AirRescue Magazine 1-2011 by Verlag Stumpf & Kossendey

EASA-OPS

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

ERC-Guidelines Applied in Practice

Medical Care & Air Rescue Hygiene Strategies

Fixed-Wing Operations Repatriation from Japan

ISSUE 1 | Vol. 1 | 2011/4

life energy

corpuls3 – developed for highest demands • Modular concept offers unrivalled ergonomics • Time saving handling – simple application • Practically tested system solution corpuls3 has been developed for the exacting conditions and high demands in air medical situations. System meets RTCA DO 160 F and MIL STD 810 F requirements.

L CA

TECHNOLOG Y

ANY

ME DI

GS Elektromedizinische Geräte GmbH · Hauswiesenstraße 26 · 86916 Kaufering - Germany Tel. +49 8191 65722-0 · Fax +49 8191 65722-22 · info@corpuls.com · www.corpuls.com

E M A D E IN G

EHAC

E di tori a l Dear AirRescue Reader, Voilà. This is the birth of EHAC’s new magazine AirRescue. It is designed for HEMS and air ambulance operators, the relevant aviation industry, and their crews, staff and all interested people in professional aeromedical services. We have teamed up with our new partner S&K Publishing to continue the association’s communication strategy. As every birth is a difficult process, also the new team had to stand and overcome some difficulties in April. But, as you know: April showers bring May flowers. I am excited about this first issue and hope so are you. The teamwork between S&K Publishing and EHAC has been on a very high professional level paired with bilateral understanding and respect. Altogether that is a very good basis for the future – both for the parents EHAC and S&K Publishing as well as the newborn magazine AirRescue. In times like these it is very important for EHAC to be able to raise the voice. And it is and always will be the voice of the professional European HEMS and air ambulance operators. They strive for better and safer conditions in their industry while focusing a steady improvement of the emergency patient’s outcome. AirRescue Magazine will be a platform for all occupational groups – pilots, doctors, flight technicians, paramedics and nurses, CEOs and other management as well as maintenance staff.

1 · 2011 I Vol. 1 I AirRescue

We will carefully monitor the activities of the implementation of the new EASA-OPS. And we hope that EASA has considered the submitted comments of the HEMS industry as they are vital to our operations. We have not claimed exemptions to reduce safety, and we do not have claimed exemptions to make more profit. We have claimed exemptions to continue with our HEMS operations – at the same level of safety and reliability as today here in Europe. Confidence comes from our meetings with EASA officials that it is not EASA’s intention to curtail HEMS operations. They know that EHAC members operate on a high safety level and that we aim at improving safety, both patient and flight safety! We will continue our so far successful cooperation with EASA and politicians to achieve that goal – for you and the patients in Europe. And AirRescue Magazine will be the link between you, EHAC and the European authorities and institutions. We at EHAC look forward to your appreciated feedback and hope you enjoy the first issue of AirRescue.

Yours, Christoph Breitenbach President of the European HEMS & Air Ambulance Committee

4 | CONTENTS

AirRescue

International Air Rescue & Air Ambulance

ISSN: 2192-3167 Publisher: L. Kossendey Verlagsgesellschaft Stumpf & Kossendey mbH Rathausstraße 1 26188 Edewecht Germany service@skverlag.de Tel.: +49 (0)4405 9181-0 Fax: +49 (0)4405 9181-33 www.airrescue-magazine.eu Medical Advisor: Dr Erwin Stolpe Medical Director EHAC Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: poguntke@airrescue-magazine.eu Editors: Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: frieling@skverlag.de Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: bader@skverlag.de Marketing · Advertising · Subscription Ch. Niemann Tel.: +49 (0) 4405 9181-16 Fax: +49 (0) 4405 9181-33 E-Mail: sales@airrescue-magazine.eu Subscription Rate: Europe: 35  (Shipping included) World: 40  Price per Issue: 9  (Shipping not included) Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF

Dear Readers, Any attempt to address all the people working in air rescue all over Europe – and in some cases, even all over the world – within a single journal is an ambitious one. But this is something we at Stumpf & Kossendey Publishing will strive to do. We are proud that EHAC has entrusted us to produce its official publication and hope that this issue of AirRescue contains something of interest to everyone involved in air rescue: doctors, paramedics, pilots, technicians, air rescue organisations, industry, and public authorities active in the field. AirRescue is not intended as a platform for airing rigid opinions, instead we want it to serve as a forum for open discussion and to be an information source on emergency medicine, aviation technology and the legal issues surrounding air rescue. Stumpf & Kossendey Publishing has decades of experience in the field of emergency rescue. With the help of a large number of specialist authors, for over 30 years Stumpf & Kossendey has been publishing the journal RETTUNGSDIENST (“Emergency Medical Service”), one of the bestselling German-language publications on pre-hospital emergency medicine. Since its first edition, RETTUNGSDIENST has featured regular reports on the development of air rescue in Germany and other countries in Europe. We also publish the journals IM EINSATZ (“On Duty”), mainly targeted at those working in rapid deployment units and the emergency services, and 112 MAGAZIN (the German emergency telephone number), which specialises in fire fighting. We are delighted that we are now able to publish a journal dedicated to air rescue and are especially pleased to be presenting the first edition of AirRescue at an event as prestigious as AIRMED 2011. We will be grateful for any feedback on our work. The members of our editorial team attending AIRMED would also be happy to speak to you in person. We hope you enjoy reading this brand-new publication! Yours Peter Poguntke, Editor-in-chief

Production: Bürger Verlag Oldenburg GmbH & Co. KG Rathausstrasse 1 26188 Edewecht | Germany

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

1 · 2011 I Vol. 1 I AirRescue

CONTENTS | 5 The ERC-Guidelines 2010: Implementing them in air ambulance services

Compliance with the guidelines are ensured at the at the large air ambulance organisations through qms.

Air ambulance flight to Japan

Japan was hit by an earthquake off the eastcoast – followed by a tsunami – on 11 March 2011. Swiss air rescue service Rega carried out a repatriation flight from the northeastern part of the island nation.

Cover Image: DRF Luftrettung

06 12 20 26 33

News Developing a comprehensive hygiene strategy for ADAC Air Rescue: looking back Case Report

It all began with a tourist from Greece – fixed-wing operator Tyrol Air Ambulance

A step into the future for Polish Medical Air Rescue

With a complete fleet of EC135 and a flight simulator, Polish Medical Air Rescue is ready to face new challenges. At the end of 2010, a new era of air rescue began.

Are unapproved hospital landing pads putting airborne emergency medical services at risk? Draft amendment to the German Air Traffic Act must be improved

Comments by EHAC on the planned EASA-OP

EVENTS EHAC Aeromedical Crew Resource Management (ACRM) Workshop

May

Brighton, UK

Air Medical Physician Association (AMPA) Symposium

May

Brighton, UK

AIRMED

May

24-27

Brighton, UK

Paris Air Show

June

20-26

Le Bourget, France

23rd Scientific Meeting of the Aeromedical Society of Australasia

August / September

31-03

Perth, Australia

Aviation Expo

September

21-24

Beijing, China

Helitech

September

27-29

Duxford, UK

Air-Medical Transport Conference (AMTC)

October

17-19

St. Louis, USA

International Helicopter Safety Symposium (IHSS)

November

8-9

Fort Worth, USA

1 · 2011 I Vol. 1 I AirRescue

Eine deutsche Ausgabe des AirRescue Magazine finden Sie als e-paper unter: www.airrescue-magazine.eu

6 | NEWS Challenging mission to save two heli pilots – Rescue at 2,300 metres nally manage to land, the pilots had to be cut from the wreckage using heavy machinery. Six hours later, when the two pilots were finally freed, the Rega team flew them to hospital. Joller reported that the pilots’ delayed rescue and prolonged exposure to the winter weather caused them to come down with hypothermia. However, despite the fact that they also broke several bones, their lives were never in danger. The accident took place during a course training for pilots to fly the new Cougar helicopters. The helicopter in question took off at 1:50 p.m. from Alpnach in the canton of Obwalden. It made the emergency call to Rega at 3:45 p.m. But it was another two hours before a rescue helicopter could land at the accident site. The Cougar helicopter involved in the crash is a further development of the Super Puma. The Swiss air force has 27 Super Puma and Cougar helicopters, each of which can carry up to 18 passengers or a fourtonne load. The rest of the wreckage has now been brought down from the mountain. Because of its weight, it had to be transported down to the valley using the largest helicopter in operation in Switzerland, a Kamov KA 32 from the company Heliswiss.

M. Lehmann

On the afternoon of 30 March 2011, two military pilots lay trapped and seriously injured after their Cougar military helicopter crashed in the Maderanertal valley in the Swiss canton of Uri. As the on-board loadmaster was only slightly injured, he was picked up and flown to a hospital around 6 p.m. Later, Rega emergency doctor, Sonja Joller, was deposited at the accident site to care for the two pilots until the air ambulance helicopter could rescue them. The two seriously injured pilots, a commander and his trainee, were trapped in the wreckage of their helicopter, which had crashed in deep snow 2,300 metres above sea level. Their rescue was further complicated by adverse weather conditions. According to Bernhard Müller, Chief of Air Force Operations, a compact layer of cloud and hanging fog greatly impeded the rescue mission by making it almost impossible for a rescue helicopter to land at the accident site. Once it did fi-

Slovakian Air Transport Europe celebrates 20th anniversary The only Slovakian Air Rescue operator ATE (Air Transport Europe), based in the city of Poprad, celebrated its 20th anniversary on 12 May 2011. Numerous guests from the European air rescue sector attended the celebration, held in the congress hall of the Aqua City Business Centre in Poprad. Besides a press conference at 11 a.m., flight demonstrations of ATE machines were part of the programme. Viliam Krivák, director of ATE, commented: “We are very proud of what we have accomplished during the past two decades and are glad to celebrate these achievements with our guests.” For more information, visit: ››› www.ate.sk

iRega app saves injured paraglider pilot’s life – Casualty found 60 km from originally reported position

For more information, visit: ››› www.lw.admin.ch

Rescue helicopter to be based in Augsburg – Optimising air rescue in Bavaria

H. Scholl

As reported in the German newspaper Augsburger Allgemeine of 6 April 2011, following lengthy discussions, the Bavarian Ministry of the Interior has decided to set up a new air rescue centre at the Klinikum Augsburg hospital. The aim is to optimise rapid air rescue in the region of Bavarian Swabia. According to Minister Joachim Herrmann (CSU), notification was already sent to the Zweckverband für Rettungsdienst- und Feuerwehralarmierung (communal firefighting and EMS authority) Augsburg last Tuesday. The fact that Klinikum Augsburg is the only full-service hospital in Bavarian Swabia played a decisive role in the choice of location. Furthermore, the hospital has wider regional importance, treating patients across the region. On top of that, Klinikum Augsburg is an academic teaching hospital for the University

of Munich. It has some 1,750 beds and a large number of specialised units. The new base is in southern Bavaria, around 60 kilometres northwest of the Bavarian capital, putting it between the “Christoph 1” Air Rescue Centre in Munich and “Christoph 22” in Ulm. The ministry also aims to optimise air rescue in Northern Bavarian Swabia and the southern part of Middle Franconia, where cooperation with the state of Baden-Württemberg is important. In Augsburg, planning will begin as soon as possible on setting up the necessary base equipment on the roof and initiating the call for tender for a suitable operator so that flights and deployments can commence promptly. However, the choice of location remains very controversial. While the people of Augsburg were clearly pleased about the decision, the head of the district authority of Donau-Ries, Stefan Rößle (CSU) expressed his disappointment. He would have much preferred the new rescue helicopter, the 14th in Bavaria, to be stationed in the area where Eurocopter Deutschland is also based, i.e. Donauwörth. He stated his intention to continue lobbying for the location although it is no longer possible to make any appeal against the Interior Ministry’s decision. (Scholl)

Rega

Late in the afternoon on Saturday, 16 April 2011 a downed paraglider pilot dialled 1414 to call Rega, the Swiss air rescue service. He reported that he had crashed with his orange paraglider in Sapün in the Swiss canton of Grisons. Soon after, a rescue helicopter set out from the base at Untervaz and headed for the reported accident site. Upon their arrival, however, the Rega crew could see no sign of the paraglider. While they searched in vain from the air, the Rega operations centre remained in phone contact with the injured man. They encouraged him, despite his serious injuries, to download the free iRega application onto his iPhone and to send out a new alert. This provided the helicopter crew with the exact coordinates they needed to finally discover him. It turned out that the pilot was actually 60 km from the location he had originally reported, not in Sapün but in Waltensburg near Ilanz. The man could not remember his exact position when he crashed as he was suffering from shock, as well as serious pelvis injuries. For more information, visit: ››› www.rega.ch

1 · 2011 I Vol. 1 I AirRescue

NEWS | 7 Air rescue experts meet at annual DRF conference in Freiburg The tenth annual DRF Luftrettung medical conference took place in early April 2011 in the southern German city of Freiburg. Around 100 emergency doctors and rescue assistants, as well as representatives of the German police service’s air rescue stations and the ADAC Air Rescue attended. The event provided medical personnel with a forum for discussing emergency medical care issues and creating important guidelines for their work. Dr Monika Stolz, Baden-Württemberg’s Minister for Work, Social Affairs, Families and Senior Citizens, opened the conference and praised the DRF’s efforts to set up a 24-hour air rescue station, which will provide nightime intensive care transport in the state of Baden-Württemberg. DRF Luftrettung’s Medical Director Dr Jörg Braun and Chairman Steffen Lutz then took to the stage to report on the DRF’s latest organisational developments and medical projects, such as intensive care helicopters and the new ventilation machine for air ambulance aeroplanes. They also announced further training opportunities for medical personnel, including 16 simulator courses, six obligatory HCM sessions, six PHTLS courses and two modules in rescue technique. In his speech, Dr Wolfgang Lenz, Medical Director of the Main-Kinzig-Kreis rescue service, reported on the current status of the BoLuS study, a system-wide interface analysis of ground and air emergency medical services in Hesse. Psychological and social support for rescue crews involved in particularly upsetting or stressful missions was also discussed. On the second day of the conference, Dr Nina Eulitz, senior physician for palliative medicine at the Rotes Kreuz Krankenhaus Kassel, discussed difficult air rescue scenarios in her talk

on how best to treat palliative patients. Next on the agenda were talks on multidrug-resistant infections and hygiene management. Dr Marcus Roessler, chief physician at Göttingen air ambulance station, concluded the event with a summary of the new resuscitation guidelines issued by the European Resuscitation Council in 2010. He also gave details of recent experiences of their implementation. Dr Mark Frank, chief physician at Dresden air ambulance station, talked about the advantages and disadvantages of using mechanical resuscitation in a helicopter. The new guidelines aim to improve the quality of cardiac massage to increase the chances of successful resuscitation. Roessler believes that mechanical systems can provide medical teams with valuable assistance in situations where CPR is required.

DRF Luftrettung

For more information, visit: ››› www.drf-luftrettung.de

New Mission Management: “Sky Commander” GENA Systems has launched a new moving map system. According to the Austrian company, the system for moving map display is small, light and user-friendly. The “Sky Commander” integrates several aspects relevant to SAR: Moving map, Flight following and Control Centre modules are provided in a single unit. Furthermore, the easy-to-use interface helps to improve situational awareness. It also features multilayer mapping, which can be switched at the pilots’ convenience. The control knobs and push button around the display combine to form an easy input interface for entering data. GENA states that one of the striking features is the automatic update function of the waypoints – without any need to enter it manually. With the provision of Iridium connection, the fleet can be managed worldwide. Hence, the mission can be uploaded to the selected helicopter through control centre or simple USB-interface. The “Sky Commander” processes the data received from

1 · 2011 I Vol. 1 I AirRescue

the control centre and automatically indicates the waypoints to the target and thus, reducing the pilots’ workload. In addition, the mission control centre is always up-to-date with the status and position of its helicopter fleet and this allows for a more efficient fleet management. “Sky Commander” features transreflective, sunlight readable, anti-reflective surface 5.7” color display, internal memory of 2 GB, expandable up to 160 GB, 1 VGA and USBinterface, up-to-date Jeppesen Navdata, Multilayer Map system, online/USB mission update, automatic online obstacle management and waypoint management update through control centre, display of text messages from control centre, Iridium-2way messaging, fleet management, RTCA DO 160F qualified, communication via Iridium satellite phone is also possible. For more information, visit: ››› www.gena.at

Heli-Expo 2011 Breaks Record International Helicopter Safety Team Initiative signed

EHAC has initiated a commitment letter of the world’s major HEMS organisations. On behalf of EHAC, Board Member Dr Erwin Stolpe has signed the commitment letter at the meeting of the International Helicopter Safety Team (IHST). FLTR: Erwin Stolpe (EHAC), Rex Alexander (NEMSPA), Daniel Hankins (AAMS), Kevin Hutton (MFI), Howard Ragsdale (AMOA), Thomas Judge (ACCT)

The 2011 Heli-Expo by the Helicopter Association International (HAI) saw a record attendee and exhibitor numbers, indicating a strong performance by the rotorcraft industry during 2010. According to the HAI, attendance reached more than 20,000 and exhibitors totaled 625, up from 15,243 attendees and 596 exhibitors in 2010. More than 50 helicopters were on display, exhibitors and vendors filled around 93,0000 m2 of exhibit hall and meeting space at the Orange County Convention Center in Orlando, Florida. A private heliport at the convention center helped manufacturers to provide more than 90 demo flights during the exhibition, some 39 helicopters flew into the convention center. In addition to the usual committee meetings, safety classes, the job fair and manufacturer briefings, an official commitment signing ceremony – initiated by the EHAC – was held on 6 March 2011, in which a number of organizations signed on to the International Helicopter Safety Team Initiative. These included the Association of Air Medical Services, Air Medical Operators Association, Association of Critical Care Transport, MedEvac Foundation International, National EMS Pilots Association, Aeromedical Society of Australasia and European HEMS and Air Ambulance Committee (EHAC). Heli-Expo 2011 is solid proof of the international helicopter community’s strength, which is built on the helicopter’s ability to meet the diverse needs of society, said HAI president Matt Zuccaro. Next year’s show will be held from 11 to 14 February in Dallas, USA. For more information, visit: ››› www.rotor.com

Make your ad space reservation for the upcoming

AirRescue International Air Rescue & Air Ambulance

Deadline: 15 July 2011

8 | MEDICAL CARE

Fig. 1: CPR is part of normal day-to-day operations for air ambulance services, such as DRF Luftrettung, which recorded 429 cases of initially successful CPR in 2010 (Photos: DRF Luftrettung)

The ERC-Guidelines 2010: Implementing them in air ambulance services Over 350,000 people in Europe die from cardiac arrest each year, even when CPR has been initiated. That’s 1,000 people every day (1, 2). The annual incidence of cardiac arrest in Germany is between 35 and 40 per 100,000 population. In cases where CPR is initiated, around 10 to 50 percent of patients have return of spontaneous circulation (ROSC). But only between 2 and 10 percent of these patients survive without suffering any significant neurological deficits. CPR is part of normal day-today operations for air ambulance services (3). DRF Luftrettung, for example, recorded 429 cases of initially successful CPR at its 28 locations in Germany in 2010. That equates to some 2 percent of all emergency procedures in that year. Shockable rhythms were identified in 20.5 percent of cases, and air ambulances transported 37.3 percent of those patients to appropriate medical centres. Defibrillation

Chest compression

The ECG in around 60 percent of cardiac arrest patients initially shows ventricular fibrillation. This means that, if indicated, rescuers should start defibrillation as soon as possible. Almost all air ambulance organisations in Germany use biphasic defibrillators. Comprehensive tests carried out with defibrillator and helicopter manufacturers revealed electromagnetic compatibility for the models used, meaning that medical teams can administer defibrillation during a flight if necessary. Only using adhesive electrodes makes the procedure more effective and safe for patients while also improving safety for rescuers. Thus, we must now consider as outdated the view (still widely held) that patients who are suffering or who have just suffered a cardiac arrest cannot be transported by air.

Providing continual chest compression and artificial respiration to maintain minimal circulation are the most crucial factors in ensuring patient survival. Thus, the 2010 Guidelines for Resuscitation place particular importance on effective chest compression, provided at a frequency of 100 to 120 compressions per minute with a depth of 5 to 6 cm for adults. There are numerous case reports of patients, particularly those who suffered hypothermia, being released with excellent neurological outcomes after rescuers performed effective manual chest compressions on them during extended helicopter journeys. However, it remains unclear whether we can achieve similar results in all transport situations with in-flight resuscitation in all models of helicopter. Because the important role that

1 · 2011 I Vol. 1 I AirRescue

MEDICAL CARE | 9 air ambulance services play in serving rural areas is increasing, it is very likely that the numbers of cases where medical teams have to resuscitate patients during the flight to a cardiology clinic will also increase. Mechanical resuscitation devices have the advantage of ensuring that patients receive safe, effective chest compressions even under difficult transport conditions, during loading and unloading, etc. They leave medical teams free to monitor (the devices) and to focus on other logistical matters. Such devices are already in routine use in some air ambulance aircraft. However, space constraints in air ambulance helicopters and the weight of current devices make it difficult for air ambulance services to make full use of the technology.

Ventilation and oxygen If an endotracheal tube or a supraglottic airway device has been used to secure the airway, the guidelines say that rescuers should try to deliver continuous chest compressions during ventilation. Because manual ventilation often causes the patient to hyperventilate, medical staff should try to use automated ventilation devices as soon as possible. Capnography should always be used to monitor tube placement and ventilation. If peripheral oxygen saturation can be reliably measured, rescuers should adjust inspiratory oxygen concentration so that the SpO2 values are between 94 and 98 percent. All air ambulance stations in Germany have access to suitable portable respirators and can perform capnography monitoring.

Medicines and methods of application The ALS algorithm recommends giving adrenaline (1 mg IV or IO) every 3 to 5 minutes. The new guidelines state

that rescuers should give amiodarone (300 mg) after the third shock. If the patient is still in ventricular fibrillation or pulseless ventricular tachydardia after the third shock, rescuers can consider giving another dose of 150 mg

SUBSCRIBE NOW!

Fig. 2: Mechanical resuscitation devices have the advantage of ensuring that patients receive safe and effective chest compressions – even under difficult transport conditions (Photo: Zoll)

1-year subscription 2-year subscription 8 issues – 55 €* 4 issues – 30 €*

www.airrescue-magazine.eu/subscribe

1 · 2011 I Vol. 1 I AirRescue

10 | MEDICAL CARE

Fig. 3: All air ambulance centres in Germany can effectively implement the new ERC-guidelines due to medical qms (Photo: P. Knacke)

amiodarone. Thrombolytic therapy has proven effective during CPR in patients suffering acute pulmonary embolism and in patients suffering ST-elevation myocardial infarction (STEMI) when a percutaneous coronary intervention (PCI) cannot be performed in the near-term. Air ambulance aircraft in Germany are equipped with the same medicines as ground-based ambulances operated by emergency doctors. This means that crew members have access to all medicines that might be required for resuscitation. Alongside intravenous administration, the new guidelines place greater focus on intraosseous infusion. They no longer recommend administering drugs endobronchially. The DRF Luftrettung’s entire helicopter fleet uses the EZ-IO system because it is extremely reliable and very easy to use.

The post-resuscitation phase – mild hypothermia Cooling comatose patients to between 32 and 34°C as soon as possible following ROSC can improve treatment outcome. To date, no single cooling method has been proven to be superior to any other. Cold infusions (4°C) are particularly suited to preclinical applications, because giving 30 ml/kgKG cold NaCl solution or full-electrolyte solution can reduce core body temperature by around 1.5°C (4). All HEMS bases in Germany have the equipment necessary for continuously measuring core body temperature. Although the EN 13718-2 standard stipulates that all air rescue helicopters and intensive-care helicopters should have a refrigeration compartment, only newer helicopter models currently offer compressor-driven cooling systems. The main problems are a lack of space, the weight of the systems and the costs of approval in line with aviation law. A cost-effective, transportable solution

is a mobile passive cooling system of the kind that has been successfully used for transporting blood for years.

Summary The Guidelines for Resuscitation published by the European Resuscitation Council on 18 October 2010 more precisely define some of the 2005 measures and pay particular attention to the quality of chest compression, early defibrillation and therapeutic hypothermia. In principle, all air ambulance centres in Germany can effectively implement the new guidelines. The medical quality management systems in place at the large air ambulance organisations ADAC Air Rescue and DRF Luftrettung monitor and ensure compliance with these guidelines. 

Author: Jörg Braun Head of Medical Department, DRF Stiftung Luftrettung gemeinnützige AG, Rita-Maiburg-Str. 2, 70794 Filderstadt, Germany

References: (1) Böttiger B (2011) Hauptsache heftige Herzmassage. Editorial Notfallmedizin up2date 6:1 (2) Nolan JP, Soar J, Zideman DA et al. (2010) European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 81: 1219-1276 (3) European Resuscitation Council (2010) Guidelines for Resuscitation 2010: www.erc.edu. (4) Braunecker S, Fischer M, Böttiger BW (2011) PostReanimations-Phase – neue Leitlinien. Notfallmedizin up2date 6: 53-60

1 · 2011 I Vol. 1 I AirRescue

It was a good day… …thanks to C-MAC®

ry a s r e v i s Ann ope

r c 10 yea H Video Laryngos OS

AN 25/E/10/09/A

T MACIN

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

12 | MEDICAL CARE

Fig. 1: Of the vast number of standards that exist, very few apply specifically to air ambulance services, which are left to lead a “miserable existence” when it comes to hygiene (Photo: A. Rippe)

Developing a comprehensive hygiene strategy for ADAC Air Rescue: looking back All those who participated in the first meeting of the Hygiene working group at ADAC-Luftrettung can still clearly remember the event. It brought together a leading helicopter doctor and doctor of hospital hygiene, three HEMS crew members (HCMs) who are certified disinfectors, a HCM and expert in social welfare and healthcare, and as project manager, an anaesthesiologist. Their task was to develop a new hygiene strategy that was tailored to fit the specific requirements of the organisation. Filled with enthusiasm and armed with a wide range of specialist literature, they set about achieving their goal. But they were soon brought down to earth with a bump. The issue of ventilation was the first to be singled out. This is a key field of operations, with over 4,000 patients being treated with the measure each year on ADAC helicopters alone. However, it was not possible to fully answer all the related hygiene questions, which included: • What filter is best suited to work on air ambulance helicopters and intensive-care helicopters? • How can multi-use tracheal tubes be uniformly certified for 32 air rescue centres in 15 states in Germany, and how can they be sterilised in an economical and environmentally friendly manner?

• How long can a tracheal tube connected to a ventilator be used without actually performing ventilation? • If the tracheal tube is supposed to be changed after every patient, what is the point of using the filters?

These questions on ventilation were temporarily forced into the background as a number of fundamental questions suddenly arose that the participants considered to be of much greater importance:

1 · 2011 I Vol. 1 I AirRescue

MEDICAL CARE | 13

Fig. 2: In addition to protecting patients, it is also very important to ensure that staff are protected. One key way of achieving this is by implementing comprehensive hygiene measures (Photo: A. Rippe)

• What normative standards are applicable here? • Are there federal, state or regional standards that go beyond these that also must be observed? • What developments can be expected in the coming years and to what extent can these be taken into account today? • What are other organisations doing? • What must be taken into account and implemented to ensure that staff and patients receive optimal protection?

In this context it must be mentioned that the group’s research found 38 standards – including the Infection Protection Act, the Drinking Water Ordinance, guidelines from the Robert Koch Institute (RKI) and technical regulations – which, depending on the possible development or implementation of measures in the hygiene strategy, would also be brought to bear to a greater or lesser extent. It is striking that, despite the enormous number of standards, only very few are usable by or offer guidance to emergency medical services, much less to air medical services. While the standards offer extensive descriptions of hygiene measures for hospitals, doctor’s surgeries, laboratories and even veterinary surgeries, emergency medical services are hardly mentioned and are left to lead a “miserable existence” when it comes to hygiene. The ADAC Air Rescue working group therefore had to pose the important question: Where does ADAC Air Rescue fit

1 · 2011 I Vol. 1 I AirRescue

Fig. 3: Sterilisation procedures being performed with safety goggles, nitrile gloves and disposable wipes. The aim is to maintain an acceptably high standard in regard to hygienic precautions (Photo: A. Rippe)

into the institutions mentioned above and where would it like to see itself, particularly with regard to the patients it treats? In line with regulations, land and air emergency medical services are responsible for prehospital care which, as shown in the table, operates in too many different locations to allow for just a basic hygiene strategy. However, a full hygiene strategy is expensive, potentially impracticable and highly complex. If we want to aspire to the high standards in place at hospitals, we have to consider what measures need to be implemented and maintained, how much these would reduce the ability of emergency medical staff to do their job, and the additional costs that implementing the measures would entail.

Table 1: Rescue resource points of contact

Rescue resource

Task

Pick-up locations

Drop-off locations

Air ambulance helicopter / (ambulance)

Emergency medical care Secondary care (urgent & immediate)

Incident scenes, accident scenes, homes, nursing homes, doctor’s surgeries

Hospitals: A&E or resuscitation room

Intensive-care helicopter / (intensivecare ambulance)

Secondary care

Hospitals: intensivecare wards

Dual-use system

Intensive-care helicopter, also used as an air ambulance helicopter

See air ambulance helicopter and intensive-care helicopter

14 | MEDICAL CARE After answering the questions this raised, the group was able to at least lay the foundation for ADAC Air Rescue’s future hygiene strategy: “All our activities are focused on the patient. All procedures performed on patients before, during and after air transport must serve the ultimate goal of helping patients, alleviating their suffering and protecting them from greater danger or death. The medical products in use must be able to meet this challenge and must also provide consistent, high quality.” (1) Those providing emergency medical services can never know what their next call-out will entail. Thus it is all the more important to maintain high standards in regard to hygienic precautions, specifications for the transport of infectious patients and the medical care provided in general, both for the sake of patients and the sake of the staff. The protection of staff is based on two pillars: Pillar I: Training and advanced training in hygiene Pillar II: High-quality materials and devices

Pillar I The position of “hygiene manager” (2) was established as an active link between the air ambulance station and the hygiene commission and to provide special training for the staff at the air ambulance stations. The International Red Cross guidelines for hygiene and the prevention of infection in hospitals recommend that all hospitals instate hygiene managers. It should generally be a permanent position held by a very experienced, high-ranking doctor in a permanent position, since such people are in a better position to convince management to make the expensive and sometimes unpopular decisions that implementing hygiene standards can involve. “A hygiene manager shall be appointed for each air ambulance centre from among the group of active HEMS Crew Members. The hygiene manager shall primarily be responsible for ensuring that the respective air ambu-

lance centre implements and complies with the guidelines set out in the ADAC-Luftrettung Hygiene Manual. Hygiene managers will receive the necessary training in a 40-hour basic course and in annual advanced training seminars.” (3)

Why no disinfector training? Each federal state in Germany organises disinfector training differently, often with little regard for the target groups. And at 160 hours, a course is very time-consuming and cost-intensive. This means that it provides only a limited basis for the targeted development of the necessary knowledge and skills. Furthermore, none of the disinfectors participating were in favour of disinfector training because they feel that it lacks any relevance to operational reality. Rather than working at an air ambulance station, those responsible for disinfection are more likely to be performing their tasks within the hygiene commission. They do not need the comprehensive theoretical knowledge of a certified disinfector; they need to be able to successfully set up and run a strict hygiene strategy that applies to all occupational groups in their area of responsibility. Their training focuses on practical principles and on teaching implementation strategies for operations at air ambulance stations. The content for the RKI hygiene manager course (3) teaches the following: • Legal and normative standards for hospital hygiene • How to recognise and combat hospital infections • Tasks of the hygiene commission and its members • Specific methods of preventing staff from suffering work-related damages (such as infections) • Waste disposal

Hygiene managers work with head helicopter doctors to decide on continuing hygiene training at the respective air ambulance station. They must arrange at least two hours

Fig. 4: Training for hygiene managers, which are responsible for ensuring the implementation of and compliance with the guidelines set out in the ADAC Air Rescue Hygiene Manual (Photo: ADAC Air Rescue)

Fig. 5: Disinfection and protective measures cannot succeed without staff acceptance (Photo: A. Rippe)

Fig. 6: Because disinfectants can cause changes in materials, aircraft manufacturers must approve all such products (Photo: A. Rippe)

1 · 2011 I Vol. 1 I AirRescue

MEDICAL CARE | 15 of training each year. In addition to training on hygiene issues, all active staff at an air ambulance station must receive instruction on working with the appropriate cleaning agents and disinfectants. (4)

Pillar II Disinfection and protection measures, cleaning agents and detergents, supplies and algorithms can only be effective if HEMS crew members accept them. Right from the start of the project, ADAC Air Rescue worked hard to develop this acceptance. In addition to the basic values described at the beginning, the work was guided by two mottos, which still apply today and will continue to do so in future: “By colleagues for colleagues” and “Keep it simple”. Achieving this goal involved the group continually questioning its own work and aligning it with the everyday, routine situations that air ambulance services encounter. This enabled them to identify and correct undesirable developments at an early stage. Another advantage of this approach was that active air ambulance staff recognised members of the working group and the hygiene commission as “active air rescuers”. This helped to considerably increase acceptance of the new practices. Deciding early on to only focus on the essentials of air ambulance work also helped ensure that the hygiene strategy could ultimately be established successfully. With these conditions in place, the actual work began. Topics were distributed as tasks. The members of the working group then prepared and edited them, producing documents as one might do a homework assignment. Because many topics exhibited parallels, informally exchanging information was a key part of participants’ work. At the workshops, members presented individual results to the team, who then discussed them as a group. The discussions resulted in new tasks, so the meetings were also about identifying and defining these tasks.

Insight into work practices It is important to select appropriate, certified companies for sterilising materials. Given the decentralised structure of ADAC Air Rescue in Germany, the group had to find companies that could take this into account. In addition to preparing materials (e.g. sterilising surgical instruments and disinfecting and cleaning uniforms), companies also had to be able to offer an effective nationwide logistics service. This was to ensure that they could quickly and reliably transport materials between each air ambulance station and call-out location. The group received some surprising responses to their enquiries: • “We (service provider) prepare the materials. You (ADAC Air Rescue) are responsible for arranging delivery...” • “Why not switch to single-use products? That’s why they’re there! Please don’t tell my boss that I said this.”

This opened up another chapter in the ADAC Air Rescue story: comparing multi-use and single-use products. The group had to examine and evaluate every new aspect this raised – from economic feasibility studies to staff acceptance, from procurement and storage to proper disposal in line with the provisions of the Federal/Länder Working Group on Waste (LAGA). The final result was that ADAC Air Rescue began using single-use products for almost all its medical supplies. This also meant that it could, to a large extent, do away with instrument (or immersion) disinfectant.

Which disinfectants can be used in the helicopters and how successful are they likely to be? Because cleaning agents and disinfectants can cause changes in materials, all products used in an aircraft must be approved by the aircraft manufacturer. In the case of ADAC Air Rescue, this is Eurocopter Deutschland GmbH,

Fig. 7: Control panel on dosing device for Incidur®, one of the disinfectants approved by the helicopter manufacturer (Photo: ADAC Air Rescue) Fig. 8: If disinfectants have to be used in conjunction with another agent, there is a risk that staff may confuse the products or use them in the wrong concentration (Photo: ADAC Air Rescue)

1 · 2011 I Vol. 1 I AirRescue

16 | MEDICAL CARE Module 1 Day 1

Module 2 Day 2

Day 3

Module 3 Day 4

Day 5

09:00 - 09:45

1.1.

Official opening and general remarks

2.1.

Variety of Disinfectants

3.1.

Infectious Diseases (pt. 1)

4.1.

Waste Management

5.1.

Final Exam

09:45 - 10:30

1.2.

General Introduction to Microbiology

2.2.

Variety of Disinfectants

3.2.

Infectious Diseases (pt. 2)

4.2.

Continuous Improvement

5.2.

ADAC Hygiene Strategy

10:30 - 10:45

Break

10:45 - 11:30

1.3.

General Introduction to Microbiology

2.3.

Infection Protection Act

3.3.

Infectious Diseases (pt. 3)

4.3.

Hand hygiene

5.3.

ADAC Hygiene Strategy

11:30 - 12:15

1.4.

General Introduction to Microbiology

2.4.

Medical Devices Act

3.4.

Infectious Diseases (pt. 4)

4.4.

Hand hygiene

5.4.

ADAC Hygiene Strategy

13:15 - 14:00

1.5.

General Introduction to Germs Reduction

2.5.

General and Special Infectiology

3.5.

Methods of Disinfection

4.5.

Documentation

5.5.

ADAC Hygiene Strategy

14:00 - 14:45

1.6.

General Introduction to Infection Protection and Epidemiology (pt. 1)

2.6.

General and Special Infectiology

3.6.

Hygienic standards at the air ambulance station

4.6.

Material Science

5.6.

ADAC Hygiene Strategy

12:15 - 13:15

Break

14:45 - 15:00

Break

15:00 - 15:45

1.7.

General Introduction to Infection Protection and Epidemiology (pt. 2)

2.7.

Occupational Health and Safety

3.7.

Airborne transportation of infected patients

4.7.

Training 4

5.7.

ADAC Hygiene Strategy

15:45 - 16:30

1.8.

Training 1

2.8.

Training 2

3.8.

Training 3

4.8.

Preparations for Exam / Recap

5.8.

ADAC Hygiene Strategy

16:30 - 17:00

1.9.

Concluding remarks

2.9.

Concluding remarks

4.9.

Concluding remarks

5.9.

End of training course

Table 2: Hygiene manager course timetable (Source: ADAC Air Rescue hygiene commission)

based in the town of Donauwörth. Previously approved products include Incidur® and Minutil® from Ecolab GmbH & Co. Ohg in Düsseldorf and Dismozon® pure from Bode Chemie in Hamburg. A large number of participants complained that Dismozon® pure has a highly unpleasant smell. It is important to take these kinds of complaints seriously, since a lack of acceptance might result in inconsistent use of the product. Both Ecolab products also share a serious functional disadvantage: Incidur® only has limited virucidal properties and must therefore be used in conjunction with a virucidal disinfectant like Minutil®. This brings with it not only the risk of confusing the two products, but also of using them in the wrong concentration – too high a concentration is dangerous for staff and can cause more radical changes in materials, while too low a concentration can reduce the efficacy of the disinfectant and thereby put patients and staff at risk. As a result, the search began for a new product that was approved for all operating areas. The group’s research and extensive evaluations identified Kohrsolin® extra from Bode Chemie as the product best suited to the field of application described here. It is an aldehyde-based surface disinfectant. In summer 2010 the Robert Koch Institute approved it as a virucidal disinfectant. An electronic dosing device protects patients and staff by making it impossible to use too high or too low a concentration. The finished solution is stored in a dispenser with single-use cloth wipes (X-Wipes® dispenser and wipes from Bode Chemie). If kept between +10°C and +25°C, it will remain usable for up to 28

days. Kohrsolin® extra was submitted to Eurocopter for approval about two years ago. It has yet to issue a final assessment and approval.

Preparing uniforms The many different branches of ADAC Air Rescue make it difficult to ensure that staff always have clean uniforms at the ready. What makes the situation even more challenging is that staff often have to change stations at short notice. The group had to find a system for preparing uniforms that took this into account. This involved weighing options for “uniform pools” against solutions that provided individual uniforms to each member on the team. After collaborating with external experts and taking the specific framework conditions into account, the group found that the best system was to give each station its own uniform preparation service. The only way to implement this concept was to use a disinfectant washing process. The washing machines have a program for chemo-thermal disinfection that runs at 60°C for 20 minutes, and they are also designed to handle the special detergent required for the process.

Combining “homework” tasks At the end of the development process, which lasted over a year, the working group had to consolidate around 30 thematic blocks and individual chapters from all nine members. This was not a matter of simply copying and pasting the individual texts into a single document. Rather, they took great care to bring them all into alignment and

1 · 2011 I Vol. 1 I AirRescue

18 | MEDICAL CARE • Changing to single-use tracheal tubes means the initial question is no longer relevant. • A tracheal tube can remain attached to a ventilator for a week at most. For the device tests and self tests, which are carried out each day before any call-outs, the same tube should be attached that will later be used on patients. Because this brings the tube into contact with ambient air, staff must assume that it is contaminated after a week and replace it with a new one (5, 6, 7, 8). • Tracheal tubes can be used for as long as a week because only HEPA filters are used. However, if a staff member fails to use a HEPA filter or uses an inferior filter, the tube must be changed immediately after treating the patient (5, 6, 7, 8). 

Fig. 9: Disinfectant concentration must be just right – too low and the solution will be ineffective, too high and staff will be at risk (Photo: A. Rippe)

transfer them into a single, unified format. The result was ADAC Air Rescue’s brand-new, comprehensive Hygiene Handbook, which the decision-makers of the organisation approved on 10 September 2009.

Why go to all this trouble? The “old” ADAC Air Rescue hygiene strategy was drawn up in 2001 and did not fully respond to the complex issues and demands of this area. The regulatory authorities attested to this on occasion. The option of amending the old hygiene strategy was considered but not pursued. It became clear very early on that a well thought out new strategy was often more effective than a patchwork of existing documents and procedures.

What are the next steps? Hygiene is an ongoing process that requires regular review and adaptation. New developments must be analysed and evaluated. New products have to be tested and assessed. And of course all defined processes must be checked and amended to ensure that they are suitable for everyday use. As a result, one-and-a-half years after it was created, the Hygiene Handbook’s first revision is on the agenda. It will not be the last revision.

Solving the ventilation questions The ventilation questions mentioned at the beginning should be answered for the sake of completeness, even though participants only dealt with them as a side issue.

The authors confirm that there are no conflicts of interest.

• There are various grades of filter available, the highest being HEPA filters. High efficiency particulate air filters are mechanical and deliver a retention efficiency of 99.9999%.

References: 1. ADAC-Luftrettung GmbH (2009) Handbuch Hygiene, Chapter 1.1. “Präambel”, Version 0, 10 September 2009 2. Robert Koch-Institut (2003) Richtlinie für Krankenhaushygiene und Infektionsprävention für Krankenhäuser. Chapter 5.3.5., “Hygienebeauftragter” 3. ADAC-Luftrettung GmbH (2009) Handbuch Hygiene, Chapter 2.5., “Hygienebeauftragter”, Version 0, 10 September 2009 4. Biostoffverordnung (BioStoffV) Section 12, of 27 January 1999, latest amendment 18 December 2008 5. Kranabetter R., Leier M., Kammermeier D., Krodel U. (2006) “HME-Filter versus patientenbezogener Wechsel der Beatmungsschläuche von Narkosegeräten”, Der Anästhesist 55 (5): 561-7 6. Kober P. (2007) Wechselrhythmen und Standzeiten von Medizinprodukten. Landesamt für Gesundheit und Soziales Mecklenburg-Vorpommern 7. Gerstner A. (2006) Einsparpotenzial durch geändertes Hygienemanagement in der Anästhesie. Bayerische Krankenhaus Gesellschaft (BKG) 8. Standzeit Einweg-Beatmungsschlauchsysteme in Verbindung mit einem mechanischen Bakterienfilter, Dräger Medical, Lübeck

Authors: Andreas Rippe ADAC Air Rescue, Munich, c/o Universitätsmedizin Mainz, Building 708, fourth floor, Langenbeckstr. 1, 55101 Mainz, Germany andreas.rippe@adac.de Maria von Nathusius ADAC Air Rescue, Munich Matthias Ruppert ADAC Air Rescue, Munich

Pædiatric Critical Care Transport. NETS - Sydney, Australia. Senior medical trainees in pædiatrics, paediatric emergency medicine, pædiatric intensive care or neonatology are invited to apply to train in emergency medical retrieval. Inter-hospital transport by road, helicopter or fixed wing of newborns, infants and children < 16 years. 6 or 12 month postings starting in January or July. Full details at NETS.org.au/employment.aspx

1 · 2011 I Vol. 1 I AirRescue

Towards a safer world

AgustaWestland at the forefront of SAR agustawestland.com

20 | MEDICAL CARE

Fig. 1: Helicopter, ambulance car and police near the scene (Photos: P. Knacke)

Fig. 2: The man had fallen to the ground from a height of almost three metres

Case Report Fig. 3: A graze resulting from the fall Fig. 4: The spineboard was used to transport the man

One afternoon in April 2011, rescue helicopter “Christoph 12“ (Eurocopter 135 T2i) and an ambulance car were sent on a mission to a nearby accident scene in a rural area. The helicopter crew consisted of a pilot, a paramedic (HEMS crew member) and an emergency doctor (an anaesthetist). The weather was good, the sun was shining; it was a warm spring day. A man had fallen to the ground from a height of almost three metres. Alarm The helicopter approached the site ten minutes after the alarm had been sounded. It was able to land close to the scene of the accident. The ambulance car had arrived about four minutes earlier.

Situation A man aged 68 had fallen from the shovel of an excavator raised around 2.5 metres from the ground. He was lying on sandy ground, close to a quantity of building timber. After performing emergency vaccinations, the paramedics correctly fitted a Stifneck™.

1 · 2011 I Vol. 1 I AirRescue

MEDICAL AIR MEDICINE CARE | 21 Fig. 5: An intravenous catheter was fitted to the man’s left arm without complication

Fig. 6: The man was kept constantly immobilised using a Stifneck™ and a spineboard

Integrated Training Centre for helicopter pilots, emergency doctors and rescue paramedics Case history and results The man had fallen onto some beams that were lying on the ground. His fall was witnessed by innocent bystanders. The man was not suffering from any A, B or C problems, but could not remember what had happened and felt nauseous. Bystanders reported that the man was unconscious for about four minutes. A swelling could be felt on the back of the patient’s head. Findings from the neurological investigation were normal. Blood pressure (140/90 mmHg), heart rate (62/min), and oxygen saturation (99%) were also normal. Electrocardiography revealed that the man had a pacemaker. The paramedic immobilised the man and then carefully turned him, discovering a graze on his back; the man felt pain in this region. The examination was carried out while using the spineboard to transport the man.

Therapy An intravenous catheter was fitted without complication to the man’s left arm to allow for the possibility of infusion (500 ml of Ringeracetat) and analgesia. After infusion of 0.15 mg of Fentanyl the pain lessened. The man was kept constantly immobilised using a Stifneck™ and a spineboard. The closest hospital (trauma centre) to the scene of accident is 10 km away. Before the ambulance set off, the crew communicated with the hospital by mobile telephone so that the accident and emergency department could prepare for the man’s arrival.

1 · 2011 I Vol. 1 I AirRescue

The ambulance car set off for the hospital 17 minutes after the helicopter had landed. It arrived at the hospital ten minutes later. There were no problems along the way. The emergency doctor provided ongoing documentation of the diagnosis and therapy.

Discussion Rescue helicopters are used for the emergency care and transportation of accident patients. In the case documented here, transportation over a long distance was not required; the medical team, including, most importantly, an emergency doctor, arrived within ten minutes. The main advantage of a rescue helicopter is that it is able to quickly transport medical crews and patients over longer distances, typically in rural areas. But, of course, space is limited on board the helicopters and noise levels are high. For example, it is almost impossible to carry out chest compressions without a mechanical device. The patient was not found to be suffering from any other injuries, although he did have concussion. Findings from radiographs and sonography were normal. 

Author: Peer G. Knacke Head of Department of Anaesthesia, Emergency and Pain Medicine, Sana Kliniken Ostholstein, Hospitalstraße 22, 23701 Eutin, Germany

Full Flight Simulators

Medical Training ADAC HEMS Academy GmbH Airﬁeld Bonn-Hangelar Richthofenstraße 142 D-53757 Sankt Augustin www.hems-academy.de

22 | FIXED-WING

Fig. 1: A member of the SHA-team was diagnosed with diverticulitis and flown home later by the Swiss air rescue service Rega (Photos: Rega)

Air ambulance flight to Japan On 11 March 2011 an earthquake measuring 9.0 Mw off the east coast of Japan rocked large areas of the island nation. The earthquake itself and the tsunami it triggered devastated much of north-eastern Japan. Fukushima nuclear power station, located in the disaster zone, suffered major damage as a result of the quake and began leaking nuclear radiation. At the request of the Japanese government, Switzerland sent a team of 25 experts and nine dogs to help with search and rescue operations. The team from the Swiss Humanitarian Aid Unit (SHA) arrived in Japan on 13 March and got to work immediately. The patient Two days after arriving in the crisis region, a member of the team complained of stomach pains. These were diagnosed as diverticulitis, an existing condition that the patient had already been treated for twice with conservative methods several years before. The SHA team’s physician recommended a course of treatment with the antibiotic Ciprofloxacin. However, the patient’s condition worsened the next day, showing signs of peritonitis and the onset of sepsis. The team physician contacted the Swiss Embassy and the decision was made to fly the patient home. Given the looming threat of nuclear disaster, the patient was first taken out of the danger zone to the city of Hachinohe, where a diagnostic laparotomy was performed at once. As the procedure showed no perforation of the intestine, treatment proceeded on the assumption that the existing diverticulitis had involved micro-perforation which had already healed spontaneously. The intestine was irrigated extensively and a transverse colostomy was performed.

Antibiotic treatment was continued with Imipenem/Cilastatin (Tienam®), and the patient’s general condition rapidly improved, as did the inflammatory parameters. Since intestinal peristalsis was present, enteral nutrition could begin on the fourth day after the operation, and the patient was taken off the antibiotics on the fifth day after the operation. From the moment the patient’s condition was diagnosed, the Swiss air rescue service Rega and the SHA team physician in Japan were in close contact over the phone so that the situation could be assessed regularly. Despite the excellent standards of medical care in Japan, the decision was made to fly the patient home as soon as his condition stabilised, given the risks associated with the nuclear accident and potential supply shortages. And since the rest of the team had meanwhile been recalled back to Switzerland, the patient would have had to remain behind in Japan alone, where communicating would have been difficult for him.

1 · 2011 I Vol. 1 I AirRescue

FIXED-WING | 23 Planning the mission Because the situation in Japan was very unclear at the time the flight was being planned, particularly with regard to radioactive contamination and possible wind conditions, Rega decided to put together an extended cockpit crew to allow them to operate over longer periods (more than 20 hours). A night stop was planned in Seoul on the flight over, however, so that the team and the crew would have to spend as little time as possible in Japan the next day. This would also allow the mission to be aborted at any time without the crew being exposed to radiation. Thus, the second part of the mission included the flight from Seoul to Hachinohe (or, in the end, nearby Misawa), picking up the patient and the team physician and then flying back to Zurich over Russia, with a refuelling stop in Surgut. Throughout the mission, the crew kept constant tabs on the situation in Japan (developments in the disaster zone around Fukushima, radiation levels in Aomori Prefecture, the wind direction and other meteorological conditions, etc.) in order to be able to change plans quickly if necessary.

The flight The crew included four pilots, a doctor and a qualified nurse. After refueling in the Russian city of Surgut, the plane continued on to Seoul as planned. During this time the crew was in constant contact with the Rega Mission Control Centre, which provided them with regular

Fig. 2: Despite the excellent standards of medical care in Japan, the decision was made to fly the patient home given the precarious situation

Fig. 3: The second part of the mission included the flight from Seoul to Hachinohe (or, in the end, nearby Misawa), picking up the patient and the team physician

1 路 2011 I Vol. 1 I AirRescue

Fig. 4: Throughout the mission, the crew kept constant tabs on the situation in Japan in order to be able to change plans quickly if necessary

24 | FIXED-WING updates on the situation in general and on the spread of the radioactive cloud over Japan. The original plan to fly to the airfield in Hachinohe had to be abandoned as only the shorter runway was useable and it was not possible to obtain additional information. The decision was therefore made to land at the US airbase 25 km away in Misawa. On the plus side, the crew learned that they did not have to land in Sapporo to deal with customs formalities. An hour after taking off in Seoul, the plane reached the airport in Misawa, where the patient had been taken by ambulance and was already waiting and doing remarkably well. The return trip (again, with a refuelling stop in Surgut) began just under an hour later, and the patient’s cardiopulmonary function remained stable throughout the flight. The only medical measures taken consisted of inserting an IV drip to prevent the patient from becoming dehydrated in the extremely dry air on board and administering oxygen 2 L/min via nasal probe. In addition, the patient was given paracetamol against the pain and Nadroparin (Fraxiparine ®) 0.4 ml sc. as a prophylaxis against thrombosis. The staff also attended to the colostoma and the three remaining abdominal drainages. The air ambulance landed in Zurich at 5:15 p.m. local time on 21 March 2011. Before the plane was taken to its hangar, a team from SR Technics examined it for radioactive contamination. Their tests came up negative.

Fig. 5: An hour after taking off in Seoul, the plane reached the airport in Misawa, where the patient had been taken to by ambulance and was already waiting

Fig. 6: Before the plane was taken to its hangar, a team from SR Technics examined it for radioactive contamination

1 · 2011 I Vol. 1 I AirRescue

FIXED-WING | 25 A team of experts from the Paul Scherrer Institute (PSI) then performed physical examinations on the patient, the SHA physician and the rest of the crew, checking their thyroids in particular. Finally, all luggage and equipment was checked; thankfully, no high levels of radiation were detected (Paul Scherrer Institute test report SUZM/01/220311). The checks were carried out despite the very low probability of contamination partly to set a good example, partly to remove any trace of doubt, and partly to give the people involved in the mission the psychological security that all was well.

Discussion It was clear from the very beginning that the mission had to provide maximum safety for the crew and their aircraft. This meant it had to be possible to adapt the schedule at any time during the mission if conditions in Japan changed drastically. The plan was therefore kept as flexible as possible. The constant flow of communication between the Mission Control Centre and the crew, made possible by modern technologies such as satellite phones and ACARS, proved to be of crucial importance. It is interesting to close with a quote from the crew’s concluding report on their mission: “When asked during the debriefing if we weren’t afraid, we all answered ‘no’. Looking back, our state of mind was more one of tense alertness than of fear.” 

1 · 2011 I Vol. 1 I AirRescue

Authors: Olivier Seiler · Benedetta Rei Medical unit, Swiss Air Rescue (Rega). PO Box 1414, 8058 Zurich Airport, Switzerland

Fig. 7: A team of experts from the Paul Scherrer Institute (PSI) also performed physical examinations on the patient as well as on staff

26 | IN PROFILE

Fig 1.: TAA is one of the world’s most experienced medical airlift organizations and repatriates nearly 3,000 patients per year (Photos: Tyrol Air Ambulance)

It all began with a tourist from Greece – fixed-wing operator Tyrol Air Ambulance Tyrol Air Ambulance (TAA) has its origins in “Aircraft Innsbruck”. The company was granted its flight operating licence in 1963 in order to rescue skiers from the Tyrolean Glaciers. In July 1976 an air ambulance jet repatriated an injured tourist from Greece for the first time. From then on, “Aircraft Innsbruck” operated under the trade name “Tyrol Air Ambulance” (former Tyrolean Air Ambulance) with state-of-the-art medical equipment on board. In the 80s TAA introduced a regular air ambulance shuttle flight system in the Alps for patients with injuries after skiing accidents. Since then, these scheduled air ambulance shuttle services have been further developed and nowadays ambulance shuttle flights link the Canary Islands, Morocco and Spain with Continental Europe all year round. During summer, flight destinations also include popular holiday resorts around the Mediterranean Sea, especially in Turkey, Greece and Egypt. During wintertime, ambulance shuttle flights are operated from the Austrian Alps, Northern Italy and the French Alps back to the Netherlands, Belgium, Scandinavia and England. TAA is one of the world‘s most experienced medical airlift organizations and repatriates nearly 3,000 patients per year. Tyrol Air Ambulance started into the new millennium with a new owner and an expansion of its fleet. Dornier 328 Turbo-Prob and Dornier 328 JET were introduced for multiple passenger transportation with space for up to 12 patients. A Citation aircraft was added to the air ambulance fleet, offering single or double patient capacity. Recently a Gulfstream G100 was integrated into the fleet

for long distance air transports for up to two ICU patients simultaneously (see Fig. 3 and 4). This aircraft type allows repatriation flights across continents and enables TAA to provide flight medicine – developed during the last 40 years – at almost any place on the globe, regardless of the medical situation (stretcher patient, intensive care patient, advanced and complex ICU patient with special

1 · 2011 I Vol. 1 I AirRescue

IN PROFILE | 27

Fig. 2: Dornier 328 TurboProb and Dornier 328 JET were introduced for multiple passenger transportation with space for up to 12 patients

treatment and care, ECMO, IABP, left or right heart assist devices, etc.). Special medical support for the repatriation of patients with severe ARDS can also be provided (iLA, iLA active, etc). Tyrol Air Ambulance is specialized in the transport of children, toddlers, babies and neonates, even in doubleincubator transports. Very heavy patients over 160kg (even in ICU conditions) can also be transported. Early in 2011, a 4-year-old girl with a newly diagnosed lifethreatening disease was repatriated – together with her accompanying parents – from Beijing (China) to Vienna (Austria). Since autumn 2010 ambulance long distance flights with the Gulfstream G100 aircraft have taken TAA crews to destinations like Bangkok (Thailand), Dubai (United Arab Emirates), Cape Verdean Islands or even transatlantic destinations like Brasília, capital of Brazil. Cooperation with other worldwide operating air ambulances is also part of the business.

Case report 1 A 65-year-old Philippine citizen, visiting his daughter in Austria, suffered a dislocation fracture C3/C4 with tetraparesis complicated by sepsis and ARDS. As soon as the patient was in stable condition, his insurance made plans for repatriation back home to which he himself had to agree. In the case of this critical care patient it was impossible to carry out repatriation procedures on a scheduled commercial flight without a PTC for instance, as he needed ventilation support and intensive care. Air transport was initiated immediately and only 20 hours after taking off in Vienna, the patient arrived in Manila,

1 · 2011 I Vol. 1 I AirRescue

Fig. 3: Ambulance long distance flights with the Gulfstream G100 aircraft have taken TAA crews to destinations like Bangkok, Dubai or even transatlantic destinations like Brasília, the capital of Brazil

28 | IN PROFILE

Fig. 4: A Gulfstream G100 has recently been integrated into the fleet for long distance air transports for up to two ICU patients simultaneously

Fig. 5: Just 20 hours after taking off in Vienna, the patient arrived in Manila, Philippines and was admitted to hospital

Philippines (distance: 10,300 km / 5,600 nm) and was admitted to hospital. The benefits for the patient’s health are evident: he benefited from fast flight planning and the efficient organisation of repatriation by the TAA alarm centre (24-hour support) as well as from the short total time of the repatriation procedure and also from maintaining high standards of the ICU.

Case report 2 In December 2010 a patient and his relative were flown from Salzburg to Brasília (Brazil). The patient needed medical care suffering from dysphagia and muscle weakness caused by a neuromuscular disease of unknown origin. One of the two ICU-stretchers was taken out and replaced by two business chairs, ensuring that the patient was able to change between a horizontal position (stretcher with medical equipment on ICU level in stand-by mode) and a comfortable sitting position whenever he wanted. After 16 hours flight, the Gulfstream G100 landed in Brasília. The medical team escorted the patient and his relative to the final destination 150 km away from the airport. On the ferry-flight back to Europe another patient was picked up at the Cape Verdean Islands and brought to Austria. An additional fuel stop was not needed. Patients repatriated by Tyrol Air Ambulance benefit from the high flexibility in flight planning, flight operation and aircraft type.

A regular working day on board the Gulfstream G100 At about noon on 5 January 2011, a Swiss tourist (aged 65) slipped in a water fun park in Egypt and injured his leg. He was brought to the nearby Port Ghalib Hospital close to Marsa Alam Airport in South Egypt. The patient was diagnosed with a femur neck fracture on the left side. The hospital suggested to get him operated the next day. Surgeons would be flown in from Cairo for this purpose. But the patient refused surgical treatment there and called his insurance company in order to organize fast repatriation.

1 · 2011 I Vol. 1 I AirRescue

IN PROFILE | 29 On 6 January 2011 at 5.00 a.m. the phone rang for captain, first officer, flight nurse and flight physician on duty of Tyrol Air Ambulance. The Gulfstream 100 took off from Innsbruck Kranebitten Airport in Austria, home base of Tyrol Air Ambulance, at 7.00 a.m. local time and landed at Marsa Alam Airport in South Egypt at the Red Sea Coast at about noon. After medical examination, basic checkups and pre-flight preparing by the medical crew together with the local medical staff at Hospital Port Ghalib, they escorted the patient and his wife to Marsa Alam Airport in a local ambulance car. At about 2.00 p.m. the Gulfstream G100 took off from Marsa Alam Airport and landed in Zurich Kloten Airport (distance: 3,300 km/1,775 nm) after an uneventful air transport at about 7.00 p.m. The patient and his wife were escorted to the organised hospital admission again by the medical crew and handed over to the medical staff of Zurich University Clinic together with all medical information and documents after a total transport time of 7 hours and 30 minutes. One hour later the Gulfstream G100 took off once again for Innsbruck, where flight nurse and flight physician left the airport after routine check of the medical equipment at about 10.30 p.m. The crew looked back on a long day, but were very satisfied with the result of their endeavour: Within 30 hours after the accident, a safe and quick repatriation from Egypt to Switzerland had successfully been accomplished. ď&#x201A;¤

1 Âˇ 2011 I Vol. 1 I AirRescue

Fig. 6: Patients benefit from flexible flight planning and flight operations as well as dispatching the appropriate aircraft type

Authors: Manuela Sax Tyrol Air Ambulance, PO Box 81, 6026 Innsbruck Airport, Austria Hans Geisler Tyrol Air Ambulance Michael Wirnsberger Tyrol Air Ambulance

30 | TECHNOLOGY

A step into the future for Polish Medical Air Rescue With a complete fleet of EC135 and a flight simulator, Polish Medical Air Rescue is ready to face new challenges. At the end of 2010, a new era of air rescue began. The two last EC135 P2+ helicopters from the Eurocopter Donauwörth factory landed in front of the Headquarter of Polish Medical Air Rescue in Warsaw. These were the last two machines purchased by the Polish Ministry of Health under the contract for 23 helicopters and for a flight simulator. Now, Polish Helicopter Emergency Medical Services (HEMS) has a brand new fleet of rescue helicopters replacing the Mi-2 Plus serving in Polish sanitary aviation for nearly 40 years. The purchase of those new machines and their introduction to service opens a new chapter in the history of Polish Medical Air Rescue as well as it offers many new operational capabilities.

Fig. 1: Before entering into the field of night operations, the Ministry of Health facilitated the establishment of a financial program to support the building of 24/7 landing places (Photos: R. Galazkowski)

1 · 2011 I Vol. 1 I AirRescue

TECHNOLOGY | 31

The comfort of possessing a flight simulator (FTD Level 3 MCC) allowed entering into an advanced training program for day and night operations. This program is dedicated to pilots and paramedics with special emphasis on emergency situations and multi crew cooperation in various situations. All this has been preceded by a deep and extended analysis of needs, operational limitations and safety factors. The use of the flight simulator for the training process has now become standard in the preparation of HEMS crew members in Poland. This training significantly raised the level of safety in the everyday HEMS service using the new helicopters.

illustrates the consistent implementation of strategic decisions p ositioning HEMS service as the responsibility of the State.

Fig. 2: Headquarter of Polish Medical Air Rescue in Warsaw, Poland

Respect to human resources With respect to human resources management (pilots), an additional set of medical and psychological examinations was developed – added to the ones already established through the air regulations – in order to look more closely at each individual pilot and to determine their level of capability to perform night flights. Such an approach, although it might meet with opposition by some pilots, has been designed to minimize the risk as much as possible.

Night Operations now possible After more than two years of intensive preparations, the last one of 17 Polish HEMS stations, located in Olsztyn (Masuria), took up service on 26 April 2011with a new rescue helicopter. From then onwards, the new fleet was no longer in operational use for daylight operations. Opportunities arising from the performance and advanced equipment of the new helicopters as well as the scope of the European Aviation Safety Agency (EASA) certificates fulfilling the current EU aviation regulations, caused Polish HEMS service to expand its activities – including night operations. The preparations for night operations were preceded by a thorough analysis of possibilities including human capabilities and constraints. Being aware that night operations carry much more risk than flights during the day, a comprehensive range of organizational and training activities were undertaken with the main aim of risk reduction. It is important to mention that the whole program has become feasible – also thanks to new strategic changes in the field of Air Rescue service in Poland. Before entering the field of night operations, the Ministry of Health facilitated the establishment of a financial program to support the building of 24/7 landing places at the trauma centers and other important hospitals. This

1 · 2011 I Vol. 1 I AirRescue

A landing place in each municipality The next step in the strategy is to determine a landing place for HEMS helicopter in each municipality, safe and well known to local fire brigade units. Rescue helicopters will pick up patients from these sites during the night and transport them directly to a trauma center or specialized hospitals, omitting local hospitals with limited capabilities regarding medical treatment. By the end of June 2011,

Fig. 3: The next step is to determine a landing place for HEMS helicopters in each municipality, safe and also known to local fire brigade units

32 | TECHNOLOGY

Fig. 4: The use of the flight simulator for the training process has now become standard in the preparation of HEMS crew members in Poland

Fig. 5: Preparations for night operations were preceded by a thorough analysis of possibilities including human capabilities and constraints

there will be approximately 1,700 designated places, and by mid-2012, more than 2,500 all over the country. Independent of the training for pilots, paramedics and doctors, a separate training for the firefighters is being conducted countrywide with the aim to professionally identify safe landing places close to the accident site (during the day) and secure well-known municipal landing places at night. This training is conducted on the basis of a training program – consisting of theoretical and practical elements – in which HEMS helicopters are involved. The practical training is intended to develop mutual trust between helicopter crew members and firefighters, who welcome the helicopter on the ground, and to make them aware of the great responsibility and importance of their work. By the end of April 2011, ten thousand firefighters will be trained and these trainings will be continued.

Dispatcher training program Another key element in the strategy of improvement of the State Rescue Services is the National Training Program for medical dispatchers. When the program is completed by the end of 2011, there will be over 3,000 medical dispatchers trained to make use of new HEMS capabilities. The purpose of that training is the introduction of standards and principles of cooperation of the medical emergency service units with regard to the disposal of HEMS helicopters during night rescue actions. The importance of these trainings is essential for an effective use of helicopters during night operations. The timetable assumes to finalize the necessary skills and know-how transfer at least one month before the individual HEMS station will enter into night operations. The governmental program of the HEMS helicopter fleet replacement designed for Polish Medical Air Rescue became a real opening for the upcoming years in the ability to help people, who are in need of quick medical assistance. The Polish Medical Air Rescue team is aware of its responsibilities and will continue to serve those in need of rescue service with humility and without selfadmiration – last but not least, with due respect for the rules of reason and safety. 

Author: Robert Galazkowski Director of Polish Medical Air Rescue, Lotnicze Pogotowie Ratunkowe, Polish Medical Air Rescue, 01-934 Warszawa ul. Ksiycowa 5 Tel.: +48 22 56 81 930, Fax: +48 22 56 81 929

1 · 2011 I Vol. 1 I AirRescue

RULES & LAWS | 33

Are unapproved hospital landing pads putting airborne emergency medical services at risk? Draft amendment to the German Air Traffic Act must be improved Experts fear that a planned revision of Germany‘s Air Traffic Act (Luftverkehrsgesetz, LuftVG) could have grave consequences for the country’s air ambulance services. The amendment envisions only permitting regular air ambulance operations on hospitals’ permanent landing pads or open spaces that have been approved in line with Section 6 of the LuftVG. In practice this would make it almost impossible to operate flights to or from hospitals without LuftVG-approved landing pads. This is because, according to the plan set out by the Federal Ministry of Transport, “regular air operations” exist when more than four flights (counted as separate flights) are made per month – and that means just two flights, because take-off and landing are counted in each case. Currently, flights to or from hospitals without LuftVG-approved landing pads are covered by the exemption clause in Section 25(2)(2) of the LuftVG (Landing and take-off to assist a person whose life or health is in danger). Taking the German state of Hesse as an example – although this also applies to the rest of the country – the amendment would make most of the emergency hospitals in the state inaccessible to air ambulance helicopters and intensive-care helicopters. According to the Kassel and Darmstadt Regional Commissioner’s Offices (the competent air transport authorities), of the approximately 120 facilities listed in Hesse’s 2011 hospital register for mass-casualty incidents (MCIs), only eleven have a helipad approved in line with Section 6 of the LuftVG. Approval proceedings have begun at three other hospitals (Information correct as of February 2011) With the situation represented as a graphic (see Fig. 3), we can see that nine percent of the hospitals in the register have landing pads, that three percent are involved in approval proceedings, and that 88 percent of the landing pads at emergency medical centres in Hesse are not approved. Air ambulances can only use the latter on the basis of the current exemption clause in Section 25(2)(2) of the LuftVG. This corresponds to findings from other German states. If the bill, which does not even contain a transitional regulation, enters into force with the actual wording, airborne emergency medical services in many parts of Hesse, particularly rural areas, would have to be ceased. In the case of providing emergency medical care to patients (those whose lives are already or likely to be in immediate danger, and those who are at risk of serious bodily injuries), the public chain of care and the emergency medical care task do not end at the accident site. Rather, the overwhelming majority of call-outs involving HEMS helicopters, and intensive-care helicopters end by transporting or transferring the patient to a suitable hospital. Hesse’s air ambulance service plan (Fachplan Luftrettung, due to be updated) says that the state’s air ambulance services are only intended to supplement ground-

1 · 2011 I Vol. 1 I AirRescue

based emergency care. However, ever since structural problems in prehospital emergency medical services resulted in air ambulance helicopters in some areas of Hesse practically becoming part of standard emergency care, the time factor and the advantage of air ambulance resources over ground-based transport are playing an increasingly important role in getting patients out of immediate mortal danger and in optimising treatment success. The profound changes affecting Hesse’s hospitals are intensifying the situation. For a long time now, these changes have meant that the hospital closest to an accident site is not automatically the best hospital for emergency diagnosis and treatment. Because the changes to hospital care structures have increased the distance and time that must be travelled to get patients to the hospital best suited to treat their injuries or illnesses, it would be impossible for even the

Fig. 1: A comprehensive network of hospital landing pads is crucial to ensuring efficient emergency medical care (Photo: Jonas Braun/ JUH)

34 | RULES & LAWS ground transport necessary for standard care to make up for any “outage” of air ambulance services brought about by the amendment to the Air Traffic Act. This means that, in addition to the continuing, pressing need for a nationwide network of helipads in or near to hospitals, we also require landing pads at smaller, rural emergency care facilities. This is because rural facilities are often the only landing option in large remote areas. This is why Hesse’s Ministry of Social Affairs, which is responsible for rescue and healthcare services, has issued a statement to the Hessian Ministry of Economics, Traffic and Regional and Urban Development (the highest air transport authority in the state), calling on it to delete the planned amendment to Section 25(2) of the LuftVG without substitution. Private organisations like ADAC Air Rescue, which operate air ambulance bases for individual federal states, are also against the amendment. If it proves impossible to have the amendment deleted without substitution, any change to Section 25(2) of the LuftVG must include two things: firstly, an appropriate transitional regulation of at least five years that can be applied flexibly in individual cases up to the time that any general approval requirement comes into force for hospital helipads; secondly, and more importantly, it must include a significant increase in the air-traffic movement limit that makes approval necessary for helicopter landing pads. The bill’s threshold value of four air-traffic movements per month equates to just 24 call-outs every year. An evaluation of hospital-related air-traffic movements for the Christoph Hessen intensive-care helicopter alone proves that the planned limits would make it impossible to secure a statewide network of landing pads at Hesse’s hospitals. As a result, the bill is in dire need of improvement. The option of scrapping the amendment can be supported by the fact that transposing EU standards into national law, which has been cited as the reason for

amending the Air Traffic Act, does not make it absolutely necessary to amend Section 25(2) of the LuftVG. However, one cannot reject the plan’s basic aim – to increase flight safety by using air transport law to bring “permanent landing pads” at hospitals into alignment with the minimum standards of the general administrative regulation that pertains to Section 6 of the LuftVG and applies to the approval and operation of helipads. This will become even more relevant if night-flight operations are gradually expanded in the future. But, due to the aforementioned effects on emergency medical care structures, any alignment of this kind must be applied with a sense of proportion and provide scope for workable solutions to individual problems. Local conditions at numerous hospitals will make it impossible for them to gain approval for their landing pads. Problems include high building density on hospital grounds, surrounding residential buildings, and immovable obstacles such as above-ground electricity lines in the approach and take-off areas. In addition, making the necessary structural and flight-safety changes can be extremely expensive. Just fitting a rooftop landing pad with the necessary fire-protection facilities can set hospitals back between € 200,000 and € 300,000. With this in mind, in addition to a flexible transitional regulation and an appropriate increase in the air-traffic movement limit, it would also make sense to offer statutory transitional support under Section 25(1) of the LuftVG. Rather than issuing an “ultimate” approval, this would involve granting a permit that runs for a limited period (and is extendable) and that requires fulfilment of mandatory safety measures only. This would make it possible to at least regularly assess these hospital landing pads through random spot checks. Hesse’s air traffic authorities are already carrying out safety checks of unapproved hospital landing pads that have a high volume of air traffic. The checks currently

Fig. 2: “Cramped conditions” – the “Christoph 7” air ambulance helicopter on the rooftop landing pad at the Rot Kreuz Krankenhaus Kassel (Photo: Peter Stahl/LRZ Chr 7)

1 · 2011 I Vol. 1 I AirRescue

RULES & LAWS | 35

Hospitals in Hesse providing emergency care [according to the MCI hospital register, Hesse 2011] - Helicopter landing pads -

Fig. 3: Hospitals in Hesse providing emergency medical care (according to Hesse’s 2001 MCI hospital register – MANVKrankenhauskataster)

Hospitals in Hesse providing emergency care - Helicopter landing pads -

3 %

•••••••••••

9 % ••• ••••• ••••••

•••••• ••• •••••••• •••

••••••

••••

•••• •••••••

88 %

•• ••• •••

••

•••

Approval as per Section 6 LuftVG/AVV (Air Traffic Act / administrative regulations)

Approval

Approval pending

No approval

seem to be paying particular attention to rooftop landing pads that do not have adequate fire-protection and lifesaving facilities – St. Vincenz-Krankenhaus Limburg is one such example. The current legal situation means that any legal consequences of delaying or refusing to make the necessary amendments to landing-pad safety would only affect the HEMS operator or the air ambulance pilots. They would not affect the hospital operator as owner and “operator” of the unapproved landing pad. However, this is a purely theoretical consideration because it is in the interest of every hospital operator – and Limburg is no exception – to secure the ongoing success of its facility.

••••

•••• •••• •••• •• •••• •• ••••

•••••••

•• •

Fig. 4: Hospitals in Hesse providing emergency medical care – helicopter landing pads

One way of doing so is to gain landing-pad approval that will allow the hospital to continue being part of the air ambulance service network. 

Author: Jochen Decher Assistant Ministerial Counsellor, Gießen Regional Commissioner’s Office, Central Implementation and Regulatory Authority for Air Ambulance Services in Hesse Landgraf-Philipp-Platz 1-7, 35390 Gießen, Germany jochen.decher@rpgi.hessen.de Fig. 5: Outdoor accident sites are not affected by the planned change to the Air Traffic Act (Photo: M. Müller)

1 · 2011 I Vol. 1 I AirRescue

36 | RULES AND LAWS

DRF Luftrettung

Comments by EHAC on the planned EASA-OPS The European HEMS Air Ambulance Committee (EHAC) has asked the European Aviation Safety Agency (EASA) to make some amendments to its planned EASA-OPS (1). For example, EHAC is calling for the existing special permits for takeoffs and landings in the public interest to be expanded to include rescue flights in general. Takeoffs and landings at hospitals and air rescue centres would thus be clearly defined as in the public interest and could therefore be exempt from restrictive regulations that appear to serve bureaucracy rather than the wellbeing of patients and do nothing to improve flight safety. Hospital landing pads under threat Not all helipads for rescue helicopters in Europe have as yet been certified in accordance with the regulations contained in JAR-OPS 3 and ICAO Annex 14, which define major technical prerequisites for these sites. According to EASA’s plan, 1 July 2002 is to be the defining date for the new EASA-OPS regulations. As a result, it will no longer be possible to use non-certified helipads that started operating after this date. This would affect 700 hospital helipads in Germany alone. EHAC is therefore campaigning for a cut-off date of 1 April 2014 instead. EASA also places high technical demands of the airworthiness of the helicopters, including a slope factor of eight percent in all weather conditions. EHAC, which is not questioning the importance of flight safety, would like this demand to be restricted to altitudes above 2,200 feet and temperatures above 20°C. The reason for this is that there are currently no HEMS-certified helicopters on the market that can deliver the desired performance in all conditions. “For the sake of emergency patients all over Europe, we hope that we can and will continue to work well together and that the agency will be flexible,” said Stefan Becker from EHAC. He went on to emphasise that “without the amendments to the planned EASA-OPS – the need for which EHAC has explained in great detail – there may be considerable reductions in European air rescue and pre-hospital care, and this may well affect the outcome for emergency patients.”

in Germany in DRF Luftrettung’s “Christoph München”. In the paper, EHAC describes the different certifications depending on use and the different definitions of “minor change” and “major change” as the greatest challenges in the introduction of these new technologies. In cases of a “major change”, a switch to NVG can involve high costs, depending on how many other changes must be made in the cockpit in order to install the new technology. EHAC stated that the aim of using NVG is not to increase the number of missions by undertaking more night flights. Instead, it is a question of making it easier, and safer, to fly at night. If the NVG malfunction, it must still always be possible to complete the mission. Will several simultaneous optical alerts be needed on flights where the pilot is wearing NVG? EHAC is against this as it might well represent a dangerous sensory overload for pilots; it argues that it is sufficient for the alarm signal to remain visible during the entire flight.

A different distribution of votes in EASA EHAC has different ideas about the current distribution of votes within EASA. For example, each member state has one vote within the organisation, yet EHAC, the umbrella organisation for most air rescue organisations in Europe, also has just one vote. EHAC therefore proposes rethinking the system of vote distribution.  (1) See the following pages for details regarding the EHAC comments on the planned EASA-OPS

Night vision goggles Discussion is also needed on the equipment that is to be used in rescue helicopter cockpits in the future. At the request of EASA, EHAC produced a position paper on night vision goggles (NVG), which were used for the first time

Author: Peter Poguntke Landhausstraße 263, 70188 Stuttgart, Germany

1 · 2011 I Vol. 1 I AirRescue

RULES AND LAWS | 37 European HEMS Air Ambulance Committee (EHAC)

Document

Reference

CRD.a1.

XII. SPA.HEMS: Subpart J - Helicopter emergency medical service operations

CRD OPS Phase 1 Comments Explanatory Note

Proposal/Comment

383. Following inclusion of HSST/WP-07/03.4 in the NPA text and the question related to which option to choose in the Explanatory Note to the NPA, commentators requested the following: • several individuals repeated the opinion of the stakeholder organisation that represented them; these opinions only indicated the agreement with that opinion and were therefore set aside;

Individual comments NOT coming from members of stakeholder organisation where counted as the ONE stakeholder vote, too!

• 1 stakeholder organisation opted for option 2(a);

This stakeholder (ECA) does not represent HEMS operators

• 1 Member State and 1 stakeholder organisation opted for option 2(b); and

The stakeholder organisation (EHAC) represents numerous HEMS operators from all over Europe

• 2 Member States and 1 manufacturer opted for option 2(c).

Individual comments from different member states where counted as TWO votes!

384. The Agency therefore decided to incorporate option 2(c), …

384. The Agency therefore decided to incorporate option 2(b) , …

385. To facilitate implementation GM1-CAT. POL.H.305 (b) explains that a full authority digital engine control (FADEC), with recording and downloading facilities, could partly, or in whole, fulfil the usage monitoring system (UMS) requirement; the cost of compliance will consist only of the additional procedures and not equipment fitting.

European HEMS Air Ambulance Committee (EHAC) CRD OPS Phase 1 Comments Part SPA

Justification

Document

Reference

CRD.b4.

SPA.NVIS.110 Equipment requirements for NVIS operations

Large parts of today’s fleets operate to “PIS-like” sites throughout Europe without incidents and accidents related to engine accountability. Furthermore, this decision fails to reflect the “democratic” outcome of the vote. It was assumed by TG11 that FADEC data would be acceptable and the cost of implementation would be limited to the cost of implementing the procedures; in reality there are huge costs associated with the installation of an UMS, just ask the manufacturers for a quotation!

Proposal/Comment

Justification

(ii) have an instrument panel coaming repeater light at each cockpit crew station to ensure adequate attention-getting-capability for head up operations, if visual warning provided is not visible during head up operations .

If the visual warning provided by the system is visible during head-up operations, the fitting of a coaming repeater light seems overdone. The need for a coaming repeater light should be subject to competent authority evaluation or certification of the NVIS equipment.

(2) an NVIS adjustment kit or eye lane;

Delete this requirement

There is no need for an NVIS adjustment kit or eye lane to correctly focus an NVG. Furthermore this equipment is not present when Goggling up away from the (HEMS) operating base.

(f) All required NVG on an NVIS flight shall be of the same type, generation and model.

(f) All required NVG on an NVIS flight shall be of the types and models certified for the NVIS.

The NVGs are part of the technical NVIS certification of the helicopter. Further limiting to use of same type, generation and model is overdone for an aid to VFR.

(a) Operations shall not be conducted below the flight rules weather minima for the type of night operations being conducted.

Consider future rulemaking: Restatement allows for use of NVG with lower than VFR minima if an IFR backup possibility is provided.

Except for HHO at a HEMS operating site and HEMS HHO operational training, HHO shall be capable of sustaining a critical engine failure with the remaining engine(s) at the appropriate power setting without hazard to the suspended person(s)/cargo, third parties, or property.

Realistic training should be possible.

(b) Radio altimeter….. (2) The visual warning system shall: (i) provide clear visual warning at each cockpit crew station of height below the pilot-selectable warning height; and (ii) have an instrument panel coaming repeater light at each cockpit crew station to ensure adequate attention-getting-capability for head up operations.

(e) Additional NVIS equipment….

SPA.NVIS.120 NVIS operating minima (a) Operations shall not be conducted below the visual flight rules (VFR) weather minima for the type of night operations being conducted. SPA.HHO.125 Performance requirements for HHO Except for HHO at a HEMS operating site, HHO shall be capable of sustaining a critical engine failure with the remaining engine(s) at the appropriate power setting without hazard to the suspended person(s)/cargo, third parties, or property.

1 · 2011 I Vol. 1 I AirRescue

38 | RULES AND LAWS European HEMS Air Ambulance Committee (EHAC) CRD OPS Phase 1 Comments Part CAT

Document

Reference

CRD.b3

CAT.POL.H.100 Applicability

Proposal/Comment

Justification

(1) when operated to/from aerodromes/operating sites located in a congested hostile environment, except when operated to/from a public interest site(PIS) and all HEMS operating sites in accordance with CAT.POL.H.225; or

Even today's modern twins (EC135, EC145) are not able to operate in PC 1 at mission weight in all circumstances; The alleviation to operate in accordance with CAT.POL.H.225 should also be applicable to hospital sites (ICAO Annex14) and HEMS-operating bases;

(a) The operator shall ensure that helicopters are operated in accordance with the applicable performance class requirements. (1) when operated to/from aerodromes/operating sites located in a congested hostile environment, except when operated to/from a public interest site (PIS) in accordance with CAT.POL.H.225; or

Circumstances: At altitudes/temperature combinations as low as 2200 feet/20 degrees celsius parts of today’s fleet are unable to meet PC1 at mission weight, it is unrealistic to require the fleet to be renewed by April 2012. Even the newer twins like EC145 and EC135 are unable to perform in PC 1 above 3500 feet/20 degrees celcius at mission weight.

(2) …

HEMS operating sites: OPS.CAT.POL.H.225 does only allow for PC 2 operations to PIS. The fact that most of today’s fleet is unable to operate in PC 1 to hospital sites (ICAO Annex 14) and HEMS-operating bases would have a huge negative impact on pre-hospital health care systems throughout Europe (if the requirement for PC 1 isn’t changed). CAT.POL.H.225 Helicopter operations at a public interest site (a) Multi-turbine powered helicopters, with a maximum passenger seating configuration (MPSC) of six or less, operating to/from public interest sites (PIS): (1) located in a congested hostile environment; and (2) which were established as aerodrome/ operating site before 1 July 2002,

(2) which were established as aerodrome/ operating site before 1 April 2014 ,

The date lies in the past while many counties have not adopted JAR-OPS 3.005(i); If the date of 1 July 2002 is maintained, this would have a huge negative impact on pre-hospital health care systems throughout Europe; The date should be changed to a future date, giving authorities and operators the time to meet the requirements of CAT.POL.H.225 (a) till (d)

shall have the prior approval of the competent authority issuing the AOC and the authority of the State in which it is intended to conduct such operations.

Few authorities, if any, have either issued an official prior approval or published a list with accepted PIS. In the meantime, operations to sites eligible for a "PIS" status continue throughout Europe. In most countries these sites are operated as HEMS operating sites.

(b) Where the size of the PIS, or its obstacle environment, does not allow the helicopter to be operated in performance class 1, operations may be conducted in performance class 2 and are exempt from the requirements of CAT.POL.H.310(a)(2) and CAT.POL.H.325(a) (2), provided that:

The references mentioned here are wrong

(2) the helicopter mass does not exceed the maximum mass specified in the AFM for a climb gradient of 8 % in still air at the appropriate take-off safety speed (VTOSS) with the critical engine inoperative and the remaining engines operating at an appropriate power rating.

(2) the helicopter mass does not exceed the maximum mass specified in the AFM for a climb gradient of 8 % in still air at 2000 feet and 20 degrees celsius at the appropriate take-off safety speed (VTOSS) with the critical engine inoperative and the remaining engines operating at an appropriate power rating .

Parts of today's fleets cannot meet these requirements at mission weights under all conditions. Problems arise with a combination of higher altitude and high temperatures. The introduction of 8 % climb in still air at 2000 feet and 20 degrees celsius allows continued operations to PIS. It rules out or only allows less performing helicopters at a weight penalty as was intended when the original rule was written, but does not preclude operations to PIS at higher altitude and temperature combinations by modern twin helicopters.

(c) Site-specific procedures shall be established in the operations manual to minimize the period during which there would be danger to helicopter occupants and persons on the surface in the event of an engine failure during take-off and landing at a PIS. CAT.POL.H.305 Operations without an assured safe forced landing capability (3) Implement a usage monitoring system.

Delete this requirement for HEMS

1 · 2011 I Vol. 1 I AirRescue

SUBSCRIBE NOW! The international air rescue and air ambulance magazine

1-year subscription 4 issues – 30 E*

AIRMED 2011

Airrescue InternatIona l aIr rescue & aIr ambul ance

M A g A zine

EHAC

AIRMED World Congress 2011

Medical Care & Air Rescue Hygiene in Air Ambulances

Fixed-Wing Operations

2-year subscription 8 issues – 55 E*

Air Repatriation from Japan

ISSUE 1 | Vol. 1 | 2011/4

Air Repatriation from Japan

Fixed-Wing Operations Hygiene in Air Ambulances

M A g A zine

Subscribe online at:

Airrescue

Medical Care & Air Rescue AIRMED World Congress 2011

EHAC

InternatIona l aIr rescue & aIr ambul ance

www.airrescue-magazine.eu/subscribe AIRMED 2011

*shipping not included (Europe 5 E, World 10 E)

AirRescue International Air Rescue & Air Ambul ance

Subscribe until June 15th for a 10% discount. Just use the coupon „Airmed“ in our Online Shop.

M a g a zine

Thinking without limits

More than a helicopter. A place where medical science can work wonders. Quieter, smoother, and with more flexible options, Eurocopter EMS helicopters are designed by doctors for doctors with the highest levels of emergency medical care in mind. Ergonomic cabins with easy patient access. Space onboard maximised for superior medical treatment, from transporting patients to offering in-flight intensive care. Engineered for faster response times to get patients to the treatment they need quicker. When you think saving lives, think without limits.