AirMed & Rescue Apr / May 2018

ISSUE 89 | APR / MAY 2018

AIRMED&RESCUE MAGAZINE

magazine

ISSUE 89

MAR / APR 2018

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In this issue

Editor-in-chief: Ian Cameron Editor: Mandy Langfield Sub-editors: Christian Northwood, Lauren Haigh, Stefan Mohamed, Sarah Watson Advertising Sales: James Miller, Mike Forster

INDUSTRY INPUT Patient privacy in a confined workspace

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UAV raft rescue in Australia

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In-field amputation training

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Design: Tommy Baker, Will McClelland Marketing: Isabel Sturgess, Kate Knowles Finance: Elspeth Reid, Alex Rogers, Kirstin Reid Contact Information: Editorial: tel: +44 (0)117 922 6600 (Ext. 3) email: editorial@airmedandrescue.com Advertising: tel: +44 (0)117 922 6600 (Ext. 1) email: jamesm@airmedandrescue.com Online: www.airmedandrescue.com @airmedandrescue www.airmedandrescue.com/facebook www.airmedandrescue.com/linkedin www.vimeo.com/airmedandrescue

FEATURES Dynamic hoisting – a brave new world for rescuers

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Infection – fighting the hidden enemy on aircraft

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Night sight – the continuing evolution of FLIR and NVIS

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Communication is key – satellite, radio or cellular?

PROVIDER PROFILES Dorset and Somerset Air Ambulance

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Jet Rescue Air Ambulance

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CONTRIBUTORS

Subscriptions: www.airmedandrescue.com/subscribe subscriptions@voyageur.co.uk Published on behalf of Voyageur Publishing & Events Ltd Voyageur Buildings, 19 Lower Park Row, Bristol, BS1 5BN, UK The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy.

Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. The views expressed do not necessarily reflect those of the publisher. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned, is hereby excluded.

Printed by Pensord Press Limited © Voyageur Publishing & Events 2018

magazine AIRMED & RESCUE ISSUE 88 ISSN 2059-0822 (Print) ISSN 2059-0830 (Online) Materials in this publication may not be reproduced in any form without permission.

Dr Joetey Attariwala Dr Attariwala trained as a medical doctor and has established himself as a highly regarded journalist who contributes to various aerospace, defence, training and simulation, and law enforcement publications around the world. He is a regular contributor to AirMed&Rescue Magazine.

Dr Erik Bornemeier Dr Bornemeier completed a degree in Health Education and Emergency Medicine at the University of Utah, served 15 years as commander of Davis County Search and Rescue, worked as a Medic in the US Air Force and founder of the Utah Training and Education Center. His passion is learning and teaching best medical practices, which has involved travelling to the Kingdom of Morocco, where he was part of a task force that developed an advanced pre-hospital care programme that hopefully one day will benefit other African countries.

Frank Condron Frank Condron is a journalist and communications consultant based in Toronto, Canada. He has worked as a professional writer and editor for numerous North American media outlets and provided corporate communications services for both private and public companies. Mr. Condron has served as Public Relations Officer for Fox Flight Air Ambulance since 2015.

Femke van Iperen Femke van Iperen is a freelance bilingual journalist. Since graduating with a postgraduate diploma from the London School of Journalism in 2003, she has been writing background features for a variety of commissioning and international clients, in both Dutch and English. The magazines she writes for are read by global readerships.

Mario Pierobon Mario Pierobon is a safety management consultant and content producer. He writes extensively about aviation safety and has in-depth knowledge of the European aviation safety regulations on both fixed and rotary wing operations. His rotary wing expertise is concerned primarily with specialised operations and the operations requiring specific approval, such as HEMS, hoist operations and performance-based navigation.

James Paul Wallis Previously editor of AirMed&Rescue Magazine from launch up till issue 87, James Paul Wallis continues to write on air medical matters. He also contributes to the International Travel & Health Insurance Journal.

Stephen R. Wirth, Esq., EMT-P Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC, which represents EMS agencies throughout the US, and a co-founder of the National Academy of Ambulance Compliance. In a distinguished public safety career that spans over four decades, Steve has worked in virtually every facet of EMS – as a firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive – and was one of central Pennsylvania’s first paramedics.

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No boundaries for Latitude Supplier of flight data management, flight following, and satcom solutions for fleet operators Latitude Technologies showcased the new S200-012P Iridium Satellite Push-to-Talk (PTT) device for air medical and first responder organisations at HELI EXPO in February.

Designed to support public safety, Latitude said that the S200-012P ‘allows air crews, air-operations stakeholders and outside organisations to interoperate across different regions with no delay and without dialling a telephone number’.

“There are no dead zones or boundaries typical of mobile radio systems. Operators can be anywhere in the world actively listening and participating in secure group conversations when responding to

emergency situations or natural disasters,” added the company.

Commenting on how this technology is groundbreaking for airborne public safety communications, Latitude President Mark Insley noted: “Previous airborne use of PTT was limited to direct line of sight and relay between radios and was open to eavesdropping scanning technologies. Our application of Iridium PTT provides private group conversations with no geographic limitations. And using the Technisonic upgrade, it functions seamlessly with 9100’s tactical radio frequencies. Crews can respond and take action faster while working together without worrying about losing connections even in the most remote areas.”

Restube

Drone drops Restube to kitesurfer in Brazil

In December last year, drones equipped with a Restube have been available for rescues in Sao Paulo, Brazil, and at the end of March, a kitesufer’s life was saved by just such a drone. Restubes are self-inflating rescue rafts that can be dropped to people in distress in the water, giving them the support they need until a rescue boat can get to the scene.

When a kitesurfer lost his board near the Guarapiranga dam, he first swam towards shore and waited for help, watched 44

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carefully by the local fire department, but when he started to tire, the operators launched the drone.

SkyDrone, a local company, worked with Restube GmbH to develop the unmanned air vehicle and combine it with the rescue raft. CEO of SkyDrone Ulf Bogdowa commented: “It is not about replacing lifeguards, but providing a very quick first aid with flotation until the lifeguards arrive – time is the most relevant factor when it comes to safety in the water.”

Editor’s comment I’ve been lucky enough over the past couple of months to get out and about as part of my new role at AirMed&Rescue, and my sorties, I’m glad to say, have proved very useful. The first visit, to international fixed-wing operator Capital Air Ambulance, offered some great insights into the real-life workings of the company, with calls coming in for evacuations being dealt with quickly and smoothly. The interoperability of the flight ops team and medical experts was also a pleasure to witness first hand, and brought home how integral teamwork is to this industry.

This was reinforced by my visit to Dorset and Somerset Air Ambulance (featured on p22), where I was privileged to be shown around the new AW169 by the pilot and medical crew. Only interrupted by an emergency call that saw the helicopter airborne within five minutes of the phone going (by the way, the ringtone is the Airwolf theme tune!), it was really interesting to find out more about the charity, its modus operandi, and the staff that keep the rotors turning all day long – and for most of the night as well.

Without the engineers working to keep the aircraft flying, the operations team co-ordinating the flight and crew, and the medical team working to prepare for the patient, airborne medical transport services couldn’t be provided. The dedication and professionalism shown by each member of the teams I spoke to was humbling.

There’s loads of original content in this issue of AirMed&Rescue – a look at the complexities of dynamic hoisting (p12), the options for helicopter communications systems (p42), a report into what led Surf Life Saving Australia to its first rescue using a drone-dropped liferaft (p20) and more. We also discuss how to keep patient data private in an emergency setting (p18), and how different air ambulance operators choose to disinfect their aircraft after use (p26).

Enjoy, and safe flying to all.

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Kopter launches into the market Aircraft manufacturer Marenco Swiss Helicopter unveiled its new brand name during an inauguration event held at its recently completed corporate/engineering facility. The company’s CEO, Andreas Loewenstein, introduced Kopter to customers, suppliers, partners and staff, saying: “Kopter marks a new chapter in the company’s history. The launch is an opportunity for the company’s leadership to share its ambitious business strategy, as well as news about its upcoming flight test programme and the start of production of the SH09 helicopter.”

DZMx enhancement on offer The Flightcell DZMx is to be enhanced with a built-in WiFi hotspot and router.

This provides a cellular broadband data connection for onboard smart devices and connected equipment without the need for

a separate WiFi router installation. The WiFi antenna and components are installed within the existing DZMx housing.

“Space is at a premium in the cockpit, which is why we have designed the DZMx to be a compact all-in-one unit in the first place,” said John Wyllie, CEO of Flightcell.

“We’ve now provided our customers with an additional and highly desirable capability and at the same time we are saving them the cost, time and space that a separate installation demands.”

Built-in WiFi will be an optional extra for all new purchases that ship from July 2018.

DZMx customers will have the option to upgrade their existing units.

King Airs to benefit from tech additions Nextant Aerospace has received the final piece of Federal Aviation Administration (FAA) certification that combines the new single-lever power control system with the previously certified engine and avionics combination on the G90XT turbo-prop aircraft. “From the launch of this programme, our goal was to bring a level of technology to the King Air platform that has been missing for decades,” stated Nextant Executive Jay Heublein. “While the King Air is recognised as the most successful platform in the history of business aviation, the fleet has not benefited from the significant advances in technology that its counterpart in the jet market

has.” Now, however, the G90XT features the GE H75 engine along with a fully integrated GARMIN G1000 flight deck.

In addition to the new power control system, other key technology ‘firsts’ for this airframe include: a cockpit that integrates both engine and fuel monitoring on a digital basis into the MFD, an all-new digital pressurisation system, new environmental cooling system that triples the previous cooling capacity of the plane, and an all-new interior that features a new composite shell and incorporates new seats along with an improved cabin layout. In addition to the new technology, the aircraft demonstrates a 20-knot speed

advantage at altitude when compared to current production, competitive aircraft.

“All along, our goal was to introduce technology that would significantly reduce pilot workload in the cockpit and improve the ability for pilots to safely operate the aircraft,” stated Nathan Marker, Vice President for Flight Operations. “I can say with complete certainty that I have never operated a twin-engine turbo-prop that was easier to fly and that better positions pilots to effectively manage potential emergency situations.”

With FAA certification now complete, Nextant expects that EASA validation will occur within 90 to 120 days.

AirMed World Congress preview In June 2018, Polish Medical Air Rescue will host the AIRMED World Congress This time, the recurring event organised under the auspices of EHAC (the European HEMS and Air Ambulance Association) will take place in Warsaw, the capital of Poland. Professor Robert Gałązkowski, Chairman of the Organising Committee, said: “This Congress will be a time to face the scientific dimension of our air rescue teams, 66

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where we can exchange our experiences and recommendations of good practice in healthcare for our patients. Air ambulance and HEMS were established to rescue people in various health conditions. Our duty is to provide this help at the highest possible level. As air rescue teams, we have to improve our qualifications all the time, but we also have to discuss essential issues. And this is indeed the focus of the AIRMED World Congress.”

The wide-ranging agenda will feature expert presentations on subjects including quality management standardisation and certification programmes in HEMS, risk assessment in an operational HEMS environment and fatigue management for crewmembers. The breakaway sessions include ones with a focus on accidental hypothermia, violence toward HEMS personnel, medical interiors and how HEMS services react following a terror attack.

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Helipad safety assured thanks to donation The Royal Sussex County Hospital (RSCH) has welcomed a £650,000 donation from the HELP Appeal – a UK charity dedicated to funding hospital helipads – which will be used to incorporate a fire suppression system for the hospital’s new helipad. Typically used

for off shore oil rigs, the Deck Integrated Fire Fighting System can extinguish a fire within 15 seconds by using a series of nozzles built into the helipad that spray water and foam. RSCH will be among the first five hospitals in the country to have the system in place.

The helipad, which is part of the major redevelopment of the hospital, is due to come into operation at the end of this year. It will enable air ambulances to land directly on the hospital site for the first time – a massive boost to the hospital’s role as the region’s major trauma centre.

Airbus signs contract with Hokkaido Government Airbus Helicopters has signed a contract for one AS365 N3+ Dauphin helicopter for the Hokkaido prefecture in Japan, where the aircraft will be used for rescue missions and other supporting activities. Airbus has also delivered one AS365 N3+ helicopter each to the Fukuoka City Fire Department and the Kumamoto prefecture respectively, for firefighting work, search-and-rescue missions and emergency support.

“The successive orders and deliveries signal a good start to the new year in Japan, as we renew long-lasting relationships and welcome new ones,” said Olivier Tillier, managing director of Airbus Helicopters in Japan. “With more orders expected in the coming months, we are all geared to provide total support through our well established value chain to serve the growing needs of our customers.”

TracPlus and AgriTrack team up to help Australian Firefighters TracPlus Global and AgriTrack have announced an agreement to deliver timecritical fire information from AgriTrack’s FireTrack into TracPlus’ global tracking and

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messaging service. Under the agreement, fire break and fire line information captured

by FireTrack using Android tablets will be delivered via TracPlus to firefighting operators and coordinating agencies throughout Australia.

The agreement will also allow AgriTracks agricultural products to work outside cellular coverage using TracPlus equipment such as the RockAIR satellite and cellular tracker.

Over the last decade, TracPlus has gathered tracking data from every firefighting aircraft in Australia and delivered it

to 19 state and federal organisations to help improve the effectiveness of the airborne fire-fighting response. “By working with FireTrack to capture additional location information about ground-based assets and the fire itself, we can help all those organisations achieve better mission outcomes” said Chris Hinch, CIO of TracPlus.

AgriTrack has been providing logistics solutions to the agricultural sector for more than five years. “The commercial viability of our new FireTrack product relied on a global satellite messaging service, so our agreement with TracPlus is critical in taking this to market,” said Andrew Humphries, CEO of AgriTrack.

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RAeS/CCAT conference review ‘International Aeromedical Transport – Concepts in airborne patient management’ was a great opportunity for experts to share best practice for the treatment of patients in the environment of a fixed-wing aircraft and helicopters

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rganised by the CCAT Aeromedical Training organisation (CCAT) and held in the historic headquarters of the Royal Aeronautical Society in London, UK, the event offered detailed insights into the management of several different patient types and conditions, including neonates, and those suffering from respiratory illnesses, mental health disturbances and traumatic brain injuries.

lungs’ reaction to cabin pressure depends on which respiratory illness the patient suffers from – this is a result of different oxygen diffusion rates within the parenchyma of the lungs due to the effects the two illnesses had on the lungs.

Dr Terry Martin’s presentation centred on the risks posed by multi-drug-resistant organisms.

He pointed out that where there are passengers, there are pathogens, and with the

the lungs’ reaction to cabin pressure depends on which respiratory illness the patient suffers from Presentations Dr Jon Warwick gave a detailed presentation on the effects of cabin pressure on patients with respiratory illnesses. Describing two seemingly similar patient presentations in a hospital setting (if one were just to see the X-rays), these two patients reacted very differently in flight. One suffered from pulmonary fibrosis, while the other had H1N1 pneumonia. Dr Warwick showed that the 10 10

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ever-increasing number of people travelling on aircraft, the risk of disease transmission is higher. Most drug-resistant diseases are caught in a hospital setting, and with private air ambulance operators collecting patients from hospitals around the world, there is a risk that some of these patients will carry an infection. Certain countries, where regulations surrounding antibiotic use are not very well controlled, may pose more of a risk in terms

of the likelihood of a patient contracting a multi-drug-resistant infection. Previously, physicians have used carpabenem antibiotics, which are ‘drugs of last resort’, to treat such infections, but bacteria are increasingly becoming resistant to this class of drug as well, Dr Martin warned. Anyone involved in the transfer of patients should ask the treating hospital for a full microbiology report on any patient they are going to pick up, so they can prepare appropriately and take the necessary precautions.

Dr Simon Forrington offered attendees insights into the treatment and prevention of traumatic brain injuries, from his perspective as a helicopter emergency medical service (HEMS) doctor in the UK and also as a flight physician transporting intensive care patients very long distances in fixed- wing air ambulances. What is essential in prehospital emergency medicine, he said, is the prevention of a secondary brain injury, which is often caused by raised intracranial pressure.

Sadly, good quality evidence for interventions to prevent secondary brain injuries is lacking; although there are several methods in use, none present an overwhelmingly positive result over the other. The options include: osmotherapy; decompressive craniectomy;

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external ventricular drains; ventilation strategy; avoidance of hypothermia and PTS; and the neuroprotective properties of barbiturates. Whether in HEMS or fixedwing transfers of these types of patients, concluded Dr Forrington, the principles for the prevention of the secondary brain injury remain the same.

The next presentation, from Ian Braithwaite, reported on a medical evacuation of a premature baby that had been born in Samoa under difficult conditions, as the island had just suffered a tsunami. The baby was suffering from a trachea-oesophageal fistula that meant he needed constant suction to keep his airway clear, and he also had Pierre Robin syndrome, requiring significant monitoring and re-positioning of his airway throughout the long journey. The transfer to New Zealand was performed without incident, although Ian pointed out that the neonatal consultant who had been brought on the trip to offer her

management of the patient in terms of restraint, whether physical or through the administration of drugs such as ketamine. After Ian’s presentation, there was a discussion of how different regions approach the management of delirious, confused and mentally ill patients, and the experts present shared how their various organisations use different strategies.

The need for risk assessment was next on the agenda, with a presentation from Dr Martin A400 Atlas transport aircraft used by the RAF that defined what risk is, and all the time (as was the case between 2003 and demonstrated that the benefit of any transfer 2004 in Iraq), then skill fade creeps in and an must be weighed against the potential for evacuation can take longer to complete. harm. The greatest challenge, he said, is The day concluded with a look into the future to gather sufficient information to make a in a presentation from AW609 test pilot sensible – risk managed – decision about a Paul Edwards, who demonstrated (not live!) patient’s ‘fitness’ to fly. Risks can be managed by prevention, reduction, segregation, transfer the capabilities of Leonardo’s new tiltrotor aircraft, and how it can be used for air medical missions.

good quality evidence for interventions to prevent secondary brain injuries is lacking expertise suffered severe nausea and vomiting during the flight. “Always think what might happen on a flight,” he warned the audience, “whether to the patient or the crew.”

Dr James Garwood then offered attendees insights into the management of patients suffering from mental health disturbances, based on his experiences working with the Royal Flying Doctors Service in Western Australia. Describing a case involving a lengthy patient transfer, he discussed

(of the risk to another organisation) and endurance (recognising there is nothing you can do about the risk and doing it anyway, such as in the case of an end-of-life flight). Dr Martin mentioned that there is no absolute contraindications to patient transfer, but there may well be relative contra-indications, and the aim is to assess and analyse each case individually.

A presentation from Wing Commander Alexander Blacklock detailed the strategic aeromedical evacuation capabilities of the UK Royal Air Force, including the aircraft used, composition of the evacuation teams in their different iterations for different missions, and how the system works as a whole. In peacetime, he pointed out, the system works very smoothly, as the teams involved on the ground and in the air work regularly together, but when the aeromedical evacuation teams are not being called on

This is the second of a series of annual international fixed-wing aeromedical transport conferences held at the Royal Aeronautical Society in London. The audience travelled from all around Europe and took part in active debates after each individual presentation.

Speakers: Dr Terry Martin FRAeS, Consultant in Anaesthesia and Intensive Care Medicine, Medical Director, Capital Air Ambulance Dr Jon Warwick, Consultant Anaesthetist, Oxford University Hospitals, NHS Foundation Trust and flight physician Air Alliance Dr Simon Forrington, Consultant in Anaesthesia and Intensive Care Medicine, Wythenshawe Hospital Manchester University Foundation Trust and flight physician Ian Braithwaite, Transport Nurse Educator, Embrace Dr James Garwood, StR (ST6) Anaesthetics and Pre-Hospital Emergency Medicine, Musgrove Park Hospital and flight physician Wg Cdr Alexander Blacklock, SO2 Aeromed / Aeromedical Evacuation Control Centre, Royal Air Force Brize Norton Paul Edwards, AW609 Experimental Test Pilot, Leonardo Helicopters Division, Philadelphia, USA.

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In constant motion

Air Zermatt

Dynamic hoisting is becoming a viable alternative to traditional static hoisting

While traditionally, the helicopter is in a static hover during hoisting operations, during dynamic hoisting, the distinctive feature is that the helicopter is in motion and this means a reduction in the exposure of people on the ground to the effects of down wash, as well as spinning.

When conducting dynamic hoist operations, there are two simultaneous, yet distinct flight profiles of the aircraft and the load. “Both use the rudimentary concepts of ‘descent’ and ‘closure’ rate,” says Bob Cockell, VicePresident of Air Rescue Systems. “These two movements combined comprise the 1212

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the aircraft descends to a predetermined point in space while progressively slowing to a hover components of ‘lineal deceleration’. By employing this composite movement, the aircraft descends to a predetermined point in space while progressively slowing to a hover.

The load, via the hoist/cable also descends to a fixed point on the ground, vessel, tower, cliff, ocean etc. When accomplished properly, arrival of the load to target should be timed with the aircraft coming to its holding (hover) position above the target.”

Developing critical mass Even though the search and rescue (SAR) world is getting smaller and SAR operators are increasingly exposed to non-traditional practices – be it only because of social media – the use of dynamic hoisting is not yet significantly widespread across the world,

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arrival of the load to target should be timed with the aircraft coming to its holding (hover) position above the target deployed was in Europe for a para-public operator performing a glacier rescue in 2000, and the particular method was called ‘drop and drag’,” said Brad Matheson, President

and Director of Training for Priority1 Air Rescue. “We modified the technique for our use to correlate with our risk management and safety standards and we have been teaching a modified shortfinal version of ‘dynamic hoisting’ to our customers since 2003.” According to Matheson, although dynamic hoisting is performed by certain civil and para-public operators, the most common military standard for hoisting is the traditional hover hoist insertion/extractions, and he still doesn’t see many military agencies performing dynamic hoisting unless involved in combat SAR (CSAR) or personnel recovery missions. “As a cross-section of the industry, now that many commercial and para-public operators are conducting hoist SAR missions Air Zermatt

according to experts. “It is more common in Europe at this point than in the US. All helicopter providers in Switzerland are practising dynamic hoisting,” noted Oliver Kreuzer, a SAR Paramedic at Air Zermatt.

“The first time we saw this technique being

that were previously operated by military programmes, less traditional methods of hoisting, hoist training, and civil aviation approved human external cargo and SAR standards have become more prevalent,” he told AirMed&Rescue.

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Operational advantages There are some significant advantages that can be obtained from deploying dynamic hoisting procedures. Apart from reduced rotor wash on the scene or hoist extraction point, a primary benefit is reduced hover time. “It reduces the time the aircraft is below single engine fly away speed. As a result, it also reduces the time the rescue personnel are outside the aircraft below single engine fly away speed,” pointed out Casey Ping of Travis County STAR Flight Dynamic. “Dynamic hoisting also reduces aircraft power requirements. This is especially important for us, because of the high temperatures and high gross weights characterising our operations. The use of dynamic hoisting has virtually eliminated exceedances of the five-minute power limit of the EC145.”

When correctly performed, dynamic hoist operations reduce risk through decreased exposure

Air Rescue Systems

The fact that the aircraft is moving at altitude offers better options for aircrews in the event of aircraft emergencies, and provides a better chance of flyaway if they already are in forward motion rather than in a hover and/or the corresponding ‘dead man’ curve.

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Air Rescue Systems

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“Another example [of the advantage of dynamic hoisting] is related to open ocean SAR procedures for a person in water, [where] traditional hoisting from a static location over the target will generate greater winds below the aircraft, which will correspondingly form surface winds that can blow the survivor in the water away from the helicopter in the hoisting position, causing the aircrews to end up ‘chasing’ the survivor. This is also a very relevant factor for smaller pleasure vessels and sailboats,” pointed out Matheson.

According to Cockell, in many parts of the world, the benefits of dynamic hoisting are under-utilised for several reasons, including misunderstanding of the technique, and the mistaken belief that there is necessarily greater risk involved. He said: “When correctly

performed, dynamic hoist operations reduce risk through decreased exposure, and the team gains increased situational awareness by performing checklist functions, pre-door opening safeties and hoist hook-ups prior to arrival at the target. Through completion of these requisite procedures early on, the team has time to gain composure, reassess the gono-go statement and chose alternate tactics prior to taking on the exposure associated with the extended hover.”

Challenges While it provides for significant operational advantages, dynamic hoisting also brings some challenges. “The hill country around Austin and San Antonio frequently floods, resulting in significant impact to people in vehicles and homes. Many of these incidents result in the victims on trees, vehicles or other obstacles.

After searching for victims and locating them, the last thing we want to do is lose sight of them, especially at night,” said Ping. “As a result, we will use a modified dynamic hoist technique that may result in a short approach flight before becoming stationary.”

As with any other technique in SAR, dynamic hoisting also requires the correct application and training. “We strongly advocate training in recognising and reacting to hazards related to entanglement and the actions to take in the event the cable or load becomes entangled during a hoist operation, especially for dynamic hoisting,” said Matheson.

“Operators would never be able to simulate this type of emergency procedure and situational awareness type training during live flight flying evolutions, due to the high

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the benefits of dynamic hoisting are under-utilised for several reasons consequently, there is a possibility for the aircraft to inadvertently depart the scene with the tag-line still attached. “Although it seems obvious to release the tag-line, hoist system operators that are used to traditional hoisting are now being conditioned to transition

forward as soon as possible, and therefore aircrews should address the possibility of ‘what actions would the rescue specialist take as an emergency procedure if the aircraft jumps the gun and takes off with the tag-line still attached to the rescue device?’ If that tag-line is pulled off the deck and gets airborne it is highly likely it could get entangled in the tail rotor as the aircraft is flying away,” pointed out Matheson.

rescues due to fire and smoke. We provided this particular mission training to the Estado de Mexico Unidad de Rescate Aereo, and as odds >>

Rescue scenarios Examples of scenarios where dynamic hoisting is particularly suitable include clear area hoist extraction points that are free of obstructions such as maritime operations, and highaltitude hoist operations where there is possible risk of power issues due to variable winds and the operators want to reduce the risks associated with hovering the helicopter for long periods of time.

“Another scenario is high-rise

Air Rescue Systems

amount of risks involved and the impossibility of creating organic or staged events for cable entanglement, or power failures, and then cutting the cable during flight for training purposes.”

A common practice for aircrews employing dynamic hoisting is to transition to forward flight as soon as possible when the hoist load is clear of terrain and obstacles, and

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would have it, they responded to a live highrise incident in Mexico City shortly after and were able to perform multiple hoist rescues saving people from the top of a burning highrise,” Matheson told AirMed&Rescue. “This technique is very well suited [to this scenario] as it reduces the possible risk of ingesting smoke into the engines during a hover, and does not create significant sustained winds that would make the fire worse. We have also used this technique with the New Jersey State Police

to conduct hoist rescue training from a 165 ft construction tower crane.”

According to Ping of Travis County STAR Flight Dynamic, the technique is not just for special occasions: “We use it on all rescues.

Even when we modify the technique with a very short approach distance. Our crews have the authority to use both static and dynamic hoist procedures. We have found that training for static hoisting is not necessary; if you can perform a dynamic hoist you can manage a

static hoisting event. While we rarely use tag lines, we carry them in case a static hoist with tag line is needed.”

Indeed, dynamic hoisting may be used in almost every execution, even those requiring some component of static operations.

“There are basically no limitations to the use of dynamic hoisting. This operation can be executed even in canyons or above tall trees. The helicopter just needs to take the load above the tree top or the obstacles and whenever the axis is clear, the helicopter flies away while the hoist is taking in the load,” said Kreuzer.

Cockell of Air Rescue Systems agrees that a mixture of dynamic and static hoisting can be used to great effect: “Canopy insertion or extraction, for example, requires dynamic hoisting of the load to the canopy insertion point, then maintaining a static hoist position until the load has negotiated the height of

dynamic hoisting may be used in almost every execution, even those requiring some component of static operations the canopy and made it to ground. This ‘combination hoisting’ technique is used in many other hoist missions such as ship transfers, urban operations, power utility function and ‘vertical picks’. The overriding objective is to reduce the exposure and impact of the rotor-flow by minimising the hover in one place longer than required.”

Air Zermatt

Safety precautions Hoist operations almost inevitably entail the risk of entanglement during the approach and departure to the insertion/extraction site. “This risk is significantly compounded when applying dynamic hoisting during night time operations, be it aided or unaided, and consequently, we use a more conservative modified version of dynamic hoisting,” says Matheson. “Best practices for dynamic hoisting include the assessment of where the crews are at most risk and deciding which method will best address 1616

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that risk. We would also strongly recommend not doing double rescuer insertions, or making any high gravitational force/acceleration turns when performing insertions or extractions.

This safety concern is due to the subsequent G-loading and the associated cautions with the overload protection clutch system on various hoist models when the aircraft is operating in conditions outside the relevant external load operational flight envelopes.”

In addition to the traditional hoist failures, dynamic hoisting requires the development of two additional emergency procedures by the operators wanting to adopt dynamic hoisting.

“One is in case the load starts to spin (most likely because the helicopter has insufficient forward speed), then it is difficult to arrest the spin if the hoist operator continues to retrieve the load.

The procedure [in this case] is to tell the pilot to fly between 35-45 knots while letting the hoist cable out again to ensure it is out of reach of the downwash. The load will then stabilise, and it will be possible to hoist up the load once the helicopter has sufficient forward airspeed,” said Kreuzer. “The other emergency procedure is in case any obstacle is hit between the load

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and the hoist or between the load and the helicopter (a suspended cable, for example).

An immediate release of the load is paramount, and the cable cut away button should be on the hoist pendant instead of inside the aircraft on a panel. Gravitational force may pull the hoist operator outside the cabin, [and] this would make [it] impossible to release the load in time.”

Some of the other factors to consider before exploring dynamic hoisting are the size of the rotorwash produced by the aircraft, the power available to hover and the one engine inoperative (OEI) performance, the type and features of the automatic flight control system on the aircraft, the frequency of night time operations, and the speed and safety features of the hoist system, including the slip or reactive overload clutch.

“We would not recommend employing this method without understanding

all of the variables,” cautioned Matheson. “If an operator is interested in performing dynamic hoisting only because of spins and rotor wash issues, then we would suggest perhaps starting by utilising a tag-line to prevent spins when possible and practising the relevant emergency procedures for spins. For mitigating rotor wash, it may be sufficient to come to a higher altitude in the hoisting position, or move back and left from the scene when possible. If conducting dynamic hoisting were mainly to reduce exposure and risk to the aircraft and crews from possible power failure or OEI, we would strongly recommend evaluating the method further.”

Without doubt, risk managed and safetyorientated training is the overriding consideration in being able to perform dynamic hoisting to the degree required. Cockell told AirMed&Rescue that it is a case of ‘slow and steady wins the race’ when it comes to starting dynamic hoist operations: “Focus on team communications is paramount in developing a true dynamic hoisting capability.

This training should reflect the missions it is intended to respond to, and must be built upon robust safety management. Teams that lack experience should develop these techniques and competencies in a crawl, walk, run manner and only proceed to the next level when ample time in training and response has been amassed.”

Dynamic hoisting, then, is not to be underestimated in its complexities, but certainly those responders that do already practise such operations are fulsome in their praise of its benefits.

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INDUSTRY VOICE

Article published with permission from JEMS (Journal of Emergency Medical Services)/Penwell Corp.

CAN YOU REALLY PROTECT ALL PATIENT INFORMATION? Steve Wirth argues that, in reality, patient privacy can only go so far

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any communication practices play an important role in ensuring that a patient receives prompt and effective pre-hospital healthcare. Due to the nature of these practices, as well as the unique environment of emergency medical services (EMS) field medicine, the potential exists for the patient’s protected health information (PHI) to be disclosed ‘incidentally’. Incidental disclosure is part of the normal

Agencies must analyse their own needs and circumstances, and assess the potential risks to patient privacy course of providing care to the patient, or, put another way, is ‘incident to’ that care. A bystander may overhear an EMS provider’s conversation with another provider about the patient, see the care that’s being provided on scene, or overhear patient information being communicated to the 18 18

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hospital. These would be considered incidental disclosures.

Regulations in place The Health Insurance Portability and Accountability Act (HIPAA) isn’t intended to impede these customary and essential communications and practices. The regulations don’t require that all risks of incidental disclosure of patient information be eliminated. Instead, HIPAA adopts a commonsense approach, and permits certain incidental uses and disclosures of PHI to occur – as long as your agency has reasonable safeguards in place to minimise disclosures and protect the patient’s privacy.

The reduction of incidental disclosures can be achieved through various means. Below are five areas where incidental disclosures are likely to occur in the field, and suggestions for reasonable safeguards to reduce their impact: Verbal patient information Regardless of physical location, only discuss PHI with those who are involved in the care of the patient. When

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discussing PHI with patients, take reasonable steps to make sure that only those involved in the care of the patient are within earshot. If it doesn’t interfere with patient care, EMS providers should try to remove those not engaged in patient care before discussing.

Bystanders seeing a patient This may be unavoidable in the uncontrolled environment of EMS field medicine. The priority should always be caring for the patient. If you’re at the scene of an extended extrication and the patient is visible to the public, particularly the news media, it would be reasonable to use a tarp to shield the public and media from viewing the patient. Should you have curtains or screens that cover the patient compartment windows? There are real safety concerns for the crew and the patient if you can’t adequately see out the window. You shouldn’t do things to protect patient privacy if they interfere with your ability to safely provide care. Each situation needs to be evaluated independently. If you can shade the windows easily while still maintaining visibility, then do so. Newer technologies, such as mirrored windows and windows that can go from clear to opaque, are becoming more common and should be used if you have them.

Paper patient care reports (PCRs) All paper PCRs should be stored in secure areas when not in use. No paper records concerning a patient should be left in open bins or on desktops or other surfaces. Additionally, billing records, including notes, remittance advices, charge slips or claim forms shouldn’t be left out in the open. They should be stored in an area with access limited only to those who need the information for the completion of their duties.

Electronic PCRs (ePCRs) Computer terminals and other mobile devices should be secure, and staff members must be sensitive to who may be in viewing range of a monitor. All mobile devices such as laptops, toughbooks, tablets and cellphones should always remain in the physical possession of the individual to whom they are assigned.

Multiple patients Just as hospitals aren’t required to give every patient a private room, neither are ambulances limited to transporting only one patient at a time. In such a case, HIPAA requires that you take reasonable precautions to minimise the chance of an incidental disclosure of PHI. It wouldn’t be a HIPAA violation to communicate information about multiple patients while a patient can overhear; those are simply unavoidable incidental disclosures. Reasonable precautions might include making the radio transmission from the front of the ambulance and closing the door between the cab and the patient compartment.

Take action to limit disclosure Reasonable safeguards to limit incidental disclosures of PHI will vary, and may depend on many factors. Agencies must analyse their own needs and circumstances, and assess the

potential risks to patient privacy. EMS agencies should also consider the potential effects on patient care and other issues, such as the financial and administrative burden of implementing safeguards. The bottom line, however, is

HIPAA adopts a common-sense approach, and permits certain incidental uses and disclosures of PHI to occur this: all EMS providers and staff should be sensitive to the possibility of incidental disclosures of patient information and should avoid incidental disclosures to others who don’t need to know the information.

REFERENCES 1. Wolfberg D, Wirth S, editors. The ambulance service guide to HIPAA compliance, fourth edition. Page, Wolfberg & Wirth, LLC: Mechanicsburg, Pa., 2013.

2. U.S. Department of Health and Human Services. (2002.) 45 CFR 164.502(a)(1) (iii). Fact Sheet: incidental uses and disclosures. Retrieved Dec. 4, 2017, from www. hhs.gov/hipaa/for-professionals/privacy/guidance/incidental-uses-and-wdisclosures/ index.html.

STEPHEN R. WIRTH, ESQ., EMT-P Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC, which represents EMS agencies throughout the US, and a cofounder of the National Academy of Ambulance Compliance. In a distinguished public safety career that spans over four decades, Steve has worked in virtually every facet of EMS – as a firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive – and was one of central Pennsylvania’s first paramedics. He is a contributing writer for JEMS, (where he serves on the editorial board), EMS Insider, EMS1 and EMS World. Steve teaches EMS law for the University of Pittsburgh EMS degree program and is also past Chair of the Panel of Commissioners for CAAS, the ambulance service accrediting body.

Steve can be reached at swirth@pwwemslaw.com.

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LITTLE RIPPER RESCUE:

BEHIND THE SCENES Dr Joetey Attariwala looks into the story behind the UAV rescue in Australia

On 18 January 2018, Australian lifeguards at Lennox Head, New South Wales (NSW), carried out the world’s first drone rescue. The drone, or unmanned aerial vehicle (UAV), took only a few seconds to rescue two distressed swimmers by way of dropping inflatable rescue pods in what is said to be the first recorded instance of a drone deploying a Search and Rescue (SAR) payload in an actual emergency. It was sheer coincidence that the drone happened to be at Lennox Head that day for a local media launch as Jai Sheridan, 2017 Lifeguard of the Year, was demonstrating the UAV’s capabilities.

Service progression The implementation of UAVs into the Surf Life Saving NSW (SLSNSW) operation is not something that happened by chance. The organisation’s three-year organisational strategic goals refer to much greater use of technology and innovation in surf lifesaving operations, so it could be said that it was inevitable that drones would be introduced into beach operations. However, it is not something that just simply occurred, but is rather the outcome of a disciplined approach, a great deal of trial and error, and a strategy of attempting to achieve specified outcomes.

In the preceding two years before the rescue, UAVs from different manufacturers were tried and tested with varying degrees of success – and failure. However, as UAV technology has evolved and improved, so too has reliability, robustness and ease of use – all essential factors to consider when implementing a solution that is required to save lives, and where every second counts. Whilst The Little Ripper rescue drone underwent extensive development and various prototype iterations before the version responsible for effecting the world’s first drone rescue was released for trials into the Surf Life Saving NSW UAV programme, it has wider expectations for UAVs. 20 20

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Finding the right solution Kelvin Morton, Air Boss at DroneAdvantage Australia and Surf Life Saving NSW UAV Project Manager, explained: “The Little Ripper UAV is one component of a wider scope to assess the capabilities that UAVs have to offer. Whilst it was successfully able to save the lives of the two teenage boys from drowning in just a few seconds, there are other aspects of surf lifesaving operations for which the current version of The Little Ripper may not be the most appropriate to respond with. For example, there are specific requirements when searching for missing persons or trying to locate a body in bad weather for which The Little Ripper’s effectiveness is reduced.” SLSNSW is this looking at what improvements can be made to The Little Ripper or consider other UAVs that might be a better fit for those particular scenarios. Morton added: “I take the view that there is no ‘onesize-fits-all’ solution to SAR when it comes to UAVs, but rather, you pick the best tool to do the job.”

An important consideration to keep in mind is that Surf Life Saving NSW has a UAV solution – with the operative word being ‘solution’ – and The Little Ripper UAV is a component which makes up part of the UAV rescue solution. UAV type, training, operating procedures and support are other critical areas that have to be tested, so Surf Life Saving NSW emphasises the need to define requirements up front before starting to identify a UAV solution.

“The Little Ripper is a nickname for a DJI M600 Pro drone, which is outfitted with a high-definition zoom camera, siren, and a release mechanism which holds two water-activated SOS Marine Rescue Pod (ULB) which inflate to 6.5 feet in length. But there are other components that make up the UAV solution. As part of our trial, we are also evaluating machine learning AI Shark Spotting algorithms, power generators, battery capacity, speed chargers, data collection management tools, UAV training content and

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assessment criteria, scenario based operational procedures, UAV support requirements and a lot more,” said Morton.

It is extremely important that requirements are properly and fully identified up front, since they will drive a solution and inform test case scenarios to evaluate against. “Only then,” Morton continued, “can you properly make an assessment as to whether you have the right solution that meets your needs. Some examples of requirements would be things like the UAV must have a proven history of less than 0.5 per cent power failure rate or 0.1 per cent motor failure rate; the UAV must have autopilot capability; and it must provide real-time video feed or thermal images to police and rescue units.

“UAV requirements specify what needs to be achieved by the entire UAV solution. The risk of not having clearly defined and prioritised UAV requirements in place prior to identifying and implementing a UAV solution will manifest in an initiative delivering a solution which is not fit for purpose. This dramatically increases the risk of failure through not having the required UAVs, equipment, operational processes, training, support or organisational structure to meet business needs. A UAV solution should

IT IS EXTREMELY IMPORTANT THAT REQUIREMENTS ARE PROPERLY AND FULLY IDENTIFIED UP FRONT, SINCE THEY WILL DRIVE A SOLUTION AND INFORM TEST CASE SCENARIOS TO EVALUATE AGAINST be the focus, rather than just the UAV. There is no point in deploying a state-of-the-art UAV designed to save drowning swimmers by dropping a self-inflating pod if the pilot dropping the pod from the UAV cannot consistently drop it so that it hits the water close enough for the swimmer to grab on to.”

Getting it right first time In speaking specifically about UAV platforms, Morton urged potential users of SAR drones to carefully consider their needs before choosing a definite product: “Setting your sights on a specific UAV from the outset is not something I would recommend. The technology is expensive and changes so fast. Each operational environment is also different. What’s most important is that you have a structured approach to identifying and implementing a UAV solution and that should always start with ensuring that requirements have been defined and you assess any UAV solution against them.”

No other surf lifesaving organisation anywhere in the world is implementing a UAV solution close to the size and scale as Surf Life Saving NSW. Because of this, there are no other sources they can refer to for any for lessons learned to guide their journey. It is for these reasons that this article is meant to give insight into the story and background behind the rescue such that other organisations can focus their energies from lessons learned by Surf Life Saving NSW. The SLSNSW trials continue through 28 April, at which time a comprehensive review will be conducted.

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DORSET AND SOMERSET AIR AMBULANCE Although the first UK air ambulance charity was formed in Cornwall in 1987, the pace of change since then has been quite staggering. In 2000, a grant from a fund established by the Automobile Association (AA) of £14 million was distributed to existing air ambulances and to those who required ‘seed funds’ to start. Dorset and Somerset Air Ambulance (DSAA) was one of the latter. The service launched in March 2000, operating out of Henstridge in Somerset in a BO105 with two paramedics and a pilot as crew. The aircraft, pilots and engineering support all came from Bond Air Services and the paramedics were seconded from the Ambulance Service.

On the first day of operations, DSAA came online at 08:00 hrs and at 08:52 hrs, was tasked with its first mission.

In the first three years of operation, aircraft costs were met by the AA grant and medical costs were met by the UK’s Ambulance Service. Charity staff were therefore able to concentrate their efforts on establishing a fundraising model that was resilient, rather than be pressed into short-term gains. This model still operates today.

The clinical model DSAA’s original model of operation was pretty much the standard of the time and changed very little for many years. The principle was to get to the patient as quickly as possible, carry out immediate assessment, stabilise them and package them for transportation to hospital. As the years have passed, what was initially a single model for delivery has developed into a multitude of models. Variances in aviation and clinical governance, ownership of aircraft and employment of clinical staff are all now part of the mix. Over the years, there have been cries for a more consistent, national approach. Economies of scale in procurement and ease of understanding for

Funding, staffing, logistics and priorities for categories of care are all subject to local influences bodies such as the Department of Health and the Civil Aviation Authority are but two arguments for taking that line. However, it fails to recognise why such variability exists in the first place.

The way DSAA operates is subject to several variable factors – geography is an obvious one, but the key factor is that of the UK National Health Service (NHS) environment in which it sits. Funding, staffing, logistics and priorities for categories of care are all subject to local influences and shape the environment in which an air ambulance operates. >>

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Clinical development In 2011, DSAA started looking for ways to further develop its clinical capability. Given that it remained strategically committed to a twin paramedic model of delivery, it was decided that the best course of action was to upskill the paramedics already working on the helicopter.

Thus, the crew undertook post-graduate level education, which would provide them with a qualification they could take with them anywhere.

Bill Sivewright, Chief Executive of the DSAA, said: “We elected to fund a course accredited by the University of Hertfordshire which would be delivered onsite at our Henstridge airbase. A ‘flying faculty’ of consultants would act as mentors for the paramedics both on land and in the air. The Service Level Agreements required to secure the doctors from local hospitals enabled us to establish close working relationships with them and has benefited our patients who experience a much smoother transition from air ambulance into hospital.” Having secured approvals from South Western Ambulance Service NHS Foundation Trust (SWASFT) and the University (which had never run the education this way before), the course started in 2013. From the outset, data was gathered to examine the effect that having doctors in the mix had on clinical delivery. Within a very short time, it was apparent that the enthusiasm of the paramedics for the exposure they were getting to high-grade consultant mentorship in real-world experience, coupled with the consultant’s complete buy-in, was delivering much more than the sum of the parts. In 2015, DSAA’s commitment to this project was recognised nationally when it won a Health Service Journal Award for Improving Outcomes through Learning and Development.

The charity was not, of course, the first organisation to have doctors as part of the team. However, terms such as ‘Doctor on Board’ and ‘Doctor Led’ did not sit comfortably with our team ethos. So, in 2015, it embarked on a restructuring exercise that saw the formal creation of a Critical Care Team.

The aircraft The development of the service in aviation terms has been much more straightforward than that of clinical development. It started the service flying the BO105; in 2007, the ‘upgrade’ was made to the EC135 – a much more modern aircraft, offering more space, more payload and improved safety. “This aircraft became one of the most prolific air ambulance platforms and served as a fantastic development tool for our service,” noted Sivewright. So, if the EC135 was so good, why did

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another change occur?

In April 2012, the National Trauma Network was established by the NHS. This pooled expertise and facilities into Major Trauma Centres (MTC) around the country and became the preferred destination for all patients suffering major trauma. Without a MTC in Dorset or Somerset, patients who would have previously been taken to the county hospitals would now have to be flown to Southampton, Bristol or Plymouth.

Although the flight-time increase could be measured in tens of minutes, that is a very long time in the life of a critically ill or injured patient.

Therefore, the crew needed the ability to fully treat a patient en-route to hospital. “Further examination of the requirement also revealed something quite simple,” added Sivewright. “If the patient was at the centre of our thinking, and on scene the patient is at the centre of the ‘treatment zone’, should the patient not be at the centre of the cabin of the air ambulance?”

Once this logic was applied, the choice of a successor aircraft was quite straightforward, he explained. That is not to say that factors such as cost, safety, and potential for night operations were not considered, but only one platform offered DSAA the cabin format to meet its fundamental requirement – the AW169.

Sivewright said: “During our first 17 years of operations, Bond Air Services (latterly Babcock Mission Critical Services) acted magnificently as our air operator with both the BO105 and the EC135. We are now delighted to be in partnership with Specialist Aviation Services. Not only have they demonstrated their significant commitment to the AW169, they have also introduced us to the MD902 whilst we waited for the European Aviation Safety Agency to certify what we consider to be the most advanced air ambulance helicopter in the country today.”

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Bill Sivewright, Chief Executive of DSAA, spoke to AirMed&Rescue about the service’s operational capabilities How wide is DSAA’s geographic response area?

DSAA covers an area of approximately 2,500 sq miles. The number of incidents where the skills of an air ambulance team are needed is rapidly increasing, as is the number of serious road traffic incidents that involve multiple casualties.

How is the helicopter staffed typically?

Our cohort of clinicians (12 doctors and 10 Specialist Practitioners in Critical Care), include a mixture of Senior Emergency Physicians, Intensive Care Consultants and Anaesthetists and Specialist Practitioners in Critical Care. All form part of the air operations crew and, as part of their role, assist the pilot with navigation and operation of some of the aircraft systems.

The doctors are predominantly drawn from NHS Hospital Trusts across the region and the Practitioners from the SWASFT. More recently, some clinicians have joined us from further afield, broadening the skills and experience of the team. Our pilots are provided by Specialist Aviation Services Ltd, who operate our aircraft.

How many staff members does DSAA have?

The Charity is managed by full and part-time staff of 16 (13 full-time equivalent).

How active is the service in terms of average number of missions per day?

Our service is operational 19 hours a day (07:00hrs – 02:00hrs), 365 days a year. Since our launch, we have flown more than 12,500 missions. We are tasked by a dedicated Helicopter Emergency Medical Service (HEMS) desk located at Ambulance Control (paid for by the South West Air Ambulance Charities) and can attend up to eight or nine incidents in a single day. From our base at Henstridge, we can be at any point in the two counties in less than 20 minutes. More importantly, the helicopter can, if required, then take a patient to the nearest Major Trauma Centre in the South West within a further 20 minutes.

What do you hope to do in the future to ensure you can continue to provide this vital service to UK residents?

The specialist nature and extremely high clinical standards required for Critical Care means that the pool of suitably qualified personnel is limited. In order to ensure continuity of service, we work closely with SWASFT and all our local Acute Trusts, including conducting joint recruitment for consultant posts in hospitals. Giving candidates the incentive of working 50 per cent of their time in hospital and 50 per cent with DSAA has helped attract highly motivated and qualified individuals to the benefit of both organisations and, more importantly, patients.

Given the relatively small proportion of the total pre-hospital patient volume actually attended by air ambulances, I feel it most unlikely that we will ever see HEMS being directly funded by Government. However, air ambulances do receive some support from their local ambulance services. The nature of that support varies considerably around the country, but in the South West extends to the provision of clinical governance, some clinical personnel, drugs and equipment. It might only be a small part of the total funded by the Charity, but we value it as a significant commitment to what we do on behalf of patients.

Avionics in the AW169 used by DSAA • • • • • • • • • • • •

Full digital glass cockpit with 3 Active Matrix LCD 10” x 8” Displays Dual Aircraft Monitoring & Mission Systems 4-axis dual-duplex digital automatic AFCS Next Generation Multi-sensor Navigation system (dual Rad Alt, dual GNSS SBAS and GBAS provision, WAAS/EGNOS) Extended range of communication and surveillance equipment (included Enhanced Transponder/ADS-B) Traffic and terrain avoidance systems (TCAS II, HTAWS/SVS) Digital Map Emergency Avionics systems (CVR/FDR, ELT) HUMS (Health and Usage Monitoring system) HFDM (Helicopter Flight Data Monitoring) Direction Finder Lights NVG compatible

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INFECTION FIGHTING THE HIDDEN ENEMY Air ambulances carry patients with many different illnesses and injuries, and ensuring that an aircraft is meticulously clean is essential for both patients and crew There are many different approaches to disinfecting an aircraft, from the products used, to how regularly a deep clean is carried out. There may not be one ‘right’ way to do it, but it’s interesting to see the different approaches taken by air ambulance operators around the world.

Stuart Cox, a Royal College of Nursing Critical Care and Flight Nursing Committee Member, told AirMed&Rescue: “One protocoled approach should not apply to all services or all types of airframes. It depends on their nature of operation, remit, and the countries the air ambulance is operating. Regardless [of the scope of operation], all protocols must be comprehensive and evidenced based, utilising the latest clinical guidance’s in the country or countries of operation.”

The increasing number and varieties of viruses and germs, partly due to the increase in travel, is a key challenge. Michelle Black, Nurse Unit Manager and Flight Nurse for Lifeflight Retrieval Medicine in Australia, whose role is to ensure that the company’s clinical practice meets national standards for quality and safety, listed pandemics and Ebola as some of the main challenges for aeromedical crews in recent times.

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retrieval of patients from all around the world, the prevalence of diseases that had been eradicated from First World countries are being encountered,” she said.

Mentioning the increase of diseases such as swine and avian flu and Middle East Respiratory Syndrome, Gert Muurling, CEO of GlobalMED International in Germany and founder of the International Academy for Air Medical Education, also talked about ‘the spread of multi and extreme drug resistant tuberculosis (TB)’, a disease that he says is often diagnosed months after an infected person starts to show early signs of weakness.

Cox said that before even discussing disinfection of a plane and the protocols required, it is worth knowing (as much as possible) the microbiology of the patients carried: “If you cast your mind back to 2012,” he said, “it was an air ambulance that brought the UK’s first Coronavirus in, seemingly unaware what the patient had.”

Scrubbing up well Muurling, who in January 2018 also became the Medical Director for Air Alliance’s Germany base, explained: “For the air ambulance industry, most initial disinfecting will be done on the flight back from the admitting hospital to base. Then, after every patient flown, the equipment needs disinfection (typically of blood pressure cuffs, ECG cables and pulse oxymeters).” Stretcher handrails deserve the most attention, he added,

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as they have ‘the highest proven bacterial colonisation’.

Cox told AirMed&Rescue that ‘all air ambulances should be decontaminated between each mission regardless of the patient, as the crew may not know if they have an infection’, adding: “Any air ambulance mission needs time built into the schedule post-flight for the plane to be decontaminated fully, and this should be undertaken when the plane is on the ground. Deep cleaning needs scheduled downtime where the plane is taken offline.”

With limited available time to disinfect an air ambulance cabin between missions, there are nonetheless minimum requirements for companies to meet during a clean. Muurling said: “We refer to national hygiene guidelines for hospitals, rescue organisations and commercial airline guidelines in our hygiene plan.” Accreditation organisations, such as the European Aeromedical Institute (EURAMI), also require certain standards from their accredited members – for example, companies must provide an aircraft cleaning policy, with stipulations on how often each aircraft is routinely cleaned, deep cleaned and decontaminated, and swabbed for microbiology testing. The EURAMI standards have further advice on floor coverings, ceilings, indoor walls and patient compartment doors, which should all be lined or made in a way that makes them easy to clean and disinfect.

Cox agreed that cleaning protocols should be evidence-based and auditable. Minimising the spread of infection is key, he added, and a range of control measures can be employed to reduce environmental

contamination in air transport. For the patients themselves, strategies can include use of a closed tracheal suction system for all patients receiving mechanical ventilation. Infectious patients can also potentially transmit germs through contact with equipment, surfaces, and materials, which is also why ‘medical staff should not shake out bed linen’, said Muurling, adding that correct pre-flight procedures should include ‘a skin-friendly disinfection fluid for the patient’s hands and underarms’.

Multi-resistant organisms are rapidly changing and becoming more prevalent Deep cleaning The time an air ambulance company spends on a standard clean can vary, but it usually lasts about one and a half hours at European Air Ambulance (EAA)/Luxembourg Air Ambulance, said Didier Dandrifosse, who heads the company’s medical department, and who also works >>

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as a Graduated Nurse specialised in Intensive Care and Emergency Medicine. However, he said, time is not the most important factor: “More important is the infectious status of the patient and the potentially contaminated aircraft interior.” Depending on the severity of the medical case and how infectious the patient is, and whether a patient carries or may carry a multi-resistant germ, standard disinfection may need to be backed up by a deep clean.

The way companies perform a deep clean can, however, differ. Muurling said: “Some companies say that fogging of the cabin constitutes a deep clean; others empty all drawers and cupboards and clean them or even take out the seats.” More and more assistance companies require proof of disinfection, asking the air ambulance companies to take swabs regularly, he added.

How often air ambulance companies perform a deep clean also

varies, depending on the type of patients flown, company policy and aircraft interior, among other things. At EAA, for example, deep cleans are scheduled once a month and are also carried out following each transport of an infectious – or potentially infectious – patient.

At LifeFlight in Australia, a deep clean takes place either every six to nine months when the aircraft undertakes its major services, or when the cabin has been contaminated with bodily fluids, such as during

standard disinfection may need to be backed up by a deep clean major haemorrhage or burns cases. The crew at Flying Doctors Asia, meanwhile, perform a deep clean after every contagious case, or every two weeks. Since microbiological testing is not always conducted in all countries, ‘it is wise to do a deep clean regularly once every week or second week, depending on the number of patients flown’, said Muurling.

Product choice How often to clean, and how long a deep clean lasts for, is a matter of opinion, and then we move onto the product used to clean – another area where there are differences in approach. Stuart Cox said: “The decision of an appropriate product is difficult as most do not meet aviation approval for the surfaces they are used on. It depends on many factors such as the aircraft interior surfaces and appropriate approval.

Some services use an aerosol-based solution, however, they need to

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be aware of any effect nebulisation/aerosol/fogging may have on the avionics within the airframe.”

Jet Rescue Air Ambulance in the US uses the Saniswiss automate aHP biosanitizer as part of its minimum cleaning requirements between missions, but deep cleans its aircraft once a month. “Even if we just had a deep clean in between missions due to an infectious patient, the Quality and Assurance Manager, with the Safety Officer, would perform another deep clean,” said Irina Agapi, Program Director. The company has its own infection control policy and procedures manual and also follows the Centers for Disease Control and Prevention Guidelines for Disinfections and Sterilisation in Healthcare facilities.

Crew need to be able to access all areas needing disinfection during such a deep clean, and an EAA aircraft, for example, will be unloaded completely, after which it is vacuumed and all surfaces disinfected, explained Dandrifosse, who further said that all disinfections are monitored and recorded by the company’s Head of Medical Department. For disinfections, the company uses a comprehensive range of hospital-grade products from Huckert’s International that helps

Crew need to be able to access all areas needing disinfection it to protect against a variety of different viruses. “It is important to choose a non-corrosive disinfectant, but one that is still able to kill all ‘live’ bacteria and viruses,” said Dandrifosse, “since medical equipment or aircraft interiors can be damaged by aggressive cleaning products.”

During a deep clean at LifeFlight, staff also remove stretchers and all equipment, after which ‘all parts of the aircraft cabin are damp dusted

and vacuumed, and an intense wash of all aspects of the cabin with the hospital-grade disinfectant is undertaken’, said Black. “Scientific evidence shows that effective disinfection is one of the most important aspects in preventing the dissemination of multi-resistant organisms,” she commented, explaining that the products used by Lifeflight – STERI-7 – are also utilised by Queensland hospitals, and not only kill multi-resistant bacteria, but are also ‘documented as being efficient in eradicating fungus and viruses, as well as able to continue to kill pathogens for seven days post application’. A further benefit, according to Black, is that the products can be stored easily within the aircraft and require no rinsing.

During a deep clean at Flying Doctors Asia, staff use a cleaning solution of 70-per-cent alcohol and five-per-cent chlorhexidine (an antimicrobial), and remove the cabin carpet, soak it with the disinfection solution, and let it dry. They also thoroughly clean the cabin seats, stretcher, windows, ceiling, and other interior surfaces, allow them to dry, then repeat the process, explained the company’s Medical Director Dr Cheong Yee Hung (Kent), who has responsibility for Flying Doctors Asia’s aeromedical staff training, quality, and infectious control.

Capital Air Ambulance in the UK, and Westpac Helicopters in New Zealand, make use of a product called Zoono – a water-based antimicrobial solution containing a quarternary ammonium compound which, once dry, bonds with the surface to provide protection against bacteria, fungi, mould, yeast and viruses. It has proven effectiveness against E.coli, Staph, MRSA, H1N1, MERS and norovirus and has been tested an approved for use within aircraft environments by both Boeing and Airbus.

James Milnes of Zoono explained how it differs from other cleaning products: “Standard disinfectants are used to disinfect surfaces as a one-off operation to kill any harmful pathogens that may be in >>

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the compartment, especially if the patient has had an infection. After the disinfectant is used, it is no longer effective against pathogens contaminating surfaces post application. Zoono technology is a unique sophisticated polymer-based disinfectant that, once applied, permanently binds with the surface and once dry, provides continuous antimicrobial protection against harmful bacteria, viruses and fungi for up to 30 days, protecting both patients and staff from potential infection.” The use of standard disinfection products provides only a short-term solution to disinfection, he added, whereas Zoono products provide a long lasting antimicrobial ‘shield’, significantly enhancing disinfection procedures.

Some products that require surfaces to be kept wet for several minutes for the required disinfecting result can interfere with aviation safety, stated Muurling, ‘especially when fluids drain between the floor panels’. When using a disinfecting fluid with an alcohol base ‘one should not carry out a spray disinfection during flight for the risk of creating an explosive aerosol’, he added. To deal with some of these challenges, and particularly the time-consuming process of aircraft disassembly, there has been an evolution in the modification of specific air ambulance interiors.

Unique challenges When it comes to disinfecting an air ambulance, crews can encounter specific challenges related to the cabin environment itself, particularly on some older style air ambulance aircraft, as well as those used by commercial airlines.

Said Dandrifosse: “Dedicated air ambulances are transportable hospitals in which hygiene and disinfection are paramount, but this might not

Aeromedical staff should also know to undertake a multi-barrier approach in the way of hand washing, personal protection and also disinfection always be the case on charter aircraft being used now and again for patient transfer operations.” Many air ambulances are multi-use, and one aspect of such aircraft is that they are often carpeted, he said, which is more difficult to keep clean. Compared to a ground ambulance, air ambulances often also have more hard-to-reach and hard-to-clean areas and surfaces, agreed Muurling, who also highlighted the issue that many air ambulances were ‘not originally built to fly patients, but to provide a comfortable environment for well-paying passengers’. According 3030

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to Stuart Cox, “Carpets should be removed before air ambulance operations, and an airframe should be considered to be the same as a hospital environment, and therefore bespoke flooring should be used and covers for areas difficult to decontaminate such as rails for seating.”

All of the aircraft used by LifeFlight have had absorbent materials such as cloth and carpets removed. “I have also seen the introduction of storage systems for quick removal in other aircraft such as on Royal Flying Doctors Service aircraft. They are starting to appear in air ambulances around the world and have revolutionised the ability to keep aircraft clean,” said Black.

Muurling has also noticed, as a quality auditor for EURAMI, that many companies have now ‘installed a (permanent) easy-to-clean floor cover’, or use ‘floor covers that will be exchanged at their base’, as well as ‘an acrylic glass protection that can be easily disinfected on the cabin side next to the stretcher’. At EAA, all aircraft carpet has been replaced with an easy-to-disinfect synthetic flooring, and custom-made ionised aluminium medical cabinets have been installed where traditionally the aircraft model would have housed a kitchen or bar area. Its newer style aircraft also now have washable seat covers, single-use patient bedding, and easy-to-clean transfer bags that have been specially designed for medical requirements, explained Dandrifosse.

The human touch Crew may use the best products around, and work with easier-to-clean surfaces, but they still have to apply disinfection methods properly. Dr Cheong said: “I think the biggest challenge of all time [is] human noncompliance with infectious control policy, leading to spread of infection.”

Dr Cheong was involved in the transfer of 150 patients during his work with the aeromedical transfer service at a hospital in Malaysia, and stated: “It is always important to closely monitor the disinfection process.”

Listing correct protocol as one of the reasons why the value of staff training should not be underestimated, Muurling, who also provides air medical training on hygiene and transferring infectious patients at both the International Academy for Air Medical Education and the German Red Cross, argued that it pays for crew members and pilots to know,

FEATURE

for instance, that by using a surgical mask on an infectious patient and an FFP3 mask with an expiration valve for medical staff, protection against the transmission of such illnesses as measles, TB and chickenpox through small aerogenic droplets can be achieved. “As most air ambulance jets have the engines at the tail, ventilation in the cabin is from back to front, and with no real separation between the cabin and the cockpit, it is not wise to fly these patients without special protective infection devices,” he said. “Even Ebola, Lassa and other haemorrhagic fever viruses are transmitted by droplets (saliva, sweat, blood), so distance means safety.”

Suitably trained and experienced air ambulance crew would also know to leave their contact details at the receiving hospital in case staff there identify a potential risk of infection after admission of the patient, said Muurling. Aeromedical staff should also know to ‘undertake a multi-barrier approach in the way of hand washing, personal protection and also disinfection, as this prevents multi-resistant organism dissemination’, added Black. And it’s not just medical crew – pilots often help load patients onto aircraft, so they need to be issued with suitable PPE, and ground staff too.

Innovative solutions for the future There may be plenty of challenges that air ambulance crew have to deal with on a daily basis when it comes to keeping aircraft clean between missions, but, as Black said, these challenges have also pushed forward positive changes with regards to innovative cleaning and disinfecting solutions.

“The outbreak of Ebola gave rise to the challenge of retrieving patients without contaminating the retrieval teams and pilots; and whilst the implementation of specialised transport pods and policies was challenging and time consuming, it saw the successful retrieval of many Ebola patients around the world by different aeromedical companies.”

For the future, Dr Cheong envisions UV-light exposure as a process of cleaning and disinfection: “Probably after the cleaning with disinfectant, a device with UV-light can be switched on and placed in the cabin for 10 to 15 minutes,” he said, adding that while it is not something that is being used in his company’s region or country yet, he has found UV-light exposure being used in some hospitals in Russia for disinfecting wards.

According to Muurling, there is potential in ‘special materials with a certain coating that will reduce adhesion of germs’. Although he wondered whether something like that would be necessary with the current disinfection options available: “It is a question of how much more insurance companies are willing to pay per flight hour to have things like that installed.”

One thing remains for certain, and that’s the fact that aircraft cleaning and disinfecting will remain a challenge. As Dandrifosse put it: “People travel to more exotic destinations and viruses travel faster across the world, and [the air ambulance industry] does not have the luxury of sitting back and relaxing. We cannot prepare for all eventualities in advance, but we have to stay alert to be able to cope with new infectious diseases and virus mutations.”

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Life before limb forward-thinking surgical solutions by air Erik Bornemeier NREMT /BSEM describes how training for the worst scenarios can lead to better outcomes when it comes to in-field amputations There are only a few regions in the US that have solid protocols when it comes to in-field amputations. In Utah, a joint agency consortium, along with the University of Utah, have put modern protocols to the test.

The problem Removal of a patient from the scene of an accident needing in-field amputation(s) presents rescuers with many problems and questions. Without protocols and training, it is easy to get stuck into the ‘analysis paralysis’ phase of the rescue, which could lead to prolonged patient extrications, worse outcomes, and possibly death. Many first responders encounter the absences of solid directions to follow when it comes to extricating a patient from the scene of an accident involving an entrapped victim. This problem is exacerbated with the lack of effective training and access to the correct materials for the job, and this is even more true in rural communities. In pre-hospital emergency medical services (EMS), in-field amputation is a low-frequency, high-risk event that warrants a systematised approach. An evaluation in 1996 discovered that the majority of EMS agencies did not have protocols, nor did they have sufficient

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training and supplies for such an event.1 Of over 200 emergency centres polled, 143 responded and noted the following: Over a five-year period, 26 field amputations were performed The most common reason for amputation was a motor vehicle crash 53 per cent of amputations were performed by a surgeon, 36 per cent by an emergency physician and 12 per cent by ‘unknown’ No training was available for this procedure Only two EMS systems at the time had known existing protocols.

So, the problem presented itself, and agencies across the US started to develop or adopt protocols and checklists that would aim to find answers to questions such as: how long do you work on a patient in the field in order to save a limb, how do you perform the amputation, and who has the ability to perform the procedure?

The solution The State of Utah is divided into 29 counties, contains roughly three million people, and geographically, is the size of England and Scotland combined. The population is densely centered in the Salt Lake Valley or scattered in rural agricultural communities. There are only three Level One trauma-rated facilities, and one of those specifically is dedicated for paediatrics only. Following lessons learned from historical rescues, and utilising multiple articles on in-field amputation, the University of Utah AirMed and Trauma Service developed a comprehensive guide, which clearly defines how to prepare and respond to pre-hospital field amputation. This programme was developed as a regional response with over a 200 nautical mile reach for surgical emergencies specific to counties without a Level One trauma facility, and critical to this protocol is the use of an air ambulance service.

The University of Utah Hospital is a Level One trauma facility that has the surgical staff on hand to deploy a quick response amputation team using AirMed, while AirMed has the resources and

SPECIAL REPORT

equipment to get the surgical staff to the scene in a timely manner.

How the AirMed policy works When a flight request is made for a field amputation, it is done through the AirMed Flight Centre, and goes as follows: • Flight Centre to notify the University of Utah Medical Centre (UUMC) emergency department (ED) Charge Nurse that a field amputation is needed • Charge Nurse to call for a Level One trauma activation and flight time from UUMC to the scene.

• On-scene flight team to contact the ED Charge Nurse and ED attending position about the request.

• One AirMed staff member to accompany the trauma surgeon in a second aircraft • Prior to the surgeon’s arrival, 2gm cefazolin (Ancef) should be administered • Prior to the surgeon’s arrival, a tourniquet should be placed on the extremity being amputated; if the amputation is being done on the thigh, consider using two tourniquets • AirMed to provide the trauma surgeon with a helmet/headset for communications while in flight.

• The trauma surgeon to both retrieve and return the appropriate flight attire and field amputation kit, and blood product • AirMed personnel to intubate the trauma victim and maintain sedation as per guidelines • Upon in-field amputation, the patient will be taken to the University of Utah Health Centre for additional trauma care.

Putting in the practice On 6 November 2017, The University of Utah and a joint agency training force consisting of Layton City Fire, Davis County Sheriff, Utah Training and Education Center (UTEC), AirMed, and North American Rescue came together to practise dealing with in field amputation. The following scenario was

built by Utah Training and Education Center: Reports of a 70-year-old male who was working at a construction site when large concrete debris shifted and trapped him. To complicate things, he also has a piece of metal in his leg pinning him to the ground.

The morning of the training was cold – 300F – and cloud cover was off and on with light snow. There was a real-world concern of hypothermia to role players, so precautions were taken to keep people warm. The use of actual people as role players and victims proved invaluable to the quality of training as it forced EMS personnel on the ground to ‘engage and interact’.

In addition to live actors, UTEC had created realistic body limbs out of animal bone, pork loins, PVC tubing and pig skin to simulate the tib/fib area of the leg and fastened this to a 70-year-old amputee role player.

The scenario was designed to be performed twice.

On the second iteration, lessons learned from the first were polished and the best practices continued.

In the first round, EMS personnel that arrived were shocked to find a realistic event staged, but after three seconds of ‘wide-eyed surprise’, immediately engaged and immersed into the scenario. They followed their protocols and assessments. When they determined that the patient could not be moved, they followed the new protocol and requested the surgical team and helicopter transport.

Within 10 minutes, the surgical team was in the air and responding to the scene. The surgeon arrived with O-negative blood and the

equipment needed to extricate. Again, the surgeon was surprised to find an anatomically correct leg to amputate. This allowed the surgeon to put equipment to the test and prove its effectiveness.

Upon extrication, the patient was packaged and flown to the hospital, where the scenario continued through the assessment in the emergency room.

In each of the two scenarios, teams commented

on how beneficial it was to practise through each of the steps and validated the effectiveness of the protocol. Because of this training, the EMS agencies on the ground and in the air have a solid plan to respond to in-field amputation emergencies. This equates to faster, more effective patient care in our region. Former US President Abraham Lincoln wisely stated: “By general law, life and limb must be protected; yet often a limb must be amputated to save a life; but a life is never wisely given to save a limb.”

Reference 1. Kampen KE, Krohmer JR, Jones JS, et al. In-field extremity amputation: Prevalence and protocols in emergency medical services. Prehosp Disaster Med. 1996;11(1):63-66.

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Based in Mexico, Jet Rescue provides international fixed-wing air ambulance services to insurance and private clients.

James Paul Wallis spoke to CEO Carlos Salinas to find out more about the company’s progression and future plans With its headquarters in Mexico City, Jet Rescue positions itself as the largest fixedwing air ambulance company in Mexico and Central America. The service has been flying patients since 1994, specialising in long-range, critical-care air ambulance missions using its own fleet of dedicated medical aircraft. Since its foundation, it has completed thousands of patient transports around the world in its own aircraft, and also provides commercial medical escort and ground ambulance services. Jet Rescue is the marketing brand for Mexican air operator’s certificate holder Med Jets S.A. de C.V. The service has been a member of the US-based Association of Air Medical Services since 2011.

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Mexico and the Caribbean, including Cuba.

The firm says it offers the best response time in the industry (less than two hours) to popular destinations such as Cozumel, Cancun, Puerto Vallarta, Cabo San Lucas, Acapulco, Ixtapa, San Felipe, Puerto Peñasco and Guerrero Negro. In the winter, Jet Rescue also flies from a seasonal base in Guadalajara, Mexico, and has a permanent base across the border in Miami, US. Given the emergency nature of the business, ensuring that evacuation services can be provided in a timely manner is essential.

Salinas commented: “In Mexico and other places in Latin America, the airports are not opened 24 hours – they close at night. With the right relationships and contacts, we are able to open those airports to operate emergency missions at night.”

Calls come in via Jet Rescue’s 24-hour mission control centre, which is run by Chief Flight Coordinator Rafael Meade.

Medical expertise According to Jet Rescue, its success and efficiency depends on its most important asset:

its people. The medical side of the business is headed by medical director Dr Xochitl Padua, a physician/paramedic who specialises in critical care and internal medicine. All medical personnel undergo initial orientation and ‘uphold stringent continuing education requirements on an annual basis’.

The company states: “All of our medical staff are board certified, have extensive training in aviation medicine and flight physiology, and have at least five years’ experience in emergency medicine. They undergo a rigorous initial orientation prior to flying with patients.

Additionally, all medical personnel participate in 100 hours of didactic and clinical continuing education annually. We also perform a quality review following each trip.”

Standard medical equipment onboard each aircraft includes a stretcher, oxygen, suction and medical air, a volumetric ventilator, a cardiac monitor/defibrillator, multiparameter invasive and non-invasive monitoring, resuscitation equipment, advanced airway management equipment, a three channel infusion pump, IV, and an ACLS drug complement, along with any

PROVIDER PROFILE

other specialised equipment necessary for each individual patient. A wide array of antibiotics are carried to treat bacterial and parasitic infections.

Other kit that Jet Rescue offers, added Salinas, includes a portable ultrasound machine, and a Seattle Tarp/STC Environmental Specialty Products Isolation Chamber for the transport of infectious patients. On the subject of infection control, Jet Rescue is also one of the few providers on the market that makes use of the SaniSwiss, a water-based antimicrobial technology that uses a tiny concentration (<1.5 per cent) of H202 (hydrogen peroxide) to kill germs from a portable robotic device.

Among Jet Rescue’s specialisms is neonatal specialty care. Neonatal air ambulance missions always include two critical care neonatal nurses and a neonatologist trained in neonatal advanced life support. For these missions, the crew is able to benefit from transport incubators, neonatal critical care equipment and ventilators, and nitric oxide systems. Salinas added: “For neonatal transfers in the US, we have contact with Miami Children’s Hospital to transport patients on our jets with their medical staff.”

Fleet Jet Rescue owns and operates all of its planes, which the firm says allows it ‘to configure the jets with dedicated air ambulance interiors and the latest in medical technology’. The fixedwing fleet consists of 10 Learjets: two 25Ds (which the company will soon dispose of), five 35s, two 55s and a 60.

Overseen by Chief Pilot Paulo Bello, flight crews complete simulator training in the relevant aircraft type, perform US Federal Aviation Administration (FAA) check rides and fulfil all other FAA requirements. For the captains, this involves semi-annual simulator training with FlightSafety or Simuflite, in the make and model aircraft they fly; for first officers the training is annual.

Alongside the fixed-wing aircraft, Jet Rescue also owns two ground ambulances and a helicopter.

supplies are charged at $500 per flight, and overnight expenses per crew member come in at $275. Salinas explained the rationale behind sharing a break-down of costs: “We want full transparency for our clients. In some cases, private paying clients are able to figure out on their own whether they can afford a flight or not without even contacting us.”

More than international flights There’s more to Jet Rescue than international fixed-wing patient flights. For example, the company has conducted joint missions with the Mexican Air Force and Federal Police, assisting them with medical teams and equipment to transport multiple patients onboard C-130 and the B727 aircraft. Salinas explained: “Those missions were conducted within Mexico in certain cases in which they required advanced critical care support, especially in situations like combat against drug cartels in Michoacan and Guerrero.”

The company also offers a helicopter under the ‘Heli Rescue’ brand. The BO105 is used to fly paying patients or members who pay $300 per year subscription, providing what it says is the only medical helicopter service in Mexico.

As well as taking patients on its own jets, the company offers commercial medical escort services. Jet Rescue works closely with major airlines to repatriate patients on stretchers or as sitting patients. The firm owns and uses portable oxygen concentrators for use onboard airlines that allow them to do this.

Adding a further string to its bow, Jet Rescue

conducts organ transport flights for hospitals within Mexico.

Constant development Recent years have seen a marked increase in demand, said Salinas, and Jet Rescue continues to develop its fleet and services offered. He commented: “We have grown in the past three years at a rate of 40-per-cent call volume increase each year. Our fleet has grown from four jets to 10 and a helicopter.

We have focused on long-range advanced critical care where there is less competition – basically transporting what others can’t.” The company has concentrated on developing its capabilities to transport neonates, highrisk obstetric patients and infectious patients, said Salinas: “We have heavily invested in the latest equipment including isolation units and Hamilton T1 ventilators.” He added that Jet Rescue is the only carrier in the Americas with ultrasound onboard. In October 2017, Jet Rescue added video laryngoscopes to the flight equipment.

The company is also engaged in a programme to renovate the aircraft fleet. Salinas explained: “In the last year, we have been going through a cockpit modernisation in all aircraft, installing TCAS 7.1 and ADSB in and out, as well as dual Garmin 750s on all jets.” The firm is also changing the models of planes in the line-up: “We have already purchased our first Learjet 60, and we aim to get rid of most of our 35s.

We will get into the heavy jet market, either with a Challenger or a Falcon.”

Open pricing One of the things that makes Jet Rescue different to other air ambulance operators is its transparency – according to the company, it is the only air ambulance provider in the world to publishes its rate card online. For example, use of the service’s medical aircraft is charged at $20.00 per loaded mile, international landings at $850, and ground ambulances at $1,500 per patient transfer. Medical equipment and

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FEATURE

NIGHT SIGHT The continuing evolution of FLIR and NVGs The US Helicopter Safety Team recently named enhanced vision technology as one of the four key helicopter technologies that will save lives. James Paul Wallis looks at how the two main systems, FLIR and NVGs, have evolved over time, and what tomorrow’s solutions may look like

Today’s fixed-wing and helicopter pilots can stay in the air when the sun goes down, often using night vision goggles (NVGs) and forward-looking infrared (FLIR) to help them to see in the dark, and the technology available right now is better than ever. Before we look at what the next-generation of systems might bring, it’s instructive to look back at how to how far we’ve come.

Evolution The origins of NVGs can be traced back to early inventions such as the ‘blacklight telescope’ created by Dr Vladimir Zworykin of the Radio Corporation of America, which used a silver-coated plate to convert invisible infrared rays into electrons that were projected onto a fluorescent viewing screen, as explained in Popular Science magazine back in 1936.

It was a time when scientists and engineers were working intently to harness electromagnetic waves to create radio and electro-optical devices. The technology was sufficiently developed by the Second World War to give a tactical advantage on the battlefield. Due to a limited sensitivity, the monocular scopes of that era (considered night vision ‘Generation 0’ or ‘GEN 0’) were used in tandem with infrared lights to illuminate the scene and were powerhungry – little hindrance for mounting on a tank perhaps, but it meant a bulky outfit for the rifleman, who would need to carry a large battery pack on his back.

In the following decades, although they still needed the accompanying lights, the scopes improved, and the batteries became small enough be worn on a belt.

The creation of passive ‘GEN I’ tubes in the 1960s was a major step forward, as the upgraded image intensification technology amplified ambient light by around 3636

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1,000 times, allowing for use without an infrared illumination, although they still needed moonlight and clear skies.

The ‘GEN II’ tubes of the 1970s introduced micro-channel plates and twisted fibre-optics, resulting in units that were both more powerful (light amplification of around 20,000 times) and more compact, with features including automatic brightness control. NVGs with a ‘full face’ mask began to be adopted by military pilots, but limitations such as weight (around 2 lb/1 kg) and the need to read cockpit instruments through the tubes meant they were uncomfortable and

advances have been made in some designs with ‘autogated’ automatic brightness control and light sensitivity tiring to use. ‘Cut-away’ masks came in the 1980s, affording the ability to look under the tubes to read instruments, but the design of NVGs for aviation can be said to have fully matured in the 1990s, when ‘GEN III’ NVGs emerged with the best-ever performance (light amplification of around 30,000 to 50,000 times) and lightest weight, allowing for prolonged use. NVGs had reached a point where they could be widely adopted by civilian aircrews.

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Recent refinements The NVG tubes produced today are still deemed GEN III units, although advances have been made in some designs with ‘autogated’ automatic brightness control and light sensitivity. Darrell Hackler, Senior Director of Global Business Development at NVG tube-maker Harris Corporation, said that they’re getting more out of today’s GEN III image intensifiers than expected, with resolution and intensification improving over the past five years. One factor, he said, is the use of cleaner manufacturing environments, which result in reduced contamination in the tubes.

cleaner manufacturing environments … result in reduced contamination in the tubes

FLIR

Perhaps the biggest change in recent years has been the adoption of white phosphor goggles for civilian operators, allowing crews to see in something close to black-and-white (traditional NVGs used green-and-white as it was thought to be better for the eyes, Hackler explained).

Jim Winkel is President of ASU, Inc., which announced its white phosphor NVGs at the Airborne Law Enforcement Agency Annual Convention in 2014. Whitephosphor NVGs have better low-light performance and are more reliable, as well as exhibiting reduced halos, increased contrast and clearer images, said ASU. Winkel told AirMed&Rescue: “White phosphor provides crewmembers with better image clarity and decreased eye fatigue, resulting in a more natural

FLIR

Although the predecessors of today’s NVGs used infrared light, modern forward-looking infrared (FLIR) devices have a different ancestry. Raytheon describes how in 1963, Texas Instruments’ Defense Systems and Electronics Division experimented with replacing the infrared film in aerial reconnaissance cameras with photoconductive detectors that could drive TV-style displays.

These first-generation systems were used in the Vietnam War to pick up enemy movements at night. Early units were of considerable size and consumed a lot of power, as they had to be cooled far below freezing point, only later becoming smaller and able to operate at higher temperatures – current second-generation sensors are uncooled and of low power consumption.

Image taken using an SS380-HDc

and comfortable flight experience. The air medical community has been the early adopter of white phosphor – even ahead of the US Department of Defense, which is quickly catching up.”

Hackler commented that white is fast becoming the industry standard, with many users sending their NVGs to have green tubes replaced with white phosphor units.Other than the performance of the tubes, work has been done to make the goggle sets more comfortable to wear, an example being a lighter battery pack and mount (paired with a lighter helmet), as revealed by ASU, Inc. at HeliEXPO in 2017. ASU senior business development manager Kim Harris said at the time: “This combination of the new helmet and mount vastly improves the user experience. As a pilot that has flown with night vision goggles for decades, I have experienced first-hand how much the lighter helmet, battery pack and goggle mount can decrease strain on a pilot or crew members wearing the equipment. When flying several missions, every ounce matters.”

Advancements continue Regarding airborne thermal-imaging surveillance systems, Adam DeAngelis, Director of Marketing, Surveillance Group, at FLIR Systems, Inc., commented that the technology has drastically improved: “Almost 20 years ago, the thermal imaging detectors in stabilised airborne systems were scanning arrays. What that meant was that there was typically a small group of detector ‘pixels’ and a mirror-like device would scan these rapidly to produce a full resolution image – typically 320x240. As technology increased, the detector became a staring array with a full group of detector ‘pixels’ in full resolutions of 320x240 and eventually 640x480 or 640x512 (PAL).

This allowed much greater sensitivity and resolution. With the higher resolutions, it wasn’t just picking out the thermally different object on screen, it was actually seeing detail in the scene and of the object. FLIR’s current Star SAFIRE 380-HD and Star SAFIRE 380-HDc have full high-definition arrays of 1280x720 pixel ‘detectors’.” He continued: “For search and rescue, this means identifying someone in the water from much further away as well, since the level of detail has increased. In addition to this, multi-spectral options such as SWIR (short wave IR) and I^2 (image intensifying) sensors add to the ‘toolkit’ available for the airborne operator.”

As another example, a representative of Safran Electronics & Defense told AirMed&Rescue how the company’s latest, fourth-generation Euroflir 410 device improves on previous iterations. Changes include a move to high-definition resolution and a new, large-aperture lens system. It also now boasts an optional target laser for illumination of the scene to facilitate, for example, boat name identification. >>

Image taken using an Inframetrics MK-II www.airmedandrescue.com

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Stay tuned for more The history of NVG development features design improvements to reduce their size, weight and power consumption (a common goal in military equipment acquisition, known by the acronym SWaP). It’s likely that future evolutions will continue to improve in these areas, not least as producers such as mobile phone and electric car manufacturers seek to develop better battery technology. Said Winkel: “Stay tuned as more enhancements are on the horizon. Measures to reduce overall helmet weight on the crew member are underway, which will increase crew comfort and reduce neck strain.” Specifically, Hackler indicated that there could be weight savings from using lighter optics – the use of polymer lenses is being explored, as these are less dense than the glass currently used. Harris is also looking at

the biggest change in recent years has been the adoption of white phosphor goggles for civilian operators

the use of polymer lenses is being explored looked at changing the field of view, said Hackler, but it seems that military aviators he’s spoken to suggested it isn’t a significant issue, as they have their heads ‘on a swivel’ in any case. Also, the trade off to increasing the field of view would be larger, heavier tubes, he noted.

On another tack, if you appreciated the move from green to white phosphor aviation NVGs, the next step could be full-colour goggles. There are a couple of ways that makers could implement this. For example, SCI Corp uses highly-sensitive digital sensors in its scopes aimed at ground users.

ColorTac, on the other hand, is exploring a different methodology: a pair of matched coloured filters rotate in sync, one in front and one behind the NVG tube, providing two channels of light that the eye perceives as full colour. There are also the Sentinel-CNV goggles from Adams Industries, again for ground users, which ‘utilise proprietary modifications to deliver meaningful and repeatable colour contrast at low light levels associated with night-time operations’.

As for infrared cameras, Raytheon says it is now introducing third-generation devices, which promise even better imagery.

FLIR

reducing forward projection, to bring the centre of gravity closer to the head, he added.

However, the next breakthrough in NVG tech may take the devices in a different direction. When you consider how modern life is dominated by digital solutions, it’s almost surprising that aviation NVGs remain so resolutely analogue. In fact, digital night vision is already in use in some military devices – and is even on sale to consumers.

Retail website Night Vision, which markets digital scopes to hunters, says of the tech: “Digital night vision technology truly has turned our industry on its head. From toy store novelty only a few years ago, to today’s line of category killers, these products represent the future.”

Digital scopes work similarly to digital cameras: a sensor detects light and a screen displays the image. A gain of going digital would be the possibility to relay or record the signals, as is already the case with aircraft-mounted FLIR cameras.

Furthermore, Armasite (a division of FLIR Systems, Inc.) highlights the fact that unlike traditional NVGs, they are not damaged by exposure to daylight. For flight, a major advantage of digital NVGs would be the flexibility of where you site the lens and sensor, with only the display screen

being worn by the pilot – this would significantly reduce the weight of gear on the helmet.

It’s unlikely, though, that a single lens and sensor would be enough, as even if mounted in a moving turret and slaved to follow the movements of the pilot’s helmet, there would be significant, disorientating (possibly even nauseating) lag. You could, however, adopt a system similar to that used on the F-35 fighter jet, where imagery is processed from six external infrared cameras and projected onto the helmet visor. While the exact set-up may be costly to replicate (the F-35 helmet alone comes with a budget-busting price tag of some US$400,000), in 2016 Elbit Systems demoed its BriteNite system, which uses the same concept of piping digital imagery to the user.

In this case, the feeds from an array of fixed external infrared and visible light sensors are processed and the appropriate section is fed to helmet-mounted goggles to match where the user is looking. In both systems, the imagery can be overlaid with instrument data and 3D mission symbology.

It’s worth noting that by using the visor for the heads-up display on the F-35, the user is afforded a wider field of view than the relative ‘tunnel vision’ of NVGs, which is often cited as a limitation on the current gear. Harris has

Image taken using an SS380-HDc

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FEATURE

SOURCES https://www.verticalmag.com/press-releases/ushst-4-key-helicopter-technologies-willsave-lives/ https://en.wikipedia.org/wiki/Night_vision https://en.wikipedia.org/wiki/Night_vision_device

FLIR

http://www.armasight.com/night-vision-academy/night-vision-history

Image taken using an Inframetrics MK-II

As with most fields in technology, it’s likely that we’ll mostly see gradual improvements in the devices offered, with occasional leaps forward, some of which may be surprising. For now, though, it seems safe to predict that we’ll move from analogue to fully digital systems. Hackler confirmed that moving away from direct-view imaging is a goal, and work is now being done to test digital night vision solutions for aviation. Perhaps today’s greenscreen NVG tubes will be tomorrow’s museum pieces, fashionably retro with the hipster pilot?

https://books.google.pl/books?id=fCYDAAAAMBAJ&pg=PA33&dq=Popular+Science+ 1933+plane+%22Popular+Science%22&hl=en&ei=pppoTZqaIoet8AaMw4y7C w&sa=X&oi=book_result&ct=result&redir_esc=y#v=onepage&q=Popular%20 Science%201933%20plane%20%22Popular%20Science%22&f=false https://www.globalsecurity.org/military/systems/ground/nvg.htm https://www.youtube.com/watch?v=ykX1e8M8SmA https://www.raytheon.com/news/feature/rtn13_flir01 https://www.osapublishing.org/optica/fulltext.cfm?uri=optica-4-12-1474&id=377343

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PROFILE

BRAD SIMMONS

Base Manager for Erlanger’s Health System’s Life Force Air Medical, and NEMPSA’s Pilot of the Year in 2017, spoke to AirMed&Rescue about his experiences in the provision of helicopter emergency medical services (HEMS)

For how long have you worked in the HEMS industry, and what major changes have you seen over the course of your career?

I have flown helicopters in the HEMS industry for 34 years. There have been numerous changes over the course of my career – three of the major changes are: the broader use of IFR aircraft, the introduction of GPS navigation in the early 90s, and the use of night vision goggles.

What did you do before you became a HEMS pilot, and why did you choose to become involved in HEMS rather than in private aviation?

My start in aviation was with the US Army in 1976. After leaving the Army in 1980, I moved to Texas and flew helicopters with a company called Pumpkin Air. After four years of corporate flying, I was given the opportunity to be lead pilot on their first EMS contract, Careflite, at Harris Methodist Hospital in Fort Worth, Texas.

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Five years later, I accepted a position with Lifeforce at Erlanger Hospital in Chattanooga, Tennessee, where I have spent the last 29 years. I had no idea at the time I began my EMS career that it would become my lifelong calling.

Combining something that you love to do, and helping people in the process, has been such a rewarding experience.

As Base Manager, what are your responsibilities on a day-to-day basis?

As a Base Manager/Line Pilot, I deal with a comprehensive package of keeping the base supplied, scheduling of pilots, record keeping, time cards, monthly reports and, most importantly, being mission ready during my 12-hour shift.

What role have you played in the development of safety procedures and protocols at Med-Trans?

All pilots of Med-Trans have input when it comes to safety-related items. Any time a

safety matter has come up, it has always been addressed in a timely manner. I can honestly say with Med-Trans, that they have fostered an atmosphere that safety will always be where we start and stop. The main area that I have personally been involved in has been with my feedback regarding IFR related topics.

The ‘go-no go’ decision with regards to safety of a mission is always down to the pilot in the end, but if you know what the mission profile is (eg. child in an accident), do you think this can affect the decision-making ability of a HEMS pilot? How can you avoid overhearing the medics discuss the patient?

When a call is received at our base, the only information that the pilot is given is whether it is a scene or a hospital transfer, as well as location. We are only given specifics about the call after the flight has been accepted. What we have done is to eliminate the emotional aspect of the decision-making process.

PROFILE

What is most important is to determine whether we can safely fly from point A to point B, and return home.

You flew to San Antonio, Texas, following Hurricane Harvey, to assist with disaster relief efforts; what sort of missions did you fly during this time?

The mission at the beginning of the relief effort during Hurricane Harvey, was to get our companyâ&#x20AC;&#x2122;s assets in place and establish a base of operation. This was accomplished through the combined efforts of the corporate managers, staff members, maintenance and flight crews that were mobilised to our initial base in San Antonio, Texas. On first arrival, the hurricane was still unleashing its fury on the Houston area, which made it difficult to immediately go into the affected areas. Once weather allowed, we were given the task of evacuating patients from hospitals in the flood zone.

My first mission was to transport a patient from a Houston hospital to a hospital in Plano, Texas, which is north of Dallas. As the storm moved out of Texas, our base of operation was moved to George Bush Intercontinental Airport in Houston.

Initially at this location, we shuttled personnel by air to our staging area 60 miles east of Houston at the Beaumont, Texas airport. Once there, we were given missions to evacuate more patients from hospitals that were closing due to flooding, as well as transporting assets related to the relief effort. The support that we were given to safely undertake this relief effort was above and beyond anything that I have ever experienced. Looking back on the event, I cannot help but stand in awe of the human spirit and to be able to witness the overwhelming support that was provided was truly life changing on many levels.

how have advancements in technology helped you as a pilot since then; and what has been the biggest leap forward, as far as you are concerned?

I can honestly say that the use of GPS in our EMS environment has vastly improved the safety aspects of our day-to-day operations. The greatest impact has been in the area of the IFR infrastructure. The implementation of special use approaches into and out of hospitals has made the decision-making process a much easier and safer choice. If you combine this with the use of NVGs, you have created an efficient and safe operation. Almost 10 years ago, when Med-Trans became the aviation provider for Lifeforce, we transitioned into the EC-135 with its all-glass cockpit. This was the final piece to the package with which we operate today.

Having all the tools I need to do this job, combined with the support from top to bottom, has allowed me the privilege to do this.

In 1994, you completed the worldâ&#x20AC;&#x2122;s first stand-alone GPS approach to a hospital;

In 2017, NEMPSA named you as Pilot of the Year; what did this mean to you?

This award was such an honour, and I was truly humbled upon receiving this unexpected recognition. I have been very fortunate to work with so many great individuals, in both aviation and medicine, through my 34 years in the HEMS industry. Survival in this environment would be impossible without the support of the team and most importantly of my family.

Little did I know that the decision to fly helicopters 40 years ago would result in a lifelong career that I am still passionate about, and look forward to every day I get to fly.

When not in the cockpit, what do you enjoy doing with your time?

Travelling with my wife of 40 years, and spending time with my two sons and their wives is my top priority. I value time spent with family and friends. Golf is another passion that I pursue regularly when time permits. I enjoy tinkering on my first car that I got in 1970, a 1968 Ford Mustang, which was restored last year.

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FEATURE

COMMUNICATION IS KEY Whether it is satellite, radio or cellular networks, medical and air rescue helicopters rely on multiple communication devices to carry out their life-saving work

For the helicopter crew taking part in a rescue mission, good communication is crucial to every aspect of their work. From receiving the original tasking from the operations centre, to calling air traffic control, speaking to emergency responders – or even casualties – at the scene, and liaising with the receiving hospital, it’s vital that the rescue team can keep in touch with those involved.

The hitch is that no one system is best suited to making all these calls, which is why it’s common to see a range of communication devices installed. There are three main communication methods in common use – radio, satellite and cellular – and it’s worth looking at the application and limitations of each before deciding which one(s) fits the needs of your organisation.

Satellite comms For ‘goanywhereability’, nothing beats satellite. In essence, these devices are similar to the cellular (mobile) phone you carry in your pocket, but rather than linking up with a ground-based mast, these devices link up with dedicated satellites that orbit the earth. The result is the ability to connect anywhere in the world, a major advantage compared to the limited range of radio and cellular signals.

Of course, the fancy part of satellite communications is the satellites. One network has been set up by Iridium and offers both voice and data services using a low earth orbit (LEO) satellite ‘constellation’. Another set of satellites is run by Inmarsat. Cobham SATCOM’s AVIATOR SP (Special Purpose) system uses Inmarsat’s SwiftBroadband service for satellite communications. Cobham promotes the system, which provides in-flight access to the internet, including emails and IP voice calls, for special applications ranging from fire-fighting 4242

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helicopters to military uses. It includes Cobham’s compact antennas, available in high, intermediate or low gain versions, such as the HGA-6000 with the smallest swept volume for a mechanically steered antenna and the IGA-5001 which is 60-per-cent smaller and 34-per-cent lighter than competing IGA products on the market. With a small component footprint, the system is ruggedised for high vibration and temperature fluctuations. Previous uses mentioned by Cobham include installations on Mi-8 and Bell 407 helicopters for FLIR imagery and communication.

In terms of the data transfer speed you might get with satellite devices, Cobham says the single channel AVIATOR SP can deliver up to 432 Kb/s, while the multichannel version can get up to 1,600 Kb/s. Honeywell quotes its Aspire 200 satellite communications system, which also uses the Inmarsat network, as being capable of simultaneous voice and data connectivity at rates of up to 600 kb/s, which the manufacturer describes as a ‘true broadband experience’.

The major advantage of satellite comms is that (unlike cellular and radio solutions) you’re always in range – as long as the antenna can see the sky, it can see the satellites. It’s even possible to send and receive signals upwards through the rotor disc. Discussing its Aspire 200, Honeywell states: “The Aspire 200 provides a true broadband experience for the helicopter operator and offers reliable, consistent and high-speed connectivity through the rotor wash utilising its high data rate interleaved waveform for error free connectivity. No solution prior to the Aspire 200 could penetrate the rotor wash to provide pilots and operators with connectivity, making Honeywell the first to bring a solution like this to the market.”

Meanwhile, Iridium told AirMed&Rescue: “Our LEO L-band network enables installations under the rotor blades due to having ‘low look angle’, and this is further complemented by small form factor antennas that enable easy

FEATURE

installation. With the Iridium network creating what is essentially a web of coverage enveloping the Earth from LEO, we have a distinct advantage of being able to create smaller antennas.”

It’s even possible to use satellite devices in radio-style push-to-talk (PTT) mode.

Flightcell International released its Iridium PTT functionality for its DZMx in June 2016, and Latitude recently launched the S200-102P, which allows the crew members to communicate via PTT securely with other devices that have been set up in a ‘talk group’. Latitude president Mark Insley commented: “Previous airborne use of PTT was limited to direct line of sight and relay between radios, and was open to eavesdropping scanning technologies. Our application of Iridium PTT provides private group conversations with no geographic limitations … crews can respond and take action faster while working together without worrying about losing connections even in the most remote areas.”

There are downsides to satellite comms, though, which make it unlikely to be the preferred choice of crews that operate in radio and/or cellular range. For example, Mike Biasatti, a US-based HEMS pilot, mentioned a slightly greater delay in satellite signals as a potential issue.

Cellular comms Comparing satellite and cellular networks, Michael Eddy of Flightcell International, maker of the DZMx (see box out on p43) commented: “The satellite provides global coverage, but is more expensive and has lower data speeds, whereas cellular needs to be in cellular network range, but when it is in range, it offers broadband data and it’s cheaper.”

Airborne cellular devices access the same networks as standard mobile phones, and need to be in range of cell masts in the same way. As well as voice calls and text messages, 3G/4G signals allow mobile broadband connections, so crews can, for example, check weather and landing zone information while on the move. Another application would be to send medical data from patient monitoring systems to the hospital, or to receive patient records from the hospital while in the air. As Michael Eddy suggested above, in terms of data transfer speed, cellular is king – 4G cellular/mobile internet speeds are measured in double-digit Mb/s, an order of magnitude above what you might see via a satellite device.

Cellular devices should be proper, aircraft-specific models, which will have been certified and tested to ensure they will not interfere with the helicopter’s systems. However, low-cost consumer phones can in some cases be utilised.

The company for which Mike Biasatti works issues its crew members with an iPhone 6s. However, this is under the proviso that they are only used for critical communication when unable to contact air traffic control or the dispatch centre, and they can only be used when on the ground and away from the aircraft.

Radio The use of radio waves to communicate predates both the satellite and cellular systems significantly. While there’s, roughly speaking, a line-of-sight range limitation (sending and receiving antennas need to be able to ‘see’ each other), a radio device can broadcast to all others within range with no network to go through and no call charges. Radios are therefore ideally suited to PTT comms.

As an example, Biasatti said: “Aboard our aircraft, for contact with local EMS agencies, fire department, etc., we use a TDFM-6158/NW FM Transceiver.

Ours has dual transmit and receive channels, since we also use this for contact in flight with our dispatch. We program it with the discrete frequencies of all agencies within about 150 NM radius. These are pretty reliable, but the range is sometimes limited to less than 10 NM depending on terrain and altitude.”

He also uses a VHF radio for air-to-air communications with other helicopters, including those operated by the police, other air medical organisations and border patrol. He added: “We make position reports in the blind at 10 NM, 5 NM and 1 NM into and out from area hospitals.”

For the security conscious, it’s worth noting that unless encrypted, radios are susceptible to eavesdropping – the internet is awash with forums where interested amateurs discuss the frequencies commonly used by their local providers. UK HEMS charity Magpas Air Ambulance told AirMed&Rescue that while it uses VHFM radio to communicate with air traffic control, it uses a secure terrestrial trunked radio (TETRA) radio system for ‘everything else’ while in the air. The network is the digitally encrypted ‘Airwave’ system used by the police, fire and ambulance services, enabling the helicopter crew to communicate with emergency responders on the ground as well as hospitals. TETRA also allows access to the mobile phone network and even transmission of mobile data, albeit at slow speeds. Cobham explains that TETRA is ‘similar in architecture to commercial cell-phone systems’. Calls can be made point-to-point (between two individual users) or to groups of users.

Almost all of the UK’s air ambulances were upgraded to TETRA in 2010, when Medical Aviation Services (MAS) completed installations on 24 helicopters across the country. However, the UK Government has launched the Emergency Services Mobile Communications Programme, which is intended to replace the Airwave TETRA radios with a new 4G cellular-based system being implemented for all emergency services.

Standard radio can be particularly useful for communicating with casualties in areas where boaters or mountaineers carry VHF units. There is even a use for radios to help members from the same helicopter crew talk to each other. For >>

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FEATURE

example, a crew member at the end of a winchline has to rely on hand signals, which are limited and may be difficult to interpret, unless a reliable radio is available. Northland Rescue Helicopters in New Zealand saw an improvement when the MOTOTRBO DP4400 portable radio was adopted for this purpose.

Tony Devanney, then District Operations Manager, St John Northern Region, said at the time of the acquisition: “Previously, there was no communication between the winch man and the craft, which was unsafe and made rescues difficult. The team used portable ambulance radios, which had poor quality reception and were unreliable, or hand signals.” He added: “The gear has changed our practices, by making them more streamlined, safer, quicker and clearer.”

Similarly, the Westpac Rescue Helicopter crew based in Christchurch, New Zealand, received TP8120 handheld radios donated by Tait Communications in 2013, which allow medics to keep in contact with the crew onboard, even after exiting the aircraft to attend patients on scene.

More than just communication Although in this article we’ve focused on the systems that allow crews to communicate with personnel on the ground, there are other important uses for the equipment. For example, there are helipad lighting systems, such as those offered by FEC Heliports Worldwide and S4GA, that can be activated remotely through radio or cell phone signals. Satellite devices can be used to transmit aircraft data, such as heading, altitude and engine parameters – a capability that becomes all the more relevant with the implementation this year of the US Federal Aviation Administration’s requirement for larger helicopter air ambulance operators to have flight data management (FDM) capabilities. For example, Air Methods uses the Honeywell Tracker III to tap into and transmit the data running through its helicopters’ data buses. Flight tracking can also be achieved through cellular and satellite systems, allowing control centres to see the position of their aircraft at all times.

Another feature is the ability to stream video, sharing the feeds from the helicopter’s onboard sensors. Honeywell mentions this as a benefit of

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the Aspire 200 for aerial firefighting users: “The steady, highspeed connection means that real-time video can be streamed from the aircraft, documenting that the target was hit.” Cobham also highlights how its AVIATOR SP range with SwiftBroadband service supports video streaming, video conferencing and aerial surveillance.

The ongoing development of satellite systems and improvements to mobile technology systems mean that without doubt, it will only become more straightforward for air medical and rescue teams to communicate with each other, fellow responders, and receiving medical centres. Although the initial outlay for a comms system may be significant, the fact is that good communication means more lives saved.

Doubling up To make things easier, some devices combine options, such as the S200-102P satellite unit, which can be linked to a radio to simulcast messages. Another example is Flightcell’s DZMx, as used on Bristow’s search and rescue S-92 and AW189 helicopters in the UK, which can send and receive via satellite, but switches to 3G/4G cellular phone networks whenever in range. It also allows for GPS tracking. Another combination is TETRA radio alongside cellular phone capability, as offered by Motorola’s ZeniCopter system. The system includes separate GPS, TETRA and GSM (cellular) antennas.

The TETRA radio is used for group calls, individual calls or short-data messages, while the GSM module is used for voice calls.

Backup of the backup Anthony De Wit, manager air operations at Australia’s Ambulance Victoria, discusses how his service’s crew take advantage of multiple means of communication: “The safety of our patients, crew and aircraft is paramount so we have a variety of communications means including several back-ups. The various communications systems allow us to liaise with our paramedics on the ground, in communications centres, and staff at hospitals. The systems also keep us in contact with other aircraft and air traffic control, emergency services including marine, state emergency services, fire agencies, police and coast guard. Included in our communications are two systems to allow contact between the air crew and winch rescue crewman.

The communications systems include: • ambulance radios (metropolitan & rural) to liaise with ambulance road crews, flight co-ordination centre, ambulance communication centres & hospitals • mobile phone • satellite phone • Cobham FLEXCOMM (formerly Wulfsberg) radio with multichannel capability (allows communications with marine, state emergency service, fire authorities, police, coast guard, ground ambulance) • trunking radio • hand-held GPS with radio • wiJAC to allow communication between aircrew and winch rescue crewman; • Polycom to allow communication between aircrew and winch rescue crewman; • and VHF aviation radios.”

FEATURE

• Transmit 12-Lead ECG data in-flight • Upload patient and mission data • Cellular broadband connection • Open WiFi for connected devices • Secure VPN options available • Dual cockpit and cabin voice

For more information please visit

www.flightcell.com/medical www.airmedandrescue.com

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CASE STUDY

Eight flights six countries 22 hours A wing-to-wing transfer by Fox Flight in Canada and South Africa-based Awesome Air Evac saw a patient being transferred almost 10,000 miles. Frank Condron of Fox Flight gave AirMed&Rescue insights into how the mission was co-ordinated

Awesome Air Evac: Johannesburg-Luanda-Accra-Dakar-Tenerife Fox Flight: Toronto-St. John’s, Newfoundland-Santa Maria-Tenerife

The mission saw the two air ambulance operators combine to complete a journey made up of eight individual flight legs, touching down in six different countries, before terminating some 22 hours later. The incredible logistical challenges of the transfer were compounded by the fact the patient was categorised as high-risk, requiring ventilation throughout the flight.

The challenge In early June 2017, Awesome Air Evac was contracted to transfer a high-risk patient from a hospital in Johannesburg, South Africa to Kansas City, Missouri, US. Given the distance involved, Awesome Air Evac opted to partner on the mission with Fox Flight Air Ambulance via a wing-to-wing patient transfer. The companies agreed that Tenerife South, in the Canary Islands, would be the most convenient airport to conduct the transfer due to its relative location and the

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Close collaboration between flight and medical teams ensured impressive patient care continuity airport’s extended operating hours.

In Johannesburg, the patient presented with an intracerebral bleed with a nosocomial pneumonia, which was further compounded by the patient being non-ambulant and fully ventilated. While both companies have experience with ventilated critical care retrieval missions, due to airport closure restrictions faced by Fox Flight at the final destination, this mission posed a time complexity concern that had to be carefully planned for. The total mission time placed additional pressure on ventilation calculations as well as pharmacological quantities.

Obviously, a mission this complex presents a range of logistical challenges. The routing that was required needed to be the safest, yet most direct, in order to meet FDP (Flight and Duty Period) limitations while keeping in mind the timeline needed to obtain the multiple clearances at each stop along the way.

The flight operations departments of both Fox Flight and Awesome Air Evac had to ensure that all ground services were immediately available at the multiple airports where the aircraft

CASE STUDY

had to make technical stops for refuelling. The timing of each leg had to line up perfectly, as this mission involved airports closing at different times and both sets of crew needed to be prepped and ready to transfer the patient from the one aircraft to the other with minimal ground time in-between.

The flight The official go-ahead for the mission was given on the morning of 15 June. Based on Awesome Air’s anticipated flying time of 11 hours 36 minutes to Tenerife, excluding ground time for technical stops, Fox Flight proposed to make the patient exchange on 17 June at approximately 16:30 hrs local time.

A Fox Flight Learjet 36 air ambulance, carrying two pilots and a medical crew, comprised of an ICU doctor and a critical care nurse, took off for Tenerife at 18:30 hrs Toronto time on 15 June. The journey included technical stops at St John’s, Newfoundland and Santa Maria in the Azores. The Fox Flight crew arrived in Tenerife at 11:30 hrs local time on 16 June and immediately went off

Photos courtesy Awesome Air Evac

duty to rest up in preparation for the return journey.

The Awesome Air Evac Learjet 35 air ambulance departed from Johannesburg on the first leg of the transfer at around 02:30 hrs local time on 16 June with a two-person medical crew comprised of an ICU doctor and an Advanced Life Support Paramedic. The plane made its first refuelling stop about three and half hours later in Luanda, Angola. After about 30 minutes on the ground, the crew took off on the second leg to Accra, Ghana. From Accra, the jet made a stopover in Dakar, Senegal, before heading to Tenerife for its rendezvous with

Repatriation flight: Tenerife-Azores-St Johns-Toronto-Missouri

the Fox Flight air crew and medical team. The Awesome Air Evac jet arrived in Tenerife late in the afternoon of 16 June.

As soon as the patient was safely transferred, the Fox Flight air ambulance took off on the first leg of its journey, and the fifth in the transfer, to the Azores. After refuelling, the Fox Flight crew proceeded to St John’s, Newfoundland. Leg seven of the journey took the Fox Flight crew back for a brief stopover at their home base in Toronto, where two new pilots had to take over due to duty time restrictions. The final leg, number eight in total, took the patient from Toronto to Kansas City.

The patient was closely monitored and remained stable during all phases of the flight, with neither medical crew encountering an adverse clinical event. Oxygen calculations, pharmacological quantities, patient nutritional requirements and pressure care were completed at optimal clinical levels during all phases of the mission. The patient arrived in Kansas City in stable condition at 03:30 hrs local time, just two hours later than estimated, and was transferred to hospital by the Fox Flight medical crew.

Conclusion Close collaboration between flight and medical teams ensured impressive patient care continuity and the wing-to-wing transition was well executed.

Constant communication was the key to the success of this mission. Both aircraft were tracked via satellite by flight operations throughout, and all relevant parties were notified of departure and arrival movements to ensure both aircraft were in Tenerife on time and were parked in close proximity to ensure minimum ground time with the patient during the transfer. In addition, flight operations had to communicate with handling agents at each stopover to assist with arrangements on the ground, such as fuel bowsers being ready for aircraft refuelling, assisting with customs and airport procedures and filing enroute flight plans.

The use of multiple communication channels, in particular frequent verbal discussions, ensured that all parties were involved in decision making and that all team members were informed of potential risks and the related mitigation.

Technologies such as aircraft satellite tracking allowed both companies to have a simultaneous live view of mission progress and appropriately manage the teams taking part in the transfer.

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diary dates

BIGGLES GIGGLES

Send your diary dates to: info@airmedandrescue.com

Biggles strange giggles part II A few more creepy stories from reddit user searchandrescuewoods to freak you out this month!

On the way back from one of his first rescues as a trainee, our intrepid rescuer reports that his trainer decided to take him on a detour to a ‘hot spot’ where missing people are often located. They reach the spot, and … I’ll let him tell it from here.

“As we’re walking around the area and she’s pointing out places she’s found people in the past, I see something in the distance. Now, this area we’re in is about eight miles from the main parking area, though there are back roads you can take to get closer if you don’t want to hike that far. But we’re on state-protected land, which means there can’t be any kind of commercial or residential development out here. The most you’ll ever see is a fire tower or makeshift shelter built by homeless people.

But I can see from here that whatever this thing is, it has straight edges, and if there’s one thing you learn quickly, it’s that nature rarely makes straight lines. I point it out, but she doesn’t say anything. She just hangs back and lets me wander over and check it out. I get within about 20 feet of it, and all the hair on the back of my neck stands up. It’s a staircase. In the middle of the woods. In the proper context, it would literally be the most benign thing ever. It’s just a normal staircase, with beige carpet, and about 10 steps tall. But instead of being in a house, where it obviously should be, it’s out here in the middle of the woods. The sides aren’t carpeted, obviously, and I can see the wood it’s made of. It’s almost like a video game glitch, where the house has failed to load completely and the stairs are the only thing visible.

I stand there, and it’s like my brain is working overtime

to try and make sense of what I’m seeing. My trainer comes and stands next to me, and she just stands there casually, looking at it as if it’s the least interesting thing in the world. I ask her what in the world this thing is doing here, and she just chuckles. ‘Get used to it, rookie. You’re gonna see a lot of them’. I start to move closer, but she grabs my arm. Hard. ‘I wouldn’t do that’. She says. Her voice is casual, but her grip is tight, and I just stand there looking at her. ‘You’re gonna see them all the time, but don’t go near them. Don’t touch them, don’t go up them. Just ignore them’. I start to ask her about it, but something in the way she’s looking at me tells me that it’s best if I don’t. We end up moving on, and the subject doesn’t come up again for the rest of my training.

She was right, though. I’d say about every fifth call I go on, I end up running across a set of stairs. Sometimes they’re relatively close to the path, maybe within two or three miles. Sometimes they’re 20, 30 miles out, literally in the middle of nowhere, and I only find them during the broadest searches or training weekends.

They’re usually in good condition, but sometimes it looks like they’ve been out there for [a long time]. All different kinds, all different sizes. The biggest I ever saw looked like they came out of a turn-of-the-century mansion, and were at least 10 feet wide, with steps leading up at least 15 or 20 feet. I’ve tried talking about it with people, but they just give me the same response my trainer did. ‘It’s normal. Don’t worry about it, they’re not a big deal, but don’t go close to them or up them’. When trainees ask me about it now, I give them the same response. I don’t really know what else to tell them. I’m really hoping someday I get a better answer, but it hasn’t happened yet.”

25-26 April RETRIEVAL 2018 UK’s National Prehospital & Critical Care Transfer Conference Glasgow, UK

21-24 May Pav-Con Police Aviation Conference 2018 Warsaw, Poland

22-24 May Maritime Search & Rescue conference Helsinki, Finland

23 May Australian & New Zealand Search & Rescue Conference Star Gold Coast, Australia

7-9 June 5th Rescue Swimmer Meeting Reykjavik, Iceland

11-13 June Fire-Rescue Med Conference Nevada, US

12-14 June AIRMED World Congress Warsaw, Poland

26-28 June Search and Rescue Europe London, UK

9-14 July ALEA Expo 2018

Airborne Law Enforcement Association Louisville, Kentucky, US

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

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

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

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

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Medic’Air International

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

+263 (4) 302 141

AMREF Flying Doctors Dr Bettina Vadera Medical Director

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

20 6000 090 fax: +254 20 344 170

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

medic-air.com

+212 5 24 38 13 88

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

+668 9896 9000

asiaairambulance.com

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

+65 9836 3265

eds-aviation.com

+65 6483 5412

flyingdoctorsasia.com

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

LifeFlight

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

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

ace-ambulance.com

(ASIA-PACIFIC)

AIR AMBULANCE (AFRICA)

SERVICE DIRECTORY

+27 11 430 1777

awesomeairevac.com

+61 7 5553 5955

LifeFlight.org.au

Medic’Air International 每递安国际

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

PO Box 15166, City East, QLD 4002, AUSTRALIA

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

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

+86 2163 558289

medic-air.com

www.airmedandrescue.com

49 49

>>

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

+662 247 3392

medicalwings.com

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

(EUROPE)

AIR AMBULANCE (EUROPE) (ASIA-PACIFIC)

SERVICE DIRECTORY

+49 170 366 4933

+335 56 34 02 14

+356 2703 4129

+41 44 654 33 11

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

airlecairespace.com

rega.ch

+49 7007 3010

drf-luftrettung.de/air-ambulance

EURO LINK GmbH +49 89 6137 2103

Allgemeine Luftfahrt, D -85356 München Flughafen, GERMANY

FlyEuroLink.de

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

+352 26 26 00

air-ambulance.com

taa.at

+43 512 22422 100

Fuerstenweg 180, A-6026 Innsbruck-Airport, AUSTRIA

capitalairambulance.co.uk

AIR AMBULANCE (NORTH AMERICA)

+44 845 055 2828

DRF Luftrettung / German Air Rescue

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

+(800) 462 0911 eromedevac.com

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

aeiamericas.com

+1 619 754-6755

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

+1 720 875 9182

AMRAirAmbulance.com

Global Jetcare, Inc.

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

+49 911 36009 31

fai.ag

+212 5 24 38 13 88

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

medic-air.com

+1 352 799 7771

globaljetcare.com

+49 211 602 7775

2561 Rescue Way, Brooksville, FL 34604, USA

+1 352 796 2540

jeticu.com

Jet-Rescue Air Ambulance

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

15421 Technology Dr. Brooksville, FL 34604, USA

JET ICU

GlobalMed International

jetexecutive.com

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

+1 786 619 1268

medjetsUSA.com

REVA Inc

Malteser Service Center +49 221 98 22 333

malteser-service-center.de

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

+1 954 730 9300

flyreva.com

Skyservice Air Ambulance

Medic’Air International

AIRMED&RESCUE

quickair.de

+49 2203 955 700

Tyrol Air Ambulance

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

50 50

Quick Air Jet Charter GmbH

186 Ix Xatt Santa Maria Estate Mellieha MLH 2771, MALTA

air-alliance.de

Capital Air Ambulance

35 rue Jules Ferry, 93170 Bagnolet, Paris, FRANCE

northflying.com

Swiss Air-Rescue (Rega)

Zone Aviation Générale, 33700 Mérignac Cidex 05 FRANCE

Malteser Service Center Kalker Hauptstr.

22-2, 51103 Köln, GERMANY

+45 9632 2900

Rescue Wings Malta

AIRLEC Air Espace

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

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

Hangar 3, Cologne Airport, 51147 Cologne, GERMANY

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

North Flying a/s

+33 141 72 1414

medic-air.com

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

+1 514 497 7000

skyserviceairambulance.com

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

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

836-8732 836-8920

website: www.aams.org

IAFCCP Monica Newman Executive Director

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

website: www.iafccp.org

fax: +770-979-6500

MEDICAL ESCORT ON COMMERCIAL AIRLINES

ASSOCIATIONS

SERVICE DIRECTORY

AMREF Flying Doctors Dr Bettina Vadera Medical Director

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

20 6000 090 20 344 170

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

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

GROUND TRANSPORT - MEDICAL

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

+1-202-499-2294

+49 6742 897 425

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

globalmed-international.com

LIFESUPPORT Patient Transport Graham Williamson CEO

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

250 947 9641 877 288 2908

email: graham.williamson@LifeSupportTransport.com

website: www.LifeSupportTransport.com

Medical Wings gateway-ems.com

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

air-ambulance.com

GlobalMed International

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

+352 26 26 00

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

+662 247 3392

medicalwings.com

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

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

+1 754 999 0460

primenursingcare.com

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

630 444 2100 630 823 2900

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

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

www.airmedandrescue.com

51 51

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