys and storage compartments for the long-haul Airbus A330, the giant Airbus A380 and the brand-new Boing 747-8i jumbo jet, among others. It also makes a variety of other products for use in aircraft cabins, including components like tray tables or complete consoles for first class and business class seats. And Bucher products contribute to passenger
comfort on the ground, too – in automobile interiors for Daimler’s ultra-luxury brand Maybach. As Rolf Kraus, Director of Sales Medical & Interior Components, explains, Bucher Leichtbau’s air rescue career began back in the days when almost all of Germany’s rescue helicopters were still painted bright orange. The first requests came in to the company founder Heinrich Bucher, asking whether he was interested in tackling the challenges that were emerging during that new era of flight technology. Bucher recognised the opportunities the new market offered and signed the first deal. That marked
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IN PROFILE | 65 the beginning of a success story for his company, and in 1978 it delivered its first EMS equipment – for a Bo 105. What made Bucher Leichtbau so successful and propelled it ahead of its competitors? We were not expecting the company to put all of its cards on the table, but Rolf Kraus was happy to show us a few of its trumps. For example, Bucher Leichtbau has several mission profiles for the EC135, all of which have been approved under one STC (supplemental type certificate). If a customer wants other devices or a different mission profile, these can be immediately approved under the same certificate. The only thing customers need to know is what they want. Kraus says the technical strategy will be no different for the next mass-production rescue helicopter model to hit the market, the Eurocopter EC145 T2. It’s worth mentioning that all of Bucher’s EMS systems are compatible with EN 13718 (the European standard for rescue helicopters) and night vision goggles – Bucher equips the patient space in line with all EASA safety regulations. Even more noteworthy is that every single medical device Bucher installs in rescue helicopters has the CE marking in line with 93/42/EEC. That guarantees the highest testing, documentation and safety standards for all those Bucher products. But what exactly do all these labels mean? Well, the first thing they do is distinguish between different classes of medical devices, Class I, IIa, IIb and III. Class I includes simple products like stretchers and accessories – devices that have a relatively small impact on patients. Class IIb features items like oxygen equipment and X-ray units as well as Mediwall, the wall of devices above a patient that houses the oxygen tubes, etc. on board a rescue helicopter. Invasive devices such as pacemakers
are characteristic of Class III. Every single device used in the helicopter now needs the CE mark, a process that can easily take a year to complete. Rolf Kraus’ colleague Alen Salihovic points to two A4 folders filled with paperwork: “These contain everything we need to get the CE mark for a device.” What’s more, the company that installs the devices has to show that it is capable of carrying out the tests necessary for meeting the Directive’s demanding safety criteria. Bucher adapted its internal organisational guidelines and introduced a CE-compliant supplier management system that enables the company to quickly identify and trace any material defects back to their source. Each step in the development process is accompanied by a corresponding risk analysis that has been designed to eliminate potential technical uncertainties in advance. When the CE process is finished, the thoroughly tested devices receive a coveted CE marking from the TÜV, one of the few test labs that is permitted to issue the certificates. Products in Class IIb get an additional TÜV reference number. Once in use, the products are monitored using a specially designed notification process. It ensures that any defects can be examined and reported as soon as they are recognised. The company’s ability to trace the history of any part enables it to determine exactly which production batch was affected. Bucher gives each of its new customers an individual briefing on product configurations and features to ensure they use the products correctly. It is a time-consuming process, and one that Bucher Leichtbau can claim to have pioneered. But the result is worth the effort because it provides full technical and legal peace of mind for both the manufacturer and the customer – and superlative care for patients.
Fig. 2: ATS Stretcher for commercial Aircrafts
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66 | EVENTS
1 Heli China 2012 Flight Inspection Center of CAAC, Beijing Capital International Airport, China 11.-13. April 2012 www.helichina-shanghai.com/en 2 Aero 2012 Friedrichshafen, Germany 18.-21. April 2012 www.aero-expo.com/ 3 HeliRussia 2012 Moscow, Russia 17-.19. May 2012 www.helirussia.ru/en/index.html
4 ILA Berlin, Germany 11.-16. September 2012 www.ila-berlin.de
7 AMTC 2012 Seattle, Washington 22.-24. October 2012 www.aams.org
5 ISAS 24th Annual Scientific Meeting Cairns, Australia August 29 - Sept 1, 2012 www.aeromedconference.org.au/
8 Dubai Helishow 2012 Dubai, UAE 6.-8. November 2012 www.dubaihelishow.com
9 Heli & UV Pacific 2012 RACV Royal Pines Resort Queensland, Australia 23.-24. May 2012 www.shephardmedia.com/events
6 Japan International Aerospace Exhibition 2012 Nagoya, Japan 9.-14. October 2012 www.japanaerospace.jp/english/
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( THINK MEDICAL ASSISTANCE ) A Eurocopter helicopter is a flying life support system for paramedics and rescue services. Always on call to reach casualties of accidents and disasters or evacuate critical care patients. Prescribe an EC135.
Thinking without limits