Airrescue Magazine 2013-01 by Verlag Stumpf & Kossendey

SAFETY

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

Technology

Characteristics of lithium-ion batteries

Medical Care

HEMS and organ transplantation in Spain

Safety

Substance abuse in HEMS

ISSUE 1 | Vol. 3 | 2013

C-MAC® – Pocket Monitor Mobilität ist unsere Leidenschaft… …und höchste Hygieneansprüche unser Standard!

8 IP X

AN 34/07/11/A-D

U E N

KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Deutschland, Tel.: +49 (0)7461 708-0, Fax: + 49 (0)7461 708-105, E-Mail: info@karlstorz.de KARL STORZ Endoskop Austria GmbH, Landstraßer-Hauptstraße 148/1/G1, A-1030 Wien/Österreich, Tel.: +43 1 715 6047-0, Fax: +43 1 715 6047-9, E-Mail: storz-austria@karlstorz.at www.karlstorz.com

E di tori a l Dear Readers, Running the German non-profit HEMS operator ADAC Air Rescue for 13 years allowed me to have a deep insight into how “Luftrettung” became “HEMS” and how requirements, operational costs, bureaucracy and the national health system evolved. This was complemented by many years on the EHAC Board. I noticed that all business-influencing aspects became more complex, required more documentation and created progressively rising cost levels. I believe that my fellow international EHAC Board members are of the same impression. Is there anything we can do? Yes, there is. However we need to do the right things. I will return to this later. There are many positive aspects, in particular with regard to the top-level subject of safety. Thanks to some EHAC member organisations and with a little financial help from Brussels, the Aeromedical Crew Resource Management was initiated. In HEMS missions this extensive safetytraining programme integrates the aviation CRM with the medical part by working on the soft skills of the crew. We believe that – at least in the HEMS environment – this was a big step towards further increasing safety. Thus, in connection with an excellent team of safety managers and a consistently-applied “Just Culture” process, we felt that flying 49,000 missions last year was much safer compared to the safety level in the year 2000, when we had just 25,000 patients to attend to. Yes, the effort to train a crew of about 1,000 people is very high. We are certain that this effort will pay off. Continuous learning is one of the fundamental elements for safety in HEMS. For the aviation part this was never scrutinised, as regular recurrent training and check flights have been done ever since aviation existed. Medicine and in particular emergency medicine started to learn from the aviators on how to handle mistakes. To spread experience and knowledge, ADAC started the series of AirMed world congresses back in 1980. The next AirMed to be held in Rome in 2014 will be another good chance to gain and share new knowledge and experience within the international community on all HEMS-related subjects. Compared to the medical and organisational part of HEMS, the aviation sector is more difficult and complicated to handle. From the very beginning, I was a firm believer in the European aviation idea. Today I feel that we are still far away from accomplishing this mission. An enormous amount of initiative and collective work still needs to be invested.

1 · 2013 I Vol. 3 I AirRescue I 3

However, I believe that we can all work together on achieving our goal. The authorities, the industry and the private sector have to pick up their share. For EASA, this means that they need to start listening and, moreover, acting on what the rulemaking processes bring to EASA’s attention. There has been much input given by the rotorcraft community demonstrating the impracticability of the drafted rules. This has largely been ignored. Viewed from the outside, rulemaking within EASA seems to be a solely administrative and time-consuming process. There are also some open tasks for the rotorcraft industry. In particular, the HEMS operators need to address their requirements in a much clearer, more uniform and much quicker manner. There are good signs that EHAC and NewEHA will work together more efficiently. The outcome of the working groups will improve and will give EASA far better input. I must admit that this is a very difficult task to accomplish. Members of the working groups are at the same time key personnel for their own operator and do not have much spare time to work with their international teams on safer and more practical rules. Associations like NewEHA and EHAC have proven their positive contribution to the regulatory bodies and therefore the necessity of their work. As a matter of fact, the entire rotorcraft industry is benefiting here. Every now and then the question arises of why we need two rotorcraft associations for Europe. The answer is very simple: NewEHA is an umbrella organisation for the national helicopter associations. The member operators are involved in activities such as agriculture, executive, fire fighting, offshore, logging, HEMS and so on. Streamlining these often-diverging expert interests is complicated at the national level and all the more at the European level. Therefore, the configuration of EHAC is more effective in working on HEMS regulations with the regulator. It is my firm wish for the future months and years that the rotorcraft community and EASA develop good, effective and strong communication that can lead to regulations that enhance commonality, safety, and ease of use for all operators in aviation. My future life leads me to a continent in the southern hemisphere, but I will continue to monitor the HEMS world closely, and with great interest.

Friedrich Rehkopf

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

Patient safety in air ambulances: Where do we stand? S. Sollid

Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: poguntke@airrescue-magazine.eu Editors: Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: bader@skverlag.de Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: frieling@skverlag.de Christoph Kossendey Tel.: +49 (0)4405 9181-14 E-Mail: cko@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

Substance abuse in HEMS: Silent tragedy or dirty little secret? J. Davidoff, J. Falk, W. Romeril

I mproving patient safety: The importance of simulation team training M. Rall, S. Oberfrank, G. Conrad

Subscription Rate: Europe: 35  (Shipping included) World: 40  Price per Issue: 9  (Shipping not included) Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF Production and Design: Bürger Verlag GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany

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

“The Bell 429 is one of the best helicopters”: Interview with G. Biner, pilot and CEO of Air Zermatt H. Scholl

1 · 2013 I Vol. 3 I AirRescue I 4

CONTENTS | 5

“High-quality patient care”: Improving outcome with the Zoll X Series D. Jadwiczek

HEMS and organ transplantation: Saving the life of “the other” patients C. Carriedo Scher

Direct vs. inter-hospital transfer of pediatric road traffic trauma victims

News

EHAC

Interview with B. Baksteen, keynote speaker at the EHAC Symposium: “Safety is not an add-on” T. Bader

ew EHAC-member MedCareProfesN sional (Germany): Interview with MD Dr J. Friese P. Poguntke

S. Suvorov, V. Rozinov, G Chogovadze, et al.

TECHNOLOGY

EVENTS

onference on Russian Air C Ambulances and MedEvac M. Shcherbakova

First AgustaWestland EMS Seminar: Sustaining healthcare through HEMS

32 41

Mitigating Fatigue

EMS in Switzerland: Cantonal H organisation and nationwide coverage

U. Pietsch

IN PROFILE

“ Medicine on the Move”: Improving healthcare in rural Ghana

T. Ridley

Helicopter flight in a degraded visual environment H. Haverdings

1 · 2013 I Vol. 3 I AirRescue I 5

safe solution to concerns with A lithium-ion batteries J. Bond

MEDICAL CARE

Editorial Team

SAFETY

J. Bohn, T. Stieber

HEMS in Germany: Female pilots are still few and far between P. Poguntke

Cover Image: Norsk Luftambulanse/ Norwegian Air Ambulance

6 | NEWS ADAC Air Rescue Medical Director receives Cross of Merit

P. Poguntke

The occasion could not have been more fitting: Dr Erwin Stolpe celebrated his award of the Federal Merit Cross on Ribbon together with friends, colleagues and long-time companions at the HEMS base in Munich, where the ADAC EMS helicopter “Christoph 1” is stationed. Dr Stolpe had previously been awarded the decoration from the Minister-President of Bavaria, Horst Seehofer, at the State Chancellery. EHAC board member, Dr Stolpe thanked his staff and colleagues for their unfailing support, remarking that “such achievements are only possible in a certain environment.” Susanne Matzke-Ahl from the ADAC Air Rescue Management Board praised the Medical Director for his contribution to air rescue services in Germany and throughout Europe. She said that Dr Stolpe had instilled his passion for air rescue in many other people and had always shown admirable tenacity, patience and a high level of expertise. The AirRescue Magazine editorial team would in turn like to extend their heartfelt congratulations to Dr Stolpe who also works as a consultant for us. For more information, visit: ››› www.adac.de/luftrettung

“Avionics Avenue” at AERO 2013 The Preparations for AERO 2013 are in full swing. Organisers are confident that the international aviation trade show, which will be held in Friedrichshafen (Germany) between 24 and 27 April 2013, will attract a full turnout. The event is expected to bring together 600 exhibitors from 30 different countries. The number of visitors is expected to reach 30,000. AERO 2013 aims to exhibit the full range of general aviation aircraft Hall A6 will feature a new exhibition area, focussing on the topic of avionics. Garmin, leading provider of mobile navigation solutions, has already announced some new features to be presented at the AERO. Another highlight of the exhibition is “Avionics Avenue”, where visitors will be able to test the latest equipment in a designated area under night-time conditions. For more information, visit: ››› www. www.aero-expo.de

15th Air Rescue Symposium in Mainz Having taken a six-year break, the 15th Air Rescue Symposium will be held between 29 and 31 October 2013 at the Rheingoldhalle conference centre in Mainz (Germany). This venue will be host to air rescue experts from all over the German-speaking world discussing and dissecting the latest developments in the world of HEMS. In the light of profound changes to rescue service infrastructure and the situation in hospitals, there will definitely be plenty to talk about. EMS helicopters are now being increasingly deployed in less developed areas and are sometimes the first form of aid to arrive on the scene. New laws governing aviation and medicine are keeping all those involved in air rescue on their toes as they endeavour to create a legally compliant air rescue infrastructure; sometimes they have to make huge investments in technology and training for crews. All this has to be seen in the context of the much-talked-about

ADAC Air Rescue

cost pressure in the health care system. Innovative ideas and concepts, shared through increased dialogue and networking, are therefore essential in order to keep moving forwards. The ADAC Air Rescue service has announced that the Symposium is intended to provide a platform on which to hone the medical, technical, organisational and political aspects of air rescue services. A wide range of different topics is set to be discussed in line with the motto “Air rescue – a 24/7 emergency healthcare service?” These include the development of emergency medical supply infrastructure, requirements planning and deployment strategies to meet future air rescue demands, the demands placed on coordination centres and traffic management processes, innovations in emergency medicine, medical research findings and ongoing research projects, specialised intensive care transportation and special patient groups in air rescue and air ambulance flights, safety management, safety culture and crisis management in high reliability organisations, selection and qualification of staff for air rescue and air ambulance flights and emergency care for people in offshore wind farms. These are also topics which the AirRescue Magazine will continue to discuss. For more information (and registration), visit: ››› www.fachtagung-luftrettung.org

Cooperation between Rega and the Swiss Air Force Rega and the Swiss Air Force have stationed another EMS helicopter near a hospital in the town of Scuol in eastern Switzerland. During a limited trial period in February and March 2013, the EC635 helicopter, which is owned by the Swiss Air Force, is being deployed at weekends in the area around Scuol. During times of good weather and high deployment forecasts, the helicopter will take off from an airfield near the Ospidal d’Engiadina Bassa hospital to perform day-time rescue and patient transport operations in the Lower Engadine valley. In a joint statement, Rega and the Swiss Air Force announced that the helicopter is being deployed “to maintain the core competence of the military air rescue service.” This arrangement is in keeping with existing agreements between Rega and the Swiss Air Force – a partnership which also comprises the deployment of the Swiss army to provide security during the World Economic Forum in Davos. The crews of the military helicopter form part of Rega’s everyday operations. The two organisations hope that they will continue to gain “valuable experiences” by working together. Until now, Rega and the Swiss Air Force have cooperated to provide SAR services and emergency aid in large-scale operations. Both organisations stress that their partnership is “subject to

a limited period” and is temporarily considered a “one-time-only” arrangement. They say that it will terminate on 31 March 2013 and will be rounded off by a debriefing session which will assess the lessons that will have been learnt. For more information, visit: ››› www.rega.ch

Swiss Air Force

1 · 2013 I Vol. 3 I AirRescue I 6

NEWS | 7 Number of DRF and ADAC Air Rescue missions rose again in 2012

Unterstützen Sie die DRF Luftrettung. Werden Sie Fördermitglied. Info-Telefon 0711 7007-2211 www.drf-luftrettung.de

In 2012, the DRF Air Rescue helicopters flew a total of 38,748 missions, 382 missions more than the previous year (2011: 38,366), whereas ADAC’s total number of missions was 49,243 (compared to around 47,000 in 2011) – an increase of 4% compared to 2011. On top of the list were emergencies such as acute heart failure and circulatory problems. Second came accidents at work and/or at school, followed by accidents during leisure activities/at home (15.2%). Neurological emergencies (12.5%) ranked third. “Christoph Europa 1” (Aachen/Charlemagne) carried out the highest number of missions (2,238), followed by “Christoph 31” in Berlin (2,175) and “Christoph 10” in Wittlich (2,039). DRF Air Rescue operates 31 HEMS bases in Germany, Austria and Denmark. Another 35 bases are being operated by ADAC – making HEMS coverage in Germany very efficient.

Government support in Russia

The Turbomeca (Safran) Arriel 2E engine has been certified by EASA. The engine, with a takeoff power of 894 shp, will power the EC145 T2 helicopter. The first engine’s entry into service is scheduled end of 2013. This follows the certification of the Arriel 2D in May 2011, to power the EC130 T2 and AS350 B3e helicopters. Since 1978, Turbomeca has been producing over 10,000 Arriel engines. The Arriel family flying records total 37 million flying hours with 1,300 customers in 110 countries. The Arriel 2E offers better performances with lower specific fuel consumption, resulting in lower operating costs. Its modular design, combined with a higher time between overhaul, up to 4,000 hours at entry into service, then up to the goal of 6,000 hours at maturity, allow a simplified maintenance at lower cost. The new engine is controlled by a new-generation dual-channel full authority digital engine control, a benchmark for efficient power control, reducing pilot’s workload and increasing safety. The new engine data recorder further shifts the emphasis to preventive maintenance. These innovations, according to Turbomeca, also drastically reduce unscheduled removals and improve helicopter availability.

The Russian government looks set to provide state funding for the development of its air rescue system. In its online edition, “Voice of Russia” has reported that the aviation industry cluster (and base) in Zhukovsky near Moscow is set to build a number of modernised Antonov An-2 aircraft. Other models are also expected to be deployed at a later stage. The infrastructure is designed to coordinate operations on three levels: international, cross regional and regional. A fleet of long- & middle-distance as well as light aircraft, backed up by helicopters, will be deployed with medical equipment to cover each of these levels. Mr Gussarov, senior editor for “Avia.ru”, says that modernised An-2 propeller planes are his preferred choice for regional air rescue operations. Two prototypes have already been built and contain a new jet engine, which should enable them to fly more efficiently than previous models. According to Gussarov, all the technical features are enhanced by new avionic systems, the aircraft’s range has increased by 50% and its fuel consumption rate has been reduced. An enthralled A. Komarov (“Aviatransportnoye Obozreniye” magazine) added: “The An-2 is a veteran. It only requires a short runway for take off and landing. It can take off from a 100 m long, unpaved runway.”

For more information, visit: ››› www.turbomeca.com

For more information, visit: ››› english.ruvr.ru

Photo Air Zermatt

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

Turbomeca’s Arriel 2E engine certified by EASA

Tailor-made Medical interiors that fit your mission

Performance Lightweight equipment and excellent handling

Aerolite Max Bucher AG | Aumühlestrasse 10 6373 Ennetbürgen | Switzerland Phone +41 41 624 58 58 | www.aerolite.ch

Flexibility Quick change capabilities for different missions

Completion Center | Ueberlandstrasse 255 8600 Dübendorf | Switzerland Phone +41 44 822 93 33 | www.aerolite.ch

Aerolite America LLC | 1012 Market Street, Suite 305 Fort Mill | SC 29708 | USA Phone +1 803 802 44 42 | www.aerolite.aero

8 | NEWS LAA (I): Graham Hodgkin as new CEO

LAA (II): Helicopter with a new look

London’s Air Ambulance announced the appointment of Graham Hodgkin to the role of Chief Executive Officer. He joins at an exciting time of rapid transition and will lead the service through its next stages of development and growth. Commenting on his appointment, Graham said: “I am incredibly excited about the opportunity to use my skills and experience to benefit this superb charity, which not only saves people’s lives daily, but also leads the way for other air ambulance services globally. I look forward to the challenge that lies ahead.” Graham has more than two decades of experience in the City. He is a former Managing Director at Deutsche Bank, where he led a variety of client facing businesses, as well as being heavily involved with its Corporate Social Responsibility initiatives. Graham also previously founded an independent consultancy, providing a range of business advisory, coaching, training & leadership to the financial services, social enterprise and charitable sectors. Dr Gareth Davies, Medical Director and Chair of the Trustees of LAA, said: “Building on our worldwide reputation for clinical excellence, Graham will lead the charity through its next phase of growth and development and will continue to enhance our capacity to serve the capital.”

The London’s Air Ambulance helicopter, an MD902 Explorer twin engine, has returned from its annual service with a new look – emblazoned with emergency markings and key messages. The changing message on the tail boom details the number of critical missions attended by the medical team (currently at 28,502). The charity that delivers an advanced trauma team to critically injured people in London believes the helicopter is the focal point to create greater awareness of the vital life-saving interventions that are carried out by the service 24/7. Graham Hodgkin, Chief Executive Officer of London’s Air Ambulance, said: “Despite our

extraordinary life saving work and prestigious reputation for medical excellence throughout the world, our charity remains relatively unknown within the city in which we operate. A stronger, more powerful relationship with all of our supporters will be a key component of the current fundraising effort for a new, second helicopter this year.” Compared to other major world cities with 3 or 4 medical helicopters, London is the only capital city in the world with only one helicopter for its air ambulance service. For more information, visit: ››› www.londonsairambulance.co.uk

For more information, visit: ››› www.londonsairambulance.co.uk

LAA

Weinmann with separate Emergency Care business

LAA

Weinmann Medical Technology (Germany), manufacturer of the well-known portable Life Base system and other devices, has been pursuing a focus strategy for the past few years in order to better serve its different target groups. As of 1 June 2013, its large business units Homecare and Emergency will become two independent companies in order to be able to better focus on satisfying the respective target group’s requirements. An investor will be taken on for the Homecare business. Weinmann wants to “speed up expansion” on these two different international market segments. With the separation, Weinmann aims at creating two independent, powerful entities. “By taking on a strategic investor, we will strengthen our existing strategy in the Homecare business”, says Managing Partner Marc Griefahn. “As we increase our focus on the two different market segments, we will be in a better position to fulfil customer needs.” The carefully planned split

of the two businesses will be carried out in the coming months. During the transition period Weinmann wants to encourage the involvement of its customers, suppliers and business associates in order to make the “existing partnerships even stronger.” For more information, visit: ››› www.weinmann.de

Weinmann

AgustaWestland

1 · 2013 I Vol. 3 I AirRescue I 8

EAAA with two new medical experts

the latest and most comprehensive technology available, also including an L3 Wescam MX-15iHD FLIR/TV camera turret; a Honeywell Skyforce Observer 2000 mapping system; multiple communications systems, including high frequency, VHF AM/FM radio and UHF radio; a multiple casualtystretcher arrangement; a dual Goodrich rescue hoist installation and a Nightsun XP steerable searchlight. The GAP SAR contract start date is 1 June this year, with the transition of the Sumburgh base from the present contractor to Bristow. The transition of the second base, Stornoway, will take place on July 1. Two S-92s will be stationed at each base.

East Anglian Air Ambulance has appointed two new medical experts: Dr David Anthony Zideman and Professor Professor Timothy Hodgetts. Dr Zideman (below), Olympic Doctor and Honorary Physician to the Queen, has been appointed to take up a new role of Director of Clinical Operations. Prof. Timothy Hodgetts (left), a serving Colonel in the British Army, joins EAAA as Director of Clinical Quality and Development. Both new appointees have distinguished careers and are known for developing clinical advances in prehospital and emergency care. Dr Zideman has a distinguished career in Resuscitation medicine, and prior to the EAAA Olympics he was recognised for his services to the Royal Family, as a Queen’s Honorary Physician, by being awarded as Lieutenant in the Royal Victorian Order (LVO). Professor Hodgetts has been a leader for over a decade in developing the clinical advances in pre-hospital and emergency care in the Armed Services that have led to exceptional outcomes. He was awarded the CBE in 2009 for his contribution to combat casualty care development and was awarded the Danish Defence Medal in 2010 for clinical leadership of a multinational field hospital in Afghanistan. Both experts praised EAAA’s activities. Dr Zideman said: “As a doctor EAAA already flying missions with the EAAA I am very impressed with the professional approach and clinical excellence that I see in EAAA. I am honoured to be working for the charity in this important new role.” Professor Hodgetts also said, “This is a fantastic opportunity for me to further develop the advances we have made in the areas of combat to improve the care and treatment that we are able to offer to local people who experience a medical emergency. I am really looking forward to working with the skilled and very talented people at EAAA.”

For more information, visit: ››› www.bristowgroup.com

For more information, visit: ››› www.eaaa.org.uk

DLR

Airflow gives helicopters more “puff” Researchers at the German Aerospace Center (DLR) in Goettingen have discovered a way of making helicopters more manoeuvrable. In a unique wind tunnel experiment, they have been blowing air through holes in the rotor blades to actively influence airflow. Although the rotor gives the helicopter its unique ability to take off and land vertically, there are also aerodynamic disadvantages to be associated with it. “Dynamic stall” causes turbulence, lift is lost and enormous forces act on the rotor. Air resistance increases and the rotor head control rods are subjected to enormous dynamic loads. The concept now devised by the researchers in Goettingen acts like a kind of aerodynamic damper on helicopter rotors. There are small

holes in the rotor blades through which air is passed outwards – under high pressure –, which reduces the amount of harmful turbulence when stalling occurs. This substantially reduces the pitching moments exerted on the rotor blades. The pilot has the option of applying this function for brief periods during difficult flight manoeuvres. There is nothing new about the idea of actively influencing aircraft aerodynamics by blowing air in this way. But now, DLR researchers successfully demonstrated that the idea works on helicopters – in a wind tunnel experiment under realistic conditions. For more information, visit: ››› www.dlr.de

Bristow

Bristow with first GAP SAR aircraft The first of four Sikorsky S-92 helicopters that will service the UK GAP SAR contract starting later this year is nearly finished and on track to begin training flights very soon. It is equipped with the latest NVG technology. “The Department for Transport and the Maritime and Coastguard Agency contracted Bristow to provide SAR helicopters that can operate in Northern Scotland in all weather conditions, day and night. Our GAP SAR helicopters are entering a completely new field of operations using this technology”, says GAP SAR Project Manager Ian Middleton. The latest-generation image intensifier tubes used in NVG are difficult to obtain and require an export license agreement with the U.S. State Department. In addition to night vision capabilities, other SAR-related features on the S-92 represent

1 · 2013 I Vol. 3 I AirRescue I 9

10 | NEWS Bond and EAAA in a “light-tight tent” Bond Helicopters Europe confirmed that EASA has approved one of its EC135 aircraft for NVG operations to ground level, a significant step towards the UK’s first night air ambulance operations. According to Bond, there is currently no air ambulance service in the UK that is able to operate HEMS flights at night. Bond has received EASA Supplemental Type Certificate (STC) approval for a night vision imaging system (NVIS) modification to an EC135 helicopter. With this technical approval secured, the next step will be to secure operational approval from the UK Civil Aviation Authority (CAA), a process that is still on-going. In summer 2012, Bond took delivery of a new EC135 for use by East Anglian Air Ambulance (see AirRescue Magazine 4/2012). Upon delivery, the aircraft was not certified to fly using NVG. Bond’s Design & Completions department then undertook the necessary design, certification, installation and testing work to modify and equip the aircraft for NVG operations. The first step of this process was to install various items of special equipment (including moving maps, engine Usage Monitoring System and a Powerline Detection System) on the aircraft, and to modify standard items of equipment to make them NVIS compatible. This involved lightlaboratory tests on the lit instruments inside the aircraft to ensure that they were emitting only the correct wavelength light, which wouldn’t interfere with the NVG worn by the pilot and crew. A “dark hangar” test was carried out as well. This involved building a special light-tight tent into which the aircraft was placed to simulate “starlight” (i.e. very dark) conditions. For more information, visit: ››› www.eaaa.org.uk ››› www.bondaviationgroup.com

Make your ad space reservation for the upcoming

AirRescue International Air Rescue & Air Ambulance

Deadline: 3 May 2013

Bond Air Services aircraft reaches 10,000 hours milestone Bond Air Services (Bond) announced that one of the two helicopter air ambulances it operates on behalf of the Scottish Ambulance Service (SAS) has reached 10,000 flying hours. The aircraft, a Eurocopter EC135 T2i, reached this milestone transferring a maternity patient with abdominal pains from Cambeltown hospital to Crosshouse hospital in Kilmarnock. The helicopter flew in excess of 930 hours during 2012. This high specification modern technology aircraft is the most popular helicopter air ambulance operating in the UK, located at 18 of Bond’s bases throughout Scotland, England and Wales. The aircraft was one of the first EC135s introduced into Bond’s fleet, replacing the BO105

aircraft operated from the commencement of the service in April 1989 up until October 2000. It provides HEMS and air ambulance support across the Scottish Lowlands, Highlands and Islands, including patient transfer for areas without major hospital facilities. As part of the recently renewed contract between Bond and SAS, two of the latest medically equipped EC145 T2 aircraft will be introduced in September 2014. The new aircraft type will further enhance this service by delivering improved range and endurance, whilst also providing more room for patients and equipment. For more information, visit: ››› www.scottishambulance.com

Unusal landing sites in Wales

Bond

Rugby clubs across Wales from Colwyn Bay to Aberdare have signed up as EMS helicopter landing sites as part of a new scheme introduced by the Wales Air Ambulance Service and the Welsh Rugby Union. More than 50 new sites for landing the lifesaving air ambulances have already been established with the potential for 300 sites across the nation being provided by member clubs of the Welsh Rugby Union. The Wales 2013 RBS 6 Nations rugby squad helped launch the initiative at WRU headquarters and WAA clinical and operations manager Jason Williams says he has been overwhelmed by the response. “We are extremely pleased and encouraged by the amount of clubs who have signed up to the scheme so far, already the new sites we are establishing will make a real difference to the lifesaving work of the Wales Air Ambulance service,” said Mr Williams. The Wales Air Ambulance charity and the Welsh Rugby Union have launched the project to establish hundreds of potential landing sites for the helicopter charity on rugby pitches across Wales. A large selection of the 300 plus rugby

pitches in Wales have been identified as potential landing sites in emergencies. If clubs respond positively to the WAA questionnaire, on site visits will take place to assess the potential of the pitches as landing sites. Questionnaires have been sent out to all member clubs, asking them to indicate whether their grounds are suitable for emergency use by the helicopters – also at night. For more information, visit: ››› www.wru.co.uk

WRU

1 · 2013 I Vol. 3 I AirRescue I 10

NEWS | 11 New simulator for ADAC HEMS Academy HEMS Academy, the simulator training arm of German ADAC Air Rescue, has announced that it will add a new EC145 T2 full-flight simulator in 2015. This follows ADAC’s order last September for 14 new EC145 T2 helicopters that will be equipped with the EuroAvionics EuroNav7 navigation system upgrades, which will also be included in the simulator. Meanwhile, an EC145 T2 systems training device will be brought online in mid-2014, allowing for web-based training on the type. “All EC145 T2 customers are invited to participate in the development and customization of the respective full flight simulator and the system trainer,” said Thomas Gassman, HEMS Academy director of business development and sales. The Academy has also launched a project to convert

its EC135 analog-instrumented full flight simulator into an EC135 EFIS-equipped digital-cockpit simulator, which will be qualified by the end of this year. The Academy highlights that its base at Airfield Bonn-Hangelar in Sankt Augustin, Germany, is centrally located, within an hour drive of three international airports in Frankfurt, Cologne and Duesseldorf. Launched in 2009, the Academy specializes in pilot training in EC135 and EC145 full-flight simulators, and customers include operators from all over the world. The simulators are built by QinetiQ subsidiary cueSim. (Source: AIN Online) For more information, visit: ››› www.hems-academy.de

ADAC HEMS Academy

Aviators India: Seven EC135 ordered for HEMS

Eurocopter

Marking a key milestone in India’s development of modern HEMS missions, Aviators Pvt Ltd signed – in the presence of French President François Hollande – a firm order for an initial batch of seven EC135 aircraft for HEMS operations (image depicts an EC135 of SAMU, SAF Helicopteres, France). A second order is expected to be carried out later this year and rapid growth is anticipated in the HEMS market – as many as 50 helicopters are expected to be deployed throughout the

1 · 2013 I Vol. 3 I AirRescue I 11

Blood On Board at KSSAAT The Kent, Surrey and Sussex Air Ambulance Trust (KSSAAT), a charity that operates two MD902 helicopters in the Southeast of England, has become one of the first UK HEMS operators, outside of London, to carry blood – enabling its medical crews to administer pre hospital blood transfusions. The KSSAAT medical teams operate from bases located in rural parts of Kent and Surrey and have no direct access to hospital blood supplies. Using a model devised and evaluated by Dr Anne Weaver and the team at The Royal London Hospital and London’s Air Ambulance, project leader and Clinical Manager Gary Wareham, was faced with the logistical problem of ensuring a consistent supply of blood units to the helicopter bases. Staff from the Transfusion Departments at the William Harvey Hospital in Ashford, Kent and the East Surrey Hospital in Redhill, Surrey, pack four units of O-negative blood into Credo™ “Golden Hour” containers, manufactured by Minnesota Thermal Science (USA), which are then transported to the KSSAAT bases by volunteer members of the SERV groups. The containers maintain the temperature of the blood units between +2 and +6 degrees centigrade as required by UK legislation and ensures that any unused units are able to be returned to the hospitals blood bank. Two containers are available at each base that allows for the supply to be immediately replenished on the crews return to the base after a mission. The blood units have been available to crews since the beginning of February this year and have already been used to stabilise the condition of seriously injured patients at both the scene of the incident and whilst en route to Major Trauma Centres. (G. Wareham, Clinical Manager, KSSAAT) For more information, visit: ››› www.kssairambulance.org.uk/

country in the coming years. With first deliveries planned to take place by late 2013, Aviators is establishing itself as a pioneering HEMS operator in India. “As the EC135 is a global reference in HEMS, it is highly appropriate that Aviators will introduce such operations in India with these extremely capable helicopters,” explained Norbert Ducrot, Eurocopter Senior Vice President for Asia Pacific. The EC135 is operated worldwide for a broad range of missions, including HEMS, rescue operations and business aviation. Equipped with a Fenestron shrouded tail rotor and bearingless main rotor, the helicopter delivers extraordinary range and payload capacity. Its large, unobstructed cabin, oversized sliding side doors and rear clamshell doors enable rapid loading/unloading of patients and equipment – even with the rotors turning – which facilitates operations during time-critical emergency medical missions. For more information, visit: ››› www.eurocopter.com

KSSAAT

12 | EHAC

“Safety is not an add-on” Interview with Benno Baksteen, keynote speaker at the EHAC Safety Symposium 2013 Benno Baksteen, born in Rotterdam in 1948, received his first flight captaincy in 1982 on the DC-9. He moved on to captain on the Boeing 747 in 1988, rounding out his career with a three-year captaincy on a fourth-generation high-tech transport, the Boeing 777, before retiring in September 2006. During his career he also held several positions in the Dutch Airline Pilot Association (VNV); from 1989 till 1997 he was its President. In 2007, Mr. Baksteen was appointed Chair of the Dutch Expert Group on Aviation Safety (DEGAS) an international oriented advisory committee that reported to the Dutch Cabinet and the Dutch Parliament. Mr. Baksteen is the keynote speaker at the EHAC Safety Symposium 2013 that is going to be held in Warsaw, Poland, on 22 and 23 May 2013. Tobias Bader interviewed Mr Baksteen for the AirRescue Magazine and asked him about safety culture(s) in HEMS operations.

ARM: Mr. Baksteen, you are going to give the keynote speech on ‘safety culture’ at the EHAC Safety Symposium 2013, to be held in Warsaw, Poland, from 22-23 May 2013. ‘Safety culture’, it seems, is the topic that preoccupied you the most during your whole professional career. In your opinion, what are the main aspects of such a safety culture in flight operations? Benno Baksteen: The most important component is a Just Culture, a culture in which only criminal intent or gross negligence will lead to sanctions. All other occurrences, whether they are accidents, incidents, mistakes

and violations, both intentional and unintentional, should lead to analysis and system improvements. For a system to improve you need to know what goes wrong and only in a Just Culture will people feel free to report what goes wrong. Whether or not they were part of the sequence of events, or even the key. Next on the list is the set of rules and procedures that people have to work with. These should represent best practices instead of, what is unfortunately rather common, distrust. Nor should the main purpose be to try to protect from legal and/or administrative penalties, sometimes referred to as CYA – cover your ass – rules. The third ingredient is the acceptance of the fact that rules are tools. You can and should follow good rules and procedures almost all of the time, but it is not an automatic process that could be carried out by a robot. The first-line professional has to confirm each and every time before applying a specific rule or procedure whether or not it indeed applies in the specific situation and will indeed lead to the intended outcome. The final component, needed when you want to move from a high level of safety to a very high level, is the acceptance of the fact that the unexpected will happen. So not everything can be covered with rules and procedures. The best bet here is resilience, both of the professional as an individual and of the organization as a whole. ARM: Are these points also applicable to HEMS operations? Where do you see certain differences or peculiarities? And do the differences between rotary and fixed wing play an important role? Benno Baksteen: Absolutely, these points are quite universal. There are differences of course. One of these is, that airlines use airports, in other words, properly equipped points of departure and arrival, about which everything you need to know is documented. Including

1 · 2013 I Vol. 3 I AirRescue I 12

EHAC | 13 navigation and landing aids, detailed terrain information and weather reports. The uncertainties in HEMS operations are far greater. The biggest difference however might be that with airline operations the goal is to arrive at your destination and preferably on time. But if you encounter adverse circumstances, the decision to divert or even to abort in the interest of safety is just a matter of financial consequences and inconvenience. HEMS operations involve by definition matters of life and death. Canceling or aborting a flight means that probably someone will die who would have had a chance to survive. So the pressure to accept operational risk might be greater than with airline operations. ARM: Do you have any suggestion on how an operator or organization should develop a safety strategy and how to maintain it? Benno Baksteen: It all starts with the acceptance of the fact that safety is not an add-on. Safety is an integral part of normal every day operation and of the whole of the organization. It is part of every decision. There will always be economic and other pressures away from safety and that is just the way it is. Safety will unavoidably always be a compromise. If you accept that, you should then be able to strike an optimal and accountable balance between safety and other goals. For that to happen on a daily basis you need to organize counter-pressure against the pressure of, for instance, financial constraints. A good Safety Management System (SMS) does just that. An effective SMS is not a one-time exercise: it is a continuous, dynamic and cyclical process.

1 · 2013 I Vol. 3 I AirRescue I 13

ARM: How should a best-practice safety culture look like in order to develop and foster a safety culture at HEMS operators? Benno Baksteen: Professionals in a best practice culture will feel free to report mistakes and failures, even if no harm was actually done. Reports will never be held against them, but will be analyzed and will lead to improvements in for instance knowledge, training, rules, procedures, technical equipment, and/or other tools. The safety culture should be clearly stated by the organization and rigorously adhered to from the CEO down. Only then will it become part of everyday life at the sharp end of operations. ARM: One of the reports that the DEGAS published was called ‘Rules as Solidified Experience’. An almost philosophical description, which implies that safety culture actually cannot be implemented ‘top down’. Do you agree? Benno Baksteen: Indeed I do. It is not possible to ‘rule’ or ‘inspect’ safety into a system, other than at a very basic level. High levels of safety are only possible when the system generates rules and procedures that represent best practices. What we choose to call solidified experience. Bottom-up development based on what really happens is essential for that. Of course, you need at least two top-down elements, too. The initial framework needs to be established top-down, and even more important is the commitment of higher management to the bottom-up process. It is quite natural for people who are one or more steps removed from the daily operation to feel that the

Fig. 1: “Safety is an integral part of normal every day operation and of the whole of the organization, it is part of every decision” (Photograph: Norsk Luftambulanse)

14 | EHAC

Fig. 2: “It is not possible to ‘rule’ or ‘inspect’ safety into a system: high levels of safety are only possible when the system generates best-practice rules and procedures” (Photograph: Norsk Luftambulanse)

rules are excellent and that if only the professionals would make no mistakes and would always adhere to the rules, there would be no problems. However that is a fallacy. The real world is too messy and most organizations are too complicated for that to work. Apart from the fact that neither people nor systems will ever be infallible.

If a specific culture prevents or restricts that openness you either have to accept lower levels of safety or the culture has to change. A culture is basically a set of customs, so change should be possible. Especially in our increasingly global society. But this will no doubt be a very lengthy process.

ARM: How does a ‘bottom-up’ strategy that takes into account the needs and safety issues of the staff and crew members working ‘at the forefront’ may look like?

ARM: Do you think the issue of safety can be boiled down to the question of which technologies are being used and is it finally only a matter of financial means – those who can afford ‘buy’ themselves a safety culture?

Benno Baksteen: Staring point would be a dynamic SMS, based on an open reporting system made possible by a Just Culture. This will generate bottom-up the bestpractice way to do what needs to be done in a system that will actually work in the real operational environment. As opposed to top-down systems that create manuals of rules and procedures that typically gather dust on a shelf because they are unworkable in real life. ARM: It seems that there are many different cultural/ national approaches towards safety or even different national safety cultures as such. Do you think one has to live with these differences and accept it as ‘cultural diversity’? Or do you think they have to be leveled out, completely standardized and universalized? Benno Baksteen: You have to live with them in the sense that they cannot be ignored. In the interest of safety you have to be aware of these differences. Having said that, it is obvious that for very high levels of safety you need an open culture without fear for losing status or power when being open about things that go wrong.

Benno Baksteen: Absolutely not. Advanced technologies and adequate financial means can be helpful, but what these mainly do is make more things possible. A safety culture has nothing to do with that. Whatever your tools and means are, a safety culture will help you make the best of it. And it will stop you doing things you cannot safely do with the technology and financial means at your disposal. Actually it might even be the other way around. Making more things possible tends to decrease margins to disaster and to increase the consequences when things go wrong. So the more advanced your technology and the more ample your resources, the more sophisticated your SMS should be to at least have the same level of safety as a less complicated and cheaper system. And the more difficult it is to accomplish that, because one might easily feel safe-guarded by technology. And nothing seems to go wrong anyway. So the resources to put that extra effort in your SMS might be difficult to obtain. ARM: Mr Baksteen, we thank you for the interview.

1 · 2013 I Vol. 3 I AirRescue I 14

The first high end transport ventilator with ICU performance The Hamilton-T1 is designed to provide all advanced modes of ventilation to the adult and pediatric ICU patient anywhere around the world. With its compact size of less than 6.5 kg, built in batteries with up to 5.5 hours of operating time, 8.4â&#x20AC;? color touch screen and its advanced turbine, this transport ventilator with ICU capabilities can accompany your patient within the hospital and between hospitals, whether on the ground or in the air. Its high performance NIV capabilities add state-of-the art therapy options for every transport situation. For further information: www.hamilton-medical.com/T1

HAMILTON MEDICAL AG Via Crusch 8, CH-7402 Bonaduz, Switzerland (+41) 81 660 60 10 (+41) 81 660 60 20 www.hamilton-medical.com info@hamilton-medical.com

16 | EHAC

Fig. 1: “In the coming years, EHAC will hopefully be a platform for fixed wing rescue with worldwide accepted standards” (Photographs: MedCareProfessional)

New EHAC-member: MedCareProfessional (Germany) Although MedCareProfessional offers a wide range of ambulance services, its true passion is for air ambulances. The company was founded in 2005 by Dr Joachim Friese (MD) and Michael Weber and received EURAMI (re-) accreditation in 2012. MedCareProfessional GmbH is air ambulance provider with international operations, however their main base is in Hattingen (North Rhine-Westphalia, Germany). The company runs its own 24-hour flight coordination centre, and its flight coordinators are specially trained to assist MedCare’s customers to ensure a smooth, safe and efficient patient transfer.

MedCareProfessional

MedCareProfessional had already received accreditation by EURAMI (European Aeromedical Institute) in 2009 and was then fully re-accredited in 2012 with the title Full Accreditation ‘Special Care’. MedCareProfessional operates several ICU air ambulance units, each with a physician/ICU nurse crew. The interhospital transfer service is for seriously ill, mostly ventilated patients, requiring ECMO and other kinds of critical care. It is being carried out between nearby cities and/ or municipalities. Its clients include insurance companies and private clients. The ICU units are picking up and dropping off patients at nearby airports. MedCareProfessional also provides ground ambulances and crew for neonatal incubator transportation. This is mainly aimed at regional perinatal centres but it is also equipped to pick up infant patients at airports. Ground ambulance transport is available for insurance companies and private clients, mainly covering Western Europe. AirRescue Magazine spoke to Joachim Friese, the medical director of MedCareProfessional.

ARM: What was the reasoning behind MedCare joining EHAC? Joachim Friese: Our membership primarily aims at sharing experiences and utilising the expertise that EHAC has. Secondly, the quality standards of air ambulance providers differ substantially between different countries. The need to establish an international standard is pressing, and this is something EHAC is working on. In the coming years, EHAC will hopefully be a platform for fixed wing rescue with world-wide accepted standards as well as a crossborder organisation with the possibility of establishing a scientific approach to the matter. ARM: What do you think will be the main challenges in the near future? Joachim Friese: 2013 will be a year in which financial forces and economic cutbacks will influence the international market for Medical Service Providers. New paths have to be taken to ensure competitive capacity. The growing exchange of information amongst providers, concerning standards and regulations for example, especially in the air ambulance market, gives hope that

1 · 2013 I Vol. 3 I AirRescue I 16

EHAC | 17 good quality and a high standard of service will finally come out on top.

Facts & Figures Missions

1,603 international and national missions, 402 air ambulance transfers, 1,201 ground ambulance transfers by ICU units in 2012 (23 being ECMO transfers)

Staff

Permanently employed personnel: • 14 medical and non-medical, including 2 physicians

ARM: Do you see growing potential in the air ambulance sector? Joachim Friese: The last few years have seen a surge in the number of small air ambulance providers on the market. A considerable number of them offer medical flights without any profound expertise but at a low cost, meaning they are a potential threat to the solid working of established providers. These providers are put under pressure not only by the strict budget cuts in local governments and the insurance industry, but also by the ever increasing fuel prices. Providers are forced to think economically and boldly. They have to come up with innovative concepts. For example, the “fleet operating tactics” have to be checked for effectiveness, double-stretcher ambulance flights, “floating base concepts” and co-operations with other providers will be the rule rather than the exception. Despite these restrictions, I am convinced that reasonable pricing and sustained quality ensure solid positioning in the market. ARM: What are your future expectations and wishes? Joachim Friese: We would like to encourage cooperation between the government and organisations like EHAC to

Freelance personnel: • 98 physicians and nurses Aircraft fleet

• 5 Lear 35/ Lear 55 • 3 TurboProp PA 42

Air Bases

• Cologne EDDK, Germany • Siegerland EDDS, Germany

Branch Offices

• Bochum und Kempten/Allgäu (ground ambulances)

Ground Ambulance fleet

• 3 ICU Ambulance Units, Type Mercedes Sprinter • 3 Ambulance Vans, equipped for ventilation • 3 Ambulance coaches • 1 fully equipped Infant Ambulance Van • 1 Emergency Physician operational vehicle

agree upon regulations and standards for all providers. That will be the main issue in 2013. ARM: Mr Friese, we thank you for the interview.



More benefits in special cases – lightweight solutions. Air Rescue or patient transport by air. These and other special missions call for all kinds of customized equipment. We offer you a wide range of such equipment and ensure efficient and clever solutions. The result is cost-effective and flexible equipment for your missions.

NEW GENEratioN: EmErGENcy mEdical SyStEm • Flexible equipment with multiple configurations for different missions • Full medical certification with label according to 93/42 EWG • EN 13718 compatible • Night vision compatible • EASA Supplemental Type Certification

Bucher Leichtbau AG Industriestrasse 1a

1 · 2013 I Vol. 1 I AirRescue I 17

CH-8117 Fällanden Phone +41 44 806 24 24

bucher@bucher-group.com www.bucher-group.com

18 | EVENTS

Fig. 1: From 2009 to 2012, a total of 5,480 flights were made in Moscow, totalling 1,791 hours and assisting 1,668 people (Photographs: Eurocopter Vostok)

Present and future of Russian HEMS: Conference on Russian Air Ambulances and Medical Evacuation The 2nd Interdepartmental Conference on Russian Air Ambulances and Medical Evacuation will be held from 16 to 17 May 2013 at the Crocus Expo (Pavilion 1) in Moscow as part of the 6th HeliRussia 2013 International Helicopter Exhibition. The conference is being organized by the Helicopter Industry Association, Mobile Medicine LLC and HeliRussia. The organizers of the conference are providing an open forum for government officials, air ambulance service providers of various forms of ownership, designers, manufacturers and certifiers of medical evacuation aircraft and medical equipment to discuss a large range of issues associated with efforts to revive medical evacuation services in Russia.

Author: Maria Shcherbakova

Last year, the scientific meetings of the conference were attended by representatives of various Russian Ministries, among them the Ministry of Health, of Transport, the Emergency Situations Ministry (Emercom), the Federal Air Transport Agency, the Interior Ministry, Ministry of Defense, but also representatives of Russian Helicopters Company, United Aircraft Corporation, the All-Russia Center for Disaster Medicine (“Zashchita”), the Federal Medical-Biological Agency, the Moscow Institute of Pediatrics and Pediatric Surgery, the All-Russia Scientific-Research and Testing Institute for Medical Technology (part

of Roszdravnadzor, the health oversight service), scientific associations, businesses and non-profit organizations. Among the attendees was also Pavel Müller, President of the European HEMS and Air Ambulance Committee (EHAC), who gave a presentation on “Helicopter Ambulance Services in Europe.” By gathering many stakeholders in one place, it was possible to discuss – in a friendly and constructive atmosphere – the full range of emerging issues, to share experiences and get the latest information. Attendees showed their appreciation about how the conference was

1 · 2013 I Vol. 3 I AirRescue I 18

organized. This is why the conference program will be expanded in 2013. The two-day conference format includes symposia, round tables and workshops on helicopter ambulance technologies led by leading Russian experts.

Vast distances and challenging infrastructure Evacuation by aircraft is the most important component of disaster medicine. Air evacuation is crucial in a country like Russia with its vast distances and poor infrastructure for ground transport. But even in Moscow, the number of aircraft in the air ambulance fleet is few – so far. And nationwide, there are no more than a few dozen. It is very revealing that there are 6 air ambulance helicopters actively being used in Moscow, no more than 10 under separate permits, and 10 landing sites (including airports, a heliport and helipads). In comparison, Paris has an active fleet of 150 helicopters and 104 helicopter pads. In New York, the figures are 350 and 137 respectively. Creating a full-fledged, regular air ambulance service depends on many factors: What will it cost per hour of flight and who will pay for it? Will licensing be required? Will foreign-made helicopters be available? Nevertheless, there are already good examples of success in the air ambulance field. In particular, the government-run Moscow Aviation Center (MAC) has produced an optimal flowchart from the judicial standpoint and the everyday practice.

Moscow Aviation Center The MAC has been carrying out evacuations in and around Moscow for the last four years. The center has three BK117 S2 (EC145) helicopters that are fully equipped to provide emergency medical care. A total of 5,480 flights were made in Moscow from 2009 to 2012, totalling 1,791 hours and assisting 1,668 people. In the Moscow region, there were 285 flights and 167 people being attended to. The crew consists of two pilots (minimum). One of them is the commander of the crew, while the second is the co-pilot. The medical team consists of an EMS doctor and another doctor, specialized in resuscitation, from the Center for Emergency Medicine (CEM) who is also a qualified rescue worker. He or she is responsible for deciding whether to transport the patient. Together, they provide medical treatment during the flight, each in accordance with his or her professional qualifications. Victims and patients are evacuated under an agreement signed between the MAC, the Moscow Health Department and the Head Office of the Russian Emergencies Ministry (Emercom) in Moscow. The duties of the parties are delegated as follows: The CEM analyzes the

1 · 2013 I Vol. 3 I AirRescue I 19

information it receives (emergency calls), “sorts out” the calls that require the use of helicopters, submits a request to the MAC for a mission, provides the helicopter crew with medical supplies and communications equipment, determines the destination hospital, issues orders for the hospitalization, and delivers the patients from the helicopter to the hospital. The MAC is responsible for the readiness of the aircraft and crews for missions, keeping a duty officer on duty at all time. Besides this, the MAC is also in charge of dispatching properly fitted-out ambulance helicopters at the request of the CEM, getting permission from the authorized bodies, admitting and dispatching helicopters, maintaining the MAC’s helicopter pads at the hospitals and making sure that the personnel of the CEM being flown are insured. Each party bears its own costs. Since the MAC is a government agency, all of its costs are paid out of Moscow’s budget. Transportation is provided to the public free of charge. Missions are generally limited to a 200 km radius, but patients may be transported up to 500 km, this number including the extra distance flown around restricted areas.

Financial viability As one can see, the practical experience of the Moscow MAC could serve as a role model. On the other hand, the MAC, unlike commercial airlines, does not have to worry about financing. For this reason, the experience of the MAC cannot be replicated nationwide. If the financing model requires patients to pay for the service, then air ambulance service will never be a realistic option for the masses. Mandatory certification and licensing also affects the profitability of the business. To speed up and simplify the transportation process, operators do not always claim to be providers of air ambulance services. It is therefore necessary to adopt separate rules for small operators, and this subject was also discussed at the conference. The draft of such rules is ready and has even been discussed in and approved by the relevant departments. Now we have to wait for the day when they enter into force, which is not far off. Well, let us wait and see. Nevertheless, Russia has some experience with air ambulance services, albeit fragmentary. And this experience then may serve as a stepping stone for the expansion of HEMS into the rest of the country.  For more information, visit: ››› www.narkoz.ru/sanavia ››› www.helirussia.ru

Fig. 2: HEMS missions are generally limited to a 200 km radius, but patients may be transported up to 500 km Fig. 3: There are three EC145 at the disposal of the MAC, all of them are that fully equipped EMS helicopters

20 | EVENTS

1st AgustaWestland EMS Seminar: Sustaining healthcare systems through HEMS More than 70 delegates from 22 countries participated in the first AgustaWestland international seminar dedicated to Emergency Medical Services (EMS). The conference was held on 14 and 15 September 2012 in the state of Vatican City, in the exclusive Casina Pio IV – which was once a summer residence of the pope Pius IV and now houses the Pontifical Academy of Sciences (since 1926). The intention of the seminar was to share experiences, to learn from one another and to debate the future developments in the field of HEMS. Sixteen speakers covered topics around the importance of having a sustainable, accessible and effective (emergency) healthcare system across the world and how the use of helicopters can contribute to such an important challenge.

Authors: Editorial Team AirRescue Magazine

Fig. 1: The seminar was structured around three sessions dealing with clinical/social, financial and operational aspects of HEMS (Photographs: Agusta Westland)

The conference was structured around three sessions dealing with clinical/social, financial and operational aspects of HEMS. At the end of each session, there was sufficient time for debate. The cultural and leisure program around the seminar completed the two-day event. Prince Manfred Windisch-Graetz welcomed the participants on Friday 14 September at the Casina Pio IV. On behalf of AgustaWestland, Roberto Garavaglia gave a brief introduction into the seminar’s scope, the company and its representatives attending the conference.

The seminar theme, “sustaining healthcare”, was introduced by Valentina Mele, professor of Public Management at SDA Bocconi School of Management (SDA stands for “Scuola di Direzione Aziendale”, School of Business Administration). In her presentation she gave an overview of current trends on global health, described the challenges that these trends pose to the sustainability of healthcare systems and elaborated on the contribution that HEMS may offer to deal with such challenges. There was a multidisciplinary agenda that also reflected the diverse approaches to the delivery of emergency care. It was a unique opportunity to the participants to hear viewpoints from around the world and to learn new approaches to shared challenges. Andrew Pollak (University of Maryland) and Doug Floccare (Maryland State Police) presented the “Maryland system”. They demonstrated that HEMS is most effective when the continuum of resuscitative services is seamlessly integrated to provide patients timely access to high quality trauma care. A strong interface with ground EMS, Fire and Police is required to achieve effective helicopter utilization across all missions.

1 · 2013 I Vol. 3 I AirRescue I 20

EVENTS | 21 Dennis Nesdoly (STARS, Canada) helped to answer the following question: “Given a fixed budget how should we distribute our healthcare money?” He didn’t provide a simple answer, but he described the tools available to make the analysis and the criteria to evaluate choices. HEMS benefits are worth the price, but ...”the important thing is not to stop questioning”. Introducing a completely different perspective and still sharing the same main challenges, Farhaad Haffejee (AMS, South Africa) told the audience the successful story of the AMS non-profit organisation. The conclusion of his presentation was that a reliable, safe and efficient HEMS is possible in a developing world setting, but “it is important to implement local solutions for localised needs”. Nicolas Letellier (AFHSH, France) called upon politicians and regulatory bodies in France and in Europe to make HEMS flights possible in periods of bad weather and/or at night, especially with regard to the implementation of healthcare regionalization policy. The technology is available; some steps have been taken, but a lobbying action from the HEMS community is still required to transform “an option into a political obligation”. “HEMS holds a very simple, but incredibly profound social promise to the public: to be there when needed.” With an inspiring presentation, Thomas Judge (Life Flight of Maine, USA) described the challenges that are associated with this promise, especially in rural areas, where the time is as much the enemy as disease or injury. A reliable HEMS means to design a system (pilots, aircraft, infrastructure) which allows medical helicopters to become as much reliable as commercial flights. Motor vehicle accidents are a major cause of death in the U.S.A. as well as in many other countries around the world. Providing emergency medical responders with vehicle crash information may help them make the appropriate field triage decisions, so crash victims can get to the right type of health-care facility at the right time. The Advanced Automatic Collision Notification system is what Kunhiro Mashiko (Chiba-Hokusoh Hospital, Trauma & Shock Center, Japan) presented as the new technology being implemented in Japan to also create new HEMS alarm and dispatch patterns. A lively round table discussion about the importance of human factors in HEMS, also in order to integrate aviation and medical communities, ended the session. Stefan Becker gave an overview of Rega’s programmes for Aeromedical Crew Resource Management (ACRM) and the Fatigue Risk Management System (FRMS), Andrew Hodge (Lufttransport, Norway) addressed crossindustry learning opportunities from the oil & gas and commercial transportation, concerning helicopter safety. The discussion continued and Tom Judge concluded saying: “There is a wide range of regulatory regimes in the world and we can’t change the regulatory regimens in the world. What we can change is how people that are operating helicopters think about the operations of their helicopters and voluntarily adapt proven strategies to make the operations safer. Everyone’s accident is our accident and it doesn’t matter where you are in the world

1 · 2013 I Vol. 3 I AirRescue I 21

Fig. 2: Geoff Hoon gives an AW109 model to h.e. Marcelo Sànchez Sorondo, Bishop-Secretary of the Pontifical Academy of Sciences

Fig. 3: Prof Mele during her introductory speech

because in a 24-hour new cycle, all of those will affect our operations.” The Seminar ended on Saturday with a closing ceremony and a convivial lunch. Several attendees expressed their gratitude after the seminar, many appreciated “the opportunity to hear about the way the HEMS business is operated in other countries and circumstances” and added that they “picked up quite a few topics to be followed up on to see if they can be of benefit in their own circumstances.”  For more information, visit: ››› www.agustawestland.com

22 | SAFETY

Patient safety in air ambulances: Where do we stand? Safe practice in the air ambulance industry has been a hot topic since the first air ambulance systems were established. Safety in the air ambulance industry has however been synonymous with flight safety and the focus has been on avoiding incidents, events and accidents in flight operations. In light of the hazards involved with air ambulance flight operations and the often difficult and challenging missions that are carried out, this safety focus is necessary and important. However, safety in the air ambulance is more than just flight safety.

Author: Stephen JM Sollid Oslo University Hospital stephen.sollid@ norskluftambulanse.no

In the last decade there has been an increased focus on patient safety. It is said that being a patient is far more risky than flying with a commercial airliner, and the theoretical figure of close to 100,000 patients dying annually due to errors in medicine in the USA is thought-provoking (1). Studies show that patients in intensive care units (ICU) are exposed to at least one error a day (2). A third of these errors are potentially lethal, meaning that an ICU patient is exposed to a potentially lethal error every three days. There is no reason to believe that the challenges in patient safety are any different in the pre-hospital health care. Patient care in pre-hospital medicine is – for the most – carried out in places that are not designated for patient care. The optimised environment of a hospital with light, heating, privacy and access to equipment and personnel is far from the reality in pre-hospital care. Even if transport vehicles in pre-hospital care are often built around patient care, there are deficiencies: It is noisy, space is confined, access to the whole patient is often restricted or limited, and light is not always optimal. In many ways, the environmental factors that are present in pre-hospital care and transport medicine can be regarded as driving forces against safe patient care. There are very few studies that have looked at patient safety specifically in air ambulance operation. The Air Medical Physician Association published a report on safety in air medical transport in 2002, based on data from several databases related to helicopter emergency medical system (HEMS) operation in the USA (3). This report concluded that the risk of a patient dying in a HEMS accident was equivalent to less than one fatality pr. 100.000 patients transported in the USA. The data sources did however not include any data on deaths

caused by other factors than flight operation. In a study from Canada in 2008 all data from the mandatory reporting system of the air ambulance company Ornge were reviewed to determine frequency and causes of adverse events that influenced patient care between the years 2002 and 2005 (4). This study determined that 11.53 events occurred pr. 1,000 flights, and that possible harm to the patient was inflicted in 1.99 of 1,000 flights. Nonaviation related events occurred in 71% of the cases and events related to communication were the most predominant with 33.7%. According to the authors, the number of events reported in this study is comparable to what has

1 · 2013 I Vol. 3 I AirRescue I 22

SAFETY | 23

been reported from the emergency department (ED), but lower than what is reported from the intensive care unit (ICU). As the authors state, the relatively low numbers can be attributed to short patient contact, but also to the underreporting of events. In my opinion, the number of patient care related events in the air ambulance are probably somewhat higher, but they would also depend on the patient population in the system and the complexity of care provided. Systems that provide primary care probably have numbers close to what is observed in the ED, whereas systems that mainly transport critically ill patients between hospitals probably have numbers closer to

1 Âˇ 2013 I Vol. 3 I AirRescue I 23

what is seen in the ICU. The question that remains is what the short patient contact in the air ambulance â&#x20AC;&#x201C; compared to hospitals â&#x20AC;&#x201C; means for patient safety and how this is balanced by the other factors influencing patient care in air ambulances that are not found inside the hospitals. Besides being the only study so far to quantify patient safety breaches in the air ambulance, the study by MacDonald et al. also demonstrates two very important things: Unwanted events in patient care do occur in the air ambulance and need to be managed, and the predominant cause is human factors (4).

Fig. 1: The optimised environment of a hospital with light, heating, privacy and access to equipment and personnel is far from the reality in pre-hospital care (Photograph: Norsk Luftambulanse)

24 | SAFETY

Fig. 2: Errors can be prevented from evolving into adverse events and patient harm (Image: S. Sollid)

Fig. 3: A cross-professional safety management system in HEMS – rather than separate ones for aviation and medicine – is absolutely essential in order to sustain safety (Photograph: Norsk Luftambulanse)

Adverse events in patient care rarely occur as a result of intended harm, they are more often a result of a chain of events that are allowed to happen without detection or prevention. In risk management theory we often talk about hazards as the latent starters of processes leading to adverse events. In patient care, these hazards are ubiquitous; advanced medical care in itself is a hazard. Hazards can however be constrained and prevented from evolving into errors by building adequate and effective barriers. In the same way, errors can be prevented from evolving into adverse events and patient harm (see Fig. 2). James Reason described the importance of these barriers in his Swiss Cheese Model, where he states that errors are inevitable as it is in the human nature to make errors, and only effective barriers can prevent them from evolving into events and harm (5). Effective barriers can however be weakened and fail to work as intended. Human factors are effective barrier weakeners. An example to illustrate this concept is pre-hospital endotracheal intubation. Sedating and paralyzing a patient to intubate is equivalent to exposing the patient to a hazard. Only through the knowledge, skills and attitudes of the persons intubating and caring for the patent can the hazards be contained and the patient successfully be treated. These persons and their knowledge, skills and at-

titudes are the barriers. Examples of barrier weakeners in this example could be environmental factors on scene, fatigue of the personnel and failure to comply with protocol. The special challenge in air ambulance is that several non-medical factors play an important role in patient safety, not only the environmental factors mentioned earlier, but also the flight operation itself. The study by MacDonald (4) also shows that events in the flight operation can cause patient harm – not directly, but indirectly. An example of this is the inability to land at the destination, which can cause delay in patient care. Normal flight operation can however also cause unwanted events in patient care. In HEMS systems with instrument flying rules (IFR) capabilities, flying in the clouds means that you cannot return or land immediately if a medical emergency occurs; you must continue to the nearest site with instrument landing capabilities. Failing to take this into account is a serious error that can lead to an adverse event. This illustrates the importance of a cross-professional safety management system in HEMS rather than separate ones for aviation and medicine or rescue operations. Only by taking a holistic approach to safety management the particular challenges that are constituent to air ambulance systems can be encountered and barriers be built and maintained so that hazards threatening patient safety in the air ambulance are being encountered. To conclude, the challenges in patient safety outside the hospital (and in the air ambulance) are not dissimilar from the challenges inside a hospital. Human factors play a significant role in causing errors that may lead to adverse events, and measures taken to improve human factors must have priority. The special environmental and operational challenges in the air ambulance however do also play a role and must be taken into account when dealing with patient safety. In this sense, patient safety in pre-hospital critical care is a field within patient safety with special characteristics that warrant special attention and cannot be dealt with as part of in-hospital patient safety programs. Finally, more research is needed to investigate the extent of patient safety problems in air ambulance and pre-hospital critical care. For, as this article shows, we can postulate a lot based on what we know from in-hospital patient safety data and aviation safety, but we really do not know much about the current status of patient safety in the air ambulance. 

References: 1. Kohn L, Corrigan J, Donaldson MS (2000) Medicine IO: To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America. Institute of Medicine, Washington. Summary: 1-8 2. Donchin Y, Gopher D, Olin M, et al. (1995) A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 23: 294-300 3. Blumen IJ, Coto J, Maddow CL, et al. (2002) A Safety Review and Risk Assessment in Air Medical Transport. Air Medical Physician Association: 1-81 4. MacDonald RD, Banks BA, Morrison M (2008) Epidemiology of Adverse Events in Air Medical Transport. Acad Emerg Med 15: 923-931 5. Reason J (2000) Human error: models and management. Br Med J 320: 768-770

1 · 2013 I Vol. 3 I AirRescue I 24

Focus

Lives are on the line When a rescue hoist is all that stands between life and death, you need to know it will work. Breeze-Eastern equipment is designed and hand crafted by the worldâ&#x20AC;&#x2122;s most experienced and knowledgeable helicopter rescue hoist experts. Breeze-Eastern is the worldâ&#x20AC;&#x2122;s only dedicated helicopter hoist and winch provider.

breeze-eastern.com

26 | SAFETY

Substance abuse in HEMS: Silent tragedy or dirty little secret? Fig. 1: An investigation launched after the colleague’s death showed that he had apparently been using and abusing many different medications for an extended period of time (Photograph: S. Metsfan)

Author: Jack Davidoff MD, BCEM, EMT-P Jessica Falk RN, BSN, CCRN, CEN, EMT Winnie Romeril BA, MA, NREMT-P

Safety is a word and a concept that everyone in emergency medical services (EMS) strives towards, particularly in helicopter and fixed-wing EMS (HEMS). In recent years, after each fatal crash, news headlines question the safety of air medical transport. In the United States of America, the National Transportation Safety Board (NTSB) and the Federal Aviation Administration (FAA) have made various recommendations and mandates in an effort to provide a safer operating environment for HEMS. Safety talk encompasses nearly every facet of our work. Routinely overlooked, however, are the personal habits of our providers and what effect these may have, not only on their own safety, but on the safety of their colleagues and patients.

In November of 2011, our company was struck by an event that changed our world. Like other services that provide critical care for injured and ill patients, we stock a large formulary of medications. Included in this formulary are opiates, sedatives and some hallucinogens that are known to be addictive or commonly abused. Back then, we secured our medications in a locked cabinet and kept records of all medications used, wasted or damaged. We felt that we were being responsible and safe, but no company is immune to the darkest of human issues. One morning that November, one of our crew, a recently hired flight nurse/paramedic, did not emerge from

his room at the end of his shift. After many attempts to awaken him, the on-call room door was forcibly entered to find our co-worker dead of an apparent overdose. An investigation launched after his death showed that he had apparently been using and abusing many different medications for an extended period of time. He collected medications from several workplaces. We can only conjecture that he may have used medications for sleep assistance, recreation, or in an effort to keep working multiple different jobs as so many providers do. We were in shock – for the loss of a co-worker and our innocence. How could this happen at such a well-

1 · 2013 I Vol. 3 I AirRescue I 26

SAFETY | 27 respected company where only the “best of the best” work? The answer is simple: we mirror the society around us where substance abuse happens in every profession. To think that we are immune as a company (or as an industry, for that matter) is like the ostrich sticking her head in the sand. As a company we wanted to make sure this would never happen again. We looked very carefully at our bases and policies. We instituted major overhauls in how we store medications, drug test our employees, and how company physicals are performed. All of our medications and even our needles are now only accessible via an electronic system that accounts for each and every dose and device. Random urine drug screening now tests for many substances not considered previously. Our preemployment screening and physical exams look specifically for indications or signs of substance abuse. We are in the process of implementing regular sessions where all providers are screened for stress and substance abuse. The death of our co-worker was an eye-opener for us; we never want a repeat of that day. Luckily, we did not experience an in-flight incident or a negative effect on patient care. We were, however, compelled to share our story and research findings with the hope that the air medical industry will take a hard look at substance abuse among air medical providers. Substance abuse is a safety issue in any industry. It is compounded exponentially by the inherent dangers associated with HEMS. Searching for information specific to pre-hospital providers on this topic revealed that little to no research has been done on substance abuse among emergency medical workers. Therefore, we started with the substantial body of literature on generic healthcare workers to inform our research. Our initial literature search regarding substance abuse in healthcare was very enlightening. Drug diversion is much more commonplace than one might think! The number one contributing factor is the healthcare worker’s access to abusive medications. Workers who abuse are very clever at diverting medications. Relying on narcotic handoffs with a paper trail should be considered “old school” and downright risky for your organization. Tampering with vials and ampules is apparently fairly easy. We developed an anonymous, online survey – utilizing freeonlinesurveys.com – to try and understand the prevalence of substance abuse in the air medical industry. Our goals were to bring this issue to light as an industry safety issue by examining the following: beliefs on prevalence in the industry, commonly abused drugs, medication storage and tracking practices, drug testing routines at HEMS services, and tolerance for rehabilitating offenders. Constructing questions that would promote honesty was difficult as this topic is generally regarded as taboo. Rightfully so, it has cost people their jobs, careers, and worse yet their lives! The survey was trialled at our company, revised, then sent to five air medical associations and disseminated to their members. We collected and analyzed data from a total of 287 responses. The respondents were mostly

1 · 2013 I Vol. 3 I AirRescue I 27

paramedics (48%) and nurses (41%), with a few pilots, doctors, respiratory therapists, managers and communications specialists. Our results showed that, yes, this is indeed happening in various parts the world. The following includes the questions asked, responses received, and our initial reflections: 1. Substance abuse among air medical providers exists in the industry to the point of being a safety concern. How do you feel about this statement? Strongly disagree:

Disagree:

30%

Not sure:

31%

Agree:

26%

Strongly agree:

Researcher analysis ➜ One-third of respondents perceive a safety concern. We wondered if the 31% in the “Not sure” category were legitimately unsure, or hesitant about answering truthfully. Regardless, the answers are split along the entire spectrum. 2. Have you, or any colleague in HEMS that you know of, ever taken a controlled substance (CS) not prescribed to you/them for recreational purposes? (See Fig. 2) 3. Have you, or any colleagues in HEMS that you know of, ever taken a non-controlled medication (such as Phenergan, Etomidate, etc.) for recreational purposes? Researcher analysis ➜ Without having a precise margin of error, we assume some people misread the questions. Nearly 30% stated they knew of an air medical colleague who had taken a controlled substance for a recreational purpose, and 9% a non-controlled substance. 4. If you answered yes to any of the previous questions, please list the medications and administration routes here. Respondents listed fifteen controlled substances and ten non-controlled substances. We used this data to create a chart comparing drugs-of-choice named by Anesthesiologists in Recovery to the drugs named by respondents in our original research of HEMS workers (2). It suggests what other studies have shown: medical providers take what they have access to. Researcher analysis ➜ Several people responded that they knew drugs were diverted but didn’t know specifics. We reasoned, again, that a certain number of respondents might have misread the question. In the case of self-administration of anti-emetics (such as Zofran and Phenergan), it was not clear if this could have been either for nausea-related issues during work or to deter the side effects of opiates taken concurrently.

28 | SAFETY 5. If you answered ‘yes’ in any of the previous questions, did you or someone you know (with or without your knowledge), obtain the medication from the company stock?

90 CS

% of Respondents, n = 286

Non-CS

Yes, I used drugs obtained from my workplace:

Yes, someone I know used drugs obtained from their workplace:

21%

I don't know where someone else may have obtained drugs:

I didn't answer yes to any of the previous questions: Yes, I have

Yes, I know of others who have

Fig. 2: Controlled or non-controlled substance?

Comparison of “Substance Abuse in Anesthesiologists v. HEMS” (See Fig. 3) • Some drugs frequently employed in the operating room (OR), such as propofol, sufenta and ketamine, are less common in the pre-hospital arena, explaining the lack of HEMS responses in those categories. In contrast, anti-emetics, benzodiazapines, sleep aids and etomidate are readily available to advanced-level pre-hospital providers. • The surprise drug in our HEMS research was etomidate, a short-acting sedative for rapid sequence induction used to facilitate intubation. This was also a drug-of-choice for our deceased colleague. Since embarking on this research, we have heard many anecdotal reports of its recreational use among pre-hospital medical workers, including at least one other death of an air medical provider. • IV opiates have traditionally been stocked on pre-hospital units for treating patients in pain. The combined percentage of fentanyl and “Other IV Opiate” (which includes morphine and meperidine) among HEMS respondents is nearly equal to the AANA fentanyl percentage. We believe this is because most HEMS survey respondents answered from the US where fentanyl has only recently become commonplace in the pre-hospital environment, whereas it is widely utilized in the OR setting. • The AANA survey included alcohol use (ETOH), while the HEMS survey did not. We consciously chose to exclude alcohol from our questions in order to focus on controlled and non-controlled medications. Some respondents to the HEMS survey volunteered this information. Nevertheless, the percentage should not be viewed as realistic by any means. A number of substance abusers are not identified until after a fatal overdose – In some cases however, this is preventable!

• We expect that anti-emetics may be self-administered either to combat effects of flying or for concomitant opiate administration to either potentiate the narcotic effects or hide unwanted side effects.

Other:

65% 5%

Researcher analysis ➜ This confirms our suspicion that most drug-using air medical providers are getting their fix from the company stock. Which leads us to … 6. Regarding monitoring, what systems does your company use for tracking medications? (Choose all that apply) Paper trail:

86%

Patient chart:

66%

Computerized system (e.g., Pyxis, Omnicell, etc.):

14%

Video monitoring/recording of medication storage areas: Our company uses the honor system: Other:

6% 12% 6%

Researcher analysis ➜ We noted a discrepancy in the statistics between two questions (see also Fig. 4) regarding the use of computerized systems. We attribute this to our own error of using different terms in the two questions (“automated computer dispensing system” v. “computerized system (Pyxis, Omnicell, etc.)”). 7. Does your company drug-test employees? (Choose all that apply) No:

Yes, upon hire:

68%

Yes, randomly:

91%

Yes, regularly (e.g., annually):

It's policy, but I've never had one:

Researcher analysis ➜ Most agencies drug-test their employees, which is the standard at all healthcare facilities in this day and age. At our company prior to November 2011, we were tested upon hire, but not after that, even though it was policy that the company could drug test us at will. Primarily, this was due to a high degree of trust within the company. Now, we are all subject to random drug testing. Interestingly, this has not decreased the level of trust inside our company; rather we all feel increased confidence in our colleagues.

1 · 2013 I Vol. 3 I AirRescue I 28

SAFETY | 29 8. Is it your perception that you or other colleagues would be terminated if evidence came forth regarding substance abuse (i.e. stolen narcotics, failed urine test, etc.)? (Choose all that apply) Yes, because we have a no-tolerance policy:

49%

Yes, because it has happened:

26%

Unsure:

19%

No, because we have an employee rehabilitation policy:

18%

Other:

Researcher analysis ➜ This question generated numerous written responses. Three out of every four respondents stated that a no-tolerance policy either exists or had been applied at their workplace. Interestingly, nearly one in five said their agency has a rehabilitation program. It is unclear from the responses how an employee might access such a program. For instance, must the air medical provider first admit they have a problem in order to get treatment, or can they still access the program if they are found out first through random drug testing? In either case, the potential exists that they may need to beg mercy for their job, so to speak. Defining incentives for healthcare workers to self-identify their drug-related addiction is a challenge some hospitals are proactively addressing.

9. If a seasoned AMP were found to have a substance abuse problem, do you feel that employees should be given the opportunity for rehabilitation and possibly return to patient care and flying someday? Strongly disagree:

What do you call a life-support system engineered to go where most people shouldn’t? We call it “ours.”

Disagree:

15%

Spectrum Aeromed specializes in creating durable life-support systems

Undecided:

27%

designed to enhance the abilities of your crew while supporting the lives

Agree:

44%

of their patients. We offer basic and advanced systems, single- or multiple-

patient configurations, as well as customized interiors, for both fixed wing

Strongly agree:

Researcher analysis ➜ This last question was probably the most emotionally charged, as many written responses were adamant and polarized. Over 50% of the respondents believe, yes, rehabilitation is worth it. Many comments described a bright nurse or medic that was truly great at their job, always the go-to person for every clinical question, who unfortunately got caught up in this. Without advocating one policy over another, perhaps our young industry could look at the lessons learned in more established branches of healthcare where the trend is toward encouraging employees to come forward before something devastating happens with assistance offered and the possibility of returning to supervised patient care.

1 · 2013 I Vol. 3 I AirRescue I 29

and rotor wing aircraft. Visit our website and select your specific aircraft type to see your equipment options.

30 | SAFETY Substance Abuse in Anesthesiologists v. HEMS Propofol Sufenta Ketamine Amphetamines ETOH Fentanyl Demerol Oral Opioid Cocaine Dilaudid Other IV Opiate Other THC Antiemetics Benzos Sleep aids Etomidate

AANA, n = 110

3,6

HEMS, n = 283

2,7 1,8 0,9 0,2

14,5

0,7

0,7 0,7

27,0

9,1

0,7 3,6

45,5

8,2 7,1

Fig. 5: The surprise drug in this research was etomidate, a shortacting sedative for rapid sequence induction used to facilitate intubation (Image: Fvasconcellos)

2,7 2,7

17,7

2,7 1,8

3,5 13,5 11,0 6,1 4,3

% of Respondents who selected these Drugs Fig. 3: Substance Abuse in Anesthesiologists v. HEMS

Fig. 4: How are medications stored at your company?

When asked to elaborate further on the survey or the topic, here is a sample of what our colleagues said: • “Everyone I work with voluntarily follows the same restrictions placed on pilots [related to] drug use on duty, even for OTC medications. The dangers associated with HEMS are great enough without taking added risks. We are all responsible for each other and to each other. We will not tolerate such behaviors.” • “It is the skeleton in the industry’s closet. More harm will come if not recognized and dealt with...” • “Knowledge of abuse is after the fact fatality. [I] agree with policies where voluntary disclosure results in treatment, whereas involuntary disclosure results in termination.” • “I had a partner who was stealing morphine from the company, and eventually self-identified. He never posed a safety concern and his patient care skills were top-notch. No one would have ever (!) sus-

How are medications stored at your company? Open, with unrestricted access to AMP

15%

Options

Combination lock with limited access to the combo

11%

Key lock with limited access to key/s

29%

Redundant keys (carried by more than one provider) with both needed to access meds

61%

Automated medication dispensing system

If applicable, what are any differences in CS and non-CS storage?

18% 0

50 75 100 125 # of times chosen, n = 286

150

175

pected this person of stealing narcs. If he completes a rehab program, I would gladly work with this individual again and/or would allow him to treat me or my loved ones.” • “One incident involved replacing narcotics with sterile water … patients were only getting water for analgesia and sedation.” • “I really am surprised there are not standard practices in detection/testing industry wide since we promote such a safety culture.” • “This issue is the 800 lb. gorilla in the room nobody wants to admit to. It’s bad for reputation and bad for business. But it’s worse if ignored and only a matter of time before tragedy strikes. It is in the best interest of all involved if HEMS take a proactive, supportive policy and role, rather than reactive and punitive, to combat the problem and help their own people out of the holes they’ve dug.” So, what does all this mean? We are not proposing a witch-hunt of drug abusers at your agency. We are proposing vigilance in this area that may potentially save a life or many. Recommendations from our company’s experience and existing research include: • Know the warning signs. There are tell-tale physical and behavioural changes that signal when a colleague may be abusing drugs. Speak up if you suspect a colleague is in danger of harming himself or herself or someone else. • Educate yourself and your staff on drug diversion and hold everyone accountable for recognizing tampered containers (helpful tips are available at www. stopnarcotictampering.com). • Pre-hire screening is essential, to include a physical that looks for physical signs of abuse, and psychological evaluations as well. • Broad analysis drug testing should be performed at-hire and randomly thereafter. Our current lab tests for over 50 substances. • Education should start with students entering the profession. Reinforce acceptable behavior when new employees join your agency. Unfortunately, a number of substance abusers are not identified until after a fatal overdose. In some cases this is preventable! 

1 · 2013 I Vol. 3 I AirRescue I 30

SUBSCRIBE NOW! The international air rescue and air ambulance magazine

SAFETY

1-year subscription 4 issues – 30 €*

Airrescue InternatIona l aIr rescue & aIr ambul ance

M A g A zine

Technology

Characteristics of lithium-ion batteries

Medical Care

HEMS and organ transplantation in Spain

2-year subscription 8 issues – 55 €*

Safety

Substance abuse in HEMS

ISSUE 1 | Vol. 3 | 2013

Substance abuse in HEMS

Safety

in Spain HEMS and organ transplantation

M A g A zine

Subscribe online at:

Airrescue

Medical Care

Characteristics of lithium-ion batteries

Technology

InternatIona l aIr rescue & aIr ambul ance

www.airrescue-magazine.eu/subscribe

AirRescue INTERNATIONAL AIR RESCUE & AIR AMBUL ANCE

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

M A G A ZINE

32 | SAFETY

Mitigating Fatigue Fig. 1: According to a prominent study by the DLR, accumulated sleep deficit leads to “incomplete recuperation” between duty cycles, which in turn may result in increased stresses, thus exacerbating the overall situation (Photograph: ADAC Air Rescue)

Author: Tony Ridley Chairman IFALPA Helicopter Committee UK representative ECA Helicopter Working Group tonyridley@btinternet.com

A pilot’s job can be extremely stressful – especially in the helicopter community – and this may directly contribute to fatigue. Pilot fatigue is a known contributing factor in almost 20% of all human error attributed aviation accidents, but until recently, there has been no proven methodology available to mitigate this situation. The FAA describes fatigue as being “more than sleepiness”, but that its effects are “more than falling asleep”, and ICAO Annex 6 defines fatigue as being: “A physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crew member’s alertness and ability to safely operate an aircraft or perform safety-related duties”. Fatigue or mental exhaustion is a significant but often under-reported problem that is now known to be a causal factor in 15 to 20% of fatal aviation accidents worldwide.

The two most important words within ICAO’s definition are further defined as follows: alertness “being the state of paying close attention, being watchful and prompt to meet danger or emergency, or being quick to perceive and act”, and ability as “being talent, skill or proficiency in a particular area.” Whichever definition you may choose to accept – and there are many more out there – the effects of fatigue are the same in all cases. Historically, early helicopter mechanical malfunctions were more likely to be the cause of an incident and a decrease in crew performance during that era was often attributed as being “pilot error” – without any consideration of fatigue as being a possible causal factor. It was thought that the introduction of new and more reliable technology would improve the situation, but this does not appear to be the case, as the statistics clearly show. The application of scientific knowledge by some Air Accidents Investigation Branches (AAIB’s) has subsequently indicated that fatigue was, and still is, a probable cause in a number of significant aviation safety events.

DLR study on fatigue Fatigue is a very complex condition, and an individual suffering from this state of tiredness/exhaustion may not even be aware that they are under its influence until perhaps it is too late. A pilot suffering from exhaustion will often exhibit a marked lack of alertness due to reduced mental/physical performance, which subsequently impinges upon the safe performance of routine and non-routine activities. There are many factors which can further compound this situation in aircrew, the highest having been identified by the Deutsches Zentrum für Luft- und Raumfahrt (DLR) as sleep deprivation, in their 2004 study into HEMS operations in Germany. The DLR found that accumulated sleep deficit led to “incomplete recuperation” between duty cycles, which in turn resulted in increased stresses, thus exacerbating the overall situation. This study also established that sleep on the night before a run of duties is usually less than that before a day off; continuing and building up throughout the duty cycle and leading up to as much as fifteen hours lost over a seven

1 · 2013 I Vol. 3 I AirRescue I 32

SAFETY | 33

day duty run. Some individuals need only six hours sleep, whereas some others need at least nine, but research indicates that a minimum of eight hours restful sleep will reduce the onset of sleep debt, and this is a key figure in most Flight Time Limitation (FTL) schemes. There are not many HEMS or SAR operations that have duty cycles in excess of four or five consecutive days, but nevertheless that sleep debt can still accumulate and ultimately become a problem towards the end of the duty cycle. Whilst sleep loss may be the most common cause of fatigue, other stressors such as personal domestic and/or employment problems can also be major contributory factors. The cockpit environment itself can add further stressors in the form of excessive noise, insufficient heating or cooling, vibration and poor seating to name the most common. A helicopter pilot uses both hands and both feet nearly all time whilst at the controls, leaning slightly forward as a result – which leads to the upper torso not being supported. This can result in lower back pain, which is very common amongst helicopter pilots and is yet another cause of fatigue – both inside and outside of the workplace. The importance of good seating cannot be over-emphasised enough, and responsible operators have a duty of care to ensure that their expensive pilot “assets” are as well looked after as is possible. In addition, the facilities on base also need to be of a high standard so as to mitigate those problems that can be found in the aircraft, and when on base standby, the crew need to have comfortable quiet accommodation. This accommodation must allow the crew the ability to control levels of light, temperature, have access to food, drink as well as local recreation such as newspapers, books, television, etc.

HEMS & SAR In HEMS, SAR and Fire Fighting operations, there are often long periods of inactivity interspersed with occasional, almost frantic action when called out on a task. This waiting can itself be a major source of fatigue, so it’s important

1 · 2013 I Vol. 3 I AirRescue I 33

to make use of whatever facilities are on site to maintain a standby state of alertness. The mission itself also has its own stressors in the form of urgency to get to the incident, arriving at a possibly a remote location with a landing area surrounded by numerous obstructions and hazards to avoid on both, the approach as well as the departure. The pilot has his hands full, and in the case of single pilot operations, the HCM can be a valuable extra pair of eyes and ears. Fatigue is insidious and can be either transient or cumulative/chronic. Transient fatigue is short term in nature and can normally be dispelled by a sufficient, single decent period of good quality sleep. However, cumulative or chronic fatigue, resulting possibly from incomplete recovery of the transient phase – or maybe as the after-effect of overexertion – is much harder to recover from, and may take as long as three or four nights of quality sleep in order to return to a safe mental and physical state. The only remedy for sleep debt is to sleep, and a responsible pilot should not even contemplate commencing a duty whilst suffering from identifiable sleep loss. Pre-planning for a known sleep disruption is essential for managing alertness, so do try to develop a regular pre-sleep routine in a comfortable environment and do not exercise or eat a large meal directly before sleep. A proper sensible high protein diet, avoiding alcohol prior to a duty, will help your body to stay ahead and cope with fatigue effects. Try to avoid having too much caffeine in your daily routine as it could keep you awake later when you’re trying to get to sleep, and remember that water is the best way of keeping hydrated. Always carry at least one bottle of water with you in a secure stowage, readily accessible when you’re in the cockpit. When on standby, a short ten to thirty minute “power nap” can help to restore alertness for as much as three to four hours – but do make sure that you set an alarm so as to avoid going into a deep sleep, as it can take between fifteen and twenty minutes to become fully alert for flying duties after this occurs!

Fig. 2: In HEMS operations, there are often long periods of inactivity interspersed with occasional, almost frantic action when called out on a task (Photograph: DRF Luftrettung) Fig. 3: The pilot has his hands full, and in the case of single pilot operations, the HCM can be a valuable extra pair of eyes and ears (Photograph: H. Scholl)

34 | SAFETY

Fig. 4: FRMS is the way forward, as it employs tools and processes that are specifically designed to detect, classify, analyze, prioritize and mitigate fatigue risk (DRF Luftrettung)

Use of FTL So far, the only way to reduce fatigue risk has been by the use of FTL; but there is only one such scheme in Europe that is based on scientific study and research – UK CAP371. Many other worldwide FTL schemes are based on this document, but changes in Europe are with our fixed-wing colleagues and this is to be overtaken by new, less stringent regulations, which were published by EASA in October 2012. These new regulations are due to be adopted into EU law by mid 2013 and fully implemented by the end of 2015, although there is considerable disquiet over this opinion as is evident by the number of petitions and demonstrations across Europe. EASA commissioned an independent scientific and medical evaluation on FTL by Moebus Aviation, but the Association of European Airlines would appear to have rejected this as not being “scientific” in their opinion and this is the probable cause of the ongoing unrest within the fixed wing community. The wider European helicopter neighbourhood is not yet affected and EASA appears to be initially concentrating on FTL for HEMS (as a priority over CAT), and as the whole process can take up to five years to complete, there is time to try and get it right. The European Cockpit Association (ECA) is working hard to ensure safety for all, and they have a very experienced HEMS pilot representative on the EASA HEMS FTL working group.

Fatigue Risk Management Task Force

If you are interested in finding out more about FRMS, try a Google search for “FRMS” or visit: http://tinyurl.com/ a52t7nr – here you will find a wealth of information in various languages, for both regulators and operators.

FTL is not the only answer to mitigation of fatigue, and in 2009 the ICAO Fatigue Risk Management System (FRMS) Task Force was created to promote a viable alternative. This group had its first meeting in November of that year, and has established an ongoing process of Standards and Recommended Practices (SARPs) for FRMS. FRMS is defined in ICAO Annex 6 as being: “A data-driven means of continuously monitoring and managing fatigue-related safety risks, based upon scientific principles and knowledge as well as operational experience that aims to ensure relevant personnel are performing at adequate levels of alertness”. ICAO SARPs are intended to foster optimal management of fatigue risk by allowing a level playing field (“all play by the same set of rules”), by the applica-

tion of current scientific knowledge, current tools and current industry best practice. Is FRMS the way forward? Quite simply, yes it is, as it employs tools and processes that are specifically designed to detect, classify, analyze, prioritize and mitigate fatigue risk – whatever the source at or in the place of employment. It relies and adapts on ongoing operational data, and therefore allows flexible, specific and timely responses to ever changing operational needs. It is intended that FRMS should be an integral part of a company Safety Management System (SMS). However, it does need a safe and well-established FTL scheme as a starting basis. ICAO Annex 6 SARPs also specify that the state must have regulations for managing fatigue, based on scientific principles, and that there shall be Mandatory Prescriptive Regulations and Optional FRMS Regulations. Also: The operator can choose how to manage their fatigue risks where FRMS regulations are offered by having FTL fully compliant with prescriptive NAA regulations; or FRMS for all operations; or FRMS for some operations and FTL regulations for the remainder. For helicopters as well as fixed-wing, the ICAO SARPs do not have limits based on numerical values, and very few NAA’s have utilised scientific research and principles in the formation of their FTL regulations. So far, no member states have yet implemented FRMS regulations, but they are on their way. FRMS will not stop fatigue that originates outside of the workplace – neither does FTL –, but it will mitigate fatigue which is employment related, as long as the FTL basis is safe. To sum up, fatigue is an ongoing hazard to all forms of commercial aviation and perhaps even more so in rotary wing due the diverse nature of helicopter operations. Crew Resource Management (CRM) and enhanced pilot training, when coupled with safe, science based FTL, will help to mitigate this risk, and pilots must be aware of the gradual and cumulative effects that fatigue can have on their performance.

Keep Alert and Fly Safe! References: • Civil Aviation Authority (London, UK): www.caa.co.uk • Deutsches Zentrum für Luft- und Raumfahrt (Cologne, Germany): www.dlr.de • European Cockpit Association (Brussels, Belgium): www. eurocockpit.be • Federal Aviation Administration (Washington DC, USA): www. faa.gov • International Civil Aviation Organisation (Montreal, Canada): www.icao.int • International Federation of Airline Pilots Association (Montreal, Canada): www.ifalpa.org • Moebus Aviation (Zürich Flughafen, Switzerland): http:// moebus-aviation.mildlemon.com/de/ • NASA Ames Research Centre (CA, USA): www.nasa.gov/ centers/ames/home/index.html • Instituto Tecnológico de Aeronáutica Brasil/Technological Institute of Aeronautics Brazil (Rio de Janeiro, Brazil): www. ita.br • RAF Institute of Aviation Medicine (Bedfordshire, UK): https://cms.raf.mod.uk/rafpublished/organisation/rafms.cfm • Transport Canada (Ottawa, Canada): www.tc.gc.ca/eng/ menu.htm

1 · 2013 I Vol. 3 I AirRescue I 34

SAFETY | 35

Fig. 1: The most effective methods for breaking elements in the accident chain are human factors, optimised team performance and simulation team training (Photograph: M. Rall, InPASS)

Improving patient safety in air rescue: The importance of simulation team training with focus on human factors/CRM More than a decade since the publication of the IOM-report “To err is human” (1) errors in medicine continue to pose a big risk for patients. Many studies have shown that the majority of errors are not due to a lack of medical knowledge, but due to so-called Human Factors (HF). In other industries the reaction to this has been widespread education and ongoing training in human factors – using as many simulations as possible. Emergency medicine, especially air rescue, is a field with many extreme situations and high risks. In these fields, personnel need to be educated in human factors, which contribute to up to 70% of all accidents. The method chosen to do this should be realistic simulation team training. When organising simulation training, the focus should be on the didactical quality of the instructors. Modern adult learning concepts should be used, including advanced debriefing skills and self-reflective double loop learning strategies. These should be combined with profound knowledge of human factors and Crisis Resource Management (CRM). It has been shown that giving all personnel training of this kind significantly improves patient safety. When a medical air rescue team flies to an emergency, there is a big difference between the pilots and the medical team: pilots have performed simulation training on a regular base, whereas the medical team has never had to do it. In other high risk but high reliability industries, education and training in Human Factors and Crisis Resource Management (CRM) are established tools to improve system safety, this includes realistic modern simulation team

1 · 2013 I Vol. 3 I AirRescue I 35

training. The authors (in cooperation with other partners) have been providing modern simulation team training for DRF Air Rescue in Germany for ten years and have trained more than 1,500 team members so far. We believe that everyone in air rescue should have profound knowledge and skills relating to human factors and CRM, and also receive annual simulation team training. The future is now; we should make this compulsory as soon as possible.

Authors: Dr. med. Marcus Rall InPASS Institute for Patient Safety & Simulation Team Training Reutlingen Germany www.inpass.de marcus.rall@inpass.de Stephanie Oberfrank InPASS Institute for Patient Safety & Simulation Team Training Friedrich-Naumann-Str.13 Reutlingen Germany Gerson Conrad DRF Luftrettung

36 | SAFETY and complicated circumstances, in addition to unexpected or atypical environmental factors that form the “accident chain” and harm patients (see Fig. 2). The “accident chain” is a good example, because it clearly demonstrates that many factors are needed to create the series of incidents that ultimately harm patients. However, the good news is, we only need to interrupt one segment in the accident chain to prevent harm (at least for this particular patient). So, in order to prevent accidents in each individual case, we only need to interrupt the developing chain of accident at one point, we do not need to break all segments of the chain! The most effective methods for breaking elements in the accident chain are human factors, optimised team performance and simulation team training. This will make teams more resilient, meaning they are more likely to identify and break accident chain segments.

From “Blame Culture” to “Proactive Safety Culture” Fig. 2: Accident Chain: many different factors contribute to the formation of the accident chain which ultimately results in patient harm

Table 1: Human Factors – individual, team and performance shaping factors

The “accident chain” and how to break it How do errors occur? No healthcare professional gets up in the morning with the intention to make a mistake which might harm a patient. Quite the opposite in fact: we all want to help our patients, do no harm to them and try to improve their outcome as much as possible. Why then, are there so many tragic errors causing preventable patient harm? In fact, it is most often a combination of multiple errors (2, 3), underlying system insufficiencies (4, 5, 6)

Individual and cognitive factors

Interactive and cooperative team functions

Directly performance affecting elements

Sensible and Dynamic Situation Awareness

Optimal Communication Structures

Fatigue

i.e. conscious evaluation of the situation , staying calm, keeping the overview

(verbal & non-verbal)

Dynamic Decision-making and situational Reevaluation i.e. adapting priorities dynamically in case of situational aggravation

i.e. Address by name, clear, calm and loud pronounciation, affirmative answers, catching one’s eyes Team Work

Human Factors – “the good and the bad” Noise

i.e. Critical but constructive assistance, optimal team-leadership and team-followership?

Admitting one’s limited Ability for Multitasking

Organisation Distribution of Work Load?/ Utilisation of all Resources?/ Get Help in time!

Illness

Task Management

Shared Mental Models?

Mental Pressure

Are all team members on the same page? Assertiveness

Leadership Performance i.e. clear and effective leadership structures?

Professional/Private Stress

Human-Machine-Interface

Collective Ideal and Objective?

Age, Experience

i.e. Knowing the working environment and devices

Does everybody share the same values and beliefs (Safety culture)? Are these enforced and encouraged by leadership?

Keep persistent in asking relevant questions and details or making proposals

Critical Self-assessment?

Directing the blame at an individual – “Whose fault was it?” – is not the correct or most useful question to ask in an organisation based on safety culture. Studies confirm that more often than not almost all staff would have made the same mistake under the same circumstances (7). The question we should ask in order to improve safety in the organisation is: “What were the reasons?” Using so-called Critical Incident Reporting Systems (CIRS) is a powerful tool for gathering sanction-free anonymous information about critical incidents and complications in an organisation, to provide an insight into the system (8). Through this, the causes which these events stem from can be analysed systematically, allowing system vulnerabilities to be minimised by suitable countermeasures. In terms of the accident chain image, this means reducing the availability of segments to form an accident chain.

Vision, etc.

To err is human. The fact of being human implicates several skills and qualities that determine the safety and efficiency performance particularly in complex situations or systems – referred to as “Human Factors” (HF). Over the years, studies have shown that Human Factors account for up to 70% of (acute care) medical errors and preventable patient harm (9). These figures are independent of any professional field and occur within acute care medicine as well as within other HROs like nuclear power stations, aviation, space travel or oil platforms (4, 5). While the complexity of workflow and the working conditions in emergency medicine can be considered even more complex and variable than those in other high reliability organisations, the medical field falls far short of meeting the system safety standards and Human Factor/ CRM training required at HROs. Acute care medicine is more complex and variable than other HROs. However medicine falls short of equalling the same system safety standards.

1 · 2013 I Vol. 3 I AirRescue I 36

SAFETY | 37 Many HROs recognise the impossibility of erasing (human) errors in working procedures and as a result acknowledge human fallibility (10, 11). On these grounds, they have established and developed several safety strategies and training concepts, i.e. promotion of a safety culture, utilisation of Critical Incident Reporting Systems, education in Human Factors (HF), application of Crisis Resource Management (CRM) and modern simulation team training (see below), that enhance the safety performance of humans under complex working conditions (see Fig. 2). An ideal safety system can never prevent errors by individuals and teams, but it does prevent a single mistake from reaching and harming a patient. Hollnagel refers to this as “resilience” (12). HF can be categorised into three areas: individual cognitive factors, interactive team management aspects and performance affecting factors (HF in the narrowest sense). Table 1 illustrates different types of Human Factors.

Crisis Resource Management (CRM) – an effective tool to promote “resilience” Over the past few decades CRM has proven its value in many high reliability sectors worldwide. CRM originated from the aviation and aerospace sector where it was devised by Wiener & Kanki as Cockpit, and then later Crew Resource Management (15). CRM has been adapted to the world of healthcare by Gaba et al. as “Crisis Resource

Management”. Fig. 3 shows the main communicative components of CRM. The 15 CRM principles by Rall & Gaba however, give ideas about easily applied countermeasures to lessen HF pitfalls during complex settings. These principles are designed to cover all aspects of HF from multiple angles in the style of several safety nets. The redundant overlap-

#1 for

Dauphin Parts

We own and stock the largest inventory of independently held Dauphin helicopter spare parts available on the market today. Rotables, hydraulics, avionics & instruments ready to ship worldwide. Parts for exchange and outright sales.

Phone Fax US-Phone E-Mail Web

1 · 2013 I Vol. 3 I AirRescue I 37

: : : : :

Fig. 3: Components of Non-Technical-Skills/CRM – Whereas many authors do not explicitly list communication, Rall & Gaba propose that communication is of vital importance since it forms the foundations of all the other building blocks (9, 14)

+41 52 345 3605 +41 52 345 3606 +1 207-513-1921 mail@alpine.aero www.alpine.aero

38 | SAFETY Stop accepting the unacceptable! Regular and obligatory CRM-based patient simulation team training is indispensable in acute care medicine!

Fig. 4: It is of prime importance to have well-educated and specially qualified instructors, who can provide the fundamentals of HF/CRM (Photograph: DRF Air Rescue, Freiburg)

ping is desirable as the application of the 15 principles should ensure critical incidents and complications can be prevented at various levels and by different people. Please note that the implementation of these CRM principles can only be established and exercised effectively by modern team training concepts. Crisis resource management is on the one hand a tool to reduce the frequency of critical incidents (prevention aspect of CRM) and on the other hand to enhance the handling of emergency situations if they arise (crisis management aspect of CRM).

Learning CRM with new patient simulation team training Fig. 5: In order to achieve the profound “Double Loop Learning” effect, the simulation team training‘s debriefing has to include the mental processes behind the observed actions (Photograph: Team TüPASS & DRF)

In order to address and master the complex preclinical, social and logistical challenges of practicing emergency medicine it is important to seek efficient training strategies taking into account the facts and safety concepts presented above. There is a great deal of literature which confirms the effectiveness of simulation team training (13, 16-19).

As the application of CRM is based on individual and cognitive factors as well as interactive and cooperative team actions, it is necessary to practise these non-technical skills intensely and regularly under realistic conditions. At this point it is vital to understand that the effectiveness of modern simulation team training concepts is not based on their technological fidelity but on the quality of the instructors. In didactic terms, modern simulation team training concepts encourage sustainable self-reflection of healthcare professionals in facilitated debriefings. The debriefings have to take place in a cooperative atmosphere and induce profound learning experiences called “double loop learning” (see below) based on adult learning principles (20). In order to produce effective learning and benefit from HF/CRM-principles during training it is of prime importance to have well-educated and specially qualified instructors, who can provide the fundamentals of HF/ CRM and to run the simulation scenarios as well as the accompanying audio-/video-assisted debriefings. Simulation training without focusing on HF/CRM disregards the most common causes of errors and complications and is therefore no longer considered to be “state of the art”. The audio-/video-assisted debriefing is at the heart of modern simulation concepts and facilitates optimised self-reflection and analysis of the simulation scenario supported by the instructors. Good debriefings are like forecasts for a proactive safety culture: video-assisted debriefing is not about providing evidence for mistakes or criticising colleagues and their performance, but to find out cooperatively and constructively why things went wrong or right in the relevant scenario, in order to the find systematic alternatives for preventing or reinforcing performed habits, providing a broad learning experience for all participants. “Dream teams are made – not born …” Train together and work together – now!

Simulation Team Training – What to expect by way of example Fig. 6 provides ideas of what to expect in a simulation team-training scenario in air rescue settings whereas Fig. 7 shows the schedule for simulation team training provided by the authors for air rescue healthcare professionals at DRF Luftrettung. The typical schedule of a modern simulation team training course provided by the authors, since 2004, to more than 1,500 team members of DRF Air Rescue. They are always interdisciplinary, often in-situ (ambulance, helicopter, learjet etc), involve regular hand-over training in the emergency department, and always relate to the actual guidelines (ATLS, EPLS, PHTLS and ERC algorithms).

1 · 2013 I Vol. 3 I AirRescue I 38

SAFETY | 39 First day 17-19.30 hours • Welcome, introduction • Prevention (failure management, root cause analysis, handle with human errors) • Safety culture • Patient safety • Incident reporting and management of incidents • Interactive workshop with Live Incidents • CRM-based workshop supported by voting systems 19.30-20.30 hours • Familiarisation with SIM environment • Dinner

Second day 9-17 hours • Six realistic scenarios, highly relevant and adapted to individual teams needs • Groups rotate between settings and perspectives: – First perspective: active in the scenario (hot seat) – Second perspective: watching live transmission of scenarios of team buddies – Third perspective: active participation in debriefing of own or buddies scenarios (peer discussion facilitated by instructor) – Fourth perspective: role playing in the scenario (first response team, parents, relatives, bystanders etc) • Final evaluation, questionnaires, feedback, certificate, up to 18 CME points In order to ingrain the above-mentioned profound learning experiences in adults during simulation team training (see Fig. 5), the debriefing is of major importance. Previous debriefings of simulation team training often only had superficial learning effects that are referred to as “Single Loop Learning”. In order to achieve the profound “Double Loop Learning” effect, the well-trained instructors have to base their debriefing not only on the observed actions but also on the mental processes behind the action. In doing so the potential gap between the desired action on the part of the instructors and the actual scenario action can be closed taking into account that simulation is only as real as it is experienced. Such debriefing concepts therefore take healthcare professionals seriously and provide the chance to comment on their actions and thoughts. This enables the instructors to encourage the participants’ own analysis of the underlying causes of good or poor performance and therefore provide effective and self-acquired solutions in due consideration of their mental processes. In order to establish solutions for such complex situations, the abovementioned CRM-principles can be very helpful. It would be good to take this opportunity to another powerful and rather new CRM element that can be effectively incorporated in simulation team training: the

1 · 2013 I Vol. 3 I AirRescue I 39

“10-seconds-for-10-minutes-principal”. This refers to a symbolical team timeout prior to a treatment decision or in the case of helplessness or building chaos (21). We are too fast in critical situations! At first glance this might seem paradoxical especially speaking of emergency medicine. But one of the main reasons for not applying the medical knowledge we possess is down to enormous time pressure. This in turn causes us to make and act on split-second decisions, which in the long run, often cause us to lose more time than gain it. Step back for 10 seconds: Analyse the situation and organise yourself and your team. In case of chaos: Stop things from getting worse! From our point of view there is always enough time –even in emergency situations – to take a short team timeout in order to analyse the situation carefully and to organise the team based on the “10-seconds-for-10-minutes-principle” (21), called the 10-for-10-principle in short (see Fig. 6). This principle has emerged from more than ten years of experience in improving patient safety through realistic simulation team training provided for healthcare professionals (21). The first applications of the 10-for-10principle (see Table 2) have so far shown very promising results and often showed that the time lost by the brief timeout was compensated by much more effective and straight forward team action afterwards.

The path to success – simulation team training concepts to increase patient safety A few things we have learned over the last 10 years: 1. Use specially trained course-instructors for simulation team training: • Scenario designs should primarily concentrate on the main challenges in daily routine which cause the greatest potential harm to a patient, i.e. difficult airway management, allergic reaction, unconscious patient, etc… • The accompanying interactive debriefing has to be seen as a formative assessment closing performance gaps (20) and can be considered the

Diagnosis! Problems?

STOP 10 sec!

Fig. 6: The “10-seconds-for 10-minutes” concept

Problem, Team, Facts, Plan, Distribute

40 | SAFETY When to use the 10-for-10-principle

At the beginning of a medical treatment or a working diagnosis Always if you have the feeling of being stuck or the treatment does not show the expected result Whenever you have the feeling that “chaos” is taking over (increasing noise and hectic pace)

How to use the 10-for-10-principle

Do not start any treatment or assignment in the split of a second! Separate spontaneous ideas and options clearly from thoughtful decisions and strategies Take our time. Take a deep breath. Then take a formal team time out discussing the steps below Make sure everybody is listening and paying attention. Current activities ought to be paused.

Work yourself through the following steps

Problem? Ask yourself and your team members: “What’s the biggest problem right now?” or “What is the most dangerous aspect of the problem?” Opinions? Clarify the above with all available team members Facts? Gather available information Plan! Using input from the team, make a treatment plan including the sequence of action Distribute! Distribute the workload by assigning tasks and responsibilities Check! Before diving into work, involve all team members again to encourage them to raise any further concerns or suggestions for improvement or refinement

Table 2: How to execute and apply the 10-for-10-principle, modified according to (21)

Fig. 7: Difficult airway management is a recurrent topic in all trainings, be it for adults, babys, trauma or in other settings (Photograph: M. Rall, InPASS)

most important part of simulation team training as the learning process starts here. 2. Start your simulation training as soon as possible: do not wait for high quality equipment because any simulation training is better than no simulation training at all 3. During introduction of HF/CRM based simulation train your staff “en-masse” in a short space of time: this technique ensures higher and more long-lasting effects in practice 4. Train together and work together (“full team training”): it is not productive to train professional categories separately or to have training where different

professional categories need to act in role of a different professional. 5. Make simulation team training a compulsory training unit for ALL professionals at least once a year (“Oneoff does not count”!) 6. Train characteristics of medical interfaces in simulation settings: i.e. preclinic-clinic handover scenarios, etc… 7. From time to time: execute a simulation team training “in-situ”: a very effective tool to undertake a system and process check.

Take-Home-Message and Action Items Patient safety at a systemic level needs to hold the highest priority in emergency medicine. Safety culture needs fertile soil, nurture and encouragement throughout the entire organisation in order to prosper and increase patient safety as well as personal satisfaction on the job. The build-up of errors and relevant circumstances can lead to a critical incident sometimes even causing patient harm or death. However it is only necessary to break one part of the chain to prevent a patient from harm. In order to uphold the safety culture it is high time to bid farewell to the blame culture. Stop searching for a scapegoat (“Whose fault was it?”) and start systematically looking for the underlying causes (“What were the reasons?”). This ought to be in the centre of incident analysis, and even better if it is done using critical incident reporting systems. It is said that 70% of medical errors are due to Human Factors and not due to lack of academic knowledge. In terms of to the current standards in HROs: how can training within medicine to increase patient safety be optional when training on system safety is an inherent part of basic and advanced education in almost all other high reliability sectors? We do know that CRM is an efficient tool for increasing the reliability of human performance under complex and stressful conditions – but it needs to be learned and taught! The changeover towards a modern and proactive safety culture therefore includes the acknowledgement of the importance of education in Human Factors and training in Crisis Resource Management (CRM). The gold standard for introducing and implementing CRM nowadays is simulation-based CRM team training and authentic team guidance provided by specialised simulation instructors in order to develop realistic conditions for the application and implementation of Crisis Resource Management and to ingrain profound Double Loop Learning in debriefings. The authors believe all teams in emergency medicine should undergo basic education in Human Factors and Crisis Resource Management. Furthermore the author recommends at least two obligatory simulation-based full-team CRM training sessions per year in the long term for all healthcare professionals.  For references, please see: ››› www.airrescue-magazine.eu

1 · 2013 I Vol. 3 I AirRescue I 40

SAFETY | 41

Fig. 1: Extended horizon line or “Malcolm Horizon” (MH) concept

Helicopter flight in a degraded visual environment Helicopter flights are particularly vulnerable when exposed to conditions associated with a degraded visual environment (DVE). Looking at the rotorcraft accident statistics, this issue has been prevalent for quite a while within Europe. A big issue with a degraded visual environment is the safety hazard involved. From safety records it turned out that the highest frequency of occurrence of accidents with helicopters involved in DVE mishaps was with the small types (Robinson R44 like), and for a few special conditions or scenarios, viz. the inadvertent entry into instrument meteorological conditions (IMC), called ‘IIMC’, and the “controlled flight into terrain” scenario, called CFIT.

Therefore, the Dutch National Aerospace Laboratory (NLR) – under contract to the European Aviation Safety Agency (EASA) – performed a project called “Helicopter Flight in a Degraded Visual Environment” in order to provide a study on unintended helicopter flight into a degraded visual environment during VFR (Visual Flight Rules) operations, investigating the feasibility and effectiveness of a number of aids for pilots to enhance the visual cueing and situational awareness (e.g. attitude, terrain proximity) to mitigate the safety hazards associated with DVE. NLR came up with three visual enhancement concepts and one audio enhancement concept – discussed later – which were to be basic, simple systems fit to be mounted

1 · 2013 I Vol. 3 I AirRescue I 41

into a small helicopter. Piloted simulation tests were performed on NLR’s (fixed-base) helicopter simulator in order to find out to what extent these concepts did really help improve the visual cues, flight safety, and to determine the pilot’s acceptance of these devices in the cockpit of a small helicopter. Six General Aviation helicopter pilots from the Dutch General Aviation Rotorcraft Pilots Association were randomly selected from a total of 16 respondents to participate as subjects in the simulations. They were split equally into 2 groups, one with less than 300 flight hours (min. 90h, max. 280h), and one with more than 300 hours (min. 450h, max.1100h). The pilots were not instrument-

Author: Henk Haverdings National Aerospace Laboratory NLR Amsterdam The Netherlands haverdi@nlr.nl

42 | SAFETY

Fig. 2: Cockpit view in the CFIT scenario with the HUD Orange Peel and LED concept (Photograph: NLR)

The green-coloured half circle with inverted ‘T’ is quite intuitive in helping the pilot to recover to level attitude from whatever attitude he might be in. A red short line underneath the symbol indicates height above ground. This red line or bar appears whenever the height has become less than some reference height, set at 500 ft. When the red line passes through the inverted ‘T’ the rotorcraft will have reached the ground. Below 3 sequences are given to show what the HUD Orange Peel symbol presents in the various attitudes. The actions indicated are to be performed in order to resume straight and level flight. An example for a helicopter cockpit is given in Fig. 2. The “length” of the peel, i.e. how much it encompasses the inverted T, is proportional to the pitch angle, while the “rotation” of the peel depends upon the roll angle. Note that the symbology, presented on a (wide-angle) HUD, or else reflected off the windscreen, is fixed in position, i.e. it does not move across the HUD or window. This concept was tested in both scenarios (IIMC and CFIT). rated. For an entire day, EASA participated with one highly experienced test pilot (10,000 h) and a flight test engineer. They were subjected to most of the test conditions the other pilots had also been subjected to.

Visual enhancement concept: Malcolm Horizon This visual cue-enhancing device makes the pilot aware of his attitude in roll and pitch (but not quantitatively). A red-coloured horizon line, the “Malcolm Horizon”, is projected through the whole cockpit by the use of suitable devices such as scanning lasers, reflecting off the wind screens and cockpit structure. In the implementation in the simulator a line was drawn in the visual system of the simulator that generated the visual cues. This concept was tested only in the IIMC scenario. A typical example of the Malcolm Horizon is given in Fig. 1.

Visual enhancement concept: HUD Orange Peel Fig. 3: Several sequences of the “HUD Orange Peel” a) Push down and roll left b) No action c) Roll right and pull up

This concept is one that has been adopted from the fixedwing fighter aircraft domain for recovery from unusual attitudes, usually projected onto a head-up Display (HUD), hence called the “HUD Orange Peel”.

Visual enhancement concept: LED concept It was hypothesized that for orientation or attitude awareness the pilot will pick up cues from his peripheral vision. This novel concept consists of, in this case, yellow-coloured LED lights, mounted on strips placed in the pilot’s peripheral vision, that are lighted from the bottom (cabin floor) up to the point where it is on the horizon, seen from the pilot’s eye reference point (see Fig. 5). When in a banked attitude one strip of LEDs is then lit further than the other strip. The idea behind this is that the pilot will use this to determine a measure of roll angle. By using a third strip in front of the pilot it is assumed that the differential LED information between the front and the 2 rear strips of LED lights would give pitch information in the same way. Also a cue of the vertical speed was added using upward running (red-coloured) lights to indicate a descent condition. Four of those red-coloured cues are shown in Fig. 5. They appear whenever there is a sink rate, and the speed at which they are travelling upwards depends on the actual rate of descent. In case of a climb they will disappear. This concept was tested only in the IIMC scenario.

Audio enhancement concept: HTAWS Another type of cueing the pilot is by the use of audio signals, e.g. for approaching terrain (“Terrain Ahead”) or if the sink rate is too large (“Sink Rate”) etc. Instead of the radio altitude the so-called Time-To-Impact (TTI) was used, which is the ratio of the distance-along-the-lineof-sight to the ground impact point, divided by the inertial speed. If TTI comes between 20 and 30 seconds, the alert “Terrain Ahead” will be activated. When TTI becomes 20 seconds or less, the warning “Pull Up” is given. As soon as the condition clears, the respective voice alert ceases. This concept was tested only in the CFIT scenario.

Scenarios for training, IIMC and CFIT For the three scenarios, areas were selected from the available visual scene database in the fixed-base helicopter simulator. The country of Albania was selected

1 · 2013 I Vol. 3 I AirRescue I 42

SAFETY | 43 as this was NLR’s available visual database that offered possibilities for undulated and mountainous terrain. Pilots were trained in the area of Kavaj. For the IIMC scenario Lake Ohrid was selected, with the rotorcraft initially flying south alongside the western bank of the lake at 100 KIAS at about 500 ft AGL. In this scenario, visibility would suddenly drop to zero when the helicopter passed a predetermined latitude. After this point, the pilot was advised to make a left 180° turn to get out of the IMC condition due to the closeness of mountains ashore. The flight would end after a certain amount of time had elapsed. IMC conditions would remain until the end of the flight. The mountainous region near Peshkopi was selected for the CFIT scenario because of its ridges, hills, etc. In the visual scenery the ground texture was removed almost completely and a layer of snow was added to give the impression of a snow-covered place with a misty underground. A cockpit view of the scenario is shown in Fig. 2 in which the mountain ridges can be faintly seen on the left. Both, the LED concept and the HUD Orange Peel, are switched on.

also called the Attitude Director Indicator (ADI). This is not the case with all types of R44.

Data registration and recordings The type of data that was recorded during the experiments was twofold, viz. objective data and subjective data. Objective data in general were flight-parameters that were registered within the flight simulator environment (such as airspeed, altitude, pitch and roll angle etc.) as well as eye tracker data. The other type of data was the subjective data consisting of the entries made in the two questionnaires dealing with workload experienced, usefulness and acceptance of the enhancement concept, safety level, the rotorcraft’s handling qualities, situational awareness, occurrence of a crash (and why), etc.

Eye/head movement tracking and recording When validating visual enhancement concepts, it is important to know where the pilot has been looking. Was he really looking at the line or symbols or only at one part of it and how often? In order to find out, a headeye tracker was used that allows measurements of the pilot’s “line-of-sight” to be made. A picture taken during one of the flights with the pilot wearing the device is shown in Fig. 7.

The helicopter simulator and its field-of-view The outside visual field-of-view of the R44 is quite different from the field-of-view of NLR’s fixed-base helicopter simulator, the so-called Helicopter Pilot Station (HPS), with its wide, large helicopter instrument panel. In order to provide the pilot with a field-of-view which better matches that of the R44, the top instrument panel was taken out and replaced by a 19” monitor on which the R44 Raven instrument panel instrument layout was projected. The final result of what the forward part of the cockpit looks like – including the small instrument panel together with the HUD Orange Peel and the LED strips – is shown in Fig. 6. The instrumentation included an “artificial horizon”,

1 · 2013 I Vol. 3 I AirRescue I 43

Fig. 4: Albania was chosen as the training and test site for helicopter flights in a degraded visual environment

Results of the simulation tests With the many parameters registered, a wealth of data became available and evaluation results have to be narrowed down to such things as pilot’s concept acceptance, flying qualities, etc.

Effect of enhancement concepts on pilot’s concept acceptance The pilot gave concept acceptance ratings per run whenever he was flying a test run with an enhancement concept (the so-called “baseline” or “control” test runs were flown without an enhancement concept). The LED concept was much less accepted than the Malcolm Horizon or the HUD Orange Peel (“fully accepted”) for the IIMC scenario. But also for the LED concept there were 2 ratings with “fully accepted”, so the pilots were not unanimous. For the CFIT scenario the HTAWS

Fig. 5: LED lights mounted in the peripheral view of the pilot

44 | SAFETY information was OK, but that pitch or roll information was more or less useless. To some pilots, however, it was a help when flying in IMC. The HTAWS was also reported to be very helpful, giving good and clear warnings that a pilot could respond to and notice (hear!) the effect of the pilot’s action (i.e. the voice alarm stopped).

Effect of visual enhancement concepts on flying qualities

Fig 6: View from the cockpit in the IIMC scenario with the HUD Orange Peel and LED concept (Photograph: NLR)

Fig. 7: Head & eye tracker mounted on head of test subject (Photograph: NLR)

was “fully accepted” as well, just as the HUD Orange Peel. Pilots found the red ground bar very helpful. In fact from the eye measurements it became evident that pilots spent less time looking outside for obstacles as they trusted the HTAWS warnings or the red ground bar of the HUD Orange Peel warning of approached terrain. There was one case when the HTAWS failed to give an alert and it promptly led to a controlled flight into terrain, a “classic” CFIT. Pilots found the Malcolm Horizon concept to be “quiet”, giving good visibility cues, and emphasized that it is simple to understand and easy to use. With the HUD Orange Peel some pilots had difficulty interpreting the symbology (which is quite unique when it comes to presenting pitch changes, for example), others found it to be a very good system and a strong confidence builder. For the LED concept, pilots reported that the descent

The Cooper-Harper Rating (CHR) scale that is used to rate flying qualities was new to the non-test pilots, so time was taken to introduce the scale and what it stands for. Obviously, EASA’s test pilot was very familiar with the CHR scale and his ratings have been superimposed on the other CHR ratings (the test pilot did not fly all conditions). The flying qualities improved (lower CHR) from Level II (improvements in rotorcraft characteristics warranted) for the “no concept” case to level I (satisfactory) when having the Malcolm Horizon on-board. This trend was also confirmed by the ratings of the test pilot (see triangles). Noteworthy is that for the HUD Orange Peel the test pilot scored a much higher (worse) CHR of 5 than the average value of about 3.5 for that concept from the other 6 pilots. The main reason was – according to the test pilot’s comment – that this concept tended to drive him into a Pilot-Induced Oscillation (PIO), which did not occur when flying with the other concepts. The other non-test pilots did not notice this PIO tendency clearly – except perhaps one pilot.

Use of HTAWS for ground avoidance When flying with the HTAWS concept in the CFIT scenario, pilots took good advantage of the HTAWS-generated voice alerts to “skim” the terrain (see Fig. 8). It was observed during the CFIT runs with the HTAWS that pilots tended to respond quite strongly to the alerts by increasing the pitch angle in order to climb and thus avoid imminent collision with the ground. An example of this can be seen in the altitude response on the CFIT scenario in case of the HTAWS. The moment when alerts are activated are indicated in Fig. 8.

Visual Cue Ratings (VCR) and the Usable Cue Environment (UCE) An important aspect of the enhancement concepts is how they affect the Usable Cue Environment (UCE): does it improve or not when such a concept is being used on board? Per run the pilot rated the visual cues available in terms of roll, pitch or yaw information, as well as translational rate (horizontal or vertical rates) information. These “angular” (roll, pitch, yaw) and “linear” (horizontal and vertical rate) cue ratings were combined into attitude Visual Cue Ratings (VCR) and translational rate visual cue ratings. The combination yielded a diagram of attitude VCR versus translational rate VCR as given in Fig. 9. Together these VCRs form the Usable Cue Environment (UCE), as also defined in the military rotorcraft’s flying/handling qualities specification document ADS-33E. With UCE=1 (“good” environment), no additional equipment or displays are needed to allow the pilot to

1 · 2013 I Vol. 3 I AirRescue I 44

SAFETY | 45 safely fly the rotorcraft. With UCE=2 (“degraded” environment), additional equipment or displays are needed to improve the flying characteristics, otherwise the pilot’s workload will become too high. As Fig. 9 shows, the LED concept hardly improved the Usable Cue Environment relative to the baseline case (“None”). The Malcolm Horizon provided a major improvement by moving the UCE from the level 2/3 boundary to the middle of the 1/2 and 2/3 boundary, mostly along a constant translational rate VCR line. This is still not enough for unaided flight. It is the HUD Orange Peel which further improved the UCE towards the boundary of UCE=1/2, by also improving the translational rate VCR, thanks to the improved vertical rate cue coming from the (red) ground bar. This is a major improvement compared to the baseline case, although formally UCE=1 still has not been reached (yet).

Conclusions, recommendations and outlook Within the limitations of the simulation set-up (e.g. fixedbase simulator, non-test pilots used, emulated rather than “real” enhancement concepts, no cockpit windows onto which to project the imagery of some of the concepts), one might conclude and/or recommend that: • The usable cue environment reached with the Malcolm Horizon or HUD Orange Peel can be further improved to reach UCE=1 by relatively minor improvements in the display layout, functional design, etc. • The HUD Orange Peel was the best visual enhancement concept tested, in terms of Usable Cue Environment. The eye tracker data showed that the HUD Orange Peel in the CFIT scenario attracted focal attention of the pilot at the expense of looking further around outside the rotorcraft. In a scenario with other traffic besides mountains this drawing attention away may be detrimental to safety. Also it should be improved to alleviate PIO by reducing the Orange Peel-to-pitch ratio in order to reduce the overall loop gain. This could be reduced to maximally 30 percent. • The Malcolm Horizon was the second best visual enhancement concept in terms of Usable Cue Environment. It was simple to interpret and pilots were quick to understand what the line meant. The handling qualities ratings improved. • The HTAWS audio concept was greatly appreciated. The pilot comments were very favourable, the timeto-impact that was used as a threshold was much appreciated by the pilots as a simple concept. The eye tracking data showed that with the HTAWS more time was spent looking at the instruments than with “no concept” in the CFIT scenario, at the expense of looking widely outside. Apparently the system is such a “confidence builder” that pilots felt it was not necessary to look outside much to check for terrain since they had the HTAWS “guardian angel” on board. • The LED currently implemented, i.e. with “static” lights that indicate roll angle, etc. should be

1 · 2013 I Vol. 3 I AirRescue I 45

regarded as not suitable for application. The vertical rate-of-descent cues however, were appreciated. The working of peripheral cues did not materialize in the way it had been expected. Fortunately, there are ways to better define peripheral cueing mechanisms to improve the situation, e.g. by making the roll and pitch attitude cue not a steady-state cue but a moving one. While some of the additional tests still need to be performed it is believed that one or several of these visual aid concepts can rapidly enter the cockpits of the small, basically VFR-equipped light helicopter. Although no precise cost estimation has been made, it is highly desirable that these solutions remain affordable for owners or operators of small helicopters due to the significant safety benefits obtained. 

Fig. 8: Altitude and alert response during flight with HTAWS in CFIT scenario (Thirteen times there was an alert for terrain ahead on this flight, in five cases followed by the “pull up” warning) Fig. 9: Translational rate VCR versus attitude VCR of enhancement concepts

46 | TECHNOLOGY

The Bell

429 … is one of the best helicopters!“ Last summer, Swiss Air Zermatt became the first HEMS operator in Europe to use the Bell 429 in service. The versatile and agile helicopter has been heavily praised. It is now set to take the European market by storm. “The Bell 429 is one of the best helicopters that I have ever had the privilege to fly”, says Gerold Biner, pilot and CEO of Air Zermatt, on their latest purchase. Gerold Biner took the time for a brief interview with Holger Scholl.

ARM: Mr Biner, Air Zermatt has described the Bell 429 as the most advanced helicopter in Europe. What technical features and improvements have impressed you most? Gerold Biner: It is the combination of various components that makes this helicopter so special: The modern glass cockpit, the single-pilot IFR certification, the new Aerolite medical interior, side LED headlights and NVG-compatible cockpit, double cargo hook, 90m winch, ski rack, SX-5 Starbust searchlights, Max-Viz Enhanced Vision Systems infrared camera and lots of other little features that have been built in to make the helicopter a joy to pilots. ARM: As one of the newest helicopters to hit the global market, the Bell 429 is equipped with the latest avionics. What are its benefits – in general terms for helicopter flying and more specifically for air rescue missions?

Gerold Biner: The pilot is able to choose from various functions offered by the two autopilots and the flight director, depending on the situation at hand. Should the new blind flight methods, e.g. helicopter departure in fog (HDF), low-level IFR, point-in-space approaches, etc. actually prove their worth in the HEMS sector, the Bell 429 has the latest tools for this type of operation. ARM: The new Bell 429 is also enabled for night and instrument flying. What improvements have been made and what additional resources exist in order to carry out operations at night and in poor weather conditions? Gerold Biner: These machines provide us with additional support, while still staying within the VFR limits. Operations at night or in poor weather conditions should be safer as a result. However, relevant training is of course also required for such operations.

1 · 2013 I Vol. 3 I AirRescue I 46

TECHNOLOGY | 47

ARM: Talking about the latest aeronautics, there is also the question of emergency medical equipment on board the new helicopter. Where have you seen equipment improvements and what impact have they had on rescue missions? Gerold Biner: Thanks to the fact that all the equipment can be assembled and disassembled quickly, the helicopter can be used in various different ways. In high mountain ranges 4,500 metres above sea level it is vital that the balance between equipment that is “nice to have” and equipment that is “needed on board” is spot on. The Aerolite system is modular and also allows us to transport intensive-care patients without having to carry this equipment permanently. Besides the machine’s performance, and it is a powerful machine, what is also important is that there is enough space in the cabin. ARM: Do the internal dimensions and the configuration of the medical equipment provide any particular benefits

or make improvements to rescue missions in general and to emergency medical care in the cabin in particular? Gerold Biner: The more room you give to medics, the more equipment is packed into the helicopter! So the vast interior of the Bell makes debating with wide-eyed doctors over what needs to go in and what doesn’t quite difficult! However, the modular design provides enough room for manoeuvre, meaning that you can take whatever you need on board for any situation without any problems. ARM: You have been using the Bell 429 for a few months now. What is your personal experience of this ultra-modern helicopter?

Fig. 1: “All the equipment can be assembled and disassembled quickly, take for example the Aerolite system, which is modular and also allows us to transport intensive-care patients without having to carry the equipment permanently” Fig. 2: “We have clocked up over 150 hours so far and, in my opinion, the new Bell 429 is one of the best helicopters that I have ever had the privilege to fly” (Photographs: Air Zermatt)

Gerold Biner: We have clocked up over 150 hours so far and, in my opinion, the new Bell 429 is one of the best helicopters that I have ever had the privilege to fly. ARM: Mr Biner, we thank you for the interview.

SUBSCRIBE NOW!

Reduced rates for EHAC members.

Members of EHAC will get reduced subscription rates. For further details please see www.ehac.eu and/or contact us at info@airrescue-magazine.eu SAFETY

Airrescue InternatIonal aIr rescue & aIr ambul ance

M A g A zine

Technology

Characteristics of lithium-ion batteries

Medical Care

HEMS and organ transplantation in Spain

Safety

Substance abuse in HEMS

1 · 2013 I Vol. 3 I AirRescue I 47 ISSUE 1 | Vol. 3 | 2013

www.airrescue-magazine.eu/subscribe

48 | TECHNOLOGY

“High-quality patient care”: Improving outcome with the Zoll X Series When Helicopter Emergency Medical Service (HEMS) operators and air medical professionals begin their day, they can rarely predict what challenges they will face. In addition to their skill and dedication, they also have to rely on critical care technology. One of the major providers in this field is Zoll Medical Corporation. Its critical care business is focused on improving patient outcomes by developing and marketing products that deliver rapid therapy to victims of sudden cardiac arrest and other patients in need of acute care. Since its founding over 30 years ago, Zoll has been stalwart in advancing resuscitation technology with clinically-efficient products that deliver solutions to improve the way the medical transport industry delivers pre-hospital care.

Fig. 1: The X Series and AutoPulse® are part of the essential equipment the UK’s Essex and Hert HEMS carries aboard its air ambulances (standing from left to right: Pilot Nicky Smith, Dr Adam Chesters, and paramedic Erica Ley (Photograph: EHAAT)

A wealth of knowledge Zoll accumulated a wealth of knowledge concerning the physiology of resuscitation and its related therapies through active ongoing research. These findings also enabled Zoll to pioneer new approaches to proven technologies, such as the AutoPulse® (the non-invasive chest compression device that delivers uninterrupted chest compressions over long periods of time to move blood more consistently than is possible with manual cardiopulmonary resuscitation, CPR (see also A. Truhlar in AirRescue Magazine, 1/2012: “Mechanical chest compression devices in HEMS – blessing or curse?”, pp. 51-55).

requirements for more sophisticated air medical equipment. When it came to developing the X Series, researchers went out to the field and canvassed those on the front line of emergency care to describe what components would make the perfect defibrillator for their organization. “What features would it have? What would it look like?” Throughout four years of (field) research, the answers were universally similar: HEMS staff and other people working in the industry wanted something small, light, durable with a long battery life, and full-featured. As this inquiry also showed, today’s HEMS operators want the ability to rapidly obtain and smoothly exchange real-time patient care data. This would require powerful, new transmission technology – something that could have scarcely been imagined a generation ago. Zoll was able to address these concerns in order to improve patient care – size, weight, portability, ruggedness, and power supply. The new X Series monitor/ defibrillator is about half the size and weight of other full-featured models, but with greater capabilities: it weighs less than 6 kg (12 lb) – with no sacrifice of power or features. In other words, it has many features HEMS operators would want in a monitor/defibrillator: it is compact without any compromise in display size, capability or performance. As Janne Virta (MD, Medical Director FinnHEMS and Senior Consultant at Pirkanmaa Hospital District in Finland) explains, “I have been using the X Series for over a year now and it is by far the best monitor/defibrillator I have ever used – and I have over 20 years of experience in EMS/HEMS work out of hospital … It is ideal for HEMS use for many reasons. Weight is always an issue when we are talking about flying, and in this respect, the X Series is magnificent. Lightweight and small size also makes patient loading so much easier and quicker.”

Real-time CPR feedback Author: Dieter Jadwiczek Senior Marketing Manager International EMS & Military Markets Zoll Medical Corporation

Four years of field research The latest addition to the Zoll product portfolio is the new X Series™ monitor/defibrillator, which is being embraced by HEMS operators worldwide for its “game-changing” technology. According to Zoll, the advanced capabilities of the X Series meet the increasingly complex needs and

In addition, the X Series’ ability to assist and help caregivers improve CPR quality is further enhanced by Zoll’s proprietary CPR feedback technology. The X Series features See-Thru CPR® to filter out compression artifacts on the ECG monitor, so rescuers can see and analyze the underlying heart rhythm during CPR, thereby reducing

1 · 2013 I Vol. 3 I AirRescue I 48

TECHNOLOGY | 49 the duration of pauses in compressions. Also included is Real CPR Help®, real-time CPR feedback technology that guides the rescuer to the proper depth and rate of chest compression, guidance that can improve CPR quality. Zoll’s CPR Stat-padz® assists by incorporating an accelerometer that measures depth, rate and recoil, and provides real-time feedback, including configurable voice prompts and a metronome that helps to keep rescuers within the recommended guidelines. All data appear in a simple real-time visual display through the CPR Dashboard™. These features help rescuers deliver good-quality compressions and minimize unnecessary pauses. Dr Virta also added, “CPR feedback and data collection capabilities make quality control easy and handy.”

Data transmission Another feature that sets the X Series apart is its noninvasive blood pressure (NIBP) technology, which provides more accurate readings faster, even in noisy, pre-hospital environments. Other Zoll features like Sure BP® and Smartcuf® enable pressure readings in about 15 seconds, because they are detected during cuff inflation. Yet another impressive highlight is its communication capabilities. It’s the first defibrillator with integrated WiFi, one of three connectivity options. The X Series redefines how data can be transmitted, the speed at which it can be sent, and access to data in a HEMS system. Patient care data can be sent ahead to hospitals or remote locations, even while HEMS medics are caring for patients. This can expedite time-critical interventions such as catheterization for STEMI patients. When it comes to monitoring patients, all parameters are easy to read on a bright, high-contrast colour ICD with three display modes. Multiple waveforms can be displayed simultaneously – including up to four physiological waveforms or all 12 ECG leads. Split-screen capability allows rescuers to view an ECG in real-time, either as the total acquired 12-lead or as one of six separate pages of 12-lead ECG, ST segment measurements, and analysis information. If a provider misses something important on an ECG as it happens, a novel “snapshot“ capability lets them push a button to print out the previous 12 seconds, as well as the 12 second post-event, for a 24-second window of what transpired. Complete events are preserved for later review using the RescueNet® Code Review. As Gareth Grier, MD, Clinical Lead, Essex and Herts Air Ambulance (EHAAT) in the UK, mentions: “The monitor allows us to continue to safely provide life-saving treatments for the patients of Essex and Herts at the roadside, such as the delivery of an anaesthetic, something normally only available in hospital.”

Ruggedness and durability The X Series is based on a platform developed for the military and air medical operations. It is the first monitor/ defibrillator for HEMS to earn an IP55 ingress protection rating for dust and water: it is virtually immune to a threeminute, high-pressure onslaught of water and meets the most stringent specifications for shock and vibration. The X Series can also handle three invasive pressures and two

1 · 2013 I Vol. 3 I AirRescue I 49

temperatures, often needed in critical care. An additional advance is the X Series’ battery. Despite the device’s compact size, its SurePower™ II high-capacity Lithium-ion battery offers the longest available run time in the industry, even while sustaining a range of functions. It provides at least six hours of continuous monitoring of ECG, pulse oximetry, capnography, three invasive pressure channels, and two temperature channels, with NIBP measurements every 15 minutes and 10 defibrillation shocks at full energy (200 J). “The battery life is excellent and X Series has proven to work well – even in the hard winter conditions in Finland. The device is very easy to use and has all the qualities you can ask for in HEMS work,” states Dr. Virta. Dr Gareth Grier sums it up for EHAAT by saying that “the X Series will ensure that even during the harshest of conditions outside of hospital, we can easily watch the effect of our interventions on patients. We can provide cutting edge treatment, which has been published in international medical journals, and the X Series assists us in delivering that level of high-quality patient care.” 

Fig. 2: “Cutting edge” technology: the X Series is extremely small and lightweight (Photograph: Zoll)

For more information, visit: ››› www.zoll.com/xseries Fig. 3: Not only EHAAT HEMS crews praise the X series for being compact, without any compromise in display size, capability or performance (Photograph: Zoll)

50 | TECHNOLOGY

A safe solution to concerns with lithium-ion batteries As the demands on airframe manufacturers to reduce weight and improve efficiency challenge the present electrical system design capabilities, a clear option points toward the advantages of implementing a lithium-ion power source to displace the present lead-acid and nickel-cadmium batteries. Although attractive due to their notable increase in energy density, the particular operational sensitivities of lithium-ion batteries raise valid concerns regarding the prolonged safe operation for flight applications.

The European Aviation Safety Agency (EASA) has expressed concerns about the use of lithium-ion batteries in aircraft and rotorcraft applications due to the following reasons: • • • • •

Overcharging Cell component flammability Maintaining safe cell operation Prohibiting the use of corrosive fluids/gases Explosion containment, and the regulation of explosive/toxic gases • Containment of excess heat resulting from a shortcircuit • Incorporation of low state-of-charge monitoring and warning With these points in mind, the Radio Technical Commission for Aeronautics (RTCA) released the DO-311 design guideline to prevent potential failures related to lithiumion battery systems. Successful failure mitigation for lithium-ion batteries involves a layered battery design approach that includes:

1. Cells: selection of the appropriate lithium-ion cell chemistry and cell size (capacity) to support a distributed Cell Stack (power module) that will minimize the possibility of cell failure propagation. 2. Electronics: integrated monitoring and control system with suitable redundancies that incorporate monitoring and control capabilities to govern the operation of the lithium-ion cells to ensure proper charge rate current, charge voltage, discharge voltage, and cell temperatures are maintained – the battery electronics are key to mitigate those conditions which can initiate potential cell failure. 3. Encasement: a battery case design with suitable insulative layer(s) to suppress any potential cell flame or fire, and the ability to contain the explosive capabilities of the lithium-ion cells should they fail. To address RTCA and the industry’s safety concerns, EaglePicher Technologies (EPT), LLC of Joplin, Missouri (USA), has developed a “smart” lithium-ion battery architecture as a reliable solution for providing aviation power.

Fig. 1: 34 amp/hour aircraft auxiliary battery (Photograph: EaglePicher Technologies)

Author: James R. Bond Lead Electronics Engineer New Product Development EaglePicher Technologies, LLC Joplin, Missouri USA

1 · 2013 I Vol. 3 I AirRescue I 50

TECHNOLOGY | 51

BATTERY

I/O

PSB • signal conditioning / transient suppression / level-shifting • wake-up signal provided to battery electronics • service interface (Push-to-Test) support • fault status composition and notification

RPB

ARINC PTT

BMS

• • • •

• V/Tcell & Ibat monitoring • Charge, Discharge & Cell Heater “conditional control intervention” of BMS intent

V/T/Icell & V/T/Ibat measurement Cell Heater Control Cell Balance Charge Control SOC, SOH, BEL computations

embedded microcontrollers, DO-178B

Cell Stack

µC

cell 1

CHG

µC

cell 2

CHG

µC

cell 3

CHG

Isolation & Protection Switches

current limiter FBD

µC

cell n

CHG

Cell Heaters

Cells & Batteries EPT has an extensive history of supplying both cells and batteries from a number of different electro-chemistries to the defense and aerospace industries on a worldwide scale, including products powering satellites and spacecraft in critical applications. This design expertise enables EPT to custom-tailor batteries in a variety of configurations that accommodate the needs of a particular vehicle; in this case, EPT has the ability to produce batteries for a number of types of rotorcraft that can supply power for engine starting and/or auxiliary equipment needs. In recent years, lithium-ion batteries have proven to be an attractive alternative to older electro-chemistries such as lead-acid and nickel-cadmium that have seen long-time use in many aviation applications. Lithiumion batteries in general offer significant advantages that include reduced size and weight, increased operational longevity, higher power output and better recharge efficiency. Furthermore, lithium-ion batteries lack the toxic heavy-metal content of lead-acid and nickel-cadmium batteries that create environmental concerns at the time of their eventual disposal. A number of electro-chemistries fall under the “lithium-ion” nomenclature due to the wide variety of cathode materials that are utilized. EPT presently uses lithium-iron phosphate (LiFePO4, or LFP) for the cells in its smart aircraft batteries. Long cycle life is a key advantage, as are its multiple virtues regarding safety. Lithium-iron phosphate releases less heat during operation than comparable lithium-ion chemistries. Also LFP cells have a lower voltage potential and thus a reduced energy density that translates into decreased volatility when multiple cells

1 · 2013 I Vol. 3 I AirRescue I 51

Aircraft Electrical Power Bus

Ibat

are nested together to increase the rated battery capacity; the likelihood of a thermal reaction propagating from one cell to another adjacent cell is thus greatly reduced. Additionally, in their as-designed state, the lithium-ion cells do not utilize lithium metal materials. Aside from the safety of the LFP cells themselves, another important design aspect is cell encasement within the battery. EPT adds a proprietary thermal-suppression material to provide a means of containment in the event of an internal fire or explosion. Therefore, safeguards are in place to both reduce and contain flammability.

Battery Architecture The EaglePicher lithium-ion battery is comprised of a number of electronic subsystems that monitor, oversee and communicate the status of the conditions and operational parameters for the cells and the battery. A block diagram representation of the EPT smart battery is shown in Fig. 2. The battery is comprised of six primary sub-systems: 1. Cell Stack – power source for the battery 2. Battery Management System – primary monitoring, control and charge oversight 3. Redundant Protection Board – safety net to the BMS monitoring and control 4. Current Limiter – bulk charge support for the Cell Stack controlled by the BMS 5. Peripheral Support Board – aircraft-specific I/O and communications interface 6. Isolation & Protection Switches – means to isolate Cell Stack from the power bus

Fig. 2: EPT smart battery block diagram

52 | TECHNOLOGY BMS control signal(s) to disable charge, discharge or cell heater functions as may be necessary. The primary element for ensuring both safe operation of the cells and supporting discharge for Emergency Power needs is the IPS, or Isolation and Protection Switches which are comprised of solid-state relays with suitable redundancies. The BMS has primary control of the operation of the K1, K2, and K3 switches to independently support cell charge and discharge; with the RPB also interfacing to intervene the BMS control of these switches should a malfunction of the BMS occur. In addition to the EaglePicher’s safety-orientated electronic elements, the battery system is designed to interface with an array of aircraft outboard systems via the Peripheral Support Board (PSB). The ARINC 429 implementation presently supports 50 data labels with covered parameters including battery and cell voltages, cell charge and battery discharge currents, cell and battery temperatures, and state-of-charge (SOC), state-of-health (SOH) and energy-level (BEL) data. External and batterylevel discrete signal status and fault action details are also provided. Fig. 3: 30 amp/hour aircraft starter battery (Photograph: EaglePicher Technologies)

Overall Safety

The core of EaglePicher’s smart lithium-ion battery is the Battery Management System (BMS). The BMS serves as the “brain” of the lithium-ion battery implementation with functional control of cell charge, battery discharge, Cell Heater activation, deployment and status determination (State-of-Charge, State-of-Health and fault assessment) and general communication with other systems. The BMS relies on a distributed microcontroller set to measure Battery Terminal Voltage, Battery Current, Battery Temperature, Cell Module Temperature, Cell Voltage, and Cell Balance Charge Current to optimize capacity utilization of the Cell Stack and to ensure the ongoing safe operation of the cells. Software for the BMS is guided by the DO-178 process to Design Assurance Level B, although the specific Design Assurance Level needed for a given application is guided by the electrical system safety assessment or hazard analysis. Key to the extended life of the Cell Stack is optimal balance charging of the series-connected cell modules provided by EaglePicher’s patented Isolated-Source active balancing (equalization) scheme that is an integral part of the BMS. This precision charging method typically follows a bulk charge of the Cell Stack as governed by the BMS and allows each cell module to be independently charged to its optimal end-of-charge voltage and taper current limit to ensure the cells reach their full capacity. Operating as a safety net to the BMS, the Redundant Protection Board (RPB) offers fully separate, electrically isolated and dissimilar hardware-only protection circuits. The RPB implements independent monitoring circuits from the BMS to provide essential protections in the event of a potential BMS malfunction. The RPB does not act as a secondary control to the BMS, but rather interrupts the

The mechanical design of the smart lithium-ion batteries is obviously crucial to ensuring safety. EPT’s aircraft cells, batteries, electronics, and all of its assembly components and materials are designed to withstand the extremes of flight, ensuring full compliance with DO-311; for example, the design stage itself utilizes computer-aided modeling and analyses to evaluate form, fit, and function of the battery system for optimal performance. In order to verify full functionality and integrity, subassemblies and finished batteries undergo rigorous electrical and environmental testing to evaluate real-world performance as guided by DO-160. This includes vibration, mechanical shock, altitude changes, extremes in electrical loads (such as overcharging) and temperature, EMC, and resistance to dielectric problems (including short-circuits). Other testing – including visual examinations, software verification testing, and bench checks of the individual subsystems prior to assembly – provide comprehensive assurance that each of EPT’s batteries comply with safety requirements, the needs of the aviation industry and customer expectations. In conclusion, the ever-increasing power needs on today’s aircraft and rotorcraft necessitate an entirely new generation of batteries that fulfil aviation needs, while also incorporating state-of-the-art electronics to ensure the highest capabilities of safety. Utilizing its smart BMS innovations and battery design proficiency, EaglePicher Technologies offers a new benchmark for supplying electrical power for flight. EPT’s recent developments in system design, battery management, and electro-chemistry all aim at raising the performance standards for lithium-ion aircraft batteries to a new level of sophistication, while maximizing safety as an inherent capability.  For more information, visit: ››› www.eaglepicher.com

1 · 2013 I Vol. 3 I AirRescue I 52

MEDICAL CARE | 53

HEMS and organ transplantation:

Fig. 1: Transport of organs for transplantation is common in Spanish HEMS operations (Photographs: C. de la Cruz Caravaca)

Saving the life of “the other” patients Since the first successful kidney transplant in 1954, solid organ grafting is now recognized as a first line therapy. Despite the fact that the number of donors and organs available for transplantation increases every year, the number of patients on waiting lists is even higher. This causes longer waiting times for patients who deteriorate or die while waiting for an organ. For instance, in EU countries the number of patients on the waiting list for kidney transplantation increased by 29.1%, yet the annual number of kidney transplant procedures only rose by 16.6%. It is more and more common for HEMS to collaborate with organ transport for transplantation, but they also do work in another area: donor medical assistance and transport.

Spain has the highest organ donation rate in the world. The so-called Spanish model for organ donation and transplantation, developed by the Organización Nacional de Trasplantes (ONT), the National Transplant Organization, is well known amongst professionals involved in transplantation. This Spanish model is a systematic and organisational approach to the process of deceased donation and is largely overseen by a transplant coordinator.

1 · 2013 I Vol. 3 I AirRescue I 53

Donation after brain death Currently, donation after brain death (DBD) is the main source of organs for transplantation. While the number of deceased donors has been rising gradually, the annual donation rates per million population (donors pmp) have remained around the same level for years. The ONT carried out an in-depth analysis in 2006 to get to the bottom of this. They concluded that there were several factors involved in stabilisation of the organ donation rates:

Author: Cristina Carriedo Scher EMS doctor in Madrid (SAMUR-PC) HEMS doctor Castilla-La Mancha (SESCAM/INAER)

54 | MEDICAL CARE

Fig. 2: The Medical Helicopter Service of Castilla-La Mancha uses two EC135, located in Ciudad Real and Albacete, and two EC145 for the 24-hour-service in Toledo and Cuenca

• Reduction in traffic mortality • Stroke has replaced trauma as the main cause of brain death, mainly in elderly people • Huge variability in donors’ activity among different regions The final result of this analysis was “Plan 40”, a strategy designed to improve the following areas: • • • •

Detection and management of brain-dead donors Expanded criteria for donors Special surgery techniques Donation after cardiac death

One of the alternatives to increase the number of organs for transplant is dealing with the donors who die after cardiac arrest. They have been called “non-heart-beating donors”, “donors after cardiac death” and, more recently, “donors after circulatory death” (DCD). They are patients who receive advanced life support after suffering a cardiac arrest but without resulting in successful recovery of circulation. In certain patients, an unsuccessful Advanced Table 1: NHBD – Maastricht classification (1995) Type I

Dead on arrival

Type II

Unsuccessful CPR

Type III

Awaiting cardiac arrest

Type IV

Cardiac arrest in DBD patient

Table 2: Madrid Classification Proposal (2011) Type I Type II

Dead on arrival a

Out of hospital unsuccessful CPR

In hospital unsuccessful CPR

Type III

Awaiting cardiac arrest

Type IV

Cardiac arrest in DBD patient

Life Support procedure makes them potential organ donors. Although this process sounds relatively simple, a brief explanation suggests otherwise. It involves a lot of different activities, which have to happen in rapid succession to avoid the negative effects of the ischemia on the organs and to account for all of the ethic and legal considerations. A DCD program must be based on a well-structured procedure of professional and technical elements involving in- and out-of-hospital teams. Spain is a pioneer in this kind of donors, thanks to the coordination of Critical Care Units (CCU), transplant surgery teams and emergency out-of-hospital systems. After cardiac arrest and unsuccessful Advanced Life Support, the patient still receives cardiac compression and ventilation; the aim is to provide effective circulation to maintain organs availability for transplant. Initially, the failure rate of the organs of DCD was mainly due to the prolonged warm ischemic period. The improvement of surgical techniques and organ preservation, along with the development and standardisation of cardiopulmonary resuscitation techniques (including intubation and cardiac massage), has managed to maintain adequate perfusion in the bodies of unresponsive patients. In 2008, Spain had a rate of 34.2 donors pmp, and 77 of the 1,577 (5%) organ donors were DCD. The National Organization of Transplants (ONT) believes a reasonable and achievable target to have between 5 and 8 donors pmp from patients suffering cardiopulmonary arrest (between 225 and 350 donors/year) at the national level. The implementation of a program of DCD has to take into account a number of basic requirements, such as the availability of an Out-of-Hospital Emergency Service and a hospital capable of accepting the potential donor. The main constraint for the DCD program is the transfer time of the potential donor to maintain the best conditions for performing cardiac massage. In addition, there are other determining factors such as geographical distance, the landscape of the route of shipment, the type of population (rural or urban), the transport infrastructure (roads, availability of Medical Helicarrier Service and Helipads), the weather and the training of out-of-hospital emergency teams. Categories for non-heart-beating donors (NHBD) or DCD are different depending on the country and develop ments over the years. Currently, DCD type III (Tables I and II) are predominant in Japan and European countries, except Spain. In contrast, since 2006, the largest category of DCD donation in Spain has been the non-controlled donation based on Maastricht type II. The pioneering work at Hospital Clínico de San Carlos in Madrid has become world reference for this kind of donation. The number of organs extracted and transplanted is less than the number of organs from DBD patients. However, the results of kidney transplantation are very satisfactory, with higher incidence of delayed renal function – though with proper long term renal function. Currently, other organs from DCD used for transplantation, are the lungs and liver with both showing promising results.

1 · 2013 I Vol. 3 I AirRescue I 54

MEDICAL CARE | 55 In 1995 Spain developed the “document of consensus about organ extraction from donors in asystolia” to tackle legal, ethical and technical issues for this kind of donation. This set of laws and rules have enabled the development of DCD programs in some cities with highly motivated donation in- and out-of-hospital teams. There are currently a number of active DCD protocols in Spain (Madrid, Barcelona, La Coruña, Alicante and Granada). The Emergency Service “SAMUR-PC”, from Madrid, is a pioneering company in this field (Code 9) and has gained a wealth of experience since beginning of its activities in 1996.

Selection of the potential donor The general criteria for the inclusion and exclusion of donors are those that allow us to rule out the presence of systemic diseases with visceral impact and cancerous diseases (except some primitive tumours of the central nervous system). The inclusion and exclusion criteria of the potential donor are: • Beginning massage and mechanical ventilation (measures of Advanced Life Support) no more than 15 minutes after cardiac arrest. • Entire time of cardiac arrest must be less than 15 minutes. • Age between 7 and 55-60 years old. • Cardiac arrest time known; the time of cardiac arrest is determined on the basis of the testimony of the observers, if present. • Cause of death known (or suspected). • Absence of chest or abdominal injuries that cause massive haemorrhage. • Healthy overall appearance; assessing HIV risk factors. Support Time (including transfers) to Hospital Emergency Facility should be made in less than 120 minutes: This is the time between cardiac arrest and arrival at the hospital while maintaining Advanced Life Support (ALS) processes. This time varies between 90 and 120 min., depending on different DCD programs (DCD program from Castilla-La Mancha, Spain). Warm ischemic time is the period that elapses between the cardiopulmonary arrest and starting the cardiopulmonary bypass. This has to happen in less than 150 min (DCD program from Castilla-La Mancha is the only program using 120 min. for support time and 150 min. for the whole process until the cardiopulmonary bypass procedure begins in the operating theatre. At other programs, like in Madrid, Alicante, etc. the time frames are 90 and 120 min. respectively). Of this time, the hospital requires approximately 30 min. to execute the cannulation and perfusion of the donor, meaning the emergency team has only a maximum of 120 min. This period is measured from the time of PCR up to the transfer to the hospital, and includes time spent on ALS processes at the same time as the transfer to the hospital. The inclusion and exclusion criteria can present some small differences between emergency services in different regions of Spain, which have their own individual conditions.

1 · 2013 I Vol. 3 I AirRescue I 55

DCD in Castilla-La Mancha region Castilla-La Mancha is one of the largest regions in Spain. With a population of nearly two million, geographical dispersion is the determining factor for a DCD program. There are over 1,700 villages, with only 7 relatively large cities (over 50,000 inhabitants). The EMS has 24 ALS mobile units (UMEs) and 4 EMS helicopters. The Medical Helicopter Service uses two EC135 located in Ciudad Real and Albacete and two EC145 for 24 hour service in Toledo and Cuenca. Every HEMS crew consists of a doctor, a nurse, a pilot and a co-pilot. Emergency activities are organised by the “112” Coordination Centre (CCU) which is located in Toledo and serves the whole region. Doctors and nurses working at the CCU coordinate the activity of the Emergency Units, including medical helicopters. There is a weather office, available 24 hours, to provide meteorological information for the planning and execution of the flights. It works in close collaboration with the medical staff to advise on the helicopter flight route and the closest helipad available from a total of more than 200. The DCD program became active in Castilla-La Mancha in January 2011 after five years of collaboration between the Regional Emergency Medical Service (SESCAM) and the local office of the National Transplant Organization (ONT).

Case report The patient was a 47-year-old man, formerly healthy. Relevant medical history: he gave up smoking three months earlier. After a bike ride, he returned home and told his wife he felt sick and he had difficulties breathing. Suddenly, his wife found him on the floor with respiratory difficulties and she called “112” for help. Due to suspected cardiac arrest, the CCU activated the nearest ALS unit 8 km away from the village. At the same time, HEMS Toledo was activated in case of an unsuccessful reanimation and DCD. During the flight, the HEMS team received information about the patient’s clinical conditions. He had suffered a cardiac arrest and basic resuscitation procedures were given by the local “técnicos de emergencias sanitarias”

Fig. 3: AutoPulse® used for automated chest compressions during flight (image shows an EC145 interior)

56 | MEDICAL CARE

Fig. 4: HEMS in Castilla-La Mancha (timing & deployment)

Acknowledgement: The author would like to express her gratitude to Commander Mr Carlos de la Cruz Caravaca, INAER Espana, HEMS pilot in Castilla-La Mancha, for his contributions to writing this paper and the graphic documentation provided.

(which may be translated as emergency assistants) after 4 min. of the cardiac arrest. ALS was given by the emergency medical team 10 min. after the cardiac arrest. CCU confirmed the appropriate timing (flight and on-ground transport) and the hospital acceptance of the patient in case of unsuccessful resuscitation for DCD. Once the HEMS team reached the patient, manual cardiac massage was replaced by mechanical chest compression using an AutoPulse®. The Oxylog Transport Ventilator 3000 was used for mechanical ventilation. The patient remained in asystolia despite the cardiopulmonary resuscitation (CPR) being given, following the current recommendations (ERC 2010). His relatives were asked for permission to move the patient to a hospital with a DCD program, to allow for donation if the patient remained in asystolia. They gave clearance and agreed. The patient was taken to a hospital 190 km away from his home using the HEMS Toledo EC145. Flight time was 45 min. and non-stop CPR was given in-flight. The whole assistance from cardiac arrest at home to the helicopter landing at the hospital helipad took 115 minutes. The inhospital transplantation team was waiting for the HEMS directly at the helipad to move the patient to the ICU unit to confirm the patient dead and begin the process of organ retrieval. The Hospital Transplantation Coordination team prepared for the relatives arrival and interview to achieve the organ donation. After the donation process, the patient’s two kidneys were successfully transplanted and one month later renal function was optimal.

Conclusions Organ donation is a well-established and recognised field in the medical community as a whole. The cost-to-benefit

ratio must not be quantified in terms of the cost of each donation process, but as the number of lives saved, the useful years (work years) recovered and the costs saved in long-term medical treatments for chronic patients who became healthy after organ transplantation. Special attention needs to be given to the relatives of a donor. One of the reasons for the success of the Spanish model of organ donation is the close attention given to the family of a potential organ donor. It is essential to formalise the family approach according to the logistics of each service and to foster social integration of organ donation in each community. HEMS activity has to become an integral part of the organ donation process. HEMS units have to collaborate in this process. From the detection of donors to the organ implementation, the entire process is time dependent. Medical helicopter transport is currently involved in the transfer of organs, but it has to consolidate its involvement in assisting transfers of potential donors. The helicopter is a suitable and fast means of transport, which allows the use of mechanical devices that facilitate the maintenance of ALS care. The increasing presence of helipads at hospitals provides direct access to the helicopters and transfer of patients. The success of an organ donation program is based on coaching of all of those involved, from the out-ofhospital teams, HEMS crews, emergency coordination centres and in-hospital medical and surgical teams. The in and out-of-hospital staff commitment to organ donation depends on the training and the conviction that an assisted cardiac arrest without success does not end with the death of the patient, but with the possibility of healing other patients. 

References: 1. Matesanz R, Marazuela R, Domínguez-Gil B, et al. (2009) The 40 donors PMP plan: an action plan for improvement of organ donation and transplantation in Spain. Transplantation Proceedings 41/8: 3453-3456 2. Organización Nacional de Trasplantes (2012) Donation and transplantation data. http://www.ont.es/infesp/Paginas/ DatosdeDonacionyTrasplante.aspx. Accessed: 12 February 2013 3. Matesanz R (2008) El modelo español de donación y trasplantes. Aula Médica, Madrid 4. Sánchez-Fructuoso AI, Marqués M, Prats D, et al. (2006) Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys. Ann Intern Med 145: 157-164 5. Alvarez J, Del Barrio R, Arias J, et al. (1999) Non-heartbeating donors and emergency health care systems. Transplant Proc 31/6: 2215-2216 6. Bernat JL, Capron AM, et al. (2010) The circulatory-respiratory determination of death in organ donation. Crit Care Med 38: 963-970 7. Sánchez Carretero MJ, Carriedo Scher C (2011) Donación a Corazón Parado. Cap 10. El proceso de la Donación y Trasplantes. Centro Coordinador de Trasplantes, Castilla-La Mancha. SESCAM Servicio de Salud de Castilla-La Mancha: 157-170 8. Donación en Asistolia en España: Situación Actual y Recomendaciones: http://bit.ly/ONT_Esp

1 · 2013 I Vol. 3 I AirRescue I 56

MEDICAL CARE | 57

Fig. 1: Taking into account large distances in Russia, it is impossible to provide effective medical care without medical aviation

Direct transfer versus inter-hospital transfer: Medical helicopter evacuation of paediatric road traffic trauma victims in Russia Road accidents among children are a serious problem in Russia. Over the last decade, the number of children injured annually exceeded 20,000 – over 1,000 of whom died. The potential for improving medical management in this group lies mainly in the reduction of the period between the patient arriving at the hospital and them receiving specialist medical care. Furthermore, patient outlook is linked to the use of air medical services. In the USSR, the first medical aeroplane was built in 1927 and by the end of 1990, the Russian Federation’s air medical services had 96 planes and 94 helicopters, with more than 200,000 patients receiving air medical care annually. Today, the reestablishment of Russia’s medical air services demands a rational approach to the use of resources and marking out the most efficient ways of using aviation equipment.

1 · 2013 I Vol. 3 I AirRescue I 57

Authors: Sergei G Suvorov Vladimir M Rozinov George A Chogovadze Moscow Scientific Research Institute of Paediatrics and Paediatric Surgery Olga A Garmash All-Russian Centre for Disaster Medicine “Zaschita” Ministry of Healthcare of Russia, Moscow Sergey A Fedotov Vyacheslav G Makhnev Scientific-Practical Centre for Emergency Medicine Moscow Corresponding author: suvorov@narkoz.ru

58 | MEDICAL CARE Group A (n=106)

Group B (n=74)

absolute

Minor

7.55

Moderate

70.75

6.76

Major (severe)

14.15

43.24

Critical

6.60

44.59

Terminal

0.94

5.41

Isolated

66.0

12.2

Polytrauma

32.1

87.8

No injuries

1.9

Severity

Type of trauma

Degree of severity

No trauma

1.9

Level 1

90.6

33.8

Level 2

3.8

29.7

Level 3

2.8

17.6

Level 4

0.9

18.9

Table 1: Degree of severity of patient status on admission to hospital (clinical assessment) Table 2: Types of trauma among children injured in road traffic accidents Table 3: Degree of severity by PTS (Hanover Polytrauma Score)

The least studied area in Russia’s public health system is the introduction of EMS helicopters in regions with a high density of buildings and complex tiered road systems. The medical and economical advisability of adopting different arrangements and clinical models for the use of air medical services (1–3) is still under debate. The current stage of development of air medical services is of vital importance for gathering evidence of the efficient use of light and medium class EMS helicopters (corresponding to ‘transport’ and ‘normal’ categories in the Aviation Regulations) in a major metropolitan area.

The authors have considerable experience in the application of air medical services – between November 1996 and June 2012, 327 children were transferred by helicopter to the surgical clinic (level 1 paediatric trauma centre) of the Moscow Scientific Research Institute of Paediatrics and Paediatric Surgery. The majority of children transported by air were suffering mechanical and thermal traumas. The aim of the study was to compare two types of medical helicopter usage during the transfer of children injured in road accidents to the paediatric hospital (paediatric trauma centre): from the accident site (direct transfer) and from other local municipal hospitals (interhospital transfer). The outcome of medical evacuation by helicopter of 180 children injured in traffic accidents in the period from 1 January 2001 to 31 December 2011 has been analysed retrospectively. The Eurocopter Bo105, Eurocopter BK117 and Eurocopter EC145 (BK117 C2) helicopters, property of EMERCOM, Russia, were used. The HEMS team included one or two doctors (anaesthesiologists and intensivists) of the Scientific-Practical Centre of Emergency Medicine of the Department of Public Health in Moscow and the Russian Ministry of Emergency Situations (EMERCOM). The dispatch centre of the Scientific-Practical Centre of Emergency Medicine was responsible for the operational management. The research methodology was based on the comparison of two groups of patients – 106 children were airlifted from the accident site (group A) and 74 patients were transferred from municipal hospitals in the Moscow region (inter-hospital transfer) (group B). Medical triage prior to the inter-hospital transfer meant that children with severe injuries requiring specialist (including high technology) types of medical care could be selected for treatment

Fig. 2: Since 1996, more than 330 children were transferred by medical helicopters to the Clinic of Paediatric Surgery, located at Moscow Children‘s Hospital No. 9 (Photographs: S. Suvorov)

1 · 2013 I Vol. 3 I AirRescue I 58

MEDICAL CARE | 59 in the specialist paediatric hospital (level 1 paediatric trauma centre). The comparison was made according to: • Demographic characteristics • Estimation of degree of severity of status and injuries • Amount and type of therapeutic care during the transfer (on board) • Frequency of admission to intensive care unit at the paediatric hospital • Surgical intervention requirements • Duration of hospital stay (including treatment in ICU) • Fatalities Statistical treatment of data was carried out using parametric and nonparametric statistics methods with StatSoft STATISTICA 6.0 software. This included descriptive statistics, frequency contingency tables with the calculation of χ2 criteria using the Pearson method and indication of number of degrees of freedom and actual value of reached significance level (p), median test, and calculation of Spearman correlation coefficient. The level of statistical significance p<0.05 was used as an acceptable error level. In order to calculate the correlation of odds within the limits of retrospective research, the public health epidemiologic statistics online open resource, OpenEpi version 2.3.1, was used (4). In both groups, the majority of patients were male: group A had 57 boys (53.8%) and group B had 50 (67.6%). No statistically significant differences between

the two groups according to sex were revealed: Pearson χ2=3.44, df=1, p=0.06. The ages of children in group A were 8.0 years (median), 4.0–12.0 years (25–75% percentile) and 0.5–15.0 years (min–max). In group B, older children prevailed: 12.0 years, 8.0–14.0 years and 1.4–16.0 years. Statistically significant differences between groups according to age were confirmed by the results of the median test: χ2=8.13; df=1; p=0.004. Results of the clinical assessment of the degree of severity of the children’s status on admission to hospital are shown in Table 1.

Fig. 3: Spacious interior of the Mi-8MTV-1 (Mi-17V-1), where four medical modules can be quickly installed, accommodating up to 8 patients (including 4 in critical condition)

EHAC Safety Symposium & AGM 2013 Warsaw, 22-23 May 2013

Safety Culture at the forefront The EHAC leadership has decided to start organizing regular professional meetings of experts under the title of the EHAC Symposium. Along with the successful AIRMED world congresses in air medical services, it is another professional event for our members. The first Symposium of this type will take place this year on 22 and 23 May in Warsaw. The main theme is Safety Culture. Topics to be covered also include EHAC’s Human Factor Programme, Fatigue Risk Management System and Safety increasing technology, just to name a few. Pavel Müller, President, emphasises that attendees “can be sure of the program’s high professional level. The organizers have carefully selected topics and chosen some excellent speakers.” Precisely those issues currently at the forefront of the HEMS community’s attention will be discussed. In conjunction with the Symposium, the EHAC General Annual Membership Meeting will also be held, which will “simultaneously further benefit the value and efficiency of EHAC members’ membership rights.” Müller expressed his gratitude to the hosts, LPR, and cordially invites all EHAC members to attend the Symposium.

For more information, please visit: www.ehac.eu 1 · 2013 I Vol. 3 I AirRescue I 59

60 | MEDICAL CARE

Fig. 4: The Mil Mi-8, or Mi-17, a legendary Russian helicopter, is a reliable and an undemanding medium twinturbine helicopter, suitable for military and emergency ops, but too large and expensive to transport 1 to 2 patients

Table 4: Types of treatment in helicopter Table 5: Treatment in specialist paediatric hospital

We found statistically significant differences between groups according to the results of the clinical assessment of degree of severity on admission to the hospital (χ2=91.3, df=4, p<0.001). In the majority of cases (78.3%), the degree of severity of children delivered to the hospital from the accident site (group A) was assessed as minor or moderate. Of those children transferred from the accident site by helicopter, 2 had no traumatic injuries and 17 had superficial scratches. Overall, children with minimal or no traumatic injuries made up 10.6% of group A. Indirect confirmation of a relatively high proportion of children with minimal injuries among those delivered from the accident site was the fact that 4 children were allowed to return home following the examination and 19 children refused hospitalisation. In total, this represented one fifth (21.7%) of all children in group A. The status of the vast majority (93.2%) of children in group B was classed as severe, critical or terminal. Half the children undergoing inter-hospital transfer were estimated as having either critical or terminal status. This situation was the result of a preliminary triage of patients who were first transferred from the accident site to local municipal hospitals and then those who needed interhospital transfer being classed as requiring specialised (including high technology) medical care. In group B, only 6.8% of patients were classed as having moderate severity. Group A (n=106)

Group B (n=74)

χ2

52.7

40.7

p<0.001

90.5

34.0

p<0.001

94.6

61.9

p<0.001

77.0

60.2

p<0.001

absolute

Mechanical ventilation

9.4

Oxygen therapy

48.1

Infusion therapy

35.8

Type of treatment

Treatment in specialist paediatric hospital (level 1 trauma center)

ICU admission

18.9

Surgical intervention

22.6

85.1

68.1

p<0.001

Fatality

2.8

10.8

4.84

p=0.028

Type of traumatic injury is shown in Table 2. In group A, two thirds of all injuries were isolated. Mainly, these were head traumas with varying degrees of severity. In group B, children with polytrauma prevailed (87.8%). Two children were delivered with combined injury types: mechanical trauma and thermal burns. The prevalence of isolated injuries in group A is statistically significant (χ2=51.4, df=1, p<0.001). Clinical symptoms of traumatic shock were diagnosed in 51 children from group B, which represents more than two thirds (68.9%), and in just 18 children from group A, or one sixth of the group (17.0%). The difference in the frequency of shock development between the groups was also significant (χ2=49.7, df=1, p<0.001). The ratio of chances of developing shock among children in group B was 10.7 times higher than among those who were delivered directly from the accident site (considering 95% confidence interval – 5.32, 22.1). An assessment of injury severity according to the Injury Severity Score (ISS) gave the number of children with a score of more than 15 as 10 (9.4%) in group A, and 64 (86.5%) in group B. We have shown the significant difference between the groups in the number of children with severe traumas (χ2=106.9; df=1; p<0.001). The majority of children evacuated by air from medical institutions in the Moscow region were suffering from severe traumas (assessed as scoring over 15 on the ISS scale). In absolute values, trauma severity scores on the ISS scale in group A were 4.0 (median), 4.0–8.0 (25–75% percentile) and 0.0–43.0 (min–max). Scores in group B were 29.0, 20.0–41.0 and 6.0–59.0. There was a strong correlation between the clinical assessment of the degree of severity and the trauma severity score on the ISS scale (Spearman correlation coefficient r=0.86, t(n-2)=22.5, p<0.001, n=180). In accordance with the definition of the German Society of Emergency Surgery, traumas may be assessed as “polytrauma” (i.e. wounds affecting more than one part of the body simultaneously) when any one of these wounds or a combination thereof threatens the life and health of a patient (5). A similar situation was observed in a comparative assessment of injury severity using the PTS (Hanover Polytrauma Score). Table 3 shows that the degree of severity of almost two thirds of patients in group B corresponded to level 2–4, compared with just 7.5% in group A. The difference between the groups was statistically significant (χ2 =70.2, df=4, p<0.001). The difference in the severity of the initial status of patients injured in road accidents was reflected in the degree of use of medical treatment such as mechanical ventilation, oxygen and infusion therapy during air evacuation. Table 4 shows significant differences between the groups in this regard, which can be explained by the severity of the status of children transferred from municipal medical institutions in the Moscow region following primary triage, measured by the severity of their injuries and the assessment of the need to continue their treatment in a specialist paediatric hospital. Treatment administered to patients in a paediatric surgical hospital is shown in Table 5. Patients transferred

1 · 2013 I Vol. 3 I AirRescue I 60

MEDICAL CARE | 61 from other medical institutions required significantly more surgical intervention and hospitalisation in resuscitation and intensive care units. Fatality in group B was 10.8%, compared with 2.8 % in group A, which can be explained by a higher number of injuries and higher severity of patients transferred from other hospitals. In group B, a patient’s likelihood of dying was on average 4.13 times higher than in group A (considering 95% of confident interval: 1.09–19.8). In group B, the duration of hospitalisation for surviving patients was 40.0 days (median), 26.0–60.0 days (25–75% percentile) and 2.0–191.0 days (min–max) (n=67). In group A, the same statistics were 5.0 days, 1.0–13.0 days and 0–73.0 days (n=97). There was a significant difference between groups in the median duration of hospitalisation: total median = 14.5 days, χ2=76.3, df=1, p<0.001. In group B, the duration of treatment in the intensive care unit for surviving patients was 7.5 days (median), 3.5–19.0 days (25–75 percentile) and 1.0–57.0 days (min–max) (n=52). Correspondingly in group A, figures were 2.0 days, 1.0–4.0 days and 1.0–8.0 days (n=18). The median result showed a significant difference between the groups in the duration of hospitalisation in the intensive care unit: total median = 5.5 days, χ2=14.7, df=1, p<0.001. There were also significant differences in the clinical outcomes of patients in the two groups. Among the 106 children in group A, 4 (3.8%) were allowed to go home due to the absence of any injury or because their injuries were mild, 19 (17.9%) refused hospitalisation, 79 (74.5%) were discharged from the hospital after recovery or improvement in health, 1 (0.9%) was transferred to another paediatric hospital and 3 (2.8%) died. Among the 74 children in group B, who were transferred from local municipal hospitals in the Moscow region, none refused hospitalisation, 54 (73.0%) were discharged after recovery or improvement in health, 10 (13.5%) were left disabled, 2 (2.7%) were transferred to other paediatric hospitals and 8 (10.8%) died. From the above data it can be seen that children transferred from local hospitals (located near main roads) in the Moscow region (group B) were characterised by a significantly higher severity of injuries and status. They often required replacement of vital functions and performance of surgical procedures. The duration of hospital treatment and stay in intensive care was significantly higher than among the group of children transferred directly from the accident site (group A). This regularity in general is typical for children with traumas of different types, for whom medical assistance is administered with the use of HEMS technologies (6). It should be taken into account that the use of EMS helicopters for administering emergency medicine at the accident site is limited because flights are not possible in the evening or at night (when road traffic accidents involving children occur most frequently and are most serious) and a large number of non-flying days every year (7). Developing technology for medical triage of injured persons at the accident site could play an important role in increasing the efficiency of the use of helicopters at

1 · 2013 I Vol. 3 I AirRescue I 61

the site of a road traffic accident. Concentrating on children with serious injuries who require specialised medical care (including high technology care) in specialist paediatric hospitals (level 1 trauma centres) being transferred quickly considerably decreases the risk of death and disability (8). Therefore, using medical helicopters for inter-hospital transfer to paediatric hospitals (level 1 trauma centre) is advisable and efficient from a medical and economical point of view, taking into account cost-based technologies.  References:

1. Suvorov SG (2007) ‘Some debatable questions of organization and amount of medical assistance given to children injured in road traffic accidents in developed countries.’ Literature survey//Information on the 4th Russian Congress on Paediatric anaesthesiology and intensive therapy. Tver. publishing house “Triada”: 49-55. [Суворов С.Г. Некоторые дискуссионные вопросы организации и объема медицинской помощи, оказываемой детям, пострадавшим в дорожно-транспортных происшествиях в промышленно развитых странах. Обзор зарубежной литературы // Материалы Четвертого Российского конгресса «Педиатрическая анестезиология и интенсивная терапия». Тверь: ООО «Издательство “Триада”», 2007. С. 49-55] 2. Galvagno SM, Haut ER, Nabeel Zafar S, Millin MG, et al. (2012) Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA 307(15): 16021610 3. Bledsoe BE (2003) EMS Mythology Part 6: Helicopters. Emergency Medical Services (EMS) 32 (8): 88-90. 4. Dean AG, Sullivan KM, Soe MM, OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 2.3.1. URL: http://www.openepi.com 5. Bernhard M, Helm M, Grieles A (2004) Präklinisches Management des Polytraumas. Der Anaesthesist 53: 887-904 6. Suvorov SG, Rozinov VM, Chogovadze GA, et al. (2012) ‘Medical helicopters in the system of rendering medical assistance to children with trauma. Interdepartmental scientific-practical conference Air medical service of Russia and medical evacuation.’ Tver. Publishing house “Triada” 60-63 [Суворов С.Г., Розинов В.М., Чоговадзе Г.А., Дивилина Ю.В., Езельская Л.В., Махнев В.Г. Санитарная вертолетная авиация в системе оказания медицинской помощи детям с травмами // Материалы межведомственной научнопрактической конференции «Санитарная авиация России и медицинская эвакуация». Тверь: ООО «Издательство “Триада”», 2012. С. 60-63] 7. Suvorov SG, Lekmanov AU, Rozinov VM (2010) ‘Epidemiology of children road traumatism in Russia. Medical alphabet.’ Emergency medicine 17(4): 5-11 [Суворов С.Г., Лекманов А.У., Розинов В.М. Эпидемиология детского дорожно-транспортного травматизма в России // Медицинский алфавит. Неотложная медицина. 2010. Т. 17. № 4. С. 5-11] 8. Rozinov VM, Goncharov SF, Makarov IA, et al. (2010) Management and rendering emergency specialized medical care to children, injured in road traffic accidents. Disaster medicine 2: 58-61 [Розинов В.М., Гончаров С.Ф., Макаров И.А., Суворов С.Г., Потапов В.И., Езельская Л.В., Дивилина Ю.В. Система организации и оказания неотложной специализированной медицинской помощи детям, пострадавшим в дорожнотранспортных происшествиях. // Медицина катастроф. 2010. № 2. С. 58-61]

62 | MEDICAL CARE Fig. 1: Switzerland and Norway for example have almost full nationwide coverage 24 hours a day, whereas in other countries night-flying EMS helicopters are the exception (Photograph: Air Zermatt)

HEMS in Switzerland Cantonal organisation and nationwide coverage Helicopter Emergency Medical Services (HEMS) and the potential positive impact that they have on an outcome, particularly in the case of trauma patients, have for a long time been the subject of many studies and debates (1). However, it is not easy to obtain clear-cut findings from studies on the importance of HEMS for trauma patients, as there are a number of varying factors which influence the outcome. Schrötter et al. state that it is beneficial for patients who have suffered severe trauma, who require pre-hospital treatment due to the severity of their injuries, to receive that treatment from the best available team with a doctor at the scene (2). In most rescue systems, this is the EMS helicopter’s crew.

Author: Dr Urs Pietsch, DESA Specialist in anaesthesia & intensive care Air Zermatt Emergency physician

garding the outcome. The advantage remains even if there is a time delay due to a second alarm and, if necessary, additional medical intervention (3, 4). However, as air rescue is a very expensive rescue service and has mainly been found to have positive effects on the survival rates of trauma patients, it will certainly take many more studies to put a clear price on the benefit for the health system, for example, in terms of a cost-benefit ratio. In view of the facts above, the logical outcome for a trauma patient would be a clear request for HEMS, irrespective of the area or time of day. If we look at Europe, during the day there is very good topographical coverage using HEMS resources. During the night, however, an entirely different picture emerges. There are huge

1 · 2013 I Vol. 3 I AirRescue I 62

MEDICAL CARE | 63 differences between the various countries. Switzerland and Norway, for example, have almost full nationwide coverage 24 hours a day, whereas in other countries, night-flying EMS helicopters are the exception rather than the rule. For example, the DRF air rescue service has just 8 night bases for the whole of Germany. Very different infrastructure conditions and contrasting national guidelines in terms of helicopters’ night flight capabilities and operations are surely to blame for these huge national differences.

Bus crash in Sierre on 13 March 2012 A bus crash, which happened almost a year ago in the Swiss canton of Valais, demonstrated the importance, particularly in the case of major incidents and accidents in rural areas, of the time taken to transport patients to the nearest trauma centre and how, in some cases, road transport is simply unacceptable and can even be detrimental to patients. Late in the evening of 13 March 2012, a full bus carrying 52 people crashed head-on into the wall at the end of a hard shoulder section in the Sierre Tunnel (5, 6). Most of the passengers were school children aged between 11 and 13. Due to the mechanism of the accident and related kinematics, a large number of passengers were severely or fatally injured. It became apparent that the children sitting at the front of the coach suffered more severe injuries than those further back. The terrible death toll after the initial triage already included more than 18 children. After a technical rescue by the fire brigade had been carried out, five polytraumatised children were found in the middle section of the destroyed bus. After a brief triage they were treated in the treatment area and assigned by the leading EMS doctor to the other supporting crew members at the scene. After initial treatment and airway management via induction of anaesthesia and (orotracheal) intubation as well as prehospital anaesthetisa, two severely traumatised children were flown to the Inselspital in Bern in the EMS helicopter for the best treatment. Unfortunately, one of the patients suffered a cardiac arrest during the flight and died before reaching the hospital. The other severely injured children were flown to Sion hospital, located just a few minutes away by air, for prompt diagnosis and treatment. The remaining children, suffering from minor injuries, were taken by road to nearby hospitals in Visp and Sierre for diagnosis and treatment. This distribution ensured that no hospital was overloaded by an unmanageably large number of patients. During the night, one child was flown to the University Hospital of Lausanne after its circulatory system had been initially stabilised at Sion hospital. This impressive number of HEMS crews could be used because, due to the extent of the accident and in accordance with the canton’s rescue concept, all available air rescue services were immediately called upon in addition to the road-based rescue services. Within one hour, four Air Zermatt helicopters, two Air-Glaciers helicopters and one Rega helicopter were at the scene of the accident. The impressive number of EMS helicopters

1 · 2013 I Vol. 3 I AirRescue I 63

manned with doctors that were at the scene in less than one hour shows the huge potential of the Swiss HEMS rescue system – even at night.

HEMS in Switzerland In Switzerland, the rescue service, including air rescue, is first and foremost regulated independently by each canton. Rega, with its 13 HEMS bases, provides nationwide air rescue coverage 24 hours a day. However, there are also regional and cantonal exceptions. Regional exceptions include the two bases in Lauterbrunnen and Saanen in the canton of Bern, which are served by Air-Glaciers, which actively covers certain areas of the Bernese uplands. Cantonal exceptions include the canton of Valais, where air rescue services are not provided by Rega, but the other two private helicopter companies, Air-Glaciers and Air Zermatt. The cantonal government stipulates that Air-Glaciers is to cover Lower Valais and that Air Zermatt, with its two bases, is to cover Upper Valais. Air Zermatt has two twin-engine helicopters, an EC135 and a Bell 429, dedicated exclusively to HEMS, which are ready for action 24 hours a day at both the bases in Zermatt and Raron. Air Zermatt alone, with more than 1,600 rescue missions a year, therefore makes a huge contribution to HEMS in Switzerland. In extraordinary situations, such as major incidents, other helicopters that are primarily used for transportation and taxi flights can also be called upon. These extra resources have been used on several occasions, including a bus crash in Goms in 2010, a Glacier Express train crash in 2010 and most recently the Sierre bus crash in 2012. Mobilizing such a large number of HEMS crews on short notice to the accident site in Sierre was most certainly a unique event and will prove difficult to be repeated anywhere else in Europe. It is, however, evident that the importance of providing timecritical patients with both the best possible pre-hospital treatment and the fastest possible transportation to a qualified trauma centre has been recognised. The excellent nationwide HEMS coverage of Switzerland ensures that even patients in rural areas and areas where there is a less effective infrastructure, have the same access to the highest quality treatment as patients in the centre of a major city.  For references, please see: ››› www.airrescue-magazine.eu

Fig. 2: In Switzerland, the rescue service, including air rescue, is first and foremost regulated independently by each canton (Photograph: Rega)

64 | IN PROFILE

“Medicine on the Move”: Improving healthcare in rural Ghana

Medicine on the Move (MoM) is an NGO in Ghana that aims to improve the healthcare situation of West Africans through community-based healthcare education. Many communities in West Africa are remote, healthcare facilities may be far away and the prevalence of preventable morbidities and mortalities is higher than in other locations. MoM’s mission is to empower villagers to improve the health of their community members through extensive healthcare training, provision of healthcare-related material, and development of an aviation-based support structure for remote villages.

Authors: Joerg Bohn Youth Education Centre Theodor Wuppermann e.V. Juist, Germany Tony Stieber Medicine on the Move USA

MoM’s goal is to transport health educators (specializing in general healthcare, basic first aid, hygiene and disease prevention) and educational materials to communities that are beyond the reach of ground based aid agencies. Medicine on the Move utilizes aviation in this work and is currently engaged in an airdrop program for educational materials, which is being expanded to include mosquito nets and other supplies via a development grant from UNICEF. The founder of the organization, Jonathan Porter, also known as Capt. Yaw, is also the Chief Flying Instructor and Chief Engineer of WAASPS, an aviation/ engineering based social entrepreneurship and aviation services company that is the leader in light aviation in West Africa, building, maintaining and providing flight training in 2-seat light aircraft, as well as other aviationrelated services. Through its partnership with WAASPS, Medicine on the Move is also able to offer vocational skills training and education to young and disadvantaged women from the rural villages in the the regions around Lake Volta. Students are invited to take the opportunity to prove their talents and aptitudes for learning during a trial period at the AvTech Academy training facility. The selected recruits then receive a four-year education that combines the best of a vocational school and boarding environment along with an apprenticeship programme where they build small aircraft. They are also trained in

health care education and first aid, and they and they can practise their skills in an on-site mini clinic.

Aircraft of choice: CH701 There are many aircraft on the market that could be used in developing nations, but there are particular constraints that are essential to take into account in the developing nations. One of those is fuel. The best aircraft engine for fuel acceptance is the Rotax 912 UL – 80Hp. There is this joke that says you could urinate in the tanks and the engine would still keep on running. At times it is forced to drink the local 89 Octane (87AKI) – at times cocktailed to make it go further. Now that you have the engine of choice you need an airframe. For bush operations in the tropics it is best to operate a tricycle, braced high-wing, tractor, STOL aircraft. That limits the field. The CH701 is the most copied aircraft in that category around. It wins the game for a number of reasons: 1. The 701 can be built from plans– meaning we can make with factory “sanction” all of the parts in country should we need to.T6 is an excellent corrosion resistant material for tropical applications. 2. T6 aluminium is an excellent corrosion resistant material for tropical applications. 3. Zenith’s factory support is second to none – and

1 · 2013 I Vol. 3 I AirRescue I 64

IN PROFILE | 65 they stand by their product like no other. 4. They are in use around the world, making CAA acceptance easier. 5. They fly like a dream and are robust, of simple construction and are easy to understand for first time builders – like the girls we train here. The CH801 is the “mother” of the 701 and has incredible payload flexibility and power plant options. We chose the XP360 because it can run on low octane fuels – and should soon be available again. The Zenith aircraft are proven rugged designs, purchased inexpensively and built using the most basic of tools. The CH701 and CH801 are renowned for their short take off and landing (STOL) performance, rugged all metal design, ease of construction, and basic field maintenance. They were designed from the ground up for off airport operations. As we establish a network of community-maintained airstrips, an aircraft capable of taking off and landing on a short rough strip is critical. A CH701, fully loaded with a pilot and 100 kg of provisions, is capable of becoming airborne on as little as 120 feet of unprepared grass. Known throughout the world as the “Sky Jeep”, this rugged little aircraft will serve a critical role in our educational and support missions. We can easily cover distances in an hour that would require more than a day’s ground travel, allowing us to extend our service area to villages previously unreachable. A CH801 can easily become airborne in 300 feet, carrying 4 passengers or up to a 400 kg payload. Designed with the air ambulance role in mind, the passenger seats can be removed and a stretcher can be loaded into the aircraft in less than a minute. We hope to have a fully operational CH801 in service in 2013. With the CH801 we will be able to offer service to rural villages far exceeding anything currently in existence. The build, operation, and maintenance of these aircraft is supported by WAASPS, overseen by Ghana Civil Aviation Authority.

MoM’s international support MoM is supported by non-profit “friends of MoM”-organizations in Germany, in the UK and in the USA. MoM also gets particularly visible support from international sympathizers like Mr George Manu (from Ghana), Mr Jan Wuppermann and Mr Joerg Bohn (both from Germany), who undertook an adventurous flight in order to raise awareness for Medicine on the Move. They flew from Westerstede, in the North of Germany, to Ghana via Limoges, Seville, Agadir, Dakhla (both in Morocco), Dakar (Senegal) and Monrovia (Liberia). It took them nine days to reach Accra!

Future plans MoM currently operates in Ghana, but has the potential for expansion into other countries such as Togo, Burkina Faso, and Benin. It is hoped that this concept of rural health care education will be embraced across West Africa and the African continent. Medicine on the Move is based in Kpong in the eastern region of Ghana, approximately 80 km from Accra’s international airport. In addition to

1 · 2013 I Vol. 3 I AirRescue I 65

Here is what Joerg Bohn, one of the active supports of MoM, says on his support-tour:

Fig. 1: Zenith CH 701 being worked on by AvTech students (Photographs: T. Stieber)

“It was my first trip to West Africa and I didn’t know what to expect. Flying on a visual flight plan is a real surprise for most controllers enroute. Everywhere on our trip we met great people who treated us well. The fuel in Ghana as well as the landing fee in Monrovia were expensive, but besides that, everything was more than OK. After seeing MoM operating at Kpong Field, we knew immediately that we did the right thing. Knowing how little is done for the people in Africa; here is a project that goes in the opposite direction. In MoM young women are being trained to become aircraft mechanics and pilots. In a country, where women are more or less still ‘in the kitchen’, this is a very unusual approach. But exactly this is what makes it so special. All apprentices realize what opportunities there are in their lives, and that they can be in control – not only in the cockpit. All of them are thankful and want to see this little plant grow. I never expected such dedication, self-discipline and daily hard work. The aviation standards are as high as at home. I am full of respect of what has been achieved by Capt. Yaw and all his crew! I also wish to see this plant grow into a plantation that goes beyond the borders of Ghana. We can all support it in our own way – and perhaps you have an idea, too?!” basic accommodation and an administrative centre on the 52-acre property, there’s a 200 square metre workshop, a hangar, two small airstrips as well as a training area for up to 90 delegates. MoM was founded in 2006, and it has gone through enormous growth during the past few years, and now has a much more solid foundation. MoM, Avtech Academy and WAASPS have been set up as three organizations working in close partnership to be sustainable and essentially form a social enterprise. The operation is currently in a multi-year capacity development programme to build up; not only the physical infrastructure but to train personnel through AvTech that will be employed at the airfield or by external partners. The goal is for this to be a West African organization run by West Africans to serve the people of West Africa for a long time – “one flight at a time”. 

Support MoM MoM does not actively seek donations, but welcomes individuals who may want to volunteer. If you are interested in contributing through volunteering, please send an email to info@ medicineonthemove.org. However, if you still wish to make a monetary donation, please get in touch with MoM through: jp@medicineonthemove.org.

66 | IN PROFILE

HEMS in Germany: Female pilots are still few and far between You may not be surprised to see a female pilot these days, but they are still something of a rarity in the air rescue industry. The pilot association “Cockpit” claims that the proportion of female captains in Germany is just 5%. However, there is no record of how many of them fly EMS helicopters. For many people, seeing a female pilot at the controls is still somewhat of a novelty. Nothing really explains this better than the experience that Melanie von Allwörden, a pilot at the ADAC air rescue base in Perleberg, had at the beginning of her career. Whilst on duty, as she approached the scene of an accident where the emergency services and medical crew from her helicopter were working together, a paramedic patronizingly asked her: “Can we take you with us afterwards?” Melanie politely declined: “Thank you, but I actually have to fly the helicopter back.” Dr. Peter Poguntke, using the texts “Pilotin im Anflug” (Female pilot on the approach) from “ADAC Motorwelt” and “Der tollste Beruf auf Erden” (The greatest job on earth) from DRF’s “Luftrettung” magazine.

Due to the high number of seriously injured patients treated by HEMS, there is a considerably higher likelihood that advanced medical treatments, e.g. pre-hospital anaesthetisation, the insertion of a chest tube and intraosseous cannulation, will be required. As these types of treatment are required more frequently in HEMS than in ground EMS, a certain routine has been developed for those treatments – thanks to the fact that they are carried out so often. Before Melanie became an EMS helicopter pilot (when she joined ADAC air rescue she was the first female pilot at ADAC) she worked for the police. She patrolled the streets of Hamburg for a few years before signing up to be trained as a helicopter pilot. Even as a child she wanted to become a pilot and was obviously born for the role: “You have to have a feel for flying in your gut.” She has it and successfully applied to ADAC after she had clocked up 500 flying hours with the police. She has never felt that her male colleagues have ever had any reservations about her: “As the newcomer, you always get stared at, regardless of whether you’re male or female.” Being at the helm of an EMS helicopter was simply the dream job for her colleague, Adriana Langer, who

dropped out of her medical degree to pursue her dream. As she watched an EMS helicopter being landed whilst she was on a placement at the University Hospital of Greifswald, she knew instantly: “I want to be a pilot, not an emergency physician.” She spent the next two and a half years getting her private, professional and flying instructor licences and eventually became a helicopter examiner. Since the beginning of 2010, Adriana has been a pilot for DRF air rescue, and currently flies “Christoph Weser”, a BK117. Before that she gained a wealth of experience as a flight instructor in Europe and North Africa, mobilising helicopters and training pilots. For her, teamwork is the most important and fascinating part of this challenging form of flying. “The EMS helicopter will have to land in uncharted territory 99% of the time which requires us to apply the ‘multiple eyes’ principle, whereby all HEMS crew members watch the skies and the ground very closely.” Melanie von Allwörden agrees: “If, during a landing, you get even the slightest bad feeling, it’s normally better to execute a go-around. You usually get a gut feeling for a good reason.” On being asked when she expects to see her next female colleague, the pioneer Melanie smiles confidently and replies: “Any time now”. 

Fig. 1: The pilot association “Cockpit” claims that the proportion of female captains in Germany is just 5%

Author: Peter Poguntke Editor-in-chief AirRescue Magazine

1 · 2013 I Vol. 3 I AirRescue I 66

( THINK MEDICAL ASSISTANCE ) A Eurocopter helicopter is a flying life support system for paramedics and rescue services. Always on call to reach casualties of accidents and disasters or evacuate critical care patients. Prescribe an EC135.

Thinking without limits