AirRescue Magazine 3/2012 by Verlag Stumpf & Kossendey

European HEMS

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

EHAC

Interview with President M端ller

Medical Care

CO-Poisoning: A Case in HEMS

Technology

Paperless Cockpit

ISSUE 3 | Vol. 2 | 2012

C-MAC® – Pocket Monitor Mobility is our Passion… …and Highest Requirements of Hygiene our Standard!

AN 34/07/11/A-E

NEW

8 IP X

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., 2345 Argentia Road, Suite 100, Mississauga, Ontario L5N 8K4, Phone: +1 905 816-8100, Fax: +1 905 858-0933, E-Mail: info@karlstorz.ca www.karlstorz.com

E di tori a l Dear colleagues and friends, One would expect quiet times during the summer months. However, in summer some things can also heat up. This is what apparently happened with the European AeroMedical Institute (EURAMI), now that the board decided to resign. It is a sad thing to see that organizations with the professional interest of our business in mind somehow do not seem to achieve what they aim to. And in our dynamic and fast changing world with more and more regulations and less and less money available – due to substantial budget cuts – it is increasingly important that we join forces. Unfortunately we are not always successful, our industry is not always capable to overcome personal interests and strive for the interest of our business as a whole. Others have to do little to implement a “divide and conquer” strategy: the government will do as it sees fit if we are not able to give adequate input with one voice. Common standards will never become common standards if not implemented by a majority of the operators. Thus the European HEMS and Air Ambulance Committee (EHAC) has the noble task not only to support and protect the interest of HEMS and Air Ambulance Operators, it also has the task to overcome personal interests and to unite the helicopter industry. With our current fellow organizations such as the New EHA, I am sure we will be able to do so. The articles in this issue of the AirRescue Magazine reflect the importance of what the EHAC stands for. Medical insights, fascinating case reports and profile reports on different operators succeed each other. Case reports include articles on “carbon monoxide poisoning” by Weinberg, on “traumatic amputations” that

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require rapid and complex decision making by Skinner and a report by Cipolotti et al. on an “avalanche burial” and the successful rescue of the victims. The tremendous diversity of the European and global HEMS community, its success-stories, future challenges and developments are also being covered in this issue. Various profile reports on HEMS operators and organizations from the Netherlands (ANWB MAA), Czech Republic (Alfa-Helicopter), France (Centre médical des Armées de Brest-Lorient), Belgium (Centre Médical Héliporté) and Switzerland (Air Zermatt) make this a truly European issue. We are especially proud to present two new EHAC members: ADAC Service GmbH from Germany and Midlands Air Ambulance from the UK. See also the interviews with Hanna Sebright, CEO of Midlands Air Ambulance, and with Dr Irmgard Seidl, Managing Medical Director of ADAC Service GmbH, on pages 14 and 15 of this issue. Please enjoy this issue of AirRescue Magazine and support us in our efforts to keep our business safe and sound! Yours sincerely,

Denise Eikelenboom Vice-President of the European HEMS and Air Ambulance Committee

140 | 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

Pioneers in their own respect: An interview with Dr Pavel Müller (EHAC) and Jan Šebek (Alfa Helicopter)

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Air Zermatt is flying high: From small-time helicopter operator to revered air rescue service P. Grand

“ So others may live”: SAR activities in Brittany J. Weinberg

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

in Belgian Skies “24/7” – Centre Médical Héliporté O.Pirotte, D. Moens, O. Lambert

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CONTENTS | 5

Prehospital use of portable ultrasound for stroke diagnosis and treatment initiation T. Hölscher

06 14

News New EHAC-members

Rescue Chain Offshore Wind: Developing a concept for trauma patients in offshore wind turbines

Seminar at Hyères Naval Air Base: EU regulations and French HEMS

T. Clément

FIXED WING

1 4 patients in 6 flights on one day Rega-repatriation after Sierre bus crash S. Becker IN PROFILE

N. Weinrich, D. Dethleff, C. Friebe, M. Stuhr, K. Seide, C. Jürgens

MEDICAL CARE

Carbon monoxide poisoning: A case in HEMS J. Weinberg

Traumatic Amputations: rapid and complex decision making

D. Skinner

CASE REPORT

“Christoph 26” uses rescue winch over famous cruise ship

Within reach of the people: ANWB MAA’s “Lifeliners”

Minniti, P. Zanatta

OFFSHORE

EVENTS

Surviving an avalanche burial: successful rescue in two and a half hours G. Cipolotti, L. De Lazzer, G.

Editorial Team

“A day in the life of an MAA pilot”: An interview with Marco van den Berg

TECHNOLOGY

ALLFlight: Assisted Low Level Flight and Landing on Unprepared Landing Sites

Air rescue in the Czech Republic: Alfa-Helicopter’s “Kryštof 12” T. Bader, P. Poguntke

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D. Hessenius, B Freese

R. Lantzsch, S. Greiser, J. Wolfram, J. Wartmann, M. Müllhäuser, T. Lüken, H. Döhler, N. Peinecke

ÖAMTC Air Rescue Service makes the move towards a “paperless cockpit” Editorial Team

Cover Image: Valentin Bianchi

6 | NEWS Association of Air Ambulances (UK): Conference and National Week 2012 The Association of Air Ambulances (AAA) will be hosting its annual conference on Monday 19th and Tuesday 20th November at the Telford International Conference and Exhibition Centre in Shropshire (West Midlands, UK). The national conference looks forward to building upon previous successful events and will bring together delegates from the air ambulance community to cover all aspects of their work including clinical, air operations and charity fundraising.

Bell Helicopter

Bell 429 gaining momentum in Europe Keynote speakers will include Health Minister Simon Burns and Anthony Marsh, CEO, West Midlands Ambulance Service. Other speakers are drawn from the charity, medical and business world and will take a leading part during the two-day event organised by the AAA, the representative body of the majority of air ambulance operators in the UK. The programme includes plenary sessions, symposia and a gala dinner. Clive Dickin, National Director of the Association of Air Ambulances, said: “The conference will provide delegates with an ideal opportunity to discuss all aspects of air ambulance operations across the UK.” Clive added, “This year’s conference will be bigger than previous events, thereby giving air ambulance organisations the recognition it deserves. The Association will also launch its prestigious “Air Ambulance Awards of Excellence”. These awards will reflect the dedication to duty and support of those involved in the air ambulance community.” Furthermore, the AAA will hold the first National Air Ambulance Week from 24th to 30th September 2012, supported by one of Britain’s most famous and respected actors, David Jason.

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

The Bell 429 in EMS and rescue operations is gaining a lot of momentum in Europe: Swiss operator Air Zermatt has taken delivery of the first Bell 429 to be registered in Western Europe. It is the 67th production example and will be flying as HB-ZSU. Painted all red, the helicopter has a hoist (90 metres) fitted to the starboard side and would thus be used for mountain rescues. The helicopter is equipped with a SX-5 Starburst searchlight, an infrared aviation system, „Max-Viz Enhanced Vision Systems“, and certified NVGs. It will be taken into service mid-September 2012. Furthermore, Scandinavian Air Ambulance has been awarded a new contract starting 1 April 2014 with a Bell 429 to be based in Visby on

the island of Gotland (Sweden). The new contract runs for five years with a two-year option (i.e. five plus two years). In HEMS configuration the Bell 429 includes a spacious 200ft³ cabin that provides unobstructed full body patient access. There is ample space to install various medical equipments. The deck height is designed for one man loading litter system without back strain. The Bell 429 is regarded as one of the most advanced light twin IFR helicopters. For more information, visit: ››› www.bellhelicopter.com ››› www.airzermatt.ch

Care for pregnant women at risk – on land and in the air Air ambulance teams are not called on to provide intensive care transport for high-risk obstetric patients very frequently. But when they are, inadequate knowledge on their part can have serious consequences. And indeed, conditions such as pre-eclampsia and HELLP syndrome pose considerable challenges for ambulance crews, both in the air and on the ground. The German chapter of the International Association of Flight and Critical Care Paramedics (IAFCCP) is offering a two-day CME event on the topic on 2 and 3 February 2013. The course is based on a concept developed by O.B. STAT, whose president, Pam Adams, will take part as a guest lecturer. Ms Adams has a 24-year background in nursing and a 27-year background in emergency medicine. She has been involved in flight medicine since 1989 and currently chairs

the ASTNA Maternal Transport Special Interest Group. She is a frequent lecturer at Association of Air Medical Services (AAMS) conventions. The course will take place in the auditorium wing of the University Hospital Munich. Ms Adams, who comes from the United States, will give her talk in English. The IAFCCP has provided funding for the event to cover her travel costs. IAFCCP members will be reimbursed for 15 Euros of the attendance fee upon submitting written confirmation of participation in the course. The event programme and registration form can be downloaded here as a zip file: http:// db.tt/BS3fcuvE. For more information, contact: ››› iafpgerm@t-online.de.

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NEWS | 7 Aerolite and Kuerzi Avionics: strategic partners Aerolite recently signed a partnership agreement with Kuerzi Avionics to provide state-ofthe-art electronic system solution for airplanes and rotorcrafts EMS cabin solutions. Aerolite’s exhaustive experience in developing, producing and certifying customized EMS interiors solutions perfectly combines with Kuerzi’s engineering strength to tailor cabin systems in line with customer needs and requirements. Due to the new partnership, Aerolite is now able to offer NVG cockpit and cabin certification. “For Kuerzi Avionics, the synergy with Aerolite is a logical enhancement of our current business

relationship in order to drive cabin innovations to the next level. Existing and new EMS customers across the world will benefit from the combined capabilities of both companies”, said Ralf Kürzi, CEO of Kuerzi Avionics. “For Aerolite, the synergy with Kuerzi creates a solid foundation of aviation expertise to offer new electronic technologies for tomorrow’s EMS interiors”, said Max Bucher, Aerolite’s President & CEO. For more information, visit: ››› www.aerolite.ch

Aerolite

Tailor-made Medical interiors that fit your mission

Performance Lightweight equipment and excellent handling

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

EURAMI: New board members to be elected in November After the board members of the European AeroMedical Institute (EURAMI) resigned on 28 June 2012 (quoting conflict with Dr Michael Weinlich, the Institute’s president), a new interim board took over until permanent board members are elected at the EURAMI members meeting in November this year. Weinlich will remain president until the elections take place. Members of the interim board are: Chris Connor, vice-president and operations manager for Life Flight International, Canada; Milan Floribus, founder and vice-president of American Care Air Ambulance, USA; Mark Jones, president of Air Ambulance Worldwide, USA; Philipp Schneider, key account manager at Quick Air Jet Charter, Germany; and Dr Jon Warwick, medical director of Air Medical Ltd (AirMed UK), UK. According to news reports, the former board members explained that their resignation was prompted by a “complete lack of confidence in the current leadership”. While they still believe in EURAMI as a “professional organisation”, the situation did not leave them a choice but to resign. For more information, visit: ››› www.eurami-academy.com

Flexibility Quick change capabilities for different missions

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

Turnkey solutions From design to completion

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

8 | NEWS Lite Flite with Quick Release Box Mk-4  The Quick Release Box (QRB) Mk-4 is manufactured from anti-corrosion treated stainless steel, which makes it extremely resistant to saltwater corrosion. Furthermore, the body of the QRB is given a special surface treatment. A very thin layer – less than 5 microns – of carbon and chrome ions is bonded to the surface, making it glass hard, scratch resistant and super smooth. The solid black surface adds another important feature: It makes the moving parts less vulnerable to lack of lubrication. Daily maintenance after use in saltwater is limited to a quick shower in fresh water. Once a year the QRB must be disassembled, cleaned, lubricated with special aero grade grease and has to get new stainless springs. The colour of the lid is black and a lime green bar is inserted into the lid. The contrasting colours enable the crew members to tell – even from a distance and in low light conditions – if the QRB is in the safe position. The design of the suspension strap allows the middle ring to carry load in both directions. Downwards if you want to carry extra equipment, upwards if the rescue man is forced to shift from one hoist cable to another in the air under a dual hoist equipped helicopter. The NATO stock number 1680-22-309-1736 (Lite Flite P/N 80049010) covers the complete assembly of the QRB as well as of the suspension strap. For more information, visit: ››› www.lite-flite.aero

AW609 Tilt Rotor for EMS/SAR operations AgustaWestland is also moving forward with the development of the AW609 tiltrotor programme. The company will continue the certification process with the FAA, targeting AW609 certification in the first half of 2016 and deliveries shall follow immediately afterwards. The new AgustaWestland Tilt Rotor Company (AWTRC) subsidiary has now been established at the new site in Arlington to continue FAA certification and flight-testing of the first prototype. The first two prototypes have achieved more than 650 flight hours so far and are said to have “validated the AW609’s unique flight envelope, including the ability to fly at altitudes of up to 25,000 feet and cruise at speeds up to 275 knots, all at the aircraft’s maximum weight.” The AW609 is a multi-mission tiltrotor aircraft designed to employ the speed of a turboprop airplane with the vertical takeoff and landing capability of a helicopter offering unique capabilities to EMS/ SAR operators. For EMS and SAR operations, the AW609 offers basket, litter and a 600 lb capacity exterior hoist option. For more information, visit: ››› www.agustawestland.com

Turbomeca announces European HEMS SBH contracts Turbomeca signed Support by the Hour (SBH) contracts with DRF Luftrettung and ADAC Luftfahrt Technik. The five-year contract with DRF Luftrettung covers 26 Arriel 1E2 engines powering the BK117C1 and EC145 helicopters. The organisation has over 50 helicopters of various types. DRF Luftrettung recently ordered a further 25 EC145 T2s (see AirRescue Magazine 3/2011), which will be powered by the Turbomeca Arriel 2E engine. The ADAC SBH contract covers 10 Arrius 2B2 engines powering five EC 135T2 of ADAC’s end

customer, ANWB Medical Air Assistance. ADAC Luftfahrt Technik provides airframe and engine maintenance for various helicopter operators in Europe including ADAC, ANWB and Luxembourg Air Rescue. ANWB’s subsidiary Medical Air Assistance (MAA) is located in Utrecht, Netherlands and manages the EC135 fleet covering the Netherlands. For more information, visit: ››› www.urbomeca.com

ANWB MAA

AW139 at the Olympics AgustaWestland had been selected as the sole supplier of helicopters for the London 2012 Olympic Games Opening Ceremony. Three helicopters were prepared in special colour schemes and undertook the planning and flying of the sequences filmed in advance and during the Opening Ceremony, working in close cooperation with the UK’s Civil Aviation Authority (CAA). The helicopters featured in the Opening Ceremony comprised an AW109 Power, that was seen overflying iconic London landmarks, an AW139 (G-OLYM) which transported two VIPs – body doubles of James Bond and The Queen – to the Stadium to officially declare the London 2012 Olympic Games open and an AW101 which released eight billion pieces of confetti.

The G-OLYM also flew over famous London landmarks and through Tower Bridge (three times) while being filmed from a second helicopter before arriving overhead the Olympic Stadium. The AW139 is capable of carrying up to 15 passengers. The internal dimensions of the large and unobstructed cabin make it one of the best choices for primary and secondary EMS applications. The flat floor and ceiling provide maximum cabin flexibility for easy reconfiguration. An 8 m3 cabin volume and a height of 1,42 m allows the medical attendants easy access to casualties. For more information, visit: ››› www.agustawestland.com

AgustaWestland

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NEWS | 9 Scottish Ambulance Service awards new seven-year contract The Scottish Ambulance Service has awarded a new seven-year contract to Gama Aviation in partnership with Gloucestershire-based aviation company, Bond Air Services Ltd. The contract valued at 120 million UK-Pounds, is to provide both rotary and fixed-wing air ambulance services for the people of Scotland. Under the new contract Bond will continue to use the current Eurocopter EC135T2i helicopters on an interim basis; however, from September 2014 the company will introduce two new medically-equipped Eurocopter EC145T2 helicopters to replace the existing EC135s. The new technology helicopters will further enhance the service by delivering improved range and endurance, whilst also providing larger payloads and increased cabin space. Gama Aviation will continue to operate the two existing King Air 200c fixed-wing aircraft based in Aberdeen and Glasgow.

Gama Aviation and Bond Air Services are the incumbent operators of fixed-wing and rotary air ambulance services in Scotland, and this contract renewal builds on the very successful partnership between the Scottish Ambulance Service, Bond Air Services and Gama Aviation over the last 16 years. Chris Greenhill, Managing Director of Bond Air Services, said: “For 23 years Bond has enjoyed a very successful partnership with the Scottish Ambulance Service, in which time we have developed a detailed understanding of their requirements. We look forward to continuing our partnership with Gama and enhancing our service for the Scottish Ambulance Service going forward, particularly with the introduction of the new EC145T2 helicopters.” For more information, visit: ››› www.scottishambulance.com

Scottish AA

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Axnes Aviation: Wireless Intercom System for Norwegian Air Ambulance The Norwegian Air Ambulance (Norsk Luftambulanse) has ordered the Polycon Wireless Intercom Extension systems from Axnes Aviation for its entire EMS fleet of helicopters on behalf of the National Air Ambulance Service of Norway. Norsk Luftambulanse operates eight of Norway’s eleven air ambulance helicopter bases. The systems will be installed in the company’s ten EC135s and one EC145 by Heli-One. It is classified as a “minor” modification under their EASA Part 21 J approval (EASEA GM 21A.91), and will include design verification testing, non-ingression verification, antenna radiation pattern and crosstalk prevention as well as mechanical and structural systems assessments. No STC will be needed. Norwegian Air Ambulance Fleet Manager, Lasse Dahl, said of the selection: “It has long been a request from our EMS personnel to be able to communicate as if they were all in the helicopter, also when operating outside of the aircraft during a rescue mission. Through tests, Polycon has proven to us that it will provide our operative units with this ability, even over longer distances and under difficult environmental conditions.” For more information, visit: ››› www.axnes.com

10 | NEWS Austrian patients often have to pay their own way

OEAMTC

Austria lacks uniform standards governing the funding of air ambulance services. According to the Austrian daily Kronen Zeitung, this inconsistency results from the fact that the Interior Ministry, which is responsible for emergency medical services, terminated contracts with the providers of such services several years ago. Since January 2011, each Austrian state has been responsible for organising air ambulance services within its own territory. Thus it is up to each one to sign contracts with air ambulance operators, and each decides independently how the costs will be allocated. Health insurance providers, if they pay at all, only assume costs up to a maximum of 950 Euros – a measly sum compared to the several thousands of euros that an air ambulance operation actually costs. Due to the lack of uniform standards and because “not all states did their homework”, patients frequently have to pay the difference themselves. However, Kronen Zeitung also reported that two states, Vienna and Lower Austria, did manage to work out a patient-friendly arrangement. These two states agreed to share the costs, which amount to several hundreds of thousands of euros annually, according to Thomas Klavana, the commercial director of Vienna’s Municipal Ambulance Service. Klavana said that he considers it unacceptable that patients should have to pay several thousands of euros for helicopter transports out of their own pockets. For more information, visit: ››› www.bmi.gv.at

Make your ad space reservation for the upcoming

AirRescue International Air Rescue & Air Ambulance

Deadline: 15 November 2012

TCS (I): Joining forces with AAA for repatriations Touring Club Schweiz (Touring Club Switzerland, TCS) plans to work with Alpine Air Ambulance (AAA) to provide comprehensive emergency care for its customers from a single source, repatriating patients with its own equipment. According to TCS, by taking over 49 per cent of Zurich-based AAA, it will gain three emergency helicopters and two medical vehicles for repatriations and transfers (secondary transport). The takeover also means full-time access to ambulance planes such as the Airbus 320 and Gulfstream 100. In future, all repatriations and medical-related transfers will be organised centrally, incorporating several partners such as Rega. TCS has expressly denied claims that its repatriation activities are an “attack on Rega”. The TCS medical service ETI-Med was founded in December 2010, and the specialist advice it provides to holders of ETI cover letters – a requirement for TCS assistance abroad

TCS

– is widely recognised. The medical service is made up of doctors and other specialist medical personnel (medical officers, operation managers, operation assistants, etc.). For more information, visit: ››› www.tcs.ch ››› www.air-ambulance.ch

TCS (II): On board for organ transportation in Switzerland Swiss TV recently reported that Touring Club Schweiz (TCS) is branching out into a new field: its new ambulance fleet will also transport organs – by air if necessary. In addition, TCS has signed an advertising contract with Swisstransplant, the Swiss National Organisation for organ donation and transplantation. Under the agreement, which took effect on 1 July, TCS ambulances and a helicopter belonging to Alpine Air Ambulance (a joint venture between TCS and Lions Air Group AG) now bear a Swisstransplant slogan promoting general awareness of the importance of organ donation.

The new partnership enables Swisstransplant to offer a complete organ transportation service from a single provider: TCS ambulances can take care of ground-based transport all over the country, and transport by air will be covered by Alpine Air Ambulance. Swisstransplant will continue to work with Rega, as well, although Rega will mainly handle emergency transports. For more information, visit: ››› www.tcs.ch

HEMS operations in India: Coimbatore first city to get an air ambulance? As the Indian newspaper “Deccan Chronicle” reported recently, the city of Coimbatore (southern state of Tamil Nadu) may be first Indian city to get an air ambulance. Interestingly, HEMS is being planned by the industries and hospitals of the city. A few top hospitals are said to have already agreed in principle to set up helipad facilities to make the city an (air-) medical hub. “If all goes well, Coimbatore will be the first city in the country to have an organised air ambulance service, which is the next step in effective emergency and patient care,” Mr Krishnan, president of the Indian chamber of commerce and industry (ICCI), Coimbatore, told the newspaper. Initiating the service, ICCI is already promoting the ambitious health care city (HCC) project on about 500 acres (around 2 squarekilometres) to provide affordable, quality healthcare. According to the HCC project, all kinds of treatment will then be provided “under one roof”. “Roads are congested now. Many patients requiring emergency service for example from hill stations like Ooty, Coonoor and Yercaud (Tamil Nadu) are also rushed to Coimbatore, which is one among the

best in healthcare services. An air service can reduce the travel time considerably and help save patients’ lives,” Mr Krishnan pointed out. Dr S. Rajasabapathy, the coordinator of the HCC project, will prepare the feasibility report for the air ambulance service: “We will discuss the financing details of this air ambulance service. Ultimately, patients will benefit.” A meeting on the issue was held at the end of April 2012, where Capt. Uday Gelli, CEO of Heligo Charters, Mumbai, and Mr V. Krishnan, CEO and president of OSS air management in New Delhi, participated. For more information, visit: ››› www.heligocharters.com

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The only thing

| 11 youNEWS can’t see

is how you ever got along

Canadian Coast Guard Fleet replaced soon?

without them.

SP Barrette/Wiki

The current CCG fleet includes 14 of its original 16 MBB Bo105s, manufactured in Germany but assembled and delivered by Eurocopter Canada between 1983 and 1987. The remainder of its helicopters are Bells manufactured in the United States, including three 206Bs that date to the late 1960s and five 212s that date to the late 1970s. According to news reports, AgustaWestland, Bell and Eurocopter are all potential contenders for the new contract. Possible lighttwin helicopter candidates include the AW109, the Bell 429 and the Eurocopter EC135 or 145. Potential medium-twin candidates include the AW139, the Bell 412 and the Eurocopter EC175. Sikorsky may also offer a modified S-76D in the medium category. For more information, visit: ››› www.ccg-gcc.gc.ca

Italo-Russian version of AW139

Visit us at AMTC, booth #913

AgustaWestland

Russian Helicopters and AgustaWestland announced that they have signed a Preliminary Agreement to jointly develop, produce and market an all-new 2.5 tonne class single-engine helicopter. The agreement was signed by Bruno Spagnolini, CEO of AgustaWestland, and Russian Helicopters CEO Dmitry Petrov. The overall programme will be shared on a 50/50 basis, with the new helicopter being designed for the worldwide market and a wide range of applications. AgustaWestland and Russian Helicopters established the joint venture company HeliVert in 2010 to assemble AW139 helicopters at a new plant in Tomilino, near Moscow. The plant will meet the growing demand for the AW139 helicopter in both Russian and Commonwealth of Independent States (CIS) civil markets with production starting this year.. For more information, visit: ››› www.agustawestland.com

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12 | NEWS Great North Air Ambulance (UK) allowed flying in darkness The Great North Air Ambulance Service (GNAAS), a HEMS operator that is covering an area of 8,000 square miles and operating from the Scottish Borders to North Yorkshire, from East Coast to West, is able to fly in darkness after its pilots completed training to comply with Civil Aviation Authority night-time flying rules. GNAAS pilots are now allowed to airlift patients in darkness but must still land at the scene in daylight. Chief pilot JJ Smith and his colleagues at the charity had previously been restricted to flying only in daylight hours. Mr Smith told the BBC: “I’ve been at GNAAS for three years and there have been occasions where we have been able to land, but have had to leave the doctor and paramedic on the site because we have not had the right qualifications to fly at night.” This is now a thing of the past and means that the region can be served better, according to the GNAAS. Patients can be carried to landing areas for treatment at hospitals in Newcastle, Middlesbrough and Carlisle.

Herts Air Ambulance with more than 1,000 missions Since its launch in November 2008, the Herts Air Ambulance (HAA) has flown over 1,000 lifesaving HEMS missions. Of the 1,000 missions attended by the life-saving helicopter based at North Weald Airfield, almost half were road traffic collisions, approx 16% were falls and 20% were medical cases. The Herts Air Ambulance is operational 5 days per week and attends on average 1 to 2 incidents per day. Working in partnership with the East of England Ambulance Service NHS Trust (EEAST) who task the helicopter mainly by receiving 999 emergency calls, the aircraft is dispatched to patients with serious illness or injury caused by such incidents as traffic collisions, falls

from height, heart attacks, stabbings, cardiac arrests and strokes. Herts Air Ambulance is part of the Essex & Herts Air Ambulance Trust, a Charity responsible for operating two Air Ambulances and providing free life-saving Helicopter Emergency Medical Services (HEMS) for Hertfordshire, Essex and surrounding areas. The people of Essex and Herts benefit from two helicopters as the Herts aircraft will fly into Essex and the Essex aircraft would, of course, respond to those in need of advanced pre-hospital care in Hertfordshire. For more information, visit: ››› www.hertsairambulance.uk.com

Herts AA

For more information, visit: ››› www.greatnorthairambulance.co.uk/main

uk hems Clinical Excellence in Helicopter Medicine

www.ukhems.co.uk

DRF Luftrettung: slight mission increase According to its mid-year statistics, the DRF Luftrettung flew a total of 19,667 missions in the first half of the year 2012, involving helicopter missions at 31 HEMS bases in Germany, Austria and Denmark as well as worldwide repatriations with ambulance aircrafts: a total mission increase of 2% compared to the same period of the previous year. In the field of ambulance flights, DRF Luftrettung together with LAR (Luxembourg Air Rescue) conducted 305 repatriations under the name of EAA (European Air Ambulance). These repatriation flights were coordinated by the respec-

tive dispatch centers at the airports of Karlsruhe/ Baden-Baden (Germany) and Luxembourg. At 31 HEMS bases in Germany, Austria and Denmark, DRF Luftrettung is operating helicopters for emergency rescue and the transport of intensive care patients between clinics, at eight HEMS bases, 24/7. Approximately 660 emergency physicians, 320 paramedics, 160 pilots and 80 technicians are on duty for DRF Luftrettung. For more information, visit: ››› www.drf-luftrettung.de

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 ambulanceindustry 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

DRF

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

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14 | EHAC

New EHAC-members The Midlands Air Ambulance Charity from the U.K. and ADAC Service GmbH from Germany joined the European HEMS and Air Ambulance Committee (EHAC) recently. AirRescue Magazine spoke to representatives of the two new members: Dr Irmgard Seidl, Managing Medical Director of ADAC Service GmbH, and to Hanna Sebright, CEO of Midlands Air Ambulance, about the reasons for joining the EHAC.

Midlands Air Ambulance Charity (MAAC)

MAAC is the only charity responsible for funding and operating three Air Ambulances serving the communities of Gloucestershire, Herefordshire, Shropshire, Staffordshire, Worcestershire and the West Midlands. This constitutes the largest air ambulance operatingregion in the UK. Since 1991, the Charity has responded to more than 37,000 missions, averaging 3,000 per year or nearly ten each day, making it one of the longest established and busiest Air Ambulance organisations in the UK. The Charity’s three EC135 Aircraft each carry a crew comprising of a pilot, two paramedics or flight doctors plus full life-support medical equipment. Operating from strategically located regional air bases, the maximum flying time to hospital from anywhere in the region is less than 15 minutes. AirRescue Magazine spoke to Hanna Sebright, the operator’s CEO. ARM: What is you position within Midlands Air Ambulance Charity? Hanna Sebright: I am Chief Executive Officer of Midlands Air Ambulance Charity.

is donated entirely by the public and local businesses, with 4 in 10 of those we help funded by Gifts in Wills. So the biggest challenge is to sustain our current levels of income – donations – during the current challenging economy, whilst receiving no government funding. Besides this, the increasing fuel costs and the growing needs of night time flights; an operational model has to be identified to meet this growing demand for retrieval and transfer of critically injured patients, is another issue we have to deal with. We are currently reviewing the East Aglian Air Ambulance trial of night HEMS, due to start in Autumn 2012. ARM: How many bases and helicopters are you operating? Hanna Sebright: We have three airbases across the counties which we serve and these are located at Strensham, Cosford and Tatenhill. ARM: How many mission are flown per year? Hanna Sebright: On average, we respond to 3,000 incidents each year. ARM: How many people are living within your missions area? Hanna Sebright: There are about 5.5 million people staying in the area covered by the MAAC. 

ARM: How long are you working for Midlands Air Ambulance Charity? Hanna Sebright: I joined MAAC in August 2009. ARM: Why have you decided to become a member of EHAC, and what do you anticipate from the membership? Hanna Sebright: MAAC is keen to gain an understanding of how the European HEMS model works. It is also an opportunity to develop networks, share good practices and lessons learnt from across Europe. ARM: What will be the biggest challenges for your organization within the next years?

For more information, visit: ››› www.midlands airambulance.com

Hanna Sebright: What is not widely known is that Midlands Air Ambulance receives no Government or National Lottery funding. An excess of £6 million is needed each year to keep its three Air Ambulances operational which

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EHAC | 15

ADAC Service GmbH

ADAC Service GmbH is an ADAC subsidiary that assists the insurance subsidiary ADAC Schutzbrief Versicherung by looking after ADAC members and policyholders who have an accident or fall ill while travelling. However, ADAC Service GmbH also offer these services to other people and organisations. Services include establishing the precise medical details involved and arranging and providing patient transport, transferal and repatriation. ARM: Dr Seidl, perhaps you would like to start by telling us something about theservices at your company? Gladly. Each year, we oversee 50,000 cases and carry out around 15,000 air and ground repatriations. As Managing Medical Director at ADAC Service GmbH, I am responsible for all medical matters within the company. I manage a group of 19 doctors working at the company and a group of six doctors at our emergency call centre in Spain. I also supervise a network of over 20 doctors across Europe who give their medical opinion in acute cases and make transport recommendations on our behalf. We also have a Medical Director of Operations, Dr Michael Meyer, who is based at Universitätsklinikum Erlangen and is responsible for all air ambulance transports. I initially trained as a consultant in general internal medicine and worked in a group practice for several years after qualifying. From 1997 to 2003, I was a doctor at ADAC Service GmbH, making decisions on transports and accompanying patients. I was then given the chance to build up the medical department at ADAC Schutzbrief Versicherung.

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ARM: What hopes do you have for your company’s membership of EHAC? Irmgard Seidl: Joining EHAC in April this year was part of a long-standing management strategy at ADAC Service GmbH. Our aims are to be a part of a flight ambulance advocacy group and to help shape its targets; to conduct a useful exchange of information and experience with other European companies; to achieve synergy effects in our field; to define standards for air ambulance transport; and to help devise a training concept for medical personnel. Our overall goal is to make patient transport safer. Air Rescue: What do you think will be the biggest challenges in this area? Irmgard Seidl: I believe that the biggest challenges will be optimising patient safety and satisfaction while continuing to make the best use of our resources and ensuring we operate cost-effectively on behalf of our client, ADAC Schutzbrief Versicherung. Ideally, we will also be able to leverage synergy effects in our work with other European organisations and make further improvements, including when it comes to the environment. 

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

16 | EVENTS

Fig.1: The seminar took place at the Hyères Naval Air Base in June 2012 (Photographs: Sauveur Schintu)

Seminar at Hyères Naval Air Base: EU regulations and their implications for French HEMS Author: Thomas Clément Vice President of ANSMUH National Association for Helicopter Emergency Medical Service

A seminar took place at the Hyères Naval Air Base in June 2012 (see AirRescue Magazine 2/2012), introducing the (new) concept of the HEMS Crew Member to all stakeholders – hospitals, operators, crew members – and offering them a solution to this new step for French HEMS. The new regulations will become mandatory in 2014 with the EU-OPS. It will be the operators and the customers who will make the final decision; nevertheless, it is important to consider the needs and preferences of all involved. EU regulations The creation of the European Aviation Safety Agency (EASA) in 2003 brought major changes to aeronautic regulations. The initial recommendations from the European Union have gradually developed into obligations and the Joint Aviation Requirements have been replaced by the Joint Aviation Authorities. This notion of authority has also contributed to the harmonisation of policies in Member States’, creating a common regulation for the whole of the European Union, which until now was made up of country-specific aviation regulations. Previously, the JAR OPS-3 was the reference text for helicopter commercial air transport in Europe, although certain countries had special dispensation, as is the case in France. Following on from the review of the JAR OPS-3,

France has decided to operate under a national version of the European text, OPS-3, which permits HEMS operations with a crew composed of just one pilot, for example. The EASA has now decided to introduce the EU-OPS, which is the regulation text for CAT, based largely on JAR OPS-3. The introduction of the EU-OPS in 2012 will bring an end to all special dispensations; however an application delay of 2 years means that in reality these will end in 2014. The main change in France will be the requirement of two crew members, which will be mandatory for HEMS. Most countries in Europe do apply HEMS Crew Member regulations for their HEMS operations and some also have a co-pilot. However, in order to understand the problem, we need to explain how HEMS works in France.

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EVENTS | 17 France-specific features The French emergency medical services, le Service d’Aide Médicale d’Urgence (SAMU), is governed by the French Ministry of Health and is present in every department of the country. The service is organised into two parts: • Centre de Réception et de Régulation des Appels (CRRA), the dispatch centre • Service Mobile d’Urgence et de Réanimation (SMUR), the mobile element of the emergency services Helicopters are supplied by a provider company through a tendering process, either from the region by the Regional Agency for Hospitals or from the hospital itself. The contracts include a number of flight hours per year for the hospital (usually 500) and the necessary crew for operations (three or five pilots, one flight engineer). Currently, the basic crew for HEMS mission in France is one pilot, one nurse and one doctor. The fourth seat is either free or occupied by a trainee doctor, an ambulance driver, a member of the SAMU or another person not involved in the mission. The medical team (doctor and nurse) are employed by the hospital and managed by the SMUR. Their duties are not exclusively related to HEMS and they can be assigned other missions with ambulances. During a shift, the medical team boarding the helicopter is subject to change depending on availability and missions. This allocation can also delay the departure of the helicopter.

Introduction of HEMS crew members in France In 2009, a Belgian company working in HEMS in France had to introduce HEMS crew member requirements in their bases. Initially, nurses were to work as HEMS crew members, as in other countries. However, as HEMS Crew

Member status implies aeronautical expertise, which is the field of expertise of the helicopter company, and as nurses were managed by the SAMU and not by the operator, the hospital administration refused this solution. Many problems were raised, such as responsibility, training, status and salary of nurses employed as HEMS crew members, but no suitable solutions were found. The hospital administration decided that HEMS crew members should be employed and trained directly by the company. With the application of the EU-OPS, HEMS crews will be composed of one pilot, one crew member, one nurse and one doctor. As indicated in the EU-OPS, the minimum crew should be one pilot and one HEMS crew member, but can also be two pilots. In this case, the two pilots must be qualified to work on the helicopter and meet strict training and skills preservation requirements. Many HEMS helicopters in France are equipped with a single pilot panel, only displaying the flight information in the right-hand seat. For two-pilot operations, both pilots need access to the flight information and so the avionics have to be upgraded in these helicopters. Furthermore, HEMS pilots are not permitted to assist the medical team and tasks such as patient handling are prohibited. The HEMS crew member solution offers full training and use, allowing operational gains such as NVIS or IFR, and is a cost-effective solution compared to a co-pilot.

Conclusion Whatever the opinion about the second crew member, it will become mandatory in 2014 with the EU-OPS. Now is the time to consider development and implementation in France. It will be the operators and the customers who will make the final decision; nevertheless, it is important to consider the needs and preferences of all involved.  Fig. 2: Currently, the basic crew for HEMS mission in France is one pilot, one nurse and one doctor

For more information, visit: ››› www.smuh.fr

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18 | INTERVIEW

Fig. 1: Jan Šebek (right) and Pavel Müller (middle), the two owners and partners of AlfaHelicopter: Mr Šebek focuses on strategic planning, Dr Müller is also involved in the daily operations (Photographs: T. Bader)

Pioneers in their own respect: An interview with Dr Pavel Müller, President of EHAC, and Jan Šebek, founding member of Alfa-Helicopter It was one key moment that kick-started Pavel Müller’s career as an air rescue pilot. The qualified lawyer had always been an aviation enthusiast. Following a serious skiing accident when Müller was 14 years old, he had to stay in hospital for a long time and his father, also enthusiastic about flying, brought him some foreign aviation magazines to read and Pavel became fascinated by air rescue. His passion led him to join Alfa-Helicopter in 1993 as a partner, and today he runs the business – his dream job. Since 2012, Müller has also been President of the European HEMS and Air Ambulance Committee (EHAC). The editorial team, Peter Poguntke and Tobias Bader, were delighted by a recent opportunity to speak with Pavel Müller, also Managing Director of Alfa-Helicopter, and Jan Šebek, President and Founding Member of Alfa-Helicopter and pioneer of non-governmental HEMS operations in the Czech Republic.

ARM: Dr Müller, in your editorial for the last issue of AirRescue Magazine you mention half-jokingly that your election was partly due to ‘geopolitical reasons’. Do you think there’s a ‘door-opener function’ attached to this position?

Fig. 2: “The New EHA is about flying, EHAC is about medical care, so EHAC has its own unquestionable position and importance”

Pavel Müller: It seems that my reference to ‘geopolitical considerations’ has been misunderstood. It was my impression that previously our distinguished EHAC members had not been in complete harmony, a fact which did not help all of our good efforts. In discussions with colleagues, it was felt that the best candidate for EHAC President would essentially be someone who did not belong to any one camp; a candidate who could count on the support

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INTERVIEW | 19 of the majority in the elections and also contribute to the internal harmony within EHAC. Whether we were correct in assumptions, I will leave to our readers and EHAC members to decide. Other than that, I don’t believe there’s a ‘door-opener function’ attached to this position. ARM: Regarding EHAC’s future activities and tasks: Where do you see (urgent) need for action? What are the most important future challenges? Pavel Müller: I do not see any urgent need for action. However, there are many things that need immediate attention. I would begin with the need to improve the internal functioning of EHAC, starting with the transparency of decision making, a high level of ethics, compliance, optimizing the use of our huge expert potential, greater involvement of members in the work of the organization, planning and prioritizing our activities, and last, but not least, careful evaluation and revision of our key documents, for instance, our statutes. As for external activities, there is above all a need for EHAC to play a more active expert role in developing the legal environment for HEMS and Air Ambulance. We will also continue in our efforts towards long-term improvements in the safety, quality and availability of our services. Personally, I would like to see the inclusion into our community of the operation centre dispatchers who decide and manage our deployment. In my opinion, this issue is highly important as our service begins with our deployment. I don’t know, however, if my idea will be successful. ARM: Does EHAC pursue a general ‘strategy for growth?’ What does it look like? Is EHAC planning to ‘expand’ in specific countries? Pavel Müller: I’m not so sure that the term ‘growth strategy’ is really appropriate for organizations such as EHAC. Our primary goal is our members’ services and I believe our members’ main focus is on the patients. Growth in membership is primarily an increase in the possibility for sharing experiences and utilising the expert potential that our organization has. Of course, we will continue to promote EHAC’s good work, and the expansion of our membership is always a positive thing. For me, a larger community means a larger space for sharing experience, knowledge and information, all of which I believe to be essential. ARM: Are there any plans to intensify talks and maybe a further cooperation with the New EHA (bearing in mind that ‘productive’ talks were already held)? Are there ideas of even merging the two? Pavel Müller: The New EHA is a very good representative for helicopter operations in Europe. In this respect, the New EHA would theoretically also be a very good representative for EHAC’s expert interests; however, EHAC primarily represents the provision of health care – although admittedly, through a specific form of transport, which is air transport. To put it in simple terms; the New EHA is about flying, EHAC

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is about medical care. This clearly shows that EHAC has its own unquestionable position and importance. We are here for a specific service – Air-medicine. The New EHA can represent EHAC’s helicopter themes, but whenever and wherever aviation meets health care provision, it is EHAC who must unconditionally give their expert opinion. My position on this is known within the New EHA; consequently, we have yet to move forward on this matter. ARM: Are there any connections and cooperations established with (partner) organizations from other countries? What about the so-called emerging countries and economies like China and India? Pavel Müller: The emergence of large new markets, while important to aircraft manufacturers, has a rather different significance for organisations such as EHAC. Our mission is not to gain influence but rather to enable the opportunity for expert collaboration. This attitude applies to all countries and regions. I believe in a close cooperation with the different communities; we are in touch with our American friends, we are in touch with the community in Australasia, and it’s very important. For instance, both of these communities are involved in preparing the 2014 AIRMED Scientific Programme, as they were with Prague and Brighton. We all know each other really well, and in some cases, we are also best friends outside of what we do. I can’t say what we as EHAC could specifically do, let’s say, for a particular operator outside Europe, for instance, but I definitely believe in a close cooperation between the communities throughout the world. ARM: You participated in the HeliRussia that took place in Moscow recently. What were your impressions? Is it fair to speak of a ‘pioneer mood’ with regard to the establishment of a nationwide HEMS system in Russia – or at least in the capital? Pavel Müller: I briefly participated in an expert conference which was part of HeliRussia. The presentations

Fig. 3: “The future development in terms of the economic sustainability of the service seems unclear, especially because aircraft prices increase almost automatically” (P. Müller)

20 | INTERVIEW As for aviation technology, this primarily concerns: safety in the broadest sense; sufficient space for the patient, medical crew and medical technology; a very good view from the cockpit; reducing time-consuming procedures in maintenance; and high reliability. Further benefits would be measures taken to reduce crew workload and noise pollution. What is not clear to me, however, is our future development in terms of the economic sustainability of our service. To put it very simply; aircraft prices increase almost automatically. A significant part of our service’s financing comes from public funds and currently, the most common word mentioned in connection with public funds is cuts. It is a strong impetus for reflection for all involved. ARM: Could you tell us a little about how HEMS and Air Ambulance are being organized in the Czech Republic? Fig. 4: “I am in favour of significant public involvement, especially in the organisation and deployment of the service” (P. Müller)

were in Russian so here I share my impressions rather than opinions. What I did pick up on I would not call a ‘pioneer mood’. In many ways, I felt there was a very good expert base and motivation to provide the best possible service. I would gladly open up the possibility of sharing EHAC’s potential with colleagues from Russia. ARM: Our impression is that Fixed-Wing seems to be somewhat underrepresented within the EHAC. Is this correct? Do you think that this may change in the near future? Does it possibly have something to do with less (technological) innovations in the last few years? Do you think that this field is more or less saturated and that innovations are not to be expected? Pavel Müller: Perhaps it is because planes fly so high that they aren’t as visible as helicopters. But, joking aside. I must admit that unfortunately I do not personally know as much about air ambulance services. What I can say is that it’s just as important a discipline as HEMS. In this spirit, I will try to both educate myself about air ambulance, AA, and pay particular attention to ensuring this area is represented in EHAC. I would certainly not overestimate the technological side of things, in either AA or HEMS. But generally speaking, innovation is always expected everywhere, although it is not what determines the level of service. The level of service, which is valued by the benefit to the patient, primarily comes from its staff. AA’s benefits are undoubtedly large. ARM: What are EHAC’s future expectations towards the aircraft manufacturers and manufacturers of medical appliances (as operators)? Pavel Müller: I’m not an expert in medical technology, but, for instance, I have been following the discussions on the implementation of Chest Compression Devices in HEMS with great interest. Here, then, is a simple request to the manufacturers: the lightest, most compact device possible, with the longest battery life [laughs].

Pavel Müller: In the Czech Republic, the system itself is public, but the aircraft provider is private and is not responsible for medical care. The typical structure in the Czech Republic is thus: the aircraft and the pilot are provided by a private company, the medical crew and equipment comes from the regional EMS department. The HEMS helicopter and its crew are dispatched by the Dispatch centre of the regional EMS department, which therefore means significant public involvement. The aviation part of the service is paid for by the Ministry of Health, another example of significant governmental involvement. The Ministry also influences the deployment of the service in terms of the location of bases, which in my view is very important as the service has to follow people and not money. In some places, such as Jihlava, the base – the building and heliport - belongs to the regional EMS department and we rent it, in exceptional cases, such as Brno, the base belongs to us and we provide rooms for the crews and equipment to the regional EMS department. ARM: Do you see advantages in a HEMS system that is privately organized, compared to one that is state-run – and vice versa? Pavel Müller: I am in favour of significant governmental involvement, especially in the organisation and deployment of the service. The service must definitely follow people. The environment of regular business organisations is better in decision making and economic efficiency. But if you look at the models in Germany and Austria or Switzerland for example, they are non-profit organisations but the economic efficiency is also very high. What I personally think is that the public’s acceptance of this service in Europe is higher when the provider works on a non-profit principle. To be honest, I know many very good examples of the service, the character of the provider is not important. The only thing I would emphasize is the governmental involvement in the service deployment, based especially on population density, geographical aspects and hospital networks.

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INTERVIEW | 21 Heli-memorabilia at the Rotor Bar Never one to shy away from new challenges, Müller also has his own vineyard and swears by Müller-Thurgau grapes. The result goes down extremely well – as you can find out for yourself if you pay a visit to the Rotor Bar in Brno. The bar is another string to Müller’s bow – you can’t help but wonder when he gets time to put his feet up. The cosy bar is in the basement of one of the lovely old buildings that line Brno’s streets. Inside, it’s all dark wood and helicopter memorabilia – including HEMS crew patches from around the world and a stretcher hanging from the ceiling. Even the ventilation louvres in the ceiling are designed to look like rotor blades. The bar is a popular destination for an after-work beer and a hit with helicopter fans, as it’s a great place to hear stories of exciting air rescues.

ARM: Mr Šebek, you being one of the pioneers in HEMS in the Czech Republic, could you tell us about the early years of Alfa Helicopter and ‘how it all began’? Jan Šebek: In 1989 I was an employee of Slov Air, a state helicopter company, which carried aerial work in agriculture, mostly crop dusting. I was the Manager of the Mobile Maintenance unit. The demand for work was decreasing and the company started to lay off staff; we knew we were going to be made redundant and so we started thinking of what to do next. We had the idea of setting up our own small helicopter company, with smaller aircraft, as these were more competitive in price. Until this time, we had been flying Mi 2s, which were bigger and more expensive. ARM: And you decided to buy a Bell for this purpose? Jan Šebek: Yes, we contacted Mack Gibson from Bell Helicopter in Bonn, Germany, about buying a used Bell 47, which we considered the most convenient model for our needs. They wrote back to us to say that it would be better to buy a new helicopter, especially from the point of view of warranty and after-sales support and they invited us to a demo of the Bell 206 L3 with a medically-equipped interior in Prague. I knew the EMS environment well as I had been working with HEMS helicopters while at Slov Air, too. Meanwhile, we set up Alfa-Helicopter. We wanted to be the first helicopter company in the Czech Republic, hence our choice of Alfa in our company name. [Slov Air, as suggested by its name, had been based in the Slovak territory of the then Czechoslovakian state.] Mi2s weren’t powerful enough for HEMS, I knew we had to upgrade our fleet and that they were using 206s in HEMS in the USA. I was impressed by the Bell 206 and met with Mack Gibson, one of the Bell representatives – we are still very good friends to this day – and I decided to sign a purchase agreement in March 1991. We planned out the financing and down payment as we wanted to start operating in two HEMS bases at the earliest possibility. Our first HEMS

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flight was on 1 January 1992; in the interim we rented two Mi 2s from Poland. ARM: What were the next steps then? Jan Šebek: We succeeded in getting contracts for two HEMS bases – Olomouc and Brno – and a Czech bank agreed to finance us for the down payment. Two pilots and two mechanics flew to Bell Texas for the transition training. By November the helicopter had been produced and was ready for the hand over. We reached an agreement for the financing with Bell, and we took delivery of the first 206 in April 1992, refitting it with a medical interior, and it entered into service in Olomouc in May 1992. On 1 January 1993 we started operating out of our third base in Jihlava, and we ordered a second 206 L3 which was put into service in Brno in 1993. During the same year, we successfully negotiated our first long term contract with the Ministry of Health, lasting 8 years, which helped us obtain the financing for the third 206 – a 206 L4. Part of Alfa-Helicopter’s aim was to develop and update the HEMS service in the Czech Republic by replacing the Mi 2s with more modern aircraft, we were very much pioneers in this respect and it partly accounts for our success both as a company and as a HEMS provider. ARM: How was HEMS organized before that? What were the first steps? Jan Šebek: The Czech HEMS service first started in 1987 in Prague, in 1988 in Brno, and in 1989 in Olomouc and Jihlava. By the end of the 1980s, the network was very similar to the one we have today. At that time it was run by the Police, the Air Force and the State helicopter operator. Alfa-Helicopter took over from the State helicopter operator; we were successful thanks to our fleet upgrade and focus on the medical side of the service. ARM: Mr Šebek and Dr Müller, we thank you for the interview. Fig. 5: “In the early years, we had the idea of setting up our own small helicopter company, with smaller aircraft, as these were more competitive in price” (J. Šebek)

22 | FIXED-WING

Fig. 1: All Rega jets are staffed with an experienced emergency physician and a registered flight nurse (Photographs: Rega)

Author: Stefan Becker Head of Corporate Development Swiss Air-Rescue Rega

14 patients in 6 flights on one day Rega-repatriation after Sierre bus crash Swiss Air-Ambulance (Rega) repatriated 18 severely injured Belgian children after a major bus accident in the Sierre tunnel on 13 March 2012. For the first time in its history, all three Rega Challenger CL-604 dedicated air-ambulance jets were assigned to the same mission. On 15 March 2012, only two days after the bus accident, Rega repatriated 14 partly severely injured pupils as well as their relatives to Brussels. The night before these took place, two Rega emergency physicians had been preparing and coordinating the young patients at Sion Hospital (Switzerland) to ensure smooth and professional flights for the patients. 14 patients in 6 flights on one day

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

Half of the patients (7 out of 14) were suffering from major trauma, 2 patients had isolated traumatic brain injuries (TBI), whereas 4 patients were suffering from combined TBI plus major trauma. In the major trauma group, multiple fractures of the lower extremities (femur, tibia & fibula) were prevailing (5 out of 9 patients), followed by fractures of the upper extremities (humerus, scapula, olecranon; 4 out of 9 patients), and spinal injuries (Th6-9 compression fractures, L1 fracture; 2 out of 9 patients). In the combined TBI plus major trauma patient group all 4 patients had multiple fractures of the lower extremities (femur, tibia, fibula, anckle) and fractures of the facial bones (Os nasale, Os frontale, Os maxillaris, Os mandibularis, orbita, all partly w/ hemosini), followed by intra-cerebral bleedings (2 out of 4 patients) and a severe abdominal trauma incl. pneumoperitoneum (1 out of 4 patients). Furthermore, 11 out of 14 patients had lung contusions and/ or pneumothoraces, and 12 out of 14 patients suffered from rhabdomyolysis. The most severely injured pupils were repatriated last, on 22 March 2012 in three additional flights. All these patients had combined severe TBI and major trauma injuries. They suffered from multiple fractures of the lower extremities incl. pelvis (4 out of 4 patients), profound brain

injuries (bifrontal lesion down to the Nucleus caudatus, lesion of the capsula interna, subarachnoid haemorrhage, calvaria impression fractures, pneumencephalon, epidural haematoma, brain oedema) and spinal injuries (C3-C5 fracture with tetraplegia, C7 fracture). The size of Rega’s CL-604 ambulance jets permits the professional handling of potential in-flight complications for two intensive care patients. The characteristics of the injuries made it necessary to use advanced ventilation devices such as the Hamilton T1 and to conduct some flights at sea level. Altogether, Rega executed 9 flights with patients and relatives with an average flight time of one hour. All Rega jets are staffed with an experienced emergency physician and a registered flight nurse. The latest Hamilton T1 ventilators are also standard on all Rega ambulance jets and a joint development by Hamilton and Rega. There is also additional equipment available at the airport Zurich base for critical-care transports. The aircraft’s cabin dimensions permit such transports – together with specialists and equipment.

Bus rammed concrete wall at 100km/h The crash occurred in a stretch of tunnel where the speed limit was 100 km/h. The school class was on its way from an excursion in Val d’Anniviers back to Lommel and

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FIXED-WING | 23

Haverlee (Belgium) when the bus veered, hit the right kerb, then – approximately three seconds later at 9.15 p.m. – rammed into a concrete wall in an emergency bay at the speed of 97-100km/h: at right angles with the road. Rescue specialists and disaster response teams activated immediately and rushed to the scene, were facing a horrible scenario: 28 out of 52 people died inside the bus that was substantially destructed. Twenty-two pupils, the teachers and both the bus drivers died. Most of the

victims had taken seats in the front rows of the bus. More than 200 rescue specialists saved the lives of 24 pupils, aged between 10 and 11. They were immediately transported to hospitals in Sion, Lausanne and Geneva by eight helicopters and 12 ambulance cars for further treatment and emergency operations. The investigations into the causes of the worst bus accident in Switzerland in 30 years are still ongoing. 

Figs. 2 & 3: In 2011, more than 14,000 missions were conducted by Rega which have not been possible without the contributions of their patrons – the backbone of the organisation

Fig. 3: EMS physician checking CT scans

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24 | IN PROFILE

Fig. 1: ANWB Medical Air Assistance (MAA), founded in 1995 as an independent subsidiary of the Royal Dutch Touring Club, is the number one HEMS operator in the Netherlands (Photographs: ANWB MAA)

Within reach of the people: ANWB MAA’s “Lifeliners” Authors: Editorial Team AirRescue Magazine

With more than 4,200 flights a year, ANWB Medical Air Assistance (MAA) is the number one HEMS operator in the Netherlands. The organisation was founded in 1995 as an independent subsidiary of the Koninklijke Nederlandse Toeristenbond ANWB (Royal Dutch Touring Club) and has its head office at Lelystad Airport. It is currently served by a fleet of four air ambulances, plus two in reserve, consisting of six EC135 T2, T2+ and P2+ helicopters, known as “Lifeliners”. The helicopter fleet covers the whole of the Netherlands, with “Lifeliner 1” covering the Amsterdam area, “Lifeliner 2” used for emergency callouts in the Rotterdam and South-Western regions, “Lifeliner 3” covering the Nijmegen/Volkel area and the Eastern region and “Lifeliner Europa 4” (operated in cooperation with ADAC Air Rescue), which came into around-the-clock operation in April 2011, based in Groningen and covering the Northern part of the country. Border regions are also covered by MAA in cooperation with ADAC Air Rescue (Germany) and MUG (Belgium). The reserve helicopters are based in Lelystad, capital of Flevoland province. MAA has 36 staff members, including 27 pilots, and – needless to say – each one of them is well-trained, dedicated and committed. ANWB MAA provides helicopter emergency medical services (HEMS) on behalf of four trauma centres, as well as for governmental, semi-governmental bodies and events organisations. Assistance

is available seven days a week, 24 hours a day. The four trauma centres are: • • • •

VU Medical Centre (Amsterdam) Erasmus Medical Centre (Rotterdam) University Medical Centre St Radboud (Nijmegen) University Medical Centre Groningen

Like in the U.S.A., the Dutch emergency medical assistance system relies on highly trained nursing staff. Standard procedures ensure that the quality of patient care remains consistently high. In 1995, when VU Medical Centre and ANWB began operations using a trial helicopter, the use of helicopters for pre-hospital trauma care was completely new in the Netherlands. In conjunction with the Erasmus Medical Centre and a number of subsidiary providers, ANWB began a second experiment in 1997 with a second air ambulance based at Rotterdam Airport. Halfway through 1998, a survey on air rescue operations

3 · 2012 I Vol. 2 I AirRescue I 160

IN PROFILE | 25 conducted by the Netherlands Institute of Road Safety Research (SWOV) and Erasmus University revealed that: • air ambulances save lives • road traffic casualties in particular benefit from the use of air ambulances • the duration of care/rehabilitation does not change when an air ambulance is used • the costs of this life-saving assistance are acceptable.

ANWB MAA has operated with night vision goggles (NVGs) since 2006, when the first trial night-flight operations were carried out from the Volkel base (commissioned by and in collaboration with the Eastern Region Trauma Centre of the Radboud Hospital in Nijmegen). Research was carried out into whether the mobile medical team could access accident sites safely by helicopter during the hours of darkness. After the positive results were presented to the Ministry of Health, Welfare and Sport, MAA was granted permission to continue to use night vision devices. The air ambulance’s mobile medical team (MMT) is made up of a pilot, a physician and a nurse. The pilot is primarily responsible for transport; however, he or she may also assist the physician and nurse on the scene. In such cases, the police take over supervision of the helicopter. The nurse, usually a paramedic, will have taken MMT training courses, as well as air communication and navigation training. During flights, the nurse is responsible for partly visual navigation. As the nurse supports the pilot as a crew member, he or she is also familiar with the technology of the helicopter. The physician, either an anaesthetist or surgeon, will have received specific training in emergency medicine. He or she can take action on the spot to stabilise vital functions. The air ambulance physician has no flight duties but does deal with communications with the dispatch centre. MAA staff receive regular training, with a dedicated Type Rating Training Organisation (TRTO) providing the following courses: HEMS, CRM, EC135 Type Rating, Instructor

The Dutch helicopter rescue system* Emergency Call Dialling “112” from a landline will connect you to the local emergency centre. Calls from mobile phones go through to the National Police Services Agency (KLPD) call centre in Driebergen. An emergency centre agent (known as a switchboard operator) will ask whether the caller wants to speak to the police, the fire service or the ambulance service. The switchboard operator will then put the caller through to the requested emergency service.

Notification If a mobile medical team (MMT) is required, the respective on-duty team will be notified by pager and will be sent an address. During the flight, the physician is provided with further *Courtesy of ANWB Medical Air Assistance (www.anwb-maa.nl) 3 · 2012 I Vol. 2 I AirRescue I 161

Fig. 2: In 1995, when ANWB began operations using a trial helicopter, the use of helicopters for pre-hospital trauma care was completely new in the Netherlands (Photograph: ANWB MAA)

Training, NVG and HEMS Crew Member Training. With the knowledge and experience gained during more than 4,000 emergency flights a year – 15% of which are night calls (the number of which continues to grow) – as well as more than 30,000 HEMS flights, ANWB MAA continues to offer cost-effective and reliable round-the-clock service. 

information from the switchboard operator at the ambulance dispatch centre via the C2000 radio system.

is in a location that is inaccessible by road. In such cases, the decision is made by the physician.

Choice of transport

Flying

Air ambulances are deployed in order to get a nurse and physician to the scene as quickly as possible. The helicopter is not a replacement for but an addition to the ambulance on the ground. The air ambulance has more specialist equipment and the physician has greater authority to perform medical procedures than the nurse. As a rule, patients are taken to the hospital by road, accompanied by the MMT physician if necessary. However, there are cases where a patient is taken to hospital by helicopter, for instance if the patient is located on one of the Wadden Islands. Transport by helicopter can also be considered if the patient

In principle, an air ambulance always takes precedence over other air traffic. Furthermore, helicopters are permitted to fly in areas where other air traffic is restricted. However, helicopters cannot fly in thick fog or low clouds as there is insufficient visibility for pilots to land. In such cases, the MMT is transported to the scene by road. During darkness hours, pilots fly using night vision goggles and the landing area must measure at least 25 x 50 metres. During the day, only 25 x 25 metres is required. If pilots have to land in unfamiliar locations at night, they will do so on the outskirts of urban areas.

26 | IN PROFILE A n i n t e r v i e w w i t h M a r c o va n d e n B e r g :

“A day in the life of an MAA pilot” Marco van den Berg is a pilot of the “Lifeliner 2” helicopter and base manager at Zestienhoven airport in Rotterdam. In this interview, he describes his daily work routine as a HEMS pilot. An earlier version of this interview appeared online at www.anwb-maa.nl. Courtesy of ANWB Medical Air Assistance (Photograph by M. vd Voorde).

van den Berg: I’m the base manager, so I’m responsible for the flight operations. I stay in contact with organisations such as air traffic control, the Erasmus hospital and industrial sites within our flying area. All pilots have an ancillary task – keeping our navigation computers or the checklist up to date, for example. But of course, during a shift you also have time to rest and read the paper. ARM: What happens when a call comes in? van den Berg: I am sent the address we have to go to on the pager. I immediately run to the chopper, inform air traffic control of where I’m going – they ensure I get precedence over other air traffic –start the engines and carry out the checks. By this time, the physician and the nurse will have taken their seats. Once all the checks have been completed, I take off. That’s around two minutes after receiving the call. ARM: Do you use visual navigation or a navigation system?

Marco van den Berg

ARM: Marco, at what time do you start work? van den Berg: The day shift begins at 6.30 am, the night shift at 7.30 pm. Pilots spend the first half hour of their shift checking the helicopter and reading through notices to aviators. These are updates about potential flight hazards, such as the presence of a crane nearby or people parachute-jumping in the vicinity. ARM: And after that first half hour? van den Berg: Shortly before the new shift begins and the next team takes over, a briefing is held to discuss the weather and the helicopter. We also go through a checklist of essential points. Once we have ticked off all those points, the physician, nurse and I take our seats in the helicopter to carry out the cockpit and cabin checks and to adjust all the belts. The handover takes place at 7 am/7 pm sharp. ARM: How long does a shift last? van den Berg: More than half a day – twelve hours and forty-five minutes to be precise. The first half hour is used to carry out all the checks and the briefing, the final quarter of an hour – from 7 until 7.15 – for the handover to the new team. If we are still busy on a flight at the end of our shift, it may even stretch to fifteen and a half hours. But that only is permitted if we have had a break of at least two consecutive hours that day. ARM: What do you do if you’re waiting to be called out?

van den Berg: Both. The nurse is also the navigator. We search for the final destination visually. I circle around it until I find a suitable landing place. I then describe out loud what I see – obstacles such as trees and antennas, the ground surface, whether the zone is big enough, etc. After this reconnaissance I can land. ARM: How quickly can you get there? van den Berg: I can get almost anywhere in Rotterdam within six minutes of receiving the call. If we have to go further, for example to Zeeuws-Vlaanderen, it can take up to 25 minutes. ARM: Do you also have a task to perform at the scene? van den Berg: Not officially. But I can assist the physician and the nurse if required. For instance, I can prepare a drip, make observations and help secure the patient on the gurney – the same as an ambulance driver does. ARM: On average, how many calls a day does the MMT receive? van den Berg: In Rotterdam – five or six. One or two of these are usually so close-by that the physician and nurse can get there more quickly by car. If it’s dark, that is. I then stay behind at the base. ARM: When are the two reserve helicopters in Lelystad used? van den Berg: Every helicopter undergoes a major service once a year. This takes two to three weeks. During that time we use one of the two reserve helicopters. They are also used for flight training and checking and at events such as the Dutch TT in Assen. 

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IN PROFILE | 27

Fig. 1: The Bell 427 air rescue helicopter transfers a patient before refuelling for its next flight (Photograph: C. Kossendey)

Air rescue in the Czech Republic: Alfa-Helicopter’s “Kryštof 12” Alfa-Helicopter was the first private HEMS operator in the Czech Republic – hence “Alfa” – and has been providing air rescue services for 20 years now. It celebrated its anniversary on 22 May this year. The editorial team of AirRescue Magazine paid a visit to the Alfa-Helicopter headquarters in Brno as well as to its bases in Brno and Jihlava, where “Krystof 12” is flown by pilot Pavel Müller, who is also the Managing Partner of Alfa-Helicopter. “Krystof 12” stands on the helipad at Jihlava hospital, its rotor blades gradually slowing to a halt. Pavel Müller has just brought the Bell 427 air rescue helicopter safely into land, and now it is being refuelled to get it ready for its next flight. It is the end of another successful ambulance flight – and all in a day’s work for Alfa-Helicopter’s crew and pilots. The hospital in the small Czech town of Jihlava, at the heart of the Vysocˇina region, provides healthcare services to around 150,000 people. Its departments, which include surgery, orthopaedics, internal medicine, cardiology and traumatology, are equipped with the state-of-the-art technology. As well as a control centre for dispatching land and air resources, the spacious grounds next to the hospital also house one of Alfa-Helicopter’s air rescue bases. There are ten air rescue bases in the Czech Republic. They are spread across the various regions and each one covers an area with a 50 kilometre radius. Alongside Alfa-Helicopter, another private operator, DSA Inc., also provides air rescue services. It has bases in Ostrava,

3 · 2012 I Vol. 2 I AirRescue I 163

Hradec Králové, Ústí nad Labem and Liberec. Other, governmental providers of helicopter ambulance services are the Czech police force, which has its own base in Prague, and the Czech air force, which has a base in Líneˇ, near Plzenˇ (see Table 1). Alfa-Helicopter was the first private HEMS operator in the Czech Republic – hence “Alfa” – and has been providing air rescue services for 20 years now. It carried out its first missions using a Russian helicopter – an Mi-2 SP-SDB. Alfa-Helicopter celebrated its anniversary on 22 May this year and many Czech and foreign guests came together to mark the event. Present were the very first EMS crew, led by Dr Michael Fischer (now deputy governor of the Olomouc region), as well as other important guests including Martin Tesarˇ ík, the governor of the Olomouc region, and the city’s mayor, Martin Novotný. Alfa-Helicopter and DSA – both members of the European HEMS & Air Ambulance Committee (EHAC) – entered a national call for tenders to run the country’s air rescue services. The contract, which lasts for eight years, was

Authors: Tobias Bader Editorial Team AirRescue Magazine Dr Peter Poguntke Editor-in-chief AirRescue Magazine

28 | IN PROFILE

Table 1: Overview of air rescue bases in the Czech Republic (Source: Wikipedia)

Base

Operator

Service

Helicopter Type

Kryštof 01

Prague

Police Force

24/7 (1)

EC135 T2

Kryštof 04

Brno

Alfa-Helicopter

24/7 (2)

EC135 T2+

Kryštof 05

Ostrava

DSA

24/7

EC135 T2+

Kryštof 06

Hradec Králvolé

DSA

day

EC135 T2

Kryštof 07

Líneˇ near Plzenˇ

Air Force

24/7

PZL W3A Sokol

Kryštof 09

Olomouc

Alfa-Helicopter

day (1)

EC135 T2+

Kryštof 12

Jihlava

Alfa-Helicopter

day

Bell 427

Kryštof 13

Cˇ eské Budeˇ jovice

Alfa-Helicopter

day

Bell 427

Kryštof 15

Ústí nad Labem

DSA

day (3)

EC135 T2

Kryštof 18

Liberec

DSA

day

EC135 T2

Sources: (1) Mediafax.cz, (2) Zzsjmk.cz, (3) Zzsuk.cz

Fig. 2: Alfa-Helicopter was the first private HEMS operator in the Czech Republic and has been providing air rescue services for 20 years now (Photograph: J. Špacˇek)

awarded jointly to the two operators. As well as at the Jihlava base, Alfa has rescue helicopters stationed in Olomouc, Cˇeské Budeˇjovice and in Brno, just outside the city on a former military airfield. Back at the base in Jihlava, the HEMS crew members who have just landed disappear into the common room. It’s 11:30 a.m. Cooking smells mingle with the odour of disinfectant and fill the halls with a curious scent quite typical of hospital facilities. But this domestic bliss is interrupted when a piercing alarm sounds. Müller heads for the stairs leading to the helipad. The flashing red lights in the corridors signal a medical emergency. Rescue helicopters in the Czech Republic are alerted through the general EMS number – 155 – and the country’s dense network of resources generally ensures quick response times. Alfa-Helicopter’s headquarters are in Brno, the second biggest city in the Czech Republic and the administrative centre of the South Moravian Region. The capital Prague is located to the north-west, at least two hours away by car.

Alfa’s offices are located down a side street off the main shopping area. The old building has plenty of charm, with ceiling moulding and creaking wood floors. Although a good 98 percent of Alfa’s work is concerned with HEMS, it also provides aerial photography, aerial surveying, inspection flights, scenic flights, flights for forestry and conservation organisations, and aerial work for the construction industry. The company’s bases employ 15 pilots in total (4 pilots for day shifts and 2 for night shifts – so 6 pilots a day), with almost 40 other staff members working in the technology, maintenance and administration departments.

Beginnings of air rescue in the Czech Republic Czech air rescue began in the 1960s with trial operations carried out in the High Tatras (part of the Carpathians) in what was then Czechoslovakia. The first helicopters used were Soviet Mil Mi-4s. But when an Mil Mi-8 crashed in the High Tatras in June 1979, the flights were suspended. Then, in 1985, the ministry of transport set up a coordinating committee tasked with preparing a nationwide air rescue network. The advisors to the committee included experts from ADAC Luftrettung. And their efforts finally bore fruit: on 1 April 1987, Prague and the Central Bohemian Region began trial operations with “Kryštof 01”, a Mil Mi-2 helicopter. Three months later trials began with “Kryštof 02”, which was based at Banská Bystrica and covered the Central and Eastern Slovak Regions. Based on the trial operations, the decision was taken to set up an air rescue network that would cover the whole Czech Republic. The network, in its current form, was completed around 1992. Pavel Müller’s partner, Jan Šebek, a founding member of Alfa-Helicopter, has clear memories of those early days, before the Cold War had ended. He was an employee of Slov Air, a state helicopter company and it was he who, shortly after the collapse of Communism, had the idea of introducing a private helicopter operator serving the aims of an air rescue system in the Czech Republic.

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IN PROFILE | 29 Fig. 3: In less than 90 seconds, the Bell 427 is off the ground and soon disappears behind the hospital buildings, racing towards its next rescue (Photograph: C. Kossendey)

As part of its air rescue work, Alfa sometimes carries out fixed-rope operations in order to lower paramedics down to the scene so that they can start treating the patient or accident victim as quickly as possible. Alfa first trialled underslung load operations in 1996, and the technique proved particularly useful during the 1997 floods. HEMS crews from the South Bohemian Region recently completed fixed-rope training at the Cˇeské Budeˇjovice base. DSA and Alfa supply the Czech air rescue system with technical infrastructure and the necessary staff – like pilots and mechanics. The regional EMS departments provide and finance the medical crews and run the HEMS helicopters and ground ambulances; the medical crews are with the ground ambulance one day and with the helicopter the next. HEMS is part of the entire EMS structure of dispatch centres, hospital emergency departments, specialised treatment centres, ground ambulances (with or without doctors) and helicopters. Back at the Jihlava base, Müller runs down the stairs, keeping his cool despite his hurry. He pushes open the door, crosses the field to where the helicopter is standing, and leaps into the cockpit. In less than 60 seconds, the rotors begin turning, while Müller receives the necessary information from Dispatch via radio. The emergency doctor is close on his heels. In less than 90 seconds, the Bell 427 is off the ground. It soon disappears behind the hospital buildings, racing towards its next rescue. 

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3 · 2012 I Vol. 2 I AirRescue I 165

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30 | IN PROFILE

Fig. 1: Today, Air Zermatt has a staff base of around 65, providing cargo, sightseeing, taxi and rescue flights – approximately 38% of the flights (Photographs: Air Zermatt)

Air Zermatt is flying high: From small-time helicopter operator to revered air rescue service Author: Philipp Grand Emergency medical technician Air Zermatt AG

Air Zermatt started out in 1968. According to co-founder Beat H. Perren, the company’s primary purpose was to simply provide quick rescue services to accident victims in the mountains. To this end, a heliport was constructed on a suitable rock promontory north of Zermatt. In the beginning, the company owned a single helicopter; staff numbers were equally modest, with just one pilot and one mechanic. Milestones A brief overview of Air Zermatt’s history: On 14 April 1968, the company’s Jet Ranger helicopter completed its first rescue operation (of a child with a broken leg). In 1969, an Alouette III (SA 3160) helicopter was stationed at the Zermatt heliport. This was the first helicopter in Switzerland to be fitted with a rescue winch. An airbase in the Rhone Valley was added in 1986. Today, Air Zermatt maintains bases in Raron, Sion and Zermatt (Valais). The centrally situated Raron base is a particularly good location for emergency services, as it provides quick access to the entire Upper Valais region. In 1972, Air Zermatt pilot Günther Amann became the first to perform a direct rescue mission on the infamous

Eiger North Face, an act of heroism for which he received an award in the United States. Over the following years, Air Zermatt carried out many other direct rescues on the Eiger North Face. In 1973, Air Zermatt became Switzerland’s first rescue operator to maintain a permanent team of doctors and anaesthetists at its base, supplementing the helicopter personnel with medical crews for joint rescue missions. Particularly high-profile rescues took place following a major landslide in Gondo, Zwischbergen in October 2000 and in the area above Leuk in August 2003 during one of Switzerland’s most devastating forest fires (both sites are in the Valais canton). Over the past 44 years, Air Zermatt has continued to grow steadily. Today, the company has a staff base

3 · 2012 I Vol. 2 I AirRescue I 166

IN PROFILE | 31 of around 65, providing rescue flights as well as cargo, sightseeing and taxi flights. Approximately 38 percent of the flights are for rescues; cargo transports account for 45 percent and pleasure trips another 12 percent. The remaining flights are for training, provided by the company’s very own Alpine Rescue Center. Air Zermatt’s Alpine Rescue Center (ARC) is a training facility that provides a range of courses for both medical professionals and lay rescuers. Mountain rescue courses are offered in summer as well as winter. Air Zermatt also runs AHEMS-AFCEST (Alpine Helicopter Emergency Medical Services Alpine Flight Crew Emergency and Survival Training Courses). All of the courses offered are internationally approved and certified.

More than 30,000 rescue missions Most HEMS missions are deployed to help mountain climbers and hikers in distress. Since it began, Air Zermatt has completed more than 30,000 rescue missions and 100,000 flying hours. In addition, each year the company takes more than 7,000 passengers on sightseeing trips or taxi rides and shifts more than 25,000 metric tons of cargo. Air Zermatt’s helicopter fleet is continuously being upgraded and expanded. In the early years, an SA 315B Lama and an SA 316/SA 319 Alouette III were used for all flights. After some time, these were joined by an Ecureuil B2. Today, the fleet consists of seven helicopters: one Ecureuil AS 350 B3; two Ecureuil AS 350 B3+; one Ecureuil AS 350 B3+e; two SA 315B Lamas; and, for occasional use, a double-turbine EC135 T2. In the summertime, the fleet is expanded to include a double-turbine Bell 429 and a second Ecureuil AS 350 B+e. Air Zermatt’s rescue flights are controlled by Valais rescue organisation KWRO’s Mission Control Centre 144. The rescue service operates around the clock, every day of the year. Approximately 1,600 helicopter rescue missions take place each year, and Air Zermatt provides an ambulance service for the central Matter Valley. On-ground services are also 24/7, with approximately 1,000 deployments per year. The rescue equipment is meticulously kept up to date, and all medical personnel are fully qualified. Every rescue mission, even those on the ground, involves one flight paramedic and helicopter mission crews also include an emergency doctor, qualified in anaesthesia and intensive care. Air Zermatt’s helicopters are fitted with Night Vision Imaging Systems (NVIS) for night-time rescue flights. The company also owns several Spectrolab SX 16 searchlights, which can be fitted to various helicopters. If a rescue has to take place on uneven terrain, a winch or Air Zermatt’s Multi Evacuation and Rescue System (MERS) is used. The rescue winch provides a rope length of up to 50 metres. If required, the haulage rope can be further extended using a fixed rope. The rescue winch has a weight limit of 230 kg, so up to two persons can be rescued at a time. With the MERS, six persons can be carried at the same time, and the MERS can be extended to a length of 220 metres. The MERS has a much higher load-bearing ca-

3 · 2012 I Vol. 2 I AirRescue I 167

Air Zermatt staff

• • • • • •

11 pilots 16 flight assistants 12 licensed helicopter mechanics 15 administration and customer service staff 6 flight paramedics 45 freelancers

pacity than the rescue winch because it attaches to the cargo hook. Unlike with the rescue winch, this means there are no centre-of-gravity or weight-and-balance issues. Due to its collaboration with KWRO, Air Zermatt can also take extra rescue specialists on its flights. This is particularly useful for rescue missions over challenging terrain, when the doctors require additional support.

Decorated heroes Over its 44-year history, Air Zermatt has received three prestigious Heroism Awards, the highest civil aviation accolade, for its rescue excellence. • In 1972, Air Zermatt pilot Günther Amann successfully completed the first-ever direct air rescue on the treacherous north face of the Eiger. • In 1976, Siegfried Stangier and Beat H. Perren completed a daring rescue on the north face of Piz Badile. • In 2010, Daniel Aufdenblatten and Richard Lehner flew the highest-ever rescue mission, at an altitude of 7,000 metres, on the Annapurna massif in Nepal. For this, they received the Heroism Award in March 2011.

Fig. 2: For Beat H. Perren (second from left), co-founder, Air Zermatt‘s primary purpose still is providing quick rescue services to accident victims in the mountains

32 | IN PROFILE

Fig. 3: In the early years, an SA 315B Lama and an SA 316/SA 319 Alouette III were used for all flights

Fig. 4: If a rescue has to take place on uneven terrain, a winch or Air Zermatt’s Multi Evacuation and Rescue System (MERS) is used

Fig. 5: Air Zermatt runs its own, internationally certified maintenance and overhaul workshop

Air Zermatt’s rescue service was also commended by the Interverband für Rettungswesen (IVR) in 2009, and in the autumn of 2012 it will receive an award for being the first European air rescue operator to use flight paramedics on its rescue missions.

not covered, or only partially covered, by a member’s health/accident insurance or other provider. For this, Air Zermatt maintains individual member rescue cards in its file system. This service is provided in response to all the solidarity and support that the Valais helicopter rescue infrastructure has received. Aside from medical air rescues, one of the service’s biggest advantages is its ambulance transports. Another advantage is that family membership cards also cover livestock.

Air Zermatt in the media spotlight Maintenance and overhaul Air Zermatt runs its own, internationally certified maintenance and overhaul workshop. From 1985 to 2002, Air Zermatt was contracted to provide technical service for Swiss Army helicopters. After the army was restructured, all maintenance contracts were terminated, with the army now completing all maintenance tasks itself. Today, Air Zermatt provides maintenance services for a number of commercial customers. Air Zermatt has not only had a pioneering role in rescue flights; it is also a design innovator. The company has helped to develop a range of helicopter modifications, including the LAMA bubble door, the LAMA runner, the load-viewing mirror for the Ecureuil, and ski baskets for Ecureuil and EC135 helicopters.

Rescue cards as membership ID Air Zermatt bears the costs (excluding excess) incurred by its members for ambulance services, helicopter transport and repatriation services outside Switzerland, if these are

Air Zermatt regularly receives media attention and acclaim. Back in the mid-80s, former pilot Siegfried Stangier wrote a whole book, Retter, die vom Himmel kommen (Rescuers from the sky), about Air Zermatt. In the book, Stangier describes the long-line rescue method he himself devised whereby a rescue rope up to 220 metres long is attached directly to the helicopter. As described above, this was first used in 1972 on the Eiger North Face. Several years ago, Switzerland’s DRS television network ran a documentary called Die Bergretter – unterwegs mit der Air Zermatt (Mountain rescuers – on the move with Air Zermatt). The seven-part series was broadcast from May 2007, and a second season followed in the winter of 2007/2008. In early 2012, Germany’s Geo magazine published a major article on air rescue in the Himalayas, showing Air Zermatt’s HEMS crew members training local air rescuers. Media attention in Switzerland continues unabated, with Swiss TV broadcasting a threepart series last winter called Die Bergretter im Himalaya (Mountain rescuers in the Himalayas). 

3 · 2012 I Vol. 2 I AirRescue I 168

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0 | IN PROFILE

Fig. 1: Winching exercise of Naval Air Station flotillas 32F and 33F (Photograph: A Doiré/ ECPAD)

Authors: Christophe Albert Senior Flight Surgeon Lanvéoc Naval Air Station Lanvéoc-Poulmic Medical Unit Centre médical des Armées de Brest-Lorient christophe_albert@yahoo.fr

“So others may live”: Aerial rescue operations and SAR activities in Crozon, Brittany The Crozon peninsula in the Finisterre area of Brittany boasts one of the most spectacular landscapes in France and, as its name suggests, this area is often described as ‘the end of the world’. The area is also famous for its French marine military installations, among them the Lanvéoc Poulmic Naval Air Station (Base de l’Aéronautique Navale de Lanvéoc-Poulmic) and French Naval Academy (École Navale), where future French naval officers undergo training. This strategic position in the harbour of Brest is an ideal location for keeping an eye on the Ushant traffic lane, one of the world’s busiest shipping lanes. Indeed, 25% of the world’s maritime trade (oil tankers, ferries, fishing vessels, yachts and military vessels) uses this route to access the major ports of the North Sea.

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IN PROFILE | 35 ice for all types of maritime emergencies alongside their other missions, 24 hours a day 365 days a year. Living up to its motto, ‘Evit Mar Vevo Ar Re All’ (‘So others may live’ in Breton language), flotilla 32F has rescued more than 2,200 people since its formation. This rescue activity is part of the ‘Search and Rescue’ (SAR) action plan, in line with SAR regulations from the International Civil Aviation Organisation (ICAO) and International Maritime Organisation (IMO). These missions are carried out by the crew and helicopters of flotillas 32F and 33F, in partnership with medical teams from the Brest-Lorient military medical centre (Centre médical des armées de Brest-Lorient, CMA-BL). Beyond its primary role of supporting French navy personnel during operations, the main aspect of the centre’s operations is dedicated to civilian call-outs signalling distress at sea or for medical evacuations (MEDEVAC) of sick or injured seafarers. MEDEVAC comes from a medical regulation led by the Centre de Consultations Médicales Maritimes (CCMM), the French Telemedical Assistance Service (TMAS), based in Toulouse. Different courses of action are possible according to medical symptoms and the severity of the case: • Type I: Care on board, no re-routing, no evacuation (MEDICO) • Type II: Care on board, re-routing to nearest harbour, no evacuation • Type III: Evacuation without medical escort (EVASAN) • Type IV: Evacuation with medical escort (EVAMED) • Type V: Diving-related incident • Type VI: Mass-casualty incident at sea triggering ‘ORSEC mer’ evacuation plan

For more information, visit:

MEDEVAC helicopters Since the operational launch of the Caïman in December 2011, SAR operations have been carried out using two helicopters:

The high traffic density, combined with rapid changes in weather and sea conditions, make this area one of the most hazardous in the world. Following the traumatic shipwrecks of the 1970s – among them the sad incident of the oil tanker “Amoco Cadiz”, which ran aground in 1978 causing the largest oil spill in history to that date – France has developed a state policy of coastguard operations (Action de l’État en mer). These operations have been put in place to manage potentially catastrophic events at sea and are the responsibility of the Port Admiral (Préfet maritime) in Brest, appointed directly by the French Prime Minister. French maritime aviation undertakes about 60% of global maritime aerial rescue operations. The air force, police, civil defence, border patrols and other HEMS ambulance services are other parties involved. The French Navy and the French Defence Health Service (Service de Santé des Armées) provide a medical assistance serv-

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• 32F uses a Eurocopter EC225. Crew required: pilot, co-pilot and winchman. Weight: 11 tonnes. Endurance: 4 hours. All Weather Day and Night capability. Radius: 225 Nm. Capacity: 18 passengers. • 33F uses a Caïman Marine NH90. Entered operations last winter (standby). Crew required: pilot, tactical officer (TACCO) and sonar/hoist operator. Weight: 11 tonnes. Endurance: >3.5 hours (to be increased in the near future with the addition of two further fuel tanks). Both helicopters have All Weather Day and Night (AWDN) capability, emergency flotation and searchlights and Night Vision Goggles (NVG). Forward Looking Infrared (FLIR) is also available in the Caïman. Improvements to the helicopters used previously for the MEDEVAC missions have also been made, particularly in terms of the space available for in-flight care. Both helicopters are authorised to carry a full medical crew (including a rescue diver, a nurse and an emergency physician).

Flotilla 32F at the Ministry of Defence, France ››› http://bit.ly/OVZ2vf

Préfecture maritime de l’Atlantique (PREMAR) ››› http://bit.ly/OkzqKA

Le Centre de Consultation Médicale Maritime (CCMM) Centre for Maritime Medical Consultation ››› http://bit.ly/OVZg5A

36 | IN PROFILE achieve the highest possible level of care, even in extreme conditions, medical kit bags have been chosen that are compact and sturdy, water-resistant and hoistable. Up-to-date Chemical, Biological, Radiological and Nuclear (CBRN) knowledge is also very important, as there is a permanent risk of these threats due to the intensity of chemical tanker traffic in the Ushant shipping lane at the south-western end of the English Channel. Two operations, one last year and one in 2010, proved that adapted equipment is required on board for pilots and medical crew and frequent exercises are also necessary to maintain this highly specialist skill.

Phases of standard offshore MEDEVAC Standard offshore MEDEVAC is divided into 3 phases:

Fig. 2: In-flight monitoring of patient (Photograph: L Poinot/ Marine Nationale)

Fig. 3: Inside the cockpit of the EC225 used by flotilla 32F (Photograph: A Doiré/ECPAD)

The current staffing of the Lanvéoc-Poulmic branch of the CMA-BL comprises military physicians and militaryregistered nurses. All are trained in emergency medicine and management of aeronautical physiological effects. They have also been trained in marine rescue and survival at sea, including the evacuation of ditched aircraft, at CESSAN (Centre d’Entrainement au Sauvetage et à la Survie de l’Aéronautique Navale), the military training centre in charge of survival training for all French military crew. In addition to the specialist skills already mentioned, the physician medical crew have been trained in disaster medicine and crisis management and assume the position of Head of Medical Operations in the event of a masscasualty incident at sea. It is possible to increase medical staff with operational reserves who are usually employed in civilian emergency departments. Close relationships with civilian emergency medical services such as SAMU 29, the emergency response unit in Finisterre, are the key to success. Several training opportunities are offered during European coastal exercises involving all major public authorities in simulated disaster situations. The medical equipment provided by the army is the same as that used by civilian emergency medical services. In order to

• Phase 1 of the alert covers the decision to carry out an aeromedical evacuation following a medical evaluation by the Toulouse CCMM organised in collaboration with the SAMU de Coordination Médicale Maritime (SCMM), based at Brest University Hospital, which coordinates the local emergency response. A medical team is then deployed to evaluate the situation following transfer to the area. • Phase 2 involves the removal of the patient and is the most risky phase. After the applicant ship is located, the pilot hovers above the ship. The search and rescue helicopters carry a rescue diver, a doctor and a nurse, who are typically winched down to the vessels to provide treatment. If there is sufficient time, patients are stabilised before being hoisted to the helicopter, otherwise they can be hoisted on board quickly and stabilised in flight. Life support is monitored (heart and breathing rate, blood pressure, oximetry, temperature and blood glucose) and a multi-ECG and intravenous catheters are commonly introduced. Patients are usually on a drip (IV or EZ-IO for patients suffering from shock), given the risk of motion sickness and unstable conditions. • Phase 3 involves transfer of the patient to hospital. Once aboard the helicopter, stabilisation of the patient continues until arrival at the hospital. For the air and medical crew the keys to success are working together as a team and having confidence in each other’s abilities. Crew members need to be able to cope with stress effectively, as well as with the linguistic barriers that come from dealing with patients on international shipping vessels who often speak foreign languages other than English (including Russian and Polish).

MEDEVAC missions According to the 2011 activity report, the Lanvéoc Naval Air Station’s helicopters conducted over 100 rescue missions – of which the majority were MEDEVAC flights – and provided care for patients with a variety of medical problems. These figures are similar to those seen in 2010. In addition to the maritime missions, a number

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of land MEDEVAC missions also took place. These are necessary particularly in adverse weather conditions or when other aerial resources are engaged elsewhere. The proportion of land-based missions (16%) was double that of 2010. As in previous years, the busiest periods were spring and autumn. In February, for example, fishermen experienced poor weather conditions. September was notable for the number of passengers with pre-existing medical conditions who were unable to travel by plane and therefore chose to travel by ferry. Around a third of call-outs came from fishing vessels and a quarter from passenger vessels. Forty-three per cent of medical emergencies involved orthopaedic injuries, 24% were cardiology-related and 15% were for gastro-intestinal conditions. The main types of traumatic injuries treated were head (22%), spine (14%), plus hand, foot and upper limb (13%). Overall, the typical patient profiles were fishermen with trauma injuries and ferry passengers with cardiac conditions. The average length of medical missions was roughly two hours, with 30 minutes spent at the vessel. The average ‘medic-to-ship’ time was less than an hour – a faster response than might be achieved by ground vehicles for some land-based emergencies. As many of you who work in this area are aware, our challenge is to overcome the many limitations that are present and to practise medicine at the same level of excellence as in the ICU. Medical search and rescue missions often involve high-risk or severely injured patients and also reflect the particularity of the unusual environments in which these take place. In addition to the limited time available for on-board intervention, there are other

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difficulties related to being in a helicopter, including noise, low-intensity lighting, vibrations, equipment constraints (tight flight suit) and limited space in which to work. To summarise, all these different factors are also what make the job amazing and different from everyday emergency practice. Intervening on vessels is never a routine operation. It demands specific criteria for the recruitment, not only in terms of medical skills but also standards of physical fitness and aeronautical knowledge. Regular training with flight crew is also essential. Developing new technologies, such as medical on-board simulation and portable ultrasound, should be explored to enhance performance during high seas MEDEVAC operations. 

Fig. 4: The Caïman NH90 is an 11-ton class helicopter by NH Industries with endurance of over three and a half hours (Photograph: D’Erbecourt/ Marine Nationale)

Fig. 5: Rescue operation: the rescue diver hoists survivors after a shipwreck high seas MEDEVAC operation (Photograph: M.Prigent/ Marine Nationale)

The author would like to thank Dr Clodagh Cashman, Capitaine de frégate (CDR) Stanislas Azzis (32F) and Capitaine de frégate (CDR) Rodolphe Goupil (33F) for their valuable assistance.

0 | IN PROFILE

In Belgian skies “24/7” – Centre Médical Héliporté For fifteen years, the Centre Médical Héliporté (CMH) has been developing a helicopter emergency medical and resuscitation service in Belgium – an undertaking full of peculiarities and transformations. CMH – a real pioneer in the field of helicopter emergency services in Belgium – started operations in 1997. The service has reliable partners and popular support, and is the only Helicopter Emergency Medical Service in Belgium available 24/7, exclusively at the request of “112” call centres.

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At the centre of a “red zone” Any discussion involving the operations of the CMH must include its geographical location, as it provides specialist medical assistance from its base in the small village of Bra-sur-Lienne. The choice of this location as a base for helicopter missions is a strategic one: it is right in the middle of the largest demographic “red zone” in Belgium. This is an area in which the rural population does not have access to any medical or resuscitation services by road within less than fifteen minutes. In addition, the region is isolated from medical centres specialising in the treatment of serious illnesses, such as coronary angiography, thoracic surgery, paediatric or neonatal intensive care units as well as neurosurgery. On top of this, accessibility in this rural area is made even more challenging with its hilly road network, which does not allow for easy access or rapid transportation by land. The only solution is transportation by helicopter; therefore the service has been developed with this in mind.

Predominantly primary missions According to CMH’s latest activities report, of the 1,102 helicopter missions carried out in 2011, the service recorded a requisition rate of 92% for primary missions. These were missions in which CMH’s helicopter was

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dispatched as the fastest carrier to rescue a patient. The primary mission is the most important aspect of all the CMH team’s competencies. Other responsibilities include requests for transfers between hospitals with an urgent need for rapid transportation. This is commonplace in the rural area covered by the carrier, as the peripheral hospitals in this region do not have specialist technical facilities.

Fig. 1: HEMS provide patients living in rural areas with the same accessibility to medical treatment as those in urban areas or those living close to specialist medical services (All photographs: Valentin Bianchi) Fig. 2: Centre Médical Héliporté has popular support and is the only HEMS in Belgium available 24/7

Four speed levels More than ever, speed is paramount to each mission, with rigorous guidelines for the three responders on duty in terms of time saving measures. Firstly, the time of requisition needs to be reduced. Annual statistics reveal an average time frame of 3 minutes and 42 seconds between the demand coming through from the call centre and the moment the helicopter is dispatched. Another objective is to reduce the interval without medical treatment. The results recorded are significant: the CMH helicopter speeds up the medical team’s transfer by a factor of between three and five. On the ground, this means that the CMH team provides patients with an adapted emergency service that arrives within fifteen minutes or even ten minutes of the call being received from the call centre. The helicopter also has to be positioned as close as possible

Authors: Olivier Pirotte Operations Manager Didier Moens Head of Medical Dept. Olivier Lambert Communications Consultant Centre Médical Héliporté ASBL (CMH) B-4990 Lierneux Belgium olivier.pirotte@centremedical heliporte.be

40 | IN PROFILE

Fig. 3: Analysis of the operational statistics confirms a positioning of less than 100 m from the patient in 85% of all day missions

to the patient so that they can be reached by the team as quickly as possible. Analysis of the operational statistics confirms a positioning of less than 100 m from the patient in 85% of all day missions. The greatest time savings are achieved when the patient is being transported to a specialist medical centre.

Equipment The Centre Médical Héliporté has selected high-quality equipment adapted for use in the helicopter. For almost seven years the CMH has been using state-of-the-art technology in helicopter medical emergency assistance in the form of an EC145 with wall-fixed medical equipment. The EC meets the needs of the field-specific missions and the local rural landscape perfectly and also offers enough space to transport two patients on artificial respiration. In terms of equipment, the CMH carrier is better equipped Fig. 4: In all interventions, the choice of the specialist medical centre is based solely on the patient’s best interests

than a land-based emergency service, with an automated band chest compression device (AutoPulse®), a portable ultrasound (SonoSite Turbo), two portable respirators (Weinmann) and a monitor/defibrillator (Zoll X Series™).

Training The quality of the logistic apparatus goes hand in hand with choosing a highly skilled medical and paramedical team. The staff members, doctors and nurses are employed as freelancers, which ensures independence with regard to the wide range of expertise in the development of the service for patients, as well as neutrality towards the different medical structures when selecting the patient’s destination. The team selection criteria are very strict. There are fifteen doctors at CMH and all are specialists in medical emergency, anaesthesia-resuscitation, cardiology, or surgery. Ten nurses specialise in intensive care and emergency medicine. One specific requirement is that team members’ main activity must have been based in an emergency and resuscitation unit within a hospital environment. The nurses’ training is coupled with a HEMS certificate. All the medical professionals, both doctors and nurses, are recruited from among the country’s largest specialist medical centres.

Maximum availability Why use a helicopter? Firstly, to maximise the quality and efficiency of patient care in the rural area covered by the carrier. Secondly, to maximise availability of the specialist medical team and its carrier for every mission where their specialist skills are genuinely needed for patient care, such as multiple trauma patients, head injuries, haemorrhagic shocks, severed limbs, serious burns, cardiac arrest and acute myocardial infarction. In all interventions, the choice of the specialist medical centre is based solely on the patient’s best interests.

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A complementary resource Though the CMH’s operational guidelines are distinct and often innovative in a landscape deprived of any other established helicopter service, the history of the service has suffered – and still suffers – from a lack of recognition at the level of the Belgian Federal Ministry of Public Health. In Belgian skies, the helicopter carrier has often been viewed as an object of medical lobbying thanks to its ability to radically increase the activity of a specialist structure’s emergency service. The public authorities, however, have considered it a resource that only offers a minimum value – an assumption certainly marked by a complete lack of knowledge about the specificities of what a helicopter service can offer. In order to succeed in its gradual integration into the medical emergency response system in Belgium, the CMH works daily to create awareness among Federal Agencies and its field workers. The service works to promote the value of the helicopter as an emergency resource that complements existing resources. The Ministry of Health reported an interest in viewing expert reports on all missions requiring the CMH helicopter carrier, which included mission reports, analysis of reasons for refusal and unavailability of the carrier, measurement of time savings in transfer time to hospitals compared with land-based carriers, hospitalisation period compared with a land-based service, seriousness criteria determined by NACA scores as well as the rate of endotracheal intubation and the time spent by the medical team on the ground. In short, all operational activities.

HEMS important for rural areas Since its trial agreement, the service has continued to gather reports demonstrating the value of the helicopter carrier in rural areas. To complement the scientific findings, the Centre Médical Héliporté has conducted a study over a period of 30 months based on its own operational activities, which focused on patients suffering from acute myocardial infarction. The purpose of this study was to record the time savings achieved using a helicopter carrier compared to a land-based carrier, in terms of improved accessibility to the patient (transfer time) and transfer to the specialist medical centre offering treatment for coronary angiography. To simulate the comparative time for a land-based carrier, the CMH used a commercial mapping program. The study found that 1,988 patients benefited from the intervention of the helicopter carrier, including 254

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who were suffering from acute myocardial infarction. The results and statistics recorded showed that these 254 patients received treatment well within the maximum time period of 90 minutes recommended by international scientific organisations. In addition, the “112” call centre admitted almost all the patients assisted by the CMH carrier directly to a coronary angiography facility within an hour of the call and request. All of the patients underwent treatment to reopen the blocked artery. The study also showed that had the interventions been carried out by a land-based carrier, none of the patients would have been able to benefit from this specific treatment according to the defined recommendations. To conclude, the study provides scientifically proven results: significant time savings in transfer to hospital to prevent complications of acute myocardial infarction (cardiac arrest and ventricular fibrillation), prompt medical patient care in under fifteen minutes, access to coronary angiography platforms within the recommended timeframes and increased availability of the carrier for other missions. These conclusions show that using the helicopter offers patients in rural areas the same chances and access to treatment as those in urban areas or those living close to specialist medical services. This study was also presented at the Airmed conference in Brighton in June 2011.

Fig. 5a and 5b: PTCI Time Gain and Free Medical Interval (Study AMI 2007-2009, by Dr D. Moens, CHU Liège)

Night flights Over and above its obligations, the CMH provides emergency night services. Having equipped its carrier with a Nightsun SX-5 searchlight, for the past three years it has also been investing in a patented system for automatic markers on football pitches. Night flights are subject to different constraints than day missions. The darkness not only slows down flight procedures, but also makes it difficult to identify urban and rural landscapes, especially approaching touchdown points or surfaces that could accommodate a helicopter under the strictest safety conditions. The team identified football pitches equipped with a lighting system as suitable night-time touchdown points. A system of automatic markers has been developed to quickly illuminate the identified football pitch during night missions without the need for human intervention. The automatic control uses a secure mobile phone minutes before the team is due to land. More than sixty-five pitches have been equipped for this procedure. Today, emergency night flights account for 30% of all activities. 

For more information, visit: ››› www.centremedical heliporte.be

42 | OFFSHORE

Fig. 1: Activities for the avoidance of offshore wind farm work accidents have to be adapted (Photograph: AREVA Wind/Jan Oelker)

Authors: Nils Weinrich Dirk Dethleff Caroline Friebe Markus Stuhr Klaus Seide Christian J眉rgens Berufsgenossenschaftliches Unfallkrankenhaus Trauma Hospital Hamburg Germany

Rescue Chain Offshore Wind: Developing a concept for trauma patients in offshore wind turbines The energy concept issued by the German Government in September 2010 schedules the development of offshore wind energy in the coming years. In this context, particularly the significant future increase of working places in the wind farms has to be anticipated. Subsequently, activities for the avoidance of work accidents in this context have to be adapted steadily to the expected development. It has to be considered that particular requisites and standards apply for the construction and operation of offshore wind farms. Thus, the particular offshore conditions at open sea require specific education, training and knowledge from the personnel appointed. From the viewpoint of the Statutory Accident Insurance, the particularities of the primary medical attendance under the specific offshore wind farm conditions and circumstances need definite consideration. For instance, the access of the offshore wind turbines is definitely governed by weather and sea state conditions. Also, the difficult conditions of over-sea rescue transport from offshore wind farms towards onshore hospitals need to be taken into account.

This very important topic devotes an interdisciplinary team in the framework of a research project established at the BG Trauma Hospital Hamburg (BUKH). Based on scientific knowledge of rescue logistics, -techniques and -medicine, the overall aim of the project is to develop a rescue chain concept for trauma patients in offshore wind farms in order to finally derive recommendations for the future development and implementation of a rescue chain. The three-year project is funded by the Institution for Statutory Accident Insurance and Prevention for Trade and Merchandise Distribution (BGHW) and runs under the leadership of the BUKH Medical Director, Prof. Dr. med.

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Main research topics of the project • Analysis of currently existing rescue concepts for offshore wind farms • Investigation and optimization of existing restraint systems from the biomechanical-medical perspective • Needs assessment of telemedical rescue assistance systems • Analysis of previous accident scenarios in terms of needed classification of injuries as well as acutely occurring and emergency diseases • Analysis of existing safety and emergency training programs • Needs assessment of medicine and rescue means as well as additional personal protection equipment or communication facilities/means from a medical-scientific perspective • Examination of present medical treatment concepts following the current S3-guideline for polytrauma from the German Society of Orthopedics and Trauma Surgery (DGOU) • Needs assessment of professional primary medical attendance • Analysis of additional hazards for trauma patients and rescue staff considering the maritime environment and offshore weather conditions • Development of recommendations for optimum rescue concepts

Ch. Jürgens. Various BUKH departments like the Department of Trauma Surgery, Orthopedics and Sports Traumatology, the Department of Anesthesiology, Intensive Care and Emergency Medicine as well as the Laboratory for Biomechanics contribute to the project. The official start of the research work was in spring 2012. Project team members were recruited from various professional disciplines like emergency-, rescueand trauma medicine, biomechanics, marine sciences, physics, engineering, law and Institutions for Statutory Accident Insurance and Prevention. It is further intended to collaborate with additional institutions, associations and specialists in terms of a beneficial maritime safety partnership for offshore wind farms. 

Fig. 2: The overall aim of the project is to develop a rescue chain concept for trauma patients in offshore wind farms (Photograph: Fotoabteilung BUKH)

For more information, visit: ›››http://bit.ly/O6gGj8

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44 | MEDICAL CARE

Fig. 1: The helicopter took off at 8.36 a.m. and landed about 300 metres from the house, on the edge of the village, at 8.45 a.m. (Photograph: Filip Kotek)

Authors: Jan Weinberg Olomouc Regional EMS Aksamitova 8 779 00 Olomouc Czech Republic jan.weinberg@zzsol.cz

EHAC President Pavel Müller recently attended a presentation based on the following article, at an EMS conference in the Czech Republic. Given the significance of the HEMS crew’s experience during the mission, he asked the attending HEMS doctor to publish the article internationally and share his valuable experience with the community.

Carbon monoxide poisoning: A case in HEMS Missions involving carbon monoxide poisoning are quite frequent for the emergency medical services, especially during the autumn and winter months. The consequences of this kind of poisoning are fatal in many cases, because the most common indication of the source of the problem is usually unconsciousness, and therefore only revealed at the time the patient receives treatment. Nevertheless, prognosis depends on the length of exposure. The following article examines a case where the basic on-scene diagnosis of carbon monoxide poisoning was hindered by a number of other atypical symptoms which differed from the so-called textbook cases, and where the danger to the lives of all present was only discovered due to the clinical signs of poisoning affecting the emergency crew. Fortunately, in this case the crew were able to recognise the threat and react accordingly. Moderate carbon monoxide poisoning occurs when the carboxyhaemoglobin level reaches more than 25%. Apart from possible vomiting, the clinical signs range, above all, from confusion to a loss of awareness, and from drowsiness to stupor. Severe acute poisoning occurs when the level of carboxyhaemoglobin reaches more than 45%, leading to a loss of consciousness, impaired breathing and circulatory shock. In carbon monoxide fatalities with more than 60% carboxyhaemoglobin, the victims are described as having red faces and limbs, with any marks on the body also having a reddish tinge. As mentioned above, haemoglobin combined with carbon monoxide forms carboxyhaemoglobin (COHb). The higher the percentage of carbon monoxide combined with haemoglobin, the lower the blood stream’s capacity to carry oxygen. The very

strong binding of carbon monoxide is a determinant in the strategy for treatment. Breathing in fresh air reduces the half-life of COHb to about 4 hours; inhaling pure oxygen reduces the half-life to about 90 minutes. With hyperbaric oxygen therapy (inhaling pure oxygen in a pressurised chamber), the half-life can fall to 15 minutes. Carbon monoxide poisoning is not a marginal problem – the statistics show that in the Czech Republic alone there are 1,000 cases diagnosed each year, 200 of which are fatal.

Case study The regional EMS Operations Centre in Olomouc, Czech Republic received a call at 8.33 a.m. on 22 December 2009. A woman had been found unconscious at a house in the Prosteˇ jov area (Olomouc region). The woman was

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MEDICAL CARE | 45 unconscious but breathing. The HEMS helicopter took off at 8.36 and landed about 300 metres from the house, on the edge of the village, at 8.45. The HEMS crew arrived on scene at 8.47. Anamnestic data was not available. The woman, born 1952, who had been receiving low doses of thyroid replacement, had last been seen by her family around 8.00. She was found unconscious on the kitchen floor at about 8.30. Objective findings were: • • • • • • • • •

unconscious GCS 3 pupils isochoric and reactive to light blood pressure 100/60 pulse 79/min no injuries blood oxygen saturation 80-84% skin with no apparent pathology glucose level 4.8 mmol/L

There were three other people in the kitchen, which was about 30 m2; the husband (born 1947), son, and daughter-in-law. In view of the facts apparent at the scene, the woman was given a peripheral venous catheter while being monitored, orotracheal intubation with pre-medication was administered, and finally she was put on artificial pulmonary ventilation (APV). The patient’s son was asked to help and went to the helicopter to collect a ventilator, which took about 5 minutes. The woman was connected to a controlled ventilator with a fraction of inspired oxygen

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Carbon monoxide

Carbon monoxide is a colourless, odourless, nonirritant gas. In nature, it occurs in minute amounts, mainly where there is photosynthesis of carbon dioxide influenced by UV radiation. It is also contained in volcanic gases and occurs as a product of incomplete combustion of fossil fuels and biomass. Its toxicity is based on its strong affinity to haemoglobin, to which its binding is approximately 200-220 times higher than that of oxygen. This forms the foundations for the clinical manifestations of the different stages of acute poisoning. The early signs of mild poisoning can be recognised when just 10% of haemoglobin has been transformed to carboxyhaemoglobin and causes headaches, vertigo, sickness, and slower reactions and thought processing. In addition, the victim’s face might show signs of increased blood flow.

46 | MEDICAL CARE (FiO2) of 1.0. Suddenly, her husband, who had previously undergone triple-bypass surgery, announced that he was having chest pains. At this point, the immediate care of the woman had been completed, she was receiving APV, the therapy was set, and her vital functions had been checked: blood pressure 110/70, pulse 70/min, blood oxygen saturation 99%. She was left in the care of the paramedic, while the doctor went to the aid of the husband, who was sweating and complaining of intensifying pressure in his chest. As the doctor started his examination, the young woman, the daughter-in-law, who had been standing beside the doctor, also collapsed. At that Fig. 2: A further recommendation is for the doctor and paramedic to maintain audio contact with the pilot – should they be separated due to the patient’s location (Photograph: Roman Slezák)

Fig. 3: The patient’s son was asked to help and went to the helicopter to collect a ventilator (Photograph: Roman Slezák)

moment the doctor started to feel dizzy and increasing pressure in his chest, and, on the basis of the events that were unfolding, at 9.00 came to a new diagnosis – carbon monoxide poisoning. This fact is confirmed by the paramedic, who, when prompted by the doctor to open the window closest to him, felt unable to reach it even though the window was only about 1.5 metres away. After both took several breaths of fresh air, the doctor carried the young woman outside to the garden, while the paramedic opened all the other windows. After that, the doctor and paramedic managed with some difficulty to carry the husband suffering from chest pain to the next room. There, he was seated by an open window and this led to an immediate reduction in his symptoms. The daughter-in-law outside regained consciousness and declared herself to be without any problems or injuries, only feelings of anxiety. The son was still outside with no apparent difficulties, which was probably due to the positive effects of running to fetch the ventilator. The husband was moderately sedated from the effects of the gas, with normal blood pressure, and an elevated heart rate. An ambulance crew was called from Prosteˇ jov, and the Fire Department and Police were informed. Meanwhile, the female patient was flown on an artificial ventilator to the specialised hyperbaric treatment unit at OstravaFifejdy hospital for immediate hyperbaric oxygen therapy. She arrived there with stabilised circulation. The male patient, her husband, was transported by ambulance to the hospital in Prosteˇ jov, where further investigation discovered he had a COHb level of 25%, after which he was also transferred by helicopter to Ostrava-Fifejdy hospital. The son and daughter-in-law were taken by ambulance also to Prosteˇ jov hospital, where they were found to have a COHb level of 14% and 17% respectively, and both were treated in Prosteˇ jov. The HEMS crew felt well enough to continue their shift and completed three more missions that day. The doctor was inhaling oxygen during the flights, while the paramedic, due to the apparent absence of any symptoms, did not feel it necessary. During the flight from Ostrava, at about 15.00, he started to feel sick. A blood sample was taken and he was found to have a COHb level of 8%. A short course of oxygen therapy was given and the symptoms disappeared.

Summary Carbon monoxide poisoning is not an uncommon diagnosis. If there is a gas appliance directly at the scene of the incident, then the cause is usually clear to the intervening EMS crew. In the case described, however, all the evidence pointed away from the eventual diagnosis; only one of the four people present was unconscious. Furthermore, it was a large room whose access led from a narrow hallway that led directly outside the house. Moreover, there was no textbook red discoloration of the skin, typical in these cases. Diagnosis of the actual cause only occurred when the other four people present began to succumb to the effects and their health condition rapidly worsened. In this sense, personal experience is always irreplaceable. Carbon mon-

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MEDICAL CARE | 47 oxide is odourless and is not an irritant. It also clearly and stealthily slows down the body’s sense of alertness, as shown by comparing the audio recording of the doctor’s initial call with the dispatch centre and his voice three minutes after arriving on scene. Thirteen minutes in the room was long enough for a clear indication of clinical symptoms. This case has justified the introduction of new technologies into practice – more specifically, Olomouc Regional EMS service’s introduction of equipment that gives Carboxyhaemoglobin (SpCO®) readings during routine oxygen (SpO2) measurements. A further recommendation is for the doctor and paramedic to maintain audio contact with the pilot, should they be separated due to the patient’s location. From this perspective, it was a textbook case; the mission was to a house in a village, the landing site was about 200 meters from the scene and the pilot could not leave the helicopter unattended. In such conditions, should the crew have become unconscious due to the effects of carbon monoxide poisoning, it is possible that it would have been too late for the pilot to react. On 23 December, the female patient (born 1952) was transferred from the Hospital Department of Anaesthesiology and Intensive Care in Ostrava to the Hospital Department of Internal Medicine in Prosteˇ jov. After regaining consciousness, she had a slight loss in memory function, which returned after treatment and she was released

home with no further difficulties on 8 January 2010. The three other family members had left hospital on 24 December 2009 without suffering any further effects. The house itself had been newly renovated, including UPVC windows. The source of carbon monoxide was found to be coming from a gas water heater, located in a bathroom on the opposite side of the house. It had just been checked for carbon monoxide emissions a week earlier and had been deemed safe. 

Fig. 4: The source of carbon monoxide was found to be coming from a gas water heater, located in a bathroom on the opposite side of the house ( Photograph: Jirˇ í Kratochvíl)

4 th International

HELI World

Conference • Exhibition • B2B HELICOPTER Technologies and Operations

November 7 – 8, 2012 Exhibition Centre Frankfurt / Main Germany

48 | MEDICAL CARE

Fig. 1: The use of prehospital transcranial ultrasound to diagnose embolic strokes, performed by trained EMS personnel, could significantly improve stroke care (Photograph: AAMS/Mark Mennie)

Prehospital use of portable ultrasound for stroke diagnosis and treatment initiation Author: Thilo Hölscher Director Brain Ultrasound Research Laboratory (BURL) University of California San Diego

For more information, visit: ››› http://bit.ly/burldevice

Despite all advancements in medical science, stroke remains the second common cause of death worldwide (1). There is an increasing number of stroke victims each year, independent of the cultural, the geographical or the socio-economic background (2). Stroke has been the most common cause of early invalidity worldwide for many years, contributing to the rapidly increasing costs for Medicare and long-term support. Similar to other ischemic diseases, such as myocardial infarction, the success of treatment is highly dependent on early diagnosis and onset of treatment at the earliest time-point possible. Different from other ischemic diseases, however, is the time sensitivity of neuronal cells under ischemic conditions. Recent investigations show that about 2,000,000 neurons die every minute during cerebral ischemia without chance of recovery or long-term substitution (3). This number underscores best the need for early diagnosis and, more so, treatment at the earliest time point possible. The today’s armoury of acute stroke treatment options, however, is alarmingly poor and offers currently not more than one lytic drug and a few newly developed intravascular techniques to remove vessel occluding blood clots. The drug is well known as tissue Plasminogen Activator (tPA), it is approved by the U.S. Food and Drug Administration (FDA) and defines the current gold standard for stroke therapy. Besides its potential benefit, the administration of tPA is restricted, for example, by a required cranial Computed Tomography (cCT) to exclude a pre-existing hemorrhage or the limited treatment window of 4 hours between symptom onset and initiation of the treatment. These and other reasons lead to the fact that not more

than 3% of all stroke victims actually receive tPA. Beyond, of those patients who did receive tPA, only about 30% do show a significantly improved clinical outcome on the long-term. Neurointerventional procedures to retrieve the brain vessel occluding thrombus are very promising (58) and might achieve future success rates equivalent or close to the ones known from cardiointervention. Downside is that these innovative procedures are restricted to highly specialized medical centers in industrialized countries and they are costly. In contrast, 85% of the world’s population lives in low or middle-income countries with limited access or availability of appropriate medical care and in which 85% of deadly strokes occur.

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MEDICAL CARE | 49 Although “time is brain”, it is noteworthy that all known or currently developed strategies to tackle stroke take place in the hospital. With regard to existing emergency medicine services (EMS), time is the only ally. Successful stroke diagnosis and treatment becomes a race against the clock. Patient transport times of 10 minutes between first patient contact and hospital admission are common in well-covered metropolitan areas (9). This time window is significantly increased in suburban or rural areas where EMS coverage is limited and transport times of up to several hours are not unusual.

Transcranial ultrasound and microbubbles Transcranial duplex ultrasound is a non-invasive imaging technique for examination of the central nervous system (CNS) with ultrasound (10). Since the introduction of this technique by Bogdahn et al. in 1990 (10), the method has been proven to be a valid bedside tool for vascular and parenchymal imaging of the brain (11, 12). However, significant limitations of transcranial duplex ultrasound have been: low reproducibility, inter-investigator variability and often unfavorable acoustic bone windows with poor signal-to-noise ratio (13, 14). Signal absorption and reflection at different bone components, like the trabecular and compact bone layers, account for a loss of ultrasound energy of up to 90% (15). Technical development with regard to innovative transducer technologies and advanced computational capabilities increased the transcranial image quality significantly over the last couple of years. The introduction of transpulmonary stable ultrasound contrast agents (UCA), so called microbubbles, beginning in the early 90’s improved the color-coded image quality significantly. This was an important step to overcome an insufficient signal-to-noise ratio for transtemporal as well as transforaminal examinations (16). The evaluation of the intracranial macrovasculature, mainly of the Circle of Willis, achieved clinical relevance with contrast-enhanced transcranial duplex ultrasound, especially in the early diagnosis of acute ischemic stroke (17-19). The increasing knowledge about the acoustic properties of UCA microbubbles led to new imaging opportunities. Non-linear scattering behavior in the ultrasound field yielded new imaging techniques like harmonic imaging (HI). Harmonic frequencies, which are UCA specific, can be separated from the fundamental frequency and can be used for image generation. Based on these specific acoustic properties, microbubble-specific imaging methods have been developed and enabling, for example, the visualization of the intracranial vasculature in a MR-angiography-like fashion (20). Microbubbles are primarily designed for diagnostic purposes to enhance the image quality (21, 22). Microbubbles are spheres with an average diameter of 2-3µm. The shell structure is commonly either a phospholipid or human albumin, whereas the inside of the sphere is filled with a perfluorcarbon gas. The agents are administered via a peripheral vein and they are stabilized to pass the lungs to enter the arterial circulation. The half-life of these agents is within the minutes range. Once a microbubble passes an ultrasound field, it undergoes frequent pres-

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sure changes, leading to either bubble oscillation (stable cavitation) or bubble destruction (inertial cavitation). Once microbubbles degrade, the gaseous content will be exhaled and the shell structures will be metabolized either in the liver or the spleen.

The International Prehospital Stroke Project (IPSP) To investigate whether acute ischemic stroke can be detected already in the field, the International Prehospital Stroke Project (IPSP) has been initiated in late 2008. Current active study sites are the University of California, San Diego/USA, and the University of Regensburg/Germany. The project is divided into three main parts. Part I, which was performed in Bavaria/Germany, aimed for the proof of concept that portable transcranial duplex ultrasound can be used either at the site of the emergency or during patient transport by ambulance or helicopter (see Fig. 1) to visualize intracranial vessels in real time (23). In this study, the average time between arrival at the patient’s site and performance of the transcranial ultrasound study was 12min. The study protocol required the primary patient evaluation by the paramedics and the stabilization of the vital signs. The bilateral assessment of the MCA took an average 2min. From this first study we have learned that the emergency assessment of intracranial arteries using portable duplex ultrasound devices is feasible shortly after arrival at the patient’s site. Part II aimed for the field diagnosis of acute vessel occlusion using transcranial duplex ultrasound, without or in combination with ultrasound microbubbles. This part is currently ongoing, first results have been published recently (24), showing that main MCA occlusions can be detected with high sensitivity and specificity already at the site of the emergency or during patient transport. The added use of contrast agent microbubbles was beneficial when there was a) an insufficient temporal bone window, it was also useful b) to shorten examination time, c) to increase diagnostic confidence, or d) during difficult examinations. Part III will aim for the potential treatment initiation in the field using transcranial ultrasound in combination with ultrasound microbubbles. A concept has been suggested

Fig. 2: Transcranial duplex ultrasound, axial scanning view (Visualization of the Circle of Willis, CW, after intravenous injection of ultrasound microbubbles. Left Image: display of CW in standard Color Doppler Mode; red represents blood flow towards the ultrasound probe, blue represents blood flow away from the ultrasound probe. MCA: middle cerebral artery, PCA: posterior cerebral artery, ACA: anterior cerebral artery. Right Image: Same image plane, display of CW using a microbubble specific imaging mode, transcranial Ultrasound Angiography, tUSA)

50 | MEDICAL CARE projects have demonstrated with great success that stroke expertise can be accessed even in rural areas using telecommunication (25-27). Similar to this, a project has been initiated recently at the University of California, San Diego (UCSD) to build in wireless capability into a portable duplex ultrasound device and to send image/ video data instantaneously from the device to a certified stroke center for real-time evaluation during patient transport. In collaboration with Philips Medical Solutions a portable, high-end duplex ultrasound device has been modified using 4G-bandwidth for wireless data transfer. To date, the technical feasibility to send image/video data within seconds and over short (urban district) or long (West Coast to East Coast of the USA) distances has been shown. Recently, an according research project has been funded and the study protocol has been approved by the UCSD ethic’s committee. Approximate start date of this project is August 2012. Fig. 3: Transcranial duplex ultrasound assessment in the helicopter prior to airborne patient transport (Photograph: AAMS)

recently of how a future prehospital stroke treatment initiation using a dedicated device might look like (see link at the margin).

Prehospital Brain Ultrasound – From Concept to Practice Training Program for EMS Personnel ➜ Based on the promising results of Part I and Part II of the IPSP, one of the project’s aims is to introduce the technology of prehospital transcranial duplex ultrasound to all EMS professionals who do have first contact with a potential stroke victim. The success of prehospital stroke care will depend on the skills of paramedics, EMTs and emergency physicians to perform a transcranial ultrasound study at the site of the emergency or during transport to the hospital. To accomplish this, a first transcranial ultrasound training program for paramedics has been initiated recently. In early May 2012, 45 paramedics of the San Diego Fire Department participated in a single day transcranial ultrasound course, which took place at the University of California, San Diego. The program included an introduction into the overall concept of prehospital stroke care and the use of portable ultrasound in this context, technical education in device technology and anatomy and extended hands-on sessions. Goal of this first course was to identify the ipsilateral MCA from both sides, to perform flow measurements in the visualized vessel and to evaluate in each individual case, based on predefined image criteria, whether a diagnostic useful information can be assessed without the use of ultrasound microbubbles. The MCA was chosen as the target vessel because about 80% of all ischemic strokes occur in the MCA supply area. Plan is to continue the training program and to offer it to the community. Portable Transcranial Ultrasound and Wireless Technology ➜ A reasonable approach to significantly improve prehospital stroke care would be the immediate case evaluation by a stroke expert in a remote fashion. Throughout the last years, several stroke telemedicine

Summary Amongst all medical professionals there is common agreement that stroke is a devastating disease. Stroke has a significant socio-economic impact on stroke victims as well as society. Despite the fact that stroke is one of the most time sensitive diseases, there is currently no compelling concept – diagnostically as well as therapeutically – to provide stroke care already at the earliest time possible, which is at the site of the emergency or during patient transport to the admitting hospital. The use of prehospital transcranial ultrasound to diagnose embolic strokes, performed by trained EMS personnel, which includes physicians, paramedics or EMTs and using wireless technology for remote diagnostic evaluation by stroke and ultrasound specialists, could significantly improve stroke care and therefore decrease the socioeconomic burden. The initiation of stroke treatment already in the prehospital scenario would potentiate the use of prehospital transcranial ultrasound far beyond its diagnostic capabilities. The concept of prehospital stroke diagnosis and potential pre treatment, however, should be seen in addition, not competition to existing and established paradigms of stroke care. 

Acknowledgement The Prehospital Transcranial Stroke Diagnosis using Ultrasound and Wireless Technology project at the University of California, San Diego, has been supported by the MedEvac Foundation International. Philips Medical Solutions, Bothell/Washington, USA, provides the portable duplex ultrasound device, equipped with 4G wireless capability, for the above mentioned project. The Bavaria California Technology Center (BaCaTec) provides travel funds for the ongoing joint project between the University of Regensburg, Germany, and the University of California San Diego, U.S.A. For references, please see: ››› www.airrescue-magazine.eu

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AOAA-A4 Conference2012 Advert_Layout 1 16/08/2012 11:56 Page 1

Association of Air Ambulances

ANNUAL CONFERENCE

2012 19th & 20th NOVEMBER

Speakers covering Clinical, Aviation and Charity subjects Gain CPD Points Question Time Panel Gala Dinner and Entertainment Conference Speakers:

Simon Burns MP

Minister of State for Health Ambulance Minister

Anthony Marsh

CEO West Midlands Ambulance Service and Chairman of the AAA

Mark Docherty

Chair National Ambulance Commissioners Group ‘Air Ambulance and Public Funding’

International Centre Telford St Quentin Gate, Telford, Shropshire, TF3 4JH.

Jonathan Benger

Professor of Emergency Care University of West of England 'Should Paramedics Intubate?' *See website for full details

BOOK ONLINE AT: www.aoaa.org.uk/conference

ITH ON, W I TE MAT S A O D FOR NION T P IN OPI U T EP TES ND E K LA S A L E TH SKIL

0 | MEDICAL CARE

Fig. 1: While on a research dive, a 22-year-old male was attacked and bitten by a shark off the east coast of South Africa (Image does not represent the incident discussed. Photograph: K. Gorby/US Navy)

Author: David L. Skinner MBChB, FCS (SA) Trauma Unit and Trauma ICU Inkosi Albert Luthuli Central Hospital Durban South Africa drdavidskinner@gmail.com

Traumatic Amputations: rapid and complex decision making Traumatic limb amputations are not uncommon after (poly)trauma â&#x20AC;&#x201C; and a disturbing entity. Their management entails both medical and strategic planning as well as the psychosocial effects that can be extremely distressing not only to the patient but also to the medical personnel involved. The approach to such a critically injured patient must be expedient and involve multiple disciplines, including the surgeon, anaesthetists and allied disciplines such as orthotics, physiotherapy, occupational therapy and psychology. A 22-year-old male from the U.S. was attacked and bitten by a shark off the east coast of South Africa while on a research dive. He sustained severe injuries to his left lower limb and multiple lacerations to both his hands. He was rapidly brought to shore and a tourniquet applied to his lower limb to prevent exsanguination. The aeromedical crew was activated and he was transported by helicopter to the nearby Level 1 Trauma Centre. Upon arrival, he was found to be in hypovolaemic shock and was resuscitated with blood and blood products. He was transported immediately to the operating theatre for assessment of the injuries, whereupon a non-

salvageable lower limb injury was found. The decision was made to amputate the limb at a below-knee-level by the trauma consultant and further repairs to his hands for both vascular and tendon injuries were undertaken. The patient had a series of staged operations on his lower limb and his stump was eventually closed at a through-knee-level. Unfortunately, knee joint preservation was not possible due to the extensive tissue damage. He was repatriated to his home country after stabilisation, where he has received extensive rehabilitation to both his upper and lower limbs. A prosthetic lower limb was fitted and he is currently leading an active lifestyle.

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MEDICAL CARE | 53 Discussion Trauma amputations require rapid and complex decision making for pre-hospital care providers, the trauma care physician and allied health workers.

Mechanism of injury Major limb injuries involve damage to both soft tissue (muscle, nerve and vascular) and bone. The mechanism of action can vary from a crush type injury (such as a motor vehicle collision or animal bite) to guillotine-type injuries where a sharp edge injures the tissues. Interpersonal violence with large edged weapons such as machetes can inflict devastating limb injuries resulting in primary (where the limb is amputated by the injury) or secondary (performed by medical personnel) amputation. Crush injuries sustain far more tissue destruction and can make limb reconstruction difficult in comparison to guillotine injuries. If bone is injured, the amputation may be partial where some soft tissue continuity remains or complete where the limb is severed from the body. The likelihood of reattachment decreases with more soft and bony tissue damage and is usually only feasible with guillotine type injuries. An important aspect for consideration of limb reconstruction/reattachment is the time taken to reach an appropriate care facility. Pre-hospital approach to major limb injury Initial assessment of the patient should be by the recognised standard of evaluation of the airway, breathing and circulation, followed by a rapid assessment of the patient’s neurological status. Any exsanguinating injury that is identified should have haemorrhage control performed as a priority – this can be done with either direct pressure on the wound or by the application of a tourniquet. Immediate life threatening issues take priority thereafter and need to be dealt with accordingly. The use of tourniquets has seen a recent resurgence in exsanguinating limb trauma, especially with the experiences in the theatre of war. They are proving to be valuable in the initial management of the severely injured limb and their use in the civilian population seems to be increasing. As such, pre-hospital care providers should be familiar with indication for use and application (1). The injured limb can be irrigated with saline if contaminated, and a non-adherent dressing applied. The limb should be elevated to prevent swelling and tight bandaging of the stump should be avoided. Concurrent injuries should be evaluated and treated on their merits as required. Basic history taking is important and pertinent facts include the mechanism of injury and the time that it occurred. Hand dominance in upper limb injuries is another crucial piece of information. All available information should be relayed to an appropriate care facility that is ready to accept the patient. Transfer should be as expedient as possible to definitive care. If the limb has been completely amputated, it should be located and dressed with a moist dressing and sealed in plastic and transported on ice with the patient. Care must be taken to avoid cold or frostbite damage to the limb and should not be placed directly on ice.

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In-hospital approach to major limb injury Re-evaluation of patient An initial approach to the in-hospital care of the patient is similar to pre-hospital care with a complete review of the initial primary survey. This includes a succinct history and handover and then dealing with any airway, breathing and circulation issues that have arisen in transfer. Multisystem trauma patients need to be carefully evaluated for “hidden” or missed injuries that will influence the further management of the patient with an injured extremity. Haemodynamic instability in a patient who has had an exsanguinating injury dealt with, needs urgent re-evaluation to exclude any other cause of haemorrhage and life threatening injuries. Isolated limb trauma requires careful clinical evaluation of the vascular and neurological state of the limb. Further advanced imaging, such as angiography, needs to be performed if clinically indicated. Compartment syndrome, which is an increased pressure within a closed osteo-fascial compartment, can occur even in the presence of an open (compound) fracture and must be actively excluded. The decision then rests with the trauma team

Fig. 2: The aeromedical crew was activated and he was transported by helicopter to the nearby Level 1 Trauma Centre (Photograph: AMS)

Fig. 3: Initial haemorrhage control and assessment of injuries (Photograph: D. Skinner)

54 | MEDICAL CARE as to whether to proceed with limb reconstruction or for ablative amputation. This depends on the severity of the injury, physiological stability and the available resources in the health care facility (2). Tourniquets that have been applied in the field need to be released in a controlled manner, normally in an operating theatre environment with adequate preparation by the anaesthetic and surgical teams.

Management 1. Resuscitation 2. Decision making (whether or not to attempt limb salvage; this is dependent on two factors: patient physiology and the extent of the injury to the limb) 3. Surgical intervention (timely and rapid; must include multiple disciplines such as trauma/ orthopaedic and vascular surgeons) 4. Prevention of sepsis 5. Continued resuscitation in high care/ICU 6. Early involvement of multi-disciplinary team (including orthotics/physiotherapy/occupational therapy and psychologists)

be suspected and actively excluded. Patients with isolated limb trauma are at risk for exsanguination and the manoeuvres in a hospital environment include temporary tourniquet, direct pressure over the bleeding point or proximal pressure on the vessel. Other problems such as tension pneumothorax and concealed haemorrhage must be identified rapidly and dealt with appropriately. Detection, prevention and reversal of shock state ➜ Shock, where there is inadequate perfusion to the body’s tissues to meet their demands, must be aggressively treated with a combination of fluid therapy and vasoactive drugs. The most common cause of shock in major limb trauma is blood loss with associated hypovolaemia. The massive blood loss that occurs will result in the patient receiving blood and blood products. A massive blood transfusion protocol should be employed. This varies depending on local practise and availability of blood products. Whole blood containing red cells, platelets and plasma is the most efficient means of replacing blood loss. This is not available in all countries currently, so blood component therapy of packed red cells, platelets and either fresh frozen or freeze-dried plasma is commonly used. The ratio of each of these blood components in massive transfusion is currently a matter of investigation (3).

Resuscitation The two large groups that exist in patients with major extremity trauma are those who have isolated limb injury and the polytrauma patient. The technique of management of these patients is distinctly different, although certain similarities exist between the two. Goals of resuscitation 1. Deal with immediate life-threatening problems first (such as exsanguination/tension pneumothorax/ airway compromise) 2. Detection, prevention and reversal of shock state 3. Detect and reverse any coagulopathy 4. Adequate sedation and analgesia

Table 1: The Mangled Extremity Severity Score

Life-threatening problems ➜ The mechanism of the injury will often point towards the injuries that should

Criteria

Score

Skeletal and soft tissue injury Low energy (stab, simple fracture, low velocity GSW) Medium energy (dislocation, open fracture) High energy (crush, close range shot gun, high velocity GSW) Very high energy (above plus contamination, avulsion)

1 2 3 4

Limb ischaemia (>6 hrs.) Pulse reduced but perfusion normal Pulseless, parasthesia, decreased capillary refill Cool, paralyzed, insensate limb, numb

1 2 3

Shock Systolic BP always >90mmhg Transient hypotension Persistent hypotension

0 1 2

Age <30 yrs. 30-50 yrs. >50 yrs.

0 1 2

Prevention of coagulopathy ➜ Patients with major limb trauma can develop coagulopathy for a number of reasons. The acute coagulopathy of trauma shock is a type of coagulation disorder that occurs in critically injured patients and consists of an endogenous coagulopathy from tissue hypoperfusion. Infusion of large volumes of crystalloids and colloids combined with a loss of red cells, platelets and clotting factors can result in a dilutional coagulopathy. The subsequent acidosis that occurs also contributes to worsening of the coagulation disturbance, as clotting factors work best at normal body pH. Replacement of specific clotting factors and fibrinogen is normally performed after more advanced tests of coagulation, such as a thromboelastogram. Decision-making This can be the most difficult of the processes that the patient requires. The decision to attempt limb salvage versus an amputation can often be challenging and emotionally charged. There are essentially four types of scenarios that are encountered: 1. Gross tissue damage of the limb requiring amputation 2. Minimal tissue damage with physiological stability allowing re-attachment or limb salvage 3. Moderate tissue damage of a limb that in isolation would allow limb salvage but the presence of major haemodynamic and metabolic instability precludes a prolonged limb salvage procedure and requires an amputation

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MEDICAL CARE | 55 4. Delayed presentation with established sepsis or fasciitis The third scenario is often the hardest to deal with by the attending trauma team, as a potentially salvageable limb is sacrificed in order to preserve the life of the patient. The dictum “life over limb” is applied here. In an attempt to help decision making in the role of amputation versus limb preservation in severe lower limb trauma, the LEAP study (Lower Extremity Assessment Project) examined characteristics and outcomes of these injuries (4). This study is quoted by both proponents for and against aggressive limb salvage, but overall outcomes remain poor in both groups. Scoring Systems The Mangled Extremity Severity Score, MESS (5), is one such system commonly used, along with Predictive Salvage Index, Limb Salvage Index and the NISSSA (Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock and Age of Patient) scoring systems. Bosse et al. in a prospective study of 556 limbs found that all the above lower-extremity injury severity scoring systems have limited usefulness and cannot be used as the sole criterion by which amputation decisions are made (6). This is reflected in later work by the Western Trauma Association (2). A score of 0-6 predicts good functional result with reperfusion and a score of >6 predicts poor functional result with reperfusion. Although a useful tool, scoring systems such as the MESS should be used as a guide in the management of a patient and treatment needs to be individualised. Problems and Pitfalls Trauma amputations should be viewed as distinctly different from those performed for reasons of sepsis or peripheral vascular disease. Attempted formal amputation at the primary setting leads to loss of limb length (7). Initial surgery should include the removal of all nonviable tissue and low-pressure lavage of the wound. High-pressure lavage has been shown to increase rates of sepsis and should be avoided. The wound should be left unclosed and a relook operation planned in the following 24 to 48 hours to assess tissue viability and evidence of sepsis. Formal closure can then take place as part of the staged series of operations. A proximal fracture in a severely injured limb is not an indication for amputation through the fracture site. It is essential to preserve as much length as feasible to improve function and fractures can be managed via standard techniques and the distal injury addressed on its merits (7). Significant effort should be made to preserve the elbow joint in upper limb trauma. Care should be taken with the peripheral nerves in order to facilitate rehabilitation. Particular attention to the specific types of injuries such as animal bites and injuries in fresh or seawater is required. Antimicrobial cover needs to be directed towards the suspected organisms that could possibly cause sepsis. Rabies and other vector borne diseases need to be considered in the management of severe animal bites.

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Fig. 4: 48 hours post index amputation (Photograph: D. Skinner)

Rehabilitation The process of rehabilitation should start as soon as the patient is received into the health care facility. Involvement of the psychologist early on in the management of the patient helps with adjustment to lifestyle as an amputee. Orthotists have a critical role to play in the rehabilitation of the patient. Technology of prosthetics is advancing rapidly and is allowing greater movement and function. Physiotherapists and biokineticists will assist in mobilisation and muscle strengthening and to adjust to ambulation on a prosthesis.

Conclusion Trauma amputations are a devastating consequence of severe limb trauma. Unfortunately, outcomes remain generally poor with either aggressive limb conservation or primary amputation with early prosthetic fitment (4). Basic principles of adequate resuscitation initially followed by individualised treatment plans based on the patient’s physiology and anatomical injuries remain the goals of management.  References: 1. Brodie S, Hodgetts TJ, Ollerton J et al. (2007) Tourniquet use in combat trauma: UK military experience. Journal of the Royal Army Medical Corps 153(4): 310-3 2. Scalea TM, DuBose J, Moore EE et al. (2012) Western Trauma Association critical decisions in trauma: management of the mangled extremity. J Trauma Acute Care Surg 72(1): 86-93 3. Allen SR, Kashuk JL (2011) Unanswered questions in the use of blood component therapy in trauma. Scandinavian journal of trauma, resuscitation and emergency medicine 19: 5 [Editorial] 4. Higgins TF, Klatt JB, Beals TC (2010) Lower Extremity Assessment Project (LEAP) – the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 41(2): 233-9 5. Helfet DL, Howey T, Sanders R et al. (1990) Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clinical orthopaedics and related research 256: 80-6 6. Bosse MJ, MacKenzie EJ, Kellam JF et al. (2001) A prospective evaluation of the clinical utility of the lowerextremity injury-severity scores. J Bone Joint Surg Am 83-A(1): 3-14. 7. Tintle SM, Keeling JJ, Shawen SB et al. (2010) Traumatic and trauma-related amputations – part I: general principles and lower-extremity amputations. J Bone Joint Surg Am 92 (17): 2852-68

56 | MEDICAL CARE

Fig. 1: Information obtained from the survivors allowed rescuers to immediately locate one of the companions, who had suffered fatal injuries from severe multiple trauma (Photographs: CNSAS Dolomiti Alpine Rescue)

Surviving an avalanche burial: successful rescue in two and a half hours Authors: Giovanni Cipolotti SUEM 118 HEMS Pieve di Cadore Belluno Italy Luigi De Lazzer SUEM 118 HEMS Pieve di Cadore Belluno Italy Guisseppe Minniti Cardiac Surgery Unit Treviso Regional Hospital Treviso Italy Paolo Zanatta Department of Anaesthesia and Intensive Care Treviso Regional Hospital Treviso Italy

Avalanches can pose a substantial threat to people, especially in places such as ski resorts and mountain towns, or on roads and railways. Although preventive measures are taken to reduce their impact and the level of destruction, avalanches still take place. Even small avalanches are a seriously lifethreatening. According to the ‘Avalanche Handbook’, between 55 and 65 percent of victims buried in avalanches are killed. Chances of survival drop dramatically from 92 percent within 15 minutes of the incident to just 30 percent after 35 minutes, when victims die of suffocation. After two hours, chances of survival are almost zero and victims usually die as a result of their injuries or of hypothermia. In the case of avalanche burials, the saying holds true that “every minute counts”. 7 February, 11.52 a.m. At 11.52 a.m. on Sunday, 7 February 2009, the dispatch centre in Pieve di Cadore (Dolomiti Mountains, Belluno province, North-eastern Italy) received an emergency call from a young man who had survived an avalanche and was now calling for help for his companions in the Palantina Alta area, a 15-minute flight away from the Pieve di Cadore airbase, 1560 metres above mean sea level (AMSL). At 11.56 a.m. the AgustaWestland helicopter AW109 Grand took off from Pieve di Cadore and during the approach flight (in accordance with Avalanche Protocol) the SAR bases in the area were put on alert. At 12.13 p.m. an anaesthesiologist, an SAR technician with an avalanche search dog and the dog’s trainer disembarked 50 m from the base of the avalanche. The AW109

from Pieve di Cadore, the AW109 from Treviso HEMS Air Base, a Eurocopter SA 365 Dauphin from Trentino HEMS Fire Rescue and a privately owned Ecureuil B3 began to fly CNSAS volunteers into the rescue area. Information obtained from the survivors allowed r escuers to immediately locate one of the companions, who had suffered fatal injuries from severe multiple trauma. A search for a second skier buried in the avalanche was carried out with avalanche search dogs and an Arva (Apparecchio di ricerca in valanga) transceiver but was unsuccessful, due to the sheer size of the avalanche. A search using RECCO ® detectors was also unsuccessful, probably due to local electromagnetic interferences caused by mobile telephones, cameras and radio devices.

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MEDICAL CARE | 57

Fig. 2: The AW 109 from Pieve di Cadore, the AW 109 from Treviso HEMS Air Base, a Eurocopter SA 365 Dauphin from Trentino HEMS Fire Rescue and a privately owned Ecureuil B3 began to fly CNSAS volunteers into the rescue area

2.35 p.m.

8 February

In the meantime, more rescue teams were brought into the area (5 helicopters, 50 volunteers, 3 rescue dogs and 3 medical), but even their first two attempts to locate the buried skier with probes were unsuccessful due to the deep and heavy layers of snow – in some places more than 2 metres thick. At 2.35 p.m. during the third attempt, a human body was located 90 cm deep, face up, head turned to the left side in a deeper position. A small air pocket in front of the face was noticed; no snow was found in the mouth or airways but the patient showed almost complete respiratory depression. The head was freed immediately, a cervical collar and a tracheal tube were fitted and artificial ventilation was started. Initial assessment showed no evidence of trauma to the limbs, while a neurologic evaluation revealed minimal motor response to pain. Body temperature was recorded at 19°C, warm fluids were infused during CPR; the patient was carried on board the helicopter and transported to the nearest Cardiac Surgery Department at Treviso Hospital. An Arva transmitter was found inside the patient’s backpack and switched off.

At 11.30 a.m. after a transaesophageal ecocardiographic evaluation that showed a good biventricular function, the ECMO was suspended. In the morning, GCS was E1VtM1 (Eye response 1, Verbal response intubated, motor response 1), a CT scan showed left cerebellar ischemia and widespread edema and an EEG showed non-convulsive

3.26 p.m. The Pieve di Cadore AW109 landed in Treviso Hospital; on entering the emergency department, the patient was asystolic, nasopharyngeal temperature was 19.5°C, serum potassium levels were 5 mEq/l, pH was 6.85, PaO2 was 61 and HCO3 was 7.7. Femoral arteriovenous ECMO was immediately started in the cardiac surgery department, rewarming the patient at the rate of 1C° per hour. When the patient’s temperature reached 32C°, ventricular fibrillation was successfully treated with a single shock.

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Fig. 3: No snow was found in the mouth or airways but the patient showed almost complete respiratory depression

58 | MEDICAL CARE

Fig. 4: The area in which the avalanche took place in the Dolomiti Mountains (Belluno province, North-eastern Italy): Palantina Alta area

status epilepticus. The patient was sedated and mannitol infusion was started. An intraventricular catheter was fitted to monitor intracranial pressure and allow fluid drainage. At 10 p.m. following a further CT scan showing deterioration of the clinical condition, the patient underwent a bilateral decompressive craniotomy with surgical removal of the necrotic left cerebellar hemisphere.

9 February GCS remained at E1VtM1. Low-amplitude somatosensor evoked potentials were recorded in the right brain hemisphere, while no motor response on the right hemisoma was obtained from transcranial electrical stimulation. The left brain stem acustic evoked potentials was absent while the visual evoked potentials showed the activation of the visual cortex with an increase in latency. The EEG recording showed a non-convulsive status epilepticus.

Treviso, where he slowly recovered from unconsciousness He learnt to recognise members of his family and to give correct answer to basic questions. He was able to move the left hemisoma, while the right inferior limb was paretic and the superior plegic. The patient is currently living at home with his family and continues to make progress with his rehabilitation. He is not able to be self-sufficient because of a moderate motor deficit on the right side of the body. He is able to move himself in a wheel chair, but is unable to stand because of the pain from a shortened knee tendon resulting from the long period of immobility. He will undergo orthopaedic surgery to resolve this. He is able to sustain a normal conversation with friends and new acquaintances. His long-term memory is preserved, though short-term memory is slightly impaired.

Buried alive 16 February onwards On 16 February a cerebral MRI showed widespread ischemia in the left pontine region, while neurophysiological monitoring showed the recovery of the right brain somatosensory evoked potentials and an unchanged non-convulsive status epilepticus. On 17 March the patient was transferred to Pordenone Intensive Care Unit with GCS E4VtM3, mydriasis of the pupils, minimal flexion response to pain in left superior and inferior limbs. Following 40 days of hospitalisation, the patient was transferred to the rehabilitation unit in Motta di Livenza,

The patient will never forget the incident: “I saw the avalanche coming, I ran away but the avalanche reached me and engulfed me. I was immobilised, unable to move my hands. I thought, my life is over… With my tongue I managed opened an air pocked in front of my mouth. I thought to myself, ‘you have to stay awake!’ I heard the sound of the helicopter and I felt the rescue drill on my chest. Then I heard the dog barking and the shouts of the rescuers saying, ‘we’ve found him!’ Then someone opened my mouth… I saw the helicopter… and then I blacked out.” 

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CASE REPORT | 59

“Christoph 26” uses rescue winch over famous cruise ship On 11 May 2012 the crew of “Christoph 26” was alerted by the Maritime Rescue Coordination Centre (MRCC) of the German Maritime Search and Rescue Services (DGzRS) in Bremen. A passenger on the cruise ship “AIDAmar” had suffered a stroke and urgently required medical attention. At the time the call was received the cruise ship was about eight nautical miles north of the North Sea island of Borkum. Dirk Hessenius, pilot and head of the helicopter base, accepted the call immediately, and the HEMS crew members prepared for the mission, which would require the use of a winch. The helicopter reached the scene after a flight of half an hour. The winch had to be used twice in order to get the entire emergency medical equipment on board the vessel. The crew contacted the captain of the ship on maritime radio channel 16 to determine the best place to deploy the winch. They agreed on an area of the deck between the outdoor movie screen, the whirlpool, and the bar. Emergency physician Ralf Röske was transferred aboard the “AIDAmar” in the first winch operation, followed by HCM Bernd Freese with the medical equipment. “Christoph 26” (BK 117) was flying a hold for about 15 minutes until the doctor, and the patient in the rescue bag, could be hoisted on board, followed by Bernd Freese. As arranged with the pilot, Dirk Hessenius, the captain of the “AIDAmar” continued towards Hamburg at a speed of 15 knots during the rescue operation. Once on board, the patient was transferred to the hospital in Sanderbusch,

where “Christoph 26” is also based. The HEMS crew was impressed by the professionalism of the “AIDAmar’s” medical and fire-fighting teams: the on-board fire-fighters were fully equipped and at the ready in the direct vicinity of the winch area, and the ship’s medical team were already waiting for the HEMS crew on deck. That meant no time was lost. The ADAC air rescue helicopter “Christoph 26” (BK 117) has been based in Sanderbusch since 1983. It has a deployable radius of 70 km and provides emergency medical services to the entire region, including the East Frisian islands, Neuwerk and Helgoland. “Christoph 26” generally responds to calls from 7 a.m. until sundown, but if necessary it can also fly at night if an illuminated landing site is available. The helicopter has been equipped with a rescue winch since autumn 2003. It is alerted by the Jever dispatch centre in Friesland or by the Rescue Coordination Centre (RCC) Glücksburg, which passes information on to the Maritime Rescue Coordination Centre (MRCC) in Bremen. It is based at the Nordwest-Krankenhaus, a hospital in Sanderbusch. “Christoph 26” also does a particularly important job providing medical care to the inhabitants of the East Frisian islands. 

Authors: Dirk Hessenius Head of “Christoph 26” base ADAC-Luftrettung Nordwestkrankenhaus Sanderbusch 26452 Sande Bernd Freese “Christoph 26” HEMS crew member ADAC-Luftrettung Nordwestkrankenhaus Sanderbusch

Fig. 1: The crew of “Christoph 26” is called to attend to a stroke victim on the cruise ship “AIDAmar” (Photograph: B. Freese)

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

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60 | Technology

Fig. 1: ALLFlight is the first project that uses a manned in-flight simulator and covers main areas of pilot assistance (Photograph: DLR)

Authors: Robin Lantzsch Steffen Greiser Jens Wolfram Johannes Wartmann Mario Müllhäuser Institute of Flight Systems German Aerospace Center (DLR) Braunschweig Germany Thomas Lüken Hans-Ullrich Döhler Niklas Peinecke Institute of Flight Guidance German Aerospace Center (DLR)

ALLFlight: Assisted Low Level Flight and Landing on Unprepared Landing Sites DLR’s internal ALLFlight project (Assisted Low Level Flight and Landing on Unprepared Landing Sites) involves the research on helicopter pilot assistance systems that can assist the pilot through all phases of flight. The respective ALLFlight-system covers take-off, intermediate low level flight and landing on unprepared sites in the presence of obstacles and in poor visibility. This article outlines the implementation of the full-scale pilot assistance system into DLR’s Active Control Technology/Flying Helicopter Simulator (ACT/FHS) test bed. The ALLFlight pilot assistance system will provide the opportunity to test the full process, from sensors to data fusion and trajectory planning, using modern flight control techniques in real time in real situations during flight tests. Needless to say, but it is likely that the results of the ALLFlight research will also play a key role in HEMS in the future. Flying a helicopter is still relatively unsafe compared to fixed-wing aircraft. The number of accidents per 100,000 flight hours is still too high, at roughly 4.9 (1) in 2007. This figure is 0.139 per 100,000 flight hours for fixedwing commercial aircraft (2). The main contributing factors to the high numbers of accidents are misjudgement on the part of the pilot and the resulting actions (3) due to demanding workloads and poor weather conditions. It

is important to develop new ways of assisting pilots in flying helicopter in order to increase levels of safety. With ALLFlight, sensors that can see in darkness as well as in poor weather conditions are integrated into DLR’s research helicopter ACT/FHS. The sensor data are fused into a three-dimensional terrain scenery that can be presented to the pilot via a helmet mounted display (HMD). The terrain data is also used for all trajectory planning processes.

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TECHNOLOGY | 61 Each elevation map is generated from databases and the online fusion process. The planned unsteady curved trajectory can be used either to guide pilots, for example via a “sky tunnel” on their HMD, or to fly automatically on the planned path. In order to give the pilot the possibility of flying on this path, modern flight control laws with different levels of automation can be used. The corresponding level can be adjusted manually or automatically according to outdoor conditions (e.g. usable cue environment (18)). The pilot handles interaction with the flight control system via active inceptors. One outstanding characteristic to come out of this research is the fully automatic flight and landing of manned helicopter in a confined area. ALLFlight is not the first project aiming to reduce accident rates by reducing pilot workload. Over the past few years, several projects have worked on developing pilot assistance systems, for instance Photographic Landing Augmentation System, PhLASH (4, 5), LandSafe™ (6), the Sandblaster system (7), Eurocopter’s Active Control Technology for Improved Mission Effectiveness, ACTIME, Helicopter Active Control Technology, HACT (8, 9), Pilot Assistance in the Vicinity of Helipads, PAVE (10), and Pilot Assistance System (PILAS). In addition, the US-Army’s RASCAL is used as a test bed for control law design (11, 12), and Boeing’s Unmanned Little Bird (ULB) is used as a full-scale unmanned helicopter for autonomous flight through unmapped, obstacle-laden terrain (13). Common to all of these projects is that they focus on just one aspect of assistance or demonstrate their function without human interaction on unmanned helicopters. ALLFlight is the first project which uses a manned inflight simulator and covers all areas of pilot assistance: acquiring and processing sensor data, trajectory planning, modifying flight dynamics, using active inceptors and displaying the necessary information in a head-down or head-up display. This article describes the setup of this full-scale pilot assistance test environment.

The ALLFlight Project ALLFlight is a DLR internally funded project. It began in 2008 and will be completed by the end of 2012. The objective of ALLFlight is to achieve safe and effective 24-hour, all-weather operational capability in the abovementioned conditions by providing pilots with an optimal combination of assistance subsystems. This system reduces their workload and increases both situational and mission awareness by means of advanced cues (visual and tactile) and control augmentation. Fig. 2 shows the system architecture of the ALLFlight full-scale pilot assistance research environment. It consists of 6 basic parts: sensors, 3D-model sensor data fusion, trajectory planning, model-based control, active inceptors and headdown display (HDD), as well as helmet mounted display (HMD). Sensors ➜ To generate the 3D environment model, the DLR research helicopter ACT/FHS is upgraded with different types of sensor (laser, radar, infrared) to acquire data from the external environment (see Table 1 for more details on the sensors used).

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HELLAS

AI-130

EVS-1000

Camera

ladar

radar

infrared

1.5 micron

35 GHz pulse radar

8-12 micron

visible spectrum

FOV 31,5°x32°

FOV 180°x110°

FOV 53°x40°

95x200 pixels max. range 1000 m

beam width 2,4°x1,8° range 1...8 NM

320x240 pixels

768x494 pixels

range res. 0.6 m

range res. 1.8 m

NETD 0.2 K

sensitivity 0.1 lux

scan freq. 2 Hz

scan time 1.8 sec for FOV 30°x21°

LANInterface

RS-170 Interface

FOV… Field of View; NETD… Noise Equivalent Temperature Difference

Table 1: Overview of the sensors used

3D Model Sensor Data Fusion ➜ The data from the different imaging sensors is fused to create a digital map (3D terrain model). A trajectory-planning algorithm is then applied based on this digital map, and a scenario can be generated for the helmet mounted display. Trajectory Planning ➜ It is possible to plan curved and unsteady trajectories (in space and time) for all phases of the helicopter flight (take-off, low-level flight, landing) in all conditions (day, night, reduced visibility). Generation of the trajectory takes into account the pilot’s cognitive decision-making processes, as well as the atmospheric conditions and the helicopter’s mechanical flight limits. Of course, autopilot can be used for fully automatic flight; however, the pilot still has the option to control the helicopter indirectly by controlling the resulting trajectories. In a pre-planning process, the unsteady curved trajectory will be mapped using a digital elevation map. During flight the trajectory will be updated online in the event of any newly detected obstacles.

Fig. 2: ALLFlight system architecture

pilot HDD and HMD

sensors

3D-model sensor data fusion terrain data base helicopter limitations

online trajectory update

unsteady curved trajectory planning

active inceptors MBCmodel based control atmospheric data pilot knowledge

62 | Technology The ACT/FHS research helicopter is based on a Eurocopter EC135, which is a light twin-engine helicopter with a bearingless main rotor and a Fenestron®. In order to arrive at a full authority flight control system, the mechanical controls were replaced with a fly-by-wire primary control system (14). This means that the dynamic data shown in this article are not comparable with data from series-produced rotorcraft. The ALLFlight full-scale pilot assistance research environment makes it possible to test all the aforementioned pilot assistance systems in real time and in real-life situations during flight tests. The following chapters will provide a more detailed description of the sensor fusion, the trajectory planning, the model based control design (MBC) and the active inceptors.

Fig. 3: TV camera image showing the surroundings of Braunschweig airport (Photograph: DLR)

Sensor Data Fusion

Fig. 4: Display variant “Octree”

Model Based Control (MBC) ➜ The latest handling qualities insights (18) drive the development and maturation of the relevant assistance systems (control augmentation, visual and haptic support) and their combination to allow the pilot to follow the generated trajectories or surfaces intuitively, depending on the current flight phase and environmental conditions. Integration of the full system, together with all relevant flight tests, will be performed on the ACT/FHS research helicopter. Active Inceptors ➜ The ACT/FHS has been equipped with two active sidesticks for cyclic, collective and, optionally, yaw control (19). The usage of active inceptors opens an additional feedback path to the pilot, known as haptic feedback. The ALLFlight project integrates this information into the human-machine interface. HDD and HMD ➜ As a first step for visualisation, the ALLFlight project will use the conventional HDD technology to present visual cues and information to the pilot. At the end of this project, DLR will also begin work in the field of conformal 3D visualisation on a wide field of view HMD system. Recently, DLR has integrated a wide field of view (80° x 40°) binocular headtracking helmet mounted display system (JedEye) produced by Elbit (Israel) into the ACT/FHS. This system offers the option to increase situational awareness, especially in reduced visibility conditions, by displaying an adequate symbol set. Integration into the ACT/FHS is currently in progress and will be finished by mid-2012.

One of the central research topics of ALLFlight is to make environmental data available to the pilot. In order to obtain a sophisticated display concept, sensor data fusion is being applied. Basically, the data fusion uses a given database, for example the Shuttle Radar Topography Mission (SRTM). Incoming data from Radar and Ladar are time-stamped, mapped to ground references and compared to the existing ground information. Based on the classification algorithm, the measured points are either assigned to the ground, previously unrecognised buildings or other obstacles. In the case of obstacle points, the decision if they belong to moving (or flying) obstacles or if their position is fixed, is based upon history records. Fig. 3 illustrates a conventional TV camera image, which was recorded during a flight test in the vicinity of Braunschweig airport. Fig. 4 shows the measured points of Fig. 3 as connected cubes of varying size. Separation from ground is possible. The obstacles appear as raw estimates of actual shapes, so poles, cranes, power lines etc. can be identified and provide an advanced form cue. In the scope of an investigation into human factors, these different display variants were presented to a number of civil and military pilots to find out the best way to represent the external environment on a helmet mounted display (15). For the detection of static or moving objects on imagebased sensor data (TV, IR etc.), feature extraction algorithms reduce the incoming flow of data in the first step. In order to detect moving objects, the same object must be detected in a number of successive frames. Moving objects are not part of the produced database and are handled separately as an independent data flow. Usage of the results of the data fusion algorithm, the digital elevation map as well as the trajectory planning are described in the following chapter.

Trajectory Planning This section outlines the design concept and methodology to assist helicopter pilots during flight path planning. In general, the planning task depends on the mission or one particular element of a mission. With ALLFlight, the aim is to compute unsteady and curved flight paths, ac-

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TECHNOLOGY | 63 counting for helicopter limitations, obstacles, terrain and pilot preferences. In ALLFlight, path planning is subdivided into local and global planning. The local planner is simply a reactionary planning aid which accounts for near-field obstacles that could collide within the next few seconds. The planner computes a three-dimensional flight path. The mission is defined by the landing point and, if necessary, by additional waypoints. The sequence of the waypoints is defined by the pilot. Therefore, it is not necessary to compute the optimal connection between the waypoints. However, the planned flight path consists of at least three flight phases, take-off, enroute and landing, which are analysed by different planning algorithms. It is not only the mission that is an important input, but also the sensor information, helicopter limitations, and the pilot’s cognitive processes. The sensor information provides a digital elevation map that can be easily accessed by interface software. The helicopter limitations as well as the pilot’s cognitive processes are modelled as knowledgebased algorithms. Helicopter limitations and pilots’ cognitive processes In general, the limitations given in the flight manual are based on charts dictated by environmental conditions, such as external air temperature or pressure. These limitations define upper limits and recommendations. Within the ALLFlight project, the values valid for the EC135 are used. As already mentioned, the pilot’s cognitive processes are also taken into account. Since these processes vary between pilots, the individual expectations for a planned flight path will also vary. To reduce the gap between expectation and computational solution, as a minimum, a subset of the overall pilot requirements which could be raised for the path planning algorithms are recorded through survey data. To date, take-off and enroute have recorded 68 participants and landing has recorded 71. Their respective backgrounds are depicted in Fig. 5. With regard to the pilots’ background, overall, 29 of the 68 pilots work in civil aviation and 39 are military pilots. The military pilots typically fly SAR as well as training and instructor flights in a military school. The pie chart (Fig. 5) shows their flight experience. The mean flight experience was 3,738 flight hours (fh) as pilot in command, ranging from pilots who had just earned their wings with 100 flight hours to experienced pilots with more than 11,000 flight hours. The average age of the pilots surveyed was 43, with a maximum age of 58 and a minimum of 24. The group of participants was a good mix of military and civil pilots, and of experienced and inexperienced pilots. Only single-engine operations and general aviation sectors were not well represented. The helicopter pilots were asked for examples of planning-related constraints. A few of these were: • • • •

Preferred true airspeed Preferred rate of climb Horizontal and vertical clearance Acceptable wind conditions

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military (39)

≤ 500 fh (8)

HEMS (16)

≤ 2000 fh (10)

police (7)

≤ 5000 fh (37)

flight test (5)

Typical standard operating procedures were also analysed (e.g. reasons to fly vertically or CAT-A take-off). This gives a first overview of the constraints and manoeuvres used for path planning and how they depend on the individual pilot. A pilot classification is therefore computed based on the data collected and using the method described in (16). Path planning algorithms During the planning process, the take-off and landing calculations are performed first. The take-off climbout point (CP) and the approach entry point are then transferred to the enroute algorithm as start and end points of the enroute phase. The following figures show an example of each planning step. Take-off ➜ By means of the SP (starting point) and TDP (take-off decision point), an initial take-off profile is calculated regarding power settings and state path constraints. The initial take-off profile is proofed so as not to collide with any obstacle; there is however no planning algorithm used that may avoid obstacles. The position of the TDP and the specifications from the flight manual are used to compute a three-dimensional surface. Within that surface, the unobstructed take-off trajectory is planned. Take-off with constant slope is shown in Fig. 6. Landing ➜ Approach planning is currently prepared for flight-testing. Level flight at constant altitude, together with a single angle approach, specifies a threedimensional surface similar to the take-off profile (17). A standard approach uses an air-path inclination angle of between -8° and -12° starting at approximately 300ft above the helipad elevation (AHE) with the recommended approach speed of 60 kts indicated airspeed. The rate of descent (R/D) should not exceed 500 ft/min to avoid any chance of entering vortex ring state (VRS). Particular attention is given to current wind conditions. Examples of approaches with constant slope are shown in Fig. 7. Enroute ➜ The current status of enroute planning is that rough planning can be performed offline for the most im-

Fig. 5: Take-off and enroute survey – pilots’ background (number of pilots)

64 | Technology

Fig. 6: Planned flight path for take-off with constant slope Fig. 7: Planned flight path for landing

portant constraints (like rate of climb or absolute height) ensuring an overall flyable trajectory. This trajectory starts at the CP (established from takeoff planning) and ends at the approach entry point. It is planned to develop a high resolution planning that considers all constraints from the flight manual of the helicopter and the pilot’s demands.

Model-Based Control System Another key element of the ALLFlight project is a complete model-based control system from hover to 120 kts forward flight together with take-off and landing. This section presents the different parts of the model-based control system: command model, feedforward controller and feedback controller (see Fig. 8). Command Model ➜ The command model is the part of the model-based control that defines the general behaviour of a virtual helicopter with which the pilot interacts. The pilot controls the command model rather than controlling the helicopter directly. In general, any dynamic model imaginable can be used as a command model. However, there are physical limits. The more the command model differs from the kinematics of the real helicopter, the harder it becomes to obtain a good model-following performance. Therefore, the goal of the command model design is to create a model that is as easy to follow as Fig. 8: MBC control environment

possible and that fulfils level 1 handling qualities criteria as defined by the ADS-33 (18). The command model encompasses different command and hold functions, which can be chosen independently for the different axes. This allows for maximum flexibility in the tuning of the closed-loop behaviour of the aircraft (mostly necessary for academic reasons). The various command model command types are: Rate Command (RC), Attitude Command (AC), Translational Rate Command (TRC), Acceleration Command (AcC), Rate of Climb Command (RocC), and Slope Command (SC). These command model types can be combined with various hold functions: Attitude Hold (AH), Attitude Levelling (AL), Position Hold (PH), Airspeed Hold (AsH), Groundspeed Hold (GsH), Directional Hold (DH), and Height Hold (HH). Additionally, a Turn Coordination (TC) module accounts for the effort of coordinating turns. These different modes can be chosen and analyzed for different mission profiles. The states and their time derivatives generated by the command model are then fed to the feedforward controller. Feedforward Controller ➜ The feedforward controller is designed to cancel the actual helicopter dynamics and to impose the desired command model dynamics on the ACT/FHS. In this way, design requirements of the feedback control branch can be separated into robustness and disturbance rejection, while leaving reference tracking to the feedforward controller. Feedback Controller ➜ The feedback controller is used to compensate for differences between commanded and measured values resulting from disturbances and inverse model deficiencies. A further dipole-cancelling controller suppresses air resonance mode oscillations (20), while the excitation of structural modes is prevented by dedicated band-stop filters. Flight tests in 2011 showed the performance of the full model based control system in hover and forward flight modes in highly dynamic and long-term manoeuvres. The performance for all axes is good and the discrepancy between commanded and measured states is regarded as insignificant. Further model-based control flight tests will be conducted to show overall performance in the frequency domain via sweeps.

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TECHNOLOGY | 65 Active Inceptors Within ALLFlight, the sidesticks fulfil two purposes. Their first role is to adapt the global force-feel dynamics (Flight Control Mechanical Characteristics, FCMC) to different response types for the controlled helicopter in order to optimize handling qualities. The second role is to use haptic cues and warnings in order to design envelope protection. This protection helps the helicopter pilot avoid exceeding structural limits and flying into obstacles or terrain. The FCMC of the active sidesticks are influenced by their equivalent model parameters, such as stiffness, damping ratio and eigenfrequency. The optimum value can be achieved by iterative modification and evaluation based on quality measures such as qualitative pilot feedback or standardised methods such as Cooper-Harper rating (CHR). The effect of inceptor force-feel characteristics on piloted handling qualities has already been investigated in flight tests. The results of the ACT/FHS and the RASCAL (i.e. a JUH-60A Black Hawk based at the U.S. Army Aeroflightdynamics Directorate in Moffett Field, CA) flight tests are detailed in (21). Transmission torque protection is a typical (and very important) example of the need for haptic limit cueing. Transmission torque is mainly influenced by the collective lever position. The purpose of haptic limit protection is to cue pilots at a position just prior to where they would exceed the limit. First flight test with the ACT/FHS showed, that the collective controller position remains below or on the soft stop position and the torque remains below the set limit, apart from a transient torque overshoot. Pilots remarked that the haptic cue helps to maintain the torque just below the limit; however they stated that the transient torque overshoot after approaching the limit cue was too high. This was because the time constant of the first-order error compensation was set too low, which led to compensation of the torque transient that was too fast. The predictor was modified and will be tested in upcoming flight tests.

Summary The ALLFlight full-scale pilot assistance research environment allows for testing of the whole chain, from sensors, data fusion and trajectory planning, through to active inceptors and modern flight control techniques. The goal is to achieve a valuable assistance system that reduces pilots’ workload and does not simply transfer the workload from flying the aircraft to operating complex systems. The next major step will be to validate each subsystem (sensor data fusion, trajectory planning, model-based control, active inceptors and HMD/HDD). Finally, the full system will also be evaluated in real flight in genuine conditions and scenarios, including fully automatic flight of the ACT/ FHS. The evaluation of handling qualities will consider the overall system and not simply the performance of the subsystems.  For further literature, please see: ››› www.airrescue-magazine.eu

References: 1. Helicopter Association International (2008) Five-Year Comparative U.S. Civil Helicopter Safety Trends through 4th Quarter (1 January – 31 December, 2008–2004). 2. NTSB (2007) Accidents, Fatalities, and Rates, 1988 through 2007, for U.S. Air Carriers Operating Under 14 CFR 121, Scheduled and Nonscheduled Service (Airlines). 3. European Helicopter Safety Team (2005) Analysis of 2000-2005 European Helicopter Accidents. European Aviation Safety Agency. 4. Swenson R (2007), AFRL develops partial solution to helicopter brownout: http://www.eglin.af.mil/news/story.asp?id=123052402 5. N.N. (2006) Flying blind in Iraq: U.S. helicopters navigate real desert storms: http://www.popularmechanics.com 6. N.N. (2008) LandSafe® Aircraft Survivability System: http://www.oads.com/ programs/landsafe.html 7. Martin C (2007) In the thick of it all – surviving the brownout. Aviation Aftermarket Defense Magazine 8. Einthoven P, Miller D (2002) The HACT Vertical Controller. American Helicopter Society 58th Annual Forum: 11-13 May, Montreal, Canada 9. Einthoven P, Miller D, Nicholas J, Margetich S (2001) Tactile Cueing Experiments with a Three Axis Sidestick. American Helicopter 57th Annual Forum: 09-11 May, Washington, DC, USA

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Fig. 9: ACT/FHS active inceptors in a side-by-side configuration (Photograph: DLR)

10. Lueken T, Korn B (2007) PAVE: A prototype of a helicopter pilot assistant system. 33rd European Rotorcraft Forum, 11-13 Sep., Kazan, Russia 11. Fujizawa B, Ivler C, Tischler M, Moralez E, Braddom S (2010) In-Flight Simulation Control Law Design and Validation for RASCAL. American Helicopter Society 66th Annual Forum, 11-13 May, Phoenix, USA 12. Fletcher J, Lusardi J, Mansur M et al. (2008) UH-60M Upgrade Fly-By-Wire Flight Control Risk Reduction using the RASCAL JUH-60A In-Flight Simulator. American Helicopter Society 64th Annual Forum, 29 April-1 May, Montréal, Canada 13. Chamberlain L, Scherer S, Singh S (2011) Self-Aware Helicopters: Full-Scale Automated Landing and Obstacle Avoidance in Unmapped Environments. American Helicopter Society 67th Annual Forum, 3-5 May, Virginia Beach, USA 14. Kaletka J, Kurscheid H, Butter U (2005) FHS, the New Research Helicopter: Ready for Service. Journal of Aerospace Science and Technology 9(5): 456467 15. Lüken T, Peinecke N, Doehler H (2012) ALLFlight – A sensor based conformal 3D situational awareness display for a wide field of view helmet mounted display”. 38th European Rotorcraft Forum, 4.-7. Sept., Amsterdam, Netherlands 16. Greiser S, Wolfram J, Gestwa M (2011) Classification of pilot requirements used for takeoff planning. 37th European Rotorcraft Forum, 13-15 Sept., Milano, Italy

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Fig. 1: Every pilot is to be issued with a tablet computer by the end of August and individually trained in how to use it (Photograph: OEAMTC)

ÖAMTC Air Rescue Service makes the move towards a “paperless cockpit” Authors: Editorial Team AirRescue Magazine

For more information, see: ››› http://bit.ly/Pon7NL

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

Communications and the transmission of information play a vital role in air rescue. Pilots need to have a wide range of different information immediately available at all times during a mission. Until now, they have had to rely on countless handbooks, checklists, navigation maps and notifications. The latest print editions of these had to be brought along in the cockpit on every call-out. The ÖAMTC has now become one of the first European air rescue organisations to make the move towards a “paperless cockpit”. In the coming year, the air rescue teams of German organisations DRF and ADAC will try out similar digital solutions – so it looks likely that they too will introduce paperless cockpits soon. In the future, the ÖAMTC will be able to replace around five kilograms of documentation with just a single lightweight tablet computer. “This will mean that our pilots can quickly access the most important information in real time from right where they’re sitting in the cockpit,” enthuses Reinhard Kraxner, managing director of the ÖAMTC Air Rescue Service and a pilot himself. The ÖAMTC Air Rescue Service has opted for the Samsung Galaxy Tab 2 10.1. The tablet’s dimensions (smaller than those of an A4 notepad) and remarkably low weight (under 600 grams) make it one of the lightest and slimmest tablets currently on the market. The Samsung Galaxy Tab 2 10.1, named for its 10.1 inch screen, runs on the Android 4.0 operating system. Tablet computers also present considerable advantages for flight safety. A range of online platforms can be used to compile important data on weather conditions, flight-path obstacles and potential landing sites, and the information is presented in an easy-to-read format. All data, from the latest weather information to up-to-date

warnings about obstacles en route to the hospital, can therefore be constantly accessed during a rescue mission. The tablets also provide additional support for the crew while they work. In Lower Austria, the 144 Notruf NÖ emergency call control centre has already set up its own interface that displays details of the mission and a satellite image of the rescue site on the screen as soon as the emergency call has been made. Tablet computers in the cockpit should help to reduce the costs of missions as well as making them more efficient. “A key advantage of electronic documentation is that updates are quicker and more consistent,” explains Kraxner. It will still be a little while before tablet computers replace all the paper in the cockpit as the authorities have yet to approve the changeover. For now, tablet computers and paper documentation are being used in parallel. Every pilot is to be issued with a tablet computer by the end of August and individually trained in how to use it. The ÖAMTC is confident that it will not be long before the paperless system receives official authorisation. 

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At AMTC 2012, you’ll find: • 2500 attendees representing over 250 international emergency medical transport programs. • More than 150 education sessions on topics pertinent to the following disciplines:

Aviation, Safety, Clinical, Communications, Management/ Administration & Marketing, Global Perspectives

• A trade show featuring more than 150 vendors presenting a wide variety of the latest products and services available for helicopter EMS providers! • Unmatched networking events and opportunities! • The CAE Cup!

Formerly called the METI Cup, this annual critical care skills event utilizes the latest in human patient simulation provided by CAE Healthcare. Up to 10 teams go head-to-head to show off their real time, real situation skills on state-ofthe-art patient simulators.

AMTC Air Medical Transport Conference October 22–24, 2012 Seattle, WA

For complete details and registration information

aams.org

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

Thinking without limits