AirRescue Magazine 2/2012 by Verlag Stumpf & Kossendey

ReGa: 60 th anniveRsaRy

Airrescue InternatIonal aIr rescue & aIr ambul ance

M A g A zine

safety

Managing Fatigue in HEMS

Technology

EGNOS Benefits

Medical Care

Video Laryngoscopy

ISSUE 2 | Vol. 2 | 2012

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AN 37 02-2012/A-E

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KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: info@karlstorz.de KARL STORZ Endoscopy America, Inc, 2151 E. Grand Avenue, El Segundo, CA 90245-5017, USA, Phone: +1 424 218-8100, Fax: +1 800 321-1304, E-Mail: info@ksea.com KARL STORZ Endoscopia Latino-America, 815 N. W. 57 Av., Suite No. 480, Miami, FL 33126-2042, USA, Phone: +1 305 262-8980, Fax: +1 305 262-89 86, E-Mail: info@ksela.com KARL STORZ Endoscopy Canada Ltd., 7171 Millcreek Drive, Mississauga, ON L5N 3R3, Phone: +1 905 816-4500, Fax: +1 905 858-4599, E-Mail: info@karlstorz.ca www.karlstorz.com

e dI torI a l Dear colleagues and friends, Time flies and so I have been asked to write a second presidential editorial. It was recommended that I provide readers with more information about myself. Here we are, then: EHAC has had three Presidents. I am the second EHAC President to have been born in the Czech Republic; the first was Gerhard Kugler. I am also the second President to have studied Law; the first was Christoph Breitenbach. Could it be that being born on Czech soil and studying Law are the definitive qualifications for this position? I don’t think so. Since 1993, I have worked in a leadership position for the first non-governmental HEMS operator in the Czech Republic – Alfa-Helicopter. I began flying in 1994, and I now have more than 10 years’ experience as a helicopter pilot in HEMS. As a 14-year-old boy who suffered a serious skiing injury, I know how slow and unpleasant a journey to hospital can be. At the same time, I was able to experience the health care environment from the other side. Hence my strong pro-patient and pro-medical viewpoint, which is accompanied by a love of flying. In my work, I have stood several times next to damaged or destroyed aircraft and spoke with the pilots who made the mistake. These people are close to me, so I listened to them very carefully. Hence my belief in the need for proactive safety management and an emphasis on the human factor. Finally, I am aware that my election was partly due to ‘geopolitical reasons’, but I secretly believe that my major supporters also saw in me a qualified person. The new EHAC board quickly got down to business. We have succeeded in harmonising the

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approach of the New EHA and EHAC in the case of Flight and Duty Time Limitations. At EASA’s preliminary hearing on this issue, EHAC was represented by prominent experts: Daan Remie from ANWB and Urs Nagel from Rega. I would like to thank both of them for this. Along with my colleague Denise Eikelenboom, I attended a meeting with the Chairman of the New EHA, Vittorio Morassi, and we started intensive ‘meditations’ on the closest possible cooperation between our two organisations for the benefit of helicopter operations in Europe. I personally believe that both organisations will work together very closely in the future and I am ready to personally contribute towards this. From 6th to 8th May, the Kick-off Meeting for the AIRMED 2014 Scientific Committee took place in Rome, attended by experts from around the world. All have made it clear that they are ready to work together to create a Scientific Program of the highest quality, which is paramount for the Congress. Here I must thank my colleagues, Erwin Stolpe and Stefan Becker, for their work done in preparing and conducting the meeting. In mid-May, the first regular board meeting of the new EHAC Board took place in Munich. The meeting was very intensive, and amongst the most important decisions was the agreement on organising the Strategic Planning Meeting, along with considerations regarding organising the annual EHAC AGM together with the new EHAC Symposium, and the election of the Vice President. With regard to the Strategic Planning Meeting, we want to create a vision for our work spanning the entire term of the new Board and

a more detailed plan for 2013. In the same year, we want to organise the first EHAC symposium. The main topic will be safety. Finally, our dear colleague, Denise Eikelenboom, was elected EHAC Vice President. To this I add my warmest congratulations. At the Board Meeting I also talked to the representatives of AirRescue Magazine, Christoph Kossendey and Peter Poguntke. During the discussions, there was an overwhelming consensus on the importance of this magazine for the HEMS community. Both the publishers and the EHAC Board are ready to contribute towards continuously improving the quality of the magazine and its distribution. An Editorial Board of experts from our community will be created. Both sides look forward to further cooperation. And finally, leaving the best news until last, a small contribution to the diversity of the magazine will be that Denise Eikelenboom, EHAC Vice President, will welcome you in the next edition’s vice-presidential editorial. Wishing you all a wonderful summer!

Yours sincerely,

Pavel Müller President of the European HEMS and Air Ambulance Committee

72 | contents

Airrescue InternatIonal aIr rescue & aIr ambulance

ISSN: 2192-3167 Publisher: L. Kossendey Verlagsgesellschaft Stumpf & Kossendey mbH Rathausstraße 1 26188 Edewecht | Germany service@skverlag.de Tel.: +49 (0)4405 9181-0 Fax: +49 (0)4405 9181-33 www.airrescue-magazine.eu Medical Advisor: Dr Erwin Stolpe Medical Director EHAC

Managing exhaustion: Rega’s FRM system U. Amann

Editor-in-chief: Dr Peter Poguntke Tel.: +49 (0) 711 4687470 Fax: +49 (0) 711 4687469 E-Mail: poguntke@airrescue-magazine.eu Editors: Tobias Bader Tel.: +49 (0)4405 9181-22 E-Mail: bader@skverlag.de Klaus von Frieling Tel.: +49 (0)4405 9181-21 E-Mail: frieling@skverlag.de Christoph Kossendey Tel.: +49 (0)4405 9181-14 E-Mail: cko@skverlag.de Marketing · Advertising · Subscription Ch. Niemann Tel.: +49 (0) 4405 9181-16 Fax: +49 (0) 4405 9181-33 E-Mail: sales@airrescue-magazine.eu Subscription Rate: Europe: (Shipping included) World: Price per Issue: (Shipping not included)

Rega’s eventful history: 60 years of airborne medical assistance S. Drolshagen

Realising EGNOS benefits in HEMS operations P. Church

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Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF Production and Design: Bürger Verlag GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany

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

DLR helicopter research from a HeMs perspective: Milestones and challenges K. Pahlke

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contents | 5

46 06 11

The more you see, the more you know: benefits of ultrasound in prehospital patient-centred care T. Kaneko, W. Heinz, G. Conrad

news

DOa at DRF Luftrettung: Creative minds with their own ideas S. Redwanz

The Risk of Fatigue – Myron B. Laver international Postgraduate Course U. Amann

saFeTy

“Golden Hour Box” and “Cool Car”: London’s air ambulance with medical innovation – not only for HeMs Editorial Team

MeDiCaL CaRe

The role of video laryngoscopy in prehospital airway management B. Hossfeld, I. Bretschneider, L. Lampl, M. Helm

Fatigue in helicopter eMs operations W. Winn

TRaininG

assessing HeMs crew members: aDaC air Rescue’s job requirement analysis C. Fricke-Ernst, A. Kluge, P. Gloger

in PROFiLe

C. Schnider, O. Seiler

“even today, Rega still has its original claim to fame” – interview with CeO Kohler

TeCHnOLOGy

Rega relies on HaMiLTOn-T1 ventilators: Reducing risks in transport ventilation

nvis from eCT industries: From military use to easa-certified HeMs J. Bouzniac

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Quality improvement in HeMs: stickers documenting intervention in non-traumatic cardiac arrest A. Chesters, A. Weaver, G. Grier

When rescuers learned to fly – The development of air rescue up to 1918 H. Moecke

Cover Image: Rega

6 | neWs irish emergency aeromedical service: launch of a 12-month pilot project On 21 May 2012, the Irish Minister for Health, Dr James Reilly TD, and the Irish Minister for Justice, Equality and Defence, Mr Alan Shatter TD, announced the launch of a 12-month pilot project which will see the Air Corps provide dedicated aeromedical support to the HSE National Ambulance Service (NAS). The pilot Emergency Aeromedical Service, which will have a particular focus on the west of Ireland, started on Monday 4 June, from Custume Barracks, Athlone. The Air Corps provide an EC135 helicopter and personnel to fly and maintain the craft. The National Ambulance Service is responsible for patient care, which is provided by National Ambulance Service Advanced Paramedics. Speaking at the launch, Minister Reilly mentioned the relatively short time frame involved in establishing the pilot programme. Speaking of his officials, the HSE staff and their counterparts in Defence and the Air Corps, he said “I am delighted to see the results of all that hard work and co-operation, along with all the planning and training at operational level that has brought us to this point. It is very satisfying to see such an ambitious project come to fruition in such a short time. The initiative is expected to be of invaluable assistance to the National Ambulance Service and will be of real benefit to patient safety.” For more information, visit: ››› www.hse.ie

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InternatIonal aIr rescue & aIr ambulance

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easa orders eC135 security checks In May 2012 the European Aviation Safety Agency (EASA) issued an Airworthiness Directive, and helicopter manufacturer Eurocopter issued an Alert Service Bulletin. The documents were in response to cracks being found in the hub plate of the rotor mast of an EC135. The find resulted in two air rescue helicopters in Devon and Cornwall (UK) being grounded. Eurocopter stressed that this is only the second time in the history of the EC135 that this kind of fault has occurred. However, Eurocopter went on to say that as safety is always its top

priority, it wasted no time in issuing the warning. Germany’s air rescue operators – DRF Air Rescue, ADAC Air Rescue and the Federal Police for the Federal Office of Civil Protection and Disaster Assistance – all declared that they had immediately carried out checks on all their helicopters of this type and that they had found no damage. For more information, visit: ››› www.easa.europa.eu

Public funding for London’s air ambulance?

Laa

While the victims’ families of the 7/7 2005 London bomb blasts had called for 32 recommendations in order to improve public safety and emergency medical care, Heather Carol Hallett, judge of the Court of Appeal and chosen to act as coroner in the inquest of the 52 fatal victims of the bombings, proposed nine recommendations, seven of which related to the emergency services. These included more first aid equipment in London’s Tube, hospital staff and paramedics examining how they handle major incidents and a review into funding and capabilities of which had saved lives after the attacks. Hallett emphasized that the recommendations shall be implemented soon and not to “lie on a shelf for 15 years”.

Hallett also raised concerns about London’s ability to respond to future terrorist attacks because of a lack of funding to agencies such as London’s Air Ambulance (LAA) and feared that London may find itself “dependent upon corporate funding and charitable donations.” The LAA, which indeed played a crucial role, suffers from a lack of funding which means that in the event of a similar attack it would fall “woefully short” of what emergency services should be able to provide.

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

seminar on new guidelines in French HeMs French HEMS procedures are set to change this year. In April 2012, France entered a transitional period in the enforcement of EASA rules in public transportation. These will have to be fully implemented by 2014 at the latest. The changes in HEMS were discussed at a seminar jointly organised by the Castel-Mauboussin Foundation, ANSMUH (the French national HEMS organisation), the Centre Hospitalier Intercommunal de Toulon – La Seyne-sur Mer (CHITS), and the Hyères naval air base. Topics that were covered included the new European rules in French HEMS flights, HEMS

crew member training routes, NVG flights, and pitfalls in aviation. The seminar was held in Hyères on the French Riviera on 21 and 22 June 2012. The first day included a presentation of the new flight rules by the Directorate General for Civil Aviation (DGAC), a talk on HEMS crew member training (by ANSMUH and Noordzee Helikopters Vlaanderen – NHV), and a session on medical training (by Dr Romain Lambert of CHITS). One talk coveres NVG flights, employment laws and training (ANSMUH/MBH/ECT) and there was also a discussion of the basic notions of HEMS pitfalls

(AGEFIPH/CAP EMPLOI). The second day of the seminar covered topics like the myths and realities of all-weather-helicopters (SAF Helicopters), methods for controlling and monitoring meteorological risks (Telvent), the changes in air ambulance and HEMS flights (by Dr Marc Fournier of Marseille Hospital Public Assistance – APHM), and the pathophysiological aspects of medical flight transportation (by P. Michelet of APHM). For more information, visit: ››› www.colloque.smuh.fr

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neWs | 7 age limit planned for air ambulance pilots According to details published by the German Federal Aviation Office, the European Commission is planning to impose an age limit on commercial helicopter pilots who operate alone in the cockpit. Commission Regulation No. 1178/2011, due to come into force on 8 April 2012, will also apply to civilian air ambulance helicopter pilots. The German Federal Police will be exempt from the legislation, but have volunteered to adhere to it, according to a report in the Hessische Allgemeine newspaper. This was explained in an interview by the head of the Fulda valley fleet – responsible

for the Kassel-based air ambulance “Christoph 7”. All its pilots over the age of 60 will then only be able to fly together with a co-pilot/colleague. But DRF Luftrettung, which almost exclusively uses single-pilot air ambulances, has been offering an age-based part-time model since February 2011 for the reasons mentioned above, in order to avoid redundancies.

aDaC air Rescue welcomes first female pilot

For more information, visit: ››› www.eur-lex.europa.eu

second helicopter landing pad at Lucerne hospital The first helicopter from Swiss Air Rescue (Rega) landed on the new platform at Lucerne’s LUKS hospital on Friday 4 November 2011. This second helicopter landing pad on the roof of the main building ensures that air rescue in Switzerland continues to provide seamless service. The 225 m2 platform meets current EU norms and allows the clinic to admit greater numbers of patients arriving by air. By taking into account prevailing weather conditions at the time of approach, pilots can minimise disturbing aircraft noise.

LUKS operates as a public-law institution and has four locations: the main clinic in Lucerne, two primary care clinics in Sursee and Wolhusen, and Luzerner Höhenklinik Montana, which is located high in the mountains. With 5,500 members of staff, LUKS is one of the biggest employers in central Switzerland. For more information, visit: ››› www.luks.ch

aDaC

German HEMS operator ADAC Air Rescue has recently welcomed the first female pilot to its roster of around 150. Melanie von Allwörden has joined its “Christoph 39” base at Perleberg (state of Brandenburg), approximately 150 km south east of Hamburg, flying a Eurocopter EC135. The 34-year old previously worked for the Hamburg Police. “Christoph 39” went on more than 1,000 call-outs in the past year. But that doesn’t worry Melanie, who says that any day she gets to fly is “perfect”. With some 1,400 flying hours under her belt, Melanie is an experienced pilot – but she still sees every call-out as a new challenge. The HEMS crew in Perleberg officially cover a radius of 70 kilometres, but they regularly fly further than that to ensure patients get to the hospital best equipped for treating their condition. This can take the crew to Lübeck, Schwerin, Potsdam, Berlin and even back to Melanie’s old stomping ground – Hamburg. For more information, visit: ››› www.adac.de/presse

LUKs

HeMs operations in india: eurocopter at the forefront

eurocopter

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On a recent trip to India, Michael Rudolph, Eurocopter’s head of business development, said that these days there is a strong political will to start implementing HEMS and to carry out emergency medical services in India as the demand for solutions in this area has been rising. With regard to funding he added that HEMS operations could be funded by non-profit organisations, charities or other foundations. Mr. Rudolph emphasised that “Eurocopter helicopters are designed to respond to emerging challenges and we have a widerange of products which are the best to accomplish highly complex missions.” At another occasion Mr. Rudolph elaborated

that “today, HEMS is gaining more significance in emerging countries. India has evolved as a mature market, especially for new age medical facilities. Hence, the improvement of the medical scene, including the implementation of Helicopter Air Ambulance Services starting with urban cities like Delhi, Mumbai, Hyderabad and Bangalore, will become one of the most demanding projects of the next decades. It’s a national challenge and responsibility that both the Governmental institutions and the private medical society must face.” For more information, visit: ››› www.eurocopter.com

8 | neWs Helmet mounted display for safer helicopter flight

eurocopter and Heli-One in a joint saR bid for norway

DLR

Conventional flight instruments require pilots to constantly switch between looking outside the helicopter and checking the instrument panel; these two functions have been combined in the new Helmet Mounted Display (HMountD) that is currently being tested by the German Aerospace Center (DLR). With the help of the HMountD, critical flight guidance information such as altitude, speed, course and attitude are displayed in the pilot’s field of view, as is information about obstacles, such as electricity pylons. The HMountD also reduces eyestrain, which in turn increases safety. In a series of tests, helicopter pilots of ADAC Air Rescue, among others, flew a range of different test scenarios using the new helmet display in the cockpit simulator and rated the results afterwards. These data are now being processed so that, by late summer 2012, real flight-testing can take place using DLR’s BO105 and EC135 research helicopters. For more information, visit: ››› www.dlr.de

eurocopter

A joint bid for an important SAR contract in Norway is being prepared by Eurocopter and Heli-One. The so-called NAWSARH competition (“Norwegian All Weather Search and Rescue Helicopter”) aims at introducing a new helicopter fleet that is capable of flying in the country’s challenging mountainous and coastal areas as well as long-reach missions in the Barent Sea (NORDSAR: Nordic Search And Rescue). The agreement will unite Eurocopter’s EC225 NORDSAR version – specifically designed

for SAR missions in the Nordic region – with HeliOne’s experience as one of the world’s largest helicopter support companies. The EC225 (along with Eurocopter’s AS332L1 version of the Super Puma family) is already being used extensively in the region for SAR missions. For more information, visit: ››› www.eurocopter.com ››› www.heli-one.ca

Kazakhstan orders eC145s for Medevac and saR

spectrum aeromed strengthens customer service in europe Thomas Redder has joined Spectrum Aeromed as the new Account Representative in the company’s Germanybased office. In his new role, Redder will be responsible for global sales and will work closely with Vice President of Internaspectrum tional Sales for Spectrum Aeromed, Horst Heinicke. “We are pleased to add Thomas to our team at Spectrum Aeromed,” said President and CEO of Spectrum Aeromed, Dean Atchison. “He adds a wealth of experience to our Germany based office with more than a decade of aviation experience that our customers will appreciate.” For more information, visit: ››› www.spectrum-aeromed.com

C. abarr/eC

The Kazakhstan government has placed additional orders for eight EC145 helicopters in terms of a framework agreement covering 45 of these multi-role rotorcrafts, which are to be assembled in-country by the Eurocopter Kazakhstan Engineering joint venture. These latest bookings consist of six EC145s in a medical evacuation configuration for the Ministry of Emergency Situations, along with two to be operated by the Ministry of Defense for search and rescue missions. They follow Kazakhstan’s initial acquisition of

six similarly-configured EC145s last year, which were assembled and delivered during 2011 to both of the government ministries. The EC145 is a helicopter of choice in its medium-size twinengine category. This rotorcraft benefits from its flexibility and versatility in worldwide operations – particularly the extreme lowtemperature conditions encountered in Kazakhstan. For more information, visit: ››› www.eurocopter.com

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neWs | 9 asU surpasses 4,500 night vision aviation system sales

Horizon

ASU recently announced that they have now sold more than 4,500 night vision aviation systems worldwide. This gives ASU more aviation systems sales to civilian operators than any supplier in the world. “I can remember when the thought of night vision systems in the civil market was just a luxurious dream,” said ASU’s founder Mike Atwood. “Our goal at ASU was to make that dream a reality and make NVGs readily available to operators around the world.” The first civil operation that ASU sold night vision systems to, was North Slope Borough Search and Rescue in Barrow, Alaska in 1996. The 4,500th system was for Classic Life-

guard Air Medical Services in Arizona. “In 2004, when we were starting up goggle operations, ASU offered a topnotch training program,” says Classic Lifeguard Director and Pilot Matt Stein. “Mike Atwood and his staff were both professional and accommodating to all of our needs, whether supplying night vision systems or flight training. ASU was also instrumental in obtaining our company’s FAA approved NVG training program.” For more information, visit: ››› www.asu-nvg.com ››› www.classiclifeguard.com

night vision compatibility for corpuls3 The corpuls3 system is now compatible with night vision devices. The new software, version 1.9, enables you to select a special night vision mode in addition to the established standard (white background) and inverted (black background) settings. The system reduces light emission, preventing the glare that can be so disturbing during night flights. The corpuls3 is also available with a clear display

for night vision devices. The special display technology reduces infrared emissions to an absolute minimum. This means the display can be used with night vision devices with no annoying glare. In addition, this option completely eliminates all radiation from LEDs and lighting elements. For more information, visit: ››› www.corpuls.com

Corpuls

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10 | neWs United Rotorcraft awarded Bell 429 interior contract

air Methods

United Rotorcraft, an Air Methods Division, has signed an agreement with Bell Helicopter (Fort Worth, Texas) to provide a medical interior kit for a new Bell 429 aircraft. The agreement includes the manufacture of an FAA (STC’d) approved medical EMS interior that will be shipped to Bell Helicopter’s facility in Piney Flats (Tennessee) for integration into a Bell 429 “demonstrator” aircraft. The aircraft is slated to be delivered during the second quarter of 2012. The medical interior will include a carbon fibre floor overlay, two adjustable aft facing crew seats as well as one forward facing seat. The litter system will be a United Rotorcraft Roll-On Fold-Up (RoFu) that includes collapsible arm rails for added safety and an adjustable headrest that can be used for taxi, take-off, and landing. On board life saving systems will include liquid oxygen, compressed air, and suction as well as an abundance of AC power. The interior is completed with medical equipment racks, customized storage pouches, and a Night Vision lighting system. For more information, visit: ››› www.airmethods.com

MBH saMU chooses Telvent for weather monitoring and forecasting Mont Blanc Hélicoptères SAMU (MBH SAMU), a leading commercial helicopter operator based in Annemasse, France, has selected MxVision AviationSentry Online® by Telvent for weather monitoring and forecasting. Founded in 1980, MBH SAMU operates a fleet of over 30 helicopters and specializes in passenger and material transportation as well as ambulance services throughout France. MxVision AviationSentry Online combines precise, real-time weather alerting with real-time weather forecasts and, thus, provides MBH SAMU pilots and crew with weather data that helps to enhance safety and improve decision-making. Telvent’s weather service capabilities will provide MBH SAMU pilots with up-to-theminute notifications at all hours of the day to help them adapt to changing weather conditions more quickly. The project rollout will begin with five ambulance heli-bases spread across France and will be extended to additional bases in 2013. The system also features

single-click access to high resolution global radar and aviation weather graphics, allowing operators to quickly visualize the best and most relevant weather and safety information. Pilots and communications centres will now be able to coordinate critical data and situational awareness much more effectively, both at pre-flight weather briefings and in flight. For more information, visit: ››› www.mbh.fr ››› www.telvent.com

Telvent

aDaC’s HeMs academy has two full flight simulators The EC135 and EC145 full flight simulators at the ADAC HEMS Academy are now both fully functional and available for training. The stateof-the-art simulators are an outstanding addition to the HEMS Academy, which is less than an hours’ drive from three international airports. The full flight simulators will help crews increase the safety and efficiency of their flight operations and

are available for immediate use. With the EC135, users can choose between an analogue or digital (EFIS) cockpit. The EC145 simulator is the world’s first and only full flight simulator for this model of helicopter. For more information, visit: ››› www.hems-academy.de

alsace puts its faith in its own air ambulance Rega helicopters have become a rare sight in Alsace. Since the hospital in Mulhouse bought its own air ambulance, France is no longer a member of the association. Rega regrets this, but understands the situation. Bruno Goulesque, medical director of the Mulhouse air ambulance, is also convinced that the level of service was not the problem. “We were satisfied with Rega.” But with its own helicopter, the goal is to organise preclinical care “on a larger, national scale”. While Rega covered southern Alsace, the range of the helicopter based at SAMU 68 (Haut-Rhin) in Mulhouse (AW109 power, picture shows interior of an identical model) is larger and so availability is improved. Nevertheless, Rega will continue to be available if needed. For more information, visit: ››› www.ch-mulhouse.fr

aDaC HeMs academy

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neWs | 11 new generation aW169 helicopter completes its maiden flight

UK HEMS Clinical Excellence in Helicopter Medicine

AgustaWestland’s first prototype of the AW169, a new generation 4.5 ton light intermediate helicopter, successfully completed its maiden flight recently. The AW169 programme is on schedule to achieve basic civil certification in 2014. The first prototype will be joined by two more aircraft later this year and a fourth prototype in 2013. A new generation twin engine helicopter, the AW169 has been designed in response to the growing market demand for an aircraft that delivers high performance, meets all the latest safety standards and has multi-role capabilities. New generation technologies are incorporated in the rotor system, engines, avionics, transmission and electric power generation and distribution systems of the AW169. Latest technologies include an APU mode capability and touch screen cockpit devices. The AW169 is set to be the most advanced and cost effective helicopter in its class for EMS, SAR, law enforcement, passenger and offshore transport as well as utility missions. For more information, visit: ››› www.agustawestland.com

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CHANGE HOW PATIENTS SEE YOU SonoSite, the SonoSite logo, and other trademarks not owned by third parties are registered or unregistered intellectual property of SonoSite, Inc. ©2012 SonoSite, Inc. All rights reserved. Subject to change. 02/12

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www.ukhems.co.uk The New Home of UK HEMS on the Internet Features • News Blog – latest clinical and operational developments from the UK HEMS community • Search Engine – contact details, aircraft information, and typical crew conﬁguration • Clinical Information – extensive collection of SOPs for downloads

• Students’ Section – information about electives and downloadable presentations • History – track the exciting history of the air ambulance industry in the UK • Governance – share governance ideas with colleagues national- and worldwide • Careers – make the site your starting point for a career in pre-hospital care

12 | eVents

Fig. 1: The new European flight and duty time limitations – expected to be released any moment – as well as the fatigue studies carried out by Rega gave rise to the idea of the congress (Photograph: Rega)

Author: Dr Ulrike amann Head of FRMS working group Swiss Air-Rescue (Rega)

The Risk of Fatigue – Myron B. Laver International Postgraduate Course Fatigue, and especially the physiological essentials and significant effects on our every day life and work was the focal point of the “32nd Myron B. Laver International Postgraduate Course” in Basel, Switzerland, on March 30th and 31st, 2012. Each and every one of us is self-opinionated to be an expert of his own fatigue management. Perusing the reality, we are faced with our inherent poor ability to assess, how tired we are all day. Our daily behaviour leads to an enormous but belittled accumulation of sleep deficit. Nowadays, nearly everybody is affected by this phenomenon, cognisant or not, due to demanding private and work-related environments. What a risk in safety relevant situations. Print media and broadcasting stations discovered this topic to be a volatile basis for discussions in many sectors of task assignments. The presently expected new European flight and duty time limitations (FTL) – that are due to be released nearly any moment – and the intensive fatigue studies carried out by Rega over the past two years gave rise to the underlying idea of the congress. Sleep loss, fatigue accumulation and loss of performance can and will affect all professional groups, especially those with safety relevant operational processes in addition to already known shift- and nightwork problems. The Department of Anaesthesia and Intensive Care Medicine of the University Hospital Basel, Swiss Air-

Fig. 2: Sleep loss, fatigue accumulation and loss of performance can and will affect all professional groups, especially those with safety relevant operational processes (Photograph: Fotolia)

Rescue (Rega) and Swiss International Air Lines were in charge of this meeting attended by renowned international fatigue experts. Their excellent expertise over years allowed a comprehensive vantage point to all aspects of fatigue and sleep. Beside the main risks related to fatigue in aviation, another central theme focused on the medical work environment. The audience, medical professionals, pilots and representatives of European Aviation Authorities, followed up and intensively discussed each of the presentations. The spectrum of the lectures ranged from the genetic human circadian rhythm (A. Borbely, emeritus professor, University of Zurich; U. Schibler, University of Geneva) to the problems of jetlag (M. Mallis, Baltimore, USA), from the value of specific sleep medication (J. Caldwell, Hawaii, USA) to the influence of light and age on individual sleeping patterns (C. Cajochen, University of Basel). Besides sound theoretical and academic backgrounds, many of the lectures pointed out several practical applications for the daily work routine (J. Horne, Louhgborough University, Leicestershire UK; E. D. Miller, John Hopkins Medicine Baltimore, USA). This means specific advice towards an effective Fatigue Risk Management (FRM) in the private as well as in the professional environment (C. A. Czeisler, Harvard Medical School, USA; D. Aeschbach, Institute of Aerospace Medicine, Cologne, Germany). Last but not least, at the end of the suspenseful congress, the members were introduced into the fatigue management of a Space Shuttle Mission. Former ESA astronaut C. Nicollier’s (Centre de Technologies Spatiales Lausanne, Switzerland) experienced sleep behaviour beyond Earth’s atmosphere in space and several impressive images from space were surely one of the congress highlights. 

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Managing exhaustion: Rega’s Fatigue Risk Management System Author: Dr Ulrike amann Head of FRMS working group Swiss Air-Rescue (Rega)

Starting this year, new rules adopted by the European Aviation Safety Agency (EASA) on work time limitations and rest requirements for pilots have formed the basis of a large-scale FRMS project relating to Rega’s repatriation missions and air rescue operations. So that it can share useful information and FRMS experiences, Rega is in close contact with the European HEMS & Air Ambulance Committee (EHAC) as well as with EASA and other major European air rescue organisations. Fatigue

Fig. 1: Rega has initiated its own collection and analysis of internal data pertaining to fatigue (Photographs: Rega)

Fatigue is a physiological function whereby the body becomes desperate for sleep and regeneration. Like hunger or thirst, fatigue is unavoidable and genetically inherent in every person. So the “F” in FRMS is at the heart of Rega’s new project. Worldwide, there is little data on fatigue during repatriation missions and air rescue operations. With an eye to future European rules on work time limitations and rest requirements for pilots, Rega has initiated its own collection and analysis of internal data pertaining to fatigue. The management board commissioned a project working group to compile and analyse these data in cooperation with a specialist company in London. All Rega’s jet and helicopter pilots are involved in the project since, as of this year, new EASA rules govern their work time limitations and rest requirements. The pilots attended a full-day training course and were also invited to take part in various voluntary anonymous studies. One of these involved testing a so-called ReadiBand™ for several weeks. Worn round the wrist, this small, watch-like computer precisely records every last movement of the hand. This allows for an accurate characterisation of the wearer’s fatigue level. Also used for data collection were a range of question-

naires on sleep behaviour. Paramedics involved in helicopter operations were purposely included in the study as they share responsibility in the cockpit and have the same work times. The participants received their results in writing and were able to speak confidentially with the experts from London. All staff in the operations centre also underwent training so that they can incorporate insights about fatigue into mission planning. Currently, the data from the main AEMS (Airborne Emergency Medical Services) and HEMS (Helicopter Emergency Medical Services) studies are being evaluated and summarised for the project management team and the board, in anonymous form. Rega’s aim is to identify potential fatigue hotspots and the related highrisk moments in everyday operations.

Risks The studies were intended to reveal potential risks in dayto-day flight operations so that these can be addressed constructively. Such risks are usually hidden, because we all have difficulty assessing our own fatigue levels. As fatigue mounts, carelessness increases and communication abilities deteriorate. One or two small mistakes creep in, multiply, and can ultimately lead to a series of errors that may well pose a serious threat. The adrenaline kick of a mission or demanding work in the cockpit may cover up the fatigue, but on no account is it overcome or eliminated.

Management These concrete risks are one thing, the way we actually experience fatigue in everyday situations is another. We all have to become more aware of the issue. People cannot prevent fatigue, but they can manage it. Several simple and effective strategies do exist, and these were communicated during the training course. In terms of safety, these strategies are not merely “nice to have”, they are “need to have”. Communication within the team, the staff and management culture, and the individual responsibility of both employers and employees all play a major role. One particularly important lesson is that fatigue cannot simply be banished through training; no one can get accustomed to too little sleep.

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saFetY | 15 system The aim is to embed the fatigue project into Rega’s entire system. This means it will form a part of the prescribed internal operational rules and of the operation manuals (OM) for jets and helicopters as well being incorporated into safety management processes. The working group is therefore cooperating closely with the flight safety officers. The project will not end with the completion of the studies and the final analyses. After reviewing the concrete The ReadiBand™ is an easy to use, wrist-worn device that measures dayto-day sleep quality, quantity and timing. It is made by Fatigue Science and relies upon the measurement and analysis of wrist movements to detect and characterise sleep/wake periods. According to Fatigue Science, a recent study showed that the ReadiBand™, coupled with the patented classification algorithms developed by Fatigue Science, assessed sleep virtually as well as by means of sleep lab polysomnography (93% accurate). Based on ReadiBand™ data, Sleep Science provides a range of sleep statistics. Once the wristband data are automatically processed through the computer model, fatigue risk levels can be calculated and displayed.

findings of the study, the management board will develop appropriate, feasible solutions. In future, EASA will require every aviation company to incorporate an FRMS such as this one in their operational procedures and to provide regular evidence of compliance. After one and a half years of intensive work, Rega’s FRMS project has made considerable progress. In order to share useful information and its experiences with fatigue management, Rega will maintain close contacts with EHAC, EASA and other major European air rescue organisations. 

Fig. 2: Rega’s fatigue project will be an integral part of the prescribed internal operational rules and of the operation manuals (OM) for jets and helicopters

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Fatigue in helicopter EMS operations Author: William T. Winn General Manager National EMS Pilots Association Safety Officer Intermountain Life Flight William.Winn@imail.org

This is a true story: shortly after returning to the United States from a tour in Vietnam in 1971, I found myself and my co-pilot on a cross country flight from Phoenix, Arizona to the Flagstaff airport in northern Arizona. It was a hot summer day and I was fighting off a nap-attack as we flew northward at 5000 above the ground. At one point in the flight I was startled to note that I had lost 2000 feet of altitude without being aware of it. The line of fresh drool down the front of my flight suit helped me to realize that I had fallen asleep during a gradual descent toward the ground. I turned my head toward my close friend and co-pilot to ask him how low he was going to allow me to descend before he woke me up. But, when I looked at him, I remained silent. He looked so peaceful there with his eyes closed and his chin resting on his chest that I didn’t have the heart to wake him up. Scenes like this one are not as rare as we would like to think, because most of them go unreported – for obvious reasons. But just last October in the U.S. a commercial airliner overflew its destination airport by more than 100 miles before the crew realized their error and reversed course. The exact cause of the over-flight remains a question, but the Wall Street Journal published this report:

Pilots of a Northwest Airlines flight approaching Minneapolis International Airport Wednesday night temporarily lost radio contact with air-traffic controllers and apparently overshot their destination by about 100 miles. The National Transportation Safety Board is investigating the incident as a possible case of pilots nodding off at the controls, according to government and industry of-

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saFetY | 17 ficials familiar with the matter. Controllers were able to re-establish contact with the Airbus A320, these people said, and the plane eventually landed safely without injuries. The plane was en route from San Diego to Minneapolis. Details are still emerging and the safety board is expected to release some information later Thursday. But based on preliminary indications, industry and government officials believe the crew may have briefly fallen asleep, flown past the airport, and then circled back to land.

Wake REM Stage 1 Stage 2 Stage 3

In another report from April 2011, this one from Europe, it was reported that, Concerns about pilot fatigue grew today after it emerged that two cockpit crewmembers fell asleep at the controls of a long-haul flight. One of the pilots told the BBC he fell asleep for about 10 minutes while his overtired co-pilot took a nap during a scheduled break. The disclosure came after a study commissioned by pilots’ union Balpa showed that 45% of 492 pilots questioned had suffered from “significant fatigue” (1). Similar to the Balpa study referred to above, a recent poll in the U.S. confirmed that fatigue-related events in aviation are much more frequent than we might suspect: In March of 2012, the National Sleep Foundation released its 2012 Sleep in America poll, the first of its kind to ask transportation professionals about how their sleep habits affect their work performance. The results are eyeopening: nearly one-quarter of pilots polled admitted that their work performance is affected at least once a week by fatigue, with one in five acknowledging a serious error (2). If crewmember fatigue is a concern in the highly regulated commercial airline industry, then it should be even more concerning to us in air medical transport operations with its 24/7 operating schedule and relatively casual oversight. This article will address those concerns by reviewing the essential causes and symptoms of fatigue in humans, along with a discussion of countermeasures and mitigations that are available to the air medical transport workforce. I should make it clear up front that I am neither a scientist nor a qualified expert on fatigue. I am a Safety Officer for an air medical provider and a former military and air medical pilot who has made it a priority to research available resources on the implications of fatigue for the safety of flight operations.

Causes of fatigue The Circadian cycle ➜ Humans are biologically programmed to alternate between periods of wakefulness and sleep. The typical adult needs approximately 7.5 to 8 hours of natural sleep during each period of approximately 24 hours: that is our Circadian clock or cycle. This need is programmed into our bodies at the cellular level and while it is subject to re-programming, it cannot be denied without serious consequences in terms of our performance. This overall cycle is not a perfectly smooth sine wave (smooth repetitive oscillation), but rather it incorporates two shorter periods of relatively elevated performance

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Stage 4 Time

2400

0100

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Fig. 1: Normal Sleep Profile (3)

and two periods of significantly degraded performance during those 24 hours. Since HEMS are generally a 24/7 operation, it follows that air crews will often be forced to perform their demanding tasks during their personal periods of Circadian low. In the presence of other systemic and environmental factors that can combine to set the stage for a serious accident, fatigue may become the proverbial straw that breaks the camel’s back. The physiological effects of the Circadian cycle cannot be eliminated, although they can be mitigated to some extent. And, there are other factors that contribute to acute fatigue that can be even more serious if they are not recognized and controlled. Sleep loss ➜ Sleep is a physiological necessity for humans and there is no substitute for it when it comes to maintaining peak physical and mental performance; and there is more to sleep than simply being unconscious. During the 7.5 to 8 hours of sleep that the typical adult requires during every 24 hour period, the brain cycles through a series of distinct stages of electrical activity that characterize the various levels of sleep. Most sources recognize four levels of sleep that are characterized by a particular brain wave activity and by a progressive decrease of both physical and mental activity. Those stages constitute non-rapid eye movement (non-REM) sleep. Stages 1 and 2 are light sleep and stages 3 and 4 are the deepest levels of sleep. Rapid eye movement (REM) sleep is the dreaming state and is characterized by a marked increase in brain activity within a still-paralyzed body. The rapid eye movement is generally believed to be the eyes following the activity occurring in the dream. As the histogram in Fig. 1 (Normal Sleep Profile) illustrates, these cycles of distinct sleep levels repeat about every 90 minutes throughout the sleep period. The most restorative levels of sleep (stages 3 and 4) occur mostly in the first half of the sleep period, with light sleep and REM sleep increasing throughout the second half. It is when we are awakened from stage 3 or 4 sleep that we experience the period of grogginess or disorientation that we refer to as sleep inertia. Sleep inertial typically lasts from 10 to 15 minutes but can persist longer in

18 | saFetY and quiet provisions for sleeping in their crewmembers’ quarters. Even so, the quality of the sleep period during a typical night shift is rarely, if ever, equivalent to the sleep profile illustrated in Figure 1, above. In my 9 years as an air medical helicopter pilot and during the previous 27 years as a pilot for the US Army, I rarely worked a night shift where I was not frequently required to respond to a patient transport (or a tactical) mission request. Depending on the number of successive night shifts assigned, HEMS pilots have the potential to accumulate a very significant sleep debt. And even when a night shift proceeds without any flight activity at all (and supposing that an especially enlightened management requires no other non-flight duties of an aircrew), we still have to question the effect on the normal sleep profile that results from sleeping fully clothed in a strange bed with ones boots on while some corner of one’s drowsy consciousness anticipates whatever obnoxious alarm is used to alert the flight crew of a new mission. For many people, attaining sleep stages 3 or 4 would be unlikely in those circumstances.

Figs. 2a and 2b: Most HEMS operators acknowledge the importance of a well-rested crew and, thus, provide comfortable and quiet provisions for sleeping: crew quarters and pilots’ sleep room at Intermountain Life Flight (Photographs: W. Winn)

HeMs accidents: How causative is fatigue? some cases. It is important that we realize that this profile of successive stages of deep sleep, light sleep, and even REM sleep must occur without disruption in order to fully restore our physical and mental capabilities (Incidentally, as a world class daydreamer I have been cautioned by experts that daydreaming does not substitute for REM sleep). Sleep debt ➜ Studies have shown that sleep loss can reduce judgment and decision-making, reaction time, attention, memory, communication skills, mood, and learning. All of these are associated with critical tasks for an air medical pilot. So how much sleep loss does it take to significantly degrade a pilot’s performance? A loss of as little as 2 hours of sleep can make a difference. And sleep loss is exacerbated by the fact that it is cumulative. So if a person loses 1.5 hours of sleep for 5 nights in succession, the result is a 7.5 hour sleep debt. That is equivalent to the loss of one entire sleep period. Recovery sleep ➜ If sleep loss were strictly a matter of the numbers, we might suppose that an accumulation of a 7.5 hour sleep debt would require that we somehow add those hours to our subsequent sleep periods in order to restore complete alertness and baseline performance. But studies have shown that it only takes two nights of uninterrupted sleep, on average, to recover from a sleep debt. And while a person with a sleep debt might sleep very slightly longer than their normal 8 hours, the real recovery occurs because the fatigued brain naturally spends more than the usual amount of time in the deepest levels of sleep (3 and 4), which are the most restorative periods of the sleep profile. Sleeping on the job ➜ Most air medical transport operators (but not all) acknowledge the importance of a well-rested aircrew. These mangers provide comfortable

The fact is that it is very difficult to determine the quantitative role that fatigue may have played in any air medical helicopter accident. Experts have stated that fatigue is a factor present in any accident that occurs “on the backside of the clock”, where our Circadian rhythm dictates that we should be asleep in our beds; nor is fatigue a rare factor during many daytime operations. But it is not possible in most circumstances to determine how significant fatigue may have been in a given accident. This is especially true when there are no survivors available to interview during the investigation. In the report of a survey of HEMS pilots conducted by the National EMS Pilots Association in 2008, one element of NEMSPA’s conclusions was that, “All air medical provider programs and operators should evaluate the policies and cultural realities of their organizations to identify and correct any practices or attitudes that could result in pressure on flight crews to accept a flight when significantly fatigued. The importance of emphasis and support for safe practices at the managerial and executive levels of HEMS provider organizations is critical in creating a safe culture” (4). symptoms of Fatigue (5) • Irritability • Difficulty with decision making • Personality or mood changes • Impaired communication (including an increase in cockpit silence) • Decreased vigilance • Task fixation (as mental processes slow down) • Increased tolerance for error and risk • Decrease in motivation • Short-term memory impairment • Increased reaction time • Increased risk of “microsleeps”

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saFetY | 19

Fig. 3: According to a NEMPSA report, the importance of emphasis and support for safe practices at the managerial and executive levels of HEMS providers is critical in creating a safe culture

Microsleeps I think that the last symptom on the list above is particularly interesting. A microsleep occurs when a person is so acutely fatigued that the brain simply decides to take a nap without any announcement. This trance-like state typically lasts from 4 to 15 seconds, but can go on for as long as 20 to 30 seconds, during which time the person’s eyes may remain open but they will not react to any visual stimuli. The person affected often does not realize what has occurred, or they may suddenly become aware that they have “lost focus” for a moment. Microsleeps have been implicated in several serious highway and railroad

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accidents. During several air medical conferences across the years, I have asked large audiences of air medical helicopter crewmembers to raise their hand if they have ever experienced a microsleep. Nearly all of the hands are raised. Then, when I ask how many have had a microsleep while driving their car, about a quarter of those same hands are raised again (along with my own). It always makes me wonder how many crewmembers were absent from those audiences because their last microsleep was also their last act.

at what point do i become unsafe? Of course, federal regulations limit the maximum length of a pilot’s duty period and how many hours he or she can fly during that period. But the regulations don’t have much to say about what you really do during that 10 hours of required “rest”, other than to state that a pilot must apply “diligence” in obtaining the rest needed to insure ad-

Fig. 4: Fatigued or Drunk? (adapted from Davenport, FN 6)

1.04

1.02 1.00 0.98

0.05

0.96 0.94 0.92

0.10 1

13 17 21 Hours of walkefullness

Blood alcohol concentration %

Part of the risks associated with fatigue is due to the fact that we are not very good at assessing our own condition when we are tired. There are two separate components to fatigue. One is the actual physiological state of fatigue, which includes the associated performance deficits that can adversely affect the vigilance, planning, decisionmaking, and reaction time that are critical elements of safe flight operations. The second component is our own subjective assessment of how tired we are. The problem here is that people typically underestimate their actual fatigue and feel that they are still operating at about 90% when tests of their performance show that they are actually performing at around 75% of their baseline. This mismatch between reality and perception can result in overconfidence and in a failure to consciously compensate for degraded capabilities. In addition, the use of stimulants, such as caffeine, tends to further mask the subjective feelings of fatigue without effectively mitigating many of the associated performance deficits. For this reason, it is important that crewmembers know the signs and symptoms of fatigue so that they can recognize them in each other and then be especially vigilant of any one of the crew who is obviously fatigued.

Mean Relative Performance

How tired are you?

20 | saFetY ated by other employment. The challenge is made greater by the fact that day-sleep is not as restorative as sleeping at night since it is opposed by Circadian physiology and by the primary circadian conditioners of light, social activity, and noise. For these and other reasons, some accumulation of sleep debt is unavoidable for shift workers. This is why many of the more conservative air medical transport operators have elected to limit the number of successive night shifts to 3 or 4 for their crewmembers.

Mitigations

Fig. 5: The dispatch center can also mitigate against crewmember fatigue by monitoring the workload of the individual crews throughout the night

equate performance while on duty. While no responsible pilot would occupy the cockpit while under the influence of alcohol, the results of a test of the performance of two groups of subjects show a significant correlation between the effects of fatigue and the effects of drinking alcohol. The legal limit for blood alcohol concentration while driving a motor vehicle is as low as 0.08% in most states in the United States (see Fig. 4, the dotted line on the graph). Mean Relative Performance is expressed as percentage of performance at the start of the sessions (immediately after a rest period or prior to drinking any alcohol). The effects of sleep deprivation on psychomotor performance begin to degrade significantly after about 17 hours without any sleep and, on average, the test subjects were performing as if they were legally intoxicated after about 22 hours without sleep.

Counter-measures

For more information, visit: ››› www.nemspa.org/page/ ZCoach

Counter-measures are the strategies used to preclude fatigue from occurring in the first place. There is no question that the most effective counter-measure is and will always be adequate natural sleep that is based on the personal needs of each individual. This can be facilitated through a combination of intelligent scheduling by air medical program administrators and by training and discipline on the parts of air medical crewmembers. Scheduling protocols should recognize the cumulative nature of sleep loss and the potential for a large sleep debt to build up during a succession of night shifts. It is for this reason that many air medical transport providers typically restrict successive night shifts to no more than 3, and then provide at least 3 days off to facilitate complete recovery before a crewmember starts a new rotation of day or night shifts. It is also incumbent on each crewmember, as an element of their professionalism, to take advantage of available opportunities to obtain the rest needed to ensure peak performance. This is admittedly a challenging requirement given the demands that may exist due to domestic, or social pressures, or the requirements cre-

Given that air medical services typically operate 24/7/365, there will always be a need to mitigate the effects of fatigue when they are present. Providing accommodations for air crews to sleep during night shift has already been mentioned. The intelligent use of stimulants in some circumstances can also mitigate against falling asleep while flying. Just keep in mind the previous observation that, while stimulants can be helpful, they cannot be expected to effectively counteract all of the cognitive or motor deficits caused by acute fatigue. In some air medical provider programs that operate multiple aircraft from multiple bases, the dispatch center can also mitigate against crewmember fatigue by monitoring the workload of the individual crews throughout the night. In my own program, we have three helicopters based at three hospitals that are approximately equally spaced along a line that runs from north to south between the cities of Ogden and Provo (Utah). That is a distance of 70 miles (113 km). The protocol is to launch the aircraft that is closest to the accident scene or to the hospital requesting an urgent patient transfer. However, in the case of inter-hospital transfers, if the crew of that closest aircraft has been flying most of the night with little or no rest between flights, and if the crew at the next nearest base has been at rest since the shift began, then the dispatcher may confirm with the requesting facility whether an additional 12-minute delay in the response time would be acceptable for this patient. This often is acceptable to the requesting facility and results in a wellrested pilot and medical crew performing the flight, rather than an extremely fatigued crew. An additional “safety valve” for many air medical transport programs is the provision for a very fatigued pilot or crewmember to take their aircraft out of service for a period of time in order to take a strategic “safety nap”.

Conclusion: education is key The range of topics associated with fatigue, including other possible countermeasures, formal tools to measure fatigue, knowledge of the effects of sleep disorders or aging, and many other topics are beyond the scope of any single article such as this. The most effective strategies to counteract and mitigate fatigue in air medical transport require that all players understand the essential facts about the effects of fatigue, including their causes and symptoms and each individual’s personalized needs for adequate sleep, and for recovery sleep. These facts indicate that education on fatigue and how to control it is an important element of crewmember training, and must

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saFetY | 89 Night vision goggles give you the ability to make molehills out of mountains. be comprehensive and recurrent for everyone involved in the performance of round-the-clock patient transport operations. At a minimum, this would include pilots, medical crewmembers, dispatchers, and aircraft maintenance personnel. One comprehensive solution to providing that education is the Z-Coach Fatigue Management Course endorsed by the U.S. National EMS Pilots Association and other professional organizations in the U.S. air medical transport community. Z-Coach is an internet-based individualized course of instruction that includes a version that is especially tailored to the needs of aviation operations, such as air medical transport. The program was initially designed by Dr. Mark R. Rosekind and associates at Alertness Solutions in Cupertino, California. Dr. Rosekind has since relinquished that company to accept confirmation as a Member of the National Transportation Safety Board in Washington D.C. Additional information about the Z-Coach program of instruction is available via a link on the NEMSPA website. In their description of the training, the developers explain that users begin the program by completing a personalized Z-Profile outlining their individual sleep habits and needs. The Z-Profile can be updated during the 12-month access period so users can track and monitor their progress toward optimal sleep and alertness. The next step is a pre-training assessment to gauge a user’s existing knowledge regarding sleep and fatigue issues. The comprehensive learning modules that follow cover issues such as the risks and real costs of fatigue, fundamentals of sleep physiology, fatigue countermeasures, and commuting. The course includes regular ‘check-forlearning’ items and two scored assessments to verify knowledge acquisition. Two optional fatigue management exercises provide an opportunity to apply skills to common operational scenarios. As an option, the course can provide periodic reports that managers can use to track the status of crewmembers as they progress through the courseware. An extensive list of additional resources is provided for those who wish to obtain an expanded knowledge of the topics presented in the course.  References: 1. see www.independent.co.uk/news/uk/home-news/ pilots-fell-asleep-during-flight-2264495.html (last accessed: 9 May 2012). 2. Riddy DA (2012) Fatigue: Aren’t You Tired of Preventable Accidents? ROTOR magazine Spring: 26. 3. Rosekind MR, Co EL, Neri DF et al. (2002) Crew Factors in Flight Operations XV: Alertness Management in General Aviation Education Module. NASA Technical Reports Server (NTRS): http://ntrs.nasa.gov/archive/ nasa/casi.ntrs.nasa.gov/20020068970_2002111151. pdf (last accessed: 9 May 2012) 4. SleepSurvey ShortReport available at: http://data. memberclicks.com/site/nemsp/SleepSurvey_ShortReport.pdf (last accessed: 9 May 2012) 5. Davenport N (2005) Fatigue in Naval Aviation. CONTACT – Newsletter of the Society of U.S. Naval Flight Surgeons 29, April, July & October. Also available at: www.uscg.mil/safety/docs/crm/fatigue_in_naval_ aviation.pdf (last accessed: 9 May 2012)

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22 | traInInG

Fig. 1: Comprehensive knowledge, skills and attitudes have to be learned and practised continuously by the HEMS crew members (Photograph: ADAC Air Recue)

Assessing HEMS crew members: ADAC Air Rescue’s job requirement analysis and its practical implications Authors: Christiane Fricke-ernst Dipl.-Psych. Research fellow Faculty of Engineering, Department of Computer and Applied Cognitive Science Specialist field: Organizational and Economic Psychology University of Duisburg-Essen annette Kluge Professor of Organizational and Economic Psychology Faculty of Engineering, Department of Computer and Applied Cognitive Science University of Duisburg-Essen Peter Gloger ADAC Air Rescue Hansastr. 19 D-80686 Munich

In High Reliability Organisations (HROs), such as the aviation or medical sector, it is particularly important that high safety standards are met since even small errors may lead to fatal consequences (1). Therefore, working in an HRO requires comprehensive knowledge, skills and attitudes (KSAs) of the members. These KSAs have to be ensured when hiring new candidates and they have to be learnt and continuously practised through regular training. Whereas such a thorough selection process and regular human factors training, especially in the sense of Crew Resource Management (CRM) for the aircraft crews (2, 3) or in the sense of Team Resource Management (TRM) for Air Traffic Controllers, ATCOs (4, 5), are routine practices in aviation, they are not yet standard for teams in the medical sector, for firefighters or the police. However, working in these so called High Responsibility Teams (HRTs) (6) in HROs, calls for even more distinctive KSAs in order to master the challenges of their everyday work (7). In air rescue, HRTs consist of team members with different professional backgrounds and responsibilities. The pilot is responsible for flying the helicopter and the emergency doctor is responsible for taking care for the patient. The HEMS Crew Member (HCM) has “the purpose of attending to any person in need of medical assistance carried in the helicopter and assisting the pilot during the mission” (8). At the place of action the air rescue crew encounters not only the patient but also other HRTs, for example teams of paramedics, firefighters or the police.

Therefore, the requirements for HCMs on teamwork are twofold: Firstly, they have to fit into an air rescue team and, secondly, they have to synchronise with the other teams on-the-spot. According to the requirements, the minimal crew during day operation has to consist of a pilot and one HCM (7). In German air rescue it is common practice that crews consist of at least one pilot, one emergency doctor and one HCM. In specific circumstances one additional person accompanies the operations: during night ops, two pilots support each other in the cockpit;

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traInInG | 23 some operations require the support of an experienced crew member, for example when the situation requires winch operations or diving. In 2008, ADAC Air Rescue, Munich, started using Assessment Centres for their selection of HCMs, in which trained assessors not only assess the candidates’ medical knowledge and skills, but also their interpersonal skills by using different scenarios and role plays. The team of assessors regards these interpersonal skills as crucial since it is easier to teach an HCM the necessary medical knowledge than to develop their interpersonal skills. The team task was analysed by physicians and HCMs based on predefined criteria like, for example, the ability to work in a team, sense of responsibility or conflict management. However, the assessors recognised when comparing their evaluations that they did not reach objectivity in their assessment to the intended extent and looked for a method that allowed an increased level of objective assessment of interpersonal skills. The objective is a) to be able to select those candidates who possess the required skills and b) to know about the stronger and less developed skills of single crew members so as to be able to improve less developed skills by training. When it comes to training, ADAC Air Rescue also made some amendments to the mandatory CRM training. Since not only flight safety but also patient safety is of paramount importance in air rescue, the European HEMS & Air Ambulance Committee (EHAC) has developed Aeromedical Crew Resource Management (ACRM) for enhancing the awareness for Human Factors issues in a joint training programme for HCMs, emergency doctors and pilots. This training was adopted by ADAC Air Rescue and has been approved by the German Federal Aviation Office (LuftfahrtBundesamt, LBA) as a substitute for the CRM training for pilots. In order to establish an Assessment Centre and develop an ACRM-based training programme that is tailored to the target group’s needs, it is crucial to perform a job analysis (9, 10). For several related HRT professions, a job analysis has already been conducted by applying the Fleishman Job Analysis Survey, F-JAS (11). The F-JAS has already been applied for firefighters and first aid workers. However, in Germany first aid workers receive a minimum training for support in emergency situations: Paramedics, in contrast, are trained to give emergency treatment. The required skills and attitudes of a paramedic and an HCM might therefore greatly differ from those of a first aid worker. The present study therefore aimed to conduct a demand analysis of HCMs and reflect how the extracted job demands can be ensured for HCMs.

Method The job requirements of an HCM were analysed in three steps, namely by 1. an unstructured, investigative observation of the normal operation, 2. the application of the F-JAS (Kleinmann et al., 2010) and 3. conducting interviews with the crew members.

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Observation For a first impression and insight, two regular working days of an HCM at “Christoph 8”, based in Luenen, North Rhine Westphalia, were observed by one of the authors, because the team consists of three “typical” crew members and because primary as well as secondary operations are routinely being carried out. The crew was accompanied from sunrise to sunset. Ten operations occurred during these 2 days so that the HCM and the whole crew could be observed in a variety of primary operations and in one secondary operation. One HCM, two emergency doctors and two pilots were observed.

Questionnaire – F-Jas The F-JAS consists of 73 KSAs in the domains (1) cognitive abilities, (2) psychomotor abilities, (3) physical abilities, (4) sensory abilities, (5) social and interpersonal abilities. Each item has to be rated on a 7 point Likert scale, with 1 “not important” and 7 “very important” for the job of an HCM. However, not every item and scale has to be used for each profession (11). For this study, 16 items were eliminated because the underlying requirements are already mandatory in the recruitment phase, e.g. mobility of the fingers and eyesight. The questionnaire with 57 items left was provided online and also included items on current task and demographics, like the role in the crew (pilot, HCM or emergency doctor), whether they had leading responsibility and how long they have worked in air rescue. All three professional groups were asked to fill in the questionnaire considering their importance for an HCM, not with regard to their own profession. ADAC crew members from all over Germany were asked to rate 57 items of the F-JAS. Overall, 223 crew

Fig. 2: The ACRM training of the EHAC was adopted by ADAC Air Rescue and has been approved by the German Federal Aviation (Photograph: ADAC Air Rescue)

24 | traInInG HCM n=108

Pilot n=52

emergency Doctor n=63

Overall n=223

Reliability

6,78 (SD=.44)

6,88 (SD=.32)

6,92 (SD=.27)

6,84 (SD=.38)

Awareness of problems

6,76 (SD=.55)

6,72 (SD=.50)

6,73 (SD=.68)

6,74 (SD=.57)

Perceptual speed

6,45 (SD=.72)

6,50 (SD=.70)

6,35 (SD=.83)

6,43 (SD=.74)

Social sensitivity

6,54 (SD=.65)**

6.10 (SD=.9)**

6,17 (SD=.83)**

6.33 (SD=.81)

Autonomy

6.62 (SD=.72)**

6.21 (SD=.99)**

6.06 (SD=1.3)**

6.37 (SD=1.0)

Poise

6.42 (SD=.7)**

5.96 (SD=.84)**

6.0 (SD=1.14)**

6.18 (SD=.89)

Originality

4.9 (SD=1.44)

4.67 (SD=1.35)

4.48 (SD=1.64)

4.73 (SD=1.48) Note: ** p < .01

Tab. 1: ANOVA results of the F-JAS with HCMs, pilots and emergency doctors on important skills for an HCM

members (25 female) completed the questionnaire online, 52 of them were pilots, 108 HCMs and 63 emergency doctors, between 28 and 62 years of age (M= 42,31; SD=7,02), with working experience between 1 and 28 years (M=11,35; SD=7,16). 72 participants had leading responsibility within their rescue centre. The online questionnaire could be completed during working hours and was available for six weeks.

interview Six pilots, five HCMs and nine emergency doctors were interviewed. The interview was semi-structured, ten of these interviews were conducted face to face, and ten were carried out by telephone. Eleven students from the University of Duisburg-Essen supported the project by carrying out the interviews. Each interview took approximately 30 minutes and consisted of a set of 14 questions. The questions targeted the most important skills and abilities that an HCM should have: positive as well as negative personal experience in working with an HCM, highest and lowest workload of an HCM and the points of intersection between the HCM and the pilot as well as the emergency doctor respectively.

Results of the observation Due to the fact that the HCM is the assistant to both the pilot and the emergency doctor, there are some situations that require supporting both at the same time so that the HCM has to prioritise tasks. The three most frequent situations are: When the helicopter lands in a crowed area, the HCM has to choose between two vital tasks: securing the helicopter as long as the rotor blades are still moving so that nobody gets injured, and supporting the emergency doctor with the patient. During the transport of the patient the HCM has to decide whether they should support the pilot

Tab. 2: Results of the interviews with HCMs, pilots and emergency doctors on important skills for an HCM

HCM n=5

Pilot n=6

emergency Doctor n=9

Overall n=223

Teamworking skills

Communication skills

Ability to cope with pressure

Multitasking ability

in the cockpit or whether they should rather support the emergency doctor with the patient in the back. After the operation at the rescue centre, the medical equipment has to be restocked and the gas has to be refilled.

Results of the questionnaire All items without any exception were rated higher than 4 on the 7-point scale by all three professional groups, which means that all of the F-JAS KSAs are regarded as important for the HCM. Several KSAs are regarded as significantly less important by the pilot and the emergency doctor. Table 1 shows three examples for those KSAs which were rated to be most important for an HCM, for those KSAs which were rated differently by the professional groups and the item which is still regarded to be important but scored the lowest of all the items. HCMs, pilots and emergency doctors agree that the HCM, first and foremost, has to be reliable (M=6,84), aware of problems (M=6,74) and needs quick perception (M=6,43). In contrast, even though skills such as social sensitivity, autonomy and poise were rated by all groups to be highly important, HCMs rate the importance of these KSAs higher than pilots or emergency doctors. Of all the items in the questionnaire, originality reached unanimously the lowest ratings. However, even these ratings are above 4.0 and are therefore very important for an HCM as well.

interview results The answers given by the interviewees were classified into categories that have been discussed by two raters. Four important skills for HCMs could then be extracted. The most frequently mentioned ability that is needed for HCMs was the ability to work in a team (mentioned by 12 interviewees). The second most frequently mentioned ability was communication skills (mentioned by nine interviewees), although it should be noted that this ability was not mentioned by the HCMs themselves. Resilience was also mentioned by eight interviewees, although none of these interviewees was a pilot. Pilots were the only crew members who rated the ability for multitasking as important. Only open questions were asked during the interviews, meaning that the interviewees answered spontaneously what they thought to be important. It might be possible that HCMs take communication skills for granted and therefore didn’t even think about mentioning them. It might also be possible that the pilots who did not mention resilience meant something similar when mentioning multitasking skills. Even though not everyone mentioned the same important skills for an HCM, the overall responses suggest a high requirement of team competence, communication skills and resilience.

Practical implications It can be summarised that the demands placed on an HCM are multifaceted. An HCM has to have high manifestation in all KSAs of the F-JAS, which is acknowledged by HCMs, pilots and emergency doctors alike. The results of the requirement analysis can now be used to develop an assessment centre and for ACRM interventions.

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traInInG | 25 During a subsequent pilot study, a selection of KSAs which were found to be important were assessed with the help of a structured observation sheet in a team-task, in which the candidates were asked to construct a marble run. In addition to the team goal to build a marble run together, each of the candidates had an individual goal, unknown to the others, which was not to be mentioned in the team. To successfully achieve all individual goals, the candidates had to communicate effectively. The observation focused on teamwork, leadership and followership and was recorded at predefined intervals to make allowance for changes in the behaviour, depending on adjusting to the situation and on specific developments during the task. This team-task was part of a two-day assessment centre and was carried out with five candidates each in February and March 2012 in the simulator centre ADAC HEMS Academy in Hangelar, North Rhine Westphalia. In a training context, the study’s results have three implications: 1. quantitative results of the F-JAS reflect the experience of HCM refresher trainers that HCMs have to fulfil a wide range of expectations. The results have already been presented in recent refresher training sessions to prepare HCMs for the high expectations that have to be met. 2. the data is included in the ACRM training to further improve all three professional groups’ awareness of the high demands placed on an HCM, with the aim of encouraging further work on an equal footing. 3. the ADAC is using this data to adjust the workload of the air rescue crew in the long run, with the aim of relieving the HCMs and reducing their stress level. In addition to the potential improvements of the selection process and the training, the results illustrate the high level of appreciation an HCM deserves due to the multitude of KSAs they have to possess.  acknowledgements Thanks to the student project team Artur Bierich, Kathrin Bischof, Enes Düzsoy, Belgen Eren, Daniel Glowatzki, Ingrid Isaak, Jurij Kalina, Patrick Preusser, Nils Schell, Bastian Weyer and Michael Wojatzki from the University of Duisburg-Essen for their commitment, thanks to the ADAC crew members who filled in the questionnaire and answered the interviews and a special thanks to the crew in Luenen who welcomed me on board of the “Christoph 8” and provided me with a good insight into the daily operations.

References: 1. Weick KE, Sutcliffe, KM (2001) Managing the unexpected: assuring high performance in an age of complexity. Jossey Bass, San Francisco 2. European Aviation Safety Agency (2009) Notice of Proposed Amendment (NPA) No 2009-02E. Implementing Rules for Air Operations of Community Operators. EASA 3. European Aviation Safety Agency (2010) Comment Response Document (CRD) to Notice of Proposed Amendment (NPA) No 2009-02E. Implementing Rules for Cabin Crew in Commercial Air Operations. EASA

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Fig. 3: MedCrew-Briefing, March 2012, at the ADAC Headquarter in Munich (Photograph: A. Rippe)

Fig. 4: Presentation of the project results at the MedCrew-Briefing (Photograph: A. Rippe)

4. EUROCONTROL (1996) Guidelines for Developing and Implementing Team Resource Management. EUROCONTROL, Brussels 5. EUROCONTROL (1999) Team Resource Management Test and Evaluation. EUROCONTROL, Brussels 6. Hagemann V (2011) Training für High Responsibility Teams [Training for High Responsibility Teams]. Pabst, Lengerich 7. Hagemann V, Kluge A, Ritzmann S. (2012, in press) Flexibility under Complexity: Work Contexts, Task Profiles and Team Processes of High Responsibility Teams. Employee Relations 34(3) 8. Joint Aviation Authorities (2007) JAR-OPS 3: Commercial Air Transportation (Helicopters). JAA, Hoofddorp 9. Cannon-Bowers JA, Bowers CA (2011) Team Development and Functioning of Teamwork. In: Zehdeck S. (ed.) APA Handbook of Industrial and Organizational Psychology Vol 1: Building and Developing the Organization. Washington, American Psychological Association: 597650 10. Goldstein IL, Ford JK (2002) Training in Organisations. Needs Assessment, Development, and Evaluation. Cengage Learning, Wadsworth 11. Kleinmann M, Manzey D, Schumacher S, Fleishman EA (2010) Fleishman – Job Analyse System für eigenschaftsbezogene Anforderungsanalysen (J-JAS). Hogrefe, Göttingen 12. European HEMS & Air Ambulance Committee (EHAC). ACRM – Aeromedical Crew Ressource Management. Available at ww.ehac.eu (accessed: 30 May 2012)

26 | In ProFIle

Fig. 1: With more than 14,000 missions only last year, Rega is in greater demand than ever before (Photographs: S. Drolshagen)

Author: sebastian Drolshagen .medienbüro Lütgendortmunder Str. 153 44388 Dortmund info@drolshagen-medien.de

Rega’s eventful history: 60 years of airborne medical assistance Six decades after it was founded, Swiss Air-Rescue (Rega) is in greater demand than ever before. Last year, Rega’s helicopters and airplanes flew more than 14,000 missions. This invaluable assistance is supported by contributions from close to 2.4 million patrons. These impressive statistics are ones which the pioneers of this service probably could have hardly imagined. Initially, Swiss Air-Rescue was only a branch of the Swiss Rescue Association. One of Rega’s pioneers was Walter Odermatt, a member of the founding group that met on 27 April 1952 at the Bären restaurant in Twann, a village in the Bernese Seeland region. He was deeply convinced of the need for such an organisation, and says he was “motivated by the desire to help people.”

The new organisation for providing airborne medical assistance, a very unusual concept back then, got up and running very quickly. By the end of the founding year, Chairman Rudolf Bucher, himself a doctor, announced that the new air rescue service had achieved operational readiness. Shortly before Christmas Eve, a small Hiller 360 helicopter lifted off to bring rescuers to the site of

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In ProFIle | 27 an avalanche. The victims were rescued at an altitude of 1,800 metres, and transported to the valley below - Swiss Air-Rescue’s first helicopter rescue. However, in the early years parachutists were used far more frequently than helicopters. They would jump out of airplanes with their rescue equipment, and sometimes even with tracking dogs strapped to their chests. Walter Odermatt became one of those rescue parachutists. He wasn’t content to just help establish the rescue service; he wanted to take an active part in its work, too. At the parachutist training centre operated by the British Royal Air Force, Odermatt received the necessary training. He jumped some 250 times for Rega, sometimes on rescue missions and sometimes for exercises and demonstrations. In March 1955, he was one of the 14 parachutists who did a demonstration jump, landing in Lake Zurich, where the water was a very chilly 7°C. They were watched by 300,000 fascinated spectators. With the years helicopters played an increasingly important role in the sphere of air rescue and the former parachutist Odermatt became a paramedic – the third helicopter crew member next to the pilot and the doctor. Operations that previously were impossible or took days to carry out can now be performed within a matter of hours. “In the beginning, the primary focus was on providing medical assistance to patients. The idea of aero-medical assistance was further refined and amended by getting patients quickly to a hospital for definitive medical care. Today we take the medical services directly to the patients, as we bring an emergency doctor and the latest medical equipment straight to the scene of the accident,” explains Rega CEO Ernst Kohler. In February 1957 the Association of Swiss Consumers’ Cooperative Societies (now known as Coop) presents Swiss Air-Rescue with a Bell 47 J helicopter. The helicopter could carry two patients lying down, and could climb to 4’000 meters. When the Bell was presented to the rescue service, Hermann Geiger, then its chief pilot, promised: “I’ll treat it as tenderly as I do my own wife.” * The acronym “Rega”, now known throughout Switzerland, did not exist back then. The name was first used in 1963 by the Sitten control tower when radioing the rescue helicopter. It’s a typically Swiss linguistic creation, reflecting all three of the country’s languages: “Re” stands for Rettungsflugwacht and “Ga” for Garde aérienne or Guardia aerea. Three years before this new brand name appeared, Swiss Air-Rescue separated from the Swiss Rescue Association and formed its own independent organization, the Swiss Air-Rescue Association (Schweizerische Rettungsflugwacht, SRFW). In May 1960, it carried out its first repatriation flight, bringing home a Swiss citizen injured abroad. The same year, Fritz Bühler became Technical Director of the service, which was still on shaky financial ground. To continue the service for the Swiss citizens the Swiss Air-Rescue Association asked the Swiss government for financial assistance, which has denied any financial help since these days until now. But Bühler, who later became Chairman, got the organisation back on track. Help for Swiss Air-Rescue came from its first patrons.

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Rega’s 60th anniversary – Open day with over 20,000 visitors

Rega is celebrating its 60 th anniversary in 2012. To mark the occasion and as a way of saying thank you to patrons, partners and the public in general for their support, the Rega Centre at Zurich Airport opened its doors to visitors on 28 and 29 April 2012. Over 20,000 people attended the special event. Thanks to its large number of patrons, Rega has always been able to operate without any state funding and state influence, driven exclusively by the needs of patients and population. The past year saw patronage rise by 3.7 percent (86,000 new members) – so that was even more reason to celebrate! With 14,240 call outs in 2011, Rega was busier than ever before. On average, the air rescue service conducts almost 30 missions per day, at all hours, 365 days a year – a feat made possible only by the support of nearly 2.4 million Rega patrons. Rega’s rescue helicopters were deployed 10,797 times (+5.7%) last year. While the number of call outs in response to avalanche accidents fell, the number of illness and accident rescue missions rose. Never before had Rega carried out so many primary missions (where crews administer emergency medical treatment at the site of the accident). The three dedicated air ambulance jets with the latest medical equipment for intensive care patients went on a total of 698 missions. The medical emergency management service, which provides telemedical care for patients abroad, was used less in 2011 than previously. Rega believes this can be explained by the introduction of similar services by other organisations.

* From the book 1414 – Die Erfolgsgeschichte der Rega und ihre Gesichter by Franziska Schläpfer, published by Wörterseh Verlag (only available in German)

Fig. 2: The acronym “Rega”, now known throughout Switzerland, did not exist in the early days, it was first used in 1963 by the Sitten control tower when radioing the rescue helicopter

28 | In ProFIle In 1966, 25,000 Swiss citizens responded to flyers and presentations appealing for help. The donations provided the urgently needed financial support to keep the fleet in the air and to continue providing medical access to the Swiss people. Rega was then able to really take off. In 1968, it purchased its first turbo-shaft helicopter, a Bell 206A. This was followed by a decade of rapid growth. Financed by contributions from its patrons, Rega acquired an Alouette III, followed by a twin-engine Bölkow BO-105C and then a Learjet 24D, the world’s first civilian air ambulance. In 1975, the Zurich government approved a test phase for investigating the use of rescue helicopters in traffic accidents. Following much contentious debate, Rega, already an independent non-governmental organisation, was transformed into a non-profit foundation in 1979. Fig. 3: Rega’s rescue helicopters were deployed 10,797 times last year – on average, the air rescue service conducts almost 30 missions per day, at all hours, 365 days a year

“What’s really striking is the fact that it took us twelve years and nine months for our first 5,000 missions, but only three years and five months for the next 5,000,” said Fritz Bühler, speaking in 1976 about Rega’s 10,000th mission.* In the last year alone, Rega conducted altogether 14,240 missions (+3.7%). Two years ago, Rega celebrated its 300,000th mission, which involved bringing newborn twins back home. Since 1997, Rega has its own nationwide emergency telephone number: 1414. But despite 60 years of success and a strong brand Rega is still competing and lobbying for more patrons, more political support, and against the competition from other repatriation services and the strict “bean counting” at health insurance companies. “We can always get better; we want to keep our pioneering spirit alive. We owe that to our founding fathers,” says Rega CEO Ernst Kohler. * 

Rega patrons Those who make an annual contribution of 30 Swiss francs (for families: 70 Swiss francs) become Rega patrons. This is a unique system that means more than a simple donation, but does not result in actual membership. That’s because – unlike those who contribute to an association – Rega’s 2.4 million patrons have no co-determination rights. Rega emphasises that its rescue operation centre “is available around the clock to anyone in need of help due to an accident or acute illness.” Rega currently operates eleven AgustaWestland AW109SP DaVinci helicopters, six Eurocopter EC145 and three Bombardier Challenger CL-604. To the extent possible and necessary, Rega can waive the costs that its patrons incur due to a rescue mission on their behalf. For further details, please see Rega’s website (www.rega.ch).

Fig. 4: Rega’s rescue operation centre is available around the clock to anyone in need of help due to an accident or acute illness

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

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“Even today, Rega still has its original claim to fame” i n t e r v i e w w i t h e r n s t K o h l e r, CeO of Rega On the occasion of the 60th anniversary of Swiss Air Rescue (Rega), the Swiss magazine Migros recently conducted an interview with Rega’s CEO, Ernst Kohler. With the kind permission of the magazine, we present this conversation as a slightly shortened translation. ernst Kohler (Photograph: s. Drolshagen)

Q: Mr Kohler, have you ever had to call Rega for help? Kohler: In my 20 years of service as a mountain rescuer I called “1414”, or the previous numbers, countless times. So when I joined Rega in 2006, it turned out that I already knew most of the staff from my telephone calls with them. Q: But you’ve never actually needed Rega yourself? Kohler: No, but once one of my sons injured his knee in a ski accident and had to be flown to hospital. And before that my grandfather was recovered by Rega after suffering a fatal heart attack while out hiking. One skiing accident and one hiking accident – the usual reasons for Rega rescue missions.

Q: And what about mountain rescues? The news media always report on mountain climbers who have to be rescued because they overestimated their abilities. Kohler: Rega has become well known for its mountain rescues. And even today, that’s still its main claim to fame. Of course, accidents on the north face of the Eiger or on the Piz Bernina are much more thrilling stories than when a certain Mr Smith twists his ankle while hiking. But by far most of our rescue missions in the mountains are due to common accidents that occur while skiing and hiking. Q: GPS, mobile phones, apps – have these new methods for sending out alarms tended to make people less careful? Fig. 1: Rega’s liquid and fixed assets now amount to around 470 million Swiss francs – ca. 391.4 million Euros (Photograph: Rega)

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30 | In ProFIle Kohler: No, I wouldn’t say so. The level of risky behaviour hasn’t changed much, and the point at which people in trouble finally decide to call Rega has remained just about the same. You see, people who overestimate their abilities or are improperly equipped were also an issue 20 years ago. However, what we have noticed is that because of these new methods of communication we’re seeing far fewer really serious accidents. That’s because people can easily send off a timely request for help before things get worse. It used to be that people would just keep on moving downwards way into the night. And it was under those very conditions, after twelve hours of heavy exertion, that severe accidents would occur. Q: In February 2011, Rega launched a new emergency app. What have you learned from the around 300 calls for help following severe incidents so far? Kohler: The free app has been a huge help to our dispatch centre. That’s because those who use it to trigger an alarm to Rega also automatically transmit their GPS coordinates. For instance, last spring we were only able to locate a paraglider who had had an accident way out in Bündnerland once he had downloaded our app. Q: You’ve been with Rega for six years now. What has been your most memorable day so far? Kohler: Well, there have been quite a lot of high points, such as getting a new mountain-rescue helicopter or, quite recently, a flight simulator. But there was also one particularly bad day.

Fig. 2: “I like to compare Rega with the fire brigade, which needs a ladder long enough for the tallest buildings” (Photograph: Rega)

Q: Of course, you’re referring to what happened on 3 January 2010, when a Rega doctor died in an avalanche cone in the Diemtig valley. Kohler: On sunny weekends, the staff in our dispatch centre often handle many accidents, and that can mean

about ernst Kohler Ernst Kohler is CEO of Rega’s Management Board. Since 2006, he has been in charge of Rega’s operational activities and bears the overall responsibility with respect to the Foundation Board. As Chairman of the Management Board, he is also responsible for ensuring compliance with legal provisions pertaining to flight operations. He obtained his postgraduate degree in management from the prestigious Management Institute in St. Gallen. Kohler holds the rank of colonel in the Swiss Air Force. He was a manager for air force operations and head of operations at the Bernese Oberland base. In 1999 Kohler joined the Rega Foundation Board, where he served as a member of the Finance Commission until 2005. He is a qualified electrician and studied at the Technical College in Winterthur. At the same time, Kohler trained to become a mountain guide, acquiring his license in 1985. He subsequently gained extensive experience as a mountain rescuer, among other things as deputy rescue chief at Swiss Alpine Rescue in Meiringen. one dramatic incident after another. Someone might collapse, be revived, and then a half an hour later the pilot suddenly radios in: “I hate to tell you this, but the patient didn’t make it. We’re coming back in now.” You can’t let something like that get to you too much because it’s simply part of our daily work. But when something like that happens to one of your own people, well, it’s really tough. You’re reminded once again of the inherent risk in all rescue flights. On the other hand, people who want to work at Rega know full well that they’re not going out there to sell chocolate. Q: How did you deal with that particular accident on a personal level? Kohler: In my 20 years as a mountain rescuer, I repeatedly experienced first-hand – up close and personal – just how tenuous life really is and how your world can drastically change from one moment to the next. I feel that this background helps me to handle such a great loss with the necessary professional detachment. Of course, you always have times to yourself when you sit alone and reflect on what life really means. Q: In the last three years, Rega has made far fewer patient repatriation flights from abroad than ever before. Why is that? Kohler: Well, first of all people aren’t travelling as much as they used to. Secondly, the quality of medical care abroad has been continuously increasing. This means that there are fewer medical reasons to move a patient from the Middle East or America back to Switzerland – especially since such a repatriation can easily end up costing thousands. A third reason is cost pressures within the healthcare system itself. Health insurance companies have become as hard as nails when it comes to controlling

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Fig. 3: “It is patronage contributions that allow this air rescue service to exist in the first place” (Photograph: S. Drolshagen)

costs and managing claims. They now insist that patients stay a week longer in local hospitals so that they can then come home on regular airline flights. Q: Does that mean that Rega will have to mothball its three special air ambulances? Kohler: Not at all. We want our fellow citizens to know that we’ll be able to bring them back home from anywhere in the world around the clock, 365 days a year. In order to fulfil this promise, we need to keep the fleet operational. You might say that it’s a nice luxury that Switzerland can afford thanks to Rega’s patronage programme. You know, I like to compare Rega with the fire brigade, which needs a ladder long enough for the tallest buildings. You just can’t say that you won’t bother having such a long ladder because you only need it every five years. Q: But an air ambulance, which costs some 50 million Swiss francs (editor’s note: currently about €41.6 million), is a lot more expensive. Kohler: That’s true, of course. Q: Altogether, Rega’s liquid and fixed assets now amount to around 470 million Swiss francs (about €391.4 million). So at first glance, it looks like Rega is doing really well. Kohler: Rega is in very good financial shape – at second glance, too! Quite honestly, I’m very grateful that, in Rega, Switzerland has an organisation that’s not struggling financially, is 100% self-financed and doesn’t need a single cent from the state. Not only that: we haven’t increased our patronage fees or the flight-time rates paid by private and public insurance companies since the 1990s. Q: Financially, things look so good that it appears that you could do without any patronage fees for two years. Kohler: If we were to just replace our three air ambulances with more modern aircraft – and that’s something

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we’re going to have deal with in the coming years – then that will take 150 million francs (about €124.9 million) from our investment reserves. In fact, we’ve just invested 100 million francs (about €83.3 million) in new mountain-rescue helicopters, and in a few years we’ll be replacing our helicopters used for flat terrain. That’s going to cost an additional 80 million francs (about €66.6 million). And to be quite honest, the Swiss have got used to having Rega’s services available to them. I mean, we can’t suddenly say tomorrow that we have to tighten our belts and do something like close down our Samedan base and then only serve the Engadin valley from our base over in Untervaz. The public service rendered throughout the country by Rega does run at a major deficit, but there’s no doubt that it saves many lives. Q: So how far in the red is this national public service? Kohler: The three helicopter bases in my home canton of Berne are running an annual deficit of some six million francs (about €4.9 million). On average, a helicopter is in the air 70 minutes each day. The rest of the time is spent waiting on alert so that a person in trouble can be reached within a flight time of just 15 minutes. Air rescue is not a business operation, nor should it be. Q: Why should I become a Rega patron? Kohler: Because it’s important that Rega exists, and it is patronage contributions that allow this air rescue service to exist in the first place. In return, to show our gratitude we waive the costs of a possible rescue when a patron has no insurance coverage. Let’s assume the case of a stay-at-home mum who has an accident while skiing. Although she isn’t gainfully employed, she does have accident insurance through her statutory health insurance plan. However, according to the Swiss Federal Health Insurance Law, only 50 percent of the rescue and transport costs are covered. The same applies for a heart attack. If the Rega mission costs 3,000 francs (about €2,500), then you’ve quickly got a financial gap that’s got to be closed somehow. 

We would like to thank Migros magazine for its permission to reprint this interview.

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Fig. 1: Within Europe, there are currently only two helicopters certified by EASA to fly LPV procedures. One of them is the Bell429 (Photograph: Bell Helicopter)

Author: Philip Church Helios philip.church@askhelios.com

Realising EGNOS benefits in HEMS operations The European GNSS Navigation Overlay Service (EGNOS) – the equivalent of the FAA WAAS – has now been available to European aviation for just over a year. The benefits to HEMS operations are easily identified, but operators have to overcome a number of obstacles before they will be able to enjoy those benefits. The issue for all airspace users – and HEMS operators in particular – is matching suitably equipped aircraft with new and planned flight procedures. Philip Church of UK air transport consultants Helios explains more. Benefits to helicopters EGNOS increases the integrity and improves the accuracy of GPS, creating a real opportunity for operators to use instrument approach procedures to fly in to locations where such procedures were not previously possible. Since EGNOS does not depend on any local ground navigation infrastructure at the aerodrome/heliport for an instrument approach procedure to be designed, even remote locations can now benefit. In particular, the integrity of the procedure can be determined by the aircraft instrumentation without requiring personnel on the ground and so it is ideally suited for use at HEMS sites or unmanned aerodromes. So what exactly are these benefits? Essentially, EGNOS enabled instrument approach procedures – such as APV or PinS (Point-in-Space) – provide operators with guided

approaches of improved minima. Previously, operators would have had to operate under Visual Flight Rules (VFR) restrictions and consequently with higher minima. By enabling these lower minima, EGNOS improves operational resilience because these instrument approach procedures allow operations to continue when they may have previously been cancelled or diverted. As an instrument approach procedure with both lateral and vertical navigation, EGNOS enabled approaches are published on charts designed according to ICAO Localizer Performance with Vertical Guidance (LPV) criteria. This minimum is currently set as a decision height (DH) of not less than 250ft. The fact that such minima can be achieved without any ground based navigation aid (i.e. ILS) opens up the possibility for flight crew to fly to locations in low cloud base conditions where previously the

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tecHnoloGY | 33 flight would have had to be cancelled, diverted or delayed. Depending on the operational range of the aircraft, and navigation requirements that it will be subject to, equipping with EGNOS could also mean that other navigation equipment is no longer required on board and can be removed – for example ADF (Automatic Direction Finder). Whilst such a move would require consultation with the national regulator, this possibility is especially attractive to helicopter operators with less space available for panel mounted instruments. Not only does EGNOS improve the instrumented landing capabilities, it also supports the concept of implementing low level RNAV routes where, due to terrain or lack of existing infrastructure, coverage from terrestrial navigation aids is insufficient to support RNAV operations. As a recognised navigation aid meeting RNAV performance requirements, EGNOS could enable the introduction of such routes between fixed points – especially for HEMS operations during IFR conditions. Where HEMS operators frequently fly between hospitals or bases subject to recurrent low cloud base conditions, low level RNAV routes would facilitate all weather operations without the requirement to climb to en-route flight levels prior to transition. Within Europe currently, the availability of these procedures does not necessarily impose any requirements for runway/FATO lighting requirements (unless night time operations are required). According to EU-OPS, even runways without lighting or markings can still benefit from

the lower minima realised from an LPV approach procedure; although higher Runway Visual Range (RVR) and visibility is required in these cases. In situations when a cloud break procedure is required, helicopter specific approaches – PinS – can be used. PinS is a procedure to a designated point in space from which the flight crew perform visual manoeuvring to the landing site. The use of cloud break procedures is one of the key benefits that helicopter operators are keen to realise. Not

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Fig. 2: The helicopters already certified – image shows the AW 109SP – are limited up to 9° LPV approaches, existing PinS criteria are based on barometric inputs and limited to an approach of 7.5° (Photograph: Rega)

34 | tecHnoloGY provided and the crew cancel the IFR flight plan after flying into VMC with landing location in sight, passing the MAP in the visual segment of the approach, or after landing.

Regulatory barriers

Fig. 3: Garmin touchscreen avionics (Photograph: Garmin)

only does this enable a direct operational cost saving from improved reliability to destinations, it also benefits patients who are able to be transferred more quickly. Without a PinS – or another LPV procedure – emergency medical flights would have to go to more equipped airfields, so increasing flight time and patient transfer time to hospital. In some cases where a cloud break cannot be found, a rendezvous with an ambulance above the cloud layer may be required to complete the final patient transfer by road. The visual segment of the PinS procedure can be performed in two ways: • As a “Proceed VFR” procedure, when the helicopter passes the missed approach point (MAP) there is no obstacle protection and the flight crew must comply with VFR and cancel the IFR flight plan after passing the MAP. • As a “Proceed Visually” procedure, the flight crew must visually acquire the landing location at or before arriving at the MAP. Obstacle protection is

Despite the clamour from users for these procedures to be enabled, the infancy of the technology within Europe still requires progress on the regulatory front before a wider uptake can happen. These procedures require the availability of both EGNOS enabled instrument approach procedures and suitably equipped aircraft. As of April 2012, only nine European aerodromes have instrument approach procedures published with LPV minima. As part of each State’s Performance Based Navigation (PBN)* implementation plan it is expected that there will be a gradual increase in the number of LPV procedures. Whilst these plans mainly target aerodromes, HEMS missions also stand to benefit once those same procedures are published to heliports, hospitals and other HEMS set down areas. The push for these additional procedures needs to come from the HEMS operators, heliports and hospitals working with the national regulators. Within Europe there are currently only two helicopters certified by EASA to fly LPV procedures: the AgustaWestland 109SP and the Bell 429. More helicopter certifications are expected by the end of 2012, but the certification authorities are faced with the difficulty that the helicopter flight envelope is different to that of fixedwing aircraft and currently no ICAO LPV design criteria for helicopters exists. This presents a certification challenge for both the manufacturer/operator and the regulator, as currently the procedure design criteria for LPV procedures are only available for fixed-wing aircraft. This can result in some limitations. For example the two helicopters already certified are limited up to 9° LPV approaches. Existing PinS criteria are based on barometric inputs and limited to an approach of 7.5°. Therefore,

Fig. 4: EGNOS has the potential to provide HEMS operators with a valuable increase in reliability and availability – increasing the opportunities to transfer patients to less equipped airfields and heliports (Photograph: Bell Helicopter)

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PinS procedures based on LPV may be essential within inner city regions or obstacle-rich environments where the steeper approach allows obstacle clearances closer to the landing site. The wide variation in helicopter vertical performance is making the assessment of the performance of helicopters against these design criteria difficult. Although options for certification are available within the ICAO and EASA framework, the onus is on the operator – which presents further challenges. It is this difficulty, amongst others, that resulted in EASA removing all helicopters from the recently approved AML for the Garmin GTN 650/750 (see Fig. 3). This All Model List provided a means by which a large number of aircraft could be approved for equipage of these Garmin products without having to procure a third-party Supplementary Type Certificate (STC). However, progress with the availability of design criteria is expected towards the end of 2012. EASA recently published their Comment Response Document (CRD) to AMC 20-28 (Airworthiness Approval and Operational Criteria for RNAV GNSS approach operation to LPV minima using SBAS). This should mean that the approval process for LPV operations within Europe is simplified. In addition, ICAO has been working on new helicopter specific LPV design criteria. This has resulted in new criteria for Helicopter PinS approaches and departures being submitted to the ICAO Air Navigation Conference in November 2012 for approval. In addition, the criteria for SBAS PinS LPV as

amendments to ICAO PANS OPS have been endorsed by the ICAO Instrument Flight Procedure Panel.

Conclusions EGNOS has the potential to provide HEMS operators with a valuable increase in reliability and availability – increasing the opportunities to transfer patients to less equipped airfields and heliports. Before these benefits can be realised, operators must first gain airworthiness and operational approval from EASA. This will require some effort on their part in exploring the issues with implementation and use of instrument approach procedures within the uncontrolled airspace environment typical of many HEMS missions. Whilst this has proven difficult to date, due to a lack of criteria, the imminent publication of the new ICAO criteria is expected to ease the acceptance of those approach procedures that have clear operational and safety benefits. With the imminent publication of design criteria, operators wishing to realise these benefits for day-to-day operations need to work with aerodromes, heliports and hospitals to implement LPV based procedures. Since both an equipped aircraft and published procedure are necessary, achieving publication of procedures will provide a foundation for regulators and operators to gain the necessary experience to achieve widespread operational approvals. Perhaps 2013 will be the year when EGNOS benefits for HEMS operators finally take off. 

PBn* ICAO’s Performance Based Navigation Concept (PBN) aims to ensure global standardisation of RNAV and RNP specifications and to limit the proliferation of navigation specifications in use worldwide.

For more details visit www.ecacnav.com/PBn

Bucher Leichtbau AG Industriestrasse 1a

CH-8117 Fällanden Phone +41 44 806 24 24

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

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Fig. 1: ANWB EC135 – classic cockpit in 2009 (Photographs: ECT Industries)

NVIS from ECT Industries: From military use to EASA-certified HEMS Author: Julien Bouzniac Business Development Manager ECT Inustries jbouzinac@nse-groupe.com

Fig. 2: Command box including Sherpa: this allows power supply and dimming of several types of light sources, i.e. floodlights, bezels, backlighting, screens, etc.

The concept of Night Vision Intensifying Systems (NVIS) has its origins in the military. These allow their users to see in environments where the naked eye cannot perform well. Consequently, NVIS are of great tactical advantage, particularly in covert operations. ECT Industries, a France-based subsidiary of the NSE group and a manufacturer of electronic systems for the aviation industry, developed and commercialised cockpit and exterior upgrade kits with a focus on covert operations and military specifications. These kits were therefore developed to comprise dual-mode (infrared and NVIS compatible) external lights, dual-mode landing lights, infrared projectors, cockpit ultraviolet technology and the very dimmest of lights. Despite its reduced monochromatic field of vision, NVIS make flights safer by enabling better vision by night, almost transforming a night flight into a daytime one and allowing better detection of terrestrial obstacles and more

accurate perception of weather conditions. Towards the end of the 1990s, upgrades and new developments in Europe started to be aimed towards the civilian market. Although the emphasis had switched from tactics to safety, the approval processes for the upgrades in the various European countries made evident the existence of quality disparities, which led to numerous incidents throughout Europe. This forced the European authority to issue guidelines in 2003 and to subsequently enforce their application in 2008. Safety had always been at the forefront of ECT’s concern, so during this period the company developed and deployed significant improvements in cockpit light management. ECT’s Sherpa and its associated software enable the simultaneous management of the large range of different light sources like lamps, screens and LEDs that can be found in today’s retrofitted cockpits. These light sources have to be harmonised at various levels of intensity to minimise pilot fatigue and stress. In

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tecHnoloGY | 37 an NVIS upgrade situation, Sherpa also maximises the use of the legacy technology already in the aircraft.

curate perception of weather conditions – a feature that is particularly important in preparing for landing at an unfamiliar site during primary medical missions. 

Helidax eC120B cockpit In 2008, ECT industries was selected to provide 36 EC120B complete certification and NVIS upgrade packages for Helidax, the DCI/INAER consortium that provides initial training to all French Army pilots. Using the Sherpa technology, ECT Industries developed one of the first European NVIS Supplemental Type Certificates (STC), thus demonstrating its expertise and the quality, reliability and safety of its systems. The benefits of a retrofit kit are: 1. Cockpit harmonisation through the use of the Sherpa technology, leading to: • reduction in pilot stress and fatigue • better performance 2. Maximisation of existing avionics 3. Lower total costs, since less configuration changes have to be carried out On the basis of the experience it gained during this extensive project and utilising Sherpa, which had proved its mettle in the meantime, ECT developed several NVIS STCs especially for the HEMS environment. The system ensures safe use of the Night Vision Goggles (NVG) and facilitates detection of terrestrial obstacles and more ac-

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abb. 3: Helidax EC 120B cockpit

eCT industries – additional sTCs With more than 20 years of experience and over 1,200 satisfied customers around the world, ECT Industries has built strong relationships with key industry players such as EADS, SNCF, RFF and DCN. ECT Industries has received STCs from EASA for the EC 120 B and the EC135 P1, P2, P2+, T1, T2, and T2+. The company is in the process of obtaining additional STCs for other types of aircraft and helicopters, both from EASA and the FAA.

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Fig. 1: NICETRIP model on a rotor test stand at DLR (Photographs: DLR)

DLR helicopter research from a HEMS perspective: Milestones and challenges Author: Dr.-ing. Klausdieter Pahlke German Aerospace Center (DLR) Program Directorate Aeronautics Head of Rotorcraft Research Program Lilienthalplatz 7 38108 Braunschweig Germany

Helicopters play a crucial role in rescue services for today’s society. They provide support in emergency situations arising in connection with business or leisure – from traffic accidents and transporting patients in need of urgent care, to rescuing people from inaccessible areas such as mountain ranges. Such operations are only possible with helicopters, because they are able to hover steadily. Neither fixed-wing aircraft nor autogyros (gyrocopters) could provide these services. The unique hovering abilities of helicopters mean that operators are willing to accept considerable disadvantages in other areas of the technology. Helicopter research at the German Aerospace Center (DLR) is therefore strongly directed towards solving problems such as design-related issues (e.g. noise and vibration), relatively high operating costs, lower horizontal airspeed than fixed-wing aircraft, and the poor ratio of useful load to take-off weight. This article gives a brief overview of DLR’s rotorcraft research programme. Not every area of the research is directly connected to air rescue operations. However, the work is still very important to this field because, alongside the capabilities that are immediately relevant to air rescue helicopters, aspects such as operating costs, noise and vibration levels, and crash safety also play key roles for HEMS rotorcraft.

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tecHnoloGY | 39

Fig. 2: CFD grid around the GOAHEAD model in the wind tunnel

Because of the specific dangers and obstacles that air rescue helicopters typically face when carrying out operations close to the ground, there is a great deal of interest in crash safety. Handling difficulties have prompted researchers to develop measures for improving handling qualities and overall control. The aerodynamic improvements are based on descriptions of the flow and structural phenomena at the rotor, and on simulations of the system as a whole. Due to the complex nature of the physical phenomena involved, these descriptions have yet to deliver the explanatory power and predictive accuracy of comparable descriptions from the field of fixed-wing aircraft. One high-priority research topic is to improve the support provided to pilots in all flight situations, particularly those that involve adverse conditions, such as obstacles. Researchers involved in this area are investigating control functions that can ease the pilot’s workload, and the possibility of integrating sensors and displays and introducing special flight procedures. To date, continuous improvements have led to considerable achievements in classic configurations (e.g. main rotor with a tail rotor or fenestron to counteract torque) and tandem-rotor configurations. However, when it comes to expanding specific aspects of the flight-envelope, in particular increasing

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range and airspeed, we need to explore new paths. These paths could include hybrid concepts like compound helicopters and tiltrotors. Due to the extremely complex processes acting on the rotors, rotorcraft research has always been a experimentally driven, and will continue to be so for the foreseeable future. DLR has two flying test helicopters (the ACT/FHS EC135, and the BO105), as well as rotor test stations for carrying out basic tests at its research centre in Braunschweig, and for use with wind tunnel models (see Fig. 2) with main-rotor diameters of about four metres that are used in the Netherlands at DNW LLF (German-Dutch Wind Tunnels, Large Low-Speed Facility). DLR also has a fixed-base flight simulator. It is used to prepare flight tests, to trial new algorithms and to investigate new solutions for pilot assistance by carrying out systematic test series with internal and external pilots. DLR is currently in the process of setting up a modern ground-based simulator facility. From 2013, the Braunschweig site will have two state-of-the-art simulators – one fixed-base and one moving-base. For 14 years now, the German Aerospace Center (DLR) has been working with the French National Aerospace Research Centre (ONERA) on rotorcraft research. The collaboration gave rise to the first close research partnership on this scale in Europe. To address the challenges mentioned, DLR has divided its rotorcraft research programme into several subsections.

Fig. 3: Calculated pressure distribution on an airfoil with air jets to suppress dynamic stall

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Fig. 4: Making a low-noise approach using a tunnel-in-thesky display

Fig. 5: Noise reduction using an optimised approach compared to a standard landing (approach from the left, landing at (0,0))

virtual Rotorcraft The Virtual Rotorcraft sub-programme develops analytical and design processes, with a specific focus on using computational fluid dynamics (CFD) simulations to calculate the unsteady aerodynamic forces acting on the helicopter. CFD methods solve the basic flow equations in a number of points in a user-defined grid. Because grids typically include several million points, only supercomputers can produce answers in an acceptable length of time. To produce the necessary comparative data, researchers carry out wind-tunnel tests with models that have a rotor diameter of four metres. The comparative data are used to confirm the accuracy of the simulations or to identify problems. One example of this kind of work is the EU project entitled Generation of Advanced Helicopter Experimental Aerodynamic Database for CFD Code Validation, or GOAHEAD for short (see Fig. 2). The Virtual Rotorcraft sub-programme aims to develop CFD methods to the extent that it becomes possible to produce such precise calculations of the flow around the helicopter, and of the interaction of the vortex systems

(generated by the main rotor, fuselage and attachments) between each other and with the helicopter components, that the aerodynamic causes of the flight envelope and of noise, vibrations and tail shake can be simulated with the level of precision necessary for design tasks. These methods are already being used to optimise airfoils, rotor blade layout and fuselage design (especially for the rear fuselage). Rescue helicopters used for offshore operations have to cover ever greater distances, leading to a demand for greater ranges and significantly faster airspeeds. By contrast, land-based rescue service providers are currently primarily concerned about reducing operating costs without compromising airspeed. These different requirements need different rotor and fuselage designs. If rotors operate under high loads, dynamic stall can occur in forward flight. Although dynamic stall does not pose an imminent danger to helicopters, unlike with fixedwing aircraft, it significantly increases the dynamic loads on the rotor blades, control rods and swashplate actuators. This results in greater wear and tear and therefore pushes up operating costs. A number of methods for avoiding dynamic stall are currently being investigated. Alongside standard solutions that involve finding the most suitable design, researchers are also looking into a number of ideas for actively reducing or at least limiting the additional loads. Figure 3 shows an example of an airfoil with air jets to reduce the effect of dynamic stall. Wind-tunnel tests showed that this could reduce loads by over 60%.

The challenge of a low-noise approach Noise is one of the main factors that limits the use of rotorcraft in civilian (and sometimes in military) contexts. A particular problem is the fact that rotorcraft often fly at low altitudes, and residents in the area can find the noise very disturbing. Although there is a high level of tolerance for helicopters on air-rescue missions, people living close to hospitals are become increasingly unwilling to accept the noise from helicopters regularly bringing in patients. The sub-programme Quiet and Comfortable Rotorcraft thus focuses on developing and validating ways of predicting external and internal noise (only ONERA) and vibrations, and on finding targeted solutions to reducing noise and vibrations. Helicopter noise is created by a very complex interplay between aerodynamic and dynamic phenomena and the different components (main and tail rotor and their interaction, the powertrain, gearbox and airframe). This means that for the foreseeable future, only flight tests that take detailed noise measurements will allow conclusive evaluations of low-noise designs. In recent years, important findings have come in the form of experimental reference data on noise and vibration, which were generated at DNW LLF as part of the EU’s Helicopter Noise and Vibration project (HeliNoVi). Other key developments include methods for noise prediction and specific techniques for low-noise approaches. To test these aspects, a system for measuring ground noise was set up, DLR’s test helicopters were equipped with the necessary instrumentation, and numerical methods were developed for designing low-noise approaches. Flight tests (see Fig. 4) were then carried out, which proved that the

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tecHnoloGY | 41 predicted noise reduction of up to 10 decibels could be achieved in practice. Figure 5 shows a comparison of the ground noise footprint in dB(A) of a standard approach (top) with an approach designed to minimise noise. Note that nothing can be done about the red (loudest) area with the coordinates (0 m, 0 m), as this is where the helicopter actually lands. Note also that this low-noise flight path was not selected on the basis of considerations of comfort (neither for the pilot nor the passengers). A major task for the coming years is thus to develop low-noise approach techniques that are suited to operational use. Research will also address the issue of vibration in helicopter interiors. The idea is to model the entire helicopter and investigate vibration paths and possibilities for applying passive and active solutions in the airframe to reduce vibration in the interior. Poor weather conditions, in particular bad visibility and icing conditions, greatly limit the success of helicopters in providing emergency medical services (EMS), carrying out save-and-rescue (SAR) operations and completing special military missions. Overall, pilots carrying out these kinds of complex operations have a much higher workload and accident risk that those flying a fixed-wing aircraft from one passenger airport to the next. DLR’s Smart Rotorcraft sub-programme is therefore doing research on flight control, human-machine interfaces, sensor development and integration, information display, pilot support, and navigation systems. It is also working on new operational procedures and on redundancy concepts that take both safety and certification into account. As part of this endeavour, DLR and ONERA collaborate closely with industry and the relevant authorities to produce appropriate solutions. A key area of research focus here is DLR’s work on developing and validating methods for predicting flight dynamics, and on describing and evaluating criteria for handling qualities. The flying helicopter simulator (ACT/FHS) with its fly-by-light/fly-by-wire control system plays a major role in these projects. Since DLR acquired the flying simulator in November 2002, it has developed a test environment (including system identification, real-time simulation, a ground-based simulator, a modelfollowing control system, and two active sidesticks plus the necessary software installed in the helicopter and the ground-based simulator) which allows researchers to use every aspect of the test system from take-off to landing.

tional sensors – radar, laser, infrared, and a video camera. All activities in this area are covered by the ALLFlight project (Assisted Low Level Flight and Landing on Unprepared Landing Sites), which will be presented in detail in the next issue of AirRescue Magazine. If helicopters are to achieve low-noise flight procedures, they either need to provide suitable flight guidance displays for pilots, or a high level of automation.

Fig. 6: An active sidestick (in the background) in the FHS

Robust Rotorcraft The Robust Rotorcraft sub-programme includes all work being done in the field of passive safety – with regard to helicopter design, crash performance, passenger safety, and all-weather capability (icing and lightning [Onera only]). The activities here involve developing methods for predicting the behaviour of fibre-reinforced composite materials in cases of helicopter failure, and generating the necessary validation data. They also involve applying these methods to set up new structures. Fig. 7: Deformation in PAM CRASH simulation: Comparison of a component crash test with the results of a simulation

Flying with external Loads AirRescue Magazine reported on this topic in a previous issue (issue 1, vol. 2/2012, pp. 18-21), when it ran an article on the HALAS project, which is developing a helicopter assistance system for controlling external loads. The main aim of this sub-programme is to provide pilotassistance functions that can deliver Level-1 handling qualities while allowing manned helicopters to land in limited visibility on an unfamiliar landing site with obstacles. Crucial factors here involve giving pilots the necessary support with special displays (head-up displays or helmet-mounted displays), active sidesticks (see Fig. 6) and partial or complete automation of certain parts of the flight. With this in mind, the ACT/FHS was fitted with addi-

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Max plast. strain o. thickness 0.006887 0.0138 0.0207 0.0275 0.0344 0.0413 0.0482 0.0551 0.062 min 0 in SHELL 1 STATE 59.9996 max 0.0688676 in SHELL 1565 STATE 59.0006

42 | tecHnoloGY divided among the partners. A key focus of HELISAFE TA research was to investigate passenger safety systems like airbags and safety seats (see Fig. 8).

innovative Rotorcraft

Fig. 8: Comparison of sled test and simulation of a helicopter safety seat

More information: Please contact the author if you have any questions about this article. You can e-mail him at klausdieter. pahlke@dlr.de – he will be happy to provide you with further information.

Fig. 9: Testing the active twist rotor blade in the whirl tower

In terms of crash scenarios, researchers cover everything from investigating individual components, to observing full-sized helicopters and their crews making emergency landings on land and on water, to assessing bird strikes and ballistic damage. In order to generate reference data for further developing prediction methods, researchers mostly investigate individual components or simplified test equipment (see Fig. 7). This is because crash tests using full-sized helicopters are generally too complex and expensive. Test data for full-sized helicopter crash tests were therefore generated in EU projects (e.g. Helicopter Occupant Safety Technology Application, also known as HELISAFE TA), which meant that costs could be

The Innovative Rotorcraft sub-programme is concerned with new approaches to rotor control, with new helicopter designs (e.g. compound helicopters) and with work on tiltrotors. The driving force behind the research is the desire to address the abovementioned problems of airspeed, range, noise and vibration, all of which are inherent to rotorcraft systems. New rotor concepts such as active flap control and active twist have considerable potential for expanding the flight envelope for main-rotor-tail-rotor configurations, while bypassing the extreme complexity of a tiltrotor. The same applies to compound helicopter designs, where components providing additional lift or thrust relieve the main rotor. One of the main achievements of this sub-programme is the design and production of an active twist rotor blade, and successfully testing it in a whirl tower. For 2013, the German Aerospace Center (DLR) is planning to apply an active twist rotor blade with four-metre diameter in a windtunnel test in order to evaluate the maturity of existing technologies. The work being done on tiltrotors is almost all tied up in EU projects and aims to produce a hybrid tiltrotor/ tiltwing design that could be a successor to the BA 609 (EU project: Novel Innovative Competitive Effective Tilt Rotor Integrated Project, or NICETRIP – see Fig. 1, model design/manufacture by NLR). Although this configuration offers great potential for increasing cruising speeds, these advantages are offset by the extreme complexity of the design, which drastically increases costs and negatively impacts on hover handling qualities. DLR is involved in developing, validating and applying numerical methods for evaluating tiltrotor configurations, and in carrying out experimental investigations of the technology. 

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Fig. 1: MARU is a joint venture of DRF Luftrettung, ESG Elektroniksystem- und Logistik-GmbH and Modular Aircraft Rescue Unit GbR (Photographs: DRF Luftrettung)

DOA at DRF Luftrettung: Creative minds with their own ideas Seven engineers are the creative force behind technical developments at German air rescue organisation DRF Luftrettung. The team is part of the organisation’s approved Design Organisation (DO) that comes up with ideas and projects to continuously improve the equipment used in aircraft. This includes the MARU modular rescue system, which allows intensive-care patients to be transferred among aircraft without being moved from one trolley to another. In a certain sense, a rescue helicopter is much like a laptop computer. Both contain lots of high tech within a very confined space. “In determining the arrangement of the medical devices on board, we exploit every single square centimetre available,” says Joachim Schanz, head of DRF Luftrettung’s DO. Working with development engineers Michael Kunze, Matthias Geiger, Sven Hannen, Frank Sommer, Michael Berkau and Holger Süßmann, Schanz is responsible for larger innovations as well as minor technical changes that are applied throughout the rescue fleet. His daily activities are shaped by the standards and regulations defined by the European Aviation Safety Agency (EASA), as well by as inventiveness and teamwork. The various projects that this team has worked on are evidence of its members’ great creativity and versatility.

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Heli-FLR A current project of DRF Luftrettung’s DO approved by the EASA is the helicopter flight/landing radar project (Heli-FLR). When visibility is extremely poor, this system displays obstacles such as high-tension power lines and trees on a 3D cockpit display. The experts at the DRF Luftrettung’s DO have been working with partners such as the company Radar Systemtechnik on this international project. The development phase started with the design of suitable radar antennae, continued with new calculation methods for displaying screen images, and went on to performing test flights. “We first worked out the operational requirements for the new radar system and then adapted them to the specific application requirements of our rescue helicopters,” Schanz explains. “For instance,

Author: stephanie Redwanz Freelance Journalist redwanz@fotofrau.de

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Fig. 2: The bracket for securing the Oxylog 3000 emergency and transport ventilator to the modular aircraft rescue unit is displayed in 3D on the computer screen (top), the forces acting on the bracket can be depicted by clicking the mouse on it (bottom)

the radar system features a take-off and landing mode that provides a precise 360° view of the terrain around the helicopter. During rescue missions under difficult conditions, it provides an extra margin of safety.”

Modular aircraft Rescue Unit

Fig. 3: Components of the MARU

Another current project is a modular system called the Modular Aircraft Rescue Unit, or MARU. Jointly developed with the German company ESG Elektroniksystemund Logistik-GmbH, this system allows intensive-care patients to receive optimum treatment during aircraft transfers without requiring movement from one trolley to another. The continuous use of a single trolley helps to prevent accidental removal of infusion tubes or monitor lines. The sophisticated modular design of the MARU system allows different application requirements and patient needs to be met. In fact, the modular system can be installed in and removed from an aircraft within

Power distributor

Medical equipment

Equipment rack

Intensive care area with locking mechanism for various stretcher types]

Retaining tray

Additional medical equipment (rucksack)

Separable into 2 subcomponents for easy assembly and transportation

just 20 minutes, as the transfer only requires moving the system base plate from one helicopter or aeroplane to another. This standardised procedure ensures high system flexibility. All the system devices, including the individual medical devices, are fully modular and integrated within the unit. DRF Luftrettung and its development partners first presented the MARU prototype to industry experts at the ILA Berlin Air Show in 2010. Currently, the MARU is undergoing intensive testing. “No on-board device can ever be allowed to impede proper operation of an aircraft,” Schanz stresses, pointing out that “this is why our DO team has to conduct all necessary examinations and practical testing and also fully document the whole process. We then submit the complete set of documentation to EASA. Every component we develop that has an influence on the flight characteristics of an aircraft must be certified by EASA before we’re allowed to install it in our helicopters.”

Oxygen supply

Adjustable base plate Standardised drawer for medical equipment

Integrated heated/cooled compartment

Drawer with integrated, lockable storage compartment (anaesthetics)

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tecHnoloGY | 45 However, this process does not apply to “minor changes”, which the Design Organisation can carry out on its own. These include the installation of modern technologies such as the Skytrack flight-tracking system. As Schanz explains, “We’re certified as per EASA Part 21J, which means that we work in accordance with applicable EASA standards. So for minor changes we can conduct all testing ourselves, create the installation instructions and pass them on to the service and maintenance organisations that install the equipment concerned.” Schanz then describes how his DO team proceeds when it comes to new medical devices. Before purchasing a device, the DO, flight operations and medical departments all examine the electrical connections on the unit concerned and determine whether it could cause electromagnetic inter-

advantages of the MaRU system • Modular concept • Quick to assemble (< 20 min.) • Equipment rack separate from the intensive care area • Adjustable base plates ensure compatibility with various aircraft • Considerably higher emergency landing load factors than those specified in FAR Part 29 (up to 20g) • Power distributor allows adaption to the respective on-board electrical system • Standard connections for medical equipment • Attachment options for various stretchers (in accordance with STANAG) • Individual choice of medical equipment • Easy to clean/disinfect

intended use of the equipment Kit 1. Ensure the provision of medical first aid as well as the rescue, recovery and transportation of the injured and the sick. 2. Provide primary medical evacuation of casualties, irrespective of the patient’s severity. 3. Continuously monitor an individual’s vital functions during transportation from the place of injury or illness to a medical facility. 4. Provide secondary transport – under intensive care – of the injured and sick between different medical facilities, irrespective of the level of severity (Patients already having been clinically treated and in a stable condition). 5. Prevent or treat life-threatening disturbances of the vital functions during transport of the patient.

Components of the equipment kit • Intensive care area that can be disassembled into subcomponents • Power distributor including connection cable • Adjustable base plate • Equipment rack that can be mounted onto the intensive care area itself or onto the aircraft structure • Standardised storage compartments • Oxygen tank holders (2 x 5 litre)

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Fig. 4: Joachim Schanz (left) and technician Clemens Kölmel compare an actual component with its design drawing (Photo: Ch. von Haussen)

ference (EMI). Then the talented DO team has to answer the following questions: Where exactly should the device be mounted? How will it be operated? How should it be positioned relative to the other devices? The mounting points for the device are then determined and all dimensions are examined with the help of a 3D CAD program.

solutions with a precise fit As soon as the design drawings are ready, a prototype of a bracket is made, installed in a helicopter and carefully checked for function, characteristics and operation. If the results are positive, a series of tests is performed in the DO’s own laboratory. These tests check the sturdiness of the bracket and document the findings. An EMI test is conducted to find out whether a given electronic device operates in a manner compatible with the other electronics installed on the helicopter. Finally, a functional test is performed in the aircraft itself – if necessary under actual flight conditions. If all EASA requirements are met, the Design Organisation issues a compliance certificate for the bracket. And then the brackets are finally installed in the helicopters. “It’s a rather long process,” Schanz concedes. Nevertheless, he believes that having an in-house Design Organisation brings many benefits: “We can develop individual solutions that precisely fit the needs of air rescue and air ambulance services. Since we don’t have to pay for external development engineers and outsourced testing, we end up saving money that the rescue service can better use for other purposes.” 

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Fig. 1: DRF Luftrettung at the scene of the accident: the biker had apparently lost control over his machine (Photographs: DRF Luftrettung)

Authors: Dr Tanja Kaneko Resident physician, internal medicine Ruppiner Kliniken GmbH, Neuruppin DEGUM (German Society for Ultrasound in Medicine) instructor for emergency ultrasound Dr Wolfgang Heinz Head physician, Medical Clinic II Leonberg hospital DEGUM course instructor Level III emergency ultrasound and internal medicine Dr Gerson Conrad Head of medical training DRF Luftrettung

The more you see, the more you know: The benefits of ultrasound in prehospital patient-centred care Using ultrasound in prehospital scenarios allows us to make more accurate diagnoses and better decisions when time is short and thus increases the quality of patient care. Especially in air ambulance services, where we encounter the most critically ill patients, new handheld ultrasound devices enable us to see what lies beneath the skin and gives us a window into the patient’s body. This article provides several examples illustrating how point-of-care ultrasound examinations can bring us a step closer to providing the best possible treatment for all our patients. Highway to hell It was a beautiful day in early summer, and bikers everywhere were revving their engines for the first outings of the season. The stage was set for a scenario that is sadly all too familiar – and indeed, a call went out to a rescue helicopter before the day was over. When the team arrived at the scene, they found a young man lying by the roadside next to his mangled bike. He had apparently lost control over his machine while travelling at about 40 to 50 km/h and skidded off the road.

The primary ATLS survey revealed the patient to be mentally alert and responding appropriately, complaining of pain on the left side of his body and in his obviously broken left arm. The fact that he felt dizzy and “slightly anxious” was attributed to the stress he was under in this situation. The following vital signs were recorded: BP 115/65 mmHg, pulse 110/min., oxygen saturation 95%, and a respiration rate of 25 minutes. A closed dislocated fracture of the forearm and pain when pressure was ap-

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medIcal care | 47 plied to the left hemithorax were the only relevant pathological findings observed by the medical team. There was one thing, however, that didn’t add up: the low oxygen saturation level despite the fact that the patient was hyperventilating. Auscultation of the lungs beside the busy road was not much help in answering this question due to the traffic noise in the background, nor was percussion, as the patient was quite obese. This prompted the doctor to apply ultrasound, which detected no free fluid in the abdominal, pleural or pericardial cavities. There was, however, a difference in the aspect of the right and left lungs: the lung sliding-sign was absent both ventrally and laterally on the left. Along with the clinical presentation, this led the physician to diagnose left-sided pneumothorax, which was treated with thoracic drainage. Thoracocentesis produced rapid improvement in the patient’s pulmonary condition, and no complications arose during transport to the nearest suitable trauma centre. The classic indication for the use of ultrasound in case of trauma is the screening for free fluid. The FAST exam was first applied in Europe in the 1970s and has been included in the Advanced Trauma Life Support course since 1997. Moreover, the extended FAST examination (EFAST) focusing on the heart and lungs is able to detect more than internal bleeding. The lungs, in particular, were long regarded as not amenable to evaluation by ultrasound, but the prevailing opinion has shifted toward a different view. The first international evidence-based recommendations for point-of-care lung ultrasound (1) were published recently, and the authors point out that lung ultrasound is more accurate than supine anterior chest radiography when it comes to ruling out a diagnosis of pneumothorax (2), for example.

The broken heart The rescue helicopter was called to a rural area to tend to a patient with an open fracture of the femur who had not been successfully stabilised despite professional care. Upon landing, the medical team found an unstable, critically ill 52-year-old patient with an open fracture of the left femur. HEMS was requested because the next trauma centre was a considerable distance from the scene and because it had not been possible to achieve haemodynamic stabilisation so far despite oxygen supplementation, infusion of almost 3,000 ml of crystalloids and adequate analgesia. The patient’s blood pressure was 82/43 mmHg, he had a pulse of 125 bpm and an oxygen saturation of 98%, which was maintained by administering five litres of oxygen per minute via face mask. Some neighbours provided the background information that the patient’s wife had recently left him while he was away at a rehabilitation centre after undergoing mitral valve replacement surgery. The patient had been very depressed since his wife left him and had felt dizzy and short of breath more often than usual in the last few days. It was a hot summer’s day, so he had decided to go for a walk in the woods to take his mind off things and to “fill his lungs with fresh

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air”. He must have somehow fallen and broken his left leg. The patient himself was unable to remember what had happened, so it was not clear whether he had simply stumbled or whether the fall had been precipitated by dizziness due to problems with blood flow. The physical examination showed no signs of pneumothorax or peritonitis, and no significant bleeding from the wound was observed. The team decided to intubate for the transport, but the ultrasound examination did not detect any free fluid in the abdominal or pleural cavities and the vena cava was not underfilled; on the contrary, it was actually distended. So what was the reason for the patient’s haemodynamic instability? The subxiphoid view answered the question: it showed no impairment of left ventricular function and no indication of right heart failure, but revealed a pericardial effusion measuring approximately two centimetres in diameter. After pericardiocentesis (Fig. 3) and drainage of approx. 200 ml of haemorrhagic effusion, the patient reached the nearest trauma centre providing cardiothoracic surgery in a stable condition.

Fig. 2: The former trucker was obviously having considerable trouble breathing. i.e. he was cyanotic and hyperventilating

Cardiac and thoracic ultrasound examinations, in particular, can contribute immensely to a better understanding of the pathophysiology of critically ill patients. The impact of using ultrasound in resuscitation is recognised, and its use is recommended in the new resuscitation guidelines issued in 2010, which conclude that “there is no doubt that echocardiography has the potential to detect reversible causes of cardiac arrest” (3). Fig. 3: Ultrasound-guided pericardiocentesis (subcostal view)

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Fig. 4: The Vscan fits into your palm and can now also be used to examine the heart and obtain images of the ventricles

DRF Luftrettung introduced mobile ultrasound at twelve of its HEMS bases in 2004. In 2011, it switched to a new, extremely lightweight device that is easier to use and provides extended functionality, better visualisation and Doppler imaging. From the second half of 2012 courses based on a new concept devised by the German Society for Ultrasound in Medicine (DEGUM) will be implemented the DRF HEMS bases to train medical staff in the use of the new device.

The wheezer The medical team of DRF Luftrettung was called to administer to a 64-year-old former trucker in acute respiratory distress. As a heavy smoker for more than 40 years, he had occasionally experienced some shortness of breath, but never such extreme discomfort. He was obviously having considerable trouble breathing. i.e. he was cyanotic and hyperventilating. Moreover, he appeared anxious and was barely able to utter even single words. A container of nitroglycerin spray could be seen on a table. The patient was found to have a rapid, irregular heart rate of around 140 bpm, Riva-Rocci blood pressure of 95/70 mmHg and an oxygen saturation of 80%. Physical examination revealed dry rales over the entire chest, no rubs, no murFig. 5: The multiple vertical B lines seen here – indicative of interstitial lung syndrome – appear to dance like disco lights

murs, abdominal breathing with a respiration rate of 30/ min., and oedema of the lower legs. An ECG showed no ST elevation, but showed ST depression in II, III, aVF and V4-6 in addition to atrial fibrillation. The patient’s condition improved only marginally after the administration of oxygen. In this situation, the doctor had to determine what the primary problem was. Was the patient’s asthmatic status due to an exacerbation of COPD with right heart failure? Or was he suffering from so-called “cardiac asthma” due to pulmonary oedema as a result of left heart failure? The atrial fibrillation and ST depression indicated that this was also a possibility. The emergency physician faced quite a dilemma: administering a beta-sympathomimetic agent could benefit the patient by partially reversing his bronchial obstruction, but there was also a significant risk of exacerbating the tachycardia. As you might guess, the physician decided to draw on ultrasound in this situation. Examination of the patient’s heart and lungs with a handheld device revealed a massively enlarged heart with dilatation of both ventricles and reduced left ventricular function. In addition, thoracic ultrasound revealed numerous so-called B lines (Fig. 5) indicating increased interstitial fluid volume (4). Now there could be no doubt about the right course of treatment, and indeed, the patient improved markedly after administration of 80 mg of furosemide and non-invasive ventilation. The transport to hospital was uneventful, and upon arrival the patient asked the casualty team where the toilets were and – just in case – where it was possible to smoke. As this last example demonstrates, ultrasound can also be an extremely useful tool when dealing with critically ill non-trauma patients, especially those who are hypotensive (5). Ultrasound: You can’t hear it, but it might help you see more – and the more you see, the more you know. Handheld ultrasound devices help us master the major challenge we face every day: assessing the condition of critically ill patients rapidly and accurately in order to provide the best possible care and make the right decisions to keep them alive. 

References: 1. Volpicelli G et al. (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38/4: 577-591 2. Galbois, A et al. (2010) Pleural ultrasound compared with chest radiographic detection of pneumothorax resolution after drainage. Chest 138/3: 648-655 3. Nolan JP et al. (2010) European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 81/10: 1219-1276 4. Picano E et al. (2006) Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 19/3: 356-363 5. Jones AE et al. (2004) Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 32/8: 1, 703-708

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medIcal care | 49 vscan ultrasound at DRF Luftrettung DRF Luftrettung introduced the Vscan, a new handheld ultrasound device manufactured by GE Healthcare, at four of its HEMS bases last year. The device increases the range of examinations emergency physicians can carry out at the scene of accidents, which can be particularly beneficial for patients suffering from severe injuries, respiratory distress or cardiac dysfunction. The Vscan was introduced after it had been successfully tested in day-to-day operations for six months. When emergency doctors are called to the scene of a serious accident, for example, portable ultrasound devices can help to detect internal bleeding. Now they can also be used to examine the heart and obtain images of the ventricles, allowing physicians to diagnose conditions such as “pulseless electrical activity”, a type of cardiac arrest, and initiate appropriate treatment. The digital device has several advantages over the device previously deployed by the DRF Luftrettung. It not only provides significantly better

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image quality, it is also smaller, weighs less (only about 400 grams) and is easier to use. The Vscan is already in use in Göttingen, Freiburg, Friedrichshafen. The next HEMS base to introduce the device will be Bad Saarow, followed by other HEMS bases as well. A first course offering medical professionals training in using the new device was held at the Friedrichshafen base in July 2011. “The course aims to give emergency doctors and paramedics more confidence in using the Vscan and help them overcome any inhibitions they might have. Portable ultrasound devices can be an enormous help in choosing the right treatment and the best hospital for severely injured patients. In addition, they can also be used for cardiac examinations, if needed. This practice is in accordance with the new ERC guidelines issued in 2010, which recommend ultrasound as a useful method of examining patients with cardiac arrest. Especially, the Vscan enhances diagnostic options regarding non-traumatic patients, e.g. patients with dyspnoea caused by pulmonary oedema”, says Dr Gerson Conrad, responsible for medical training at DRF Luftrettung. In addition to a brief general introduction to ultrasound and a presentation of case reports and results obtained in recent studies, the course included practical training sessions, giving participants the opportunity to perform almost 50 ultrasound examinations under relatively realistic conditions.

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Fig. 1: LAA is the first air ambulance in the UK to carry blood on board its helicopters (Photograph: M. Bell)

Authors: editorial Team AirRescue Magazine

“Golden Hour Box” and “Cool Car”: London’s Air Ambulance with medical innovation – not only for HEMS London’s Air Ambulance (LAA), the charity which runs London’s HEMS, is the first air ambulance in the UK to carry blood on board its helicopters. This is made possible due to a new refrigeration unit originally used by the US and British military. Every day, London’s Air Ambulance attends to victims of major trauma in the largest metropolitan area of the country. Many of the patients are suffering from catastrophic bleeding. Some die at the scene from blood loss and never make it to hospital. Until recently, the highly trained medical teams have been unable to transfuse blood at the scene of the incident. The innovation, called Golden Hour Box (SCA Cool Logistics), allows the transport of four units of O-negative blood that can be stored in the helicopter at 2 to 4 degrees Celsius for up to 72 hours. Another innovation being tested by LAA is a brain-cooling device for patients with cardiac arrest: the RhinoChill® IntraNasal Cooling System. The study will be conducted on LAA’s Physician Response Unit – also known as the “Cool Car“.

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Fig. 2: Units of universal donor type-O-negative blood are kept in the Golden Hour Box – at a steady temperature of plus 4 degrees Celsius (Screenshot)

Blood on Board Very few air ambulance services in the world carry blood on board. The US and British military carry it on their rescue helicopters, while civilian services in Australia – due to the sheer magnitude of the continent – have carried blood on board for some years. The introduction at LAA will allow the medical teams to administer blood transfusions at the scene of accidents, rather than later in hospital. They have been unable to do so until today. Normal saline has been used as an alternative but, as it does not carry oxygen, it is not the ideal resuscitation fluid. A pre-hospital blood transfusion may improve the patient’s chance of survival. Blood that is not used can be returned to hospital stores, so no stocks are wasted. The service also had to assure the authorities that precious blood stocks could be kept safely and that they could be tracked adequately. This is in accordance with the UK’s NHS Blood and Transplant Policies and Guidance.

Fig. 3: The HEMS crew pre-alerts the hospital to get blood infusions, plasma etc. ready for the patients on their arrival (Screenshot)

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Fig. 4: LAA is testing the RhinoChill IntraNasal Cooling System in pre-hospital cardiac arrest patients (Photograph: BeneChill)

London’s Air Ambulance has the advantage of having a helipad on top of the Royal London Hospital, which makes access to and monitoring of blood supplies much easier. Since LAA doesn’t fly at night, blood will also be carried aboard the service’s rapid-response cars, a fleet that operates at night as well as in the daytime. LAA believes that now hundreds of lives could be saved. According to a BBC News article that quotes Dr Anne Weaver, who is the lead clinician with the LAA, the HEMS crew members attend to about 90 patients a year who are bleeding to death when the service gets to them. Dr Weaver explained that about “160 patients don’t actually make it to hospital on top of that 90, so I think for about 250 patients we’re going to give them a better chance of survival by carrying the blood with us to the scene.”

“Golden Hour Box” Approximately 5% of London’s Air Ambulance patients will trigger the “Code Red” protocol. On the scene, these patients require early administration of blood products and rapid vascular control if they are to survive. This also means that the HEMS crew pre-alerts the hospital to get Fig. 5: RhinoChill uses a non-invasive nasal catheter that sprays a rapidly evaporating, inert coolant liquid into the nasal cavity (Photograph: BeneChill)

blood infusions, plasma etc. ready for the patients on their arrival. The Golden Hour Box, a hollow-walled container, is lightweight and easy for the team to transport. It has to be kept in the freezer at minus 18 degrees for eight hours. When the box is defrosted to the point when there is condensation on its outside, it has reached the suitable temperature of plus 4 degrees Celsius for four units of blood to go in. Emergency blood is packed into the box by BLT transfusion staff. Those units of universal donor type-O-negative blood are kept in the box – at a steady temperature of plus 4 degrees Celsius – for 24 hours and then those units that have not been used are recirculated back into the hospital where they can be used within the NHS. All boxes must remain sealed until the HEMS doctor declares “Code Red” and intention to transfuse. Zane Perkins, a trauma surgeon who works both in the air and on the ground with LAA, is convinced that transfusing blood on the scene could transform pre-hospital care: “Around half of the people with traumatic injuries who die do so from bleeding”, he told the BBC. “Often stopping the bleeding can only be done in hospital, but one of the ways to buy yourself time is to replace the blood they’re losing. I think carrying blood is a great step forward.” The Association of Air Ambulances, that represents air ambulances throughout England and Wales, also welcomed the development, according to the news report. Dr Ramzi Freij, association spokesman and medical director for air ambulance services in Kent and Essex, supports Perkins’ point of view that it will save lives: “Our work is about saving critically injured people, people who are haemorrhaging either from gunshot injuries, road traffic accidents or stabbings, where replacing like with like is really crucial.” He went on to say that carrying blood could save lives both in the cities – where violent crime is more common – and in rural areas, where ferrying patients back to hospitals for emergency transfusions and treatment can take too much time. The Mayor of London, Boris Johnson, also gave his support to this development: “London’s Air Ambulance has an international reputation for pioneering medical procedures, which have been adopted around the world. It provides a great service across the Capital and being able to carry blood on board means the team will be able to save even more lives.”

Brain-Cooling Device RhinoChill® Besides the Blood on Board, LAA is testing a novel device for directly cooling the brain using evaporative, nasal spray technology, the RhinoChill® IntraNasal Cooling System, in pre-hospital cardiac arrest patients. London’s Air Ambulance will conduct this study on its Physician Response Unit, also known as the Cool Car. Cooling the patient with sudden cardiac arrest following resuscitation (therapeutic hypothermia) has been shown to improve survival and limit brain damage from out-of-hospital cardiac arrest. The latest research, however, suggests that cooling the patient earlier – at the time of resuscitation – will have an even greater benefit.

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Fig. 6: The “Cool Car” team will be the first pre-hospital providers in the UK to start the therapeutic hypothermia process on patients during active resuscitation (Photograph: LAA)

One-year-Trial RhinoChill® has already been trialled successfully by emergency medical services in other countries, and the aim of this study will be to assess the feasibility of using this device in the UK pre-hospital arena. The study will take place over one year and, if proven successful, the device could be trialled by LAA for use with other conditions, such as head injuries. LAA received a prestigious research grant from the UK College of Emergency Medicine to undertake this research project. The team is committed to frontline resuscitation research and evaluating this new technology which has the potential to save lives. RhinoChill is a new, portable and easy-to-use system for inducing therapeutic hypothermia following cardiac arrest. Clinical data has shown that it rapidly and effectively reduces both brain and core body temperature, which can lead to improved survival rates after a cardiac arrest when administered along with standard life support procedures before the patient reaches hospital, compared with standard life support procedures only. The RhinoChill IntraNasal Cooling System uses a noninvasive nasal catheter that sprays a rapidly evaporating, inert coolant liquid into the nasal cavity, a large area situated beneath the brain that acts as a heat exchanger. As the liquid evaporates, heat is directly removed from the base of the skull and surrounding tissues via conduction and indirectly through the blood via convection. It is a battery-operated Cooling System and doesn’t require refrigeration (the coolant bottles can be stored at room temperature). Each bottle of coolant holds enough to chill a patient for 30 minutes, and bottles can be easily exchanged to maintain the cooling process until the patient reaches hospital where they will be transferred to a device to keep the patient cool for the next 24-48 hours.

“Cool Car” Commenting on the study, Dr Gareth Davies, Medical Director and Chair of the Trustees of London’s Air Ambulance, said: “London’s Air Ambulance prides itself on

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delivering medical innovation to increase the survival and recovery of its patients. Our ‘Cool Car’ sits alongside our HEMS and provides advanced medical care to medical emergencies, such as cardiac arrest.” Gareth also thanked the College of Emergency Medicine for their contribution towards this project and added that they “look forward to sharing our findings on completion of the study.” The “Cool Car” operates in the area around the Royal London Hospital, including the City and East London. It delivers a doctor and paramedic team that can provide advanced medical care to critically ill Londoners. The team provides additional equipment, expertise and drugs which can improve survival and recovery rates in victims of cardiac arrest. When the heart has stopped beating, it is imperative to ensure oxygen is reaching the brain and that blood is being pumped round the body.

Resuscitation Research In a bold innovative step, the “Cool Car” team will be the first pre-hospital providers in the UK to start the therapeutic hypothermia process on patients during active resuscitation and before return of a pulse. By using the RhinoChill device, the brain and heart will already be cooling when the patient hopefully regains a pulse, which will reduce damage to the brain from both lack of oxygen and reperfusion injury. The medical teams are also trained to deliver anaesthesia and sedation, thus allowing oxygenation and ventilation to be optimized prior to arrival at hospital. Dr Richard Lyon, Registrar in Emergency Medicine & Pre-hospital Care, commented: “We are very proud to have received this grant from the College of Emergency Medicine. Undertaking novel resuscitation research is always very challenging, but the Physician Response Unit of London’s Air Ambulance provides the ideal means to assess new ways of improving survival and patient care from sudden cardiac arrest. This project will provide us with invaluable pilot data so we can continue to undertake cutting edge pre-hospital research.” 

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Fig. 1: “Christoph 22” picking up a HEMS crew for its next mission (Photograph: B. Hossfeld)

Authors: Dr Björn Hossfeld Dept. of Anaesthesiology and Intensive Care Medicine HEMS Christoph 22 Armed Forces Hospital 89070 Ulm Germany bjoern.hossfeld@extern. uni-ulm.de Dr ingeborg Bretschneider Dept. of Anaesthesiology and Intensive Care Medicine HEMS Christoph 22 Dr Lorenz Lampl Prof., Dept. of Anaesthesiology and Intensive Care Medicine HEMS Christoph 22 Dr Matthias Helm Dept. of Anaesthesiology and Intensive Care Medicine HEMS Christoph 22

The role of video laryngoscopy in prehospital airway management Airway management is a top priority in most emergency care algorithms, such as PHTLS© and ATLS© (1), for example. Endotracheal intubation – still considered the “gold standard” in prehospital emergency medicine – is a procedure most EMS physicians perform only very rarely. If prehospital airway management is indicated, however, time is always of the essence. This fact alone makes intubation more difficult than when it is performed electively, and the difficulties may be compounded by circumstances at the site (the patient’s position, limited availability of equipment, the amount of experience the rescue team has in performing the procedure, etc.) and especially by the patient’s condition (injuries, anatomical details, etc.). Given the vital importance of a patent airway for emergency patients, it is indispensable for all doctors providing prehospital emergency care to be well versed in airway management procedures, including endotracheal intubation and suitable alternative methods, despite the relative infrequency with which they need to be performed. Any decisions on prehospital airway management should be informed both by the patient’s situation and the physician’s realistic assessment of his or her skills. It is safe to assume that difficult airway situations and the necessity

for intubation will be encountered relatively frequently in air rescue services. Using state-of-the-art video laryngoscopes as the first choice rather than merely as one of several alternatives in the difficult airway algorithm could significantly improve patient safety in prehospital emergency care.

endotracheal intubation as the “gold standard” Endotracheal intubation is still regarded as the “gold standard” when it comes to securing the airway in a pre-

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medIcal care | 55 hospital setting, and even if it is less frequently required in ground-based Emergency Medical Services (EMS) than in air rescue services, it is vital that all emergency physicians have the skills to perform it confidently. Bernhard et al. were able to show that the number of endotracheal intubations required in the course of special training for emergency physicians in Germany – 25 – does not provide enough practice to attain mastery of this skill (2). According to one study on the incidence of endotracheal intubation, doctors working in urban centres where EMS teams include an anaesthesiologist can expect to perform an intubation every 55 days on average, whereas doctors working in urban centres with interdisciplinary EMS teams perform intubations only every 77 days and EMS physicians in rural areas do so only once every 213 days on average. These numbers led the authors to conclude that emergency physicians who do not also work in hospitals cannot be assumed to have enough practice in airway management (3). Back in 2000, ILCOR (the International Liaison Committee on Resuscitation) stated that emergency physicians should perform an intubation on emergency patients at least six to twelve times a year to maintain their skills at an adequate level (4). The supposition that doctors providing prehospital emergency care do not have enough practice in prehospital airway management was strikingly confirmed in a study by Timmermann et al. The study, involving 149 outof-hospital intubations performed by emergency doctors

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with various specialisations working in ground-based EMS teams, found that the endotracheal tube was placed too low in the right mainstem bronchus in 10.7% of patients and that oesophageal malpositioning occurred in 6.7% of cases (5). It must be stressed that the out-of-hospital situation differs fundamentally from that in a hospital. The fact that emergency patients do not necessarily have an empty stomach, that rescue teams frequently have to work in cramped conditions, in poor light and under extreme time pressure, and not least, that staff do not always have the optimal level of experience and skills (6), are all factors explaining why the rate of difficult intubations in prehospital situations is more than double that observed in hospital settings (7). In light of this situation, the necessity of ensuring comprehensive special training providing a solid foundation in airway management, of regular “refresher courses”, and of establishing a “difficult airway algorithm” is evident. Using (state-of-the-art) video laryngoscopes in prehospital settings could help reduce the frequency of difficult airway situations in the future, but it can by no means replace the necessary training in airway management skills.

indications for airway management Prehospital airway management is indicated in patients who exhibit signs of or who are at risk of developing hypoxia and when controlled ventilation is required. Thus

56 | medIcal care

Fig. 3: C-MAC® prehospital wireguided intubation (Photograph: traumateam.de)

Fig. 4: A video laryngoscope – image shows the C-MAC® PM – can be helpful when intubating conditions are difficult (Photograph: Karl Storz GmbH)

patient’s situation is an approach that has gradually been gaining ground and has now been incorporated into a nationwide algorithm for the first time – the recommendations on prehospital airway management issued by the German Society of Anesthesiology and Intensive Care Medicine, DGAI (8). Another factor that should be taken into consideration is the patient’s position –it is certainly easier to intubate a patient in the relatively favourable conditions provided by an ambulance than it is in a ditch by the roadside or in some other cramped space. A study conducted by Breckwoldt indicates that emergency doctors experienced in anaesthesiology are less reluctant to perform this invasive procedure (9). However, this should not lead us to conclude that doctors with less anaesthesiological experience intubate too rarely; on the contrary, it is important that doctors do not get themselves into a situation they cannot handle. Ensuring that doctors receive regular practical training, e.g. as visiting physicians in anaesthesiology departments, could contribute significantly to improving patient safety in this regard. respiratory insufficiencies that cannot be managed by other means, including apnoea, impaired protective airway reflexes associated with a score of < 9 on the Glasgow Coma Scale (GCS), injuries resulting in swelling in the face and neck, impending airway obstruction, burns, inhalation trauma, aspiration, and severe traumatic brain injury are the chief indications for controlled artificial respiration to ensure optimal oxygenation and ventilation. Endotracheal intubation is still considered the “gold standard” in airway management because it offers the greatest possible protection against aspiration, but emergency physicians nevertheless need to be proficient in the use of alternative methods in case intubation problems are encountered. It is vital for doctors to assess their skills realistically and take them into consideration when deciding for or against prehospital airway management. Adding the physician’s capabilities into the equation rather than making the decision dependent solely on the

The difficult airway The term “difficult airway” is used in situations when a qualified anaesthesiologist well versed in the various options for securing and maintaining a patent airway is unable to implement the chosen alternative successfully (10). There are various, overlapping reasons for the higher incidence of difficult intubations in prehospital settings. Four factors appear to be particularly significant (6): • First and foremost is urgency, as there is no alternative to securing a patent airway in the life-threatening situation of compromised airways and respiratory failure, and there is often little time to assess possible risks. • Second, emergency patients cannot be assumed to have an empty stomach and are thus at increased risk of aspiration. Also, injuries, cervical spine immobilisation, anatomical changes, and blood and secretions can make laryngoscopy and intubation difficult. • Third, conditions on site such as poor light, cramped spaces and the limited availability of technical equipment to fall back on often present difficulties. • And last but not least, EMS physicians and those assisting them have widely varying qualifications and frequently do not have the optimal degree of skill and experience. The term “difficult airway” is, as described above, used in cases when experienced anaesthesiologists encounter difficulties – doctors who do not perform intubations regularly as part of their daily work face even greater challenges in prehospital situations. And indeed, the data compiled by Breckwoldt testify eloquently to the importance of experience and practice in airway management. As mentioned above, difficult intubations are encountered more than twice as often in preclinical situations than in hospitals. In a study by Thierbach et al. involving 598 prehospital intubations, only 85.4% of patients were

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successfully intubated on the first attempt (11). In view of the need to act quickly due to the risk of hypoxia, two intubation attempts are the most that can be considered acceptable in out-of-hospital situations. In order to minimise risk to patients, it is crucial for a difficult airway algorithm to be effected immediately after the first failed attempt. In a study by Albrecht et al., 98.2% of 762 prehospital intubations performed by Emergency Medical Service physicians were successful – impressive testimony to the effectiveness of comprehensive training and strict adherence to an algorithm (12).

The difficult airway algorithm The difficult airway algorithm is applied when the first attempt at intubation is unsuccessful. Even if rapid sequence intubation (RSI) is the standard procedure in prehospital airway management and the use of ventilation via bag valve mask as an interim step is generally avoided, this kind of ventilation is required after an unsuccessful intubation attempt. Should ventilation via facial mask turn out to be difficult or insufficient, the placement of a supraglottic airway device should be considered as an alternative in order to ensure adequate oxygenation. If this is successful and oxygenation is adequate, doctors need to decide if the insufficient protection against aspiration alone is a compelling enough reason for going ahead with endotracheal intubation. In any case, however, it is imperative to check that all necessary preparations have been made and if it is possible to improve intubating conditions before proceeding

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with a second attempt. From the very start, care should be taken to position the head optimally and a stylet should be used. Deepening anaesthesia should be considered when attempting intubation for the second time, especially if insufficient anaesthesia could have contributed to the failure of the first attempt. Intubating conditions can be improved by using a different size laryngoscope blade and having an assistant manually optimise the position of the larynx by performing the BURP (Backward-Upward-Right-Sided-Pressure) manoeuvre or OELM (Optimal External Laryngeal Manipulation) to improve the view of the glottis. Using the stylet – which is always employed in prehospital intubation – to bend the endotracheal tube beforehand can facilitate placement. Alternatively, if there is no clear view of the vocal cords, an airway exchange catheter (available from several manufacturers) can be inserted into the trachea as an intubation aid and the Seldinger technique can be used to insert the tube. Should the second intubation attempt also fail despite improved conditions, a supraglottic airway device is the fall-back option of choice. However, using the various available supraglottic airway devices safely also requires experience and practice. In the case that the patient cannot be adequately oxygenated either with a bag valve mask or supraglottic airway device and if intubation was attempted unsuccessfully (a so-called “cannot intubate – cannot ventilate” situation), it is imperative to perform a cricothyrotomy as a last resort.

Fig. 5: “Christoph 22” departing from the Armed Forces Hospital in Ulm (Photograph: B. Hossfeld)

58 | medIcal care video laryngoscopy

Conclusions

The use of video laryngoscopes has become firmly established in many hospitals in recent years. Video (indirect) laryngoscopy offers a major advantage over conventional laryngoscopy when it comes to potentially difficult airways because it can provide a view of the vocal cords and glottis even when the anatomical situation precludes a direct line of sight. The models available on the market have become progressively smaller and easier to handle, making them more suitable for quick deployment in prehospital situations and even for some in-hospital situations. Some video laryngoscopes currently available on the market are the GlideScope ® (Verathon, USA), the C-MAC ® video laryngoscope (Karl Storz GmbH, Germany), the Airtraq® (Prodol, USA), the A.P. advanced™ (Wenner Medical, Germany), the Airway Scope (Pentax Europe GmbH, Germany) and the Truview PCD™ (Truphatek Holdings Limited, Israel). Few studies assessing the prehospital use of video laryngoscopy have been published so far. Cavus et al. conducted a study involving the use of the C-MAC® video laryngoscope manufactured by Karl Storz GmbH & Co. KG at four air rescue centres in Germany and came to the conclusion that video laryngoscopy can be useful when intubation conditions are difficult. They also concluded that video laryngoscopes using a standard Macintosh blade offer a major advantage over other models because they allow switching to conventional laryngoscopy when monitor visibility is poor due to bad light conditions, the presence of secretions or technical problems – something that was successfully carried out during treatment of four of the 83 patients in the study (13). In addition, the C-MAC video laryngoscope allows a blade (D-blade) with a stronger curvature to be used when the view of the glottis is obstructed due to the anatomical situation. The size of the monitors the video laryngoscopes are equipped with varies. Some have large displays connected via cable, while others feature small, high-resolution monitors incorporated directly into the handle. Models with monitors that can be tilted and swivelled as necessary can be invaluable in cramped conditions, for example when the physician is not positioned directly behind the patient’s head. However, it must be said that the better view provided by video laryngoscopes does not necessarily mean that intubation is more straightforward, for although video laryngoscopes can look around “the bend”, this nevertheless remains an obstacle that must be overcome when inserting the tube. This requires considerable experience and practice. The use of flexible intubation catheters can make insertion easier. Since an acute risk of hypoxia means that the management of difficult airways is an extremely time-critical task, especially in prehospital situations, difficult airway algorithms should not simply list video laryngoscopy as one of several alternatives; instead, video laryngoscopy should replace conventional laryngoscopy as the first-line approach.

Since the incidence of difficult airways is significantly higher in prehospital than in hospital settings, sufficient clinical experience is crucial for successful prehospital airway management. Airway management should always proceed according to an algorithm in order to ensure that sufficient oxygenation is achieved and that potential obstacles and difficulties are recognised as soon as possible. Modern, portable devices such as video laryngoscopes are invaluable tools for emergency physicians, allowing them to proceed more confidently when forced to work in cramped areas or under conditions that are less than ideal and when the patient’s anatomical situation is difficult. To create the best possible conditions for the first intubation attempt, video laryngoscopy should become the first-line approach rather than being a second-line alternative in algorithms for the prehospital management of difficult airways. That said, it should not be considered an alternative for those with little experience in airway management but should always be performed by physicians who have had adequate experience and practice in applying it in hospital situations.  References: 1. American College of Surgeons (2008) ATLS – Advanced Trauma Life Support for Doctors: Student Course Manual. ACoS Chicago 2. Bernhard M, Mohr S, Weigand MA (2012) Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesth Scan 56: 164-71 3. Genzwürker HV, Finteis T, Wegener S et al. (2010) Inzidenz der endotrachealen Intubation im Notarztdienst: adäquate Erfahrung ohne klinische Routine kaum möglich. Anästhesiologie und Intensivmedizin 4: 202210 4. ILCOR (2000) Circulation 102: I86-I89 5. Timmermann A, Russo SG, Eich C et al. (2007), The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anaesth Analg 104(3): 619-23 6. Hosseld B, Lampl L, Helm M (2011) Notwendigkeit eines Algorithmus für den ‘schwierigen Atemweg’ in der Präklinik. Notfall Rettungsmed 14: 10-14 7. Helm M, Gries A, Mutzbauer T (2005) Surgical approach in difficult airway management. Best Practice Res Clin Anaesth 19: 623-640 8. Timmermann A, Byhahn C, Wenzel V et al. (2012) Handlungsempfehlung für das präklinische Atemwegsmanagement. Anästh Intensivmed 53: 294-308 9. Breckwoldt J, Klemstein S, Brunne B et al. (2012) Expertise in prehospital tracheal intubation by emergency medicine physicians – Comparing ‘proficient performers’ and ‘experts’. Resuscitation 83: 434-439 10. DGAI/BDA (2004) Leitlinie Airway Management: Leitlinie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. 4th edition 11. Thierbach A, Piepho T, Wolke B et al. (2004) Erfolgsraten und Komplikationen bei der präklinischen Sicherung der Atemwege. Anästhesist 53: 543-550 12. Albrecht E, Yersin B, Spahn DR et al. (2006) Success Rate of Airway Management by Residents in a Prehospital Emergency Setting: a Retrospective Study. Eur J Trauma 6: 516-522 13. Cavus E and Dörges V (2011) Videolaryngoskopie in der präklinischen Notfallmedizin. Notfall Rettmed 14: 25-28

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Fig. 1: Swiss Air-Rescue Rega looked for advanced ventilation technology on a stable transport platform (Photograph: Rega)

Rega relies on HAMILTON-T1 ventilators: Reducing risks in transport ventilation When Swiss Air-Rescue (Rega) was looking to replace the transport ventilators in its jets, the idea was to find a ventilator that is capable of continuing the care provided bedside during air transport. Evaluation of the transport ventilators currently available on the market did not meet their requirements – considering that The transport of patients requiring mechanical ventilation bears considerable risks. A change of equipment as well as any change in the patient’s position can affect the patient’s condition. Rega looked for advanced ventilation technology on a stable transport platform being aware of the potential complications. During the transport, hypoxemia may occur as a consequence of the inability to reproduce bedside ventilator settings adequately. Elevated O2 concentration may potentially mask deterioration in lung function and can contribute to absorption atelectases. Hyperventilation is a common complication associated with the poor control of minute ventilation by most of the portable ventilators. Hyperventilation increases intrathoracic pressure, produces air trapping, reduces cardiac output, shifts the oxyhemoglobin dissociation curve to the left hindering oxygen unloading, and causes cerebral and myocardial vasoconstriction. These combined effects may affect patient outcome adversely (Tobin, 2006). The development of dedicated transport ventilators started at the beginning of last century – independent of the ICU ventilators. The transport devices needed to be rugged, lightweight, reliable and operate from battery

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power or from the pressure of the oxygen. A basic transport ventilator supplies mechanical ventilation at a specified rate and pressure and offers minimal monitoring and alarm capabilities. Newer devices are more sophisticated and allow for synchronization and (limited) O2 therapy. Finally, Rega chose to equip its ambulance jets with the HAMILTON-T1. Hamilton Medical, a Swiss company that is specialized in critical care ventilators, had used a rather different approach when designing the ventilator: Instead of taking a transport ventilator and adding ICU features, Hamilton Medical designed a fully equipped ICU ventilator and made it shock resistant, water-protected and light-weight. In the final phase of the development, a close partnership between Rega and Hamilton Medical allowed the ventilation specialists to tailor the HAMILTONT1 exactly to the needs of mechanical ventilation during air ambulance transports.

Authors: Christa schnider Hamilton Medical AG Via Crusch, 7402 Bonaduz, Switzerland Olivier seiler Swiss Air-Rescue (Rega) PO Box 1414, 8058 Zurich Airport, Switzerland

60 | medIcal care a fully-fledged iCU ventilator is “airborne” The HAMILTON-T1 ventilator has a powerful turbine integrated that delivers up to 210 l/min flow and thus guaranteeing high performance, also during non-invasive ventilation. IntelliTrig – a unique feature of the HAMILTON-T1 – automatically adjusts inspiratory and expiratory flow trigger for a perfect synchronization between the patient and the ventilator. Besides advanced ventilation features like a FiO2 setting between 21% and 100%, biphasic modes DuoPAP and APRV, trends and loops, the HAMILTON-T1 includes the Dynamic Lung visualizing the patient’s lung conditions and Adaptive Support Ventilation (ASV). ASV relies on closed loop regulation of settings in response to changes in respiratory mechanics and spontaneous breathing. Once a target minute volume is entered by the clinician using a percent Minute Volume setting, ASV automatically determines a target tidal volume (VT) and respiratory rate combination based on the minimum work of breathing principle. The advantages of ASV have been shown in various studies. During transport, where conditions are even more difficult, this ventilation mode helps the medical team to optimally ventilate the patient with less user interactions and fewer alarms. The team can focus on on other important tasks.

Fig. 2: Hamilton Medical designed a fully equipped ICU ventilator and made it shock resistant, water-protected and light-weight (Photograph: Hamilton Medical)

Case report: Transfer of a 9-year-old boy with open chest

Fig. 3: Upon arrival, the patient was disconnected from the Hamilton-T1 and reconnected to a conventional ICU ventilator (Photograph: Rega)

Reference: Tobin MJ (2006) Principles and Practice of Mechanical Ventilation. McGraw-Hill New York: 661ff.

Air supply

Integrated turbine

FiO2

21 to 100%

CO2 measurement

Mainstream or sidestream

Weight

6.5 kg incl. batteries and power supply

Display

8.4 inch, TF colour touchscreen

Backup battery time

5.5 hours with 1 internal and 1 hot swappable battery

Degree of protection

IP24

The first mission with the HAMILTON-T1 was carried out in Germany in October 2011. The patient, a 9-year-old boy with a history of cardiac arrest of unclear origin (and therefore often in need of resuscitation), was waiting in Düsseldorf for air ambulance transport to Berlin. He developed an acute respiratory infection and, as a result, a cardiac insufficiency, which was to be treated by the implantation of a ventricular-assist device – a procedure which had to be performed in Berlin. At the takeover in Düsseldorf, the Rega team was confronted with the boy having an open chest and being connected to an extracorporeal membranoxygenation device (ECMO). Ventilation on a conventional ICU ventilator had been demanding. The patient was disconnected and reconnected to the HAMILTON-T1. The height of the patient was entered as basic setting and the mode ASV selected. Within a minute, the patient was showing normal ventilation parameters for the circumstances. During the entire flight, the ventilator HAMILTON-T1 adapted perfectly to the various changes in environmental and patient conditions and maintained a stable respiratory performance. Throughout the transfer with ongoing ECMO treatment, the Rega team could take care of the patient without the need to constantly check and adjust the ventilator settings. Upon arrival in Berlin, the patient was disconnected from the HAMILTON-T1 and reconnected to a conventional ICU ventilator. Another demanding transport was completed successfully and the Rega team – satisfied and quite impressed by the new device – headed back to their base in Zurich.  For more information, visit: ››› www.hamilton-medical.com ››› www.rega.ch

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Quality improvement in HEMS: Stickers documenting intervention in non-traumatic cardiac arrest The management of non-traumatic cardiac arrest is common to all pre-hospital care systems throughout the world. In recent years the emphasis has been placed on the quality of chest compressions in the initial response to cardiac arrest by both lay persons and medical professionals. Systems such as the Essex and Herts Air Ambulance in the UK take advanced critical care skills into the pre-hospital environment and, as such, provide an evidence-based package of care to patients in cardiac arrest. The following report describes the set of key performance indicators used by the service, introduced in the form of stickers that are intended to improve the documentation of this package of care. The key performance indicators have since evolved in line with the ERC 2010 guidelines. Between 2008 and 2009, Essex and Herts Air Ambulance Trust (EHAAT) pre-hospital care teams were tasked to around 100 non-traumatic cardiac arrests (NTCA). This is approximately two patients per week across the two counties. In addition to running standard Advanced Life Support (ALS) protocols, the team carries specialist equipment to improve the quality of cardiopulmonary resuscitation. The use of an active compression-decompression

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device (ACD) along with an impedance threshold device (ResQPODâ&#x201E;˘) aims to optimise coronary and cerebral perfusion during the resuscitation attempt. The end-tidal carbon dioxide (ETCO2) value can be used as an indication of the quality of CPR that is in progress. Survival from out-of-hospital cardiac arrest is more likely if return of spontaneous circulation (ROSC) occurs on scene and prior to transport to hospital so it is standard practice

Fig. 1: The EHAAT-team responds to major trauma and medical emergencies, with the latter accounting for approximately 20% of all missions (Photographs: EHAAT)

Authors: Dr adam Chesters Specialist registrar in Pre-Hospital Care Essex and Herts Air Ambulance Trust adam@ukhems.co.uk Dr anne Weaver Consultant in Pre-Hospital Care Essex and Herts Air Ambulance Trust Dr Gareth Grier Consultant in Pre-Hospital Care Essex and Herts Air Ambulance Trust Air Ambulance Trust

62 | medIcal care

Date

Before stickers in record

after stickers in record

Medical cardiac arrests (n)

ROSC (n)

ROSC (%)

Pre ROSC KPIs met (%)

89.8

Post ROSC KPIs met (%)

54.4

79.2

Total KPIs met (%)

55.8

86.9

Mean age

59.5

58.8

Table 1: Combined results of audit into documentation of NTCA cases attended by EHAAT

Fig. 2: Between 2008 and 2009, EHAAT pre-hospital care teams were tasked to around 100 NTCAs

Fig. 3: Essex Air Ambulance on the helipad at the Royal London Hospital: aeromedical transfer allows patients to be flown to specialist hospitals

for the EHAAT team to provide treatment on scene and only transport to the hospital once ROSC is achieved. In the event of ROSC, the clinical team will implement a number of measures including therapeutic hypothermia, which has been shown to improve the likelihood of a neurologically intact survival in patients (see also Gutiérrez Rubio JM et al., 2012, “Therapeutic hypothermia in HEMS operations”, ARM 1: 46-50) who have ventricular fibrillation as the initial rhythm, and is recommended in the latest European Resuscitation Council guidelines for patients who achieve ROSC after NTCA. The availability of an air ambulance may also allow suitable patients to be transported directly to a more distant centre for specific interventions such as primary percutaneous coronary intervention (PPCI). Clinical notes for all patients seen by the team are recorded on a patient report form (PRF), a generic A4 pro forma document. This document is used for both trauma and medical patients and has limited space. Notes relating to NTCA are commonly spread across multiple entry fields and can be unclear. It is essential that all relevant information is recorded on this form and that it is legible. In May 2010, EHAAT implemented a simple adhesive sticker listing interventions for NTCA grouped into a series of key performance indicators (KPI) that are evidence-based and should be achieved for all patients in NTCA treated by the team (Fig. 5). The EHAAT audit standard is that a sticker is placed on all PRFs relating to NTCA, and that all KPIs are met. The overall aims were to improve, clarify and standardise documentation in addition to providing an aide memoire for the package of interventions that the team can provide on scene. Following this change and in line with good practice, we performed a retrospective audit and applied the KPIs to the PRFs of all NTCAs since the inception of our doctorparamedic service. We proposed the hypothesis that the introduction of stickers into the clinical record improved the documentation of pre-hospital management of these patients.

Method A manual search of the archive of EHAAT PRFs was performed to identify patients with non-traumatic cardiac arrests that were treated by the pre-hospital care team. All PRFs from 1st October 2008 (since the introduction of full-time doctors to the service) until 30th September 2010 were included. Each PRF was reviewed to see which interventions that were later listed as KPIs were documented as complete before the introduction of the stickers, and the number of KPIs ticked as completed since the introduction of the stickers.

Results The inclusion criteria were met by 95 PRFs (66 male, 21 female, 8 not documented) and were subsequently reviewed. 79 PRFs relating to NTCA were filed for the period before the introduction of the stickers and 16 cases occurred after their introduction. The mean age of patients was similar for the two cohorts. Prior to the introduction of the stickers, 56% of interventions that later became

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medIcal care | 63 service pre-ROSC KPIs were documented as complete and 54.4% of interventions that later became service post-ROSC KPIs were documented as complete. Since the introduction of the stickers, these figures have increased to 89.8% and 79.2% respectively.

Discussion In the majority of cases the stickers improved documentation. There was a difference in the mean number of KPIs documented as completed before and after their introduction. Accurate and legible medical records are essential to good quality patient care. This was one of the driving factors in the introduction of the stickers to our service. In a number of cases attended by the doctor-paramedic team prior to the introduction of the stickers, there is no documentary evidence that the interventions that now make up the service KPIs were completed. Management steps may have been taken but not documented on the PRFs. The impedance threshold device and the ACD-CPR device were introduced to the service some time after October 2008 but we have noticed during this audit that the teams frequently did not record their use even after their introduction to the medical kit. Insistence on explicit documentation of a working diagnosis (only 39.2% prior to use of stickers) may encourage teams to think more about the underlying cause of the cardiac arrest, allowing focused interventions and triage to the most appropriate hospital when ROSC is achieved. A working diagnosis of ‘cardiac arrest’ was not deemed sufficient to meet the criteria for our KPI. Reasons may exist to explain non-compliance with KPIs (usually clinical judgement) and since May 2010 it is expected that all non-compliance be clearly documented on the PRF alongside the sticker. Since the introduction of the stickers there has been an increase in ROSC rate for our patients. This may reflect a standardised evidence-based intervention package that can now be provided and documented by our doctor-paramedic pre-hospital care teams but there are several confounding factors that may also explain this improvement. This will be the subject of ongoing audit and analysis, which will be facilitated by improved documentation.

During cardiac arrest: 

ETCO2 monitored and checked



Airway managed with LMA or ETT



Oxygenation optimised throughout



Chest compressions with ACD or Autopulse



Impedance Threshold Device applied (ResQPOD)



Intravenous or intraosseus access obtained



Defibrillation and drug therapy according to ALS guidelines



Working Diagnosis described in the patient record

after Return of spontaneous Circulation: 

ECG obtained and interpreted



30mls/kg cold intravenous fluid with temperature monitoring



Definitive airway secured

Recommendations for future practice



Long-acting neuromuscular blockade initiated

1. Ongoing use of stickers for non-traumatic cardiac arrest and monthly audit of compliance 2. Development of documentation stickers for other emergencies 3. Ongoing education and training in the management of non-traumatic cardiac arrest 4. Minor amendments to the KPI stickers in line with 2010 European Resuscitation Guidelines



No signs of anaesthetic awareness



Decision to transfer to PCI centre considered and documented

Conclusions The KPI sticker is a concept that is easily transferable to other specific emergencies attended by EHAAT pre-

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Fig. 4: The use of a helicopter to deliver a doctor-paramedic team to patients in cardiac arrest in remote or difficult-to-access locations

Fig. 5: Sticker attached to EHAAT patient record to document NTCA intervention

hospital care teams. The generic PRF can become a more specific document for individual patients. The data from this audit supports the continued use of PRF stickers to improve standard of documentation for non-traumatic cardiac arrests. Teams must be encouraged to document the reasons for non-compliance with the KPI. 

64 | HIstorY

Fig. 1: In 1892 Dutch physician Dr Cornelis de Mooy (1834-1926) started developing theoretical concepts for using dirigible balloons in military medical care

When rescuers learned to fly – The development of air rescue up to 1918 Author: Dr Heinzpeter Moecke Professor, Head of the Medicine & Science Division Head of the Institute for Emergency Medical Care Asklepios Hospital Group Hamburg h.moecke@asklepios.com

Air rescue missions in air ambulance helicopters and fixed-wing aircraft are absolutely routine these days. Carrying qualified personnel and all the necessary medical equipment, these aircraft can quickly transport patients in even the most critical of conditions. But how did it all begin? The idea of using aircraft to transport patients emerged at around the same time as the dream of flight first became feasible. However, the visionaries pioneering the first concepts in the late 19th and early 20th century initially had only military applications in mind. The idea of the “flying ambulance” actually goes back much further: The term “flying ambulance” was first used in 1792 by French surgeon Baron Dominique Jean Larrey, later surgeon-in-chief in Napoleon’s army, to describe his concept for providing first aid to wounded soldiers on the battlefield. He meant “flying” in the sense that surgeons would swoop onto the battlefield with their medical kits and treat soldiers on the spot rather than waiting for them to be brought in to the infirmary. Larrey’s idea was so successful that it was quickly imitated by other European armies.

The popular story claiming that the first air rescue took place in 1870, when 160 injured soldiers were rescued on dirigible balloons from Paris, then besieged by Prussian troops, has since turned out to be a myth. In actual fact, the Dutch physician Dr Cornelis de Mooy (1834-1926) started developing theoretical concepts for using these steerable balloons in military medical care (1) in 1892 – a quest that earned him the nickname “the Jules Verne of air ambulance services”. Prof. Charles Richet, a French doctor who later won the Nobel Prize for Medicine in 1913 for his work on describing anaphylaxis, also took

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HIstorY | 65 an interest in aircraft construction alongside his medical research. He is said to have suggested transporting patients by air in 1895. The first publications on the possibilities of using aircraft in the military medical corps emerged even before World War I. In a weekly military publication launched in 1911, Dr Otto Blau, regiment physician in the second guard field-artillery regiment, published an article entitled “Modern aids for surveying the battlefield”. Impressed by a flight demonstration in Potsdam by flight pioneer Orville Wright, he wrote: “We have yet to consider one of our most modern aids − aeronautics. I sense a smirk spreading across the lips of my readers, but I urge you to think of how quickly other technologies, underestimated at first […] have proven their worth. Of course, I am not suggesting we transport patients by air (2).” In 1913, Parisian publishing house L’Edition Aérienne (3) brought out a richly illustrated publication by C. L. Julliot called “Avions et dirigeables au secours des blessés militaires”. The early 20th century witnessed the onset of modern air travel. In 1903 the Wright brothers made their first successful flights, which were followed by others by Léon Delagrange and the brothers Henri and Maurice Farman. Experiments were carried out in aircraft construction by pioneers working in the United States and Europe, including the famous Count Ferdinand von Zeppelin. Military strategists in various armies soon took an interest in these new technological developments and their possible military applications. The physicians who turned their attention to these new modes of transport were initially concerned most of all with the effects flight had on the physiology of the pilots and their own selves. In 1917, Major Ralph N. Green from the US medical corps in Florida wrote: “I have been asked to describe the sensations that one experiences while in actual flight. I frankly admit an entirely inadequate vocabulary and power of descriptive writing to convey in an intelligent manner the numerous mental and physical impressions resulting from an altitude flight.” (4) In January 1910 at Fort Barrancas in Florida, US officers Captain George H. R. Gosman and Lieutenant Albert L. Rhoades modified an aeroplane they had constructed

themselves to enable it to transport a patient. The aircraft flew at a height of 100 feet for barely 500 metres before crashing due to mechanical problems. Despite this somewhat inauspicious beginning, they reported their experiences to the US Department of War and asked for financial support. Their idea was not pursued any further by the government, and a second application by the air force in May 1912 also went unanswered (5). It was not until February 1918 that Major Nelson E. Driver and Captain William C. Ocker in Lake Charles, Louisiana received a permit to modify a Curtiss JN-4 “Jenny” plane for transporting patients. They were therefore able to install a stretcher in the back of the cockpit (Fig. 3), and they apparently went on to carry out the very first patient transport for the US military. This development was deemed to be so positive that from 23 July 1919 all US air bases were equipped with an air ambulance plane. Over in Great Britain, test flights with fixed-wing air ambulances had already begun in 1913. Lieutenant Colonel J. D. F. Donegan and Colonel S. F. Cody were responsible for the tests (Fig. 4). On 14 January 1914, Donegan gave a lecture describing the role of an air ambulance:

Fig. 2: US officers Captain George H. R. Gosman and Lieutenant Albert L. Rhoades modified an aeroplane to enable it to transport a patient

Fig. 3: A Curtiss JN-4 “Jenny” modified for transporting patients: a stretcher was installed in the back of the cockpit

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Fig. 4: Lieutenant Colonel J. D. F. Donegan and Colonel Cody were responsible for the first air ambulance trials that took place in Great Britain in 1913

Fig. 5: The French member of parliament Dr Chassaing is credited with finally persuading the war ministry to start using air ambulances

1. To search out wounded soldiers on the battlefield 2. To simplify the tasks of the division physician by making it possible to send medical care anywhere in a significantly shorter amount of time 3. To transport specialist doctors to the front to give wounded soldiers the same level of medical care they would receive in peacetime 4. To provide additional medical personnel any place where needed The air ambulance plane carried an operating table constructed by Donegan himself. Attached to it were several boxes containing the necessary bandages, implements and medicines (7). In France, doctors, military officers and politicians had been working on concepts for transporting patients since 1912. Lieutenant-Colonel Joseph Duchaussoy and the doctor, senator and passionate aviator Dr Emile

Reymond approached the French ministry of war with their idea on 23 May 1912. However, they received no response. In the end, patients were probably transported by air for the first time during battles in Serbia in 1915 − possibly even in 1914. A certain Captain Dangelzer is said to have flown a member of the Serbian air force from Mitrovica to Prizren (8). This was not an isolated incident, however. In total, 13 wounded soldiers were reported to have been transported over distances of between 80 and 200 kilometres. The French member of parliament Dr Chassaing is credited with finally persuading the war ministry to start using air ambulances in battle zones. The first of these, the Breguet (Fig. 5), was used in Villacoublay for the first time in September 1917 (5) and then moved further afield, being successfully implemented in southern Morocco in January 1918. (9) The German military, too, began transporting the wounded by air – towards the end of WWI at the latest. “This is nothing new to us Germans,” stated a publication from the 1930s (10). “We were highly successful in transporting our sick and wounded pilots from the Palestinian front in 1917 and 1918”. The State Office for Matters of Air and Motor Vehicles created a set of guidelines called “Rescuing patients: Operations and preventative vaccinations by doctors flown in by air; transporting patients in medical aircraft” (11).The transportation of civilians also became a reality around this time. Patients were transferred from remote areas of Sweden, for instance, or were taken on board airline flights. Air ambulances made by German firms such as Dornier and Junkers were sold around the world, even after the German Reich was defeated in the First World War and the Treaty of Versailles subjected the country to severe restrictions on the building and use of aircraft. 

References: 1. Vincent A (1924) Le transport des blessés par avions. Revue internationale de la Croix-Rouge 6: 720-723 2. Blau (1910) Moderne Hilfsmittel bei der Absuchung des Schlachtfeldes. Militär-Wochenblatt 95: 917-924 3. Julliot CL (1913) Avions et dirigeables au secours des blessés militaires. L’Edition Aérienne Paris 4. Greene RN (1917) Some aero-medical observations. Mil Surgeon 41: 589-597 5. Wood FW (1923) The Airplane Ambulance. In: The medical department of the United States Army in the world war. Kapitel XXI: 416-425 6. Grant DNW (1941) Airplane Ambulance Evacuation. Mil Surg 88: 238-243 7. Flemming (1914) Kraftwagen im Heeressanitätsdienst. Veröffentlichungen aus dem Gebiet des Militär-Sanitätswesens. Heft 59: 25-26 8. Munro D (1924) The use of the aeroplane in the medical services in war. Proc Roy Soc Med (War Section) 17: 7-12 9. Tuffier T (1919) Aviation and wounded in the desert of Sahara. Mil Surg 44: 437-445 10. Hippke (1934) Flugdienst und Krankentransport. Der Deutsche Militärarzt 1: 74-75 11. Sachs-Mücke (1928) Verwendung und Eingliederung von Kraftfahrzeugen und Flugzeugen im Heeressanitätsdienst. In: Geb d. Heeressanitätswesens 82: 179-212

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