AirMed & Rescue March 2019 by AirMed & Rescue Magazine

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AIRMED&RESCUE MAGAZINE

Issue 94 | March 2019

ISSUE 94

MARCH 2019

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EDITOR’S COMMENTS I received a letter this month, which you will find on pages 44 to 45 – and it’s well worth your time to read it too. It’s from the sole survivor of an air medical helicopter crash, and what he has learnt in the aftermath of the accident about safety and constant risk assessment. It’s written from the heart, and it truly brings home the message that safety in the air medical transport sector is not just a word – it should be a way of life. Something that is at the front of my mind (no pun intended) at the moment is pilot mental wellbeing. In the past, we have written about the post-traumatic stress that medical personnel can endure after treating victims at the scenes of particularly grisly accidents. And those are trained doctors and nurses, who would be at least relatively used to seeing blood and guts and gore. Aviators though, may be seriously under prepared for such scenes, and helping the medical team on site can lead them to witness some pretty traumatising situations. Is there enough support for the pilots on air ambulance missions? If you’ve got a view on this, we’d love to hear from you. Email editor@airmedandrescue.com.

Editor

Mandy Langfield

CONTRIBUTORS

Chris Sharpe Chris Sharpe is HLTH’s resident safety and survival expert. He is the Project Manager, Chief Aircrewman, and Flight Paramedic for the HeliSOS HEMS/Rescue Helicopter in Guatemala, and the Chief Aircrewman at Black Wolf Helicopters. Chris has been flying for over 28 years; having over 15,000 flying hours to his credit and over 6,000 rescue operations. He takes a special interest in safety and survival, teaching survival techniques to both civilian and military helicopter crews in Guatemala.

Dr Robyn Holgate Dr Robyn Holgate is the Chief Medical Officer of ER24. She started her medical career as an ICU and trauma nurse, and later completed her Bachelor of Medicine and Surgery (MBBCh) at the University of Witwatersrand in Johannesburg, South Africa. She’s also obtained her MSc in Medicine (in Emergency Medicine). After gaining clinical and emergency medicine experience within the state sector, she moved to ER24 in 2009.

Dr Simon Forrington Dr Forrington is Chief Medical Director of Capital Air Ambulance (CAA). A HEMS consultant with North West Air Ambulance Service and leading figure in the UK aeromedical sector, Dr Forrington is an experienced senior flight physician. He previously served as a senior flight physician for both CAA and AMREF, and was co-designer of the standard-setting NAPSTaR course (Neonatal, Adult and Paediatric Safe Transfer and Retrieval).

Jonathan Godfrey For more than 12 years, Godfrey has presented his story of survival following an air medical helicopter crash to audiences all over the US and abroad, highlighting safety culture, crash prevention, survivability, and resiliency. Godfrey is currently a director on the board of the National EMS Memorial Service. He is involved in many other projects such as Survivor’s Network, Vision Zero, Digital Safety Stories, and US Helicopter Safety Team.

Doctor Yann Rouaud Doctor Yann Rouaud is an emergency physician with specialisation in Emergency and Disaster Medicine. After working for many years in public hospitals’ A&E departments, he joined Inter Mutuelles Assistance in 2007 as a Medical Director. In 2012 he was recruited by International SOS. In his current role of AIRLEC Group Medical Director, his daily commitment is to ensure that quality of delivery will fully match patients’ and clients’ expectations as well as meet the true spirit of AIRLEC Group: always go above and beyond.

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

Dr Adrian Hyzler Dr Hyzler is Chief Medical Officer of Healix International. He qualified as a doctor in 1990 from Sheffield University Medical School and pursued a career in Emergency Medicine which led to an interest in travel medicine. Dr Hyzler joined Healix International in May 2001 as a flight doctor. He moved on to become a medical co-ordinating officer, then Senior Medical Officer, and is now the Chief Medical Officer at Healix, with an additional responsibility as Director of Medical Communications.

Front page image © Rega www.airmedandrescue.com

Editor-in-Chief: Ian Cameron Editor: Mandy Langfield Sub-editors: Robyn Bainbridge, Lauren Haigh, Stefan Mohamed, Sarah Watson Advertising Sales:

IN THIS ISSUE

James Miller, Kathryn Zerboni & Marlon Stanley Design: Rosi Yip, Tommy Baker, Will McClelland & Robbie Gray Web: Tom Reed Marketing: Isabel Sturgess, Kate Knowles, 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.

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AIRMED & RESCUE ISSUE 94

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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NEWS 6

Time pressures and lack of pilot training to blame for AW101-612 rollover Canada invests in the modernisation of the RCAF’s CH-146 Griffon Remembering Rene Mouille

Helicopter shopping – time to stop?

FEATURES SPECIAL REPORT 16

Helmet standards in the US

CASE STUDY

Helipad innovation Technology is bringing sea change to the design and installation of helipads

Survival of the fittest Advanced Life Support Equipment for rescue and medical crew

Surf’s up The ongoing evolution of surf-based rescue tactics

AirLec Ambulance

reports on a warzone evacuation

INTERVIEW 40

Mikko Dahlman, CopterSafety

INDUSTRY VOICES PROVIDER PROFILE 32

SAFETY: The #1 priority

ER24’s Chief Medical Officer on patient safety inflight

LifeFlight Network’s operations

Never Forget

Vigilance saves lives in helicopter operations

MEDICAL INSIGHT Brains, planes and automobiles The transportation of patients with traumatic brain injuries

COMPANY PROFILE 46

Sikorsky

Home is where the heart – and head – is

Healix International on the value of bringing home patients with psychological illnesses

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NEWS

Time pressures and lack of pilot training to blame for AW101-612 rollover

Canada invests in the modernisation of the RCAF’s CH-146 Griffon

According to the Norwegian Accident Investigation Board (Statens Havarikommisjon for Forsvaret), a combination of human and organisation faults were at fault in the November 2017 incident, in which an AW101-612 search and rescue helicopter operated by the Royal Norwegian Air Force rolled over during testing. The incident occurred, according to the Board, during a test run of the aircraft’s engines following a compressor wash. The investigation found that: “Because the rotor was accelerated using two engines rather than one, it achieved full rotational speed. The combined forces from the main rotor and the tail rotor were sufficient to make the helicopter roll over.” The acquisition timeline for the new rescue aircraft, asserted the Board, was ambitious, and this, combined with delays in the development of the helicopter, meant that there were subsequent challenges in the provision of training aids and documents for the pilots. The Board reported: “The constant demand for progress negatively affected quality assurance in various parts of the organization, and contributed to elevated and unidentified operational risk.”

Bell Helicopter Textron Canada Limited is to undertake design work to extend the life of the Royal Canadian Air Force’s (RCAF) fleet of 85 CH-146 Griffon helicopters to at least 2031. The first phase of this life extension is the definition phase, during which Bell Helicopter Textron Canada Limited – the original equipment manufacturer – will develop design changes to upgrade the helicopter’s avionics systems, engines, and cockpit displays, and integrate sensor systems. This definition work, valued at up to $90 million (including taxes), will be performed under the existing support contract for the CH-146, which was awarded to Bell Helicopter Textron Canada Limited in 2011. The overall scope of the Griffon Limited Life Extension project is estimated to be valued at approximately $800 million (taxes included). The Griffon, Canada’s multi-purpose

utility helicopter, is essential to CAF operations both at home and abroad. The helicopter fills a number of functions, including tactical troop transport, reconnaissance, escort and surveillance, casualty evacuation, disaster relief, special operations aviation support, and search and rescue. “Upgrading the CH-146 will ensure that it continues to make important contributions to the success of the full range of the CAF’s missions and operations,” said the RCAF.

Remembering René Mouille René Mouille, legendary pioneer of the helicopter industry, passed away on 10 January, 2019 at 94 years old. Mouille was pivotal in pushing the helicopter industry forward and garnered a collection of groundbreaking inventions to his name Born in 1924 in France and a graduate of ICAM (Catholic Institute of Arts and Crafts of Lille) and ESTAé (Higher School of Aeronautical Works of Paris), in 1945, Mouille joined the SNCASE where he developed a passion for the helicopter, a nascent technology at the time. He is at the origin 6

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of the design for the SE3120 (Alouette I) which, in the hands of Jean Boulet, broke the 1953 world distance record over a closed circuit. Deputy to Charles Marchetti, he designed

the SE 3130 Alouette II (the first turbine helicopter) which opened the way for French helicopter industrialisation. René Mouille continued to have a great number of professional

success stories after that: the Alouette III in 1958, the Super Frelon in 1962, the Puma in 1964, the Gazelle in 1967, and the Dauphin and Ecureuil in the 1970s. In 1963, he was nominated Engineer-in-Chief of the helicopter division of Sud Aviation. With over 40 patents to his name, Mouille was instrumental in pushing the barriers of helicopter technology, such as with the hub NAT (NonArticulated Drag) with viscoelastic dampers, the famous Fenestron©, and the Starflex rotor. He also invented the SARIB suspension system (Antivibratory Suspension with Integrated Resonator and Bar).

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NEWS

Helicopter shopping – time to stop? When a medical transfer flight has been turned down by one organisation for safety reasons (i.e., below their weather minima), should the treating hospital be able to put that flight out to tender again? This matter has been brought to the forefront of everyone’s minds once again recently, following the tragic loss of three lives in Ohio. The Survival Flight helicopter, carrying pilot Jennifer L. Topper and flight nurses Bradley J. Haynes and Rachel L. Cunningham, crashed in a wooded area en route to pick up a patient in Pomeroy and transfer them to another facility with a higher level of care. Before Survival Flight accepted the mission, two other air ambulance companies said no. MedFlight declined the flight as the pilot didn’t feel that the aircraft would be able complete the flight safely. A statement from Tom Allenstein was posted on the company’s website soon after news of the crash came through: “Yesterday, a tragic accident occurred involving our air medical colleagues at Survival Flight. Our hearts and prayers go out to the team members who lost their lives, as well as their families and friends. As it relates to MedFlight, we received a request to transport a patient from the Holzer-Meigs 8

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Emergency Room in Pomeroy at 06:00 hrs on Tuesday 29 January. The assigned team’s pilot, working with the Operational Control Centre at Metro Aviation, Inc., our aviation operator, determined that weather conditions at the time of the request were below our programme’s weather minimums.” Health-Net Aero Medical Services also said it wouldn’t accept the flight. A statement from the company explained that the Air Methods Corporation pilot assigned to the base in Jackson County, West Virginia, declined to

Transportation Safety Board’s investigation into the crash. Editor’s comment: This news leaves me with a heavy heart. What a tragic waste of lives. The questions that must be asked though, are why did the Survival Flight team accept a flight that others had deemed too dangerous, and why did the hospital staff continue to push for an air medical transfer when they had been told, twice, that it was too dangerous to fly? Shouldn’t the decision then have been taken by the medical team to move the patient via road ambulance? There has been a great deal of discussion about pressure to accept medical flights on the EMS Flight Crew Facebook page complete the flight due to in relation to this accident. atmospheric conditions which fell below published operational Overwhelmingly, the comments have been sorrowful, and weather minimums. Different helicopters are capable there have been many left by of operating in different weather members of the community who praise the organisations conditions, and at this point there is no question surrounding for whom they work – those companies that don’t question it whether or not the Bell 407 if a member of the team says a flown by Survival Flight was mission should be turned down. operating outside of Federal Aviation Administration weather Sadly, this isn’t always the case, according to some members of minimums – just because the the group. MedFlight and Health-Net helicopters weren’t able to safely It’s also important that hospital staff inform air medical complete the flight, doesn’t operators if a mission has mean that the Survival Flight previously been declined by helicopter couldn’t. We await another operator for any reason. the verdict of the National

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Helipad innovations Where and how helicopters are being used as air ambulances is shifting, and in an increasingly urban environment, new designs and stricter safety protocols are changing the helipad game. Mandy Langfield spoke to industry experts to find out more Helipads, helidecks, heliports – from the traditional steel and concrete structure embedded in the ground, to helidecks onboard oil and gas platforms made from aluminium, and even matting products that can be rolled out onto soft or unstable surfaces to give helicopters a safe place to land, the wide variety of technologies employed in the design of helipads continues to evolve to promote safer environments for pilots, crew and aircraft. 10

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Changing demands

Hospitals around the world are adding helipads in their grounds, or on top of their Accident & Emergency departments. The fast reactions of helicopter emergency medical services (HEMS) to pick up a patient from their location has to be followed by immediate access to the doctors on arrival at a hospital, so the location of the helipad is carefully thought through in order to ensure optimum speed to treatment. It is no small investment either, with many hospital helipads costing in excess of GB£5 million. The difference it can make to patients, however, is undeniable. Luton and Dunstable University Hospital in the UK, for instance, is currently saving for the construction of a helipad. Chairman of the hospital Simon Linnet said: “This helipad will provide a life-changing facility for our community which will link directly into the centre of our leading emergency department.” The funding for the pad is being raised in part by the HELP Appeal – Helicopter Emergency Landing Pads is a charity dedicated to (as the name suggests) funding helipads for hospitals around the UK. Robert Bertram, Chief Executive of the HELP Appeal, added:

“This helipad will allow the East Anglian Air Ambulance and other air ambulances to land a critically ill patient on site, where he or she can be transferred comfortably and smoothly to a consultant’s care within a matter of minutes. This is a must when the slightest jolt or delay by road ambulance could jeopardise their survival.” Elsewhere, in New Zealand, a new helipad for the South Canterbury District Board is under construction on the site of the hospital’s old administration block, as part of a broader re-development of the emergency department. The move from its previous location at the local Botanic Gardens, according to the hospital’s corporate services director, was driven by the Westpac Rescue Service, which provides air ambulance services to the region. He explained: “We’ve taken onboard what the helicopter operators have been telling us. They would like to see it moved. Fundamentally, it is something we have to do.”

New construction methods

Rocky Allen, Regional Manager in Western US for Bayards, explained why helipads

FEATURE are now being constructed from different materials: “Aluminium offers many advantages over other materials used. We’ve seen the demand for aluminium since the mid-80s when we began building for the offshore market, where this metal performs well in the saline environment. The weight savings, assembly time, and long-term operational cost savings has made it a compelling choice for onshore and offshore construction. Furthermore, there has also been a movement in the construction industry in general towards the use of more sustainable products (aluminium is 100 per cent recyclable without compromising on strength or quality), and helipad manufacturers are no exception to this.” The increasingly crowded urban environment has also impacted this decision to move to aluminium, explained Allen. With its weight saving qualities, aluminium helidecks can more easily be built on rooftops. Furthermore, in seismic sensitive areas, reducing structural weight of a helipad by 60 per cent may offer more opportunities to incorporate a helipad in the design of a building. The US HEMS sector, Allen continued, has

been slow to adopt aluminium helipads at ground level. However, Tom Schuman, President of FEC Heliports, explained to AirMed&Rescue

that globally, there has been a ‘significant shift’ over the past 10 years towards the construction of helidecks from aluminium. He went on to explain: “This is more

The fact that an aluminium helideck can be moved from one site to another makes this initial pay-out more viable

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so for rooftop helipads, but we are also seeing the aluminium products being used in ground applications as well. The 6000 series aluminium has many advantages for customers. It is significantly lighter than concrete and has the same strength. The only maintenance required for the aluminium is the repainting of the markings as the aluminium will never breakdown or crack as concrete will do over time. In areas that utilise snowmelt systems in their helideck, the advantages become even more evident. The aluminium design allows the customer to access and maintain the snowmelt tubing as needed versus being encapsulated in the concrete slab.” The construction of the aluminium design is also much faster and gives contractors more options as to when the helipad can be built in the schedule. Most aluminium helipads can be assembled in three weeks, whereas a concrete helipad will take between four and five weeks to build, and an additional 28 days of curing time, weather depending, so the resources needed are increased. Schuman also noted that aluminium products are gaining ground in the offshore market, which for years has been dominated by metal. He explained: “The weight advantage of aluminium offshore is becoming more important the farther the oil rigs go offshore to explore. Many of the newer semisubmersible rigs are very dependent on overall weight in the design, as are the support vessels that have landing pads mounted on the bow. For many years, 12

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the offshore market was concerned about how the aluminium products would react to fire, but the melting temperature of the aluminium alloys are very high and the fire suppression options have also improved dramatically.”

Fire suppression

Firefighting on a helipad that is 100-feet in the air is a challenge. Foam fire protection is, however, one of ways in which helipads can be defended. compressed air foam systems (CAFS) are fire suppression units that inject compressed air into a foam solution in order to generate a foam that has a tighter and denser bubble structure than water with a standard foam solution. The bubble structure means that the foam can adhere to horizontal and vertical surfaces, while being more effective at tackling the fire as it can penetrate the flames deeper. According to Burner Fire Control, which manufactures self-contained custom fire

suppression equipment to customers’ specifications, the design criteria for CAFS are based on the size of the helicopter(s) using the deck. The company explained in more detail: “International Civil Aviation Organization (ICAO) Section 6.83 states that it is considered essential that firefighting agents are able to be applied to any part of an elevated heliport irrespective of wind direction. The Civil Aviation Authority (CAA) and Federal Aviation Administration (FAA) specifically call out the need for multiple redundant equipment as they state a helicopter accident, which results in a full spillage with wreckage and or fire and smoke, has the capability to render some of the equipment inventory unusable or preclude the use of some passenger escape routes. CAP437, similar to ICAO, states that the operational objective should be to ensure that the system is able to control a helideck fire associated with a crashed helicopter during a range of weather conditions. Section 2.2 states that if a fixed system is in place, consideration should be given to the loss of downwind foam monitors either due to limiting weather conditions or a crash situation. ICAO also states that areas of a helideck and its appendages that may, for any reason, be otherwise inaccessible to fixed monitor systems, it is necessary to provide additional hand-controlled foam branch pipes.” Deck integrated fire fighting systems (DIFFS) consist of a skid that processes firewater inflow to output foam or water. Nigel

F Barratt, Vice-President of International Business Development for Marsol Technologies, explained more about DIFFS to AirMed&Rescue: “With the DIFF system, instead of using two or three externally fixed foam discharge monitors (or even just hose reel stations), multiple nozzles (commonly referred to as pop-ups) were developed to be installed on the actual helideck surface,”

rather than just from the side. This spray of foam/water droplets has the effect of reducing the temperature while the blanket of foam that is formed covers fuel – be it ignited or otherwise – on the surface of the helideck thus suffocating and extinguishing the fire.” Recent innovation and developments have seen DIFFS further enhanced with

the UK-CAA-CAP-437 standard – meaning the nozzles are tested in various weather conditions to control a fire in less than 30 seconds after system activation. Corienne Kilgannon, Communications Director for the County Air Ambulance Trust, and the HELP Appeal, added: “DIFFS can put out a fire within 15 seconds, allowing air ambulance crews to continue

DIFF technology demonstrates far superior deck coverage than traditional Foam Monitor systems he said. “When the system is activated – be it by fire and gas sensors or manual remote push-button – the nozzle is then ‘popped up’ by the pressure from the discharging water/ foam. Producing a spray pattern that is both horizontal and vertical, the water/foam is then applied right into the heart of the fire,

the introduction of non-pop-up nozzles, which reduce the issues of malfunction and maintenance as well as removing the risk of being a trip hazard, which could be a severe hindrance during a rescue operation. As with pop-ups, the system is designed based on the specification as laid down by

treating and transferring a critically ill patient to the emergency department as quickly as possible. They can also save hospitals money every year by reducing staffing costs with firefighting teams no longer required to fight a fire. These savings have been allocated to other lifesaving services.” Working with the

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CAA, Robert Bertram, HELP Appeal Chief Executive, has enabled DIFFS to be installed at Kings College Hospital, St George’s Hospital, Bristol Royal Infirmary, Brighton Hospital and Manchester Royal Infirmary. Helipads that contain built-in automatic fire suppression systems are allowed a water-only DIFFS, while unperforated steel, concrete and aluminium helipads require the use of aqueous film forming (AFF) foam. Barratt went on to say: “The majority of foam concentrates used are suitable for Class B hydrocarbon fuel fires and classified by ICAO as Level B or Level C type, with most of the concentrates now being of the C6 formulation as opposed to the earlier C8 type formulation – this being a determination on how well the chemical composition breaks down in the environment.” He continued: “In most parts of the world the disposal of foam concentrates into the water is prohibited and strictly monitored. Therefore, foam producers have developed environmentally sustainable

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firefighting foam concentrates that effectively extinguish Class B fuel fires with no environmental concerns for persistence, bioaccumulation or toxic breakdown. While the use of Foam Concentrate plays a very important and crucial role in extinguishing fires, DIFF nozzles are also tested and approved to be used with only water for when installed on helidecks manufactured to a passive fire-retarding construction, i.e. capable of removing significant quantities of unburned fuel from the surface of the helideck in the event of, for instance, a fuel spill from a ruptured aircraft tank.” Rocky Allen of Bayards ran through some of the advances in fire suppression systems: “At the moment, DIFF technology demonstrates far superior deck coverage than traditional Foam Monitor systems, effectively complying with the NFPA’s requirement to have 95 per cent suppression coverage of a helideck. Along with integrating state-of-the-art firefighting technologies, Bayards’ contributions include the development of the SafeDeck passive fire-fighting system, which further

enhances fire safety on the deck by draining the burning liquid and starving the fire of oxygen, thus extinguishing deck fires quicker.”

Innovations

Bayards’ latest development in deck planking consists of a glass blasted surface instead of the former ribbed-serrated surface, giving the deck more friction, making it safer, but also smoother, so patients on stretchers are given a much smoother ride too. Furthermore, it is non-glare, so pilots won’t be blinded by a shiny surface while they are trying to land the helicopter. Another bonus is that there is no paint needed on the planks, significantly reducing maintenance and operational costs for owners, and they are friendlier to the environment. Other accomplishments by Bayards to improve safety include the development of a handrail that comes with LED lighting integrated into it, keeping crew members safe accessing the helipad and providing aesthetically appealing walkway lighting. Also on the eco-friendly note, Bayards has

F developed the first heated eco-friendly helideck for a client in Sweden that does not utilise any foam in its fire suppression system – it is all water. This was demanded by the client, who did not want to use chemicals as part of its firefighting system.

Mobile systems

FEC HEMS-Station® Solar Plus is a mobile system that can be installed and operationally ready within three days. It provides a relocatable, semi-permanent heliport lighting solution that can be implemented almost anywhere in the world, due to its solar power mains autonomy. The HEMS-Station® Solar Plus houses 10 HEMS-Star® portable lights in an IP65 rated secure cabinet, has VHF, UHF & SMS connectivity, comes with portable LED internally illuminated WDI, resulting in an economical yet fully compliant low visibility/ night operational helipad solution. Helipad matting is another way to create a temporary helipad, utilising a temporary and portable surface deployed on a variety of terrain to aid the safe taking off and landing

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for all types of helicopters. It improves the safety of landing and take-off by providing a visual flooring area which can be seen from high altitude, but most importantly preventing ‘Brown Out’ – an in-flight restriction of vision due to dust or sand being pushed into the air by the helicopter’s down force. This is particularly dangerous for helicopter pilots as the kick up of dust and sand can cause spatial disorientation and can lead to potential accidents on landing and takeoff.

Standards, rules and regulations

The rules and regulations that govern the construction qualities and maintenance requirements of helipads are wide ranging, and ever changing. Civil aviation authority regulations in individual countries – CAP 437, ICAO annex 14, NMD 072 and NORSOK C004 – are just some of the standards to which helidecks must adhere. Furthermore, different helicopters, with varying performance levels, can affect the

size and location of a helipad. In the UK, for example, only Group A/Class 1 performance helicopters are permitted to land at, or take off from, roof-top helipads, and the operator must require a Rule 5 permission from the CAA. The helicopter type intended for use at a helipad must possess a helipad profile for the specific rooftop site within its flight manual. According to the British Helicopter Association, this means that in the event of a failure to one of the power units occurring at any time during the take off or landing, it will enable the aircraft to reject safely onto the available helipad, or to fly away, avoiding all obstacles by a margin of at least 35 feet. Safety considerations, of course, are at the heart of all standards and regulations, but they are also at the heart of design innovations. As demand for services increases, and more air ambulance helicopters are introduced in urban environments, the enhancements in the design and technology of helipads will no doubt continue apace.

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Helmet standards Astonishingly, the US Federal Aviation Administration does not mandate the use of helmets for crew in civilian air ambulances. However, thankfully most crewmembers do use them despite this – but are they choosing the right helmet? The US Association of Air Medical Services (AAMS) notes in its Considerations for Selecting and Using Helmets that ‘crash investigators often hear from survivors that they are able to speak to us singularly because they were wearing their aviation life support equipment’. Although the Federal Aviation Administration does not mandate their use, nonetheless, helmets are considered by most involved in the industry to be essential, and thus their design and specification should be held to a high standard. For many years, however, this has not been the case in the civilian helicopter air ambulance sphere. Standards, what standards? The US Office of Aviation Safety (OAS) developed a modern, cost-effective civilian aviation helmet performance standard that was published in April of 2018. Prior to the OAS standard, though, there were no rules and regulations governing the quality of helmets being manufactured and distributed. 16

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In the 1970s, following the conclusion of the Vietnam War, the US military had a surplus of Gentex helmets and spare parts, and so sold them to surplus dealers. As helmet designs have been updated, older parts have again been sold to dealers. However, the situation now is that some surplus dealers would appear to be running out of said parts, and are instead making their own, which may not be made to a military specification. (Further analysis of this in the next issue of AirMed&Rescue). The Department of Interior and US Forest Service (DOI/USFS) Aviation Helmet Standard Specification, and Interagency Aviation Life Support Equipment Guide/ Handbook provide an avenue to allow non-military helmets to be considered for acquisition within agencies. Manufacturers

and distributors can test their helmets using an ISO certified laboratory to the DOI/USFS Aviation Helmet Standard. The Aviation Helmet Standard, according to Dudley Crosson (Aeromedical Safety Officer and Principal of Delta P, an organisation focused on increasing operational efficiency and safety and aircrew), establishes aviation helmet design and performance standards, requires helmets to be tested at a certified laboratory, requires that manufacturers certify and label each helmet, and establishes a list of approved helmets. Those meeting or exceeding these standards can be issued a certificate of compliance by the laboratory. These helmets will be identified by the manufacturer and model type on the OAS website within 30 days of receiving the certificate. When the website was checked in January 2019, there were no non-military certifications of compliance. Military helmets that have been approved by the ALSE (Interagency Aviation Life Support Equipment) handbook are: Helicopters: HGU-56/P; HGU-84/P; SPH-4B; SPH-5. Fixed Wing: HGU-55/P and HGU-68/P. Making a choice When it comes to the choice of which helmet to choose, Crosson stated in the AAMS Considerations paper: “I do not

His three top tips after helmet choice has been made are: • Ensure the vendor is recognised by the manufacturer

• •

Ensure the vendor can accurately explain the data on the safety features of their products Examine the specifications.

Post purchase, it is then vital that crewmembers ensure their helmet fits correctly. If it doesn’t, they risk short-term damage and discomfort, and then there are the longer-term considerations. The two most common pilot complaints are hearing loss and neck/back pain, both of which are often the result of poorly fitted helmets. Some helmets feature active noise reduction, which claims to work by a 180-degree out of phase signal at the same frequency and amplitude to cancel the target ambient noise, according to Crosson’s AAMS paper. “At the recent Aerospace Medical Association annual meeting,” noted Crosson, “it was presented that ANRs do not mitigate hearing loss like originally thought. So, at this time, there is no scientific evidence that supports this claim.”

What’s on the market?

SPECIAL REPORT

believe there is a ‘best’, but there are several options based on your specific needs. There are a number of acceptable helmets to select from, the key being a reputable product based on articulated supporting test data to see how the helmet performs when compared to others. Certainly, the HGU-56/P (current US Army helmet) goes through the most rigorous testing.” (www. ihst.org/portals/54/Helmets.pdf) Another key characteristic of helmets that must he considered, he added, is the nape strap. “It is imperative that the helmet has a device that can be secured below the occipital lobe (the bump on the back of your head). This prevents the helmet from sliding/ rotating forward and possibly coming off in a crash,” explained Crosson.

An internet search in October 2018 found these manufacturers offering aviation helmets for sale in the US. 1. Gentex Corporation 2. MSA Gallet (Merit is their US distributor) 3. Paraclete Aviation Life Support 4. Government Surplus Sales 5. Helicopter Helmet LLC (HHC) 6. AVI Survival LLC (Related to HHC) 7. Evolution Aviation Helmets LLC (Related to HHC) 8. Northwall 9. FlightHelmet.com 10. Sarkar Tactical (El Paso) 11. LD Project Helmets 12. Lift Aviation Companies are listed in the estimated order of number of helmets sold.

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MEDICAL INSIGHT

Brains, planes and automobiles Dr Simon Forrington discusses best practices in the aeromedical retrieval and transfer of head-injured patients Introduction An acquired brain injury (ABI) refers to damage sustained by the brain after the time of birth and is therefore not caused by a congenital abnormality. Examples of ABI include the various types of stroke, infections such as meningococcal meningitis and any injury to the brain from physical trauma. This article discusses some of the issues involved in the aeromedical retrieval of this patient group. Secondary / tertiary retrieval missions, during which a patient is transferred from a hospital facility to another healthcare facility, such as a hospital in another country, is the main focus for discussion. Primary retrieval of brain-injured patients is also common, and typically involve helicopter emergency medical services (HEMS); these are referred to at the end of the article. Acquired brain injury is increasing in frequency and represents a significant burden for healthcare providers, including within the aeromedical transfer and retrieval sector. The latest figures from Headway (the Brain Injury Association charity based in the UK) show that in 2016-17, there were 348,453 admissions to UK hospitals with ABI. That represents 531 admissions per 100,000 population, and a National Health Service (NHS) admission occurring approximately every 90 seconds. Admissions with ABI have increased in the UK by 10 per cent in the last 10 years.1 18

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Sufferers from ABI may be left with devastating and life-changing loss of brain function, including disorders of thinking, feeling, talking and walking. Survivors of ABI, their families and carers often require significant degrees of help and support in the aftermath of injury. When ABI occurs away from home, for example when on holiday or when working overseas, patients and their carers have an even greater level of difficulty and distress. Aeromedical transfer providers have an important role in delivering patients and relatives to the comfort of familiar surroundings and a healthcare system more able to service complex long-term medical and rehabilitation requirements. Crucially, the patient transfer, although in itself is unlikely to improve the outcome for the patient,

should not cause further harm. It should certainly be as painless and stress-free as possible during an undoubtedly difficult time. Primary and secondary brain injury The clinical pathology of ABI is commonly referred to as ‘primary’ and ‘secondary’ brain injury. Primary brain injury refers to the damage caused to the brain at the time of the event. This would include, for example, direct trauma to the brain resulting from a serious road traffic collision. By definition, the damage caused in primary brain injury has happened before there was an opportunity to perform medical interventions. Little can be done later to

Guidelines for management of severe traumatic brain injury (TBI) are now in their fourth edition 2. In this patient group, good quality evidence for interventions that improve outcomes with good functional recovery remains lacking. General principles involve managing raised intracranial pressure (the pressure within the cranial vault), targeting cerebral perfusion pressures (the pressure driving blood flow to the brain) and avoiding even short periods of hypoxia and hypotension.

Cerebral perfusion and blood pressure targets Cerebral perfusion pressure (CPP) can be calculated when the intracranial pressure (measured from a direct indwelling pressure monitor or ‘bolt’) is subtracted from the mean arterial blood pressure. The BTF advocate targeting a CPP of 60-70mmHg following TBI (level IIb evidence). Blood pressure should be targeted as maintaining a systolic blood pressure >100mmHg in patients 50-69 years old and >110mmHg in patients 15-49 or over 70 years old

Acquired brain injury is increasing in frequency and represents a significant burden mitigate this. Secondary brain injury is that which occurs in the hours, days and weeks after the primary injury has occurred. Examples would include complications from impaired blood flow to healthy areas of the brain due to swelling and raised intracranial pressure. Medical interventions following ABI are generally aimed at preventing or reducing secondary brain injury. Aeromedical transfer providers should aim to prevent secondary brain injury during patient transportation and continue therapies and management strategies already in place with this aim. Preventing and reducing secondary brain injury The Brain Trauma Foundation (BTF)

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(level III evidence). Simple measures such as ensuring the tube ties (on intubated patients) are not so tight that they occlude venous drainage, and sitting the patient at 30-45 degrees to aid venous drainage and minimise fluid shifts during take-off and landing are well-known and commonly practised.

Stroke In the UK, recent emphasis has been placed on the rapid diagnosis of stroke

Practicalities of transporting the brain-injured patient There are times (such as in the acute

Other therapies Other therapies such as osmotherapy and decompressive craniectomy are used, but

a thorough risk assessment needs to be made and individualised to each case

evidence of long-term improvement in outcomes remains lacking. Active cooling is no longer advocated and, instead, the maintenance of normothermia and avoidance of hyperthermia are important principles used in many neurosurgical intensive care units. Phenytoin or Keppra (Levetiracetam)3 may be used following brain injury as prophylaxis against seizures; however, post-traumatic seizures have not always been associated with worse outcomes2.

in the pre-hospital environment and expedited transfer of the patient to a tertiary specialist stroke centre. Ambulance services often use prehospital triage tools such as FAST (face-arm-speech-test). Tertiary units are able to provide specialist advanced interventions such as stroke thrombolysis. The London Hyper-Acute Stroke model has improved patient outcome by offering such specialist services whilst saving the NHS money4, 5.

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phase of the illness or immediately following a deterioration in condition) when ABI patients may be less suitable for transfer and the risks of undertaking such a mission may outweigh the benefits. Any transportation of a patient in the early stages following serious injury, either within the confines of a hospital or outside, can be difficult and dangerous for the patient. During an aeromedical transfer, particularly, there are the issues associated with cabin pressure, relative

MI hypoxia and the physical forces placed on the body, particular under heavy acceleration and deceleration during take-off and landing. Air ambulance or commercial airliner The decision relating to the platform on which to transfer a patient depends on the complexity and acuity of the injury. This is also sometimes influenced by financial constraints, particularly when the

retrieval mission is to be privately funded by individuals, as opposed to through an insurance policy. In these circumstances, if a commercial airliner is to be used, it is generally wiser to wait for relative patient stability, removal of tubes and lines and when the risks of any patient deterioration during flight is felt to be low. In more complex injuries requiring a higher level of care and where the risks of patient deterioration during flight are felt to be higher, it is generally accepted that

an air ambulance would be the transfer modality of choice. Acute phases of illness In the days immediately following ABI, patients are often unstable. TBI patients may well have other traumatic injuries, which require complex intensive care prior to transfer. Intracranial pressure is often labile and significant fluctuations can occur on minimal patient movement. In these situations, it is often prudent

to manage the case. Clearly, a thorough risk assessment needs to be made and individualised to each case, taking these factors and others into account. If intracranial pressure monitoring is still in-situ, in the form of a bolt or an extraventricular drain, this may indicate that the patient remains somewhat unstable in terms of their head injury. Caution should be taken when considering transfer of these patients. Intracranial pressure monitors are often removed when a

â&#x20AC;&#x2DC;irritable brainâ&#x20AC;&#x2122; may lead to patients becoming agitated to wait until the clinical picture is more stable and more favourable. However, there may be a perceived need to quickly move such a patient to a higher level of care, from a remote area or location with only basic medical facilities and less able

period of stability has been achieved and when the likelihood of further deterioration (such as a re-bleed from an aneurysm) is lower. Moving patients with intracranial pressure monitors can therefore be more

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MI good quality evidence for interventions that improve outcomes with good functional recovery remains lacking hazardous, both in terms of a labile intra-cranial pressure and in managing the devices themselves in the flight environment. Retrieval providers may wish to wait for removal of these devices and the patient stability that this infers. However, this needs to be balanced against the clinical urgency of the transfer. Post-neurosurgery If the patient has required some form of brain surgery, the clinical picture is likely to take some time to stabilise post-operatively. Following some types of surgeries, air may be present within the cranial vault. This in itself rarely causes a problem, but if there is no route of egress for this air, problems can be encountered during transfer. At normal cabin pressures of 5,000-8,000ft, humidified air may expand by up to 30 per cent and this expansion could cause dangerous rises

Primary retrieval / HEMS missions In the immediate aftermath of ABI, particularly following traumatic injury, HEMS services may be dispatched to manage the pre-hospital immediate medical needs of the patient. The utility of this approach is gaining continued acceptance in the literature. The UK National Institute for Health and Care Excellence Guidelines on Major Trauma7 provide a target of 45 minutes from initial call to the ‘rapid sequence induction’ of pre-hospital anaesthesia in these patients. In practical terms, many would argue that expedited delivery of a senior clinician to the scene of the incident via helicopter or rapid-response vehicle best achieves this goal. Patient management in this group again focuses on the prevention of secondary brain injury and avoidance of patient deterioration. These cases are often very challenging and patients may present with other life-threatening injuries in addition to ABI. Having instituted immediate life-preserving treatment, the HEMS clinician will manage the transfer to a major trauma centre, which may be via helicopter or ground ambulance, depending on the clinical condition of the patient. Ground transport is sometimes preferred in the most unstable patients, due to the difficulty of performing medical interventions in flight. This needs to be balanced against the time taken to deliver the patient to more definitive care.

in intracranial pressure. A period of days, or sometimes even weeks, may need to elapse to facilitate safe repatriation. Direct consultation between the aeromedical retrieval team and the treating neurosurgical team is good practice. In cases where transfer is needed expeditiously, careful consideration of using a lower cabin altitude throughout the flight needs to be made. Any decision to fly at lower altitudes, and hence at a sea-level cabin pressure, needs to be balanced against the additional time taken for such a transfer, which may also negatively impact the patient. Agitation and delirium Following ABI, it is common for patients to experience disorders of cognition. The ‘irritable brain’ may lead to patients becoming agitated, difficult to manage and potentially a danger to themselves and / or the transferring team. Clearly, this is particularly important in the confines of an aeromedical retrieval mission, with the safety of the aircraft, patient and crew at the forefront of considerations. Agitation and delirium can sometimes settle with the course of time and again it may be prudent to wait if there is potential for resolution of these symptoms. However, should transfer be indicated, effective plans for managing agitation, including controlled and targeted pharmacological sedation, should be agreed during the planning phase.

References 1. Headway. The Brain Injury Association. www.headway.org.uk. Website accessed November 2018 2. Carney N, Totten A, et al. Guidelines for the Management of Severe Traumatic Brain Injury. 4Th Edition. September 2016. Brain Trauma Foundation 3. Chaari A, Mohamed AS. Levetirecetam versus phenytoin for seizure prophylaxis in brain injured patients: a systematic review and meta analysis. In J Clin Pharm. 2017 Oct; 39(5): 998-1003 4. Jauch EC, Saver JL. et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke. AHA/ASA Guideline. 2013 5. Bouverie J. Major changes in stroke care can save lives. Blog. www.england.nhs.uk 19 July 2017 6. Whitely S. MacCartney I. et al. Guidelines for the transport of the critically ill adult (3rd Edition 2011). Intensive Care Society 7. National Institute for Health and Care Excellence. NG39. Major trauma: initial assessment and management. February 2016

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Chris Sharpe, a safety and survival expert and aircrewman for HeliSOS in Guatemala, believes that having the right tools can be the difference between life and death for air crew following an aircraft accident The aim of a survival kit is to give you the tools to enhance your chances of survival. They vary in many sizes; from a large aircraft jungle survival kit to a small personal tin. Depending on your location and weight restrictions, it may be as simple as a knife and fire-starter. Remember: You 24

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are only a survivor once you have returned to civilisation! Most aircraft carry survival equipment depending on their role and location. This is usually required as part of your country of operation’s aviation administration legislation. However, regulations can vary dramatically. Aircraft survival gear is often referred to as ‘ALSE’ from the military mnemonic: • Aviation • Life • Support • Equipment ALSE didn’t really exist until after World War 1. At that time, survival gear was meant for ‘surviving the weather and the enemy’. Even parachutes were not issued; as they were deemed as ‘cowardly’. Hence, lifespan was a maximum of three weeks for an aviator during WW1 in 1917. As WW2 progressed and aircrews became better trained and more expensive to replace, the issue of survival gear became more routine. Life preservers (the classic ‘Mae-west’), parachutes and survival kits were issued. Thankfully, helicopters were invented (Sorry, fixed wing chaps!). ALSE started, not only to advance in technology, but also make us rotary wing types look good and

super cool in the process. The Korean War (the first extensive use of helicopters in aeromedical and transport roles) introduced the flying helmet and the ‘Barbour jacket’ project that improved a WW2 design (USAAF Type C-1 Emergency vest). That was the precursor of the modern survival vest that was extensively used in the Vietnam War. The vests were designed to allow the pilot to crash and run (literally for his life), and still have the gear attached that he needed whilst waiting for rescue.

You are only a survivor once you have returned to civilisation Unfortunately, most companies would frown on you turning up for work wearing the latest generation Air Warrior gear. Many of our patients would also be slightly worried, so we have to balance our needs along with our company’s image. Working SAR services? Immersion suits, helmets,

FEATURE

Survival of the fittest and vests are no problem and should be expected. Critical care transport from ICU to ICU? Probably not the image your company wants. However, it is all based on your operational tasking / risk assessment. Survival kits This picture (right) shows the jungle survival kit that is carried on all our programmes’ helicopters here in Guatemala (in addition to a first aid kit). It is always worth spending a half day training on your kits; even if it’s

just to see what is in it, and how you can use it effectively. Plus, this can also identify potential issues with your maintenance section seals used on kits. For example, a recent military unit sealed kits with wire and lead seals. Without a cutting tool, you couldn’t open it. Unfortunately, in the event of a crash, dynamic rollover, fire or water ditching, you will probably not get a chance to use any of these aircraft kits. Why? Based on statistical fact, in the event of a crash, if it isn’t fastened to you, you won’t have it! The first place to store your gear is your pockets. This prevents you from carrying too much. (Who doesn’t overstock their med bag?). My father used to carry a butane

lighter, Swiss army pen knife, 20 Marlboro and a small bottle of whiskey. I’m not sure this fits the priorities of survival, but he was happy – bless him! Whatever method you utilise, it needs to be small, compact and lightweight, so that you get accustomed to always carrying it on your person. All items need to aid in the priorities of survival: • Protection – from the elements, weather, insects and further injury are all covered in this section. • Location – we want to be found and be rescued • Water – collection and preservation • Food – not an immediate priority, but necessary to prevent hypoglycaemia and malnutrition. Start small The below are suggestions for kits, beginning with the smallest (and cheapest!) and progressing up the pay and size scale. Survival tins The ‘combat survival tin’ is a very popular choice for many people. Designed originally by the British Special Air Service (SAS), it is designed to sit in a trouser or jacket pocket. If the soldiers had, for whatever reason, discarded their rucksacks or webbing

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equipment, then they still had their tin on their person. They contain a few simple items, that with the correct knowledge, can assist in the priorities of survival. They can be commercially bought or home-made.

Chest rigs

Go-packs

The chest rig was designed for infantrymen to carry more ammunition in a readily accessible place. MOLLE platforms are very popular with ground SAR teams. They also have the added advantage of being small, compact and don’t look too ‘gung-ho’. Easily customised, you can add a simple pouch for survival gear, pouches

A modern evolution of the tin. Available through surplus stores, eBay, etc., gopacks are a cheap way of getting a sealed kit that you can use. Depending on the type, they can be large, but are usually very thin. They are designed to fit in the ejector seat base, and they are an additional back-up to the gear the aviator already carries on his person. Personally, I don’t worry about expiration dates too much since there is usually no food content, and everything is vacuum sealed. If you decide to build your own tin or go-pack, some items for consideration may include: • Small folding knife with locking blade • Fire lighting steel, butane lighter, matches and small candle • Mosquito head net (can double as small fishing net) • Dry tinder for firelighting • Unlubricated condoms for water collection • Whistle • LED microlight • Paracord • Small fishing kit • Snare wire • Safety pins 26

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way to carry survival equipment. They are extensively used by military and civilian aircrews (usually engaged in SAR/ remote work). Vest types can range from complete, whole body vests with built in life preservers as pictured, to smaller purpose-built platforms such as the Switlik constant wear aviator vest and similar vests with modifiable pouches for custom fit. I utilise the Tac-Air G2 vest that has the integrated hoisting harness. You can get it without this at a more affordable price. What I really like about this vest is that essential survival gear is housed within removable ‘trays’ that slide in each side of the vest. This leaves the MOLLE platform free for you to customise. Build your own

Once you have your kit – practise! for essential med gear, radios, etc. The advantage of these over a full, top-of-therange aircrew survival vest is that they leave your back free; not only for your med bag, but it is also a lot cooler in the hotter places that we work in. Survival vests

For those conducting aircraft operations, the survival vest is an excellent and comfortable

It is easier to build a generic kit that applies to most world conditions, and then expand your individual knowledge on how to survive more effectively using your kit in the climatic region you are working in. Remember: knowledge weighs nothing. For example, here in Guatemala, it is perfectly feasible to survive for an extended period of time in the jungle with nothing more than a machete (and I mean three weeks or more). A machete can build shelter, produce fire-making devices, access drinking water from plants, and prepare traps and snares for food. You just need the knowledge on what to use it for. Once you have your kit – practise! It doesn’t need to be a full paid course. For example, take your firelighter (whatever the weather) and walk into a grassy area. Then, with a limit of 100 meters, gather what you need to make and start a fire. Rain, shine, or snow – practise!

F Helicopter crash survival kit Carried by all HeliSOS helicopters (plus a first aid kit) and used as an addition to individual vest equipment for larger more bulky items. • Survival Instruction Manual and contents list (which includes date last checked by maintenance section) • PVC / canvas outer cover – protects the contents and also doubles as a water collection device. Protection • Woodsman machete – small and compact so fits into kit, for shelter building or just moving anywhere in the jungle • Axe – for cutting firewood – more as a back up to the machete • Pair of work gloves – for protection from insects or plants trying to sting you • Insect repellant x 4 – everything in Guatemala wants to eat you • Matches – to create fire (applies to all of the priorities of survival) • Shelter sheet – simple orange plastic tarp, also doubles as ground / air marker sheet • 120-foot rope – to create shelters, can be separated to make snares / traps • Wet towels – the small packets that you get in hotels. Purely just to freshen up and raise morale. • Signal mirror – simply the best signaling device ever • Compass – included on all aircraft as a legacy, slowly being removed as we teach the golden rule ‘stay with the aircraft’

Location • Signal flare pistol – also a legacy item. I cannot stand flares as there are better ways of signaling, this is included due to most of the pilots being ex-military and most have had to use them in the past to get a signal above the jungle canopy. Now with training, they realise that there are far more efficient and lightweight methods. Water • Water purification kit – this is a small bottle of Potassium Permanganate. Not only can it be used to sterilise water, but in a higher concentration (mixed with water) can be used to clean wounds etc. Its further use (with the right skills) is used to start fire (either with sugar or aircraft fluids containing Glycol). • Water bag – used to collect either rain water or more commonly used to create a plant / solar still (using natures energy rather than our own to provide water). Food • Survival rations – we carry one MRE packet in each kit. Quick and easy to use, and high in calories. • Fishing kit • Knife / fork and spoon combo.

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Provider Profile: Life Flight Network Operating across four states across the north west of the US, Life Flight Network has come a long way since it began operations in the late 1970s with a single aircraft. AirMed&Rescue spoke to the organisation about its journey. Life Flight Network currently operates nine fixed-wing aircraft, including one Cessna

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Citation CJ4 and eight Pilatus PC-12NG. The rotary fleet includes 29 helicopters: 21 Leonardo AW119Kx Koalas, seven Airbus EC135s, and one Leonardo AW109E Power. Bases are spread throughout a fourstate region, with eight air bases in Oregon including the administrative offices; seven in Washington; five air bases in Idaho; and three in Montana. Life Flight Network also

operates three ground ambulance bases located in Oregon and Washington. It employs more than 550 personnel across its four-state region. Life Flight Network began as Emanuel Life Flight with a single helicopter in 1978. The programme was owned and operated by Emanuel Hospital (now Legacy Emanuel Medical Center) in Portland, Oregon. It was the first hospital-based air ambulance on the West Coast and only the fourth in the nation. Today, with 24 bases, Life Flight Network is a nationally recognised air medical transport service covering thousands of square miles, all while never losing sight of its core mission â&#x20AC;&#x201C; to serve the community by providing critical care transportation to ill or injured patients in a safe, compassionate, efficient, and expeditious manner. The consortium of Oregon Health & Science University, Legacy Emanuel Medical Center, Saint Alphonsus Regional Medical Center, and Providence Health &

PROVIDER PROFILE Services owns Life Flight Network. The combined strength of these world-class health institutions ensures the quality of the programme remains as safe and strong today as when it started in 1978. Fleet, crew and kit Although LFN provides significant input and final sign-off in the selection of medical interiors for our aircraft to best meet the needs of patients (full-body access), the outfit of all medical interiors for aircraft it outsourced to Spectrum Aeromed. Nearly all equipment carried by LFN flight crews, regardless of aircraft type, is standardized. Each flight crew carries a primary bag which contains the most commonly used equipment, and is further augmented with other bags for less common situations. In all, all LFN aircraft are equipped with the necessary equipment and supplies to meet state regulations and provide ICU-level care to the patients we transport.

In addition to minimum hiring requirements of at least five years of experience in their respective discipline, each flight nurse and flight paramedic is required to obtain licensure in the state(s) they operate in, and to obtain certification as a flight nurse or flight paramedic through one of two international certification boards. Education takes place monthly for each flight nurse, paramedic and respiratory therapist. Bi-annually, each clinician’s competency is validated on advanced skills such as needle thoracostomy, chest tube placement and management, needle cricothyrotomy, surgical cricothyrotomy, advanced airway management, and device management including ventilators, balloon pump, Impella devices, LVAD, and pacemakers. All education and competencies are overseen by the medical director. Life Flight Network’s Medical Director, Dr Jim Bryan, was awarded Medical Director

of the Year (2018) by the Oregon Health Authority. “I’m honoured and humbled by the award,” said Dr Bryan. “Even after 25 years of practicing medicine, there are new and exciting medical advancements to learn, teach and refine. I’m proud to be part of a team that shares my

Dr Jim Bryan

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passion for excellence and constant improvement.” Shannon Berg, spokesperson for the company, said: “The Oregon Health Authority honoured Dr Jim Bryan with Medical Director of the Year for his commitment to excellence and education in Emergency Medical Services. The honour recognises Dr Bryan’s career-long pursuit of ensuring and improving the highest levels of emergency medical care and training. Now in his tenth year as Life Flight Network’s medical director, Dr Bryan is one of only a few full-time medical directors for EMS agencies in the state. Life Flight Network’s clinical staff has long appreciated Dr Bryan’s guidance and mentoring, but we’re also proud that his contributions are being recognized by the medical community, at large.” Looking to the future Life Flight Network is constantly in search of new developments in medical, aviation and app technology that will allow it to pursue its mission of providing critical care transportation to ill or injured patients in a safe, compassionate, efficient and expeditious manner. Berg explained: “To that end, in 2018, Life Flight Network unveiled a new app called LFN Respond that allows hospitals and first responders to call for a life-saving air ambulance transport with the touch of a button. The tool, developed in partnership with dispatch software creator Flight Vector, saves valuable time when every second counts.” After the flight call button is activated, the app will send vital information and GPS location directly to dispatch personnel at Life Flight Network’s Communications Center. Once a flight call has 30

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PP been made using the app, users can view a real-time progress tracker that shows the aircraft’s location while en route and when it’s expected to arrive. “LFN Respond integrates seamlessly with Life Flight Network’s computer-aided dispatch and flight tracking software,” said Shannon Berg. The LFN Respond app provides additional functions including a searchable hospital directory, a landing zone guide, access to Life Flight Network’s calendar of outreach education trainings, and push notifications from Life Flight Network on education and training events. On the aviation side, Life Flight Network has proactively installed HTAWs, TCAS, synthetic vision, and cockpit data recording (Appareo), keeping our team and patients’ safety years ahead of federally mandated requirements. On the medical side, LFN has also purchased portable IABP balloon pump devices in lieu of using hospital pumps for transport, extending the ICU-level care provided to patients.

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Dr Robyn Holgate, Chief Medical Officer of ER24 Global Assist in South Africa, explains what it takes to guarantee patient safety in aeromedical transfers, and asks if there is more still to beÂ done Patient safety forms the basis of any clinical quality performance review nowadays. Since the 1999 report by the Institute of Medicine (USA), titled To Err Is Human, which estimated that as many as 98,000 patients die annually from preventable medical errors, many hospital-based healthcare providers are focusing on improving patient safety efforts. Growing financial pressures globally are forcing us to re-examine how we can better provide improved value in aviation medicine. These trends of more affordable service delivery are becoming the new norm. In light of these cost constraints and affordable healthcare solutions, are we doing enough to promote patient safety and clinical quality in the aeromedical environment? A small error in judgement could change the health of a country, hence it is critical that we implement systems within our aeromedical environment to keep our borders, healthcare providers and our patients safe.

SAFETY: The #1 priority

Check please The healthcare sector initially looked towards the aviation industry to assist and implement checklists for our patient safety initiatives. No doubt checklists have been

these checks have decreased the incidence of near misses. I recall a flight many years ago where I forgot the monitor, forgivable at 02:00 hrs? Fortunately, the flight was without incident. Checklists, discipline and teamwork that we have adapted have formed a critical part of all our patient safety initiatives at ER24 Global Assist. In order to ensure patients received the safest, most reliable care, we needed to move beyond a mechanical type environment with checklists to an integrated Quality Improvement programme which embraced the opportunity to provide compassion, dignity, discussion and empathy for our client base. Our programme thus includes a culture of safety, adverse event management, medication safety, teamwork and communication, trigger tools, and much more. For example, weekly safety meetings / team interactions, combined safety training and attending crew resource management sessions.

checklists have been instrumental and invaluable in assisting us to achieve our patient safety goal instrumental and invaluable in assisting us to achieve our patient safety goal of preventing human error in healthcare. Examples include Emergency Medical Care and Resuscitation checklists and the recent surgical safety checklist by the World Health Organization. In our own aeromedical environment, we have implemented checklists to manage equipment, preflight, in-flight and post-flight checks, and 32 32

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Confidentiality We have a confidential reporting system for adverse events, and the emphasis during our reviews has shifted from a traditional model of blame to that of a just culture. Following adverse events where a trend is identified, we have taken to releasing patient safety alerts internally. The very nature of our emergency business lends itself to adverse events, the human

INDUSTRY VOICE factor ever present. Examples of recent adverse events include dispatch delay and medication error. Although we receive less than one per cent of call volume as adverse events, less than international trends, we take every reported incident seriously, with the ultimate goal being to conclude our investigation and implement improvements to avoid a recurrence of such events. One such example is a recent adverse event where an opioid analgesic was used in place of adrenaline (Epinephrine) in an infusion; fortunately without any adverse effect for the patient. As a result thereof, all schedule analgesics are now kept in a separate pouch inside our drug bags, and resuscitation drugs are readily accessible. A small change as a result of patient safety reporting systems being implemented. We have developed trigger tools to further support our passion for patient safety. These are our red flag incidents as well as prospective triggers to evaluate the health within our environment and these are reported monthly. Cost and clinical outcomes Clinical cost efficiency is critical to sustain our business. We must strive to provide the best possible care while managing costs in order to keep our exceptional clinical reputation in a cost-sensitive environment.

Clinical indicators such as response times (a two-hour activation time for international air ambulance cases subject to clearances and other logistical challenges), intubation (>80-per-cent first pass intubation success) and intravenous insertion success (99 per cent inserted in less than three attempts) are proudly equivocal to the best in the world. We have researched

emphasis during our reviews has shifted from a traditional model of blame to that of a just culture and acknowledge that mechanical ventilation is the gold standard for all our intubated and ventilated patients, hence we have invested in the best equipment to empower our team to do their best clinically, examples include the Hamilton T1ÂŽ ventilator, DraegerÂŽOxylog 3000 plus and Zoll/Phillips ECG monitors with invasive pressure transducing and 12 lead

ECG capability for cardiac/ haemodynamic monitoring, and point of care arterial blood gas monitoring. Our neonatal successes should be celebrated: our smallest baby transported by our speciality neonatal team weighed just 500g and we were able to initiate high flow ventilation. We re-intubated six per cent of our babies due to blocked or inappropriately sized tubes, and subsequently began weaning high percentages of oxygen (which is toxic in premature neonates) in the majority of our babies. Where to next for patient safety initiatives? Our goal is always to achieve and then to maintain or exceed our standards. We have international accreditation via NAAMTA, an achievement we are proud of, that will take significant effort to maintain. We have installed state-ofthe-art software in our contact centre to ensure a faster, more accurate dispatch to any emergency with additional clinical resources to ensure our staff understand patientsâ&#x20AC;&#x2122; emergencies. The foundation for reviewing quality clinical performance has been achieved at ER24 Global Assist, our next step is to automate our reports, research and present our findings internationally.

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Surfâ&#x20AC;&#x2122;s up Surf-based rescue

scenarios challenge pilots, winchmen and rescue

swimmers to safely retrieve victims from extremely

treacherous conditions. James Paul Wallis

examines best practices and talks to the experts to find out the latest extractionÂ techniques 34

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FEATURE As a wave rolls towards a coastline, the sea floor rises until a critical point is reached which is where the water is too shallow to support the wave shape and it breaks, forming white water that sweeps into the shore. The surf zone is popular with water sports enthusiasts and casual beachgoers alike. The combination of people and powerful waves, though, creates a ripe environment for rescue work. Lately, great strides have been made in using UAVs in a surf rescue role. These remotely piloted aircraft have become mainstream for land-based missions, where their role is to locate casualties. In the surf, however, the challenge is to do something to help the victims reach the shore. Crewed helicopters, on the other hand, have been involved in surf rescue work for decades. While the equipment involved may be the same as for working in offshore waters, the techniques are different due to the action of the breaking waves and their effects on the victim. Ian T. Gaernter, Primary Instructor / Hoist

prior to other rescue personnel, then that helicopter has a very technical rescue on their hands.”

System Operator for Priority1AirRescue, commented: “In my experience, surf rescue is very unique because of its proximity to the shore. Generally, by the time a helicopter crew receives the call launches the aircraft and gets on scene, the person in distress has been rescued by another asset (i.e. lifeguards, bystanders or watercraft, drones and drop floats). But, on the rare occasions that a helicopter does arrive

Crew coordination skills One organisation that specifically trains for helicopter surf rescues is the US Coast Guard (USCG). Lt John (JJ) Briggs is the MH-65 (Dolphin helicopter) senior instructor pilot at the USCG Advanced Helicopter Rescue School, which teaches surf rescue at Cape Disappointment near Astoria, Oregon. He commented: “We utilise the Pacific Northwest’s predictably poor weather

survivors are often tired and are being continually trounced by waves www.airmedandrescue.com

and high swells as a training ground where students are placed in difficult situations with specially trained instructors to refine their skills in a highrisk environment.” Waters offshore often present consistent, predictable swell patterns, but working within the surf line the rescuer has to expect large, erratic movements of the survivor, said Briggs. He added: “If we are working in the surf with large breakers close to shore or rocks, we may change tactics to remove the swimmer and survivor quickly from immediate danger. We teach

can opt for a ‘direct deployment’ and remain attached to the hoist cable, using a strop to secure the survivor to the hoist hook. In more urgent situations, however, the swimmer can simply physically grip the survivor as the flight mechanic lifts them both out of the water. Briggs explained: “In fastmoving large waves, normally found within the surf line, survivors are often tired and are being continually trounced by waves. As this is a highly dangerous scenario, the crew may elect to direct deploy the rescue swimmer into the surf with the intention of a physical-grip pick-up to immediately reduce the likelihood of the survivor drowning or hitting rocks.” The two pilots and flight mechanic attempt to anticipate the movements of the survivor, which can be radical in high surf, to place the swimmer at a position to grab the survivor, said Briggs. He added: “Depending on the time between waves, usually between five to 18 seconds, the swimmer must decide to either secure the person with the quick strop or simply grab hold of them and lift them to safety.” Ian T. Gaernter said: “Due to the tendency to get dragged, swamped and or injured by the crashing seas, the hoist operator will pay out slack in the hoist cable to ensure the rescue swimmer can move freely. Once the swimmer is in contact with the survivor the hoist operator will conn the aircraft over the top of the swimmer and survivor to safely remove them from the water, all the while pilots are calling out and timing waves, ideally they will pull them free of

We teach crews to recognise the different types of breaking waves and how to work in them to complete hoists crews to recognise the different types of breaking waves and how to work in them to complete hoists. They use experience and judgement coupled with knowledge of wave hydraulics to create their plan of attack.” First, explained Briggs, the crew estimates the swell height, speed, type of wave and its associated dangers and chooses an appropriate hoisting altitude, usually between 25 and 55 ft above the highest wave peak. The extraction method used will then depend on the survivor’s condition, he said: “If the survivor is ambulatory, a basket may be lowered to them. If a rescue swimmer is deployed to assist the survivor, they can free fall (jump out) and swim to the person or be lowered using the rescue hoist. To lower 36

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the swimmer to the water in large seas or waves, the pilots maintain a steady hover at a fixed altitude and let the waves pass under the aircraft. The flight mechanic, who operates the rescue hoist, conns (directs the movement of the helicopter) by giving the pilots directional commands. The pilots and flight mechanic work in concert to position the helicopter and rescue swimmer into a pre-briefed location. All while the survivor is being dynamically moved by the sea.” When the rescue swimmer is lowered by the cable, they can choose to disconnect and swim to the survivor, explained Briggs, and use hand signals to request a rescue device appropriate to the survivor’s condition. Alternatively, the swimmer

F the water, from the trough of a wave prior to the next one crashing into them.” Briggs noted that if the sea state is relatively calm outside of the surf, one option is to lift the swimmer and survivor a few feet above the tops of the waves as the helicopter repositions to a safer location. They would then be lowered back into the water outside of the surf line, allowing the swimmer to use a more secure method of completing the hoist, he said. In extremely rough seas, the safest option can be to complete the physical-grip pick-up by

conduct helicopter surf rescues in the past, this would be a very rare mission for them these days, due to ‘improvements in surf life-saving technique over the years.’ Among such improvements, of course, has been the development of

The pilots and flight mechanic work in concert to position the helicopter and rescue swimmer into a pre-briefed location hoisting them into the cabin. In extreme conditions, the helicopter crew could need to ‘chase’ the survivor as they’re pushed by the waves. In the kind of conditions seen in competitive surfing, for example, the crew would typically position overhead and chase the surfer as each wave pushes them under and away, said Briggs: “During the chase, the rescue swimmer will be lowered within an arm’s length to grasp the surfer. If there is little time between swells both will likely be struck by crashing waves. The helicopter will remain in chase, and once the swimmer is ready for pick-up, the aircrew will time the extraction between crashing waves.” Such manoeuvres require precision movements and expert timing by all crew members, said Briggs. Hoisting into high seas and surf is a triad of teamwork between the pilots, flight mechanic, and rescue swimmer, he said with very small margins for error, adding: “We strive to constantly refine our skills and hone our craft though training.” While the USCG continues to train for working in the surf, some helicopter rescue providers are seeing demand drop. One civilian organisation contacted for this article said that although they used to

UAVs able to drop rescue devices to swimmers in need. Adapted drones A number of organisations around the world have been working on the problem of how to adapt drones to be effective in surf rescues. Highlighting the limited usefulness of offthe-shelf, cameraequipped UAVs in this scenario, Ulf Bogdawa, Director/ CEO of SkyDrones Tecnologia Aviônica, Brazil, put it this way: “It is fairly easy to find the victims, but you cannot do anything besides filming the drowning.” In 2018, SkyDrones

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became one of the first organisations to save a life in the surf using a UAV. In February last year, one of its customised DJIs flew to the aid of a kite surfer in trouble off São Paulo, Brazil. The remotely piloted machine dropped a Restube flotation device for him to cling to until a rescue boat could reach him and bring him to shore. While that might sound a simple mission, it was only possible due to the work that SkyDrones has done to make this possible. One element was to

In extremely rough seas, the safest option can be to complete the physical-grip pickup by hoisting them into the cabin

takes off. Then you have the option to fly to the victim by hand or to use the assisted ‘tap to fly’ to go to the victim.” After reaching the victim, a lifebuoy icon can be tapped to release the Restube. Bogdawa continued: “At the moment you drop the Restube, an SMS is sent automatically to pre-programmed receivers (usually first responders by boat) with the victim’s GPS co-ordinates in order to make rescue faster.” There are even algorithms in the SkyDrones app that help the Restube to fall close

source a flotation device small and light enough not to affect the UAV’s handling (especially important with smaller drones, which Bogdawa noted are cheaper and can be safer). For this reason, SkyDrones chose to work with Restube, whose flotation devices pack small, but instantly inflate when they hit the water. A second key ingredient was the software. Bogdawa commented that a drawback of the typical drone is that it’s not easy to get the co-ordinates of the victim’s location to share with other

rescuers: “Apps (like DJI Go) only have a dot on the map, but no co-ordinates to send the help to.” Therefore, SkyDrones worked on a custom app that takes some of the burden of flying off the pilot so they can concentrate on saving lives. He explained: “We developed a system that can be used with [a DJI] Phantom 4, Inspire 1 and 2. Other platforms can be developed at request. The app has very few things to do for a rescue operation. You have an ‘asking for help’ icon. When you press it, the drone

to the victim by compensating for wind strength and direction. The São Paulo rescue perhaps came on the heels of a mission to save two fatigued swimmers who were being washed out to sea off Lennox Head, New South Wales (NSW), Australia. Hailed as a world first, that tasking involved one of the NSW ‘Little Ripper’ drones being operated by the Australian Lifeguard Service in what started as a training flight. In this example, a flotation device was dropped to help

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F the swimmers make their way to shore, where they were met by lifeguards who had rushed to the scene on an ATV. The bigger picture It’s worth bearing in mind that helicopters and drones form just part of the wider mix of SAR assets, ranging from beach-based rescue swimmers to jet skis and life boats. What’s most suitable in a given region will depend on the factors such as the local environment and available budgets,

or await rescue, float-dropping drones could soon be the go-to option, thanks not least to lower costs, ease of pilot training and the ability to station and launch the aircraft right on the beach. As well as the examples listed above, there were other drone-assisted rescues in 2018 in inland and coastal waters around the world. And the use of drones for water rescue is spreading. Just this past July, Ocean Shores Police Department in Washington State, US, revealed plans to buy 12 UAVs specifically for surf rescue.

motivator when leaders of SAR organisations are facing the daily challenge of having to ask rescuers to perform rescues – and seeking ways to reduce the risk to their people.” Looking further forward, one possible avenue for research could be the integration of artificial intelligence into the SAR framework. Bogdawa of SkyDrones said he sees a future where more complex systems will operate together: “While a bigger (maybe solar powered) UAV makes flights over beaches, finding a rescue situation (using AI), this info is sent to one of the

SAR organisations are facing the daily challenge of having to ask rescuers to perform rescues – and seeking ways to reduce the risk to their people and will likely change as technology develops. However, given the different benefits offered by UAVs and crewed helicopters, both would seem to have an assured future in that mix. It’s likely that for the foreseeable future, there will be a role for helicopters in plucking people from danger, especially where they are unconscious or risk being washed onto rocks, both of which are scenarios in which drones would be of little benefit. However, where swimmers just need help to reach shore

Speaking on the future role of drones, Kelvin Morton, Managing Director and Airboss at DroneAdvantage and Surf Life Saving NSW UAV Project Manager, commented: “We are receiving more and more requests to lead drone projects to carry out rescue and emergency response trials and achieving increasing levels of success as the technology and capabilities improve.” It’s also significant that with drones, personnel can effect a rescue without putting themselves in harm’s way. Morton commented: “This is a very compelling

automatic and persistent ground stations who will deploy a SARtube drone.” If that sounds far-fetched, note that Bogdawa has already seen interest in developing such a system. It may be that for surf extractions, technology use in air rescue is only just getting started. Ian T. Gaernter said: “I feel like the role of helicopters being used in this manner has always been extremely limited … and as rescue personnel I would say we all welcome advancements in technology that save lives.”

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Safety first, second and third

When Mikko Dahlman, a HEMS helicopter pilot and founder and board member of Coptersafety, surveyed the effects of pilot error in helicopter crashes, he wanted to lay the foundation for change

As a pilot, Mikko has witnessed the risks of complex situations and environments that are part of the job. He realised that the most important thing would be to train the right attitude towards safety. “From the very beginning my passion and vision has been to improve the safety culture in our industry,” he told AirMed&Rescue. “Helicopter operation can be high risk,

together as a team, we can take the industry forward 40

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and the safety culture is not always where it should be – yet. However, there is a lot we can do, for example, training the pilots adequately and thoroughly. Another critical factor in improving safety within the industry is a comprehensive approach and viewpoint. After all, most accidents are due to a pilot’s error. Hence, there is much we can do such as preparing the pilots mentally and physically as well as increasing their technical know-how.” It was Mikko’s own experiences that were ultimately the inception of Coptersafety. Experience counts There is little doubt that Mikko’s 20-year

experience flying as a helicopter SAR / HEMS pilot in the demanding conditions of Finland has benefited the company. A career as a pilot for FinnHEMS (under Babcock Scandinavian Air Ambulance) has given Mikko the knowledge to evaluate areas of training that require significant focus and allows him to better understand clients and their needs. In fact, Mikko has often been in the customer’s shoes as he has had to keep his license current. Each of Coptersafety’s 20 instructors has at least 20 years of pilot experience and are still flying – something that is key to the company’s desire to provide top-notch training. Hiring highly experienced instructors

INTERVIEW

with a range of flying backgrounds is a feature that complements Coptersafety’s customised training programmes. For example, if the customer is a HEMS operator, they will always be placed with an instructor who has experience from that field of operations. Mikko said: “This is a huge part of our core competence as we see that it provides tremendous value to the customer. After all, combining theoretical and practical knowledge is an unbeaten combination. There are things you cannot learn from books.” Safety is key Industry safety continues to be of paramount importance, and for Mikko, having a comprehensive approach that takes into account the pilot as an entity is a key. k “After all,” he told AirMed&Rescue,, “most helicopter accidents are due to human error. Thus, we should consider them as decision makers and see how they make decisions, especially under pressure or stress. The importance of this grows as the automation increases. A holistic approach is crucial for this. The simulator or an aircraft in itself is not enough.” He added: “Another important thing is building a community, in which challenges and drawbacks are openly brought up and discussed. Together as a team, we can take the industry forward.” Regulations in the US and Europe do contain some key differences, some of which could be the reason why there are a higher number of helicopter accidents in the US than there are in European helicopter air ambulance operations. AirMed&Rescue asked if Mikko believes that the US could learn lessons from their European counterparts regarding safety standards. He responded: “We can all learn things from each other. Thus, increasing collaboration and discussion between different continents and countries would be significant. This also leads to my earlier point about the importance of enhancing communication and building a community.” He continued: “Over five per cent of all helicopter accidents occur in HEMS activities. A uniform HEMS safety and quality standardisation is paramount in order to improve the overall safety of helicopter emergency medical services. For example, in HEMS operations in Norway and Finland we do a lot of training and undergo frequent checks in order to keep HEMS crew current.”

our primary goal is to improve the safety level in helicopter operation

The ultimate goal Creating and building a community that can play a role in enhancing the safety of helicopter operations is just one of the elements of his role that Dahlman enjoys about his role with Coptersafety. Others, he explained to AirMed&Rescue, include seeing the customers enjoy their time with the company as they are provided with an opportunity to learn, and having flight instructors who truly bring and provide additional value to the pilots. “However,” he concluded, “our primary goal is to improve the safety level in helicopter operation;

this is the vital factor that drives the entire Coptersafety team and me. I could not be happier to have been able to surround myself with such a great group of people who are committed to our vision, and most of all to have customers who genuinely believe in us and are excited to be part of building a brighter helicopter future.”

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CASE STUDY Please kindly note that for obvious confidentiality reasons, we are not allowed to disclose sensitive details in this presentation.

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Taking a civilian air ambulance into a warzone requires careful co-ordination with different authorities. When AirLec Ambulance was called to collect a patient in the Middle East, time and information limitations added to the complexity of the case

A few months ago, one of our clients, International SOS, requested an urgent evacuation of a 33-year-old lady from a military hospital in an active war zone in the Middle East, to a place where medical care is more closely aligned with international standards for intensive care.

Patient’s medical condition This young patient had no special past medical history but had over a few days developed a fever with sore throat, odynophagia, abdominal pain, and jaundice that was not improving after six days of treatment of azithromycine and paracetamol. She was initially assessed locally and transferred to the ICU of a military hospital in good clinical condition. Her subsequent blood work up showed severe liver and kidney failure with fulminant hepatitis complicated by acute coagulopathy, thrombocytopenia and metabolic acidosis. A CT scan of her abdomen further revealed mild anasarca made of pleural effusion, pericardial effusion, ascitis with hepatomegaly, splenomegaly and lymphadenopathy. The final diagnosis was an acute Epstein Barr Virus infection with liver and kidney failure, which was complicated by acute coagulopathy, thrombocytopenia and metabolic acidosis, with a possibility for a hematophagocytic lymphohistiocytosis. The patient was at high risk of acute haemorrhage because of deep coagulation disorders, with a need for comprehensive ICU medical management and a potential liver graft. Considerations and complexities To make this flight possible, and beyond dealing with the critical medical condition, Airlec Ambulance faced many operational challenges: Because of the extremely

high confidentiality in regards to the military airport details, it was nearly impossible for our pilots to obtain any precise airport approach plate. • The team had only 120 minutes allowed on site by specific insurance policy extension. • This area is strictly forbidden to French air operators, so Airlec Ambulance had to obtain a mandatory special waiver from the French Ministry of Foreign Affairs. • Because of the location of the patient, Airlec Ambulance actively sought security information from various stakeholders in order to evaluate the risks/benefits ratio of the mission. • For safe overflight-approachlanding-take off conditions in a war zone country/airport there was a complicated necessity to liaise with many different parties: French authorities; military airport authorities; and civilian authorities in the country. • Although Airlec Ambulance anticipated this option, no military plane was sent to escort our aircraft from the air to the airport. In-flight The patient’s haemodynamic and ventilation remained stable throughout the flight, with only one acute episode of nasal bleeding which was stopped with intravenous tranexamic acid (the decision not to perform any anterior/posterior packing was made by the medical team due to the severe coagulopathy). The patient was finally safely handed over to the receiving medical team. Paul Tiba, Chief Executive of Airlec Ambulance, told AirMed&Rescue: “It was a big challenge to implement a single civilian air ambulance in a complex military war zone system. It necessitated huge efforts and commitments from our operations team and ground handling agent to ensure the safety of the patient, medical team and pilots by securing overflight-approach-landing-take off in an active war country/airport. This included timely analysis of the situation and medical/operational capabilities; timely delivery of Labile Blood Products thanks to our agreement with French Blood Institute, and timely transfusion of the patient upon arrival of the team.”

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Never forget Never forget

Jonathan Godfrey was the sole survivor of an air medical helicopter crash in 2005. He wrote to AirMed&Rescue about his experience and what heâ&#x20AC;&#x2122;s learned from it 44 44

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Never forget Never forget

sense that after an experience such as mine, I would continue to find satisfaction (understatement) in attempting to prevent suffering that accompanies a crash as well as foster resilience within the professional realm of transport, flight, EMS, nursing and many other areas that I identify with. Preventing the senseless loss of life caused by incidents, accidents and crashes needs an army of people that carry a passion for safety and survivability. I am just one of those passionate people. What does ‘Never Forget’ really mean? To me, it is bone deep personal and means You don’t need to live scared Nikki and Joe. Only through an absolute or abandon your dream, but miraculous sequence of events did I not join you need to become an expert them and end my life story. If I had died, I at evaluating, managing and would have wanted measuring risks and threats someone to carry on my legacy and suspect that they would want much of the same. Standing cold, broken and alone in the river that night, one of my biggest fears was that my children would not know me while they grew up, even forget me. Their memory living on is crucial to peace in my soul. Nikki and Joe will never be forgotten, and I will do my part I have learned, lived, accomplished or to make sure it never happens. even failed to do with my life. Surviving flight crew families, particularly those that have lost a loved one in the line Not moving on of duty (LODD) are also dear to my heart. This year I want to answer some questions It started just days after the crash when that I have heard along the way. It might I became more acquainted with Nikki be of interest to someone out there in the and Joe’s families. Drowning in my own transport and flight world. Who cares? Get survivors’ guilt and navigating what my over it. When are you going to put this place was in their lives was blinding and behind you? The simple answer is never twistedly painful. They don’t make a – never, ever, ever. Even if I wanted to, I Hallmark card for our dynamic. At one could not. I do not want to. The person point all I could do is beg for forgiveness who emerged from the water that night is for being alive. I meet and correspond very different from the person I was in my with many more families year after year life before everything changed. and witness them in their varying stages of I am a nurse. I enjoy helping to heal grief. Sometimes I am better at knowing people. It has always been a natural fit what to say than others. My first goal is for my heart and mind. It only makes not to make it any worse. Their stories

INDUSTRY VOICE

Fourteen years ago, I drove into work for a normal 24-hour flight shift. Never in my wildest imagination could I have predicted how much would change that day. I remember clearly stopping at the grocery store because it was my turn to feed the base for the day. Nikki and I started the day together, but it would not be until evening when Joe came on shift, and we lifted for our first flight that evening after the sun had set. On the anniversary of the crash, I reflect not only on that night in 2005 but also on what

are littered with people who have meant well for the most part and wound up carelessly opening up old wounds, pouring salt into existing ones and delaying their needed healing. Sometimes they come back days, weeks or years later and report that a conversation between us helped in a small or big way. Those reports drive me to remain active on the National EMS Memorial Board as well as stay in contact with families in the process of healing. What have I learned this year? I still fly full time in Washington, DC and when I have time, I travel and speak to groups on the topics of safety, survivability, and resilience. In doing so, I get to meet many people. Those friendships are rich with stories, laughter, wisdom, and endless entertainment. Trading opinions and information continuously shapes my views, hones my messages and helps to maintain my vigilance. I have learned that yes, I am capable of being apathetic and losing a level of vigilance while doing the job. If I can let those cancers creep into my practice, everyone is susceptible, and no person is immune. I have as much nauseated anger seeing it in myself as I do seeing it in other people. I am equally as judgmental of others as I am of myself. It is the single most destructive force when safety is at stake. Constant vigilance Maintaining vigilance is uncomfortable and takes work, possibly even more work the longer that I am flying. What should I say to the young flight crew? This job can kill you. Many of my colleagues get uncomfortable when this is said, and some get offended. If that has never crossed your mind, you are a fool, and you need to consider a career change. You don’t need to live scared or abandon your dream, but you need to become an expert at evaluating, managing and measuring risks and threats. This skill takes as much precedence as being a critical care provider. Safety is not a checkbox, a computerised test or an annual meeting, it is more akin to personal hygiene – put it on every day (or transport) and maybe even a couple more times during the day. Vigilance, my friends and colleagues!

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45 45

Aerospace pioneer Igor Sikorsky founded the company in 1923 as the Sikorsky Aero Engineering Corporation. Currently, all US military branches, along with military and commercial operators in 40 nations, fly Sikorsky helicopters. Commercial S-76® and S-92® helicopters provide search and rescue, VIP, and offshore oil crew transport. Rotorcraft innovation continues with the CH-53K, CH148, S-97 RAIDER® and optionally piloted aircraft technology. Sikorsky is currently the largest supplier of military helicopters to the US Government, and the Sikorsky Black Hawk is the most widely flown military utility helicopter in the world. Sikorsky was acquired by Lockheed Martin in November 2015. 46

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COMPANY PROFILE

Sikorsky / Lockheed Martin AirMed&Rescue spoke to Nathalie Previte, Sikorsky Vice-President, Strategy and Business Development, about the company’s past, present and future

Allowing for modifications to airframes keeps Sikorsky very active when it comes to repurposing helicopters. Could you tell us about the FIREHAWK modifications you are making to Black Hawks? Throughout the 40 years that Black Hawk helicopters have been in production, there have been countless modifications, which have significantly contributed to the company’s competitive advantage. To become a Firehawk, a Black Hawk is equipped with a 1,000-gallon water external belly tank, extended landing gear to give the tank added clearance from the ground, a retractable snorkel, and a rescue hoist. In the case of the Los Angeles County Fire Department (LACoFD), a single pilot cockpit and a medically equipped interior complete the transformation to the Firehawk configuration. LACoFD and Sikorsky co-developed the Firehawk in the early 2000s with second generation Black Hawk aircraft that are still operational. In 2018, Sikorsky delivered two S-70 Black Hawk aircraft to LACoFD to be converted to the Firehawk configuration

in 2019. As third generation aircraft, these

internationally and domestically.

How important is the air medical sector to the company? The air medical sector is incredibly important to Sikorsky. Igor Sikorsky founded the company with a vision for the helicopter being used as a life-saving tool. This community speaks to the foundation of our company and shares a legacy deeply invested in saving and bettering lives. The S-76 has a robust 30-year history of providing safe and reliable EMS operations. We strive to provide first responders with the highest speed, lowest vibration and high-performing equipment that is needed to properly care for patients in critical condition, with safety and reliability always our priority. We know that minutes matter to this community. By using the capabilities of the S-76 technology advancements, first responders have been able to save countless lives, both

Digital cockpits are now standard on most new aircraft – what’s the next step for cockpit design and innovation? We believe the next major step will be to change from piloting to mission management. With that change, we’ll see new ways to interact with the system. We are working on new ways to present data to the pilot, as well as to receive pilot inputs. Many customers are looking for ways to address changing mission requirements by adding functionality to aircraft. Leveraging the latest in open system design, we’re able to add specific mission equipment packages and provide additional information to the pilots in the cockpit. As we increase the level of automation in helicopters, open systems allow for rapid adaptation in the way information is consolidated and presented to most effectively manage meeting mission objectives. Sikorsky has a long history of working on cutting-edge technology while also keeping safety and reliability as a primary focus.

new Firehawks will provide greater lift and power, so that pilots carrying water at 10,000-ft (3,048 m) altitude in hot conditions are not living on the edge of their power margin.

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Sikorsky has been working on MATRIX Technology, our self-funded autonomy program, since 2013. Through MATRIX™ Technology, we are developing systems intelligence that will give operators the confidence to fly their large rotorcraft or fixed-wing aircraft safely, reliably and affordably as autonomous or optionally piloted aircraft. This technology can go

refurbishing used rotor blades teach the company about the design of new ones? We always look for ways to improve our products. That is one of the main reasons we have embedded engineers at the repair facility. The process of refurbishing rotor blades provides Sikorsky with firsthand insight into patterns of repair that

and fixed-wing aircraft. What is Sikorsky doing to make sure it’s part of this increasingly vital market? Sikorsky has been a significant part of the Asia Pacific helicopter market for decades. For more than 65 years Sikorsky helicopters have been present in Asia Pacific, during which time Sikorsky has developed a strong

can improve performance. Since CTI repairs blades from all types of customers, Sikorsky is able to develop performance and endurance changes from a myriad of different flight regimes. This data contributes to our continuous effort to improve customer satisfaction, reduce direct operating costs, and increase blade longevity, and is one of the things that sets CTI ahead of the competition.

reputation of safety, quality and trust and is today supporting a fleet of more than 700 civilian and military helicopters in the Asia Pacific area. Most recently, we relocated a Sikorsky Forward Stocking Location from the east coast of Australia to Perth, Australia, in response to our customers’ needs. On the civil side, the search and rescue mission segment is the recent standout, and in September 2018, Sikorsky sold its 20th search and rescue S-76D in Asia, and now more than half of the world’s S-76D fleet is operating in Asia. Sikorsky has invested in new technologies and the augmentation

The Sikorsky Raider on both commercial and military aircraft. MATRIX Technology is installed on SARA (Sikorsky Autonomy Research Aircraft), a modified S-76B that we consider a flying lab where we test out our capabilities and mature the technology. MATRIX Technology is like a virtual second pilot that will help operators fly safely and confidently in dangerous and complex missions. We continue to look at other ways that MATRIX Technology is applicable across the Lockheed Martin portfolio. Composite Technology Inc (CTI) is a Sikorsky company. What does 48

AIRMED&RESCUE

The Asia Pacific area is considered by most in the industry to be a largely untapped resource when it comes to the sale of helicopters

CP of the availability and distribution of parts in support of the S-76D and the S-92 in the Asia Pacific area. In addition to new sales, we are continuing to focus on sustainment improvements throughout the region and keeping our customers flying. In 2018, we authorised our first Customer Support Center in Thailand with Thai Aviation Services,

company? Is it all about helicopter autonomy? The future of vertical lift involves autonomy or optionally-piloted helicopters and much more. Sikorsky is developing and building the next generation of helicopters that can meet the future, increasingly demanding, needs of our military and commercial customers. We are increasing

Statistics Number of employees: Sikorsky’s fleet of more than 4,000 operational aircraft is supported by a worldwide network, with approximately 13,000 employees around the globe. Company locations: Sikorsky has locations in Connecticut, Alabama, Florida, Pennsylvania, New York, Poland, and Australia, with approximately 6.5 million square feet of facility space. Turnover: Sikorsky is part of Lockheed Martin’s Rotary and Mission Systems (RMS) business, which reported US$14.25 billion in 2018 revenues.

making it our seventh CSC in the Asia Pacific region. We believe that the strong Sikorsky reputation for safety, quality and trust, fostered with many customers for more than 65 years, coupled with Sikorsky’s continued focus on finding ways of facilitating customer operations, are important attributes that current and prospective customers demand and appreciate. The future of vertical lift is something that Sikorsky has been talking about for some time now – what does that really mean for the

range, speed, safety, manoeuvrability and capability to allow for effective operation in the challenging and evolving environments in which our customers operate. One example is that we submitted our Future Attack Reconnaissance Aircraft (FARA) proposal to the US Army in December, enabled by our confidence in X2 Technology that has been achieved through flight tests of our S-97 Raider aircraft. While we are developing aircraft for the future, we are also advancing technologies like data intelligence and autonomy that enhance our current aircraft to bridge the gap between today’s aircraft and the aircraft of the future.

Proﬁt: Sikorsky is part of Lockheed Martin’s Rotary and Mission Systems (RMS) business, which reported $1.3 billion in operating profit.

www.airmedandrescue.com

INDUSTRY VOICE

Home is where the heart - and

- is

Dr Adrian Hyzler sets out the justifications for mental health repatriation Insurers unquestionably look for the best health outcomes when policyholders fall ill or are involved in accidents abroad. But while physical conditions are easy to identify in order to take the right action, the psychological impact of illness while abroad is less well understood. Healix International, the global medical and security provider, has developed a tailored solution to help insurers make the right medical decisions when dealing with travellers abroad who are facing mental health as well as physical issues. “It is not uncommon for mental health issues to arise as a reaction to the stresses involved in traumatic injuries, and these will generally resolve spontaneously as the physical condition improves”, explained Dr Adrian Hyzler, Chief Medical Officer, Healix International. “Simple conditions, such as hypoxia (reduced oxygen levels) or sepsis (generalised infection) can cause a patient to become agitated and often delirious. The same can happen with specific drugs or drug combinations. Data from Healix International reveal that between five and 10 per cent of cases of physical injury cases, that we manage, have psychological complications. There are obvious contributing factors that increase the severity of the psychological effects: being outside the normal environment; being away from the support structure of friends and family; the difficulty of coping with language and cultural issues. It is crucial for everyone in the assistance industry to 50 50

AIRMED&RESCUE

recognise these symptoms and to understand the increased psychological effects in order to manage the best outcome for the policyholder.” Repatriating mental health patients presents particular challenges. They are likely to be exposed to the hurly-burly of the airport environment, to thousands of fellow travellers elbowing themselves through check-in, security and on to the plane. It is therefore vital that the patient is provided with as calm an environment as possible during the repatriation.

AIR AMBULANCE EXPERTISE

We understand the importance of having a well-designed interior to support the critical work that takes place inside an air ambulance. Our expert designers and technicians have created and installed numerous medical interiors, providing our clients with cabins that meet their specific mission requirements. All of our interiors are designed to meet the most stringent international guidelines and fashioned to keep both patients and personnel feeling comfortable in a highly functional setting. When you work with us, youâ&#x20AC;&#x2122;ll have a better experience...

MOLINE

DES MOINES

MINNEAPOLIS

ElliottAviation.com 51 51

www.airmedandrescue.com

SAVE THE DATE 2019 A chief role of medical escorts must be to provide this by utilising airport lounges, avoiding large queues, and using priority boarding. On the plane as well, patients should be protected from any potentially difficult interactions from air crew or fellow passengers. Medical escorts therefore provide a calm and capable presence, able to problem solve and take responsibility away from what is often an

As repatriations can often last 30 hours or more, it is important that at least one of the escorts is fully awake at all times. This can be achieved by the medical staff taking shifts to ensure some rest is achieved during these long journeys. In the unlikely event that the patient becomes acutely disturbed on board, it is especially important to have two healthcare professionals, both able to help

MARCH

4-7

7-8 APRIL

HAI Heli-Expo Georgia World Congress Centre US UAS Drones Disaster Conference Columbia Memorial Space Center Los Angeles US

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

MAY

14-16

22-23

JUNE

Maritime Search & Rescue Tallinn Estonia Aerospace Mental Health and Wellbeing Royal Aeronautical Society London UK

Australian & New Zealand Search &Rescue Conference RACV Royal Pines Resort, Gold Coast Australia

JULY

15-20

APSCON CenturyLink Center Omaha US

AUGUST anxiety-producing and exhausting experience for those with mental health problems. As night-time is often associated with an increase in disorientation and confusion, the same can occur when the lights go out during long inter-continental flights: a previously stable patient can become disturbed, or refuse the medication that they have previously been taking without complaint. For this reason, Healix International uses two escorts when repatriating patients with mental health issues â&#x20AC;&#x201C; usually a doctor and a nurse. 52 52

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diffuse the situation as quickly as possible. The need to create a calm and unpressured environment also justifies upgrading patients with mental health issues to business class for the repatriation. And whilst having a patientâ&#x20AC;&#x2122;s relative sitting with them can sometimes be helpful, it can also sometimes be a hindrance, depending on the state of the relationship. It is vital, therefore, to assess whether the loved-one should be upgraded with the patient or not to ensure a successful journey home.

AAMS Safety Management Training Academy Pittsburgh US

NOVEMBER

4-6

Air Medical Transport Conference 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

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

aeromedevac.com

+1 619 754-6755

aeiamericas.com

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

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

AIRMED&RESCUE

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

Jet-Rescue Air Ambulance +33 141 72 1414

medic-air.com

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

+1 786 619 1268

medjetsUSA.com

Skyservice 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

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

+1 514 497 7000

skyserviceairambulance.com

Latitude Air Ambulance Diana Iaquinto

Director Sales & Medical Ops

John C. Munro/Hamilton International Airport, 9300 Airport Rd. Mount Hope. Ontario, L0R IW0, Canada tel: +1

ASSOCIATIONS

fax: +1

289 426 1133 289 426 1132

email: 24.7@latitude2009.com website: www.latitude2009.com

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

tel: +(703)

836-8732 fax: +(703) 836-8920

website: www.aams.org

MEDICAL ESCORT ON COMMERCIAL AIRLINES

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

Graham Williamson CEO

VANCOUVER – TORONTO – HONOLULU

4835 Riveredge Cove, Snellville, GA 30039, USA website: www.iafccp.org

fax: +770-979-6500

tel: +1 fax: +1

250 947 9641 877 288 2908

email: graham.williamson@LifeSupportTransport.com

website: www.LifeSupportTransport.com

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

Gateway International EMS +1-202-499-2294

globalmed-international.com

LIFESUPPORT Patient Transport

Executive Director

GROUND TRANSPORT - MEDICAL

+49 6742 897 425

Auf Roedern 7c, 56283 Pfaffenheck, GERMANY

Monica Newman

600 Pennsylvania Ave SE, Washington DC, 20003, USA

air-ambulance.com

GlobalMed International

IAFCCP

tel: +770-979-6372

+352 26 26 00

+662 247 3392

medicalwings.com

Prime Nursing Care, Inc. gateway-ems.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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