AirRescue Magazine 2-2011

AIRMED 2011

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

Training

Pre-hospital Care in the UK

Medical Care

ECMO Retrieval in France

HEMS Accidents

Risk Assessment in the USA

ISSUE 2 | Vol. 1 | 2011

Towards a safer world

AgustaWestland at the forefront of SAR agustawestland.com

EHAC

E di tori a l Dear Reader, First of all, I want to express my sincere thanks to all AIRMED supporters: Sponsors, exhibitors, delegates, and, last but not least, our partner Kent Air Ambulance.

For three long days the Convention Centre in Brighton was a highly professional and productive melting pot of the international air rescue community.

More than • 650 experts from all involved and related professions and from all over the world, • listened to 245 presentations of well- known international speakers, • exchanged experiences, • discussed ideas, • trained skills in 8 high-level workshops, • made plans how air rescue can be further improved and • met old and made new friends under the motto “United in Quality Care by Air”.

The 10th AIRMED World Congress was a very successful event. Special thanks go to the Scientific Committee, chaired by Erwin Stolpe, who has designed again an interesting and complex scientific programme. The planning for the next AIRMED 2014 in Rome has already started and I hope to meet you there.

Air rescue must be affordable for operators, patients and insurers. Thus, we at EHAC have focussed the divergence between safety, technical feasibility, affordability and rulemaking. We will stay in close

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contact with EASA and represent the interests of Europe’s professional HEMS and air ambulance operators. It is time to find common, pragmatic and safe solutions for the upcoming challenges. Let me know what we could do for you.

The Board has been strengthened by the election of Denise Eikelenboom, Director of the Dutch ANWB-Medical Air Assistance and a former Dutch Navy helicopter pilot. And also Frédéric Bruder, Director of Corporate Strategy at INAER, has been elected Board Member. The growing number of international member organizations is also reflected in the composition of the new Board: more representatives of different countries have joined the EHAC-Board.

I started with thanks and I would like to close with thanks. These thanks go to the S&K Publishing for all their efforts to produce the AirRescue Magazine.

I was very impressed with the first issue, which was distributed at the AIRMED in Brighton. You hold the second issue of the official EHAC magazine in your hands. Enjoy reading it.

Yours,

Christoph Breitenbach President of the European HEMS & Air Ambulance Committee

4 | CONTENTS

AirRescue

International Air Rescue & Air Ambulance

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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

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Training opportunities in pre-hospital care in the South East of England A. Chesters

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

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INAER and AgustaWestland strengthen partnership

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CareFlight Australia

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

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ACS – The role of HEMS J.M. Gutiérrez Rubio, J.A. Sinisterra Aquilino

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CONTENTS | 5 Eine deutsche Ausgabe des AirRescue Magazine finden Sie als e-paper unter: www.airrescue-magazine.eu

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Strategic use of rotary wing for ECMO retrieval H. Coadou, B. Burns et al.

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Case Report: “Air 1106” responds to a rural scene call in Turkey G. Özel

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Strategies to reduce U.S. HEMS accidents W. Winn, F. Thomas et al.

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HEDGE trials enhance helicopter approaches P. Church

Cover Image: S. Drolshagen

6 | EVENTs Australia, Asia and the Pacific: Air rescuers meet in Perth

For more information, visit: www.isas.org.au

The Aeromedical Society of Australasia, the EHAC partner organisation for Australia, South-East Asia and the Pacific, is holding a conference in the Australian city of Perth from 31 August to 3 September 2011. The main focus of the conference is on technical, organisational and medical issues related to helicopter emergency rescue operations. Special attention will also be paid to safety in everyday flight operations, opportunities for air-rescue cooperation between civil and military organisations, and

A. Haapanen

Air Medical & Rescue Congress in China 2011 For more information, visit: www.pyxisconsult. com/gao/

In November 2010, China’s State Council and Central Military Commission jointly announced to open more of its low-altitude airspace below 1,000 metres: The new policy covers major cities including Changchun, Chengdu,

R. Young

long-distance air transport – a crucial issue given the vast extent of the Pacific region.

Guangzhou, Lanzhou, Jinan, and Nanjing. Low-altitude air-space will gradually be expanded to other areas and shall finally cover the whole country in 2015. The new policy is also seen and marketed as a lucrative opportunity to enter into China’s general aviation market. According to the official release, the air emergency & rescue market will be opened up in a first stage in 2011.

The Air Medical & Rescue Congress in China 2011 – with support from global leading air rescue authorities including EURAMI, AAMS and EHAC – will offer the opportunity to meet and gather with global and local general aviation & air medical as well as air rescue operators and aircraft (fixed-wing as well as rotorcraft) manufacturers.

The congress aims to promote exchange within the industry and to facilitate business networking for extensive industry cooperation. The Congress will be held on 11 and 12 October 2011 at the Pullman Skyway, Luwan District in Shanghai, China.

Air Medical Transport Conference in St. Louis

For more information, visit: www.aams.org

The programme of the Air Medical Transport Conference (AMTC), set to take place in St. Louis, Missouri from 17 to 19 October 2011, has all bases covered. The agenda features 150 presentations on a wide range of topics encompassing several medical fields as well as issues relating to aviation, flight safety, communications technology and the latest trends in air rescue research. A total of 120 manufacturers of medical equipment and supplies will be represented at the adjoining trade show.

Over 2,500 participants from the various professions and disciplines associated with air rescue have registered for the conference already. The event organiser has proudly

D. Schwen

declared that the AMTC will be the largest event of its kind and hopes that this diversity will allow networking on a scale that is truly out of the ordinary.

EVENTS

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

Helitech

September

27-29

Duxford, UK

NBAA 2011

October

10-12

Las Vegas, USA

Air-Medical Transport Conference (AMTC)

October

17-19

St. Louis, USA

Seoul Air Show

October

18-23

Seoul, South Korea

International Helicopter Safety Symposium (IHSS)

November

8-9

Fort Worth, USA

Dubai Airport Expo 2011

November

13-17

Dubai, UAE

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The first high end ICU performing transport ventilator The HAMILTON-T1 is designed to ventilate the adult or pediatric ICU patient at any place around the world. With its compact size of less than 6.5 kg, built in batteries with up to 5.5 hours operating time, 8.4” color touch screen and its high performance turbine, this ICU ventilator can accompany your patient within the hospital and between hospitals, whether on the ground or in the air. Its integrated high performing NIV capabilities add state-of-the-art therapy options for any 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

8 | NEWS New board members elected at EHAC AGM 2011

Denise Eikelenboom, Managing Director ANWB Medical Air Assistance, Netherlands, has recently joined the board of EHAC

The European air rescue operators have elected Ms Denise Eikelenboom and Mr Frédéric Bruder as new representatives on the board of the European HEMS and Air Rescue Committee (EHAC) at the annual general meeting 2011 in Brighton, UK. The new composition of the board reflects EHAC’s multiplicity and the broad approach to enable and

TAA receives Safety Award

promote high professional air rescue operations in Europe from the medical, aviational, technical and administrative point of view.

The board now consists of the following members: Mr Christoph Breitenbach (EHAC President), Mr Frédéric Bruder (Director Strategy & International Business Development at INAER Spain), Mr René Closter (President of Luxemburg Air Rescue), Ms Denise Eikelenboom (Managing Director ANWB Medical Air Assistance, Netherlands), Mr Ernst Kohler (CEO Swiss Air-Rescue / Rega), Mr Pavel Müller (Partner at afla helicopter, Czech Republic), Mr Erwin Stolpe (Medical Director ADAC Air Rescue, Germany), Mr Alexander M. Wolff (Managing Director Christophorus Air Rescue, Austria). Mr Hans-Joerg Eyrich (HDM Air Rescue) was elected as new auditor. Together with Mr Michael Rudolph (Eurocopter) he will be responsible for the annual audits and report to the General Assembly.

For more information, visit: ››› www.airrescue-magazine.eu/news

Scandinavian Air Ambulance signs contract with Saab Scandinavian Air Ambulance Holding AB (SAAH) and Saab, Swedish aerospace company, have signed an 8-year contract that relates to technical and maintenance services for SAAH. The order is worth 25 million Swedish kronor (around 2,7 million Euros). Now the first additional agreement has been signed and is an extension to the technical and maintenance services that Saab is already providing for SAAH in several locations across Scandinavia.

This means that Saab will also be supporting the helicopter ambulance operations in Gällivare in Norrbotten county (the northernmost county of Sweden) and others in Finland. Torsten Öhman,

head of Customer Alliance Solutions and responsible for the operations within the Support and Services business area at Saab, states that the “long-standing cooperation is now being further reinforced.” Currently SAAH conducts its missions with a fleet of 8 aircraft and 7 helicopters. Among its customers are a number of Swedish counties and municipalities, with the majority of contracts based on long-term agreements. Ambulance helicopters are also being used for SAR missions, for example in air, sea and mountain rescues.

TAA

Austrian fixed-wing operator Tyrol Air Ambulance (TAA) recently received the Gold Safety of Flight Award. This is the first time the highest international honour for air safety has been awarded to an air ambulance company. It is also a confirmation of TAA’s commitment to providing the highest medical standards in air rescue.

The prize was awarded in Geneva by the European Business Aviation Association (EBAA) and the National Business Aviation Association (NBAA) in the Business and General Aviation category.

According to TAA’s CEO Helmut Wurm, the prize is a tribute to “the 81,000 plus flight hours that Tyrol Air Ambulance has flown without a single accident in the last four years.” The TAA, originally called Aircraft Innsbruck, has a fleet of Citation and Gulfstream ambulance jets and Dornier 328 ambulance airliners, which can transport up to six recumbent patients.

For more information, visit: ››› www.taa.at

“Rettende Hand” in Aachen

For more information, visit: ››› www.airamb.se & www.saabgroup.com M. Müther

University Hospital Aachen recently inaugurated its new helicopter landing pad after a year of construction work. At a party under the “saving hand” as the pad is called, visitors and staff enjoyed an entertainment programme, as well as guided tours and lectures about the new helipad and air rescue in general. The Aachen architecture firm OX2architekten is responsible for the striking design of the new pad, which was made necessary by new aviation guidelines. The structure rises 15 metres into the air and is linked to the hospital via an inclined lift. Thanks to this direct connection, patients can be transported directly into A&E for diagnosis and the neighbouring operating rooms, removing the need to move the patient into an ambulance vehicle and cutting the transfer time from the helipad to the hospital from five minutes to one.

A. Hjert

For more information, visit: ››› www.ukaachen.de

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NEWS | 9 All eyes on the standards committee

Restrictions to rescue hoist operations

AgustaWestland

Air rescue crews around Europe will be watching the next session of the European Committee for Standardization (CEN) on 2 and 3 September 2011 with great interest. On the committee’s agenda are fundamental questions, such as what the criteria should be for defining all binding air-rescue standards. Given the large number of operators, companies, authorities and countries involved in the decision-making process, the experts on the committee certainly do not have an easy task ahead of them. Up for discussion this time are the EN 13718/1 and 13718/2 European standards governing air-rescue helicopters and fixed-wing aircraft.

In early July a rescue mission in South Tyrol involving a BK 117 C-1 nearly ended in a serious accident, when a hoist cable detached without warning while the helicopter was in flight. Luckily, the rescue personnel involved were already on the landing skids and clipped to the hoist when the incident took place. It was only thanks to additional safety installations that serious injury was avoided.

The investigation immediately after the incident found that the emergency cable-cutter function on the handle assembly of the rescue hoist and the pitch control had been set correctly and that the cable-cutter function had not been unintentionally triggered by either the hoist operator or the pilot.

For this reason, the manufacturer and the aviation authorities placed an international ban on the hoist’s use.

Subsequent investigations found that the incident was the combined result of poor maintenance and a construction flaw, for which the manufacturer bears responsibility.

According to paragraph 7 of the AD, a regulation EASA AD 2011-0148 has now been issued allowing the hoist to be used on BK 117s if the following six conditions are met: 1. The trigger for the cablecutter function on the hoist must be permanently deactivated in accordance with clearly defined regulations. ADAC

DRF

Airrescue InternatIonal aIr rescue & aIr ambul ance

M A g A zine

Training

Pre-hospital Care in the UK

Medical Care

ECMO Retrieval in France

HEMS Accidents

Risk Assessment in the USA

ISSUE 2 | Vol. 1 | 2011

AirRescue International Air Rescue & Air Ambulance

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Deadline: 15 October 2011

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For more information, visit: ››› h ttp://ad.easa.europa. eu/ad/2011-0131

DRF Luftrettung with 19,189 air rescue missions

Make your ad space reservation for the upcoming

AIRMED 2011

The pilot will still have access to a switch to activate the function when necessary.

2. The Rotorcraft Flight Manual must be updated to incorporate checks for this function in the pre-flight checks.

3. The operating handle must be inspected every 30 days (plus/minus three days).

4. If any damage is found, the operating handle must be replaced immediately and before any further missions.

5. Older operating handles that do not comply with the new ECD ASB MBB-BK 117-80-166 Rev. 1 specifications may not be installed.

6. Hoist operating handles should be given a general overhaul every ten years after their installation and at the latest by 12 May 2012.

As part of its crisis management system, from 30 July 2011 ADAC Air Rescue made an extra EC135 based in Munich available just for hoist rescue operations, ensuring that patients in difficult Alpine terrain could still be rescued. EASA, Eurocopter and the hoist manufacturer are still investigating the incident to improve safety in the future.

In the first half of this year, air rescue organization DRF Luftrettung flew a total of 19,189 missions, involving helicopter missions at 31 HEMS bases in Germany, Austria and Denmark. Furthermore, DRF carried out worldwide repatriation flights with its ambulance aircraft. This means a rise of 1,214 cases (8%) compared to the same period of the previous year. In Germany alone helicopters of DRF Luftrettung were alerted to 17,632 missions, meaning a rise of 987 (6%) compared to the same period in 2010 (16,645 missions).

Outside of Germany, at two HEMS bases in Austria

and one HEMS base in Denmark, DRF Luftrettung flew 1,168 helicopter missions so far.

Around 14 months after its start, the HEMS base of Ringsted, Denmark is well established today: In the first half of 2011, the helicopter, operated by Falck DRF Luftambulance A/S, was alerted 355 times. The two Austrian rescue helicopters of the ARA-Flugrettungs GmbH (part of DRF Luftrettung), were much in demand: The crews in Reutte (Tyrol) and Fresach (Carinthia) flew 813 missions altogether.

In the field of worldwide ambulance flights, European Air Ambulance – umbrella organization of a cooperation between DRF Luftrettung and Luxembourg Air Rescue – conducted 389 repatriations, meaning a plus of 25 missions compared to the same period of the previous year. With their six ambulance aircraft, they flew to 77 countries worldwide. These repatriation flights were coordinated by the respective alert centers at the airports of Karlsruhe/Baden-Baden in Germany as well as at the alert center in Luxembourg.

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

10 | NEWS Anniversary at ATE

40 years of air rescue in Ulm

ATE

A few weeks ago, Air Transport Europe (ATE) celebrated its 20th anniversary. The festivities were attended by EHAC Managing Director Mr Stefan Becker as well as by Mr Danilo Skerbinek (IKAR CISA), Mr Angelo Raimondi (AgustaWestland) and Mr Peter Hässig (Rega). Furthermore, representatives of partner organizations from neighbouring countries and many other distinguished guests from different institutions attended the celebration. Among them was also Mr Toni Lötscher (see also the profile on page 27), who has been honoured with a special ATE-award for his achievements in successfully training the ATEpilots. The representatives participated in a press conference, followed by a special demo of mission on the late afternoon in which an excellent cooperation of Rega Swiss Air-Rescue and ATE crews on A109 SP and A109 K2 helicopters was demonstrated.

ATE began operations in former Czechoslovakia in 1991 and was also the first private air company in the history of the country. Today, the company performs Helicopter Emergency Medical Service (still being the only operator in this field) and besides this, it also provides helicopter maintenance, repair and overhaul. It is also active in

the fields of aeronautical works, firefighting, construction work and logging. At present, ATE owns nine helicopters type A109 K2, one AS 355N, one Mi-8 helicopter as well as a Cessna Citation 560 Encore jet plane. During 20 years of existence, the helicopter fleet and the aircraft at ATE have completed about 45,000 flight hours altogether.

The company also acts as a service centre for AgustaWestland and is holder of an AOC license under JAR-OPS 3 Subpart M and approved Part 145 maintenance organization.

ATE performs non-governmental HEMS from seven bases across the country. The A109 K2 helicopters from Rega Swiss Air-Rescue have been in operation since 2003, including Swiss procedures and know-how. HEMS is being performed as primary and secondary missions during the day and at night (VFR, using Night Vision Goggles). Helicopter crews are able to perform missions with the cargo hook from all bases.

Furthermore, three bases close to the mountains (Poprad, Banska Bystrica, Žilina) are additionally equipped with a 50 metre cable hoist. The crews are being trained in the ATE Training Center for technical missions with the cargo hook as well as with the hoist/rescue winch. The flight with the longest cargo hook cable of 124 meters in Slovakia was performed in the Tatra Mountains.

The Cessna Citation 560 Encore is a (refurbished) medical version and is used for repatriation and international medical flights.

lying fog. Heavy fog – that is particularly prevalent in autumn and winter – often prevents an immediate and smooth transport of patients to a regional hospital. Although the rescue helicopter is able to break through the fog from below, it then remains “caught” above the dense blanket of fog and is unable to descent.

In order to address this problem, Rega has been working towards the certification of GPS approach systems for many years. In the course of numerous tests and studies it was shown that present-day technology allows – using satellitebased navigation for approach flights – to be carried out safely. In response to an application ATE the Federal Office of Civil Aviation has

by Rega, recently approved the country’s first GPS approach flight procedure for helicopters. Over the next few years, Rega will train its pilots to use the instrument flight procedure, so that it can be employed throughout the country. Its mountain helicopter fleet will also be installed with the appropriate equipment.

It may be called Christoph 22, but, after Christoph 1 in Munich, it was actually Germany’s second air ambulance helicopter. It has now been based in Ulm for four decades and is the fourth most frequently used air ambulance service in the country. The Christoph 22 project was initiated by two exceptional men: Professor Friedrich Wilhelm Ahnefeld, a pioneer of emergency medicine in Germany, and Helmut Schmidt, the defence minister in the social-liberal coalition government at the time. Ahnefeld was fascinated by the Christoph 1 project and thought that Ulm would also be an ideal base for an air ambulance helicopter. Rather than communicating his idea through official channels, he decided to approach the relevant minister directly. Ahnefeld remembers that it only took him 20 minutes to get Schmidt’s approval for the scheme. In November 1971, the first German army air ambulance helicopter was stationed in the Oberer Eselsberg district of Ulm. The collaboration with the air transport squadron 61 in Penzing, which provided the helicopters and pilots, lasted until 2003. For many years, the Bell UH 1 D with its orange doors and SAR markings was a key player in air rescue operations in southern Germany. When the helicopter was no longer authorized to fly civilian air rescue missions, the Bell in Ulm was replaced by a yellow BK 117 from ADAC Air Rescue. After 32 years of air rescue operations, the German army hospital in Ulm became the second base in Germany where a civilian organisation provides the helicopter and pilot, and the army provides the medical crew.

Forty years of air rescue is certainly an occasion worth celebrating. On Friday, 23 September 2011 in Ulm, a party will be hosted for selected guests followed by an event in a circus tent on the army hospital (BWK) sports ground. On 24 September, the public is invited to a grand open day from 10 a.m. and 6 p.m., where all the aircraft and equipment used in air rescue operations will be on display.

For more information, visit: ››› www.rega.ch

For more information, visit: ››› www.christoph-22.de

For more information, visit: ››› www.ate.sk

Helicopter GPS approach flight in Switzerland Due to satellite navigation, Rega is now able to fly directly to the Inselspital University Hospital in Berne, even if weather conditions and visibility are poor. The Federal Office of Civil Aviation in Switzerland has recently approved the GPS approach flight procedure for helicopters.

As a result, patients benefit from improved safety in adverse weather conditions and high-

Rega

H. Holder

2 · 2011 I Vol. 1 I AirRescue I 10

NEWS | 11 “Christoph – come in Christoph!” – the new ADAC Air Rescue station atlas

Increasing number of emergencies down to irresponsible calls for help?

Rega

Stevage

As the Swiss Alpine Club (SAC) recently indicated in Die Alpen magazine, the number of mountaineering accidents is on the rise. This is partly due to modern communication technologies, which have enabled people to call for help more quickly and easily than ever before. Easy access has also increased hikers’ readiness to send out an emergency signal, which has sometimes meant that rescue services are misused as a kind of night-time mountain taxi service.

Exhaustion is too often given as a reason for emergency calls.

Members of the rescue services agree that people are all too ready to reach for the phone if they are carrying one. They also suspect that

hikers do not plan their tours as thoroughly as they would have done in the past, as they know they can always rely on a quick rescue if they run into trouble. However, the rescue services do also stress that mobile phones have made their jobs much easier in “real” rescue situations.

Night-time rescue teams will only be sent out in critical emergency situations. As nighttime rescues place both rescuers and crews in serious danger, the decision to initiate one should not be taken lightly. Given the risk involved, hikers should sit tight until the next morning if they are simply tired or exhausted. Of course, there are exceptions. If a storm is on the way, rescue teams should fly in to save climbers before it hits.

ADAC Air Rescue has published a revised and updated edition of its air rescue stations atlas. First published in 1988/89, the atlas is a reference work containing details of around 75 air rescue stations, as well as a comprehensive list of all rescue helicopter bases, sorted according to operator and which of the 16 German states they are located in. The relevant state ministries, operators, aviation companies and sponsors are also listed with full contact details. In addition, the atlas contains a history of ADAC Air Rescue and a bibliography of important and useful publications on the subject of air rescue. Costing €19, the 175-page A4 atlas is published in paperback by Werner Wolfsfellner MedizinVerlag. It is available from the ADAC webshop. (Scholl) For more information, visit: ››› www.adac-shop.de

Heated harness debate

Eurocopter X3 also for rescue missions?

Waerfelu

Eurocopter officially presented its new experimental compound helicopter X3 at the last Paris Air Show (20 to 26 June 2011). The new prototype combines the flexibility of a helicopter – vertical take-off and landing – with the higher speed of a plane. Its debut in Paris was the first time the aircraft was seen flying in public. Eurocopter hopes that the X3 – already unveiled in September 2010 at Istres-Le Tubé Air Base near the manufacturer’s Marignane factory – will be a “game changer” and impress with its maneuverability. During the second flight-test campaign, which started in May

2 · 2011 I Vol. 1 I AirRescue I 11

2011, the helicopter demonstrated a rate of climb greater than 5,000 feet per minute. The crew flew pitch-up attitudes in the 30- to 50- degree range.

Further flights are scheduled this year to test vibration phenomena and wingstub aerodynamics.

Eurocopter says that applications for the high-speed, long-range X3-concept will also include search and rescue (with a rear door for the winch), combat search and rescue as well as medical evacuation. The idea to add propellers to a helicopter is not new. Several compound rotorcrafts have flown since the 1950s, but none of them made it to large-scale production. The X3 however is considered to be real novelty due to the new engineering design as well as the ability of vertical take-off and landing combined with the higher speed of a plane. Pilots can fly the X3 like a conventional helicopter up to 80 knots. Beyond that, an additional control is needed.

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

DRF

The EASA is pushing to restrict air rescue crews to using only personal carrying device systems (PCDS) that have been specifically certified by the manufacturer of the helicopter for the model they are flying in. In practice, this would mean that mountain rescuers, who have no way of knowing what air ambulance helicopter will respond to a call for help, would have to carry several different PCDSs with them – an entirely impractical suggestion, according to the EHAC, which strongly opposes the plan. The use of rescue hoists and thus the rescue of numerous people in distress in the mountains would become virtually impossible. The EHAC has therefore urged the EASA to rethink its decision.

12 | AIRMED

Fig. 1: “In the UK, air rescue has not yet attained the position it has in the healthcare systems of other countries”, said Dr Erwin Stolpe (right), AIRMED’s scientific director (Photographs: M. Mennie)

AIRMED 2011 in Brighton It was no coincidence that the 10th AIRMED took place in the seaside resort of Brighton in south-east England. Air rescue is not nearly as well established and popular in the United Kingdom as it is in many other countries. “We hope that this congress will increase the support we get in our work,” said Adrian Bell, Chief Executive of Kent, Surrey & Sussex Air Ambulance, which hosted the event, on his hopes regarding the long-term impact of holding AIRMED in his country. EHAC board member Dr Erwin Stolpe, AIRMED’s scientific director, underlined this concern at the opening press conference: “In the United Kingdom, air rescue has not yet attained the position it has in the healthcare systems of other countries, such as Germany.” Air rescue in the UK still receives 85% of its funding from charity donations.

Fig. 2: With a total of 600 guests and participants from all over the world, the four-day event was truly international and topics included safety as well as further training

The wide range of topics discussed at the AIRMED included everything from the latest medical developments to improve patient care in air rescue to the use of marketing and communication tools. Making air rescue a public issue outside of the sector and raising awareness about the benefits it offers is, after all, one of the objectives of the international air-rescue community. With a total of 600 guests and participants from all over the world and a host of industry exhibitors from aviation and medical technology, the congress was truly international. Among its main focuses were safety and further training, which also reflected the motto of the congress “United in Quality Care by Air”.

The four-day event underlined that while the use of sophisticated modern technology, such as night vision goggles (NVG), open up completely new opportunities for

air rescue, it will not be able to replace people. Training rescue teams to deal with critical situations is still an issue of central importance. Simulation procedures seem to be the method of choice for training and further education. Statistics from the US, which has more than 400 air-rescue providers, show that air safety can still be greatly improved in many places. Although the standard in Germany is comparatively high in this respect, the presentations also made clear that a culture of safety can always be further entrenched and improved upon.

The patient is the main focus in all air-rescue work.

It is the patients who benefit directly from the corporate culture of the provider and from its ability to deliver highquality and responsible care. A major concern of those in the field of air rescue is to find an appropriate standard for their work that can be applied to all organisations all over the world. A panel discussion revealed that there are many different opinions on this issue in the field of air rescue. Trying to find a consensus and create transparency here will be one of the big challenges facing air rescue in the future. It will be very interesting to hear what progress has been made in this regard at the next AIRMED in Rome. 

Author: Peter Poguntke Editor-in-chief, AirRescue Magazine, poguntke@airrescue-magazine.eu

2 · 2011 I Vol. 1 I AirRescue I 12

INTERVIEW | 13

“Helicopter patient transport will be in greater demand” Where is there room for improvement in air rescue? What are the challenges currently facing the profession and what developments can be expected in the years to come? AirRescue Magazine interviewed Erwin Stolpe, EHAC board member and Medical Director at ADAC Air Rescue, to find out.

Erwin Stolpe, EHAC board member and Medical Director at ADAC Air Rescue (Photograph: M. Mennie)

ARM: What changes and developments do you think we can expect to see in air rescue over the coming 15 years?

Stolpe: Let’s start with inter-hospital transfers. The number of flights between hospitals, particularly those between general hospitals and specialist medical centres, will increase. That’s because the number of hospitals is set to fall across the board. The importance of regional and multi-regional networks, such as the trauma network of the German Trauma Society (DGU) will grow. That means the helicopters used in patient transport will be subject to even greater demands in terms of patient monitoring and care. They will have to carry significantly more medical equipment on board than they do today. That in turn raises questions about the use of these new devices.

Can they all be authorised for use on air rescue missions?

How can these additional devices be safely secured within the helicopter, and might they have a negative effect on avionics? These are the sorts of questions we are going to have deal with in future.

ARM: That ties in directly with my next question: What kind of demands are going to be placed on air ambulance helicopter manufacturers?

Stolpe: Manufacturers will have to obtain authorisation for producing medical products, as air rescue is just as much about medical device law as it is about aviation law.

We will also need to look at equipment for special rescue situations, such as those on the water or in mountainous areas, when we ask whether all the equipment that we already have or still require meets our needs and complies with relevant regulations.

ARM: What about training? Rescue assistants have been waiting for improvements there for a long time now.

Stolpe: That’s another big issue. We’re definitely hoping that the ball will start rolling on a new rescue assistant law

2 · 2011 I Vol. 1 I AirRescue I 13

soon. Our rescue assistants were trained on the ground and were only faced with the challenges of intensive-care transport later, once they had started working with us.

Ground rescue operations transport patients in a large ambulance that has space to carry additional intensivecare specialists. Air rescue missions, by contrast, do not have room for additional personnel who can compensate for training deficits among the air rescue assistants.

Our rescue assistants need to have all that necessary knowledge themselves. Ideally, they should have an extra qualification in intensive-care medicine.

ARM: The last AIRMED conference shows that Germany is really at the fore when it comes to air rescue – and not just in terms of safety. Can other countries learn from Germany?

Stolpe: We can definitely set trends and share our experiences. There are two regions making massive progress in this area at the moment – Sub-Saharan Africa and the whole of the Asian continent, particularly India and China. EHAC would like to see more information being exchanged between Germany and these regions in the future. We are well aware of the issues each region is facing. For example, switching to glass cockpits posed a major challenge in the U.S. and Poland.

ARM: How about fixed-wing aircraft? What can we expect in that sector?

Stolpe: People’s mobility will continue to increase, which means intercontinental flights will as well. If that happens, we can only assume that repatriations will rise too. This scenario could carry with it the danger that infectious diseases latently spread across the globe at a much faster rate.

ARM: What do you expect from your industrial partners in the future?

Stolpe: I’m in favour of some kind of brainstorming session, a discussion forum where the industry sits down with everyone involved in air rescue to talk about how our job profile is going to develop over the next 20 years.

There are lots of different aspects to consider: political, epidemiological, medical, social and environmental ones, as well as those relating to aviation technology. The result could be the air rescue helicopter of the future and a lot more besides.

For more information, visit: www.airrescue-magazine.eu/news

Editor-in-chief Peter Poguntke carried out the interview with Erwin Stolpe.

14 | TRAINING

2 · 2011 I Vol. 1 I AirRescue I 14

TRAINING | 15 Fig. 1: LAA is one out of 18 air ambulance charities in the UK, overall operating around 30 helicopters and flying a total of nearly 20,000 missions per year (Photographs: A. Chesters)

Training opportunities in pre-hospital care in the South East of England

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16 | TRAINING

Fig. 2: “The first month of the job is one of the toughest: A whole variety of new skills are learned and the intensive training by experienced pre-hospital care doctors really improves practical skills”

In the United Kingdom, pre-hospital care is not a recognised specialty in law. There is currently no nationally-agreed structured training programme that trains doctors to a specialty standard in pre-hospital care. Recently, proposals have been developed to designate pre-hospital care as a subspecialty of emergency medicine and anaesthetics, and it is expected that the first cohort of trainees will be recruited and trained in the coming months and years. Many doctors in the UK are active in pre-hospital care. Some work for one of the 12 regional Ambulance Services and some are independent practitioners with voluntary organisations such as the British Association for Immediate Care (BASICS). There are 18 air ambulance charities in the UK, operating around 30 helicopters and flying a total of nearly 20,000 missions per year. Many of these air ambulances are crewed by two paramedics, often seconded by the local ambulance service. Some doctors may volunteer to fly with their local air ambulance, extending the clinical scope of the team. The author joined Essex and Herts Air Ambulance Trust and worked full time with this organisation for a year before spending 6 months as a flight physician at London’s Air Ambulance (LAA). This is his firsthand-report.

London’s Air Ambulance (LAA) was launched in 1989 and provided an opportunity for doctors to work fulltime in pre-hospital care as part of a doctor-paramedic crew responding to major trauma in the London area. Since 1989, many doctors have worked for the service and the model of training, governance, and clinical care has been adopted by a number of other air ambulances in the South East of England, covering a population of around 20 million people. Four charities (London, Essex, Herts, Kent,

Surrey and Sussex as well as East Anglia) operate seven aircraft, each with a doctor-paramedic crew, to provide medical cover for the South East of England.

Recruitment and selection LAA doctors are senior trainees or consultants, many of whom have already completed specialist training and are looking for a new challenge or to hone their pre-hospital care skills in a busy and well-governed system. Jobs are

2 · 2011 I Vol. 1 I AirRescue I 16

TRAINING | 17

advertised annually in professional journals and online, and applicants are interviewed by a panel of senior members of the LAA team. Doctors were previously appointed on a six month full time contract and working exclusively for LAA, but in recent years the post has been linked with full time jobs working for air ambulances in neighbouring counties, so that doctors can now work in pre-hospital care for up to two years. LAA has formed alliances with a number of Helicopter Emergency Medical Service (HEMS) providers in the South East of England. The shared clinical practices, clinical oversight and governance allow clinical staff to work in similar systems but to gain experience in different types of HEMS work. London offers intense exposure to urban trauma (in particular knife and gun crime), whereas the county air ambulance teams are exposed more to high speed road traffic collisions and the challenges of providing pre-hospital care in rural locations that may be some distance from a trauma hospital. In London, a training doctor can expect to see around 140 cases of serious trauma, deliver around 30 pre-hospital anaesthetics and see around 80 lower acuity cases in a 6-month period. Exposure in the county systems is variable but is approximately half that of London, with around 20% of cases being acute medical emergencies rather than major trauma.

2 · 2011 I Vol. 1 I AirRescue I 17

There are a number of different options as to when in a training programme to apply for a full time job in pre-hospital care. Some doctors choose to apply after completion of specialist training, others take time out from specialist training. For those taking time out, an application must be made to the regional Deanery that is responsible for training. The Deanery will apply to the General Medical Council to get approval for the extension of specialist training and approval will also be sought from the training standards committee of the parent medical college depending on the specialty of the doctor (typically the College of Emergency Medicine, or the Royal College of Anaesthetists).

Some posts may be counted towards training in the base specialty (emergency medicine or anaesthesia) and may not extend the total length of specialty training. These posts are designated after inspection by representatives of the medical colleges. Should a post not be accredited, or be only partially accredited, the speciality training of that doctor will be extended and the date of eligibility for certificate of completion of specialist training will be altered. LAA posts have been accredited for training in emergency medicine and anaesthesia for many years, and some of the regional air ambulance posts have also been approved over the last few years.

Fig. 3: The HEMS Crew Course (HCC) also includes practical training; London as well as Essex and Herts teams take part in such training, delivered by experienced pre-hospital care doctors and involving simulated patients

18 | TRAINING Starting the job – the “sign off month” The first month of the job is one of the toughest, but it is also the most exciting. A whole variety of new skills are learned and the intensive training by experienced prehospital care doctors really hones practical skills and operational knowledge. My first month was undoubtedly difficult and there was a huge learning curve, but it completely prepared me to do a job that offers a different challenge every day.

Doctors appointed to any of the South East of England HEMS services are from a variety of backgrounds. One of the principles of training new doctors to do the job is that everyone goes through the same process in the first month of training. This is the “sign off month”, a period in which the new doctor is supervised by current prehospital care doctors in the service, or by a consultant in pre-hospital care for every clinical shift. There is an extensive tick list of equipment with which to become completely familiar and standard operating procedures of the service to learn in detail. The members of the team with whom the new doctor works, will have gone through the same process and will devote an enormous amount of time to ensure that the new recruit is completely comfortable and competent to work without direct supervision.

This dedicated month of supervised one-to-one training is a huge contrast to many other jobs in medicine and is a hugely beneficial learning opportunity. As well as the clinical aspect of the job, there is a vast amount of operational information to learn. Many doctors will never have worked around helicopters and so this element of the job, including navigation and airmanship, is completely new.

Continuing governance and training Fig. 4: A doctor-paramedic team participates in the scenario and it is run – in real time – by another member of the aircrew, providing appropriate clinical information at relevant times

Clinical governance at LAA is considered to be the cornerstone of the operation. There is a system of clinical governance that allows the duty crews to provide cutting edge pre-hospital care to our patients. Senior consult-

ants in pre-hospital care maintain oversight of clinical and operational matters in order to ensure that everyone performs to the highest possible standard. Clinical governance is an ongoing process, but the most visible forms are the weekly death and disability meetings and the monthly clinical governance meeting.

Another key part of self-reflection and governance is the debrief system. All missions are debriefed by the duty crew, usually on the same day. This allows an opportunity to identify things that went well, and things that may be changed next time to make things run more smoothly. It is also an opportunity for any deviations from LAA standard operating procedures to be identified and discussed.

Training scenarios are debriefed in a similar way. Debriefs offer a chance for constructive comments to be made and I have found that they are one of the most valuable learning tools that we have.

Crew resource management (CRM) is a concept that was completely new to me when I began working in prehospital care. CRM focuses on the non-clinical factors that can affect our performance on scene and is now considered to be an essential component of training in the South East HEMS system. Medical decision-making is often based on facts and medical procedures are performed on the basis of the technical ability that all our clinicians have. It is CRM that forms the backbone to our interactions on scene and ultimately dictates our ability to provide excellent trauma care to our seriously injured patients in high-pressure situations. There is special emphasis on CRM throughout HEMS training (on scene, in scenario and in mission debriefs) and it is undoubtedly one of the most important concepts that I have learned during this job.

Checklists and new perspectives on trauma in the South East HEMS-system Despite the variable and unpredictable nature of pre-hospital care, there is a structure to the day. As well as the overarching governance structure and regular training, the system is made safe by a series of checklists that are conducted by challenge and response with both members of the team taking part. These checklists are used for procedural issues such as checking that all necessary equipment is loaded into the aircraft and rapid response car, and also for certain critical clinical interventions on scene, such as prior to rapid sequence intubation. The introduction of checklists into my clinical practice was a new concept for me, but it was soon clear that their use minimises the chance of mistakes being made under pressure. Even familiar tasks can become difficult when there is so much going on and the use of a well-rehearsed checklist helps to regain control of the situation and ensure that the patient receives the best possible care. I now consider the use of these checklists to be an essential part of clinical practice.

The team in London responds to major trauma following a well-defined set of activation criteria. The county systems are also set up to respond to medical emergencies. As an emergency physician, I have been used to receiving these patients into the department but being on

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TRAINING | 19 Fig. 5: A week-long residential course combined theoretical teaching on the concept of flight, airmanship, meteorology, map-reading with practical sessions on board a helicopter

scene offers an entirely new perspective. Special attention is paid to mechanism of injury and predicting patterns of injury in order to anticipate disease processes that have yet to declare themselves. The skill of being able to predict injuries and provide appropriate treatment and triage has been something unique to pre-hospital care training and is something that I intend to develop in my future career.

Unique opportunities There are a number of unique opportunities that come with a job as a pre-hospital care doctor in the South East HEMS-system. During my first month, I was entered onto the HEMS Crew Course (HCC), a three-module training programme accredited by the University of Teesside as a Post-graduate Certificate of Professional Development.

This amazing course consisted of three modules, a medical, an aviation- and a multi-agency practice module. The medical module was an intensive week of theoretical and practical training delivered by experienced pre-hospital care doctors and involving simulated patients. The simulated scenario is set up to be as realistic as possible and they are almost always based on a real case seen and managed by one of the team. A doctor-paramedic team participates in the scenario and it is run (in real time) by another member of the aircrew, who provides appropriate clinical information at relevant times.

The crew participating in the scenario are expected to do everything as if it was for real and we pay particular attention to ensure that the clinical condition of the patient is feasible and realistic. Some of the scenarios are difficult and we will try to recreate some of the stresses of a real job in order to enhance the training experience.

The debrief for our training scenarios is the same as for live missions and key learning points can be drawn out and discussed in detail. The aviation module was an incredible opportunity to learn something completely new.

A week-long residential course combined theoretical teaching on the concept of flight, airmanship, meteorology, map-reading with practical sessions on board a helicopter to practice navigation and communication in flight. Underwater rescue and escape as well as issues of flight safety were practiced during the week.

The final module was an introduction to multi-agency working with the other emergency services. The Fire and Rescue Service demonstrated and taught extrication techniques and the Police discussed the tactics of firearms situations. Media awareness is another new skill to learn.

The air ambulances in the South East of England are heavily reliant on charitable donations in order to continue to provide a year-round service. The costs to the charity can be around £250,000 a month and in order to generate income, the helicopter, the team and the brand must be as visible as possible. The jobs to which the air ambulance is tasked, are high profile and often are featured in local and national media. In addition, part of the duties of the crew is to take part in charity events such as cheque presentations and sponsorship events, which can also generate media interest. It is an important skill to learn to be able to interact with the media, deliver a

2 · 2011 I Vol. 1 I AirRescue I 19

corporate message, maintain a professional appearance and still remain aware of important issues such as patient confidentiality.

Pre-hospital care in the UK is still in development and there is much to learn by sharing experience of national and international teams. During my time in the job, there have been a number of opportunities to attend and speak at high quality national and international conferences and this has been of immense educational value. In London, in particular, there is a 24-hour response by LAA teams to major trauma. At night and when the aircraft is offline, the doctor-paramedic team response is by car. The paramedic is typically responsible for emergency response driving while the doctor navigates. The ability to plot a route in a very short space of time and with no advanced notice, and to navigate from a map through busy and unfamiliar

Fig. 6: In London in particular there is a 24-hour response by the Essex and Herts Air Ambulance doctor-paramedic team and response car to major trauma: at night and when the aircraft is offline, the response is by car

20 | TRAINING roads is honed and many of the doctors find this amongst the most challenging aspects of the job.

training, checklists and drills have been invaluable and are something that will be invaluable in hospital service development.

Preparation for the future

Fig. 7: Skills have been honed in forming cohesive teams and getting the best out of that team and this is something that is also critical for effective work in a hospital setting

Pre-hospital care is developing in the United Kingdom.

There is a move towards the introduction of regional trauma networks with major trauma centres receiving seriously injured patients from a wider area. As these systems go live, the role of specialist pre-hospital care teams will become even more important as these patients must be identified, stabilised as necessary by a clinical team and transported to the most appropriate hospital. Doctors who have been trained in the South East of England HEMS systems, will be well placed to play a significant role in this reorganisation of services in the future.

There are a number of things I will take back to the emergency department as I continue my specialist training alongside my continuing work in pre-hospital care.

Teamwork has been a large focus of the last 18 months.

Skills have been honed in forming cohesive teams and getting the best out of that team and this is something that is also critical for effective work in a hospital setting. Decision making under pressure and the importance of the concepts of crew resource management as well as forward planning and anticipation are skills that have been practiced on a daily basis. Making sure the system is safe through ongoing governance and review, continuous

Final words The last 18 months have been full of challenges for me. I have enjoyed every minute of the job and learned something new every day. It has been easy to remain motivated whilst working with some of the most experienced and passionate clinicians in the business and I feel proud and privileged to have had the opportunity to work with a dynamic team of doctors, paramedics and pilots in Essex and Herts and in London. It has been a thrill to be part of such a professional crew that brings life-saving interventions to seriously ill and injured people and I have received some of the best training of my career. I have been utterly astounded by the tireless work of the charity and volunteer staff who promote the cause and rally the donations in order to keep the aircraft flying and I would recommend this job to anyone. 

Author: Adam Chesters Specialist Registrar in Emergency Medicine and Pre-Hospital Care at London’s Air Ambulance

2 · 2011 I Vol. 1 I AirRescue I 20

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22 | INTERVIEW

“This is the best job in the world!”

An interview with Adam Chesters, Specialist Registrar in Pre-Hospital Care (HEMS) at London’s Air Ambulance, on trainings and Aeromedical Crew Rescource Management ARM: Adam, Aeromedical Crew Resource Management, developed

by EHAC, was completely new for you. What is your opinion after you have run through such training?

Chesters: I now consider the concepts and techniques associated with Aeromedical Crew Resource Management, CRM, to be an essential part of my practice. It has become clear to me that interactions on scene and human factors may be even more important than simply having the technical ability to do the job. Having experienced some of the most intensive clinical encounters in my career, I have reflected on what exactly it was that made the situation so stressful. I couldn’t understand why a procedure that may be routine in the hospital, could suddenly induce such anxiety. I realised that environmental and human factors were the unknown variables and once I was able to begin to understand these influences and how they were affecting the behaviour and decision-making ability of the crew on scene, I was able to begin to take steps to control and eliminate these factors so that I could better manage the situation and perform as part of a team providing excellent clinical care to our patients.

A huge part of the job is about managing the scene – it is essential to be completely aware of all of the apparent chaos that is going on and to try to bring some sort of order to it through good interactions with those around you. There’s so much going on and as the only doctor on the scene, the overall responsibility of making the right decisions for the patient rests with you. I am sure that Aeromedical Crew Resource Management should be taught as a crucial part of any training programme in pre-hospital care and emergency medicine.

ARM: Was there anything that impressed you in an extraordinary way?

Adam Chesters: My most memorable case was baby Frankie. We were called on a cold and rainy morning in November to a child hit by a car. Frankie was 6 months old and was in a pushchair crossing the road with his mum, when a car struck his pushchair throwing him several yards down the road. Our pilot landed about 50 metres away and as we ran down the road to the scene, we could see that paramedics were assisting ventilation with a bag-valve-mask.

I had only been doing the job for about two months and I can still

Adam Chesters says that CRM “should be taught as a crucial part of any training programme in pre-hospital care“.

remember feeling scared as we arrived on scene and realised just how badly injured Frankie was. He had a severe head injury with a dilated pupil, wasn’t breathing and barely had a pulse. Despite nearly torrential rain, the team of emergency services on that day were incredible and we safely delivered an anaesthetic, took over his ventilation and stabilised Frankie before flying him to the regional trauma centre for evacuation of his extensive sub-dural haemorrhage.

On that day, Frankie became the youngest patient I’d ever had to treat on my own. I’ll always be immensely grateful for the training and incredible support that I received from the HEMS service that day. Every member of the team performed to the very best of their ability, and being able to phone for unwavering clinical support from a senior and very experienced pre-hospital care doctor, undoubtedly helped to provide the care that was required. Frankie made a good recovery and we were lucky to be able to meet him and his parents again some months later when they came to visit the airbase.

ARM: Will you take back some principles to your daily work in the hospital?

Adam Chesters: One of the aims of taking time away from hospital medicine was to develop skills that I could take back to the hospital environment. I will continue to practice pre-hospital care, but many of the skills that I have learned over the last two years will be of tremendous value in the emergency department. The ability to lead and be a member of a team, understanding the principles of CRM – particularly when treating seriously ill or injured patients – and the decision-making that comes with the experience of treating complex patients, will all be useful. Service development and making sure that the system is safe has been a focus of the last two years, and I hope to take this back to the hospital, too. I will continue to embrace the concept of clinical governance and continuous training and learning, and I hope that my public relations experience and media awareness will also be very helpful in the coming years.

ARM: What is your personal result of the HEMS training?

Adam Chesters: It has been a privilege to do the job and I am grateful for the opportunity to have worked with such an inspirational team of colleagues who are completely on top of their game professionally. For the most seriously injured patients we see, it is a great opportunity and an awesome responsibility to really make a difference. We are all constantly aware that decisions that we make and interventions that we carry out could save a life. One of the very best things about the job has been hearing about the progress of our patients after we leave them, or perhaps even meeting them some weeks or months later, and knowing that we played a crucial part in their treatment without which they may not have survived.

In my first few weeks on the job, I remember wondering how I was going to cope with all of the extra pressure and the challenges of working in pre-hospital medicine. Fortunately, with a great team of aircrew, wonderful training and with the unfailing support of senior and very experienced doctors who are only a phone call away, the tingling apprehension I get on the way to a job is less acute than it was – although always still there.

Undoubtedly the last two years have been full of challenges for me, but I have enjoyed every minute of the job, learned something new every day and am quite sure that it is the best job in the world.

2 · 2011 I Vol. 1 I AirRescue I 22

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24 | TECHNOLOGY

Fig. 1: INAER plays a key role in supporting coastal and offshore SAR activities in Spain (Photographs: AgustaWestland)

INAER and AgustaWestland strengthen partnership INAER and AgustaWestland have recently strengthened their longstanding partnership through the signing of a contract aimed at introducing the new 4.5 ton class AW169 model into its fleet, adding one more type to the ones already used for EMS and SAR duties. INAER, a major European and global helicopter services provider and operator, also belongs to the leading companies in emergency medical services as well as in SAR operations with activities spread across several countries including Spain, Portugal, Italy and France. INAER has been part of the European aviation network for HEMS as full member of the EHAC for many years. AgustaWestland, too, supports EHAC as associated member.

A significant share of the INAER helicopter fleet relies on a range of AgustaWestland helicopter types, such as the high performance AW109 Power, the Grand light twins as well as the widely acclaimed AW139 medium twin. The latest addition of the AW169 model would lead the total amount of AgustaWestland aircraft at INAER to more than 90 (including other models and applications such as fire fighting, passenger transport and offshore transport, not to mention a recent Memorandum of Understanding based on the PZL-Swidnik W-3A Sokol medium twin helicopter).

Besides relying heavily on AW models, INAER also acts as a service centre for AgustaWestland in various European countries – such as in Spain, Italy, UK and France – to offer on-site support services.

INAER established the first EMS service in Spain in 1986 and since then gradually expanded its EMS/SAR capabilities. The company plays a key role in supporting coastal and offshore SAR activities in Spain through the national maritime rescue agency Salvamento Marítimo

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TECHNOLOGY | 25

Fig. 2: Sasemar is responsible for 8,000 km of the country’s coastline and every year it responds to thousands of emergency call-outs, ranging from SAR missions to fighting pollution

(Sasemar). It is responsible for 8,000 km of the country’s coastline and every year it responds to thousands of emergency call-outs, ranging from SAR missions to fighting pollution. Sasemar also operates an eight-strong fleet of AW139s. The organisation, which began operations in 1993 and is part of the Spanish Government’s Ministry of Works, has an enormous geographical area to cover – 1.5 million km2 of territory – and is strategically located around Spain’s coastline. With around 1,500 employees supporting 21 maritime rescue co-ordination centres, including 10 helicopter bases, Sasemar is operational 24/7 year-round. Its fleet includes – besides rescue and fast intervention vessels – 10 search and rescue helicopters with the AW139 as the backbone of its aviation unit.

Sasemar was one of the earliest customers to put the AW139 model into service for SAR missions. The organisation also became the first one to take delivery of an AW139 with a double hoist, the design specifically adjusted to its operations. This tandem configuration has since then been adopted by other AgustaWestland operators. While Sasemar owns the AW139 fleet and is responsible for SAR missions at sea, it does not have the capability to operate or maintain the aircraft. This is done

by INAER that now provides air crews and maintenance across the whole fleet.

One of the latest enhancements implemented in the AW139 suitable for Sasemar’s duties is its extended range, following an increase in its maximum gross weight from 6,400 to 6,800 kg (15,000lb). The increase in certified weight is crucial because Sasemar’s helicopters are equipped with a significant quantity of missions systems and other SAR-related kits, which means the Operative Empty Weight of the helicopter is above the AW139 basic configuration.

The result is that the operator can increase the quantity of fuel carried by 400 kg while maintaining the same payload capacity. 400kg of fuel translates into more than 100 nautical miles of range, meaning that Sasemar’s AW139s can reach emergencies that are 50 nm further from its bases. 

For more information, visit: www.salvamentomaritimo.es www.inaer.com

2 · 2011 I Vol. 1 I AirRescue I 25

Fig. 3: One of the latest enhancements is the extended range of the AW139 that increased its maximum gross weight from 6,400 to 6,800 kg (15,000lb)

26 | IN PROFILE

Fig. 1: Drawing on its 25 years of experience in the provision of aeromedical services, CareFlight will work in close partnership with the NT-Government (Photographs: CareFlight) Fig. 2: CareFlight is also operating four Beechcraft Super King Air 200

Fig. 3: Darwin is the capital of the sparsely populated Northern Territory, Australia (Map: Bidgee)

CareFlight named Australia’s Top End aeromedical provider In an historic announcement the Health Minister for Australia’s remote Northern Territory (NT) Government, Kon Vatskalis, awarded the air rescue organisation CareFlight the long term Top End aeromedical services contract. The 10-year agreement covers provision of a completely integrated medical transport service: coordination, doctors, nurses, aeroplanes, helicopters, engineering and community engagement. It is the only service in Australia covering all platforms.

The operation is centred on Darwin, capital of the sparsely populated north of Australia, with satellite bases at Gove and Katherine. In all, just over 300,000 people live in the region, almost half in the capital, while the population swells during the warm winter “dry season”, when tourists flock to enjoy access to world-renowned attractions such as Kakadu and Litchfield national parks.

The new contract came into effect just one year after CareFlight was asked by the NT-Government to provide the region with an interim service under which, at just three months’ notice, it put into operation a BK 117 B2 helicopter (fitted with long range fuel tanks), four Beechcraft Super King Air 200 turboprop aircraft, a co-ordination centre and the nurses – while at that stage the Government provided the flight doctors. In addition, Darwin is the location of the charity’s busiest medi-jet base, with CareFlight International Air Ambulance also providing doctors and nurses to fly interstate and international medical missions from Sydney, Perth and Cairns.

CareFlight CEO, Derek Colenbrander, said, the news anchors CareFlight’s future in the Top End: “Strategically, we are now well placed to expand our services and to respond as new opportunities arise.” Drawing on its 25 years of experience in the provision of aeromedical services, CareFlight will work in close partnership with the NT-Government and the community to ensure this new service model delivers exceptional support to patients at rural, regional and very remote locations. 

For more information, visit: http://careflight.org

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IN PROFILE | 27

Fig. 1: Toni Lötscher’s advice will be in demand for a long time to come, given his unparalleled amount of professional experience

Toni Lötscher It’s not often that people are able to unite their profession and their vocation to quite the same extent as Toni Lötscher. Born in Marbach in the Swiss canton of Lucerne, he obtained his private pilot licence for fixed-wing aircraft at the tender age of 18, but it wasn’t long before his love of flying machines turned to helicopters. Just five years later, in 1972, he gained his professional pilot licence for rotary wing aircraft and he has stayed true to them throughout a career that now spans several decades. His last major assignments include training air ambulance pilots from the Slovakian air-rescue company ATE to fly the Agusta A109, training medical crews for air rescue operations and training pilots on behalf of the Rega, Swiss Air-Rescue, at the French company Proteus.

Although he has now more or less retired, Lötscher’s advice will be in demand for a long time to come, given his unparalleled amount of professional experience. For 12 years, from 1992 to 2004, he worked as a pilot, deputy senior pilot and flight instructor for Rega, the Swiss air rescue service. During this period, he was also responsible for managing the Bernese Oberland base in Interlaken.

Over the course of his career, he has spent around 16,500 hours in the air and taken part in 3,600 rescue flights. Almost every standard operational procedure that Rega has worked on in past years has Lötscher and his chief-pilot colleague’s names on it, whether it be for winch operations, rope rescue procedures, long-line operations with lines up to 230 metres in length, cableway evacuations or flights using night-vision devices. These techniques are continuously incorporated into sets of rules and standards to provide Rega and other air rescue organisations with operational guidelines, as now, for example, at ATE. Lötscher, a father of three, started out working in Switzerland, but his profession has since taken him all over the world. Early on in his career, he went to Suriname and Greenland. Later he travelled to Africa and Asia, where he worked for the Aga Khan Foundation in Pakistan, Tajikistan and Kyrgyzstan. After the earthquake

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in Pakistan in 2011, Lötscher stayed in the crisis area for two months. He has 14 helicopter type ratings, as well as seven more ratings for particular procedures, devices and functions. However, it has never been his intention to keep all this knowledge to himself. He has constantly sought to share and pass it on to others. This earned him the highest mark of recognition in the field: the Helicopter Association International’s Robert E. Trimble Award, which is presented to pilots “who have displayed exceptional ability and good judgement in high altitude flying, provided outstanding service to others, contributed to high standards of safety, and brought credit and recognition to the helicopter industry”.  For more information, visit: www.t-loetscher.ch

Author: Peter Poguntke Editor-in-chief, AirRescue Magazine, poguntke@airrescue-magazine.eu

Toni Lötscher has summarised his memories in a book entitled Rettungspilot (rescue pilot): 2nd edition 2007, 132 pages, more than 70 images, bound, 35 CHF (plus 8 CHF for postage and packaging). Published by Schlaefli & Maurer AG, ISBN 13:978-3-85884-107-0.

It can also be ordered from www.cumulus.ch

28 | INTERVIEW

“ Capturing the passion of

2 · 2011 I Vol. 1 I AirRescue I 28

energy and the HEMS-crews and -pilots” An interview with photographer Mark Mennie

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30 | INTERVIEW

Fig. 1: Patient unloading at night – shot on a regular IFR flight at night, AirLife, Texas, USA, 2010

ARM: Mark, what type of training did you have and how did you get your start?

Mark has been specializing in onsite medical trauma/helicopter EMS photography for almost 20 years. He is part of the MedEvac Foundation International – among other memberships – and also works as a mission photographer for STARS in Western Canada. Mark shoots with a Canon EOS-1Ds Mark III as it is rugged enough to handle a HEMS mission.

He uses a 24-70mm f 2.8 zoom lens and two Speedlite 580EX remotely controlled Previous Pages: Patient unloading on a rooftop helipad at sunset, West Virginia, USA, 2009 (All photographs: M. Mennie)

strobes to create sunset lighting effects.

Mark can be contacted at mark@mennie.com.

Mark Mennie: I was ‘classically trained’ at the Alberta College of Art in the 1980s. Photoshop had yet to be introduced and I was fine-tuning my Black-and-White shooting and printing skills. Portraiture and documentary portraiture was my strength in Art School. I began my own studio in the early 1990s, and then in 1995, I was asked to shoot some portraits of former STARS in Alberta patients and also try a ride-along with the program to illustrate a new fund raising calendar.

After my second mission with the Edmonton base with a demanding scene call and a realization, I beat all news sources to the ‘scene’ and captured the ground EMS and air medical services ‘in real action’ and: I was hooked. I assisted STARS with my artistic photography in expanding their annual calendar campaign sales to over 100,000 copies by 2001. I then applied and was granted a special US work-visa as an air medical and trauma rescue photographer in 2002. From there I began to assist the Association of Air Medical Services to develop a new exclusive image archive of accurately portrayed air medical and critical care transport imagery. I then began other projects with other major players in the US air medical community.

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INTERVIEW | 31

ARM: Why helicopters and why air medical?

Mark Mennie: I have a keen interest in helicopters and their capabilities. From their early days – and my friendship with Sergei Sikorsky who appreciates some of my other commercial work I do – to the new technology of the V22 or the developing air med twin engine industry standard of the A139, along with the EC 155 as well as innovations and the unique re-deployment of airframes by other programs and their effort to serve rural communities – as I am originally from the “sticks”, way out in the country, as well. As for air medical, I decided to specialize with my U.S. photography focusing on the air medical community in order to become an expert in my field.

ARM: What would a typical ‘day in the life’ be like for you?

Mark Mennie: It would include arriving on base early to meet the air med crew and discuss the parameters of the project. I am also included in the pilot’s and crews’ daily briefing, and take note of the weather just like the pilots do: Good weather and sunshine is always great for flying or photography, but sometimes changing weather can create some dramatic sunsets – a photographers’ dream. I will always go through an actual safety briefing on board the aircraft, verifying emergency egress procedures, safety equipment, survival gear, emergency

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engine cut-off proceedures and even the location of the emergency location transmitter.

I find that an initial mission with a new crew generally is an opener for me and that a second mission yields greater imagery, both as I am used to the programs procedures and crews’ comfort with me. I prefer to describe my efforts to capture imagery as ‘stealthing around’, and a comment such as ‘you were there?’ is a true compliment of my effort. Relationships between programs and hospitals vary extremely and each are approached cautiously – with patient privacy in mind. Hospitals that also may include an educational element and can open up many more photo opportunities, also in the trauma room.

Photographing the car ‘wreck’ and then showing what it looked like by presenting the image on the back of my camera to the physician in charge or, even more importantly, to new resident physicians, what the ‘mechanism of injury’ was, is also a goal for me and another small element in assisting in patient care.

ARM: Mark, you are a part of a number of organizations and expos. Could you name a few that are especially important to you?

Mark Mennie: I am hoping to get more involved with EHAC and the 2014 AIRMED-Congress in Rome. I am also involved in the Dubai Helishow 2012 and we are

Fig. 2: Patient care inside of an Agusta A109, LifeFlight of Maine, USA, 2007

32 | INTERVIEW

Fig. 3: Young patient on a regular mission in Ohio: Promedica, Ohio, USA, 2007

hoping to grow it to include more air medical and rescue tangents – a growing field in the Gulf States. Furthermore, I am involved with capturing new air medical host program imagery for AAMS to promote the 2011 AMTC in St. Louis, USA.

ARM: Could you describe your most challenging missions?

Mark Mennie: I can speak in general terms saying that there are many missions that as a ‘ride along’ or ‘observer’ I am exposed to a variety of medical situations.

Some missions that transport a critical patient from hospital to hospital may sometimes expose the whole crew to airborne pathogens and proper masking and gowning is required to limit exposure – in such a small confined space. There is a calculated risk in flying and very safety conscious efforts are made to limit those risks, including active CRM (Crew Resource Management) which basically allows crew members to participate in decision making or noting the risks that may be involved in a mission.

After a few hundred missions as an air med photographer I do feel comfortable to speak up if I feel or see a risk. This however came from the experience of many missions, an understanding of how it all comes together in the medical and aviation environment. I have seen many tender moments between families and their patients as they may be saying goodbye to them prior to their flight, taking them away hours away (by vehicle) from their home

hospital. Again, the key word is ‘seen’, as I choose not to engage those settings, both from a patient privacy level as well as not to be as intrusive as a modern day ‘tmz’ (editor’s note: an aggressive but popular celebrity gossip news television show in the USA) like ‘paparazzi opportunist’.

On a lighter note, there are also other situations in where there may suddenly be dual patients or higher patient weights, which bumps me off the helicopter. I have found myself at the side of the road watching my aircraft take off (albeit it is another photo possibility) and then facing the humor of the EMS agencies or the Police of ‘missing my ride’.

ARM: How do you ‘digest’ extreme situations?

Mark Mennie: As a photographer and as a sub-contractor directly hired to capture the air medical crews and pilots in action, either in a medical or aviation setting, I have to both understand the aspects of the setting of a medical helicopter. Yes, I have seen very serious injury or sickness on a mission, and I tend to ‘digest’ this situation by believing that the EMS services involved in a very critical mission are working at 110% of human capacity to save a patients’ life by getting to an even higher level of care. A ground or air ambulance is not a ‘prevention’ agency, it is there to respond to sometimes very serious life threatening situations. I photograph that and aim to capture that energy and passion of my crews. It sometimes bothers

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INTERVIEW | 33

me, and I have seen death, but I accept this because the care that is being given is the best available in the setting the life threatening situation it may be in. I find that the level of experience of pilots and an air medical crew can exceed a combined total of 70+ years sometimes and they have ‘seen it all’ and this experience and expertise is part of the way I understand how life can be rescued from the brink of death with medical technologies and the speed of aviation.

some peripheral actions to help them with their patient care (holding the documents and x-rays so they don't blow away, helping to untangle lines, holding the i-STAT® system, helping to dispose of sharps properly) as well as assist as an extra pair of eyes when approaching a landing zone (watching for obstacles, FOD, animals, landing zone, slope or pedestrians).

ARM: What was your most impressive mission?

ARM: What are the challenges you face doing your work on a mission?

Mark Mennie: I find that air medical crews do not make great actors. They are generally humbled by the attention I give them as I focus my camera on their life saving skills and thus the later attention they may receive. They photograph best when they are working. The challenge is to be on a call and to anticipate or learn their next move.

Crews also can become uncomfortable by my presence, both as a result of my camera as well as their concern and responsibility for my safety. I generally find the ‘second mission of the day’ is much more successful, as a crew is now comfortable with my camera and with my understanding of helicopter safety. I prefer to describe myself at work as being in ‘stealth’ mode, observing and photographing, staying out of the way, not affecting the helicopter operations and – in some rare cases – are asked to put my camera down and ‘assist’ them in doing

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Mark Mennie: I have been on many missions and I know that the rapid actions of the ground EMS agencies responding, followed by the high level of trauma care and quick transport times and then the higher level of care at a trauma center, has resulted in saving a patients life and thus a greater outcome to their recovery. I have also photographed former patients and heard their heartwrenching stories of survival, recovery and acceptance.

All as a result of many agencies including a helicopter transport to ‘save their life’-stories that make me proud to be able to photograph those air medical crews and pilots that are all part of that.

Fig. 4: Unique scene call set-up; AeroMed, Michigan USA 2009

34 | MEDICAL CARE

Acute coronary syndrome – The role of HEMS Helicopter emergency medical services (HEMS) play an important role in the transport and coordination related to time-dependent pathologies such as acute coronary syndrome (ACS). HEMS are also crucial to their treatment: prehospital fibrinolysis or reperfusion therapy in hospital. Transport by HEMS needs to be considered in the regional EMS system (depending on geography) because HEMS can improve therapeutic times (“door-to-balloon”), with a therapeutic success rate of 95.7% of patients. Of those, 81.3% have no complications, and 14.4% have complications resolved in flight. Complications include ventricular fibrillation (VF) / ventricular tachycardia (VT) (11.2%) and cardio pulmonary arrest (CPA) (3.2%). HEMS achieve a high level of success here by implementing technical instruction in in-flight defibrillation for VF/VT, by applying the external cardio compressor AutoPulse® for CPA, and by inducing therapeutic hypothermia in the case of cardiopulmonary resuscitation (CPR). It is easy to achieve early detection, reduction and treatment of complications in ACS during transport via HEMS and this has a direct impact on patient mortality and morbidity.

Fig. 1: HEMS achieve a high level of success by applying the external cardio compressor AutoPulse® for CPA (Photographs: J.M. Gutiérrez Rubio)

First emergency medical service (EMS) contact The optimal treatment of ACS should be based on the implementation of an emergency medical service (EMS) that monitors a network of hospitals that have different levels of technology and are connected by an efficient ambulance and/or helicopter service. The main features of this network should be: clear definition of geographic areas of operation, shared protocols based on risk stratification and an ambulance and/or helicopter transportation service with personnel and equipment. A good regional healthcare service – based on pre-hospital diagnosis, alerting the medical facility and transporting the patient to it – is the key to successful treatment and significantly improves results (1, 2).

We analysed records of 9,692 HEMS deployments in 2010. Of these, 21% (2,035) were cancelled before takeoff or in flight (mainly for meteorological reasons).

81.26% of the deployments were primary operations.

Cardiovascular disease accounted for 46.7% of the deployments for medical causes, and 39.7% of those concerned ACS. Here, 75.27% of patients were male, and 24.73% were female. In terms of age, 40.64% were between 46 and 70. The majority (50.88%) were over 71.

Patient delay The most critical time in ST elevation myocardial infarction (STEMI) is the period immediately following its presentation, when the patient is in pain and may suffer cardiac

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MEDICAL CARE | 35 Fig. 2 and 3: HEMS Coverage in Spain (Inside Isochronous 20 min; blue circles indicate multi-role helicopters that can be medicalized)

arrest. The sooner medical teams administer treatment, particularly reperfusion, the greater its beneficial effect (“time is muscle”). However, there is typically at least a one-hour delay between the onset of symptoms and the patient seeking medical help. Elderly patients, women, diabetics and patients with congestive heart failure generally wait longer to seek medical help.

Ambulance service / HEMS HEMS play an essential role in managing STEMI (3). They should be considered not only as a means of transport but also as where the initial diagnosis is made and emergency treatment is started (4). HEMS should be able to reach the majority of patients with chest pain within a maximum of 20 minutes from receiving the call. Integrating HEMS into the ambulance network makes it possible to get patients to the cardiac catheterization laboratory within the time that is appropriate for coronary reperfusion (“door to balloon”). The quality of care provided depends on the training of the personnel involved. All HEMS should be equipped with a 12-lead ECG, defibrillators and staff trained in implementing and interpreting an ECG. Recording an ECG before admission significantly speeds up the management of the condition at the hospital (5, 6) and improves reperfusion therapy (7, 8).

HEMS provided with a medical staff can offer advanced diagnostic and therapeutic services such as conducting a 12-lead ECG, administering opiates and fibrinolysis. In our experience, HEMS improve transport times and results in some regions (9). Today, ischemic heart disease is the leading cause of death in industrialized countries. In Spain it is the leading cause of death in the overall population, although it is surpassed by cerebrovascular diseases in women. Two thirds of those who die of ACS die suddenly and unexpectedly before reaching hospital.

This distribution of mortality, with more younger patients dying before reaching hospital, continues 15 years on. ACS is a time-dependent process; early diagnosis and initial and critical care have an impact on the final prognosis of patients. Knowing now that most deaths occur in the first three or four hours, special attention must be paid to the following: controlling symptoms; preventing, detecting and treating cardiac arrhythmias; and maintaining adequate cardiac function. Our primary objective is myocardial ischemia reperfusion.

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Reperfusion therapy in the acute phase of STEMI is the most important component of treatment, as it has the greatest impact on patients’ survival and quality of life. Several methods of reperfusion are now available: thrombolysis (TBL), primary percutaneous coronary intervention (PPCI), and a combination of both. Its implementation is an independent predictor of death in the short and long term.

Reperfusion therapy PPCI is the reperfusion therapy for all patients with STEMI when it can be performed within a certain period of time after first medical contact. PPCI should be performed in catheterization laboratories that are open 24 hours a day, 7 days a week, and carry out more than 400 PPCIs per

Fig. 4: Case fatality, percentage outside hospital from acute coronary events and age group among persons with a first-time coronary event Fig. 5: Mortality and delay in diagnosis of ACS

36 | MEDICAL CARE year. This means we need to set up a network to make it possible to offer most of our patients this reperfusion therapy.

Treatment

PPCI as a method of reperfusion

•

PPCI has a Class I indication with a level of evidence from A to C, depending on the type of patient, delays in implementation, and the facility’s experience in performing the procedure. The decision to perform PPCI should be taken by the physician who makes the electrocardiographic diagnosis of STEMI.

The treatment administered in the HEMS environment is no different from that provided at other levels of healthcare:

•

• •

Ischemic drugs: β-blockers, nitrates, calcium antagonists and others (ivabradine, trimetazidine, ranolazine) Anticoagulants: Low molecular weight heparin (LMWHEnoxaparin) or unfractionated heparin (UFH), fondaparinux, bivalirudin Antiplatelets: ASA, clopidogrel, IIb-IIIa inhibitor protein Thrombolysis / revascularisation

Diagnostics

ACS complications

HEMS diagnosis is based on three pillars:

This review focuses on the aspects that are particularly relevant to the HEMS environment:

• •

•

A physical examination, clinical and medical history An ECG that should be performed within 10 minutes of arrival and contact with the patient. The ECG allows rescuers to assess the location and extent of MI, and the magnitude of the repolarization abnormalities has a prognostic value. ECG monitoring should continue for as long as rescuers remain in contact with the patient.

It is advisable to register additional leads (right precordial leads) (I-C).

The use of the biomarker troponin I. Tn-I reflects myocardial necrosis by irreversible distal thrombus embolisation of a ruptured plaque. We use it in the diagnosis of STEMI. It is the best prognostic biomarker of STEMI and death in the first month, although it retains its prognostic value over time. Its first rise is detected after the coronary event and that is why we identify the biomarker in the first hour of contact with the patient.

Table 1: Independent risk factors for intubation in cardiogenic pulmonary edema •

Infarction with ejection fraction of left ventricle severely depressed.

•

Index score APACHE II > 21

•

Refractory hypercapnia

•

pH <7.20

•

Systolic blood pressure <140 mm Hg

•

High comorbidity (Charlson index> 3)

APACHE: acute physiologic and chronic health evaluation pH <7.20 is the independent parameter of greatest risk

Table 2: Contraindications to noninvasive ventilation Inability to protect airway: •

Not hypercapnic coma or agitated patient

•

Gastrointestinal surgery or recent upper airway surgery (<15 days), vomiting uncontrolled, active HDA

•

Inability to control secretions

•

Hemodynamic instability (shock established not controlled with fluids and/or vasoactive drugs), uncontrolled malignant arrhythmia

•

Seizures

•

Impossibility of fixing the mask

•

Lack of technique

Acute heart failure Acute heart failure (AHF) and dyspnea / acute respiratory failure (ARF): During the relevant measures in the treatment of AHF and once the antianginal treatment has been optimized and afterload reduced (using nitrates, calcium antagonists, beta blockers), the preload is set and we give the appropriate analgesic and the ventilator support that some patients need in the initial phase of symptom control. Acute pulmonary edema (APE) with AHF or hypertensive crisis is a common cause of ARF in HEMS environments. The incidence and impact are increasing, and sometimes reach the epidemic (10) range in EMS. In recent decades, positive pressure non-invasive mechanical ventilation (NIMV) for the treatment of both ARF and hypoxemic-hypercapnic respiratory failure is frequently used in patients with AHF. NIMV does not require endotracheal intubation (ETI) or sedation, and has proven useful in the treatment of different forms of AHF (11, 12).

In certain patients, the main objective in some cases (Table 1) is to avoid ETI. This method of delivering mechanically assisted breathing without placing an artificial airway has become an important method of ventilator support in EMS. We therefore use small, easily portable devices (mechanical devices / Oxilog 3000 vs. non-mechanical devices / CPAP Boussignac).

In the treatment of AHF, two methods of NIMV have proven effective: continuous positive pressure in the airway (CPAP), and non-invasive ventilation mode with dual pressure (BiPAP). Both systems, compared with traditional methods of oxygenation (13) and combined with the pharmacological treatment of AHF, have improved earlier clinical parameters and blood gases, and have reduced the number of ETIs and associated complications (14), admissions to intensive care units (ICUs), and hospital mortality in some patients.

In acute pulmonary edema caused by cardiac etiologies, NIMV does the following: provides partial ventilatory support; improves gas exchange; may improve oxygenation by recruiting atelectatic alveoli, redistributing lung water and improving ventilation-perfusion matching (15); and relieves dyspnea. In addition, NIMV reduces the load on inspiratory muscles and prevents respiratory muscle fatigue. It can also improve left ventricular function and cardiac outflow by reducing preload and afterload. Both

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MEDICAL CARE | 37 CPAP and BiPAP decrease the work of breathing and prevent intubations in patients with pulmonary edema. However, despite these benefits, NIMV is not widely used in EMS, with less than 6% of AHF patients receiving it (16).

We believe that there is sufficient evidence to endorse VNI techniques over conventional methods of oxygenation in the treatment of APE, and that VNI should be considered as first-line intervention. The existence of a protocol shows that more HEMS professionals are complying with and becoming involved in NIMV (17, 18). In our opinion CPAP should be the method of choice for oxygenation in the treatment of AHF, due to its simplicity, ease of operation and low cost. There is no clear consensus on the absolute and relative contraindications to the use of NIMV (19). Some are described as exclusion criteria in many studies (Table 2).

Recurrent ischemia Recurrent ischemia (< 20%) and treating it with TBL during the transfer of patients for whom PPCI revascularization treatment has been proposed: TBL must be administered to these patients in the following cases: chest pain that persists despite the use of nitrates and opiates; appearance or persistence of hemodynamic instability; re-elevation of the ST segment; appearance of a new left bundle branch block on the ECG; ventricular arrhythmias as a side effect of electrical treatment and time to revascularization of more than 30 minutes PPCI.

Arrhythmias •

•

•

In cases where patients are hemodynamically stable, they will receive drug treatment according to clinical guidelines and protocol service.

In cases of hemodynamic instability, electrical treatment (cardioversion/defibrillation) should be used.

The higher mortality rate in these cases is associated with older patients, female patients, TAS < 90 mm Hg during assistance, tachycardia, Killip class > I, and ventricular fibrillation (VF) or ventricular tachycardia (VT) during assistance. VF occurs in ~ 5% of patients during transport. For this reason and due to the controversy surrounding the use of electrical therapy in flight, defibrillation protocols were developed. These protocols and exercises have evolved from checks and tests on animals to current electromagnetic compatibility in-flight tests on modern in-flight electrical treatment (cardioversion, defibrillation, transcutaneous pacing), a practice that is absolutely safe.

All patients transported by HEMS after suffering ACS are placed on a vacuum mattress. Rescuers apply defibrillation pads as a preventive measure and constantly monitor the ECG. Rescuers must inform the commander in the daily briefing on the procedure used if defibrillation was required in flight.

Cardiac arrest With the implementation of protocols for moderate therapeutic hypothermia and use of mechanical cardio compressors. Mechanical cardiopulmonary resuscitation (MCPR): In HEMS there are obvious advantages to using

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the AutoPulse® device in patients at risk of developing moderate to severe non-shockable rhythms and PCR, a common complication in transport by medical helicopter. That is why we need to develop procedures for the HEMS (20) transport of high-risk patients. But the AHA 2010 recommendations in particular show that the use of mechanical CPR has obvious advantages. When manual CPR is done properly, the best manual chest compressions only provide 30-40% of normal blood flow to the brain, and only 10-20% of normal blood flow to the heart.

When an interruption occurs (e.g. switching rescuers or exiting the helicopter), a sudden cardiac arrest (SCA) vic-

Fig. 6: CPAP should be the method of choice for oxygenation in the treatment of AHF

Fig. 7: Testing of defibrillators “back in the old days” using dead pigs

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Fig. 8: Checking the defibrillation protocols

tim quickly loses the benefits of the blood flow resulting from chest compressions. Even the most seasoned EMS professionals will admit that manual CPR is difficult to perform for long periods of time. Maintaining the proper rate and depth of compressions can only be done for so long, and studies show a significant decline in quality, due to fatigue, after only one minute. The quality of human-generated chest compressions also varies widely depending on training, experience and the physical characteristics of both the rescuer and SCA victim. MCPR is effective for several reasons (21): • • •

• • •

It reinstates normal levels of blood flow to and from the heart.

It provides continuous, properly timed and effective whole chest compressions.

It allows rescuers to focus on other demands during a rescue operation and eliminates the interruptions that usually occur during a code.

It provides the oxygen required to ensure the efficacy of resuscitative drugs and defibrillation.

It continues effective CPR even if medical staff have to move the patient over long distances.

It improves safety, as HEMS personnel can wear seatbelts in the back of the aircraft.

Using MCPR to maintain perfusion of vital organs during resuscitation (the increase of diastolic and mean blood pressure promises better outcomes in patients with outof-hospital cardiac arrest and may justify the use of this device in a modern ALS strategy, 22) gives rescuers more time to transfer the patient to where medical staff can solve the problem (in the case of ACS) that caused the SCA, and makes it possible to maintain coronary perfusion

while performing procedures in the catheterization laboratory (Class IIa, LOE C). Thus, MCPR serves as a bridge that allows the patient to receive the specific etiologic treatment (PPCI) of the cardiac arrest. This is why the situation is known as a “bridge code”.

Hypothermia The time to return of spontaneous circulation (ROSC) is the primary predictor of meaningful recovery from cardiac arrest. Once circulation has been restored, the primary goal of therapy is to maximize the chance of recovery by minimising damage to the brain and other organs. This can mainly be achieved by using supportive treatment and by careful monitoring in the HEMS unit. Hypothermia is usually divided into three categories: mild (33 to 35° C), moderate (28 to 32° C), and severe (< 28° C). Animal studies show that neurological damage can be minimised by initiating hypothermia as close to ROSC as possible (23-25).

There are many approaches to cooling patients and maintaining hypothermia. Early studies used ice packs positioned around the patient’s head and body. Clinical trials have also used cooling mattresses and blankets, temperature-controlled gel packs, cold water immersion, cooling helmets, rapid infusion of cold fluids, direct cooling of the patient’s blood via hemofiltration, endovascular cooling devices, and nasopharyngeal evaporative cooling.

There is no agreement on the ideal rate or method for cooling patients.

The body’s homeostatic mechanisms to maintain body temperature through peripheral vasoconstriction and shivering would blunt the effect of any of these therapeutic approaches, particularly those using sur-

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MEDICAL CARE | 39 face cooling. Patients who are treated with therapeutic hypothermia are generally paralyzed with neuromuscular blocking drugs to avoid the shivering response. This means they must be intubated and sedated. Core body temperature also needs to be monitored to ensure that the target temperature is reached. Oesophageal or bladder temperature monitors are used because patients are routinely intubated and fitted with Foley catheters.

The most recent randomized trials (26-28) evaluated the impact of pre-hospital initiation of hypothermia to shorten the time from ROSC to hypothermia. Animal model data suggests that this should improve clinical outcomes (23-25). The most recent trial, by Bernard et al.

(26), included more patients than the other two combined and was the highest quality of the three. All three of the trials used a maximum of two litres of intravenous fluids chilled to 4° C (normal saline or Ringer’s solution) to initiate hypothermia. Recent studies that compared outcomes in cardiac-arrest survivors treated using hypothermia with those in historical or contemporary controls reported improvements in survival of a similar magnitude to the initial randomised trials. They also suggest that therapeutic hypothermia offers the greatest benefit to the subgroup of patients who present with VF or VT and have ROSC more than 15 minutes after the initial cardiac arrest.

We have developed an in-flight cooling protocol using intravenous (IV) cold normal saline solution and chemical cooling packs. We describe the initial experience of cooling patients during rescue by the Emergency Medical Retrieval Service (EMRS) in the west of Scotland, a rural area with over 100 islands. Healthcare is provided by general practitioners who routinely anaesthetise patients and start cooling. Fluids cooled in a fridge to 4° C are transported in an insulated cool box containing an activated chemical ice pack. Fluids remain cold (< 6° C) for up to three hours during transport. On arrival of the HEMS and after ROSC, the patient was sedated, paralysed and intubated before controlled ventilation was started. The patient was then cooled by IV infusion of 30 ml/kg of cold saline solution.

Ice packs were activated and placed in the axillae and groin. There were no reported complications of in-flight cooling. This therefore shows that a simple, cheap, effective means of initiating mild therapeutic hypothermia in out-of-hospital cardiac arrest survivors during rescue from any location is feasible and reduces delays in initiating therapeutic hypothermia. Greater awareness among rescue teams and use of cooling when rescuing comatose out-of-hospital cardiac arrest survivors could be beneficial. In patients undergoing PPCI, it could also provide additional benefits in terms of survival and neurological outcome.

Altitude and oxygenation [Subheadline] Appropriateness of air medical transport in ACS: Hypoxia accompanying acute exposure to high altitude results in augmented sympathetic nervous activity. This therefore increases heart rate and blood pressure and the risk of effort angina and dysrhythmia in coronary patients (29).

During flights, cardiology patients in particular are put under stress by the decrease in pressure in the cabin and by the associated decrease in oxygen partial pressure in the blood. Possible risks mainly include rhythm disorders, myocardial ischemic states and excessive increase in pulmonary artery pressure (30). Patients with stable heart failure who ascend to higher altitudes should expect their maximum capacity for physical activity to decrease compared to their capacity at sea level (31).

Stress We identified several studies on stress and the impact of the HEMS environment on catecholamine release. A number of studies from the 1980s had already evaluated these considerations. The studies monitored hormonal, cardiac and psychological parameters in volunteers in a HEMS helicopter (EC135). The findings showed that at lift-off there was an increase in hormonal (51%) and cardiac (18%) parameters, and that psychological factors in the volunteers changed. During the flight, however, these increased less than expected (“fear of helicopter transport”, 32). With regard to determining and monitoring catecholamine in SCA, the studies found that extracellular norepinephrine reaches 1,000 times the normal level at 30 minutes of ischemia. This concentration is capable of producing necrosis, even in non-ischemic hearts, and for this reason we believe it plays an important role in the pathogenesis of VF in early ischemia (33, 34). Also important here are the specific features of the cabin: it

ACS complications & HEMS At this point one must ask if any of these complications are inherent to HEMS and if any of these complications have a particular impact on transporting patients with ACS. From experience and after reviewing the literature, we can note two key points: the stress and the changes in oxygenation in the damaged myocardium.

2 · 2011 I Vol. 1 I AirRescue I 39

Fig. 9: Defibrillation protocols used at INAER

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Fig. 10: HEMS crew of Bilbao has developed a system of pictograms that lets medical staff and patients communicate with each other inside the helicopter Fig. 11: The pictogram-system covers the different needs that might arise during transport, allowing rescuers to inform, assess or reassure the patient

is a small space, the patient is lying on a stretcher being monitored, there are heavy vibrations and changes in light, the noise is deafening and oral communication is impossible.

In this environment rescuers must maintain contact with patients when they are awake (look them in the eye, maintain physical contact, etc.). Rescuers should give patients a flight helmet – either one that allows them to communicate with the HEMS crew, or one that isolates him from ambient noise. For the use of the latter, the HEMS crew of Bilbao (Osakidetza-University of Pais Basque) has developed a system of pictograms that lets medical staff and patients communicate with each other inside the helicopter. The system covers the different needs that might arise during transport, allowing rescuers to inform, assess or reassure the patient.

•

ing: non-invasive systems for hemodynamic monitoring; systems to assess cerebral/coronary perfusion pressure; rapid systems for detecting biochemical markers of myocardial damage and tissue hypoperfusion; new heparins and anticoagulants to minimize the risk of bleeding; lighter chest compressors that are easier to place; a therapeutic hypothermia protocol; methods to reduce patient stress Promote and participate in new studies on HEMS that: encourage health workers in this area to do research; simplify procedures; facilitate the direct transfer of patients to hemodynamic units; allow patients to return to the hospital of reference; create a common database; break down administrative barriers. Implementing an intervention and educational programme for ACS will have a positive impact on patients rescued by the HEMS.

ACS in HEMS – Our opinion What should be our attitude towards detecting complications in ACS? And what tools do we believe are necessary in HEMS? •

•

•

Assess and evaluate factors that could help avoid complications: strict control and monitoring of low/high blood pressure, control of the replacement of volume, monitoring of heart rate, NIMV/IMV, over/underdosing of sedation and analgesia Implement a safety culture within the care provided: stress the importance of daily briefings and implement aeromedical crew resource management (ACRM), provide information, respecting confidentiality, of adverse incidents identified, and research these.

Focus on projects such as REPECO (reperfusion code), bridge code and zero code (heart-beating donors, etc.).

ACS & HEMS – Conclusions •

•

Reduce “door to balloon” times (D2BT). The D2BT is an indicator of prognosis, and should not exceed 90 minutes. We know that D2BT has to do with clinical evolution, size of AMI and mortality in the short and long term. This is why we should implement strategies to reduce D2BT (35).

Achieve reduction, early detection and treatment of ACS complications. This can be done using the follow-

Author: José Manuel Gutiérrez Rubio Medical Director, INAER, Spain Juan Antonio Sinisterra Aquilino Medical Director, HEMS INAER, Spain

References: 1. Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA, et al. (2008) A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 358: 231-40 2. Bassand JP, Danchin N, Filippatos G, Gitt A, Hamm C, Silber S, et al. (2005) Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology. Eur Heart J 26: 2733-41 3. Fukuoka Y, Dracup K, Ohno M, Kobayashi F, Hirayama H (2005) Symptom severity as a predictor of reported differences of prehospital delay between medical records and structured interviews among patients with AMI. Eur J Cardiovasc Nurs 4: 171-6

For further literature, please see: ››› www.airrescue-magazine.eu

2 · 2011 I Vol. 1 I AirRescue I 40

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42 | MEDICAL CARE

Fig. 1: ECMO retrieval with an AW139, Ambulance service of New South Wales, Sydney, Australia (Photograph: Paul Sadler)

Strategic use of rotary wing for ECMO retrieval Recently there has been renewed interest in extra-corporeal membrane oxygenation (ECMO). This has largely been due to the favourable results in the CESAR (1) trial and the success of ECMO during the H1N1 epidemic in 2009 (2). Survival in the ECMO group in the CESAR trial may have been higher if ECMO had been established at the referring centre. A robust and organised ECMO retrieval service can establish ECMO at a referring hospital and safely transport the patient back to an ECMO centre (3, 4).

This technique was first implemented in 1972 for a case of post-traumatic acute respiratory failure (5). For years there was no evidence that ECMO was superior to optimised ventilation techniques. Along with the publication of favourable results from the CESAR study, there have since been significant advancements in perfusion techniques.

This includes polymethylpentene (PMP) oxygenators and centrifugal pumps capable of several weeks of continuous operation with a low incidence of haemolysis. Furthermore, heparin-coated circuitry causes less systemic inflammatory response and requires lower levels of systemic anticoagulation than previous non-coated circuits.

During the H1N1 epidemic (2009), health systems were required to provide a mobile ECMO service. These patients had failed optimal therapies and were not deemed safe for transport with conventional ventilation.

For these patients the critical step was to establish ECMO therapy rather than the usual upgrade in care associated with a regular inter-hospital transfer. Helicopter transport became a key and integral part of the retrieval process.

ECMO principles ECMO has a broad range of appropriate indications for both veno-venous (VV) and veno-arterial (VA) ECMO. The Extracorporeal Life Support Organization (ELSO) publishes indications for ECMO (6). Examples of indications for severe respiratory failure include severe pneumonia, status asthmaticus and ARDS. Indications for VA ECMO include cardiogenic shock due to myocardial infarction, myocarditis, cardiotoxins, pulmonary embolism, refractory cardiac arrest or bridge to transplantation. ECMO may also be used in hypothermia as an invasive rewarming device.

Blood is aspirated through a venous cannula – generally the femoral or internal jugular vein in peripheral ECMO – by a pump, and it is oxygenated using a membrane (that also permits CO2 removal). The oxygenated blood is re-circulated via a second venous (femoral vein) cannula (VV-ECMO for respiratory indications) or arterial (femoral artery) cannula (VA-ECMO for cardiac indications). Central ECMO usually involves return cannulation of the aorta directly. The flow rate (L/min) is set by the pump speed

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MEDICAL CARE | 43 Fig. 2: Heli59 (SAMU59, University hospital of Lille) is a strategic asset of the ECMO care network in northern France (Photograph: Noordzee Helikopters Vlaanderen)

(rpm) and depends on a number of factors such as intravascular volume. ECMO essentially provides temporary lung (VV) or heart-lung (VA) bypass until reversal of underlying pathology is achieved or as a bridge to transplant.

Establishment of ECMO The optimal location to establish ECMO is in a cardiothoracic operating theatre. However, cannulation of peripheral vessels can easily be performed at the patient’s bedside (in an ICU or emergency department) if necessary.

Generally speaking, surgeons prefer a cut-down approach to access vessels, while intensivists/cardiac anaesthetists largely prefer the Seldinger technique. The recent arrival of the Avalon (Avalon Laboratories, USA) catheter has enabled single access (dual-lumen) placement for VV ECMO via the internal jugular vein under echocardiographic guidance. Perfusion is carried out by a medical perfusionist or perfusion scientist.

ECMO service Patients should be placed on ECMO by experienced doctors and perfusionists from an ECMO centre. Retrieval of these patients should also be performed by an experienced retrieval service staffed with specialists in pre-hospital and retrieval medicine. Once on ECMO, patients must be transferred to an ECMO centre. These centres should have a high volume of ECMO cases and full cardiothoracic back-up. Indications for ECMO retrieval should be predefined (3) and agreed upon by all parties. Equipment should be standardized and rationalised in the interest of fuel considerations. All ECMO referrals should be centrally coordinated. These retrievals stretch the logistics capacity of even the most efficient service.

The ECMO team usually comprises a cardiac surgeon and a perfusionist (medical or scientist) or an intensivist (cannulator) and a perfusionist (medical or scientist). The retrieval team usually consists of a critical care physician (emergency physician, anaesthetist or intensivist) and a flight paramedic/nurse. An experienced service can establish VV ECMO around 45 minutes after arriving at the patient. Thus it is more efficient to have the ECMO team

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and the retrieval team travel together to the referring hospital whenever possible. The AW139 helicopter has proven to be very well suited to carrying a four-person medical team, crewperson and pilot. While ECMO retrieval can also be done with a smaller airframe (such as an EC145), doing so places limitations on range, medical crew size and patient access.

Discussion When implementation of ECMO is urgently needed at a general hospital, a helicopter must be used to deliver the ECMO team promptly. The ECMO team that is on-call is often performing normal duties at their hospital when the call comes in. In most instances the helicopter enables pick-up at the hospital helipad. After stabilization has been achieved using ECMO, transportation back to the referral hospital should not be considered an emergency, so ground transportation is sometimes preferred (easier monitoring conditions, ideal ergonomics and more space).

Fig. 3: SAMU59, France: First experience of ECMO transportation in 2006 in an EC145

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Fig. 4: ECMO transport in a ground ambulance, SAMU59, France (Photograph: SAMU59)

Fig. 5: Ambulance service of New South Wales, Sydney, carrying out an ECMO retrieval with an AW139 (Photograph: Paul Featherstone)

A helicopter is essential when long distances or poor road conditions are involved. If logistics permit, all essential medical personnel should accompany the patient back to the ECMO centre (by helicopter if the cabin is large enough). Due to weight and/or fuel considerations, non-essential crew (e.g. the cardiac surgeon) sometimes have to return by other means of transportation. ECMO retrieval by helicopter can be a difficult task at the outset.

This is largely due to getting equipment tested for EMI so it can be approved for flight. Organisation, preparation and planning are key to each mission.

Greater Sydney Area HEMS and SAMU59 have developed an ECMO procedure that prepares them for any eventuality. ECMO in a helicopter is an exciting challenge but it must be done while maintaining the highest critical care standards. This includes adequate monitoring and preparing for potential complications during transport (e.g. pump failure) with the same level of efficiency as found in ground ambulances. The authors’ experience in this field shows that problems during ECMO transports (ground and air) can have deleterious consequences. With growing experience in ECMO transports that is also being shared, retrieval services have reached the same conclusions for successful missions. The three most essential points are establishment of the patient on ECMO, robust preparation/training and coordination. The cabin of the helicopter must be spacious enough to install and safely fix all the equipment needed. To help make this possible, manufacturers are now developing ECMO systems specially designed for transport (e.g. Cardiohelp, Maquet, Germany), with restraining devices fully approved by civil aviation authorities.

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MEDICAL CARE | 45

Conclusion These complicated transports were once considered a big risk in helicopters because of the helicopter’s special environment. However, given strict processes and procedure, appropriately trained teams can carry out ECMO rotary-wing retrieval in a safe manner. The risk-benefit ratio of ECMO transports by helicopter has to be assessed taking into account the distance (or estimated transportation time by ground ambulance) and the urgency of the situation. Some teams like SAMU59 prefer to use a helicopter to bring the surgical team in the hope of reducing the free interval from decision to insertion of the cannulae, but they do not systematically use the helicopter to transport the patient back to the referral hospital. As it is only available at referral hospitals, ECMO is a technology that fits perfectly in a care network, and the helicopter has certainly a role to play in this setting. 

Authors: Hervé Coadou SAMU59, Emergency Department University Hospital of Lille, France Brian Burns Greater Sydney Area HEMS, Sydney, Australia Christophe Adriansen – Anne Switonski – Patrick Goldstein – Eric Wiel SAMU59, Emergency Department University Hospital of Lille, France

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References: 1. Peek GJ, Mugford M,Tiruvoipati R et al. (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374: 13511363 2. Davies AR et al. (2009) Extracorporeal Membrane Oxygenation for 2009 Influenza A (H1N1) Acute Respiratory Distress Syndrome. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. JAMA 302 (17): 1888-95.

Epub: Oct 12 3. Forrest P, Ratchford J, Burns B et al. (2011) Retrieval of critically ill adults using extracorporeal membrane oxygenation: an Australian experience. Intensive Care Med 37 (5): 824-30. Epub: Feb 26 4. Burns BJ, Habig K, Reid C. et al. (2011) Logistics and safety of extracorporeal membrane oxygenation in medical retrieval. Prehosp Emerg Care 15 (2): 246-53.

Epub: Feb 4.

5. Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, Gerbode F (1972) Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 286 (12): 629-34 6. http://www.elso.med.umich.edu/Guidelines.html.

Accessed: 27/7/2011

Acknowledgements Thanks to Dr P Forrest, Dr R Pye, Dr A Jackson and Mr P Kernick for developing the ECMO retrieval service in Sydney (AUS). Thanks to Dr A Vincentelli, Dr F Juthier, Dr C Banfi, Dr JL Auffray and Dr S Radziun for helping to develop the Lille mobile ECMO team (FRA).

Fig. 6: ECMO Team SAMU59 at the University hospital of Lille, France (Photograph: SAMU59)

46 | MEDICAL CARE

Fig. 1: In Japan, an air ambulance with emergency doctor on board is called “Doctor-Heli” (Photographs: K. Omori)

Effects of the AutoPulse® used on patients with CPA during transportation in a “Doctor-Heli” Juntendo University Shizuoka Hospital introduced the AutoPulse® system – one out of many devices available for automated mechanical chest compression – to its “Doctor-Helis” (1). Data showed that advanced CPR using AutoPulse® performed about 12 minutes might be effective to get the ROSC, if circumstances during a flight make it very difficult to perform manual CPR. Shizuoka Hospital – located in an underpopulated rural area called the Izu Peninsula of Shizuoka – is the only hospital in the area taking care of emergency patients. There is no other emergency or critical care center nearby and only few other hospitals take care of emergency patients in general. If the regional emergency medical service (EMS) in Shimoda-city, located at the tip of the Izu Peninsula, has to transport a patient showing a critical state (including CPA), it takes about 90 minutes from the scene to the hospital at Izunokuni-city by surface transport.

Purpose The “Doctor-Helicopter”-system has recently been introduced as part of EMS in the local area, complementing the inadequate numbers of ambulances and hospitals in Japan. The “flying doctor” was implemented in the area of the Izu Peninsula in order to take care of extremely critical

patients with CPA. However, it is not easy to do effective manual chest compressions in the helicopter. The purpose of the study was to evaluate the effect of the automated load-distributing band (LDB) chest compression device, the so-called AutoPulse®, for continuous chest compression during transportation in a “Doctor-Helicopter”.

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MEDICAL CARE | 47 Patients and Methods The study included adult patients showing signs of CPA at the scene. After initial evaluation and medical care performed by EMS personnel, the medical staff – including the “flying doctor” – joined to take care of the CPApatient. Standard methods of advanced cardiopulmonary resuscitation (CPR) – including manual chest compression – were performed at the scene or landing point of the “Doctor-Helicopter”. When the decision was made to transport the patients with CPA, the AutoPulse® was prepared on the helicopter stretcher. The compression device was applied to the patient after having been moved from the ambulance stretcher to the helicopter stretcher.

When the patients arrived at the emergency room (ER) or when they showed return of spontaneous circulation (ROSC), use of AutoPulse® was stopped. If the patients were still in a CPA-state, manual chest compression was then performed immediately.

At a total number of 1,532 missions carried out by the “Doctor-Heli” of Juntendo University Shizuoka Hospital between July 2008 and March 2011, there were 140 patients with CPA conditions. AutoPulse® was used during transportation on 49 patients. These patients were divided into two groups depending on whether they showed ROSC or not (ROSC group and non-ROSC group). There were 15 patients in the ROSC group and 34 cases in the nonROSC group. Patients were analyzed upon the basis of the following components: demographic data, presence of witness and bystander CPR, the initial electrocardiogram (ECG) rhythm as well as the period regarding manual CPR and CPR carried out using AutoPulse® during pre-hospital procedures until arrival at the ER. Some data showed mean±standard deviation (SD) and statistical significance was assumed for P<0.05.

Results The difference of patients’ demographic data such as mean age, sex, cause of onset and presence of witness and bystander CPR, did not indicate any influence on the two groups (see Table 1). In the initial ECG, non-shockable rhythms – including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) – were much greater in both groups than shockable rhythms, including pulseless electrical activity (PEA) and asystole. Four cases indicated shockable rhythms, including two cases of VF and one case of VT in the ROSC group as well as one case of VF in the non-ROSC group. 12 cases showed non-shockable rhythms, including two cases of PEA and 10 cases of asystole in the ROSC group. Furthermore, out of 33 cases in the non-ROSC group, six cases showed PEA and 27 cases were asystole.

The time duration from the onset and/or EMS dispatch to the arrival of EMS personnel at the scene was 12.7±6.1 minutes in the ROSC group and 12.9±10.9 minutes in the non-ROSC group (p=0.2460). The time duration from EMS personnel arrival to medical staff arrival at the scene and/or landing points of the “Doctor-Helicopter” were 19.1±10.0 minutes in the ROSC group and 20.3±11.1 minutes in the non-ROSC group (p=0.7069). The duration of stay at the scene and/or landing points were

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16.9±13.8 minutes in the ROSC group and 18.6±8.2 minutes in the non-ROSC group (p=0.5047). The mean duration of manual CPR including bystander, EMS personnel and medical staff at pre-hospital setting was 36.6±13.8 minutes in the ROSC group and 42.4±16.6 minutes in the non-ROSC group (p=0.2472). However, the mean duration for AutoPulse® CPR were 11.9±6.7 minutes in the ROSC group and 18.1±5.2 minutes in the non-ROSC group (p=0.0011). The resuscitation time in the ROSC group was significantly shorter than the nonROSC group using AutoPulse® CPR (Table 2). At the time of hospital discharge, three cases in the ROSC group had survived, whereas the remaining cases in both groups had died.

Fig. 2: The AutoPulse®, an automated LDB chest compression device, prepared on the helicopter stretcher

Discussion The guidelines for advanced cardiac life support (ACLS) and CPA emphasize continuous and effective chest compression as one of the main factors of a successful CPR. However, manual chest compression produces coronary

EMS call

Ambulance arrival

Helicopter arrival

Fig. 3: Transportation of CPA patients using the ambulance and “Doctor-Heli”

AutoPulse® start

Bystander-CPR

Manual-CPR time including bystander-CPR

Paramedic Manual-CPR time

ER AutoPulse®CPR

Physician treatment time At accident-spot or in the ambulance

in helicopter

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Fig. 4: When not in use, the automated chest compression device is stored in the back of the helicopter (blue bag on the right) Fig. 5: The AutoPulse® inside the “Doctor-Heli”: It delivers stable chest compressions, even if flight conditions are not optimal

Table 1: Patients’ demographic data Table 2: Duration from EMS dispatch to CPR

and cerebral perfusion that is 10-30% of normal blood supply (2). If the quality of the manual chest compression is inadequate because of incorrect compression rate, depth and interruptions, blood flow to vital organs – including the heart and the brain – may be more reduced and this correlates with a poor outcome. In order to achieve a better survival rate of critical patients, performing adequate chest compressions with optimal depth and rate as well as minimized interruption might be an important factor relating to a good outcome (3). When the “Doctor-Helicopter” transportation had been chosen, there were some problems regarding the efficiency of chest compression and safety for medical staff in the helicopter because it was difficult for them to perform manual chest compressions in the helicopter while being secured to the seat by a safety belt (see Fig. 6).

The AutoPulse® CPR had several benefits: it was easy to handle, possible to perform continuous and constant ROSC group

Non-ROSC

group P-value

55.1 ± 19.3

66.3 ± 18.9

0.062

male female Cause

12 3

26 8

endogenous exogenous witness unwitness bystander non-bystander

7 8 7 8 8 7

21 13 18 16 16 18

Age (year old) Gender

ROSC group (min) EMS dispatch ∼ EMS personnel arrival EMS personnel arrival ∼ Medical staff arrival Stay at the scene Manual-CPR AutoPulse®-CPR

0.9214

0.3249 0.6855 0.6856

Non-ROSC (min)

P-value

12.7±6.1

16.9±12.9

0.246

19.1±10.0

20.3±11.0

0.7069

16.9±7.8 36.6±13.8 11.9±6.7

18.6±8.2 42.4±16.6 18.1±5.2

0.5047 0.2472 0.0011

quality chest compression, possible to concentrate on patient’s care without having to do manual chest compressions and it was feasible to transport patients on a stretcher (Fig. 2) (4, 5). Moreover, a relatively stable condition of critical patients with CPA could be maintained without relying on inadequate chest compression during a long mission in rural areas.

Conclusion Use of the LDB device AutoPulse® during transportation from the landing point of the “Doctor-Helicopter” to the ER might result in a good outcome for introducing aggressive treatment in hospital. 

Authors: Kazuhiko Omori · Hayato Takei · Masahiko Uzura Department of Emergency and Disaster Medicine, Juntendo University Shizuoka Hospital, Japan

References: 1. Casner M, Andersen D, Isaacs M: The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest. Prehospital Emergency Care 9: 61-67, 2005.

2. Duchateau FX, Gueye P, Curac S, et al. (2010) Effect of the AutoPulse® automated band chest compression device on hemodynamics in out-of-hospital cardiac arrest resuscitation. Intensive Care Med 36: 12561260 3. Krep H, Mamier M, Breil M, et al. (2007) Out-of-hospital cardiopulmonary resuscitation with the AutoPulse® system: a prospective observational study with a new load-distributing band chest compression device.

Resuscitation 73: 86-95 4. Ong MEH, Annathurai A, Shahidah A, et al. (2010) Cardiopulmonary resuscitation interruptions with use of a load-distributing band device during emergency department cardiac arrest. Ann Emerg Med 56: 233241 5. Thomas SH, Stone CK, Bryan-Berge D (1994) The ability to perform closed chest compressions in helicopters. Am J Emerg Med 12: 296-298

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MEDICAL CARE | 49

Mobile Loading System (MLS):

Better quality and more time for patients Transporting intensive-care patients is always a huge challenge for the organisations involved. On the one hand they need to develop a systematic approach to providing uninterrupted treatment and arranging the numerous devices needed for the care of critical patients. On the other hand, they have to incorporate time and quality management strategies to consistently eliminate sources of error and achieve the best possible outcomes. Working closely with doctors, intensive-care specialists and rescue teams, the author developed the mobile loading system (MLS), which aims to bring together these various aspects and guarantee maximum safety when transporting intensive-care patients by air.

The author is the deputy medical director at Flight Ambulance International (FAI), which carries out around 600 patient transport flights every year. As all air ambulance crews, the FAI crew pick up patients from the relevant hospital, transport them to the airport via ambulance, and, once they have reached their destination, transfer them to the hospital there, ensuring that the patient is accompanied by a medical team the whole way. The majority of patients in such bed-to-bed transfers are in critical condition, and thus efficient monitoring throughout is vital to ensure that care is not interrupted. This is particularly important in the case of air rescue operations where cramped conditions, high levels of background noise, visibility, the setup of medical devices, seating, jetlag, turbulence, outdoor-treatment issues, and loading and unloading procedures all place stress on team and patient alike. Teams must monitor patients at all times to be able to react quickly to any changes in their condition.

Given the conditions in an aircraft, the number of medical devices used in air ambulance operations today will always have to be streamlined compared with the number of devices usually used in intensive medical care. Most such devices were primarily designed to meet clinical needs. It is only with the rise in the numbers of specialist hospitals and centres in recent years that they

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have been adapted for use during the transport of critical patients, and technical features such as increased battery life, Bluetooth interfaces, wireless monitoring, better design and invasive pressure monitoring have been systematically added and optimised.

However, there is still no optimal solution that meets all the demands of functional design, size, weight, cable plug arrangement, fastenings as well as the monitoring parameters for patient transport and their display, although there are some promising approaches. This makes it all the more important for medical staff involved in transporting patients to share their experiences on a regular basis.

What does transport mean for the patient and what are the dangers?

For the patient, transport means being removed from a sheltered environment and being exposed to a variety of dangers. Due care should therefore be taken to identify and eliminate known sources of error in routine procedures in good time. For example, the cervical spine of sedated patients should always be stabilised to avoid trauma during transport. Other dangers include cables being torn out, kinks stopping the flow in drainage tubes, patients moving their head during the insertion of ven-

Fig. 1: The majority of patients in bed-to-bed transfers are in critical condition and thus, efficient monitoring throughout the transfer is vital to ensure that care is not interrupted (Photographs: G. Leonhardt) Fig. 2: Transport means being exposed to a variety of dangers and extra care should be taken to identify as well as to eliminate known sources of error

50 | MEDICAL CARE tricle tubes and the resulting danger of blockages or insufficient flow, the tracheal tube moving and ventilation being interrupted, traumas in sedated patients, pressure points (which may impair wound healing significantly) and iatrogenic complications, which can affect the course of treatment.

What are the benefits of transporting patients?

However, patient transport remains necessary and not just on medical grounds. Economic aspects also play a role. If transporting patients to different medical facilities speeds up the reintegration process and helps maintain their quality of life, it is worth undergoing the risks of transport. This notwithstanding, the patient’s condition should not be allowed to deteriorate during transport, but must be maintained or even optimised. A potential worsening of their condition should be ruled out in advance.

The aim is to take the patients to the hospital that can offer them the best possible care for their condition and where they have the best possible chances of recovery.

Repeated moves are not desirable, and any kind of “patient tourism” between hospitals even less so.

What does a patient transport normally involve?

Fig. 3: A large amount of equipment is needed to monitor critical patients and sometimes it is hard for the crew to maintain an overview Fig. 4: The door of an ambulance aircraft presents a bottleneck through which the patient and all the medical equipment has to fit

A large amount of equipment is needed to monitor critical patients (intravenous drips, drains, cables to electronic monitoring devices, blood transfusion bags, indwelling urinary catheters, stomach probes, ventilation tubes and CO2 sensors, central venous catheters and connecting lines, arterial lines, chest drains, defibrillator sensors, pacemaker cables, tracheal tube setups, etc.). Since all of it has to fit into a 190 cm by 50 cm space, it is easy to understand why it is sometimes hard to maintain an overview of what line is feeding in which drug and – if there is a blip on the ECG monitor – whether the ECG leads are still in the right place. Beds and stretchers have to be limited in size. There is not always a place to fasten

devices and drips. In hospitals, these issues do not pose a problem due to the availability of trolleys and IV drip stands. Even in an ambulance there is a relatively wide range of solutions. By contrast, all the difficulties of treating intensive care patients are compounded in a helicopter or fixed-wing aircraft, where the door can already be a limiting factor. And, even more challenging, the crew must – using all kinds of setups and equipment – move the patient into and out of the aircraft.

The particular demands of air rescue Air rescue operations often involve transporting patients in need of intensive medical care, but creating technical solutions for this area often involves a lot of administrative requirements, especially because of airworthiness regulations. In real-life situations it is rare that a patient can be transferred to a hangar before being moved into the aircraft. This process usually takes place in the open and in all kinds of weather conditions. The crews need plenty of helping hands to secure everything. The door of an ambulance aircraft presents a bottleneck through which the patient and all the medical equipment has to fit. The mobile loading system (MLS) brings together all the various supply and monitoring components needed for the patient’s care and allows the setup of tubes, lines and cables to be improved continually, thus enabling transport operations to run more smoothly and potential sources of error to be identified more quickly.

What ideas did you initially come up with?

The first step was to develop cable covers in different colours to help air rescue assistants maintain a better overview. Red was used to mark out IV lines, blue was for monitoring cables and orange was used for the ventilation tubes. The covers also served as safeguards by enabling medical staff to orient themselves in emergency situations. To protect tissues and organs, the devices needed to “hover” above the patient, but they also had to be

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MEDICAL CARE | 51 Fig. 5: The system has to be compact, adaptable for a wide range of devices and compatible with a narrow stretcher with a vacuum mattress or spine board

secured in such a way as to ensure that their position remains fixed during loading and unloading. In addition, the system had to be compact due to space constraints, adaptable for a wide range of devices, sterilisable and compatible with a narrow stretcher with a vacuum mattress or a spine board. It also had to provide the possibility of integrating some kind of protection against pressure sores and enable the patient to be placed in a stable position. The main aim was to be able to monitor critical patients without having to check every single device and oxygen tank individually, and to be able to provide patients the best possible intensive care in cramped conditions. The quality of care is improved because less time is wasted fiddling with equipment, leaving more time for checking the patient’s parameters.

The importance of time management Since a single pilot is generally only allowed to fly up to 12.5 hours at a time, this kind of system is a major advantage for patients. Various tests carried out by FAI showed that transports using the MLS could be up to 45 percent faster than those using conventional transport methods. Bearing in mind that the 12.5-hour time slot has to include preparing the patient for take-off, transporting patients to and from hospitals as well as the duration of the flight itself, time management is very important – particularly on long-haul flights. The MLS is very helpful here, as it ensures that the various devices, cables, IV lines, ventilation tubes and other medical equipment only have to be sorted and arranged once when the patient is picked up from the first hospital. 

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Author: Götz Leonhardt In-flight and intensive care specialist, Deputy medical director, Flight Ambulance International, FAI

Fig. 6: The MLS brings together all the various supply and monitoring components needed for the patient’s care and allows the setup of tubes, lines and cables to be improved continually

52 | MEDICAL CARE

Incident location

Gendarmerie vehicle

Fig. 1: The gendarmerie vehicle can be seen in the foreground and the incident site is also marked (Photographs: Mehmet Gök)

Case Report “Air 1106” responds to a rural scene call in Turkey On 17 May 2011 at 12:42 pm, the helicopter ambulance crew of “Air 1106” was requested by the dispatch center to respond to a patient suffering a gunshot wound in a rural area near the Turkish capital Ankara. “Air 1106” is part of Koçoğlu Air Ambulance Services, which is based in Ankara and operates 17 rotary wing aircraft since October 2008, providing emergency patient transport across the country on behalf of the Ministry of Health of Turkey. Turkey‘s biggest air rescue operator is also part of European aviation network as full member of the EHAC. The incident‘s approximate location was provided by the rescue coordination center, along with the computer coordinates. As the flight team prepared for the mission, a second set of coordinates were provided by the coordination center, based on the rough information obtained from the local gendarmerie units, also trying to reach the incident site. Following the flight plan, “Air 1106”, an AgustaWestland 109 Power – staffed with a double pilot along with a flight doctor and a flight medic team – took off for the location, 45 nautical miles away from the base.

The sky was clear with good visibility during the day.

The flight team arrived at the most recently provided coordinates (at 13:35 pm), but was unable to locate the patient. The injured was reported to be a shepherd, who accidentally shot himself in the chest with a shotgun.

The area of the incident was hilly, separated by deep

canyons. The coordination center was contacted again and transferred the call to the gendarmerie unit on the ground. The gendarmerie unit commander stated, the area of the incident was unreachable by a vehicle, and they were leaving their vehicles in order to hike to the site (see Fig. 1). The commander also stated that the

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MEDICAL CARE | 53

Fig. 2: Smoke came from a small fire made by local people and allowed the “Air 1106” to identify the incident site

injured person was accompanied by a number of locals who reached the area on a horseback after hearing the gunshot, and that they were in communication via cellphones. The “Air 1106” team requested the bystanders to start a small fire to generate smoke in order to make their location more visible to them. Shortly after the request, the “Air 1106” crew was able to locate the smoke, and thus the patient (Fig. 2). The landing time was 13:48 pm.

Upon arrival at the accident site, a 16 year old male was found to be attended by a number of locals, who had provided first aid using their shirts as pads in order to control bleeding, following the directions from the 112-communication center staff. The patient reported that he dropped his shotgun over his shoulder and it fired as the muzzle was pointing the sky. The patient suffered major tissue damage to his right pectoralis major and right axillar region of his body (Fig. 3). Surprisingly, the injuries affected only the surface tissue and the patient did not present with any signs of pneumothorax/hemothorax or shock resulting from a major vessel injury. His initial vital signs were: fully conscious, alert and oriented, with a blood pressure 120/76 mmHg, pulse 110 beats/ minute, respiration 20/minute, SpO2 89% without supplemental oxygen and pain level 10/10. His tachycardic presentation was thought to be the result of pain he experienced.

The patient was quickly loaded into the aircraft after the basic stabilization measures were provided at the scene. Two large bore IVs were started en route. The

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wound site was cleaned and covered with an occlusive dressing. The patient was provided analgesia and sedation with ketamine and midazolam, after full monitorization including continuous waveform capnography measurement was in place (Fig. 4). A total of 500 cc normal saline and 500 cc Ringer’s lactate was infused en route.

The patient’s vital signs upon arrival were: blood pressure 140/110, pulse 85 beats/minute, respiration 16/ minute and SpO2 94% with supplemental oxygen via a non-rebreather mask.

The ground unit met with the “Air 1106” at the base after a flight duration of 28 minutes and transported the

Fig. 3: The patient‘s injuries looked severe: they involved the M. pectoralis major and the arm had to be restored through plastic surgery

54 | MEDICAL CARE

Fig. 4: Treatment continues on board AW 109 Power Fig. 5: Preparing the patient for transfer into the ground ambulance

The author wishes to thank Dr. Mehmet Gök (flight doctor) for his support in writing this case study as well as Orhan Alphan (flight medic) for providing the details of this incident.

patient to a nearby trauma center in Ankara (Fig. 5). Chest surgeons initially treated the patient and inserted a chest tube to the right thorax as a precautionary measure, after X-rays revealed that several small shotgun pellets had penetrated the thoracic cavity. The patient also underwent plastic surgery to repair the functional damage to the right arm. Physiotherapy was provided following surgery to improve the functional strength on the affected side.

The patient was discharged from hospital fully recovered 30 days after the initial presentation. A recent phone interview (15 July 2011) revealed that he had returned to herding cattle in the fields.

The efficient coordination between the dispatch center, gendarmerie units, bystanders and the “Air 1106” allowed this operation to be completed successfully. As seen in

this particular case, starting a fire to generate smoke is an effective way to locate the incident site. As the HEMS system matures in Turkey – which became operational in October 2008 – one can be glad to see the increasing positive impact it makes to citizens’ health. 

Author: Gürkan Özel Chief Flight Medic Training and Quality Officer Koçoğlu Air Ambulance Services Ankara, Turkey rescuemedic@gmail.com

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TECHNOLOGY | 55

Engine protection for the EC135 – Improving EMS Heli Availability EMS helicopters must be ready 24/7 for rapid dispatch to any location. As a result, their missions cannot be delayed or restricted by operational challenges and therefore require a maintenance-free engine protection system. Airborne contamination can create a significant problem for EMS helicopters because their demanding missions mean frequent landings on unprepared grounds – sometimes as many as twenty times a day. Under such conditions, engines can suffer from severe foreign object damage (FOD) – even after just a few flight hours. Other consequences of airborne contamination are loss of first compressor stage or early engine erosion damage.

Helicopter engine air intakes are frequently challenged by the many and various airborne contaminants encountered in flight such as sand, dust, ice, FOD, snow, heavy rain and salt spray. When ingested, these contaminants can seriously affect helicopter safety and availability while driving engine maintenance costs even higher. The Centrisep® Engine Advanced Protection System (EAPS) provides a solution to cope with these threats. It shields the helicopter engine inlet from airborne contamination, which results in: • • • •

Safer operation by protecting against FOD, ice, snow, and rain Reduced pilot workload (No bypass door activation due to filter blockage) Increased operational availability with no significant or noticeable power loss, and Protection against engine erosion

This maintenance-free system is also environmentally friendly. It requires no daily maintenance and there is no need for any oil based cleaning fluids that are difficult and expensive to dispose of.

The Centrisep® EAPS relies on its vortex technology to eliminate particles by centrifugal force before they can enter the engine air intake. It can cope with all environments without any filter blockage or degradation of available power for the helicopter.

The Centrisep® panel consists of hundreds of vortex tubes carefully packaged together. This panel sits immediately upstream of the engine air inlet and contaminated air is drawn through the vortex tubes by the main engine airflow. The vortex tubes induce a swirling motion that causes the particles and water droplets to be thrown outwards radially. The contaminants are then continuously scavenged overboard while the clean air flows through the centre of the tube to the engine air inlet. On the EC135 helicopter, the Pall Centrisep® EAPS design consists of two halves situated on either side of the helicopter, immediately upstream of the engine inlets, plus a rotor mast seal. The EC135 Centrisep® EAPS was qualified in 1994 and has been in service for many years providing advanced engine protection to commercial and military operators around the world. One EC135-operator in Germany commented: “With the Pall Centrisep system, I just remove some small covers and I am quickly ready to fly. With no engine intake protection, it took me much

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Scavenge air with contaminant Clean air out

Vortex generator

Dirty air in

longer to get the helicopter ready, especially on unprepared landing zones.” The installation kit for the EC135 is fully approved for installation under Eurocopter Service Bulletin, Ref. EC135-71-028. 

Author: Olaf Schultz Mechanical Engineer, Key Account Manager, Pall GmbH Aerospace, e-mail: centrisep@pall.com

Outlet tube

Fig. 1: Eurocopter EC135 of ADAC Air Rescue fitted with Centrisep® EAPS – one out of many other protection systems – that has just entered the market (Photograph: D. Bujack) Fig. 2: Centrisep® EAPS principle of operation

56 | TECHNOLOGY

HEDGE trials enhance helicopter approaches In March this year, the European Geostationary Navigation Overlay System (EGNOS) became fully operational and certified for aviation applications. This Satellite Based Augmentation System (SBAS) improves the performance of GPS receivers. It provides an immediate opportunity for airspace users to benefit from increased integrity and position performance, in particular for approach operations. This performance improvement is delivered without any additional airport ground equipment. Therefore it can increase the reliability and continuity of service within low visibility conditions to remote and less equipped airfields and heliports.

Fig. 1: View of PFD and NAV displays during the flight trials (Photographs: Rega)

Innovative helicopter applications For helicopter operations the benefits are significant, as EGNOS provides the capability to realise instrument approach procedures to airfields and helipads that are currently without such capabilities. Over the past few years, flight trials have been undertaken to explore the operational and technical benefits that EGNOS can bring − specifically to helicopter operations. An example is the EU part-funded project HEDGE (Helicopters Deploy GNSS in Europe) led by UK aviation consultancy Helios. HEDGE has been flight trialling new instrument approach procedures specifically for helicopters to take advantage of the new capabilities and performance afforded through EGNOS constellations. This has focused on three different approaches, namely: •

APV SBAS (LPV) approaches − straight-in approaches, in which the final approach segment is aligned with the runway;

•

•

SBAS enabled PinS (Point-in-Space) approaches − in which the helicopter flies to a point-in-space (defined as the missed approach point) and from this point navigates visually; SBAS Offshore Approach Procedures (SOAP) − a new approach concept validated through HEDGE supporting offshore operations around oil and gas platforms.

Of these approaches, the PinS approach potentially provides the most benefit to HEMS operations. The advantage of the PinS approach is that it can be defined to any point-in-space (free of obstacles) from which visual flight can be commenced to the FATO. It also has the opportunity to significantly reduce the Decision Height (DH) when compared to the Baro-enabled PinS approach as defined by ICAO Doc 8168. Within HEDGE, this reduction was illustrated through the implementation at Interlaken, Switzerland. Utilising EGNOS, the instrument approach

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TECHNOLOGY | 57 procedure achieved a DH of 347ft (DA 2221ft), compared to a DH of over 1000ft, when using barometric height for the PinS approach.

Interlaken trials Flight trials were performed at Interlaken by Rega Swiss Air Ambulance. The area was of particular interest for several reasons. The hospital pad is located in uncontrolled airspace in the Berner Oberland between the Lake of Thun and the Lake of Brienz. Interlaken itself is surrounded by high mountains, forming a valley alongside the two lakes. The region is a famous tourist attraction and the hospital serves as the central medical unit, in particular during the winter.

In addition, during the winter months a relatively thin layer of stratus is quite common – although VMC conditions still exist above and below this layer. This phenomenon is also subject to strong north-easterly winds at times and therefore is quite dynamic in nature, despite its placid appearance. Without PinS, two choices exist for the recovery of a person in need of a HEMS helicopter when the stratus is present: • •

The HEMS helicopter rendezvous with an ambulance above the cloud layer for recovery by road, or The helicopter descends through the clouds, currently performed as a VFR descent in VMC through openings in the cloud layer.

Consequently, there is no guarantee of a successful descent resulting in increased workload for the HEMS flight crew as well as a delayed “time to treatment” for the patient. However, the SBAS enabled PinS procedure overcomes this obstacle by providing instrumented guidance through the clouds layer to the visual conditions below. This not only provides savings in fuel and aircraft maintenance to the HEMS operator, but also expedites the transfer of patients to the hospital − potentially saving lives.

Fig. 2: On approach to Interlaken Hospital (canton Bern), Switzerland

PinS implementation The flight trials not only validated the PinS procedure, but successfully demonstrated the technical benefits achieved by lowering the DH and improving the lateral and vertical navigation during the descent. However, for any operator wishing to deploy SBAS PinS approaches in day-to-day operations, some implementation obstacles remain before benefits of safety, operational resilience, business continuity and patient survivability can be realised. These obstacles are currently being reviewed by ICAO, EASA and national regulators to finalise the operational and procedural standards that will enable the widespread deployment of PinS. Ultimately the use of SBAS PinS approaches will decrease the risk of accidents and enable a significant improvement of life-saving helicopter operations under all meteorological conditions. 

Author: Philip Church Helios, 29 Hercules Way, Aerospace Boulevard, AeroPark, Farnborough, Hampshire, GU14 6UU, UK philip.church@askhelios.com Fig. 3: Flight trials were performed by Rega Swiss Air Ambulance

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58 | TECHNOLOGY

Air Rescue PPE Project: Developmental work for more security and comfort In the past, only scant attention was paid to the protective gear worn in air-rescue services, and the clothing itself often seemed somewhat old-fashioned. Unlike the criteria for personal protective equipment (PPE) for ground-rescue crews, which have long been established by the accident insurers’ safety and health protection regulations (GUV R-2016), protective clothing for use in air-rescue services has not been dealt with or clearly defined so far. Appropriate guidelines and recommendations are planned for the future. of helicopter due to weight constraints. Measurements have shown that temperatures can rise to up to 60°C, resulting in the risk of dehydration, poor concentration, and enormous physiological strain. Thus there is an urgent need for action purely from a flight-safety perspective. A further example is found at air-rescue helicopter bases involved in mountain rescue. Since harnesses must be worn during rescue operations, clothing should be made of stretch materials to ensure adequate comfort and thigh pockets should ideally be positioned and designed in a special way.

Close links

Fig. 1: PPE-clothing must meet higher protection requirements and multiple additional criteria (Photos: LRZ Christoph 17, Kempten)

Multiple additional requirements Many different types of clothing have been worn in air rescue services to date. However, the most common type is flight suits patterned on those worn in the US Air Force.

With the exception of the material used, which is nowadays mostly made of flame-retardant aramid fibres such as Nomex®, they have changed little since the 1970s. In addition, vests, jackets and trousers from commercially available outdoor clothing are often worn.

A combination of various factors, such as a lack of high-visibility features, insufficient protection against environmental factors during flights and at rescue sites, poor thermal regulation properties and a lack of recognition value and comfort, motivated the HEMS crew members (HCM) and the Bavarian Red Cross Oberallgäu, which funds the Christoph 17 Air Rescue Centre Kempten/ Allgäu, to tackle this challenge and try to find a satisfactory solution by designing new protective gear from scratch.

Naturally, this raises the question of why standard rescue-service PPE cannot be used in air-rescue services.

Granted, such clothing would in principle comply with the required norms and regulations. However, a closer look reveals that clothing suitable for air rescue must meet higher protection requirements and multiple additional criteria. The extraordinarily high peak temperatures faced by helicopter crews during the summer months are an example. Air conditioning cannot be installed in most types

The process started with a round-table meeting at the Kempten Air Rescue Centre over three years ago. The participants quickly recognised that further external expertise was needed for this type of project. It was evident that this could only be realised by creating close links between various experts such as the textile research and testing institute Hohenstein Laboratories, the umbrella association of German Social Accident Insurance (DGUV), and a highly experienced protective clothing manufacturer like Pfanner Schutzbekleidung. In addition, the Traunstein Air Rescue Centre, the Kassel Air Rescue Centre, the company EVG and the Federal Police Aviation Group were also involved.

The initial aim was to design an all-round, “jack-of-alltrades” garment that would cool wearers in the summer, keep them warm in the winter, be waterproof and withstand all potential hazards in air-rescue services – and look good at the same time, of course. Taking all these varied factors into account, those involved soon realised that this was simply impossible, even if the very best materials were used.

Following initial discussions, the members of the expert group identified a need to produce a hazard analysis specifically for air-rescue operations. This hazard analysis was discussed and produced in cooperation with the DGUV and representatives of the German air-rescue providers (the Federal Office of Civil Protection and Disaster Assistance, DRF Luftrettung and ADAC Air Rescue). The findings of this analysis then served as the basis for the necessary performance parameters in the catalogue of requirements for new PPE. The demands and needs of airrescue workers were a further key component. Many of the requirements they stated and features they suggested were implemented, including padded and waterproof knee

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TECHNOLOGY | 59 guards, ventilation panels in trousers and jackets, integrated pockets for mobile phones and beepers, claps for pens and intercom clips, and compatibility with safety harnesses.

The most important demands in the catalogue of requirements were: • • • • • • •

Maximum ergonomic comfort Removable layers for temperature regulation High visibility in accordance with DIN EN 471, Class 3 Compliance with health and safety regulations as per GUV R 2106, TRBA 250, EN 340 EC Directive on PPE with CE marking (“Conformité européenne”) Compatibility with flight operations (visual flight rules for night flights, no reflectivity) Compatibility with the hazard assessment

Various PPE-clothing prototypes were ordered for the trial phase. Finally, Pfanner Schutzbekleidung was commissioned to develop different prototypes in cooperation with Kempten Air Rescue Centre. Pfanner is a clothing manufacturer based in Hohenems/Austria with 20 years of experience in producing protective clothing for extreme conditions that specialises in making clothing for use in forestry, fire brigades, mountain rescue, rescue services, police and industry.

Figs. 2-4: Requirements and features of the PPE include, among other things, ventilation panels in trousers and jackets, integrated pockets for mobile phones and beepers

Development phase Extensive trials and washing tests were conducted during the following phase. The findings and insights obtained were constantly incorporated into the further development. When it came to choosing materials, only hightech textiles with daylight-fluorescent, thermoregulatory and stretch-material properties were used. Making these materials compatible with washing at 60°C in clinical laundering procedures (in line with the Robert Koch Institute’s guidelines for application areas A+B) was initially one of the biggest obstacles. However, thanks to various experimental modifications of the materials and components used, appropriate solutions were found and a most satisfactory result was achieved. The development, testing and certification process took three years. Looking back, the road was pretty challenging!

The final version of the new PPE was extensively tested by Hohenstein Laboratories. The certificate issued proves that the tested clothing complies with the essential requirements of Directive 89/686/EEC on PPE, Appendix II, and is suited for use as high-visibility clothing in accordance with DIN EN 471:2008-03 (EN 471:12003+A1:2007) in rescue services.

Figs. 5: Clothing for helicopter mountain air rescue is basically made of stretch-material, it often features padded knee guards and is compatible with safety harnesses

acceptance for the PPE and identification of staff with their workplace. Unfortunately, this is not so often the case in Germany, particularly for ground-based rescue-service providers. The reality is that cheap clothing manufactured in Asia is often used that does not really comply with the protection targets of GUV safety and health protection regulations and norms. In this respect, a fundamental change in thinking on the part of the rescue-service operators and funders would be highly desirable.

The majority of the air-rescue centres whose representatives attended the presentation indicated they would switch to the new protective clothing in the near future.

The design also convinced the DRF Luftrettung, which equipped the staff of the new air-rescue centre established in Weiden on 1 April 2011 with the new PPE. 

Successful presentation The now certified PPE was presented at the most recent annual meeting of representatives of German civil protection helicopter bases, and the presentation by the author of this article, who co-developed and initiated the Air Rescue PPE project, was very positively received.

Rather than only on financial aspects, this project also focused on the satisfaction and well-being of staff. This was regarded as a key to ensuring the greatest possible

2 · 2011 I Vol. 1 I AirRescue I 59

Author: Gerhard Frey HEMS Crew Member (HCM), EMS trainer, Christoph 17 Kempten/Allgäu Air Rescue Centre, Bavarian Red Cross Oberallgäu District Office, Unterthannen 6a 87477 Sulzberg/Allgäu, Germany gerhard.frey@online.de

60 | RULES AND LAWS

Strategies to reduce U.S. HEMS accidents Helicopter emergency medical services (HEMS) provide life-saving transports for the critically ill or injured. However, the rising number of U.S. HEMS accidents over the past decade is cause for serious questions as to their operational safety. For this reason a national effort is underway to reduce HEMS accidents. This article discusses firstly the unique risks that exist in HEMS operations, secondly methods that identify and quantify these risks and finally three major mitigation strategies that are being implemented in the U.S. in order to reduce future HEMS accidents: the OSI-HEMS Research Project, the No Pressure Initiative, and the National EMS Culture of Safety Strategy.

HEMS Operational Risks

Fig. 1: Various mitigation strategies in order to reduce HEMS accidents include the “OSI-HEMS Research Project”, the “No Pressure Initiative”, and the “National EMS Culture of Safety Strategy” (Photographs: W. Winn)

The number of annual U.S. HEMS accidents shows a bimodal distribution over the past four decades (Figure 2).

Although concern about U.S. HEMS accidents have been present since the first fatal accident occurred in 1976 (15), a record number of fatal HEMS accidents in 2008 has again raised major questions about the safety of U.S. air medical operations (6-8). Because reporting risk exposure statistics (i.e. number of transports, flight hours, take-offs and landings) for U.S. operators is voluntary, determining past accident rate data for HEMS operations has been difficult. It is only recently that U.S. operators have begun

to share risk exposure data. In the future, the U.S. Federal Aviation Administration (FAA) may require HEMS operators to collect and report this information.

To normalize HEMS data, numbers of HEMS accidents have been adjusted for number of flight hours. Except for a spike in 2008 (1.80 fatalities /100,000 flight hours), the HEMS fatal accident rates are similar to general aviation and air taxi flights (1.18 fatalities/100,000 flight hours [9]). However, when the number of HEMS fatal accidents is normalized for number of workers, an alarming statistics appears. In 2008, air medical crew member had an 8-fold fatality rate (164 deaths/100,000 workers) when

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RULES AND LAWS | 61 compared to police (21 deaths/100,000 workers). This death rate exceeded all other recognized hazardous professions including fishing crews (111 deaths/100,000 workers), loggers (86 deaths/100,000 workers) and miners (24 deaths/100,000 workers [10]). This high number of 2008 HEMS fatalities/100,000 workers made HEMS operations one of the most dangerous professions in the United States.

Even with improvements in HEMS accident data collection, care must be taken in making any direct comparison of the accident rates (i.e. accidents/100,000 flight hours) of medical helicopters with the major airlines or with other types of helicopter operations. There are several reasons why such comparisons are inappropriate: •

•

First, medical helicopters typically conduct their flights outside of the system of established federal airways, at relatively low altitudes, and in an environment that lacks an infrastructure to accommodate flight under instrument flight rules (IFR). A critical deficit in that infrastructure is the lack of reliable en route weather reporting, which increases the likelihood of encountering inadvertent meteorological conditions.

Second, there is the added pressure for helicopter medical teams to be airborne within minutes of receiving a flight request. In addition, pilots are sometimes expected to launch a flight in the general direction of an accident scene with an expectation of receiving more precise information about the destination after take-off. In many cases, the actual physical characteristics of the landing zone are unknown until the aircraft arrives and surveys the location from the air.

Considering the many unknown and sometimes unpredictable circumstances associated with HEMS flights, it seems evident that many, if not most of these flights entail greater risks than any other kind of helicopter flight operations, with the possible exception of aerial application (crop dusting) or military flying in actual combat.

It should be made clear that even though HEMS operations entail a high level of risk, it does not necessarily follow that HEMS operations cannot provide a level of safety similar to other types of commercial flying. The extent of danger associated with any kind of operation is dependent not only on the risks that are present, but also on the degree to which those risks are recognized and mitigated by pilots and by Safety Management Systems (SMS) designed to reduce these risks. Simply stated, to reduce future HEMS accidents, the risks specific to helicopter air medical operations must be identified, quantified and effective controls must be implemented to eliminate or mitigate those risks.

Identifying and quantifying HEMS risks Ideally, the identification and mitigation of HEMS risks should be proactive (i.e. before an accident), have high inter- and intra-rater reliability, be stable over time, and have associated mitigations that are easily implemented.

Proactive: Brainstorming is one method for identifying risk factors and defining pre-emptive strategies to prevent accidents. Brainstorming leads to the identi-

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fication of a large number of possible risks and subsequent mitigation strategies. The downside of brainstorming is that neither the risks nor the mitigation strategies can be easily quantified. As a consequence, all risk factors and their associated mitigation strategies tend to be treated similarly.

Inter-rater reliability: There should be fairly high agreement among HEMS pilots and other knowledgeable informants regarding what the operational hazards are and the magnitude of the risks associated with each. The same is true of the mitigations that are paired with each hazard identified.

Stable over time: For retrospective analyses, the identification and quantification of hazards for the earliest cases examined should apply with equal validity to the most recent events, except for where improvements in technology or changes to regulations may eliminate an earlier hazard altogether.

Mitigations should be easily implemented. Interventions that are excessively complex or prohibitively costly are unlikely to be implemented by air medical organizations or consistently practiced by aircrews.

Fig. 2: U.S. HEMS accidents and fatal accidents by year (modified and reprinted courtesy Dr Ira Blumen)

Fig. 3: HEMS flights, it seems, entail greater risks than any other kind of helicopter flight operations

62 | RULES AND LAWS

Fig. 4: Identification and mitigation of HEMS risks should be proactive, have high inter- and intra-rater reliability, be stable over time and have associated mitigations that are easily implemented

Given the shortcomings of a proactive analysis as described above, detailed root cause analysis of available accident investigation data is currently the preferred method for identifying and quantifying both immediate and latent accident risk factors. Quantifying risk factors and mitigation strategies enables the performance of cost efficacy analyses. Following implementation of selected interventions, a subsequent value analysis can then be performed to validate the optimal means for controlling risks in terms of effectiveness and costs.

The International Helicopter Safety Team (IHST) has developed one of the best investigational tools for accident analysis (11). It is modeled after the Commercial Aviation Safety Team (CAST) which achieved a significant reduction in U.S. commercial accidents. This tool analyzes accident data obtained from official investigative agencies (i.e. NTSB, FAA, CAA, BFU). The IHST tool identifies causative factors or events that may have contributed to the accident. The events may have been human errors (mistakes), improper actions (bad choices), or failures to act (omissions). During the analysis, one or more Standard Problem Statements (SPS) are assigned to each event.

The set of Standard Problem Statements constitute a taxonomy of accident factors with assigned numerical codes. Codifying accident factors this way permits the aggregation of related or similar risk factors. Statistical comparisons of this aggregate data can then be used to identify high value causative factors, and thus high value mitigation strategies. Indices of validity, importance and probability (VIP) are then assigned to each SPS to quantify the degree of causality and the probability that such an error or omission could lead to a future accident.

After a timeline of causal events (SPS) is determined and then qualified in terms of validity, importance, and probability for future harm (VIP), each SPS is then matched to one or more standardized intervention and mitigation strategies (IMS). Each assigned IMS is then rated on a 5-point scale for both their effectiveness (E) and feasibility (F) in mitigating the associated SPS. At this stage of the evaluation of mitigation strategies, cost is not considered in rating an IMS for feasibility.

This analysis tool has been used by the Helicopter Safety Analysis Teams in the U.S., Canada and Europe to perform analyses of the root causes of helicopter accidents in their respective areas of operation. It should be no surprise that a comparison of the results of the tool in those areas of the world show significant similarities – with Pilot Judgment, Situational Awareness, Safety Management, and Preflight Planning being top issues for each of those areas of the world. Data issues, that is a lack of data in the accident investigation reports, was also a major issue in each of those geographic areas (12).

The OSI-HEMS Research Project In January of 2008, a research project titled “Opportunities for Safety Improvement in Helicopter Emergency Medical Services” (OSI-HEMS) was initiated under the direction of Dr. Ira Blumen of the University of Chicago Air Medical Network. Dr. Blumen is a well-known advocate for the analysis and improvement of safety in air medical operations. His 2002 publication, entitled “A Safety Review and Risk Assessment in Air Medical Transport” is considered a landmark analysis of U.S. HEMS accidents (13).

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RULES AND LAWS | 63 The OSI-HEMS project is a unique application of the US JHSAT analysis tool in that it has gathered together over 40 professionals from all roles in the US air medical transport industry to perform the analyses. It includes pilots, nurses, paramedics, physicians, a respiratory therapist and an air medical communications specialist, along with representatives from major HEMS operators, the FAA, manufacturers and insurance experts. Expert aircraft maintenance technicians have also been consulted whenever needed for the review of a specific accident report. To better analyze HEMS accidents, the OSI-HEMS team modified the IHST tool to incorporate pertinent HEMS risk factors. The diverse constituency of this group has assured that, for any SPS associated with any accident report analysis, there will be at least one member of the group with expertise in that area.

The group also has at least one representative from each of the professional associations that make up the US air medical community. Those associations include the Association of Air Medical Services (AAMS), the Air Medical Physicians Association (AMPA), the Air and Surface Transport Nurses Association (ASTNA), the International Association of Flight Paramedics (IAFP), the National Association of Air medical Communications Specialists (NAACS), the Air Medical Operators Association (AMOA) and the National EMS Pilots Association (NEMSPA). Funding for the project has come from MedEvac Foundation International (formally the Foundation for Air medical Research and Education), from the Flight Safety Foundation, from air medical operators, professional associations and manufacturers.

Over the past 3 years, the OSI-HEMS research group has expended more than 12,000 man-hours to analyze nearly 12,500 pages of NTSB reports involving 144 U.S. HEMS accidents during a period from 1998 to 2010. The research group has finished the review, identified root causes and recommended mitigation strategies to prevent future accidents. An update of the OSI-HEMS project findings will be presented at the Air Medical Transport Conference in St. Louis, Missouri on 18 October 2011. Final publication of the OSI-HEMS report is expected next year.

Figure 5 illustrates the top causes of HEMS accidents identified by the OSI-HEMS project.

No Pressure Initiative (NPI) Perhaps the most disturbing of HEMS accidents are those that occur when a perfectly fit pilot flies a perfectly airworthy aircraft into the ground or into a ground-based obstruction, killing all on board without any premonition of what was about to occur. Controlled Flight Into Terrain (CFIT) accidents typically occur during conditions of darkness, marginal weather, or both. One of the authors (WTW), after reviewing NTSB reports for HEMS accidents from 1998 to 2008, identified 31 CFIT accidents that occurred during the en route phase of flight, claiming 79 lives.

Lack of experience does not appear to be a major factor in these CFIT accidents. The pilots involved were 47 ± 9.8 years old, had an average of 5178 ± 2867 hours of rotor wing flight experience, and an average of 695 ± 991

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hours in the make and model of helicopter involved. Flying in marginal weather conditions was involved in nearly all of these CFIT accidents. The large standard deviations for helicopter flight experience and time in make and model indicate a broad range of pilot experience for the 31 pilots involved in these CFIT accidents. The question of how these accidents could have been prevented must be preceded by the question of why qualified pilots were continuing to fly into conditions that were marginal at best and below the legal minimums in many cases.

In 2009, following the worst year in history for fatal U.S. HEMS accidents, the National EMS Pilots Association (NEMSPA) conducted a preliminary survey of the air medical industry to identify the factors that might pressure HEMS pilots and crew members to push the limits of safety. This survey of more than 250 HEMS pilots in the U.S.A. found that one-in-three respondents was susceptible to “internal” pressures and one-in-four pilots admit to feeling “external” pressures to fly in questionable weather conditions. The results of this survey prompted NEMSPA to promote a mitigation strategy initially dubbed the “No Pressure Initiative” or “NPI”. This initiative consists of three important elements that should be part of a HEMS provider’s risk management portfolio: 1. a safety-minded organizational culture, 2. the use of a formal preflight risk assessment tool to evaluate flight risks, and 3. the implementation of an en-route decision protocol (EDP) to assist pilots in determining when conditions are no longer safe for continued flight (Figure 6).

A Safety-minded Culture A “Safety-minded culture” is the first element of the NEMSPA “No Pressure Initiative”. It is recognized that organizational culture significantly influences decision-making.

Understanding the influence of cultural conditioners is critical in the implementation of any risk mitigation strategy. A safety-minded culture is based on the principles of a “Just Culture” (15-17) and incorporates effective techniques of Air Medical Resource Management (AMRM) as well as Aviation Decision Making (ADM). The influences of external pressures such as the patient’s condition or program financial pressures are recognized and controlled so that they do not affect in-flight decision-making.

Fig. 5: Top SPS categories from OSI-HEMS review of 142 HEMS accidents (reprinted with permission of Dr Ira Blumen)

64 | RULES AND LAWS psychological factors that can lead to pushing the limits of safe operations.

Pre-flight Risk Assessment

Fig. 6: NEMPSA “No Pressure Initiative” (modified and reprinted with permission of NEMPSA)

The CHAMPS survey HEMS operators are encouraged to validate their perceptions of their organizational culture by participating in the ‘Cultural Health Assessment and Mitigation Program for Safety’ (CHAMPS) survey. The survey evaluates the safety culture from the perspective of different disciplines (i.e. pilots, nurses, paramedics, mechanics, administrators etc.) within a HEMS provider organization.

The CHAMPS survey will be administered, analyzed and reported as aggregate data by an objective third party entity to protect respondent anonymity. Participating in this survey will enable HEMS programs to determine if cultural malignancies exist within their own organization.

Participating HEMS providers will be able to compare the anonymous responses from their own program with the aggregate responses from the air medical industry. Mitigation strategies can then be implemented to address any problems revealed by the survey. Participating air medical programs will have an option to repeat the survey at a later date to determine the effectiveness of their implemented mitigation strategies.

The CHAMPS survey has received strong endorsements from U.S. air medical community leaders and associations. The survey is expected to serve as a complement to the results of the OSI-HEMS research project by addressing the subjective, inter-personal, and individual

The second NPI element is the use of a formal ‘Pre-flight Risk Assessment’ (PRA) tool before a HEMS flight is accepted. An effective pre-flight risk assessment must incorporate those elements of risk that are known to be factors in HEMS accidents. It should also generate a mission-specific index of risk that would require that a pilot consult with another pilot or with a higher level of aviation management (e.g. Chief Pilot, Director of Operations or some other person with operational control) before making a decision on whether or not to accept a flight under conditions of elevated risk. Finally, use of the pre-flight risk assessment tool should be monitored by program managers to ensure that the PRA is applied appropriately and consistently. The Commission for Accreditation of Medical Transport Services (CAMTS) has recognized the Pre-flight Risk Assessment as a best-practice, and the FAA is on the threshold of mandating the use of a Risk Assessment prior to any HEMS flight.

The PRA tool is used to assess flight risk factors such as pilot experience, weather, night vs. daytime operations, local vs. non-local flights, familiar vs. unfamiliar terrain, fatigue factors, and knowledge of a prior pilot turn-down for the same transport. Numerical scores are applied for each factor.

Figure 8 is an example of a Pre-flight Risk Assessment tool. To calculate a total score on the PRA, each risk factor is scored individually and then the individual scores are summed. The higher the total PRAS, the greater is the perceived flight risk. For many HEMS agencies, scores exceeding a given threshold may require approval by or consultation with someone outside of the immediate flight team (i.e. another pilot, a pilot manager, or an operational controller).

En route Decision Point (EDP) Protocol The En route Decision Point (EDP) protocol is the third and final element of the No Pressure Initiative (19). It is an effective intervention that a handful of pilots have used as a personal procedure for years in order to avoid inadvertently entering into instrument meteorological conditions. The EDP is analogous to the decision height on an ILS approach. As the cloud ceiling and/or flight visibility drops, a helicopter pilot will instinctively descend to a lower altitude in order to maintain visual contact with the ground and reduce airspeed to permit the observation of obstacles in time to avoid a collision. For HEMS pilots in the U.S., the EDP would be triggered whenever the in-flight conditions would cause the pilot to descend below the minimum en route cruise altitude specified by FAA Operations Specification A-021 (20), or would cause him to slow his airspeed below an established limit (e.g.

90 knots of indicated air speed). At that point, the pilot would be required to select one of the following options: 1. Divert to better conditions, if possible.

2. Climb and request an IFR clearance, provided all requirements for IFR flight can be met.

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RULES AND LAWS | 65

3. Abort the flight and return to the point of departure, provided the weather along that route is still legal.

4. Land as soon as possible and call for assistance.

Continuing the flight into conditions that are below the established minimums would not be considered an option in any circumstances.

Fig. 7: Another NPI element is the use of a formal ‘Pre-flight Risk Assessment’ (PRA) tool before a HEMS flight is accepted and it must incorporate those elements of risk that are known to be factors in HEMS accidents

National EMS Culture of Safety Strategy In June of 2011, under a three-year cooperative agreement between the U.S. National Highway Traffic Safety Administration (NHTSA), the Health Resources and Services Administration’s (HRSA) EMS for Children (EMSC) Program, and the American College of Emergency Physicians (ACEP), the National EMS Culture of Safety Strategy project gathered together representatives from national EMS and fire organizations across the U.S. to begin developing a strategy for the establishment of a nationwide EMS culture of safety. During the 2-day conference in Washington, DC, participants from all roles in emergency medical services discussed the current challenges to safety in the EMS community and defined goals that must be established to attain a truly effective safety culture for EMS providers. During the coming year, the project steering committee will process the feedback generated by those 2 days of brainstorming and formulate a broad, strategic plan to address the risks present in the cultures of EMS provider organizations across the nation. In the

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Fig. 8: An example of a U.S.Pre-flight Risk Assessment tool

66 | RULES AND LAWS Conclusions The factors that combine to elevate the risk in emergency medical patient transport operations include the acuity of the patients, the mindset of the providers, economic pressures, a lack of accepted standards, and lax oversight (when there is any oversight at all). Those factors are compounded by the special risks that exist in the environment of HEMS operations. With proper mitigation strategies, HEMS accident numbers can be reduced.

Three new and important mitigation strategies are the OSI-HEMS Research Project, the NEMSPA No Pressure Initiative and the National EMS Culture of Safety Strategy.

These three strategies have great potential in providing major insights and possible solutions for reducing future HEMS accidents. Only time will tell how effective these interventions will be. 

Authors: William Winn Safety Officer, Intermountain Life Flight, Salt Lake City, Utah, General manager for the National EMS Pilots Association Fig. 9: All three strategies presented have great potential in providing major insights and possible solutions for reducing future HEMS accidents

summer of 2012, the larger group of participants will again convene in Washington DC to refine the blueprint for the strategy. As the project moves forward, the best pathways to take to achieve the goals will be determined and guidelines for implementation will be provided to the nationwide EMS community.

References: 1. NTSB Report (1976) LAX76AL097. First civilian HEMS accident. Loma Linda University, San Bernardino, CA 2. Helliker K (2005) Safety record of air ambulance industry under scrutiny. Wall Street Journal March 4 3. HAI (2005) Improving safety in helicopter emergency medical service (HEMS) operations. Rotor 2005 (Fall): 30-33 4. Bledsoe BD, Smith MG (2004) Medical helicopter accidents in the United States: A 10-year Review. J Trauma 56: 1325-1329 5. Baker SP, Grabowski JD, Dodd RS, et al. (2006) EMS helicopter crashes: What influences fatal outcome? Ann Emerg Med 47: 351-356 6. Worth T, Elgin N (2009) Medevac crashes on the rise.

AJN 109: 27-28 7. FAA Fact Sheet-Helicopter Emergency Medical Service Safety (2010) http://www.faa.gov/news/fact_sheets/ news_story.cfm?newsId=6763 8. Greene J (2009) Risking helicopter crash deaths spur debate over proper use of air transport. Annals of Emergency Medicine 53 (3): 15A-17A 9. Head E (2009) NTSB Hearing on HEMS – Day 4 Report.

Vertical, February 6. http://www.verticalmag.com/control/news/templates/?a=9911 10. Blumen IJ (2009) An analysis of HEMS accidents and accident rates. Presented at the NTSB Public Hearing: HEMS accidents. February 2009 11. Downey DA (2008) The International Safety Team (IHST).

Heliprops 20 (3): 1

Frank Thomas Adult Medical Director, Intermountain Life Flight, Salt Lake City, Utah Kent Johnson Chief Pilot, Intermountain Life Flight, Salt Lake City, Utah

12. Presentation by JHSAT-Canada at the IHST Fourth International Helicopter Safety Symposium in Estoril, Portugal (2010) slide #17, accessed at: http://www.easa.eu.int/ essi/documents/EHEST_IHSS2010_Day1_RU_13Canad aJHSATPresentation2010.pdf 13. Blumen IJ, Coto J, Maddow CL et. al. (2002) A safety review and risk assessment in air medical transport. Air Medical Physician Handbook, Special Supplement: 1 www.ampa.org 14. Johnson K. (2009) NEMSPA “No Pressure Initiative”.

Rotor Fall: 22-23 15. Griffith KS (2009) The growth of a just culture. The Joint Commission Perspectives on Patient Safety 19 (12): 8-9 16. Griffith KS (2010) Error Prevention in a Just Culture: Avoiding Severity Bias. The Joint Commission Perspectives on Patient Safety 10 (3): 7-8 17. Griffith KS (2010) Error Prevention in a Just Culture: System Design or Human Behavior. The Joint Commission Perspectives on Patient Safety 10 (6): 10-11 18. Thomas F, Groke S, Handrahan D (2011) Intermountain Life Flight Preflight Risk Assessment Score and Transport Outcomes. Air Medical Journal 30 (1): 49-54 19. Orgill R (2010) En-route decision point protocols: When discretion is the better part of valor. Air Medical Journal 29 (5): 250-252 20. FAA Operations Specification A-021 applies to all air medical providers in the United States and specifies a minimum en route altitude of 300 feet above the highest obstacle (AHO) on the route of flight during the day, and 500 feet AHO at night

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