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Issue 93 | Dec 2018 / Jan 2019

ISSUE 93

DECEMBER 2018 / JANUARY 2019

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EDITOR’S COMMENTS I’ve learned a great deal in the past few months about air medical transportation, and the support services that allow these fantastic organisations to do their jobs. It’s really a case of the tiniest thing making a difference at every stage – from helipad design, to the avionics on which the pilots can rely, the more effective dressings medics use to treat patients, and new aircraft that mean more space for better treatment and, ultimately, better outcomes. Advances in design and technology in every area of aviation and medicine allow our industry to continue to improve and build on their experiences. It’s humbling to report on and be part of.

This final issue of 2018 contains an eclectic mix of articles and reports from organisations around the world. Accreditation organisations of air ambulance services, which keep standards high in the industry, are becoming ever more important, and in this edition we talk to the new business development manager of the European Aero-Medical Institute (EURAMI), while Eileen Frazer of the Commission on Accreditation of Medical Transport Services (CAMTS) discusses the organisation’s latest policy changes.

The use of drones as HEMS support is being trialled in Australia, and this topic certainly has more to give – how to safely and effectively make use of unmanned systems for the betterment of patient outcomes needs to be further investigated. There are obviously concerns about drones and helicopters operating together in such close quarters, but if these devices can deliver much-needed blood products to the scene of an accident when it matters most, then they can save lives. The industry has a responsibility to assess what be achieved in this area.

I wish you all a happy festive season and a healthy and prosperous 2019!

Editor

Mandy Langfield

CONTRIBUTORS

Vlad Vorotnikov Vlad Vorotnikov is a Moscow-based multimedia freelance journalist. He holds a Master’s degree in Journalism from the Voronezh State University and has contributed to AirMed&Rescue Magazine since 2016.

Eileen Frazer Eileen Frazer, RN, CMTE, is the Executive Director of the Commission on Accreditation of Medical Transport Systems (CAMTS). Eileen is a former Chief Flight Nurse who served as the Safety Committee Chair for the Association of Air Medical Services and did the feasibility study in 1988 that led to the development of CAMTS. Eileen set up CAMTS as a non-profit corporation and wrote many of the policies and standards that guide the accreditation process.

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

Amy Gallagher Amy Gallagher is an internationally published journalist covering aviation, rescue, medical and military topics, including evidencebased research articles.

Amy has worked in both agency and corporate communications for aviation companies such as SimuFlite Training International, K-C Aviation, Chrysler Pentastar Aviation, and McKinney Aerospace.

Helen Ballantyne Helen Ballantyne is a UK Critical Care and Flight Nursing Forum committee member.

After graduating with a degree in Pharmacology in 2002, Helen qualified as Registered Veterinary Nurse in 2005. After a wide range of experience nursing animals, she decided to swap species! Currently she works at Addenbrookes Hospital, Cambridge on the Transplant High Dependency Unit and is halfway through her MSc in Healthcare Management.

Front page image © RFDS/PILATUS www.airmedandrescue.com

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Editor-in-Chief: Ian Cameron Editor: Mandy Langfield Sub-editors: Christian Northwood, Lauren Haigh, Stefan Mohamed, Sarah Watson Advertising Sales: James Miller & Kathryn Zerboni Design: Rosi Yip, Tommy Baker, Will McClelland & Katie Mitchell Web: Tom Reed Marketing: Isabel Sturgess, Kate Knowles, Kane Rich Finance: Elspeth Reid, Alex Rogers, Kirstin Reid Contact Information: Editorial: tel: +44 (0)117 922 6600 (Ext. 3) email: editor@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 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 93

ISSN 2059-0822 (Print) ISSN 2059-0830 (Online) Materials in this publication may not be reproduced in any form without permission.

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IN THIS ISSUE NEWS 6

Federal air ambulance service expands in Russia Ornge helicopters welcomes Powered Aero Loader stretcher system Aero National acquired

by Air Ambulance Worldwide

FEATURES 8

Staffing questioned for new Irish HEMS

24

Treating psychiatric patients Sedation or restraint?

36

Treating gunshot wounds The latest techniques and equipment

GALLERY 32

Clear Sky 2018 Ukraine The multinational military exercise

INTERVIEW 28

Claudia Schmiedhuber Founder and CEO of Alpine Health Consulting, and Interim Managing Director and Business Development Manager of the European Aero-Medical Institute (EURAMI)

INDUSTRY VOICE 44

CAMTS-CAMTS EU announces policy changes

PROVIDER PROFILE

SPECIAL REPORTS 14

46

FinnHEMS Insights into operations in Finland

International Travel & Health

16

Insurance Conference sessions

20

Australia trials drones with HEMS functionality

22

Royal College of Nursing Flight Nursing Workshop report

www.airmedandrescue.com

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NEWS

Federal air ambulance service expands in Russia Vladislav Vorotnik reports on the government’s latest investment in air medical services Russia’s National Service of Medical Aviation (NSMA) is steadily increasing its geographic footprint by entering new regions in the country, and its expansion will continue thanks to the Rub40 billion (US$700 million) contract for the purchase of 150 new Ansat and Mi8AMT medically equipped helicopters.

In August 2018, Russia’s Prime Minister Dmitry Medvedev signed a decree appointing NSMA as the only company authorised to provide air medical services under public contract in the country.

The decree means that the 34 regional air ambulance operators that have been established in the country during the past few years (with a total fleet of around 200 helicopters) must either become structural divisions of NSMA, or must operate as subcontractors of the federal operator.

The establishment of NSMA within the state-owned corporation Rostec, as a single federal air ambulance operator, was approved by Russia’s President Vladimir Putin in January 2018.

Fueling expansion

Under the recent contract with Rostec, the overall fleet of helicopters set to handle emergency calls in Russia will 66

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nearly double. All 150 machines are slated to be supplied to NSMA by the end of 2020, said Andrey Boginsky, General Director of Russian Helicopters, which was signed up to manufacture the aircraft.

Regional government officials said in October that NSMA will begin its operation in the Republic of Dagestan, Murmansk Oblast and Krasnoyarsk Krai.

The helicopters will be stationed near the biggest hospitals in the regions, and although NSMA is obligated to provide pilots, the hospitals will provide medical staff, according to the Health Ministry.

In total, 1,500 heliports with refueling stations are slated to be built near hospitals by 2035.

In a draft decree published on the official government website, it was estimated that to fully meet the domestic demand for air ambulance services, the country needs around 8,500 helicopters.

Nevertheless, both Rostec and the Health Ministry refused to estimate how many helicopters would actually fulfil these responsibilities in Russia in the coming years.

According to Rostec, a significant number of helicopters currently handling emergency medical transport in Russia will be scrapped in the coming years – some have already been in service for 20 to 35 years and are in rather poor technical condition – in most cases, regional funds to renew the fleet were not available.

Improved efficiency

The main idea of uniting the air ambulance system in Russia is to provide medical and evacuation services, including in remote regions, 24/7, said the press office of Russia’s Health Ministry. This also includes aligning prices throughout the country, In general, it is believed that by applying a common methodology, and through the integration of internal processes, NSMA could

optimise the average cost per flight hour, something regional air medical service operators could not achieve, according to Viktor Kiryanov, Director of Infrastructure Projects Department for Rostec.

to fully meet the domestic demand for air ambulance services, the country needs around 8,500 helicopters Vast territory

Russia needs well-established air ambulance services due to the vastness of its territory, as hundreds or even thousands of settlements are located in remote and hard-to-reach parts of the country, according to information posted on the government website.

Russian newspaper Kommersant estimated earlier this year that 30 per cent of all emergency cases in European Russia, and between 50 to 80 per cent of such cases in Siberia and the Far East require intervention from medical helicopters. Even in some parts of European Russia, the availability of primaryhealthcare is a big problem, noted Tatiana Yakovleva, Russia’s Deputy Health Minister. She told the in-house publication of the Russian Government in early 2018 that ground ambulances frequently struggle to handle the task of providing primary healthcare due to the time it takes to reach a patient. Yakovleva explained that NSMA is set to operate within the common emergency response system, although she admitted that there were certain parts of the country where no emergency hotline is established, and so for the time being, NSMA could not operate at those territories. The Ministry, however, is making significant efforts to solve that problem.

NEWS

Ornge helicopters welcomes Powered Aero Loader stretcher system

The PAL from HeliMods © HeliMods

Ornge, Canada’s provider of air ambulance and related services in Ontario, and HeliMods, an Australian aerospace technology company, announced in November that they had reached an agreement for the installation of an enhanced stretcher system in the Ornge fleet of AW139 helicopters. The new system features a self-loading power cot with an equipment bridge that will be able to hold all medical devices in all phases of flight. The system will also allow Ornge to enhance its current bariatric transport capabilities without reconfiguring the aircraft as it currently does. The centrepiece is the Powered Aero Loader (PAL), a zero-lift, push-button operated powered stretcher loader system for rapid loading and unloading of land ambulance stretchers into air ambulance helicopters. By significantly reducing the need for paramedics to manually lift or transfer patients between different stretchers and vehicles, the PAL improves safety and efficiency and allows for improved response times while significantly reducing the risk of patient and paramedic injury.

“When our crews arrive for an on-scene response or at a hospital, our patients expect us to be able to perform their transport in a timely, efficient and safe fashion,” said Dr Andrew McCallum, President and CEO of Ornge. “The Powered Aero Loader will enhance our ability to achieve this mission, while at the same time ensuring our paramedics have the best and safest possible work environment in which to deliver their life-saving care.”

Aero National acquired by Air Ambulance Worldwide US-based Air Ambulance Worldwide has finalised the acquisition of Aero National, further extending the company’s footprint in North America, and giving it a new base from which to operate air medical flights.

“Aero National is a Washington, PA-based air ambulance company and has been providing safe and compassionate aeromedical transports to clients since 1969,” said Mike Vallee, Vice-President of Business Development for Air Ambulance Worldwide. “The two Citation jets will complement our fleet of two Lear Jet 35s and one Lear Jet 55. We proudly welcome the new members to the Air Ambulance Worldwide family and look forward to the enhanced geographic area and service offering that our clients can expect from the acquisition.”

Air Ambulance Worldwide will be taking on the pilots, medical crew and medical director of Aero National as part of the acquisition, although Aero National retains their own certificate as well as operational control.

While the new Pennsylvania base will immediately adopt the Air Ambulance Worldwide medical protocols, they will undergo EURAMI auditing this summer during AAW’s scheduled process.

© Air Ambulance Worldwide www.airmedandrescue.com

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Staffing questioned As pre-hospital care charity Irish Community Rapid Response (ICRR) prepares to launch the Republic of Ireland’s first communityfunded helicopter air ambulance service, James Paul Wallis examines calls for a doctor to fly on every mission 88

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For the second time in recent years, an appeal has been made for an about-to-launch HEMS service on the island of Ireland to carry doctors on board, garnering widespread coverage in the local media. In September 2018, an open letter was submitted to Irish Taoiseach (Prime Minister) Leo Varadkar and Health Minister Simon Harris, calling for doctors to staff Ireland’s first community-funded emergency helicopter service. Signed by a number of doctors connected to air ambulance organisations around the world, the letter expressed concern that the National Ambulance Service was seeking to staff the service with an emergency medical technician (EMT) and advanced paramedic configuration. The letter claimed: “This is not up to the standard expected of a HEMS and will not be able to provide advanced prehospital medical and trauma care to the critically ill and injured patients it is tasked to. It will be not be a flying emergency department (ED) or intensive care unit (ICU).”

It’s not the first time that Ireland has seen an international call for doctors to be part of a new HEMS set-up ahead of its launch. Back in

2016, plans were being finalised for an air ambulance service covering neighbouring Northern Ireland, part of the UK. At that time, a similar letter was sent to Northern Ireland Minister of Health Michelle O’Neill appealing for Air Ambulance Northern Ireland (AANI) to carry doctors on its helicopters. AANI now operates with doctor/paramedic teams that deliver ‘critical advanced pre-hospital care’ to patients, but the service declined to comment for this article on the benefits of carrying doctors on board, or whether the geography and types of patients it deals with are similar to those likely to be handled by the new service in the Republic of Ireland.

Ambulance Victoria has staffed its helicopters with intensive care flight paramedics for primary response for more than 30 years

FEATURE

for new Irish HEMS UK-wide aim?

It’s interesting to note that both letters state that ‘all of the UK’s 35 air ambulances are physician-staffed or are in advanced planning phase to move to that model’ (the 2016 letter omits the word ‘advanced’).

Wiltshire Air Ambulance (WAA), however, is one UK service that currently flies with paramedics.

Speaking to AirMed&Rescue in 2016, David Philpott, Chief Executive of WAA, then referred to staffing with doctors as a ‘platinum standard’ and ‘very expensive’. He also suggested, though, that the medical limitations of a paramedic-only service are rarely seen. And speaking to this publication recently, he said that WAA continues to operate with a clinical team that is predominantly critical care paramedicled: “This suits our geography, funding limitations and the nature of the vast majority of medical and trauma incidents which we attend.”

However, Philpott added that a move towards a doctor-led service, ‘predominantly for the enhanced clinical training and supervision this supplies’, is highly desirable. The issue, though, remains one of cost versus benefit: “This is a complex and emotive matter of ‘health economics’

where the cost of saving a life is sometimes crudely quantified. External independent analysis of our mission profiles in 2012 and 2015 satisfied our Board of Trustees that the additional costs of employing doctors on each and every flight was not compelling enough to make the change. It always remains under review.”

Of course, funding for UK HEMS

charities largely comes through public donations, so the question of what is affordable comes down, not least, to what the public will support. Of this, Philpott said: “There are limits to which the donating public will go in terms of the fundraising ‘ask’, and my judgment after nearly 20 years in the air ambulance business is that we may have reached the limits of that ‘ask’.”

This is not up to the standard expected of a HEMS and will not be able to provide advanced prehospital medical and trauma care

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The Association of Air Ambulances (AAA), a body representing UK HEMS charities, mentioned the Scotland Charity Air Ambulance alongside WAA as an example of a paramedic staffed service. A spokesperson told AirMed&Rescue: “A number of AAA members do not fly with doctors.

This is a decision taken by the charity and one that is supported by the AAA. It is down to the size of the charity and ... the geography and

the medical limitations of a paramediconly service are rarely seen patient types. Of course, funding is also a matter to consider.”

Global differences Similarly to the open letters, the Irish Association for Emergency Medicine (IAEM) argued in a statement in September that staffing HEMS with 1010

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doctors is the accepted model not only in the UK, but also in mainland Europe and Australia. Although, as we’ve seen, it’s not the case across the whole UK, there are indeed some countries where HEMS means doctors. As an example, Poland’s state air rescue service, Lotnicze Pogotwie Ratunkowe, told AirMed&Rescue that its crews always comprise a paramedic and doctor.

Likewise in Norway, the standard is

board shall be tasked to both trauma and medical jobs.”

Dr Hervé Coadou, an Emergency Physician with UF SMUR Héliporté SAMU59, France, was among the signatories of the latest letter. He explained that all HéliSMUR (HEMS teams) in France are physicianstaffed. In his opinion, it would be nonsensical for these helicopters to fly without an emergency physician.

He told AirMed&Rescue: “We

one HCM (HEMS crew member) and one doctor, explained Dr Per Bredmose, a Consultant in Prehospital Care and Retrieval Medicine working in Norway, who was among the signatories of the letter issued in 2016. In his opinion, the patients likely to be seen in Ireland are comparable to those in Norway. He added: “I truly believe that there should be a physician on board. HEMS is rarely about the transport vehicle, but about delivering competencies to the patient. I also truly believe that in order to utilise the resources in the best possible way, that HEMS with physicians on

consider prehospital activity as a part of hospitals. The French concept is ‘hospital ICU teams going outside hospital’.”

On the other hand, doctors are not the norm worldwide. Roylen ‘Griff’ Griffin and Eileen Frazer, Executive Directors of accrediting bodies NAAMTA (National Accreditation Alliance Medical Transport Applications) and CAMTS (Commission on Accreditation of Medical Transport Systems) respectively, commented that most services in the US do not use physicians onboard their aircraft. A spokesperson for New Zealand’s

F Philips Search and Rescue Trust, meanwhile, said that the region it covers (Central and Lower North Island) uses a mixture of paramedics and doctors, adding: “The vast majority of our work is, however, undertaken without a doctor and medical care and treatment is provided via an intensive care paramedic and an additional medically qualified person (paramedic/ EMT) onboard.”

routinely responded to what we term as primary response requests (motor vehicle accidents, major trauma, heart attacks, etc.). The education, training and skillset of our intensive care flight paramedics is extensive and we have found that this system works exceptionally well as part of Victoria’s State Trauma System.”

Does it make sense to model the new Irish HEMS service on organisations elsewhere? In a

Contrary to what might be understood from IAEM’s statement, there are even Australian HEMS providers that don’t routinely fly doctors. Ambulance Victoria, for one, has staffed its helicopters with intensive care flight paramedics for primary response for more than 30 years, with ‘excellent patient outcomes’, according to Anthony De Wit, Manager of Air Operations. He added that this staffing can change for time-critical transfers between hospitals to include a specialist doctor from a retrieval service working alongside the flight paramedic.

However, he said: “Doctors are not

statement addressing the recent letter, president of the Irish College of Paramedics Shane Knox asserted: “Comparison to Australia where helicopters are staffed by doctors is an ‘oranges and apples’ comparison.”

He also said: “We have been served well over the last six years with the EMT/Advanced Paramedic model of HEMS provided by the Air Corps and the National Ambulance Service and there has been no identified need to change this model or evidence to suggest it is not working.” Knox recognised that a physician could make a ‘greater impact’ on trauma missions, but added that only a

staffing HEMS with doctors is the accepted model not only in the UK, but also in mainland Europe and Australia

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minority of emergency calls in Ireland relate to trauma.

In response, Dr Brian Burns, a signatory of both letters who is from Ireland originally but now works in Australia, told AirMed&Rescue: “Ireland is like any other country in

on every call: “STARS physicians are available 24/7 to provide patient care and medical expertise for all missions. However, physicians do not necessarily need to fly to provide this care. They are able to work with experienced STARS air medical crew

and provide the best medical care possible to the patient as they make their way to the hospital.”

Availability of doctors Could it come down to whether there are any doctors available? The IAEM alluded to a ‘national shortage of hospital consultants’. The Irish Times reported John Kearney of ICRR as saying that it would be difficult to assign doctors to be on standby for helicopter missions given the shortage of doctors in hospitals. However, Dr Burns told AirMed&Rescue he doesn’t subscribe to that theory: “To staff the helicopter in daylight hours needs one doctor a day, seven days a week. That’s four full-time equivalent positions. What’s more, in

all HéliSMUR (HEMS teams) in France are physicianstaffed Europe in terms of trauma incidence, severity and type. HEMS are only tasked to the most critically ill or injured patients. They make up a small percentage overall of the total emergency calls an ambulance service receives. These patients, however, stand to gain the most by bringing the full suite of critical care interventions and skills to them rapidly at the roadside. This will save lives and decrease long-term morbidity.” Out of interest, AANI said in September 2018 that half of its taskings since its launch in July 2017 have been for road traffic collisions.

There is also the hybrid option of having doctors involved in missions, but not on board. For example, STARS of Canada has physicians on only around six per cent of missions, Mark Oddan, Senior Communications Advisor, told AirMed&Rescue. He explained, though, that STARS’s transport physicians have oversight 1212

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(nurses and paramedics) and utilise the medical equipment on board to get information and guide care.

They guide medical care by phone and radio to the [crew] as they fly to the patient, assess the patient,

several parts of the UK, linked jobs in prehospital care with HEMS and in the hospital have been successfully done to attract specialist doctors to poorly staffed hospitals.”

The recent letter suggested that given

F the opportunity to work on the new service, Irish doctors working abroad

only a minority of emergency calls in Ireland relate to trauma might return. Likewise, the IAEM stated that overseas Irish emergency medicine and critical care consultants ‘may well be encouraged to return home and work in our hospitals with a part-time HEMS clinical commitment’.

Dr Burns concurred: “There are many motivated Irish doctors in emergency medicine and critical care in specialty training or already at consultant level working in major trauma centres in countries with mature trauma systems. They are also helping to develop and improve those systems they are operating in. They are also privileged, like me, to work with world-class prehospital services such as Sydney HEMS. Many of these doctors want to bring those skills back to the critically ill and injured patients of Ireland. Precluding doctors bringing these skills and expertise to HEMS would essentially greatly decrease the chances of them wishing to return.

I personally would consider bringing those skills and systems knowledge back to Ireland.”

Taking a step back, it is of course great news that Ireland is to benefit from increased HEMS coverage. To quote from the latest open letter, ‘the population of Ireland deserves a world-class trauma system, underpinned by a world-class HEMS’.

The question, of course, is what constitutes ‘world-class’.

Source: www.irishtimes.com/news/health/charityrejects-criticism-that-kerry-air-ambulancedoes-not-have-doctor-1.3639404

We provide expertise and care For missions worldwide, please contact 24/7: Tel: +352 26 26 00 alert@air-ambulance.com

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Air Ambulance & Medical Assistance Forum Moderators

Dr Bettina Vadera Chief Executive & Medical Director, AMREF Patrick Schomaker Director of Sales & Marketing, European Air Ambulance Eva Kluge Director of Sales & Business Development, Air Alliance Medflight GmbH David Ewing Executive Vice-President, Global Markets, Skyservice Air Ambulance Andrew Lee International Business Executive, ER24

This new forum for ITIC Global was brought together by the Air Ambulance Committee, whose forum at last year’s event was well attended by air ambulance operators. This year, keen to garner more input from insurers and assistance companies, the forum organisers decided to rebrand as the Air Ambulance & Medical Assistance Forum and put a call out for air ambulance transport case studies from ITIC attendees. Five case studies were chosen, and speakers from the companies involved presented details of their cases during the forum, followed by a discussion on each case.

“This year’s forum was very well attended, with extra seating needed due to the excellent response, and we still had people standing at the back of the room,” commented Forum moderator Andy Lee. “This was very encouraging, and the most satisfying fact was that the split was around 60/40 in terms of insurer and assistance provider attending.”

Discussion on the case studies opened the door to wider issues that exist between all parties and promoted more understanding of each other’s potential challenges. “The drive behind this session was to build a better and stronger relationship between the payers and suppliers, to create safer and risk-free patient transfers,” said Lee. Presentation: Dr Matt Kalina, Group Medical Director, Europ Assistance Dr Kalina reported on a particularly challenging case involving a medical evacuation from a cruise ship – the patient was removed from the cruise ship and left in a remote coastal town, where he was taken care of by Haiti Air Ambulance paramedics overnight in a hotel. A helicopter evacuation to Port au Prince took place the following morning, but 14 14

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the de-brief with the involved parties, Dr Kalina said that there had been excellent discussions with the air ambulance provider, but these were less productive with the cruise company, who – potentially for liability reasons – were reluctant to admit that the patient shouldn’t have been offloaded in the first place.

Dr Matt Kalina

there was no hospital with interventional cardiology capabilities available, so an evacuation to the US was required. The air ambulance provider that was supposed to take the job refused to do so, claiming that the patient was not stable enough; but in reality, asserted Dr Kalina, they were just worried about the liability issues inherent in transporting an unstable patient. The Melanie Veloso

the challenge for assistance companies is in finding air ambulance providers who can fly into warzones Europ Assistance medical director tried to speak to the air ambulance medical director, unsuccessfully, to discuss the case. After several hours’ delay, the air ambulance provider accepted the flight – but only after being provided with a discharge of responsibility.

Discussion Concerns were raised by those in the audience about doctors on cruise ships not always being appropriately trained in the medicine they will be providing, nor in the equipment they are using. It was suggested that the assistance industry approach the American College of Emergency Physicians to discuss more appropriate qualifications for onboard doctors. When asked about

Presentation: Melanie Veloso, Deputy Chief Operating Officer, MSH Americas Melanie’s presentation centred on the case of an expatriate who was hospitalised in remote Mongolia. The local clinic diagnosed flu and insisted there was no need for an evacuation as the patient was being managed in the facility. By day five, however, the treating medical officer urgently requested an evacuation, as there was no improvement in the patient’s condition. The assistance company engaged an air ambulance provider to evacuate the patient to Beijing, but there was a two-day delay due to political red tape and clearance issues getting a helicopter into the country.

The patient was then evacuated to South Korea instead. Points of discussion raised by Melanie included:

• When is it appropriate for an assistance team to override the treating doctors?

• How can an assistance company be

Discussion The issue of the assistance company having a lot of faith and trust in the air ambulance company to perform the mission, allowing them to take off without the landing permit, was brought up. There was constant communication between the assistance company and air ambulance company medical director to agree that this was the best course of action for the patient.

Yasir Ahmed

Zack Bouhlel

Presentation: Zack Bouhlel, Operations Manager Dubai Assistance Centre, RMSI AA Zack’s presentation focused on an evacuation from Baghdad to Dubai.

The patient was in rapidly deteriorating acute respiratory distress with suspected pneumonia; he required ventilation, intubation and sedation prior to the flight, which were initially performed by the treating doctor, but the facility in which the patient was being treated was not experienced in such procedures. Obtaining a landing permit for Iraq can be problematic – after hours, or during holidays, it can be especially challenging, said Zack. Due to the patient’s diagnosis and deterioration, the decision was made to take off from Dubai without the Iraqi landing permit in place, despite the fact that the patient was not stable. Communication between the treating physician and flight doctor was maintained throughout the flight, which Zack pointed out was essential to keep the case moving forward, as the treating doctor was keen to keep the patient in situ.

Presentation: Yasir Ahmed, Network Manager, SOS First, part of SOS International Yasir’s case involved a severe injury to an employee in Kandahar, Afghanistan.

There was an air ambulance already flying from Columbo (Sri Lanka) to Helsinki with a patient, and it was agreed that a co-transport would take place, picking up the second patient up in Kandahar en route. However, the first patient was then found not to be suitable for co-transport.

Evacuation of the second patient was becoming more urgent, but there was no provider ready to fly into Afghanistan to pick them up. Another provider was found eventually, and the patient was repatriated onboard a Challenger air ambulance.

Discussion The major focus of the discussion following the presentation lay in the fact that the challenge for assistance companies is in finding air ambulance providers who can fly into warzones – such dangerous destinations are becoming more common, so the need for air ambulances to fly to them is greater. The issue of insurance was brought up, and Dr Bettina Vadera pointed out that providers may not be aware of the different types of war risk insurance that is available to them. The issue of co-transports was also raised – it is always a risk that one patient’s condition may adversely affect the other patient and the ability of the air ambulance company to perform both evacuations simultaneously.

SPECIAL REPORT

more proactive in knowing what flight requirements and clearances are required?

Discussion Audience members pointed out that the reasons why treating doctors hold on to patients vary – it can be ignorance of treating facilities elsewhere, or cultural pride, or even a considerable financial incentive to treat an insured patient. It can be difficult to intervene with treating doctors due to regulation, and cultural norms, according to one audience member.

There are workarounds, though, such as talking to the patient and their relatives, which allows the assistance company to make a more informed decision about the patient’s condition.

Dr Cai Glushak

Presentation: Dr Cai Glushak, International Medical Director, AXA Partners This case centred on the evacuation of a patient with a history of breast cancer who was on holiday in the Caribbean.

Her preliminary diagnosis was cardiac failure due to chemotherapy; the patient had already arranged to be transferred by air ambulance to Toronto, but mid-flight, she suffered a ventricular fibrillation. The plane diverted to the Bahamas, but the patient was declared dead at hospital there. The rest of the family, flying to Toronto via Chicago, were expecting to be updated on her condition on their layover in Chicago.

Due to the patient’s diagnosis and deterioration, the decision was made to take off from Dubai without the Iraqi landing permit in place Discussion The discussion centred on what would other assistance companies do – when would they tell the husband, who was travelling with two young children, that his wife had passed away? A vote was held, and the majority of the room would have waited until the family reached Toronto. Cai said that AXA decided to inform the family while they were in Chicago, as it was thought that if they waited, at some point the question would be asked of ‘when did this happen, and you had the opportunity to tell me earlier, why didn’t you’? It was a difficult decision, said Cai, but one that had to be taken.

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Air ambulance industry trends

of the United Nations means that FAI receives a lot of requests to fly into conflict regions and is, thus, experienced in ensuring that as much information as possible is gathered about real-time risks en route to the patient. Detailed risk assessments are carried out before the decision to fly is taken.

Preparation, said Volker, is paramount for any

flight operations in conflict

Cyber risk and data protection This session was focused primarily on the introduction of the EU-based General Data Protection Regulation (GDPR), which came into force in May 2018. Florian Thoma, Senior Director, Global Data Privacy for

zones must be carefully considered and completed Gert Muurling

Dr Gert Muurling, Medical Director, Air Alliance Medflight GmbH, discussed how the development of new antibiotics came to a halt around 30 years ago, which has resulted in a proliferation in cases of drug resistant illnesses. There are resources available that can show which countries have cases of drug-resistant illnesses of various kinds, which can assist an air ambulance company in their decision-making process about which medications to take with them onboard the aircraft when collecting a patient. Dr Muurling

using comprehensive information and risk management air ambulance company considering carrying out high-risk missions, and flight operations in conflict zones must be carefully considered and completed using comprehensive information and risk management.

Graham Williamson, CEO of LIFESUPPORT Air Medical Services Inc., focused on the

Jerome Pin, Mickael Tome and Florian Thoma

Accenture began by pointing out that while, previously, data privacy had been a topic that only compliance officers knew or cared about, it is now an issue that is top of mind for business leaders, the media and regulators. Data ethics, said Florian, are now a key consideration.

Mickael Tome, Attorney, Barreaux de

data protection will occur by default, and systems will be designed in such a way that data is held securely, with procedures and practices being built in to businesses Graham Williamson

Volker Lemke

also discussed the hygiene risks for the patient and crew when performing a transfer, as well as the risks posed by double stretcher transfers. He then showed how aircraft and crew disinfection is performed and checked.

Volker Lemke, CSO of FAI Air Ambulance, shared with the audience his company’s experience of flying into warzones and other high-risk countries, showing that while they can be high-risk operations, there are many steps taken and tactics employed to minimise and mitigate those risks to crew and aircraft. Performing for and on behalf 16 16

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repatriation of critically ill – but stable – patients onboard commercial airlines. He pointed out the benefits of such flights, including extra space for the crew and patient, and fewer fuel stops meaning faster flights with fewer take offs and landings. They aren’t suitable for all patients, though, and there are many cases where an air ambulance transfer would be more appropriate. Effective case management, said Graham, is key. Each case must be carefully co-ordinated, and every detail is essential. There must also be contingency plans in place for every eventuality. Engaged medical leadership from all stakeholders is, furthermore, absolutely essentia

Luxembourg & de Paris at CLAW, shared his insights about the challenges that faced companies before, during and after the implementation of GDPR, and was forthright in his assessment that ‘it is not possible to achieve full compliance’. There is still time for regulators to alter the rule, though, and it can be adapted to reflect the reality of the marketplace. Going forward, said Mickael, data protection will occur by default, and systems will be designed in such a way that data is held securely, with procedures and practices being built in to businesses.

Jerome Pin, Project and Business Development Manager and Data Protection Officer for Luxembourg Air Rescue Group, gave attendees information about how his company prepared for GDPR, with audits

SR to identify gaps in data security, particularly with regards to medical data. There was a lot of work involved in changing contracts framework to ensure compliance although, in reality, compliance remains a work in progress from both a data protection and information security aspect. Jerome believes that air ambulance and assistance work is not compatible with GDPR due to the nature of

needing to exchange data swiftly, and is keen to engage the industry in discussions with the regulator to talk about potential exemption from GDPR regulation.

EURAMI Members Meeting The European Aero-Medical Institute (EURAMI) reported on their experience of ITIC Geneva, and offered some insights into their Members Meeting.

It was a banner few days for EURAMI at their exhibition booth during ITIC Global.

Dr Terry Martin (Chief Auditor) and Claudia Schmiedhuber (Interim Managing Director) proudly welcomed dedicated EURAMI members to discuss, debate and review the past year together. It was evident that accreditation and quality still hold a very prominent place in our industry and that reputable accreditation associations such as EURAMI e.V. are actively contributing to raising quality standards for patient transportation and aeromedical procedures.

However, not only current members could

be seen sitting at the EURAMI booth; many aeromedical providers are aware of the importance of standardised regulations and are looking to obtain EURAMI recognition to demonstrate quality, safety and responsibility to their insurance and assistance clients.

On 1 November, the 33rd EURAMI General Assembly was held to a packed room of members (most sacrificing their single free afternoon to attend to association business).

The presentation, led by President Dr Laurent Taymans, reviewed the last year, including financial results, new accreditations and reaccreditations as well as the achievements and developments within EURAMI. This year also marked an election year for EURAMI, with three board positions up for election. Dr Taymans (President), Pascaline Wolfermann (Vice-President) and Franziska Hollenstein had completed their terms, whereas Dr Cai Glushak, Philipp Schneider (Treasurer) and Lisa Humphries continued their Board terms.

Incumbent Franziska Hollenstein was

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All five of the aeromedical providers who were ITIJ Award finalists hold EURAMI accreditation re-elected and joined by new members Sergio Abril and Mark Chapman. With the former President and Vice-President having completed their terms, the newly elected Board also assigned the officer roles amongst its members. Dr Glushak was elected as the new President, Philipp Schneider as Vice-

President and Mark Chapman took on the role as Treasurer.

The diverse EURAMI Board is composed of members from all sides of the industry: Dr Glushak is the International Medical Director and Chief Medical Officer of AXA Partners; Philipp Schneider is the Key Account Manager for Quick Air Ambulance in Cologne, Germany; re-elected Board member Franziska Hollenstein the Founder of Prime Nursing Care, a global medical escort provider; and Lisa Humphries is the Director of Capital Air Ambulance in the UK. The newly elected Board member Sergio Abril holds the position of VP of Business Development at Airlink Air Ambulance and Treasurer Mark Chapman is the Program Director at Medway Air Ambulance.

In his address to the members, Dr Glushak thanked Dr Taymans and Pascaline Wolfermann for their contribution, being integral to the re-organisation of association leadership and business structure, and their tireless efforts to advance the work of the industry. In particular, he noted that despite the intense pressures on this highly specialised medical services field, he applauded the Board he had worked with for the past two years on its objectivity and sole dedication to quality and safety. He assured members

that he would ensure that individual commercial interests be put to the side in favor of pure attention to standards of quality care, patient safety and provider performance and reliability.

The newly elected President, Dr Glushak says that he intends to pursue the vision for EURAMI elaborated by Dr Taymans as well as specific targets during the upcoming term. These include: • Laying out a five-year plan to chart a course for advancement and sustainability of the organisation and contribution to the field of aeromedical services • Establishment of an Advisory Committee to incorporate additional experts and stakeholders of the industry that are key to EURAMI’s development and recognition • Completion and release of the EURAMI 6.0. standards spearheaded

by Dr Terry Martin • Expansion of a highly qualified auditor pool to accelerate accreditation and assure objectivity • Obtain recognition of EURAMI accreditation by key agencies and government departments • Enlarge forums for member participation, communication and exchange • Add to the state of knowledge of the industry • Ensure consistency and responsiveness to members and the client community.

Air Alliance MedFlight GmbH wins ITIJ Air Ambulance Provider of the Year award Congratulations to Air Alliance MedFlight GmbH, which has won this year’s ITIJ award for Air Ambulance Provider of the Year.

AirMed&Rescue’s sister magazine held its annual awards ceremony in Geneva, Switzerland on 2 November. The award was sponsored and presented by UC San Diego Health, with US-based REVA and Colombia-based Sarpa joining Air Alliance as finalists.

This is the second year in a row that the company has scooped the award. Air Alliance representatives said of the win: “We would like to thank all our clients and the entire team for their excellent support and great work.”

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Drone doctors Trials in Australia could be signalling the way ahead for a new role for remotely piloted aircraft in the air medical sphere, as James Paul Wallis reports

Drones have long since proved their worth as an aerial search tool and this year have grabbed headlines by assisting in rescues of swimmers in the surf. Could they also assist in responding to trauma calls alongside traditional HEMS crews?

There are two distinct avenues being actively investigated in New South Wales (NSW), Australia.

Blood back-up

In July 2017, Sydney Helicopter Emergency Medical Service team, working with DroneAdvantage, successfully carried out proof-of-concept trials to assess the feasibility of using drones to carry emergency blood plasma products to the scene of an accident, explained Kelvin Morton, Managing Director and Airboss at DroneAdvantage. The concept, he explained, is for a UAV to fly in extra blood to top up what the HEMS crew carries onboard: “The HEMS team can only carry 20 20

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three units of plasma on the helicopter, but when they get out to the scene of a trauma, they may often require many more units if they need to carry out a transfusion or if there are many victims. When that happens, there is an emergency response involving ambulances, police and fire brigades to pick up more plasma and get it to the HEMS emergency team in the field as fast as they possibly can. Having access to a fleet of drones at the blood banks to take plasma to the scene would make a significant impact.”

The trials involved short-range flights to and from the helipad at the Royal North Shore Hospital with the drone kept within visual line of sight (VLOS), but the ultimate aim is to be able to fly further afield. Dr Brian Burns, a Prehospital and Retrieval Medicine Specialist and Emergency Physician who has worked on rescue helicopters, has been vocal in his support of the drone concept, speaking both to local media and to an international audience at a Social Media and Critical Care event in 2017. He suggests a range of aerial platforms could be used as required to respond to both short-range missions as well as long-range taskings, where they would fly beyond visual line of sight (BVLOS): “I would anticipate triaging

the blood delivery request and using one of several UAV options depending on the distance, weather and local physical characteristics at the intended destination.” He added: “Whether we use the UAV in city or rural areas, in all cases the aim is to ultimately be flying BVLOS with remote monitoring from a central command and control unit.”

The idea of using UAVs to deliver blood is not new. In Rwanda, for example, the Ministry of Health has partnered with Zipline to set up a system where fixedwing drones deliver blood products to regional hospitals on demand. However, whereas the Rwandan solution involves parachute drops to designated landing zones at the clinics, the concept tested in Australia would involve drones flying to the kind of accident scenes that HEMS crews attend. In these types of missions, said Dr Burns, pre-hospital blood products are the currency that allows providers to get patients to the trauma centre alive who would otherwise have died: “Efficient delivery of life-saving blood products by drone/UAV will allow stream-lined efficient rapid access to these life-saving products.”

A second, entirely different, approach would see camera-equipped UAVs being used as scouts, arriving early on scene to gather information on, say, the number of victims and the nature of injuries.

DroneAdvantage is in discussions regarding setting up trials to assess the feasibility of using drones as ‘forward scouts’ to assess the condition of trauma patients before the HEMS team arrives on scene, allowing triage decisions to be made even before the crew touches down. Morton explained: “The forward ‘scout’ concept seeks to build on a study carried out by two University of South Australia students, Ali Al-Naji and Asanka Perera, who developed an algorithm which uses the RGB spectrum on a standard drone to calculate a person’s heart rate using only a live video feed. The HEMS concept would try to take that ground-breaking work several steps further by using radiometric thermal sensors to detect the patient’s body temperature, as well as scan the area to identify the locations of patients prior to arrival so that no time is wasted when they land.”

Regulatory challenges

For either concept to become a reality, regulatory hurdles will need to be overcome, principally the need to make BVLOS flights. In the blood trials in Sydney, the drone was always in VLOS, said Morton, in compliance with standard Civil Aviation Safety Authority (CASA) regulations. The road to BVLOS begins with showing that the concept is effective and working with CASA, he explained: “We will first prove the viability of a concept and its potential to save human life, at which point

90 per cent of preventable trauma deaths are due to exsanguination we would then invite CASA into the [proofof-concept trials]. Emergency response teams are exempted from compliance with standard regulations for ‘mercy flights’, so it’s just a matter of ensuring that we have appropriate CASA-compliant configuration of the drone to meet BVLOS standards

and detailed SOPs.” DroneAdvantage has experience here, having worked with NSW Surf Lifesaving on the Little Ripper project that saw the first life being saved in the surf by a drone in January.

Morton added: “Once we have carried out a range of VLOS tests and developed all of the SOPs, systems and fail safes, we would extend to BVLOS trials under the watchful eye of CASA.” Another key step will be selecting the most suitable models of UAVs for reallife missions. While that can only happen further down the line when more work has been done to flesh out the concept, Morton commented that a larger, fixed-

SPECIAL REPORT

Scouts

wing VTOL aircraft using hybrid propulsion ‘would work well for the rural areas’. And it’s those areas that could most benefit from help from above. Dr Burns noted that Australia suffers from the ‘tyranny of distance’ with a median pre-hospital time for severe trauma at around the 100-minute mark, well beyond the golden hour of treatment.

Underlining the need to get blood products to such patients, he added that 90 per cent of preventable trauma deaths are due to exsanguination.

Interestingly,

DroneAdvantage is not alone in exploring how to deliver blood in Australia by drone.

Leaders at the country’s mail delivery service, Australia Post, have been looking into operating blood-delivery drones.

And according to comments reported this August, Zipline has begun dialogue on replicating its Rwandan system for rural Australia. It may only be a matter of time before we see remotely piloted aircraft working alongside HEMS and lives being saved by a network of drones working across the country.

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SPECIAL REPORT Helen Ballantyne, Critical Care and Flight Nursing Forum Committee Member, reports on the Royal College of Nursing Flight Nursing Workshop, which was held in London on 6 October The Royal College of Nursing (RCN) Flight Nursing Workshop, Fit to Fly: Complex Care in the Air, was a skilfully constructed programme of topics from the RCN Critical Care and Flight Nursing Forum. The RCN forum has 8,800 members, formed with the aim of providing guidance documents; carrying out and supporting research and working with other organisations and governments to develop guidance and policy. In addition, the forum organises conferences and study events to share best practice and provide an opportunity to network with other members working and interested in flight nursing.

A varied agenda The event successfully negotiated the challenge of accommodating a diverse group delegates who ranged from students to experienced flight nurses and medical officers, and the initial session was a prime example of how this approach worked in practice. Dr Ryan Copeland from International SOS discussed five critical global health trends, air pollution, noncommunicable disease, outbreaks, mental health and digitalisation, and in doing so, established the acknowledgment and management of complexity as the key theme for the day. His insight into the changing demographics of global health offered experienced nurses the opportunity 22 22

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Education and the exchange of information to reflect on their own perceptions of changes linked to these trends, while others noted key points to direct their future learning.

Case studies provided by Dr Jude McSharry from Teladoc Health then offered attendees an insight into clinical decision making. He explained that the complexity of a patient’s condition and surroundings, combined with professional agendas from a range of stakeholders, can make the application of evidence-based medicine challenging.

His insight emphasised the importance of information gathering, clear communication

The complexity of a patient’s condition and surroundings, combined with professional agendas from a range of stakeholders, can make the application of evidence-based medicine challenging and the sourcing of expert professional opinion and prompt evacuation to a different provider or country. These points were echoed later when Gayle Falconer outlined the structure of the Military Aeromedical Evacuation team, which led to an interesting reflection on how to maintain practical clinical skills in a highly complex yet

variable volume role.

In another demonstration of a complex topic, Dr Stephen Houston from British Airways discussed fitness to fly after eye surgery. This generated much interest from the delegates, many acknowledging it was an often over-looked topic. Virgin Atlantic Airlines speaker Geraldine Lundy provided a session on passenger accessibility offering realistic, practical advice for supporting assisted travel combined with a thorough insight into the issues the subject created within the commercial airline industry.

The theme of complexity was advanced further by Transport Nurse Educator Ian Braithwaite from EMBRACE, who described his work collecting narrative experiences of flight nursing. His research highlighted the complexity of the physiology and logistics linked to this role, but importantly, it also demonstrated the depth of human emotion as nurses described the juxtaposition of feeling professional satisfaction and pleasure alongside the compassion and empathy they feel for parents.

Still to come…

The day was finished with a panel discussion with the organisers of the event, the RCN Critical Care and Flight Nurse Forum Committee. The team outlined some of their upcoming projects, which include guidelines on fatigue, medicines management and careers and personal safety advice. The fact that their planned projects for the profession echoes many of the issues highlighted throughout the day is a credit to their insight into the speciality, so put a note in your diary for next year’s flight nursing day, in October 2019 in London.

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Managing a combative patient in-flight To sedate, restrain, medicate, refrain, or deescalate?

What happens when a patient becomes violent, combative, and could potentially become a danger to themselves and/ or to the flight crew? Amy Gallagher interviewed

Treating the injury, not the crisis

a diverse network of air

Stuart Elms, Clinical Director, EHAAT

ambulance corporations, organisations and academic professionals who shared their practices, policies and procedures in managing a combative patient during air transport 2424

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“It is highly unlikely that we would ever fly a patient having an isolated mental health crisis as we do not routinely get tasked to this group of patients,” said Stuart Elms, Clinical Director, Essex & Herts Air Ambulance (EHAAT). EHAAT is a UK-based charity that provides Helicopter Emergency Medical Services (HEMS) for the critically ill and/or injured. According to Elms, one response that is not considered, however, is a chemical or a mechanical restraint on a patient in crisis. “If a patient suffering a crisis has become combative through injury,

such as a traumatic brain injury, a clinical assessment determines whether sedation or pre-hospital anaesthetic is used; we treat the injury rather than the crisis,” said Elms.

At times, however, a temporary manual restraint may be needed to gain IV access to allow patient care to take place, added Elms. “This type of response would be minimal,” he said. “We apply ‘deescalation’ techniques, such as continuously talking to the patient. All team members are trained to identify the ‘red flags’, such as positional asphyxia and excited delirium (ExDS).”

Positional [postural] asphyxia is a form of mechanical asphyxia that occurs when a person is immobilised in a position which impairs adequate pulmonary ventilation and thus, results in a respiratory failure. Based on findings published in the 2016 Front Physiol Journal, research by the National Center for Biotechnology Information (NCBI), part of the National Institutes of Health (NIH), explained the characteristic symptoms of ExDS, including bizarre and aggressive behaviour, shouting, paranoia, panic, violence toward others, unexpected physical strength, and hyperthermia.

Throughout the US and Canada, these cases are most frequently associated with cocaine, methamphetamine, and designer

FEATURE cathinone abuse.* “In all cases, we work within the guidelines of the National Institute for Health and Care Excellence (NICE) and the Mental

Throughout the US and Canada, these cases are most frequently associated with cocaine, methamphetamine, and designer cathinone abuse Health Act Code of Practice to ensure the patient receives the best possible care for the condition,” said Elms. NICE is an executive function of the Department of Health in the UK that provides guidance and training for public healthcare professionals. The Mental Health Act of 1983 Code of Practice was revised in 2015 to reflect guidance for patients, their families, and carers regarding their rights.

Front Physiol. 2016; 7: 435.Published online 2016 Oct 13. doi: 10.3389/fphys.2016.00435 Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum, Deborah C. Mash, [the article has been cited by other articles in the PMC].

Type and severity of psychosis Dr David Sinclair, consultant in Anesthesiology, Critical Care and Emergency Response Medicine, and Medical Supervisor, European Air Ambulance Personal views, as well as professional advice that European Air Ambulance (EAA), Dr David A. Sinclair would recommend to a fellow physician in his role as the medical supervisor, stated that the method of response in treating a combative patient mid-flight depends on the psychosis. “It definitely depends on the type and severity of the psychosis,” said Dr Sinclair. For example, a compliant delusional patient might need neither sedation nor restraint,

he explained. “On the other hand, an agitated schizophrenic patient might need both in extreme,” said Sinclair.

The decision to restrain or sedate the patient is made upon safety concerns knowing the cabin is a severely sensitive environment where a short outbreak by the patient can endanger the lives of the entire crew, he explained.

Minor psychotic patients with no concomitant diseases are sometimes managed on commercial aircraft with an EAA physician accompanying, he explained.

“Severe psychotic patients or patients with concomitant diseases are transported by air ambulance,” added Sinclair.

To include or not to include a family member during air transport of the patient can turn out as a ‘mixed blessing’, said Dr Sinclair. “The crucial factor is in the intellectual differentiation or emotional distance of the family member/friend,” he said. “They must be fully aware, that in extreme, they might witness disturbing scenes [and be prepared to deal with them]. Otherwise, the medical team must take care of two hysterical patients at the same time.”

Positive experiences with close friends or relatives who escorted the patient do exist,

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The key is to treat the cause of the psychosis the rate of in-flight incidents including violence remained low

however, said Sinclair. “The more distant relationship might be the better choice than close family members,” he said. “If the patient is a minor, a parent should accompany.”

Research: In-flight Pharmacological Management of Acute Mental Health Disturbance Dr James Garwood, Specialist Registrar in Anaesthetics and Pre-hospital Emergency Medicine Dr James Garwood, in conjunction with two additional researchers, published in a recent issue of Air Medical Journal their research paper, In-flight Pharmacological Management of Acute Mental Health Disturbance [AMHD]. When presenting these findings at the International Aeromedical Transport – Concepts in 2626

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Airborne Patient Management conference in London in April 2018, the research caused ‘quite a bit of controversy amongst some of the other doctors who were present (in terms of physical restraint)’, said Garwood.

The research objective studied 110 patients [air] transferred many hundreds of kilometers with AMHD for specialist mental health services in Western Australia during a four-month review of 130 flights, according to Royal Flying Doctor Service Western Operations, Australia (WA) records.

Garwood’s experience in aeromedical transfer of patients with AMHD comes from his work with the Royal Flying Doctor Service (RFDS), WA in terms of moving patients who were ‘acutely psychotic.

The RFDS ‘best practice’ followed the transfer of mental health patients policy, which was written in conjunction with WA government, WA psychiatrists, and the RFDS-WA’, according to Garwood.

AMHD causes “The causes of AMHD can be ‘organic’ or ‘non-organic’,” explained Garwood.

“Organic causes are generally a true psychiatric disorder from chemical imbalance within the brain, and are a longer-term condition, whereas the nonorganic causes are, for example, from drug abuse (crystal meth is a classic), or acute infection, such as meningitis.”

The key is to treat the cause of the psychosis, which may be with pharmacological methods (antipsychotics

such as olanzapine) or to treat the nonorganic cause by treating the infection and reversing possible physiological causes, he explained.

“The vast distances in WA necessitates the need to use air transportation to be treated by a tertiary (inpatient) psychiatric unit,” Garwood explained. “The balance of risk vs harm generally falls on the fact that it would either be a drive of over 30 hours, or a three-hour flight to transfer. It would be overall less of a risk to move the patient rapidly by a critical care team than by road by a team of police officers with minimal medical cover.”

In his current role as a senior flight doctor with Capital Air Ambulance in the UK, Dr Garwood’s workload is generally more of an Intensive Care Unit [ICU] repatriation service. “As part of our contracted work, we could be tasked with moving a patient from an offshore/island location to the UK, which would either involve a 30-minute flight (dedicated air ambulance or commercial aircraft) or a ferry crossing of some hours.”

Transporting AMHD patient protocols Garwood explained that when moving patients with AMHD, it is important to ensure: • Patients are moved for the correct reasons, such as a clinical need, as opposed to ‘commercial or organisational’ pressures • We do no harm with either the patient’s

F

sedation or manual restraint, and

• The patient causes no harm to the flight

crew or put the security of the aircraft in jeopardy.

“The aim should be for a balanced approach with a calm and relaxed patient that, although they may have restraints fitted, they are not physically restricted from movement or adjusting their position on the stretcher,” said Garwood.

According to the research conclusion, the rate of in-flight incidents including violence remained low. Additionally, the research stated the transfers of patients with AMHD ‘are challenging; and that high quality preflight assessments and in-flight care are required to minimise the associated risks’.

Fitness-to-fly and direct dialogue Graham Williamson, CEO, LIFESUPPORT Air Medical Services, Inc.

The balance of risk vs harm generally falls on the fact that it would either be a drive of over 30 hours, or a three-hour flight to transfer Research Study: In-flight pharmacological management of acute mental health disturbance, Air Medical Journal Volume 37, Issue 2, March-April 2018, Pages 115-119; Researchers: Brian Wilkinson MBBS, FRCA; James Garwood, BMBS, FRCA, MAcadMEd, DipRTM.RCS(Ed), PGCClinEd;Stephen Langford, FAFPHM, FRACGP, FACAsM, AFRACMA, DipRACOG, DipAvMed, GAICD1

Canadian-based LIFESUPPORT Air Medical Services, Inc. is a global provider of international patient transportation, by fixed-wing air ambulance, commercial airline medical escort, and intercontinental commercial airline stretcher, in which ‘each and every mission is assessed and handled on a case-by-case basis’, said CEO Graham Williamson.

Direct dialogue, conversation, and involving the patient in decision making is key, he said.

“Decision making is multi-layered, which begins with a fitness-to-fly declaration from the sending facility, followed by a review from our medical team, and our

chief medical officer, in collaboration with the assistance company,” explained Williamson. “The medical team must carefully consider the case, meet with the patient and treating team before the mission, before the transport is fully confirmed. Medical protocols are available to assist the patient in becoming comfortable and relaxed for the journey.”

Medical teams are equipped with physical and chemical restraints, but this measure is only used in an emergency. “The use of restraints is an extreme measure,” said Williamson. “If it comes to that, really, the patient was not fit to fly in the first place.

We would never plan to transport a restrained psychiatric patient in advance.”

Building a relationship, creating an understanding and collaborative relationship is fundamental; it is more powerful than any drug, explained Williamson. “In most cases, the patient wants to return home,” said Williamson.

“Having a familiar family member or friend along for the journey is very valuable. If flying commercially, the family member or friend should also be seated in business class with the medical escort and patient.”

A well-trained medical escort who is very familiar with the nuances of international air travel, security protocols, and air medical flight, working collaboratively with the patient, family and treating medical team, will have the best chance of success, he said.

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When experience counts Claudia Schmiedhuber, Founder and CEO of Alpine Health Consulting, and Interim Managing Director and Business Development Manager of the European Aero-Medical Institute (EURAMI), spoke to AirMed&Rescue Magazine about current challenges for the air ambulance sector, and how technology is both a challenge and a boon

Congratulations on your new role with EURAMI. What will this new job involve doing?

Thank you very much. My role with EURAMI includes supporting the organisation with general management tasks, process optimisation, client and member communication, as well as the development of existing and new memberships and business, to name a few of my duties.

As EURAMI has recently undergone some

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internal (health) challenges, it is my goal to ensure that we will get back on track and set the right path for the future.

How has EURAMI changed its accreditation requirements of late, to ensure that they are keeping current with technological, medical and regulatory changes?

Our standards are continuously reviewed by the Chief Auditor and Executive Board, and input from external sources such as members, auditors and other organisations is discussed during the regular Board meetings.

EURAMI understands the necessity to adapt to the changes and challenges we are currently experiencing, so therefore we are working on Version Six of our standards for accreditation right now to reflect these adjustments. I believe that it is important to continuously keep an eye on the market

EURAMI understands the necessity to adapt to the changes and challenges we are currently experiencing and its developments and ensure that our institution can answer to these innovations.

I think one important point that must be taken into consideration more thoroughly is the handling of patient and health data. With the General Data Protection Regulation (GDPR) this has become a big issue for all globally operating providers, and something that is still under development in many companies. It is

INTERVIEW

a crucial point that I want to continue to focus on moving forward, so our members can rest assured that their data is in safe hands.

Another important topic will be to take new technology and innovation into consideration, when talking about accreditation requirements. Our industry is already experiencing these changes, so it will be necessary to consider new flight monitoring, quality assurance, incident reporting and communication tools which must be reflected in the audit process and standards as well.

Having said this, I think one of the biggest advantages of EURAMI is the diversity of its members, auditors and executives, which allows the institution to reach out to all sorts of experts for their input and knowledge,

including for the topics mentioned earlier. This not only ensures that EURAMI is continuously exposed to these new developments, but also reassures members that EURAMI continues to stand for quality, expertise and trust in the aeromedical and global health and assistance industry.

Does EURAMI ever do unannounced checks to ensure that ethics and standards are being upheld, or do you think that such visits are unnecessary?

At this point EURAMI does not do unannounced checks, however, this is something that has come up in the past frequently. As our members will tell you, the accreditation and re-accreditation process is quite time consuming and requires a lot of preparation time. We understand that during daily operations it would be hard to take out the key people to sit down with an auditor to review and explain current happenings – which must happen during a thorough audit to ensure all audit requirements are being discussed, checked and confirmed.

However, our members are required to alert any incidents, accidents or violation

The implementation of the GDPR in Europe has added another layer of difficulty for providers of regulations to EURAMI. In addition, all changes in management, medical directors, aircraft and such must be reported to the institution, which means the Executive Board has an eye on its members and their development. Furthermore, external providers, institutions and affected parties are able to report any incidents directly to the EURAMI office, which will then be investigated properly.

However, we do trust our members and we are proud of their quality and daily service to our patients. Should a member or external party ever raise any concerns in these areas,

our Board will approach this member and evaluate the issue in a neutral and solutionoriented way.

Are there any plans to work with other accreditation bodies, such as CAMTS, to offer air ambulance operators a dual accreditation that will be valid in different parts of the world?

EURAMI offers a worldwide high-quality accreditation programme and we are proud to say that we have accredited providers on every continent of the world. I am not aware of any discussions yet, however EURAMI

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is always open to talk and discuss with our fellow accreditation programmes. I very much believe that the knowledge exchange

topic of aeromedical transportation and global medical assistance, and I

Unfortunately, we also still see a lot of fluctuation in ‘new providers’, who enter the market with dumping prices to score missions between institutions like EURAMI, CAMTS, NAAMTA is something that our industry could appreciate, thus EURAMI would welcome such an approach.

Your new venture is Alpine Health Consulting, which offers consulting and education services. How do you envisage your two roles complementing each other?

Alpine Health Consulting (AHC) is focused on supporting companies with a will to grow, innovate, develop and educate – so my company is offering support and solutions for exactly that. EURAMI has recently undergone a very difficult time due to internal developments, which have affected its market presence, member communication and growth, so when EURAMI approached me to work with them I immediately realised that these two entities and roles complement each other very well.

In my role within EURAMI, I now have the possibility to help rebuild the brand, market presence and the development of new business and memberships, and there is also a renewed emphasis on education and knowledge exchange – something on which I am also focusing with AHC. I currently give lectures at universities on the 3030

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believe with the expert pool that EURAMI has at its disposal, this is something that is of great interest for such programmes and institutions. After all, both EURAMI and AHC have made it their mission to improve our industry to further enhance the patient experience during medical emergencies abroad.

What are the primary challenges facing international air ambulance providers at the moment, in your opinion?

I think the implementation of new technology, the necessity to innovate and provide an up-to-date operation, as well as the increase in the number of providers and, thus, competition, in a rather small specialised market are the biggest challenges that the international air ambulance providers face now.

Due to the enormous amount of logistical work and co-ordination, the complexity of each mission, and the very small profit margin, it is challenging for air

I ambulance providers to maintain a professional, high quality and smooth service. Also, the implementation of the GDPR in Europe has added another layer of difficulty for providers, as the processes of ensuring data security in accordance with the law may not always work exactly as planned in the daily operation of an air ambulance business.

Unfortunately, we also still see a lot of fluctuation in ‘new providers’, who enter the market with dumping prices to score missions.

These providers, however, are often not

important for our industry, as they strive to provide guidance and quality assurance in this very complex market.

The key for me here – and that is why I started Alpine Health Consulting – is to close that knowledge gap by promoting knowledge exchange and help these entities to understand each other’s challenges and processes better, so that misunderstandings and unsatisfactory missions are avoided or handled differently in the future.

How do you think that Brexit will affect the international air ambulance sector? Do you think that prices for payers will go up?

This is a very popular but unfortunately also very difficult question to answer, as I am not completely sure on what the timeline and development for the Brexit will be in the end. My latest information is that Brexit will still happen on 29 March

it will be necessary to consider new flight monitoring, quality assurance, incident reporting and communication tools focused on performing to the standard that insurer or assistance clients are looking for.

This can turn very easily into a disappointing, and sometimes lifethreatening, situation for all involved and widens the gap between aeromedical providers, insurers and assistance companies as these situations lead to complaints, frustration and a mistrust that is projected on all air ambulance providers. This is also why companies like EURAMI are so

2019, however, I personally would not bet on that. I think no one will really be able to tell what will happen after the UK leaves the European Union, and how it will affect our industry. However, what I can imagine is that contract negotiations, payment, travel and existing relations could be affected by the exit of the UK. Regarding pricing, I don’t think that we will be able to increase pricing dramatically as this would put the provider in a very unfavourable position compared to the competition. As our industry is still very price sensitive, I do not believe that this would be something an air ambulance provider could endure for a longer period.

To put it in a nutshell – I think we will just have to wait and see – and make sure we monitor the development and be prepared with a strategy for when Brexit does happen.

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Clear Sky 2018 Ukraine Clear Sky 18 was the first large-scale, air-centric, multinational regional security exercise that the US Air Forces in Europe have sponsored in Eastern Europe since 2014.

Besides military personnel from Ukraine and the US, staff and aerial assets from Romania, Poland, The Netherlands, Estonia, Belgium, Denmark, and the UK also participated in Clear Sky. Images: Peter ten Berg

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GALLERY USAF C-130 crew demonstrates procedures for medical transport

California Air National Guard Commander, Major-General Clay L. Garrison, was the Exercise Director for Clear Sky 2018

AN-26 returns to Vinnitsya AB flight line

California ANG C-130H takes off just before sunset for a low level night trainings flight

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US and Ukrainian para rescue teams, helped by translaters, do final mission brief inside a Mi-8 shortly before take off.

Medical plane takes off from Vinnitsya just before sunset for a joined night flight together with C-130

Clear Sky 2018 exercise badge

Ukrainian Mi-8MT starting up for joined water trainings mission where para rescue crews will jump into lake from various heights 34 34

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Joined Special Forces conduct a fast-rope training at Starokonstantinov AB out of a Mi-8

G US and Ukrainian pararescue teams posing for MI-8MT before joined training mission

US 103rd Pararescue Squadron crew member prepares equipment

Ukraine AF AN-26 medical plane

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Traumatic Times For flight medics, sadly, treating gunshot and stabbing victims is becoming ever more common.

James Paul Wallis spoke to experts about the trends they are seeing and care they have to render 3636

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According to London’s Air Ambulance (LAA) statistics for the last year, stabbing and shooting were the most common causes of injury amongst its patients, ahead of road traffic collisions. The charity’s helicopters and rapid response ground vehicles delivered advanced trauma teams to treat 560 victims of stabbings and shootings in 2017, a 12-per-cent rise compared to the previous year.

It’s not just crews in capital cities that deal with gunshot wounds (GSWs). Also in the UK but covering less densely populated urban and rural areas is East Anglian Air Ambulance (EAAA), which hit the headlines a couple of years ago when it dispatched a helicopter (piloted by Prince William, as it happens) after a man was shot in an attempted murder in the quiet market town of Bury St Edmunds. And it’s not always due to criminal activity. This June, for example, US service Vanderbilt LifeFlight transported a nine-year-old boy who’d been accidentally wounded while shooting targets with his father.

Given the prevalence of gun crime globally,

it makes sense for air ambulance crews to prepare themselves to deal with the aftereffects of such incidents.

Penetrating trauma

In many ways, GSWs are just a type of penetrating trauma. Dr Mark Nash of Midlands Air Ambulance commented: “Both shootings and stabbings come under our chest injury clinical guidelines and trauma management guidelines.” What’s unusual about GSWs, though, is the speed with which the bullet enters the body, which can lead to the creation of a cavity that’s initially filled with hot gasses. The nature of the damage caused depends on the energy carried by the projectile at the point of impact, the path it takes through the body, and whether it deforms on entry, for example by fragmentation. There is a high risk of significant injury including organ damage, bone fractures, blood loss and disruption to the central nervous system.

The internal damage may be more severe than the external wound might suggest.

FEATURE Particular considerations for initial assessment of GSWs is that it can be helpful to establish what type of weapon was used (the victim or any witnesses may be able to advise), and to remember to check and treat not only the entry wound, but also any exit wound. Dr Ami Jones, Dafen Base Lead and former National Director

Both shootings and stabbings come under chest injury clinical guidelines and trauma management guidelines of EMRTS Cymru, noted: “Presence / absence of an exit wound is important to know, especially in cavity wounds such as chest/abdominal.” Injury patterns are likely to be more severe if the bullet hasn’t exited, she said.

The emphasis for the emergency responder is to transport the victim to a care facility as quickly as possible, only

delaying transport to provide care if it’s needed to help the patient survive the trip.

There have even been retrospective studies seeking to identify whether shooting victims have better outcomes if taken to hospital via a nearby private vehicle rather than waiting for a ground ambulance to arrive. Having said that, in many cases patients wouldn’t make it to hospital without lifesaving prehospital treatment. Let’s look at some of the options.

Bleeding control

Tourniquets have been used for thousands of years to control bleeding in the extremities, particularly in the military, and they continue to be carried by soldiers on the battlefield today. There has been controversy over the use of tourniquets in the civilian setting, however, due to the risk of complications such as ischaemia – tissue damage due to loss of circulation. The Royal College of Surgeons of Edinburgh issued a position statement in 2017, noting that recent military practice had influenced

a reintroduction of tourniquets into civilian practice. The College warned: “Tourniquets should only be used as a last resort after other stepped measures have failed except in complete traumatic amputation where a tourniquet should always be applied.”

The College added that tourniquets must be used correctly or not at all, saying: “An inappropriately used tourniquet can be harmful and an incorrectly applied tourniquet will cause increased bleeding from distal soft tissue injuries and damaged arteries if there is occlusion of the lower pressure venous outflow, but inadequate occlusion of arterial blood flow i.e. the tourniquet is not tight enough.” The advice provided was to apply the tourniquet as rapidly and as close to the wound as possible, directly to the skin to prevent slippage, and tightly enough to arrest haemorrhage. If required, the tourniquet should be tightened or a second tourniquet applied above the first, said the College.

Dr Ami Jones noted that most bleeding will be controlled with simple pressure dressings and advised caution when using

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tourniquets: “Clearly, tourniquets have a good pedigree for limb injuries where bleeding can’t be controlled with direct pressure/indirect pressure or haemostatics, but be sure that this is the only way to control the haemorrhage, especially if evacuation timelines might be prolonged … applying a tourniquet means that patient now needs immediate evacuation so as not to render their limb ischaemic, which may not be possible.”

Looking at recent innovations, inflatable tourniquets have been introduced for controlling abdominal bleeding. SAM Medical of the US produces the SAM Junctional Tourniquet (SJT), which is designed to control bleeding in the inguinal and axilla areas. The SJT can also help to

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stabilise pelvic fractures, says the company.

Another traditional approach is to stuff a wound with gauze and apply pressure.

These days, special gauze is available

Successful deployment of REBOA represents nearly two years of development work by staff with compounds that promote clotting.

UK-based Celox Medical produces gauze impregnated with chitosan, a biodegradable substance derived from the shells of shrimp and other crustaceans that

promotes clotting. In January 2018, the firm announced that the UK Ministry of Defence had placed an order for its Rapid haemostatic gauze for use in all branches of the military. According to the company, the gauze ‘can stop life threatening arterial bleeding in under 60 seconds’. The firm also sells granules, which can optionally be delivered using an applicator designed to treat narrow penetrating injuries.

New treatment methods continue to come onto the market. This April, RevMedx gained CE Mark Certification for its XSTAT 30 and smaller XSTAT 12 haemostatic devices, which feature a syringe-like applicator used to introduce sponges into a wound, where they rapidly expand to exert pressure to reduce bleeding. The US-based

F company said that unlike traditional wound treatments that may take several minutes to be effective, XSTAT can stop bleeding in seconds to stabilise injuries until patients reach an emergency facility. The devices have already been cleared by US authorities and have seen use with the US military.

They are promoted for treating narrowentrance penetrating wounds in parts of the body that aren’t suitable for tourniquet application. A large model is suitable for exit wounds from high-powered weapons, while a smaller version is sized for entry wounds and for lower-powered rounds.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an entirely different technique to reduce bleeding in patients with pelvic

haemorrhage. It involves feeding a balloon into the lower end of the aorta, the largest blood vessel in the body, and inflating it to temporarily prevent further blood flow

The medic’s own safety should be considered at all times to damaged vessels. LAA claimed a world first when it announced in 2014 that it had performed pre-hospital REBOA. Speaking at the time, Professor Karim Brohi, Consultant Vascular and Trauma Surgeon

at Barts Health NHS Trust, which worked with LAA, reflected: “While it sounds relatively simple, it is an extremely difficult technology to deliver in the emergency department in hospital, never mind at the roadside. This successful deployment of REBOA represents nearly two years of development work by our staff.”

Along with the above methods to reduce bleeding, it helps to have access to blood to give the patient. Dr Ami Jones commented: “Blood / blood products and a way to warm them are critical.” Underlining the importance of getting blood into the patient, she said: “Don’t rush to RSI [rapid sequence intubation] patients who haven’t been haemodynamically resuscitated unless they are in airway extremis.” In January

Youngest victim Let’s look at a specific example. This May, LAA Dr Vidar Magnusson and advanced trauma paramedic Caroline Appleby were among the first responders named as Emergency Lifesavers of the Year at the NHS Heroes Awards ceremony on a live TV broadcast. They were honoured for the lifesaving treatment they provided to Thusha Kamaleswaren, who as a five-year-old became the UK’s youngest ever victim of a shooting when she was caught in gang crossfire while playing in her uncle’s shop in 2011. Appleby and Dr Magnusson arrived on scene to find the girl lying in the road outside the shop, suffocating and bleeding heavily.

LAA explained that the bullet had passed through her chest, passing through an artery and her windpipe, and her lungs were collapsing and her heart had stopped beating. Dr Magnusson, who was serving with LAA on secondment from his usual role as medical director for pre-hospital emergency services in Iceland, elected to perform an emergency thorocostomy to relieve the pressure in her chest and allow her to heart to restart. Kamaleswaren was then taken to hospital by ground ambulance. Dr Magnusson commented: “All I was thinking was that I couldn’t let her die. She was five and she’d taken a bullet to the chest.”

It can be a long road to recovery after a serious gunshot wound. LAA lead Clinician Dr Gareth Grier noted: “Thusha was attended to by a huge number of people right the way through to her rehabilitation.” However, without the lifesaving interventions performed by the helicopter medics, it’s unlikely that she would have survived to reach hospital.

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Most bullets stay put It’s something of a Hollywood trope that quickly removing the bullet is the best way to ‘cure’ a gunshot wound. There’s a memorable scene of self-surgery in 2003’s Master and Commander where Paul Bettany, playing the ship’s doctor, bravely extracts a musket ball and a scrap of shirt cloth from under his rib cage, much to the relief of Russell Crowe’s Captain Aubrey.

In reality, removal is performed in only the minority of cases. Traditionally, there are limited indications for bullet removal, such as it being lodged in a joint or the orbit of the eye, and the process of removal may carry more risk than leaving the bullet in place. There is growing concern over the effects of long-term lead poisoning, as discussed in a CDC report published in 2017, but even so, removal is a non-emergent in-hospital surgical procedure. It’s also worth bearing in mind that in many cases the bullet will have separated into a number of fragments, making removal of all the pieces difficult or impossible. As for the shirt cloth, note that whereas oldfashioned round bullets travelled relatively slowly and would drag (probably grimy) fabric into the wound that could fester if left in place, modern bullets typically cut straight through clothing.

All this doesn’t stop bullet removal from persisting in the popular imagination. It’s something that Stacy Wolf, an experienced Flight Paramedic, saw first hand early during her career when she was working in ground-based EMS. Responding to a call, she arrived on scene to find a drunk man trying to fish a bullet out of his abdomen with needle-nose pliers while still drinking his Miller Lite.

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F 2018, US-based air medical provider Air Methods shared the story of Trip Collins, who accidentally shot himself when he was just three years old. According to the service, the ability of the LifeNet 3 helicopter crew from Orangeburg, South Carolina, to administer blood was a key part of his survival.

Chest wounds

A GSW can create a sucking chest wound, as the hole created by a bullet creates a new pathway for air to enter the chest cavity (pneumothorax), which can lead to a collapsed lung. It can be prudent to treat any penetrating wound to the chest as a sucking chest wound, as it isn’t always easy to determine whether air is entering.

To prevent air ingress, a chest seal can be placed over the wound. The simplest devices are little more than sterile plastic with an adhesive backing, while more advanced examples feature a vent to allow any excess air inside the chest to escape. In

traumatic cardiac arrest and boasts a success rate for the procedure of 18 per cent, which it says is the highest in the world.

For fixed-wing air ambulance providers, key considerations for GSW patients include the effects of reduced air pressure and the length of transport. US-based Trinity Air Ambulance is one provider that has experience of treating such patients.

Medical director Jeff Levy suggested carefully checking for undiagnosed pneumothorax, which could prove fatal at altitude, and also carefully checking the patient’s oxygen needs.

at Norsk Luftambulanse, responded: “The general awareness on GSW and massive external bleeding is higher than before 22 July 2011 and most HEMS bases have improved both training and equipment setup for this. Mostly however, the changes that have been implemented are in regard to the general preparedness and how situations with ongoing violence are handled.”

The incident also served to demonstrate the effectiveness of ‘load and go’ as ‘the most important strategy in mass shootings with multiple victims’. It also showed

Mass shootings

that triage can be a challenge with many ‘red/critical’ patients. Sollid commented: “We believe that this justifies the use of doctors in HEMS, since doctors with pre-hospital training are better suited to do the ‘fine triage’ of critical patients, at least in our setting where distances to the nearest trauma centre is a major factor and transports are long. So, in principle ‘bringing the hospital out to the patient’ is in our opinion critically important here.”

For dealing with mass shootings, Sollid

New treatment methods continue to come onto the market an emergency, the plastic packaging from any sterile dressing can be opened out and placed against the chest (clean inside surface down) and taped to seal.

Dr Ami Jones advised: “In a spontaneously breathing patient, chest seals are important, but you only really need one on each side of the chest; the other wounds can just be covered with a dressing but the dressing should properly seal the wound.”

She cautioned to watch out for chest seals occluding with blood and to replace them if they become blocked.

Dr Jones also noted that a patient whose breathing is compromised will need an RSI and one or more thoracostomy (where a small incision is made through the chest wall using a needle or chest tube to drain air or fluid from the lungs and reduce pressure on the heart and lungs). The similarly-named thoracotomy is a more drastic procedure – essentially open-chest surgery – used in more serious cases.

LAA was the first in the UK to offer onscene thoracotomy for patients suffering

In July 2011, Norsk Luftambulanse was among the agencies that responded to a mass shooting by a lone extremist at a summer camp on Utøya island. He killed 68 people and injured 110 more.

Asked whether the incident had led to an increase in the level of preparedness in the country for dealing with GSWs, Stephen Sollid, Head of the Prehospital Division at the Stavanger University Hospital and former Chief of Medicine

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advised: “Be prepared to do difficult triage of multiple seriously and critically injured people, and be prepared for having to triage people as dying (aka alive, but untreatable or not a priority with multiple serious casualties when EMS capacity is maxed out).”

The injuries seen in 2011 were greatly

Safety first

Perhaps the key factor that differentiates GSWs from other trauma calls is the importance of ensuring the scene is safe to enter. Dr Mark Nash, Clinical Lead at UK charity Midlands Air Ambulance, said: “The police are usually involved and will have entered the scene first to ensure the

medic’s own safety should be considered at all times. “This may be tricky,” she warned, “in an MTFA (marauding terrorist firearms attack) incident when the hot and warm zones are interchangeable, so just consider whether where you’re giving your care is the safest place for you and your patient.”

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affected by the type of ammunition used, Sollid said: “All victims from the Utøya shooting were injured by hollow point ammunition. This causes injuries with little external damage, but often major internal damage. These victims either die within few minutes due to massive internal bleeding and organ damage, or survive up to several hours even with torso and extremity injuries.”

Other than the medical aspect, one outcome from Utøya, Sollid noted, was that a new national procedure was put in place under which EMS and fire/rescue personnel can intervene and take out the perpetrator if police are not available (a common problem in Norway, he said, where police presence is low because of a low threat situation in general).

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New treatment methods continue to come onto the market safety of the aircrew and other parties.

The aircrew would need to wait for the OK from police before entering an incident scene where gun crime has been confirmed. As with all emergency services, staff safety has to come first.”

The Emergency Medical Retrieval Transfer Service in Wales (EMRTS Cymru) works in partnership with Wales Air Ambulance Charity to fly consultants and critical care practitioners to deliver pre-hospital care across Wales. Dr Ami Jones said that the

References Swift B, Rutty GN; The exploding bullet. J Clin Pathol. 2004 Jan57(1):108, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1770159/ Maurin, O., De Régloix, S., Dubourdieu, S., Lefort, H., Boizat, S., Houze, B., . . . Tourtier, J. (2015). Maxillofacial Gunshot Wounds. Prehospital and Disaster Medicine, 30(3), 316319. , https://www.cambridge.org/core/journals/prehospitaland-disaster-medicine/article/maxillofacial-gunshot-wounds/ ABADB6B1AC4F8BAFE06939807E983D36 Eur J Trauma Emerg Surg. 2012 Apr;38(2):89-93. doi: 10.1007/ s00068-011-0170-x. Epub 2011 Dec 13. https://www.ncbi.nlm.nih. gov/pubmed/26815824 Weiss D, Tomasallo CD, Meiman JG, et al. Elevated Blood Lead Levels Associated with Retained Bullet Fragments — United States, 2003–2012. MMWR Morb Mortal Wkly Rep 2017;66:130–133.

DOI: http://dx.doi.org/10.15585/mmwr.mm6605a2. https://fphc.rcsed.ac.uk/media/2398/position-statement-on-theapplication-of-tourniquets-july-2017.pdf

60 YEARS

OF AIR AMBULANCE & MEDICAL ASSISTANCE LONDON

STOCKHOLM

DUBAI

ROME

CHINA BEIJING TOKYO

DAKAR CONAKRY

DOUALA MADAGASCAR

CAPE TOWN

JOHANNESBURG AUSTRALIA

FROM AFRICA TO THE REST OF THE WORLD 24 Hour Emergency Control Centre Tel: +254 20 6992000 / +254 20 6992299 Mob: +254 (0) 733 639 088 / 722 314 239 Fax: +254 20 344170 Email: emergency@flydoc.org www.flydoc.org

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CAMTSCAMTS EU announces policy updates Eileen Frazer, Executive Director of the Commission on Accreditation of Medical Transport System (CAMTS), reports on the latest changes to the accreditation body’s requirements CAMTS and CAMTS EU policies are revised and updated on an annual basis and more frequently if needed.

Recently, the policies addressing multiple sites and multiple programmes were revised to include further clarification of current practices.

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All or None In the ‘All or None’ policy, CAMTS and CAMTS EU require that a service offering rotor wing, fixed wing, and critical care ground services under one brand name must include all parts of the service in the accreditation process. This is required to avoid confusion for the public, who see all components operating under one brand name and advertising that they achieved CAMTS or CAMTS EU accreditation.

Dual Accreditation Over the past five years, we have seen a significant increase in consolidation, mergers, and buyouts that not only affect the way medical transport services are offered, but also impact the way we conduct site visits. The Board of Directors of both organisations made some policy changes recently that address how large services with many bases apply for accreditation. The first is via ‘Dual Accreditation, CAMTS-CAMTS EU’, which has been developed for services that may have satellite bases in other countries or for

services that do repatriation with long-range aircraft. It is also available to medical escort services. The standards are very similar, but CAMTS reflects current practices in North America while CAMTS EU reflects practices, government regulations and cultural differences in Europe and worldwide. Dual accreditation is a time and cost-saving way to be recognised with one process and one site visit. Currently, there are four dual CAMTS-CAMTS EU accredited services with several others applying for dual accreditation.

Special Operations Accreditation standards have also been developed for Special Operations and accreditation for ‘Special OperationsMedical Retrieval’ is now available.

Special Operations are services that provide medical care and potential medical transport that do not necessarily fit within the accreditation standards for an established medical transport service.

Without degrading the integrity of these standards, specific criteria were developed

INDUSTRY VOICE

for Special Operations-Medical Retrieval.

These include tactical rescue or ‘SWAT’ callouts and citizen recovery from potentially unstable environments. This First Edition, entitled ‘Special Operations-Medical Retrieval’, addresses search and rescue

Dual accreditation is a time and cost-saving way to be recognised with one process and one site visit and citizen recovery operations that are often contracted by governments to assist with military and paramilitary operations in remote parts of the world. These teams are usually based in unstable and dangerous parts of the world, and much of the medical care is provided by ex-military personnel who have a different level of expertise. Compliance with the standards is always measured against the programme’s scope of service, which includes mode

of transport, response times, number of patients transported simultaneously and any exceptions to the types of requests that are accepted.

Fees Accreditation fees have also been revised for CAMTS EU programmes.

CAMTS recognises there is much more standardisation among transport services outside of North America and therefore, large programmes with many aircraft that are often based closely together are not

charged for each asset and may not require a site visit to each base.

Please see the CAMTS EU website (www.camtseu.org) for all policies and policy changes. The policy manual is offered as a free download. Changes are highlighted and dated after each Board meeting. Policy 04.01 00 entitled Accreditation Actions-Types provides details regarding Dual Accreditation and Special Operations Accreditation. The fees for accreditations mentioned above can be found in Policy 04.05.00.

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FinnHEMS Tony Mallett reports on the operations of helicopter emergency medical services in Finland Since 2011, FinnHems has been funded by the Ministry of Health and Social Security, working in partnership with university hospital district organisations.

There are six bases that serve the length and breadth of Finland – Helsinki-Vantaa Airport, Turku, Tampere, Kuopio, Oulu and Rovaniemi. In the southern area, flight operations are carried out by Skärgårdshavets Helikoptertjänst Ab (SHT), a company specialising in HEMS and air ambulance operations. SHT belongs to the Åland-based Wiklöf Holding Ab group.

In the northern area (Oulu, Kuopio and Rovaniemi), flight operations are carried out

by Babcock Scandinavian AirAmbulance AB, which is part of Babcock SAA FW AB, part of the global Babcock corporation.

SHT began its operations in 1990 in Åland.

It has operated HEMS flights in Turku since 2000 and in Vantaa since 2001. At present, the SHT fleet comprises Eurocopter EC135 P2 single pilot instrument flight rules helicopters, and the crews began using night vision goggles (NVG) with these aircraft in 2011. In February 2015, Babcock Scandinavian AirAmbulance AB became the first flight operator in the world to operate HEMS flights with a modern EC145T2 fleet.

Operations

FinnHEMS can respond to medicalemergencies for 70 per cent of Finland’s population within 30 minutes of dispatch. All FinnHEMS bases have on-duty physicians, or in the case of Rovaniemi, 46 46

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on-duty paramedics. The on-duty crew consists of a pilot, a HEMS crew member and a doctor. At the Helsinki base, there are usually two more doctors working during office hours too. Doctors are specialists in anaesthesia, intensive care and prehospital medicine and work full time in the pre-hospital setting both in administration and clinical work. HEMS crew members are firefighters or paramedics with extensive training in aviation and emergency medicine. Pilots, meanwhile, are very experienced with backgrounds in commercial aviation, teaching, military or the border guard.

The current FinnHEMS base at Helsinki Airport has been in operation for three and a half years, launching on average eight missions a day (2,918 missions in 2017, of which 1,433 were performed by helicopter). The base is fully equipped with its own refuelling station, living quarters, lecture rooms, gym, lounge, kitchen and even a sauna!

Deployment

The three emergency crew members (pilot, doctor and paramedic) receive the call to scramble from a wireless device carried within their uniform, and can be in flight within approximately five minutes.

Quick start and full authority digital engine (or electronics) control (FADEC) technology means all the pilot’s attention can be focused on monitoring the gauges while the computer system does the rest. Laser gyros are used in the instrument panels.

While en route, the doctor continues to collect additional information as the alarm centre provides the crew with patient risk assessments. The doctor carries a laptop onboard, which is connected to a panel in front of his seat. From this position, consultation calls from the paramedic at the scene of the incident can be monitored.

Physicians are further contacted for advice on medication or most appropriate hospital to which a casualty can be transported.

The crew at the Helsinki base is also on standby to attend to passenger medical emergencies within the airport terminal or Finavia staff emergencies on the airfield.

Tuomas Suominen (FinnHEMS Head of Flight Operations and Quality Unit) elaborates: “Occasionally the central emergency call dispatches the HEMS unit to the airport area if the medical criteria are

fulfilled. The HEMS unit can operate by car inside the airport area because the HCMs have special driving training and licence to drive there. There are 20 to 30 missions a year to the airport area (aircraft accident risk alarms not included). The HEMS unit also receives alarms related to technical problems in aircraft and the HEMS unit is a part of the airport accident preparation organisation. We get those alarms about 30 times a year.”

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SAVE THE DATE 2019 FEBRUARY

21-22

Aerial Search & Rescue Asia Pacific 2019 Essendon, Australia

MARCH

4-7

HAI Heli-Expo Georgia World Congress Centre US

APRIL

28

Pilot Jouni Romppanen offered his insights into his work with FinnHEMS Romppanen pilots the EC135 helicopter, the quietest helicopter in its class, equipped with IR, NVIS, HTAWS (terrain avoidance), TCAS (traffic collision avoidance), SSR, and autopilot, but as yet no radar. Night vision technology is of key importance, as the crew operates so far into the Northern Hemisphere. “Our darkest point in the year is winter, with only five and half hours of daylight,” said Romppanen. “FinnHEMS have added specific design features to the helicopter. This particular helicopter was made in 2005. We use the same type of helicopters across the three most southern bases of FinnHEMS, which helps when it comes to maintenance, parts and servicing. We have another spare helicopter on the other side of the airfield. This spare helicopter serves all our bases. We also co-operate with the border guard helicopter base that carries out operations at sea.”

He emphasised the great communication and bond that the FinnHEMS staff has with the airport, and how this eases the fast dispatch of the crew: “We have a co-operation agreement with the tower so they know exactly what I’m going to say and where we will appear within their airspace during a scramble. The co-operation between the tower and us works fantastically.”

Extreme weather can obviously affect the team’s ability to do their job: “Icing conditions, heavy snow, low clouds and poor visibility and fog are the main restrictive elements that may prevent us from flying. Of course, during the winter, icing is quite a problem. IFR during winter is out of the question but [it works] for summer time.” There is an emergency land vehicle the team can use if they need to, said Romppanen: “If the weather is really bad we always use the car. The weather cannot stop us because someone somewhere urgently requires our help! Once in my career we’ve had to take our backpacks and walk as the accident happened very close to our base. On board the helicopter, we have a minimum fuel window of 200 km with one hour of endurance or 400 km with maximum fuel. We can take extra fuel, but we also have to consider the weight increase carrying a patient and sometimes an extra doctor.” Ninety per cent of flights are within 30 minutes, or about 100 km, of a base.

As regular readers of AirMed&Rescue know only too well, quiet days are few and far between. “Interestingly,” said Romppanen, “Christmas Day is a busy time for us. I have been working for FinnHEMS for 16 years and in all that time have only ever known four or five really quiet days.” Time off, then, is even more important for crewmembers. “I fly two days, then have minimum two days off and after that a few office days. As with any pilot, rest periods between flying are very important as this is the only way to keep my mind alert and focused.”

Association of Air Medical Services Medical Transport Leadership Institute Wheeling, US

MAY

14-16

Maritime Search & Rescue Tallinn Estonia

JUNE

14

JULY

15-20

Australian & New Zealand Search &Rescue Conference RACV Royal Pines Resort, Gold Coast Australia APSCON CenturyLink Center Omaha US

AUGUST

4

AAMS Safety Management Training Academy Pittsburgh US

NOVEMBER Air Medical Transport Conference 4-6 Atlanta, Georgia US

5-7

Vertical Flight Expo & Conference Farnborough UK

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

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

+49 170 366 4933

air-alliance.de

AIRLEC Air Espace Zone Aviation Générale, 33700 Mérignac Cidex 05 FRANCE

+335 56 34 02 14

AIR AMBULANCE (EUROPE)

AIR AMBULANCE (EUROPE) (APAC)

SERVICE DIRECTORY

airlecairespace.com

quickair.de

+49 2203 955 700

Hangar 3, Cologne Airport, 51147 Cologne, GERMANY

Rescue Wings Malta +356 2703 4129

186 Ix Xatt Santa Maria Estate Mellieha MLH 2771, MALTA

Swiss Air-Rescue (Rega) Rega-Center, PO Box 1414, CH-8058 Zurich, SWITZERLAND

Capital Air Ambulance

+41 44 654 33 11

rega.ch

Tyrol Air Ambulance capitalairambulance.co.uk

DRF Luftrettung / German Air Rescue +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

FAI – rent-a-jet AG

taa.at

+43 512 22422 100

Fuerstenweg 180, A-6026 Innsbruck-Airport, AUSTRIA

AIR AMBULANCE (NORTH AMERICA)

+44 845 055 2828

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

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

Quick Air Jet Charter GmbH

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.

Flughafenstasse. 124; 90411 Nuremberg; GERMANY

+49 911 36009 31

fai.ag

GlobalMed International

+1 352 799 7771

globaljetcare.com

Helidosa Aviation Group +212 5 24 38 13 88

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

15421 Technology Dr. Brooksville, FL 34604, USA

Karla Viñas

medic-air.com

Air Ambulance Account Executive

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

+49 211 602 7775

jetexecutive.com

Malteser Service Center Malteser Service Center Kalker Hauptstr.

22-2, 51103 Köln, GERMANY

tel: +1

+49 221 98 22 333

50 50

AIRMED&RESCUE

email: k.vinas@helidosa.com website: helidosa.com

JET ICU +33 141 72 1414

medic-air.com

2561 Rescue Way, Brooksville, FL 34604, USA

+1 352 796 2540

jeticu.com

Jet-Rescue Air Ambulance

North Flying a/s North Flying Terminal, Aalborg Airport, DK-9400, Nørresundby, DENMARK

(829) 345-7219

malteser-service-center.de

Medic’Air International 35 rue Jules Ferry, 93170 Bagnolet, Paris, FRANCE

Hangar 1 10 & 14 La Isabela Airport Santo Domingo Dominican Republic

+45 9632 2900

northflying.com

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

+1 786 619 1268

medjetsUSA.com

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

flyreva.com

+1 954 730 9300

Skyservice Air Ambulance 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

MEDICAL ESCORT ON COMMERCIAL AIRLINES

ASSOCIATIONS

AIR AMB. (N. AMERICA)

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

website: www.iafccp.org

GROUND TRANSPORT - MEDICAL

fax: +770-979-6500

600 Pennsylvania Ave SE, Washington DC, 20003, USA

+1-202-499-2294

globalmed-international.com

LIFESUPPORT Patient Transport Graham Williamson CEO

VANCOUVER – TORONTO – HONOLULU tel: +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

+49 6742 897 425

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

fax: +1

Gateway International EMS

air-ambulance.com

GlobalMed International

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

+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

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