AirRescue Magazine 2/2013

MEDICAL CARE

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

Technology

The PT6 engine family in HEMS

Medical Care

Prehospital intravenous fluid and blood warmer

History

Civilian helicopter air ambulance in historical perspective ISSUE 2 | Vol. 3 | 2013

C-MAC® Pocket Monitor

AN 42 05/2013/A-E

Award-winning Airway Management Solution For the Prehospital Environment

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E di tori a l Dear Readers, After a short break, I again have the opportunity to address you in this editorial. It is now more than a year since I was elected EHAC President and so first of all I would like to take this opportunity and summarize the past year. Over the last 12 months, the number of EHAC members has increased by 4 and now we have 52 members in 16 European countries.

In the interests of our membership base, a close cooperation was agreed between EHAC and new EHA. Firstly, it was agreed that EHAC will become an associate member of new EHA, together we will establish a joint Flight OPS/HEMS Working Group, and that in the future, the AIRMED World Congress of HEMS and Air Ambulance services will be jointly held with Helitec International. It is clear that the helicopter world in Europe will work on the unification of professional attitudes, and – through new EHA – we will speak with one voice on aviation issues. Thanks must go to Vittorio Morassi, Chairman of new EHA, for his significant personal contribution to this agreement.

EHAC plays an active role in the legislative process.

Representatives from our association are working on three rule making tasks with EASA, namely Flight and Duty Times Limitations, CRM as well as HEMS Performance and Mountain OPS (including PIS). Our representatives have received very positive feedback on their work – I would like to thank Urs Nagel, Hubert Becksteiner and Bernd Lang and also state my commitment to further improving the selection process of our representatives for various expert activities. Thinking about the significant developments the past year has brought, it is also necessary to emphasize the further developments in Aeromedical Crew Resource Management training and the preparations for the 2014 AIRMED World Congress to be held from 3rd to 5th June in Rome.

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The final point to this short summary is the EHAC Symposium, held in Warsaw from 22nd to 23rd May this year. I was very pleased with the high level of expertise, the extensive support of our sponsors, the flawless organisation and great hospitality. To the sponsors, Aerolite, Bell Helicopter Textron, Eurocopter and SkyTrac, and to all those involved in preparing the event and the scientific content, I thank you very much.

And what work lies ahead of us? We will mainly continue in an active role in the legislative process. We will continue to develop Aeromedical Crew Resource Management training and organise AIRMED 2014 and the EHAC Symposiums in 2015 and 2016. We also want to create an effective pan-European system of operational reporting and contribute to the smooth implementation of the new EU OPS. Any contributions to our future activities from individual EHAC members will be very welcome. We all know that the life of our association is sustained by our members’ activities. Lastly, Daan Remie from ANWB in the Netherlands has decided to leave the HEMS environment. As Chairman of the Flight OPS Working Group, Daan is a great expert who has had an active and extremely professional influence on EHAC’s expert position.

I wholeheartedly thank him for his enormous personal contribution and I wish him all the best in his future career and life. And I wish all of you a pleasant summer!

Pavel Müller President of the European HEMS and Air Ambulance Committee

72 | CONTENTS

AirRescue

International Air Rescue & Air Ambulance

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

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Tools for HEMS units: a concept for major incident triage M. Rehn, T. Vigerust, J. Andersen, et al.

Editor-in-chief: Dr Peter Poguntke +49 (0) 711 4687470 +49 (0) 711 4687469 fax poguntke@airrescue-magazine.eu Editors: Tobias Bader +49 (0)4405 9181-22 bader@skverlag.de Klaus von Frieling +49 (0)4405 9181-21 frieling@skverlag.de Christoph Kossendey +49 (0)4405 9181-14 cko@skverlag.de Marketing · Advertising · Subscription Ch. Niemann +49 (0) 4405 9181-16 +49 (0) 4405 9181-33 fax sales@airrescue-magazine.eu

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Icefall climbing: Air - Transport Europe’s HEMS on a joint mission Z. Turoceková

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ratt & Whitney Canada: P 40+ years of leadership in helicopter engines N. Chabée

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

AirRescue Magazine is the offical publication of the European HEMS & Air Ambulance Committee (EHAC).

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Joint research project PrimAIR: Concept for a primary air rescue system in structurally weaker regions G. Ruso, R. Winter

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CONTENTS | 5

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Bond’s Jigsaw SAR: Medicine in extreme offshore conditions M. Bloch, A. Newton, J. Ferguson

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SAR in the UK: Bristow Helicopters awarded contract

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Challenges and opportunities for HEMS in JAPAN

Editorial Team

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News

EVENTS

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Safety Culture revisited: 2013 EHAC Symposium in Warsaw T. Bader

EHAC

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ir-Transport Europe in HEMS: A Courageous missions in the Tatra mountains Z. Turoceková, E. Vargová

MEDICAL CARE

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TECHNOLOGY

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E urocopter quality assurance – testing components made of fibre-reinforced materials J. Sailer

L ondon‘s Air Ambulance: Bringing blood transfusion to the patients A. Weaver

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Stroke Unit project: Airborne point- of-care stroke management

HISTORY

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Civilian helicopter air ambulance: history & future from today’s perspective G. Davies

H.M. Lossius, M.H. Ranhoff, T. Lindner

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enefits of continuous end-tidal B capnography in the aeromedical environment J. Roos

Prehospital intravenous fluid and blood warmer in aeromedical evacuation E. Vu, H. Peet, R. Schlamp, et al.

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K. Mashiko, H. Matsumoto, Y. Hara, et al.

SAFETY

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EMS operations: Challenges with the H new Implementing Rules OPS L. Simoncini

afety in HEMS: S The Million-Dollar Question

B. Winn

Cover Image: Air-Transport Europe (ATE)

6 | NEWS Tattooed gratitude

KSS AA

A former British grasstrack champion who survived a racing crash thanks to Kent Air Ambulance (KAA) has had a tattoo of the helicopter done in tribute to the medics who saved his life. Craig Drury, 19, suffered multiple injuries after he was catapulted from his 250cc machine in the last race of the day at Collier Street. He suffered a punctured lung, a lacerated liver, a torn spleen, broken ribs, three fractured vertebrae and a broken leg and collarbone.

Dutch national HEMS congress: “Samen Sterk” HEMS Rotterdam (“Lifeliner 2”) celebrates its 15th anniversary and HEMS Nijmegen (“Lifeliner 3”) its 12-and-half year anniversary. This was reason enough for the two HEMS bases to combine and organize a Dutch National HEMS congress, which will take place on Friday, October 4th 2013. Theme of this congress is “Samen Sterk”, which means “Together we are strong!” Strong, not alone with the two HEMS teams, but with all the various people who care about the prehospital patient. The emphasis is on cooperation, integrated care, quality of care and is intended for anyone involved in prehospital and hospital care.

The day will be filled with interesting lectures, time for discussion and interesting workshops, interspersed with enough breaks and opportunities to do some “networking”. The conference will take place in the Hotel Van der Valk Duiven/Arnhem, centrally located on the A12. Participation fee is € 195. The main language of the congress is Dutch.

A few lectures however will be given in English.

For registration and more information, visit: ››› www.mmtcongres.nl

The Air Ambulance doctor and critical care paramedic gave Craig emergency treatment at the trackside and carried out an advanced medical procedure usually performed only in hospital.

They then flew him to the Royal London Hospital where he underwent an emergency blood transfusion and spent 12 days in intensive care following the crash in September 2011.

Craig has since made a full recovery and has now had a tattoo of Kent Air Ambulance inked on his back. He said: “I had it done because I wanted a permanent reminder that the pilot, doctor and paramedic saved my life, and to publicise the charity.” He went on saying: “I’ve already got six tattoos but this one runs from shoulder to shoulder and took three-and-a-half hours to do.

It looks amazing.” Craig also visited the helicop-

KSS AA

ter base at Marden to show the HEMS crew and paramedic Chris Fudge his tattoo. (Source: Kent Air Ambulance Blog) For more information, visit: ››› www. kssairambulance.blogspot.de

LAA seeks additional funding London’s Air Ambulance is run as a charity and relies heavily on donations. It is not government funded and only part-funded by the NHS. Therefore, LAA has now formed strategic partnerships with major companies as part of their efforts to raise funds for a second EMS helicopter, which is currently a key objective – the one aircraft spends up to six weeks a year being serviced – leaving the air ambulance flightless for long periods. The helicopter and other operational costs are funded through a mix of charitable donations, a self-run lottery, a grant from St Bartholomew’s Hospital Trust and corporate sponsorship such as a five-year deal with Aberdeen Asset Management as well as “strategic partnerships” with big companies, such as International SOS, a leading medical assistance provider, EE, the largest mobile network operator in the UK and with Land Securities, the UK’s biggest commercial property company. The service’s six doctors and paramedics – accounting for about 25% of

the £4m annual costs – are being paid by the NHS and local authorities. LAA’s CEO, Mr Graham Hodgkin, who spent more than a decade at Deutsche Bank largely in commercial banking, is aiming to make use of his network to put funding on a more sustainable footing. Hodgkin told the Financial Times: “London is a city that can have up to 11m people in it at any time.

Instinctively it feels vulnerable to have only one aircraft to do what we do.” For this reason, he is researching the charity programmes of every big City institution and talking to representatives of large corporations in order to get their financial support to “enhance the expert medical services that are delivered across the capital” by adding not only a second helicopter, but also “additional medical teams, and an enhanced research and innovation programme” to the service.

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

LAA

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NEWS | 7 EAAA to start night air ambulance missions Following 18 months of demanding hard work from the East Anglian Air Ambulance (EAAA) and its aircraft operator Bond Air Services, the Charity can now begin flying to incidents which occur during the hours of darkness using Night Vision Imaging Systems (NVIS), the first dedicated air ambulance in England and Wales to be allowed to do so. Tim Page, Chief Executive of EAAA, said: “We are all extremely proud to be able to say that EAAA is the first dedicated air ambulance in the country to be granted permission to fly at night but, above all, this is great news for the people of East Anglia as there is evidence that this development in operations will mean that more lives will be saved across the region.” The Charity believes that it will be able to attend around 30% more missions, helping an estimated 300 more patients

a year now, it is able to operate in the dark as well as daylight hours.

The process began back in 2011 when Bond Flight Operations Team submitted a safety case to the Civil Aviation Authority (CAA) requesting permission to undertake HEMS missions at night using NVIS. Since then, the EAAA has worked with the CAA, Bond and EEAST to ensure that both the aircraft and crew are ready for the UK’s first night time HEMS missions. In order to operate at night, the aircraft is equipped with an instrumentation system and external lighting compatible with NVGs. The first step of this process was to install various items of special equipment (including moving maps, engine Usage Monitoring System and a Powerline Detection System) on the aircraft, and to modify standard items of equipment to

make them NVIS compatible. Image shows Gary Spitzer and Dr Lazslo Hetzman returning to the base.

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

EAAA

Bond signs seven-year contract with NWAA Bond Air Services, the largest operator of air ambulance aviation units in the UK, has been awarded a new seven-year contract by North West Air Ambulance (NWAA). The contract, worth just over £10 million, is to provide air ambulance support across five counties in North West England. Under the new contract, Bond will continue to provide a complete helicopter support service out of Blackpool Airport and City Airport Manchester, including aircraft, crew and maintenance support. The service will cover the counties of Cheshire, Cumbria, Lancashire, Greater Manchester and Merseyside, an area of over 5,500 square miles with a population of approximately eight million people.

Bond has operated helicopter emergency medical services for NWAA since the charity was founded in 1999, and this contract renewal

EAAA

builds on their very successful partnership. In 2005, NWAA upgraded its aircraft to a new Eurocopter EC135 T2, enabling it to cover a larger

area and carry more passengers and equipment.

The larger cabin and additional medical attendant capacity, in conjunction with the medical equipment on the EC135, combined to improve patient care. NWAA now operates two EC135s provided

by Bond. Lynda Brislin, chief executive of NWAA, said: “Working with Bond Air Services has enabled us to introduce new practices and technologies on board, which help us to save those vital minutes that can ultimately save lives. We’re sure this partnership will support us in our commitments to evolve our service further, ensuring we can be the best service we can possibly be.”

For more information, visit: ››› www.nwaa.net

Ka-226T: test flights for the Olympics 2014 The Ka-226T, a light multipurpose helicopter with coaxial rotors that was developed by Russian Helicopters (a subsidiary of Oboronprom as part of the Rostec State Corporation), took part in test SAR missions as part of preparations for the Winter Olympic Games in Sochi in 2014. Test flights took place in the Krasnaya Polyana region. The helicopter was equipped with a medical module and flights were conducted with medical staff from the Southern Regional Center for Emergency Medicine, the rescue service of “Rosengeneering Operation”, which provides services for the maintenance and operation of the organization of ski resorts, as well as senior engineers from the flight test facility of Russian Helicopters.

An evacuation of mock victims with “moderate” to “severe” injuries was conducted with an in-flight reanimation practiced in the medical module. During test flights, Ka-226T’s landing on ski slopes and rough mountainous terrain was practiced, as was loading rescue teams in the

2 · 2013 I Vol. 3 I AirRescue I 75

Russian Helicopters

helicopter with mock victims. The head doctor of the Southern Regional Center for Emergency Medicine, Igor Deryugin, noted the maximum comfort and safety of loading the victim onboard.

And the medical module, according to his words, “allows performing full-scale medical help in-

flight, including extended reanimation procedures and necessary invasive procedures.”

For more information, visit: ››› www.russianhelicopters.aero

8 | NEWS DRF Luftrettung awards research prize At this year’s annual meeting, DRF Luftrettung awarded its research prize for the second time.

The award is intended to promote research and strategic planning in pre-clinical emergency care.

The winner is chosen by the DRF Luftrettung’s medical and scientific advisory board. This year, the prize (worth € 5,000) was awarded to Dr. Jan Wnent, who works at the Schleswig-Holstein University Hospital. On behalf of the German Resuscitation Registry, he had submitted a study on the question of how the choice of hospital affects the survival of patients who had suffered a cardiac arrest outside of a hospital. The DRF Luftrettung medical and scientific advisory board was of the opinion that the study represented an important

step towards structured and standardized care of patients suffering a pre-clinical cardiac arrest in Germany. Taking care of this patient group presents a major challenge both for the groundand air-based emergency services in Germany.

The research prize will again be awarded in 2014.

The deadline for submission is 28 February 2014.

The annual conference dealt with the new Emergency Medical Services Act (Notfallsanitätergesetz) and its significance for emergency

medicine in Germany. The lectures and workshops at the conference covered a wide range of current issues in air rescue. Furthermore, the particular challenges involved in intensive care transports of children as well as in dealing with infectious patients were discussed.

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

TAA receives Safety of Flight Award On Monday 20th May, Tyrol Air Ambulance (TAA) received the Platinum Safety of Flight Award for its record of 50 years of flight operations without accident. The international award for flight safety was presented by the European Business Aviation Association (EBEAA) on the occasion of the European Business Aviation Convention and Exhibition (EBEACE) in Geneva. It is the first time that an air ambulance received this award. Manfred Helldoppler, Managing Director, expressed his satisfaction: “We are really proud that we were able to demonstrate our excellent standards also this year again.“ Tyrol Air Ambulance’s history dates back to 1958, when the company “Aircraft Innsbruck” was founded. In 1963, the first „Public Air Transport License“ was granted for aircraft and helicopters, which were also used for ambulance flights. In 1978 the company name was changed to Tyrol Air Ambulance. The team of the internationally renowned air ambulance carries out repatriation flights as well as HEMS missions in order to provide patients with adequate medical care. Each year the company flies around 3,000 missions.

Thanks to a global network and various, TAA’s deployment range is virtually unlimited.

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

EBEACE

DRF Luftrettung

DRF Luftrettung celebrates 40th anniversary German DRF Luftrettung took off on its first air rescue mission in the Stuttgart metropolitan area 40 years ago, on March 19 1973. To date, the non-profit air rescue organization has flown a total of about 700,000 missions. On the occasion of its 40-year anniversary, the organization is making important decisions for the future and will put into service one of the latest-generation helicopters, the EC145 T2, before the end of this year. “This type of helicopter, which is also ideal for night flight operations, will gradually replace our fleet of BK 117”, explains Steffen Lutz, CEO of DRF Luftrettung. “In addition, DRF Luftrettung will put a new aircraft of the type Lear 45 into service before the start of the holiday season. Among other things, the modern jet has the advantage of a larger cabin, so that we can transport two patients at the same time”, says Lutz.

DRF Luftrettung operates 31 HEMS bases in Germany, Austria and Denmark with over 50 helicopters for emergency rescue and intensive care transport between hospitals, at eight bases around the clock. Under the name of European Air Ambulance (EAA) the DRF Luftrettung and the LAA (Luxembourg Air Ambulance) operate seven ambulance aircraft, and employ experienced pilots and medical teams for worldwide repatriation

flights. Last year, a total of 839 patients were brought back home from 103 countries abroad.

AirRescue Magazine will cover the jubilee celebrations and the official inauguration of DRF’s new operation center in the September issue.

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

DRF Luftrettung

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NEWS | 9 Eurocopter Systemhaus inaugurated On 14 May 2013, Eurocopter officially opened its new Systemhaus helicopter development center at Donauwörth, Germany, in the presence of Bavarian Prime Minister Horst Seehofer (second from right). Eurocopter has invested some EUR 100 million in the development. The facility –with a total floor space of 30,000 square meters – will provide workspace for some 900 employees and offer complete system capability for Eurocopter’s production activity at its German location, which has been declared a “key aspect of the company’s worldwide innovation strategy.” This new development shall allow Eurocopter to manage the entire life-cycle of its helicopters at one German location, covering all aspects from research, development and prototype construction through manufacturing and final assembly – along with training, maintenance and product improvement.

“Today’s Systemhaus inauguration is a decisive step forward in Eurocopter’s industrial strategy,” explained Eurocopter CEO Guillaume Faury (right). “By gaining the full system capability to develop, manufacture and maintain helicopters in Donauwörth, we generate remarkable advantages in terms of product and technology cycles. It’s

a long-term investment with far reaching impact that ultimately serves both our customers and enhances our competitiveness.” Along with office space at Donauwörth, the new Systemhaus building incorporates “state-of-the-art testing and research facilities, which include simulators, avionics trainers, laboratories, test centers and a prototype shop”, according to the company’s press release. A project comparable to the Sys-

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

C. Abarr/Eurocopter

Germany’s highest rooftop helipad The EMS helicopter in Augsburg will be stationed on the roof of the city’s hospital. Ensuring the safe completion of such a venture comes at an enormous price – experts put the total figure as high as EUR 5.5 million, almost as much as the cost of the equipped helicopter which will be occupying the platform. This new landing pad for “Christoph 40” is also Germany’s most elevated helicopter platform and will be operated by the ADAC Air Rescue. In addition to the new hangar, a control room will be built on the hospital roof and the air rescue station will be linked to the hospital by a flight of stairs and a lift.

According to the developers, the air rescue station is expected to be completed in November this year – at a height of around 58 metres. The healthcare insurance organisations, which carry

temhaus is being realized at the company’s Marignane location, close to Marseille in the south of France. There, too, Eurocopter is building a new development center as part of its strategy of sustainable innovation and technology.

the costs of the rescue service, have expressed concerns over the high expenditure. The insurers believe that it would have been more reasonable to build the new station out in the open countryside and are disappointed that these cost issues were not addressed before the project was finalised. Quite unusually for Germany, Augsburg Hospital will be the owner of Germany’s most elevated air rescue station and, after its construction, will lease it out to the ADAC Air Rescue. The rent must cover the cost of all the work undertaken by the hospital, as would be the case with any complex housing or commercial building project.

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

Patrick Ky new EASA Executive Director The European Aviation Safety Agency (EASA) announced the appointment of Mr. Patrick Ky as Executive Director with effect from 1 September 2013.

Mr. Patrick Ky is currently Executive Director of the Single European Sky Air Traffic Management Research (SESAR) Joint Undertaking and has driven the set-up and execution of Europe’s ambitious air traffic management modernisation programme since October 2007. Mr Ky will succeed Mr Patrick Goudou, who has been Executive Director of EASA since its creation in September 2003 and whose term ends on 31 August 2013. “I am delighted that the EASA Management Board have nominated Patrick Ky as my successor. Patrick is a leading figure in European aviation and his experience and skills will be a tremendous asset to the Agency,” said Patrick Goudou.

Prior to leading SESAR, Mr Ky held different managerial positions in the French Civil Aviation Authority, a consulting company, and Eurocontrol.

In 2004, he joined the European Commission to work on SESAR. In total, Mr Ky has more than 23 years of work experience in Civil Aviation. A graduate from Ecole Polytechnique and the Civil Aviation Engineering School in France, Mr Ky also holds degrees in Economics from the University of Toulouse and the Massachusetts Institute of Technology.

For more information, visit: ››› www.easa.eu

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10 | NEWS Guillaume Faury new CEO of Eurocopter The EADS Board of Directors has accepted the resignation of Lutz Bertling as CEO of Eurocopter and Member of the EADS Group Executive Committee, effective 30 April 2013. Bertling, 50, has been at the helm of the Group’s helicopter Division since November 2006 and had recently expressed his desire to depart the Group in pursuit of another professional opportunity in Germany.

Guillaume Faury, 45, to succeed Lutz Bertling (effective 1 May 2013), joins Eurocopter from Peugeot S.A., where he has served as Executive Vice President for Research & Development since 2010. Tom Enders, CEO of EADS, said: “I am happy to welcome Guillaume Faury back at EADS. Early in his career, he excelled at Eurocopter in various management positions before accepting a very senior role at Peugeot. With his profound knowledge of the Division, his leadership skills, and his broad industrial expertise, I am convinced Guillaume is the right person to drive Eurocopter’s ambitious innovation roadmap and global positioning.” Faury, a licensed flight test engineer, served in various senior management functions at Eurocopter from 1998 to 2008 before joining Peugeot S.A. He holds an engineering degree from the Ecole Polytechnique in Paris as well as an aeronautics and engineering degree from the Ecole Nationale Supérieure de l’Aeronautique et de l’Espace in Toulouse.

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

Rega’s ambulance jets: increase in missions Swiss Air-Rescue Rega looks back on a successful jubilee year in 2012. Even 60 years after it was founded, stable mission figures and an evergrowing number of patrons are a clear indication that Rega’s services are frequently used and highly valued. Last year, mission numbers were down slightly compared to the previous year, with Rega organising a total of 13,966 rescue missions. This decline is principally attributable to bad weather during the weekends, which resulted in the helicopters being called out less frequently.

In contrast, the Rega ambulance jets were more in demand than ever; in 2012, they flew 847 missions (plus 21.3%) and repatriated a total of 855 patients. This is the highest number of patients that Rega jets have transported within one year.

More than 2.4 million patrons support Rega with their annual contributions. Last year, 65,000 new patronages were registered.

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

LAR completes 25-year mark Luxembourg Air Rescue (LAR) was founded in April 1988 and since then it has completed 25,000 missions in total. René Closter, founding member and LAR president, recalls: “At that time, we had no friends to lose, because we did not have any! For example, amongst countless opposition campaigns, one organisation collected 2,000 signatures to protest against the deployment of our EMS helicopter.’’

Today, LAR, with its 5 EMS helicopters, is an integral part of the Luxemburg SAMU service, having been integrated into SAMU in 1991.

Since then, the helicopters of LAR HEMS have been deployed over 18,500 times. Their missions include flying SAMU doctors to the scenes of ac-

cidents and transporting sick or injured people to hospitals. Around 75% of their missions are internal medicine emergencies, such as heart attacks, strokes, asthma attacks, or epileptic fits.

Ambulance aircraft have also been part of LAR since the beginning and have flown nearly 5,000 missions, the majority as repatriation flights. They are as well equipped with the latest technology needed in aeromedical environments. LAR has got 150 employees, including specially trained pilots, doctors, and technicians,.

For more information, visit: ››› www.lar.lu

LAR

“Christoph 18” vs Opel Corsa “Christoph 18”, the EMS helicopter of ADAC Air Rescue, deployed in the German town of Ochsenfurt (Bavaria), recently damaged an Opel Corsa vehicle during a landing operation. The report in the Mainpost newspaper goes on to explain that, according to police statements, the crew and the emergency doctor only noticed the damage after stepping out of the helicopter. The Ochsenfurt fire brigade helped raise the helicopter slightly so that the car could be pushed out from underneath it.

The photos provided by Helmust Rienecker show that the shrouded Fenestron tail rotor came to a stop right next to the driver’s door of the Opel Corsa and the right-side tail fin of the EC135 smashed through the car’s windscreen. Technicians were called to examine the helicopter for damage.

The pilot, who has been flying helicopters without incident since 1979 and has already accumulated 6,600 hours of flight, expressed his regret: “No-one could see the car. It was right in my blind spot.” Apparently, the landing conditions were not very good either; the pilot said on the following day that “Everything was very cramped” – but not unusually so; EMS helicopter pilots are familiar with these situations and practise working in them. The pilot added that “Accidents of this nature can be counted on just

H. Rienecker

one hand.” Fortunately, no one was injured in the accident. “As far as we can make out, the helicopter just picked up a few scratches,” said station manager Christian Stangl. Nevertheless, the air rescue helicopter was initially transported by land to Bonn-Hangelar Airport and the EC135 underwent maintenance work in an ADAC hangar.

“Better safe than sorry,” said Mr Stangl, who also flies the “Christoph 18” (Photograph courtesy of Helmut Rienecker/rth.info).

For more information, visit: ››› www.rth.info

2 · 2013 I Vol. 3 I AirRescue I 78

NEWS | 11 Increasing number of EMS helicopter crashes The number of fatal EMS helicopter crashes in North America saw a sudden increase this year.

There were five crashes in the first half of 2013, three within the last 10 days alone, in which seven people are reported to have died. On 11 June 2013, one person died after an EMS helicopter crashed outside Latimer County Hospital, in Oklahoma, USA. The crash occurred at the Choctaw Nation Hospital near Talihina. A representative of the Police confirmed that one person had died.

The Wilburton Fire Chief says it was an EMS helicopter. There were four people on board of the chopper that also caught on fire, according to news reports.

area. Another crash occurred in Canada: Four people died in the fatal Ornge helicopter crash near Moosonee, Ontario, Canada, on Friday, 31 May. Four crew members died. Transportation Safety Board officers are investigating the crash and have said mechanical failure does not appear to be the cause. A memorial service for the victims will be held in Toronto on June 18. National agencies will investigate the crashes.

For more information, visit: ››› www.ornge.ca ››› www.lifeteam.net

Siemens Healthcare

of interdisciplinary projects. The EURAC Institute of Mountain Emergency Medicine was founded in 2009 as the first research institute in this field.

Its main aim is to improve the diagnosis and treatment of casualties and acutely ill patients in mountainous regions by raising the standard of Alpine emergency medicine to an internationally recognised ‘evidence-based’ level. The main focus of the research embraces topics such as hypothermia and epidemiological investigations on the treatment of injuries and acute illnesses in difficult terrain, as well as the risks involved in the recovery and transportation of the casualties.

Siemens Healthcare has introduced an ultrasound system that features wireless transducers. The Acuson Freestyle “eliminates the impediment of cables in ultrasound imaging.” The system is said to expand ultrasound’s use into new and emerging applications, where the technology provides numerous workflow and image quality advantages.

Wireless real-time ultrasound data transmission is enabled through the proprietary development of a novel ultra-wideband radio technology, which, operating at a high frequency of 7.8 gigahertz, is not susceptible to interference with other electronic equipment.

Three wireless transducers are available for the Acuson Freestyle, covering a range of general imaging, vascular, and high-frequency applications such as musculoskeletal and nerve imaging.

The user can operate the transducers up to three meters away from the system, which includes an ergonomic interface that enables remote control of scanning parameters from within the sterile field. The system has a 38-centimeter, high-resolution LED display. The console can be mounted easily and also operates on battery power. Hopes are high – and prospects good – that the Acuson Freestyle will also make it into emergency medicine and HEMS, also because it’s a real lightweight and of compact size.

For more information, visit: ››› www.eurac.edu/en

For more information, visit: ››› www.healthcare.siemens.com

An Air Evac Lifeteam helicopter crashed on Thursday, 6 June 2013 in Clay County, Kentucky, USA. Three crew members were killed. The helicopter had been completely refurbished just over a year ago. There was no patient on board. Witnesses described a light fog, when the chopper crashed into the parking lot of an elementary school. Forecasters said there was no severe weather in the

Air Evac Lifeteam

LucasTM2 being tested in air rescue missions The Institute of Mountain Emergency Medicine at the European Academy (IMEM) in Bolzano, Italy, has undertaken a 3-year study to investigate the feasibility and logistical aspects of LucasTM2assisted CPR during HEMS missions. All three rescue helicopters in South Tyrol have been equipped with the chest compression device and data collection will commence in June 2013 with financial support from the Autonomous Province of Bolzano. The inclusion criteria for patients are based on the ICAR MedCom criteria for termination of CPR. Recently, the same institution performed a study using simulated air rescue scenarios and showed a dramatic improvement of logistical and mechanical parameters of chest compressions, such as hands-off time and compression depth/ frequency, using the mechanical chest compression device compared to manual CPR. The European Academy of Bozen/Bolzano (EURAC) was created in 1992 as an independent research center. It is home to researchers from all over Europe who work together on a wide range IMEM

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Siemens with world’s first wireless ultrasound system

12 | EVENTS

Fig. 1: EHAC president Pavel Muller gave a welcome speech, which was followed

by Benno Baksteen’s keynote speech on Safety Culture (Photograph: J. Sochacka/ LPR)

Safety Culture revisited: 2013 EHAC Symposium in Warsaw Safety culture, an issue that is at the forefront of the HEMS community’s attention, was the main topic of the first EHAC Symposium held in Warsaw from 22-23 May 2013. The European HEMS and Air Ambulance Committee, EHAC, aims at organizing regular professional meetings of experts. The first event of its kind saw top-notch attendees from HEMS operators (medical experts, doctors, HCM medical, pilots and engineers) as well as decision makers from helicopter, HEMS cabin and sat-com manufacturers from all over Europe and partly the United States. Attendees expressed their contentment with the event and their high hopes that there will be regular EHAC symposia in the future – after next year’s AIRMED in Rome.

Author: Tobias Bader Editorial Team AirRescue Magazine

Warsaw, one of the most important cultural and economic hubs in Central Europe, recently saw the first EHAC Symposium on “Safety Culture”. The newly renovated Mercure Grand Hotel, conveniently located at the heart of the Polish capital city and surrounded by magnificent ministerial buildings, was the ideal place with the right ambience for this kick-off symposium. The EHAC, European HEMS and Air Ambulance Committee, had initiated the symposium in order to establish and maintain regular professional meetings and foster the exchange among HEMS experts. It shall take place annually, except in those years when the AIRMED World Congresses are going to be held. The first symposium of its kind took place from 2223 May 2013 and was hosted by the Committee, represented by Polish Medical Air Rescue (Lotnicze Pogotowie

Ratunkowe, LPR) with Robert Gała˛ zkowski as chairman.

In conjunction with the symposium, the EHAC general annual membership meeting was also held.

Under the auspices of Bell Helicopters, and with the other main sponsoring partners and generous support of SkyTrac, Aerolite, Eurocopter and Alfa Helicopter, the event saw excellent speakers and renowned experts discussing safety culture in its multi-layered aspects. Among the speakers were also Benno Baksteen, who gave the keynote address, and Prof. Lossius from Norwegian Air Ambulance Foundation, just to name a few.

After a few words of appreciation by Robert Galazkowski (representing the Polish host LPR), EHAC president Pavel Muller gave a welcome speech, which was followed by Benno Baksteen’s keynote speech. According

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EVENTS | 13 to Baksteen, who focussed on safety as an organizational philosophy, the most important component of a safety culture is a “just culture”. This means that all occurrences – except those, which are based on criminal intent or gross negligence – both intentional and unintentional, should “lead to analysis and system improvements.” Baksteen stressed that he would like his talk to be understood as a general elaboration on safety as “a way of life” for high reliability organizations in general and not only for helicopter operators or HEMS operators in particular. Baksteen concluded by stressing that safety culture should be made an integral part of normal every day operation and of the whole of the organization, it shall be part of every decision.

The keynote was followed by a presentation on the Aeromedical Crew Resource Management (ACRM®) as an essential contribution to flight/crew and patient safety.

Based on the presupposition by James Reason (1991) that “technology has now reached a point where improved safety can only be achieved on the basis of a better understanding of human error mechanisms”, Bernhard Lang of OEAMTC stressed that ACRM® training is focussing on sustainably improving non-technical skills of the aeromedical team and thus increasing flight and patient safety. The training programme consists of a three-day ground school training programme, focussing on individual and team-related human factor aspects. Target groups are pilots, HEMS crew members and HEMS doctors. Mid- and long-term goal is to also include office and management staff of HEMS operators as well as hospital staff (ER, trauma center). Lang also followed Baksteen’s idea in implementing and cultivating a “non-punitive” safety culture and to take every effort in preventing a “blame culture”.

Following this idea, ACRM® training topics include team building processes, defining common goals and a common language, identifying individual vs. group expectations, sensitize team members of underlying group structures and processes, changing ones perspective: from self perception to external perception, dealing with cultural differences (cultures of silence or “talking it out” cultures, etc.) and skills development: how to utilise all available resources within the team.

Other topics that are currently at the forefront in the HEMS community and which were being discussed after the coffee break included the Fatigue Risk Management System (FRMS) implemented at Rega (Markus Rieder), satellite tracking technologies used at LPR as the “added value for safety improvement” (Marcin Wiktorzak), safety increasing technologies in the case of Eurocopter (Gilles Bruniaux), as well as the air safety reporting system (ASR) 2.0, designed by Peters Software as a joint venture project by DRF and ADAC Air Rescue (Karl Heinz Maximilian, Karl-Willi Menden) as well as the important question of what can be done with the outcome of Safety Management Systems (Karl-Heinz Heitmüller). The first day was concluded with a dinner that also included Polish cuisine in the “Olimp I” room, offering a nice view of the Warsaw skyline.

The second day of the symposium (23 May) started with the EHAC annual general meeting in which only des-

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ignated representatives of EHAC’s member organizations were allowed to attend. After a welcome and the presidential report by Pavel Müller as well as a vacant board seat election, reports from the working groups followed, such as information on EASA rulemaking task “HEMS performance” (Hubert Becksteiner, Austria), on EASA rulemaking task “FTL in EMS operations” (Stefan Becker, Switzerland) as well as on EASA rulemaking task “CRM” (Bernd Lang, Austria).

The following section focused on research and future in HEMS. Hans Morten Lossius discussed the latest results in medical research. As “helicopters are sexy, but do not intubate”, Lossius described the long-term goal of bringing “the hospital to the patient”. He described how the Norwegian Air Ambulance Foundation (SNLA) and the University Hospital of the Saarland, Homburg, Germany are preparing a mobile stroke unit (MSU) in order to bring stroke management in CT-equipped air ambulances a few steps closer to its realization.

The EASA’s view was conveyed by Darko Vucic, who emphasized that the standardization processes by EASA shall ultimately lead to more transparent and more flexible rule making. Representing EASA, he also expressed the agency’s gratitude for the expertise coming from HEMS operators and appreciated their commitment in raising the level of safety. Further on, Stefan Becker elaborated on Rega’s implementation of GNSS LFN as a means of enhancing safety and operational possibilities, Erik Normann, Norwegian Air Ambulance, looked at the PinS procedure that is already in place at Norsk Luftambulanse and successfully used for IFR. Stefan Becker also completed this section by promoting the upcoming AIRMED World Congress next year in Rome. Besides the magnificent location and the excellent venue Fiera di Roma, he emphasized the crossprofessional approach of the programme and some new features, such as the first timer sessions and the awarding of the Kugler Prize. After closing remarks by Pavel Müller, those helicopter aficionados interested in real- and Fig. 2: The new EMS cabin design was developed in cooperation with Aerolite, when the complete fleet at LPR was exchanged and the old Mil-2 Plus helicopters were replaced by the EC135 P2e (Photograph: ARM)

14 | EVENTS

Fig. 3: The simulator installed in 2010 at LPR was the key success factor for a smooth transition from the old fleet of Mil Mi-2 Plus to a brand-new fleet of EC 135 helicopters (Photograph: ARM)

virtual-life HEMS joined in for a visit to the Polish Medical Air Rescue (LPR) HQ in Warsaw, where attendees were able to see the newest Bell 429 in HEMS configuration.

Bell Helicopter Textron had made it a point to fly in the helicopter from Air Zermatt to Warsaw to give the EHAC community and all the other attendees of the symposium the chance to get familiar with the chopper, designed and tailored especially for HEMS purposes. Furthermore, the FTD EC135 level 3 MCC flight simulator as well as the newly developed EMS cabin (Aerolite) in the EC 135 P2e, equipped with inlet barrier filter (IBF), could be closely looked at and inspected.

This new EMS cabin design, along with various ergonomics and engineering fine-tuning, was developed in cooperation with Aerolite, when the complete fleet at LPR was exchanged and the old Mil-2 Plus helicopters were replaced by the EC135 P2e. The EMS cabin is character-

ized by an integrated flooring, cabinet, medical gas system (with very light composite cylinders) and a paramedic seat that allows for an easy switching from the pilot’s cockpit to the EMS cabin during the flight. Furthermore, there is an integrated incubator transportation platform as well as a finely tuned cargo compartment and new medical equipment. All the modern HEMS furnishing and tooling was of keen interest to the visitors.

The simulator installed in 2010 at LPR was the key success factor for a smooth transition from the old fleet of Mil Mi-2 Plus to a brand-new fleet of EC135 helicopters. The training device is capable of 180 emergency situations, almost all whether conditions, VFR/IFR and night flight training. The Visual Object Database, partially developed and fully maintained in-house, is assessed by many of the LPR visitors from various operators as one of the best they have ever seen. It includes the whole area of Poland, six controlled airports, more than 20 hospitals with landing helipads as well as some confined areas with realistic road accidents scenarios. The FTD team of LPR gave a thorough explanation of the routine of everyday simulator training at the FTO. Talking to some of the attendees during the transfer from LPR base to Chopin Airport, they thanked EHAC and LPR for its effort to organize such an event and the manufacturers to generously support it. They also expressed their gratitude for the great hospitality experienced – apart from the excellent choice of topics, which were accurately covered by experts of the respective fields.

One hopes that this was the first symposium in a series of annual high-class EHAC events.  For more information, visit: ››› www.ehac.eu ››› www.ehac-symposium2013.pl

EHAC: Annual General Meeting & Elections The EHAC Annual General Meeting was held in Warsaw on 23 May 2013 in conjunction with the EHAC symposium. After a welcome and presidential report by Pavel Müller, representatives of various working groups (WGs) identified their respective tasks, discussed future challenges and presented preliminary results of their activities. Participants emphasized that all WGs will have to continue to identify, develop and undertake suitable actions regarding regulations. These include the identification of stakeholders and agencies to which specific interventions should be addressed to, for example European Aviation Safety Agency (EASA), International Civil Aviation Organisation (ICAO), National Aviation Authorities (NAAs) as well as industry organisations. In this effort, WGs shall also utilize resources and action plans produced by other institutions or groups, such as the Association of Air-Medical Services (AAMS), Aeromedical Society of Australasia (ASA), EASA, ICAO and national aviation agencies in Europe.

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EVENTS | 15

Fig. 1: The EHAC Board meets with chairmen of the working groups during the 2013 EHAC Symposium (Photograph: J. Sochacka/LPR)

The following four working groups presented results and identified future challenges: Flight Ops, Safety, Aeromedical CRM as well as Medical working group.

Flight Ops WG: European issues regarding professional, efficient and lasting flight operations are identified, analysed, discussed and solutions proposed by experts in the field of aviation from EHAC member organisations. The WG has the task to organize and hold an annual Flight OPS event for EHAC member organisations and to monitor the implementation of the new EASA-OPS and its implications for daily HEMS operations.

Safety WG: This working group identifies areas of improvement related to Flight Safety. It also aims at contributing to political decision making processes and seeks to intervene on the political/institutional level for the HEMS and air ambulance sector. The WG has the tasks to organise and hold an annual Flight and Patient Safety event for EHAC member organisations and to define prerequisites for a European air safety reporting system, primarily for HEMS. ACRM WG: The ACRM working group is tasked to identify areas of improvement related to human factors, crew coordination as well as crew communication. Furthermore, it aims at contributing to political decision making processes and seeks to intervene on the political/institutional level for the HEMS and air ambulance sector. The ACRM working group has the tasks to conduct ACRM courses (according to the defined standard by the ACRM core team) and ACRM trainer programmes (with EHAC-accredited ACRM instructors), to disseminate ACRM on a global level – in coordination with the Managing Director – and to identify, develop and submit suitable actions regarding crew and human factor training. Furthermore this working group has to identify to whom the individual interventions should be addressed to, e.g. EASA, ICAO, NAAs and industry organisations. Finally, it aims at making the best possible use of materials and action plans produced by other institutions or groups, such as the (AAMS, ASA, EASA, ICAO and national aviation agencies in Europe.

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Medical WG: This working group is tasked to identify areas of improvement related to medical operations and to develop and process professional interventions for the HEMS and air ambulance sector. The Medical WG has the tasks to identify and develop ways and methods to improve medical service in terms of quality and efficacy. Such could be adapted standards and/or guidelines from medical societies. Another aspect here is to conduct scientific research. Furthermore, this group monitors the implementation of the new EASA-OPS and its implications on the daily HEMS operations. The medical group also has to identify, develop and carry out suitable actions regarding medical practice. Another task is to identify the addressees of the respective interventions (for example medical and industry organisations) and make the best possible use of resources and action plans produced by other institutions or groups such as the AAMS, ASA, European Aviation Safety EASA, the ICAO and national aviation agencies in Europe.

EHAC elections EHAC also elected a new Board Member as well as a new EHAC Auditor: Frédéric Bruder, Managing Director at ADAC Air Rescue, has been elected as EHAC Board Member by the EHAC member organisations. Previously, Friedrich Rehkopf had stepped down from his post as Managing Director at ADAC Air Rescue due to retirement. Thus, Frédéric Bruder succeeds Friedrich Rehkopf also as EHAC Board Member. Bruder took over as CEO of ADAC Air Rescue in September 2012, having previously worked as Corporate Director of Strategy and International Business Development at Inaer. Furthermore, Ralph Setz, Regional Marketing Director Asia and Segment Expert EMS & Public Service at Eurocopter, has been elected as EHAC Auditor by the EHAC member organisations.

Prior to this, Michael Rudolph had stepped down from his post since he has moved over from EMS market development to another department at Eurocopter. The elections were being held during the Annual General Meeting as part of the EHAC Symposium. Only designated representatives of EHAC’s member organisations were participating in this meeting and the elections.  For more information, visit: ››› www.ehac.eu

16 | EHAC

Fig. 1: ATE’s Cessna Citation 550 Bravo is being used for transportation of patients from medical treatment in Slovakia to specialized treatment facilities abroad (Photographs: ATE)

Air-Transport Europe in HEMS: Courageous missions in the Tatra mountains Authors: Zuzana Turocˇeková Air-Transport Europe Poprad-Tatry Airport 058 98 Poprad, Slovakia turocekova@ate.sk Emília Vargová Air-Transport Europe Poprad-Tatry Airport 058 98 Poprad, Slovakia vargova@ate.sk

Air-Transport Europe (ATE) is a private company and is one of the operators with the longest history of operations in Slovakia. The company’s portfolio comprises of five fields of activity: HEMS, charter executive jets, special aerial works, helicopter service center and trading department. In May 2013, ATE celebrated its 22nd anniversary and during all these years of its existence, the company has been providing services in the field of air rescue and air industry – thus becoming a well-established and experienced air operator and center for helicopter maintenance. The company employs over 100 people in the Poprad headquarters as well as in its seven HEMS bases. ATE is member of international organizations such as EHAC and ICAR (International Commission for Alpine Rescue).

ATE HEMS in Numbers Air-Transport Europe Ltd. (ATE) operates seven HEMS bases in Slovakia, providing services to 5 million inhabitants and also to foreign visitors. In the course of its 22 years of activities, ATE HEMS crews have accumulated almost 18,500 flight hours. Last year alone they per-

formed 1,400 missions. The nature of most missions is defined by geographical conditions of the urban centers and its surroundings. Most missions are flown in close vicinity of the mountains, forests and skiing resorts. Other HEMS missions are carried out in the case of road accidents, again others include missions in distant areas.

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EHAC | 17

Fig. 2: Map of ATE bases in Slovakia

ATE crews have been trained for demanding missions in inaccessible mountainous regions. Technical missions using hoists make up about 30 % of all primary missions.

They mostly take place in the Slovak Tatra Mountains and in dense forests in the north and east of the country. The ATE crews also won the award of the Slovak Ministry of Interior and the Air Ambulance Journal in New York for its courageous missions during the floods in the eastern part of Slovakia in 1998.

Secondary missions account for almost half of all HEMS missions. Mostly it is transport of patients with acute coronary syndrome to specialized (cardiac) catheterization centers and transports of neonates to specialized hospitals as well. ATE also conducts medical transports of patients not only in the Slovak Republic but also abroad. In 2011, the company expanded its fleet and added a Cessna Citation 560 Encore and, in 2012, a Cessna Citation 550 Bravo jet to its fleet – these are used for transportation of patients from Slovakia to medical establishments abroad. ATE also cooperates with European Assistant Services in the field of repatriation flights.

ATE Helicopter Emergency Medical Service is a part of the integrated emergency system available in Slovakia at emergency number “112”. Air-Transport Europe operates its own dispatch center, reachable at “18155”. ATE crews are on duty for 24 hours a day, 7 days a week and 365 days a year. In the so-called Visegrád (V4) countries, an alliance of four Central European states, founded to deepen European integration, ATE is numbered first in using Night Vision Goggles (NVG) during missions.

Fleet ATE HEMS fleet includes 9 Agusta A109K2 helicopters and one Eurocopter AS355N. In each of the seven centers, there is one helicopter on standby-duty, two remaining helicopters are the backup ones. AgustaWestland A109K2 helicopters were developed in cooperation with Swiss Helicopter Emergency Medical Service Rega. They are intended for demanding operations in a rugged environment and are suitable for high mountain areas. NVG are included in their equipment. The helicopters are also

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equipped with hoists, rated for a maximum working load of 204 kg and 50 m wire, used to winch the doctor to a patient in inaccessible areas. If needed, the crew may use suspension with maximum load of 500 kg. Agusta A109K2 helicopters allow providing complex intensive and resuscitation care under challenging conditions and in a difficult-to-reach environment.

Fig. 3: ATE HEMS mission after a road accident

ATE’s international activities Air-Transport Europe has a good reputation that goes far beyond the borders of the Slovakian national territory. Already in 2004, the company became member of European HEMS and Air Ambulance Committee (EHAC) and has a representative in the Flight OPS working group focussing on preparations for suitable operation regulations and standards in air rescue. Thanks to long-year experience with air rescue activities in the mountains, ATE also joined the International Commission for Alpine Rescue (ICAR). According to ATE chief pilot Viliam Krivak, “the membership in both international associations complements each other and is of great importance for ATE.” Combination of experience from air rescue and rescue in the mountains, gained by ATE crews during many years of operations, is also beneficial to the work and activity of both associations. 

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

18 | MEDICAL CARE

Fig. 1: Even in an urban setting such as London, patients may not reach hospital in time to receive a blood transfusion (Photograph: Matthew Bell)

London‘s Air Ambulance: Bringing blood transfusion to the patients The team at London’s Air Ambulance identified that there was an opportunity to improve patient care by bringing blood transfusion to the patients who were in extremis and delivering this intervention at the roadside – prior to arrival at hospital. For some patients this would be the difference between dying outside hospital from severe non-compressible haemorrhage or reaching an Emergency Department and a team who could control the bleeding with damage control techniques. London’s Air Ambulance introduced pre-hospital blood transfusion in March 2012 and other air ambulances have followed their lead since. During the first 12 months of this innovation, the service has delivered over 100 pre-hospital transfusions.

Author: Dr Anne Weaver Lead Clinician London’s Air Ambulance Consultant in Emergency Medicine & Pre-hospital Care The Royal London Hospital Barts Health NHS Trust

London’s Air Ambulance responds to severely injured patients within the greater London area. The physicianparamedic team attends over 2,000 missions per year using an aircraft and rapid response vehicles. Within this population, approximately 200 patients per year are dying from serious blood loss and a percentage of this group die before reaching hospital.

Across the world, several aeromedical services have access to blood for use on pre-hospital and retrieval missions. These services historically had access to blood, which was stored in a fridge, close to, or actually on site at their base – a refrigerated pack could be prepared and blood could be transported to the patient, if the need was identified prior to dispatch of the aircraft or medical team.

However, most services were not routinely carrying blood products on every mission.

Some patients are suffering from non-compressible haemorrhage, which can only be controlled by invasive techniques such as surgery or interventional radiology.

Many of these patients are compromised before they reach hospital. Even in an urban setting such as London, patients may not reach hospital in time to receive a blood transfusion. This is a particular issue for trapped patients e.g. in road traffic collisions, or unconscious patients who are found a while after the initial injury. In rural settings, long journey times from the scene of the incident to hospital can mean an inevitable delay to receive much needed blood and surgical control.

Increasing the survival rate If a patient has lost a significant amount of blood and has gone into cardiac arrest, it is unlikely that the administra-

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MEDICAL CARE | 19 tion of crystalloid fluid will result in a return of spontaneous circulation. However, if you are able to give blood to these patients, resuscitation may be successful. If you have lost a large amount of blood, it needs to be replaced with blood in order to perfuse organs with oxygen. Crystalloid fluid does not carry oxygen and as such will not result in perfusion of the brain and other vital organs. Traumatic cardiac arrest due to hypovolaemia has a dismal outcome in the absence of blood transfusion and damage control techniques (1).

For medical teams like those provided by London’s Air Ambulance, which regularly undertake open chest surgery to alleviate cardiac tamponade, the ability to give a pre-hospital blood transfusion to patients who are also hypovolaemic, will increase the survival rate from this procedure (2). London’s Air Ambulance has already seen patients resuscitated successfully using these techniques.

The team believes that these patients would not have survived without blood at the scene.

Blood transfusion is governed by strict legislation and extensive guidance. Hospital transfusion departments are quite rightly protective of the use of blood products.

Legislation exists to ensure that patients are protected from transfusion errors and that products are not wasted or used inappropriately. The rules and regulations make the practice of blood transfusion a necessarily onerous process, which on the face of it can appear to be impossible to negotiate for non-hospital based organisations (e.g. air ambulances).

A Standard Operating Procedure for pre-hospital blood transfusion ensures that all personnel understand the requirements and responsibilities which are associated with the administration of blood (3). No major drawbacks have been encountered and the process is now a routine practice. The teams have a traceability record of 100% which is superior to that of many hospital departments.

Wasted blood products must be avoided at all costs and unnecessary waste would be a drawback as O negative blood is a precious resource. Only one unit of blood has been wasted due to a communication error with the transfusion laboratory.

Rigorous testing by the armed forces London’s Air Ambulance investigated different blood storage options prior to introducing the innovation. The container needed to be robust, lightweight and weatherproof.

Ideally, the storage box would not require batteries or a power source. This avoided the requirement and expense of airworthiness testing. Affordability was an important consideration as many air ambulances are charitably funded. With the help and advice of the British Military, London’s Air Ambulance decided to use the Golden Hour box from SCA Cool Logistics. The box can hold 4 units of packed red blood cells (PRBC) at a steady state temperature of 2-6 °C for 48-72hrs. A data logger is kept in the box, which allows temperature data to be downloaded to demonstrate compliance with regulations. Blood, which has not been used, can be returned to the transfusion stock for use in other areas. The box had already survived rigorous testing by the armed forces in Afghanistan.

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Fig. 2: LAA carries 4 units of O-negative packed red blood cells (PRBC) in each Golden Hour box, one is available on the aircraft and on each rapid response vehicle (Screenshot)

London’s Air Ambulance is based at The Royal London Hospital (Barts Health NHS Trust) and the team have an excellent working relationship with the Transfusion Department. Every 24 hours, the transfusion staff packs the blood into specially prepared boxes with data loggers.

Three boxes are rotated every 24 hours. Replacement boxes are delivered if blood is administered.

London’s Air Ambulance carries 4 units of O negative packed red blood cells (PRBC) in each Golden Hour box.

One box is available on the aircraft and on each rapid response vehicle. The Medical Emergency Response Team (MERT) carries 2 units of O Negative PRBC and 2 units of thawed plasma in each of their Golden Hour boxes.

Kent, Surrey and Sussex Air Ambulance Since London’s Air Ambulance introduced pre-hospital blood transfusion in March 2012, other Air Ambulances have followed its lead. Teams from Kent, Surrey and Sussex Air Ambulance Trust (KSSAAT) have also seen patients who received pre-hospital blood survive from injuries – that may not have been the case if blood had not been available immediately. KSSAAT use a charity motorbike service to transport the blood boxes between hospital transfusion laboratory and the air ambulance base (as KSSAAT are not based at a hospital). Thames Valley Air Ambulance also started to carry blood on board recently.

Other air ambulances have shown interest in the results of this work and may well decide to offer this additional service.

For medical teams and Air Ambulance services that do not attend the same volume of severely injured patients as London’s Air Ambulance, the author believes that there is still a potential benefit. Even if only a small additional number of patients survive as a result of prehospital blood transfusion, then the project will have been worthwhile, as long as blood is not wasted during the process.  References: 1. Davies GE, Lockey DJ (2011) Thirteen Survivors of Prehospital Thoracotomy for penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can yield Good Results. J Trauma 70: E75-E78 .

2. Lockey DJ, Crewdson K, Davies GE (2006) Traumatic Cardiac Arrest: Who are the Survivors? Ann of Emerg Med 48: 240-244 3. London’s Air Ambulance Standard Operating Procedure – Pre-hospital Blood Transfusion.

For more information, visit: ››› www.londonsair ambulance.co.uk

20 | MEDICAL CARE

Stroke Unit project: Airborne point-of-care stroke management The Norwegian Air Ambulance Foundation (SNLA) has an ambitious research programme aimed at delivering evidence-based point-of-care services of the highest quality in a geographically challenging and sparsely populated country. An air ambulance stroke unit project increases the chances of realizing our vision to “bring the hospital to the patient”. The SNLA and the University Hospital of the Saarland, Homburg (Germany) are preparing a mobile stroke unit (MSU) project aimed at bringing stroke management in CT-equipped air ambulances a few steps forward.

Authors: Prof. Hans Morten Lossius Norwegian Air Ambulance Foundation Maren Hylen Ranhoff, MD research fellow Norwegian Air Ambulance Foundation Thomas W Lindner, MD Chief Medical Advisor Norwegian Air Ambulance Foundation

The challenge of timely stroke management Stroke is a most challenging condition; a positive outcome is heavily dependent on prompt instigation of specialist-demanding, cause-oriented treatment in eligible patients, but the pre-hospital setting is not part of the treatment chain. According to a recent metaanalysis of the major thrombolysis trials (1), the number needed to treat strongly correlates with the beginning of treatment after symptom onset; up to 15 in the time range 181-270 min, more than 9 in the range 91-180 min and 5 within 90 min. Every minute counts when it comes to re-establishing cerebral circulation in ischemic areas.

1.7 million brain cells are estimated lost per minute

(2) − the expression “time is brain” is most appropriate.

A European multicenter registry study from 2007 (6,483 patients) showed that median time from symptom onset to start of standard iv thrombolytic treatment was 140 min (3). The swift response time of the air ambulance in Norway (maximum 15 min [mean 2-4 min] from alarm to take-off), enables them to reach most of the population within those 90 min when thrombolytic treatment is most successful (1). However, air ambulances are not equipped to precisely diagnose stroke patients, and guidelines (4) on stroke treatment presuppose that precise diagnosis and treatment starts in hospitals.

Fig. 1: NAA has 11 helicopter bases, fully financed from public funds, the HEMS crew comprise a pilot, a HCM medical and a doctor (anaesthetist) (Photograph: Fredrik Neumann) 2 · 2013 I Vol. 3 I AirRescue I 88

MEDICAL CARE | 21 Stroke management in air ambulances

The MSU project

The SNLA has initiated a comprehensive project, aimed at defining procedures, competence and training requirements for pre-hospital, cause-oriented stroke treatment in CT-equipped air ambulances. CT scanners for use in helicopters are not currently available, but the project includes adapting a CT scanner suitable for their air ambulance fleet. One goal of that project is to end up with a CT scanner that will fit in a helicopter and produce images of sufficient quality to eliminate brain hemorrhage; information needed to determine patient eligibility for thrombolytic treatment.

Professor David Russell, the most prominent stroke expert in Norway, was enthusiastic about the plans for more ambitious stroke management presented at the annual Norwegian stroke conference earlier this year.

He expressed a need to raise the standards for stroke treatment, which are 10 years behind those for cardiac infarction.

In Norway, treatment is complicated by the fact that cerebrovascular disease (stroke being the most important) is not a separate medical specialty like cardiovascular disease. Patients with cardiac infarctions are immediately transferred to the right treatment unit and the treatment procedures are standardized, while stroke patients can end up in different departments (neurological, medical and geriatric departments) and are treated in variable unstandardized ways.

The Norwegian Air Ambulance Foundation (SNLA) and the University Hospital of the Saarland, Homburg, Germany are preparing a mobile stroke unit (MSU) project aimed at bringing stroke management in CT-equipped air ambulances quite a few steps closer. The team in Homburg (Fassbender, Walters and collaborators) recently reported encouraging results from the first MSU trial (5) to be published on pre-hospital stroke management. That randomized controlled trial investigated the time needed to diagnose and treat patients with stroke symptoms in a CT-equipped MSU on wheels compared to that in a conventional hospital unit. The time from alarm to therapy decision for the MSU group was substantially lower than that for the hospital group (78 to 35 min median time).

A stepwise parallel approach is planned in the project to be started in autumn 2013. The SNLA will use ambulance cars with the smallest available CT scanners that still are too large and heavy to use in air ambulances, but otherwise equipped to mirror air ambulances that could be used for stroke treatment. Appropriate staffing and training in pre-hospital care − to be assessed in this project − is defined as one of 5 top priority research areas in a European consensus report about physicianprovided pre-hospital critical care (6). The pilot project will emphasise competence rather than type of staff needed, because a subsequent multicenter study will be undertaken in several countries with different cul-

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22 | MEDICAL CARE the hospital. Part of the project will be to find the optimal size of “data packages” and the number of data transmitting units needed for effective transferal of imaging data. Norway has been a pioneer when it comes to mobile X-ray, which also entails sending image data to radiology departments for interpretation; three mobile X-ray cars currently transmit imaging data regularly and successfully to radiology departments in Norwegian hospitals (7).

Our MSU pilot project will not entail actual treatment of stroke patients, but rather collect information needed for detailed planning of a European multicentre study of CTequipped appropriately staffed ambulance cars mirroring all that is needed in air ambulances.

Fig. 2: The air ambulance stroke unit project increases the chances of realizing the common vision of “bringing the hospital to the patient”

tures and health service organizations. The competence needed to treat stroke is the same in different geographical locations, but the type of staff varies; one example is that neurologists in Germany regularly take on duties that only anesthesiologists are trained to do in Norway.

Norwegian PhD project MD Maren Hylen Ranhoff, SNLA PhD candidate, supported by an experienced research group at the Department of Neurology, Oslo University Hospital, in her thesis aims at defining the minimum skills and training required to interpret stroke symptoms and CT images in the ambulance with sufficient accuracy to eliminate brain hemorrhage and infarctions that are too large to benefit from thrombolytic treatment. The plan is to use anesthesiologists (who are already part of the staff on air ambulances in Norway) to make a preliminary diagnosis and interpret the CT images, but those minimum skills to be defined in the project will also be applicable for other personnel groups in other countries.

Imaging data from the stroke examinations will be sent to radiology departments in hospitals with stroke units for interpretation. Accuracy of the diagnoses made by anesthesiologists in the ambulance cars will be compared with accuracy of diagnoses made by radiologists in Fig. 3: The swift response time of the air ambulance in Norway enables NLA to reach most of the population within those 90 min when thrombolytic treatment is most successful (Photograph: Fredrik Neumann)

Multicentre testing of air ambulances “on wheels” Based on results from the PhD project, the plan is to test the effectiveness of “air ambulances on wheels” as a part of a European multicentre study. This study, chaired by the group of Prof. Klaus Fassbender, Saarland University Hospital, will retrieve data from MSU’s in several areas with different population densities and health service organisations to measure their effect on long-term health outcome, QALY’s (quality-adjusted life year) gained and costs saved.

Adapting the system to the patients’ needs Time and provider competence are the two most important factors when dealing with critically ill and injured patients. Irreversible and detrimental pathophysiological processes develop rapidly. It is often unfeasible to quickly match patient needs with crucial provider competence within specialised, complex and sectorized hospital organisations. A more patient-centred strategy is needed to reduce mortality rates and disabling sequelae. The Norwegian Air Ambulance Foundation continuously strives to define and develop pre-hospital critical care for the future. Our air ambulance stroke project is a serious attempt towards timely delivery of patient-centred and tailored critical care.  References: 1. Lees KR, Bluhmki E, von Kummer R, et al. (2010) Time to treatment with intravenous altephase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS and EPITHET trials. Lancet 375: 1695-1703 2. Saver JL (2006) Time is brain-quantified. Stroke 37: 263-66 3. Wahlgren N, Ahmed N, Dávalos A, et al. (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 369: 275-82 4. Norwegian national guidelines for the treatment and rehabilitation in stroke: The Norwegian Directorate of Health 2010.

5. Walter S, Kostopoulos P, Haass A, et al. (2012) Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 11: 397-404 6. Fevang E, Lockey D, Thompson J, et al. (2011) The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration. Scand J Trauma Resusc Emerg Med 19: 57 7. Project Report (November 2010-June 2012) Mobile X-ray services by Akershus University Hospital to nursing homes and prisons in 8 distant municipalities.

2 · 2013 I Vol. 3 I AirRescue I 90

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24 | MEDICAL CARE

Fig. 1: In a high-noise environment such as a helicopter, it is almost impossible to effectively auscultate a patient’s chest in order to diagnose and assess bronchospasm and the response to treatment (Photograph: AMS South Africa)

Benefits of continuous end-tidal capnography in the aeromedical environment There are a number of frightening reports in the literature on the incidence of missed oesophageal intubation and the incidence of post-intubation migration of the tracheal tube into either the oesophagus, right mainstem bronchus or the supraglottic laryngopharynx (1, 2, 3, 4, 5). All clinical methods employed to ensure correct placement are “single snapshots in time” and become clinically and historically irrelevant almost immediately after each test has been completed. The placement of the tracheal tube must be verified after each time the patient is moved from one surface or stretcher to another, each time that the patient is moved from one vehicle, aircraft or Emergency Department to another, and each time that responsibility for patient care is transferred from one clinician to another.

Author: Dr John Roos Head of Dept. of Anaesthesia GF Jooste Hospital Cape Town South Africa johnroos@iafrica.com

This article will focus on the valuable diagnostic information that may be gleaned specifically from a critical analysis of the waveform shape during continuous waveform capnography. This continuous verification of tracheal tube placement – as opposed to the LED light-bar type capnographic displays – can provide a considerable amount of extra clinical information, if one is aware of what to look for. Firstly, one needs to develop a clear understanding of the capnographic waveform, in order to be able to fully interpret the capnogram (see Fig. 1).

Phase I expiration relates to expiration of dead space volume. Even though dead space gas is exhaled, there is no reflection of CO 2 in this volume, as no gaseous

exchange takes place in the dead space of the tracheobronchial tree. Phase II expiration relates to the mixed deadspace gas and alveolar gas, and Phase III relates to almost pure expiration of alveolar gas, which plateaus out at the maximal end-tidal carbon dioxide level. It has to be noted that the absent Phase 4 relates to inspiration – where end-tidal CO2 drops of precipitously on inspiration (clearly, no expired CO2 can be detected during the patient’s inhalation phase).

The capnographic traces presented here are contracted graphic representations of a few breaths, but may reflect physiologic processes that may unfold over several minutes or more. It is critically important to have

2 · 2013 I Vol. 3 I AirRescue I 92

MEDICAL CARE | 25 a clear understanding of where inspiration and expiration start and stop on the capnographic tracing: Note that A in Fig. 3 is the starting point of expiration (beginning of the appearance of exhaled CO2), and B is the starting point of inspiration (sudden disappearance of exhaled CO2). If one imagines that there is a higher breath rate on the left (A), in comparison to the right (B), it is very plausible that capnography may serve as a breath rate monitor.

Simultaneously, capnography acts as a surrogate spirometer, in that it gives an indication of tidal volume.

Note that in Fig. 4 there are three tracings depicting three different tidal volumes, according to the end-tidal CO 2 plateaus. In B the patient is subjected to a higher tidal or minute volume than in A, as CO 2 is being “blown off”.

In C a lower tidal or minute volume has been set, as CO 2 is being retained. Rate and tidal volume together provide an estimation of minute ventilation.

Under most circumstances, one can safely titrate ventilator settings to airway pressure and end-tidal CO 2, without requiring the addition of a spirometer to the circuit. The capnograph plateau (alveolar gas) provides an accurate quantitative measure of end-tidal CO 2 (which correlates well with PaCO 2) in the assessment of hypoand hyperventilation. This is especially important, for example, in ventilating traumatic brain injury with raised intracranial pressure.

Note the more gradual up-slope of the expiratory phase seen in Fig. 5. Note that as well as the up-slope being more gradual, the total expiratory phase is significantly prolonged. This phenomenon is seen in any form of airway outflow obstruction, and is therefore diagnostic of bronchospasm of any cause, but most commonly that seen in asthma.

The gradient of the curve becomes steeper as the patient responds to treatment, and becomes flatter as the bronchospasm worsens. This observation is particularly useful in a high-noise environment such as a helicopter, where it is almost impossible to effectively auscultate a patient’s chest in order to diagnose and assess bronchospasm and the response to treatment.

As a breath-by-breath ventilatory monitor, the capnograph provides an instant apnoea alarm (as most capnographs will have a default apnoea alarm setting triggered by a flat-line tracing). Such an alarm function would alert the clinician to a ventilator circuit disconnect, an inadvertent extubation, intrinsic ventilator failure, gas supply failure and total airway obstruction from any other cause (such as a saturated and blocked Heat and Moisture Exchange (HME) device.

Fig. 6 demonstrates progressive hypoventilation from any cause. This may be due to inadequate (minute volume) ventilator settings, it could signify a ventilator circuit leak, a ruptured tracheal tube cuff, tension pneumothorax or an intrinsic ventilator failure.

One may be tempted to interpret the above trace as hyperventilation rather than hypoventilation. Be aware, however, that the above graph is not a volume vs time graph but end-tidal CO2 vs time graph. Similarly, one may be trapped into interpreting the graph of Fig. 6 as a

2 · 2013 I Vol. 3 I AirRescue I 93

Expiration I

II

Inspiration III

Fig. 2: Phases of ex- and inspiration

pressure vs time graph, and thus spuriously diagnose a tension pneumothorax. Whilst this graph may very well represent a tension pneumothorax, this would be on the basis of inadequate ventilation.

The tracing below (Fig. 7) demonstrates patient effort whilst “fighting” the ventilator. The “bites” out of the expiratory waveform represent inspiratory effort in the midst of the ventilator’s expiratory phase. These are known as “curare dips”, as they were first noted by anaesthesiologists, who identified the pattern as the early curare-based non-depolarising muscle relaxants progressively wore off, and the patients started to breathe against the ventilator. Curare dips are a direct monitor of neuromuscular blockade, and an indirect monitor of adequacy of sedation. If one sees curare dips, then one must consider whether or not to re-paralyse a patient, or deepen sedation and/or analgesia.

Fig. 8 below could be interpreted in two ways, depending on whether or not there is a changing minute volume. In the face of a changing minute volume, the trace below represents progressive hyperventilation,

Fig. 3: Start of expiration (A) and start of inspiration (B) Fig. 4: Tidal volumes, according to the end-tidal CO2 plateaus Fig. 5: Up-slope of the expiratory phase

B A

C

B

A

26 | MEDICAL CARE

Fig. 6: Progressive hypoventilation Fig. 7: Patient effort “fighting” the ventilator Fig. 8: Need for imminent resuscitation?

Fig. 9: Patient is re-breathing expired CO2 Fig. 10: Increasing baseline and plateau

which could be from any cause – most commonly due to overzealous ventilator settings. One can clearly see that CO2 is being progressively blown off. However, in the face of a constant minute volume, a steadily decreasing end-tidal CO2 is indeed an ominous warning of impending calamity, and should alert the medical team to the need for imminent resuscitation.

This is usually seen in the context of major exsanguinating haemorrhage, where the patient has passed into the phase of “compensated” shock, and is peripherally “shut-down”. A drop in end-tidal CO2 heralds the onset of central (heart, lungs and brain) circulatory collapse. The explanation for this phenomenon is that the mitochondria continue to generate CO2 through normal metabolic processes, but with the onset of central circulatory collapse, the CO2 load cannot be delivered to the lungs in order to be exhaled.

The above clinical scenario may be seen, for example, in the situation where a haemodynamically unstable patient is flown either by rotor-wing or fixed-wing aircraft, in a reverse-Trendelenberg (feet-down) position for any length of time. The first warning of in-flight circulatory collapse, in the absence of invasive blood pressure monitoring, would be an immediate decrease in end-tidal CO 2.

Non-invasive blood pressure monitoring would typically cycle every three to five minutes, and in the event of an unrecordable blood pressure, would continue to recycle for a number of precious minutes before the medical crew became aware of the severity of the patient’s

clinical status. The early-warning advantage of breathby-breath end-tidal CO2, facilitating immediate evasive action under such circumstances, is undisputed.

In Fig. 9, the level of inspired CO 2 has risen above the baseline – indicating that the patient is re-breathing expired CO2. The relevance of this is that either fresh gas flows are too low, there is a malfunction of the ventilator’s inspiratory or expiratory valve, or that the carbon dioxide absorber (soda lime or equivalent) has become exhausted.

The take-home point from this is that end-tidal CO2 provides an indication of the adequacy of gas flow as well as the quality of inspired gas, besides providing an indirect monitor of ventilator and CO2 absorber functionality. In Fig. 10 it is both the baseline and the plateau that is increasing. This is either due to an increase in CO 2 production, a failure of CO2 elimination, or a combination of both.

An increased CO2 production, and a failure to eliminate CO2 (simply on the basis of excessive production), signifies a hypermetabolic state. Hypermetabolism is seen in thyroid storm (thyrotoxic crisis), severe sepsis and malignant hyperthermia. Whilst malignant hyperthermia might be extremely rare in the prehospital or transport environment, it is still theoretically possible, as suxemethonium (one of its triggers) is certainly used in the prehospital environment. Finally, cardiac oscillations’ have little clinical significance, but need to be included in order that they are recognized for what they are. They represent the heart beating against the lungs, transmitted to the expiratory waveform and may represent a hyperdynamic circulation.

In summary, end-tidal capnography is a continuous early-warning monitor of tracheal tube placement, ventilator circuit disconnection and apnoea alarm, circuit integrity, ventilator malfunction, gas supply, gas flow and quality of inspired gas. It is a respiratory rate monitor, an indirect monitor of tidal or minute volume, a direct monitor of neuromuscular blockade and an indirect but valuable monitor of sedation. Capnography provides an accurate indication of airway obstruction, bronchospasm and response to treatment. It is also an indirect yet accurate monitor of cardiac output, and in addition, a metabolic rate monitor – albeit a fairly blunt instrument in this regard.

The above represents separate parameters monitored either directly or indirectly by capnograph, and reliably so in the peripherally shut-down, haemodynamically unstable patient. In contrast, pulse oximetry only monitors two separate parameters, those being heart rate and oxygen saturation. Yet, in a peripherally shut-down, hypovolaemic and/or hypothermic vasoconstricted patient, a pulse oximeter tells you absolutely nothing! One can therefore make a very strong argument that, in an intubated and ventilated patient, end-tidal capnography is of far greater value than pulse oximetry. 

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2 · 2013 I Vol. 3 I AirRescue I 94

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28 | MEDICAL CARE

Fig. 1: HEMS units are regularly involved in the management of major incidents that need structuring and standardising – given the multitude of responders (Photographs: Norwegian Air Ambulance Foundation)

Authors: Marius Rehn Norwegian Air Ambulance Foundation Dpt. of Anaesthesia and Intensive Care, Akershus University Hospital,Lørenskog marius.rehn@ norskluftambulanse.no Trond Vigerust Norwegian Air Ambulance Drøbak Jan E. Andersen Norwegian Air Ambulance Foundation Drøbak Andreas J. Krüger Norwegian Air Ambulance Foundation Drøbak & St. Olav University Hospital, Department of Anesthesia and Emergency Medicine, Trondheim, Norway Hans M. Lossius Norwegian Air Ambulance Foundation Drøbak & University of Bergen, Department of Surgical Sciences Bergen, Norway

Tools for HEMS units: a concept for major incident triage HEMS units are regularly involved in the immediate response during major incidents. Efficient management of these incidents involves triage, treatment and transport. HEMS units often operate in several regions and must adapt to local systems for incident management, when national standards are lacking. In the absence of a standardised interdisciplinary major incident management approach, the Norwegian Air Ambulance Foundation developed the Interdisciplinary Emergency Service Cooperation Course (TAS). The TAS-program was established in 1998 and by 2011, approx. 17,000 emergency service professionals had participated in one of more than 600 courses free of charge.

The TAS-triage concept has modified the established triage sieve, as slap-wrap reflective triage tags and paediatric triage stretchers have been integrated. Feasibility and accuracy of the TAS-triage concept by the Norwegian Air Ambulance Foundation were evaluated through full-scale bus crash simulations. Learners participated in a self-report survey – as a before-after study – in which triage accuracy as well as time consumption were measured. The modified triage sieve tool was found to be feasible, time-efficient and accurate in allocating priority during simulated bus accidents and may be a candidate for a future national standard for major incident triage.

Major incidents are heterogeneous in nature and their unexpectedness favours an “all-hazards” approach. Since rescue capacity varies within systems, the conditions of a major incident that may be relevant for a rural emergency service, may not apply to a larger urban emergency service (1). Rapid access to advanced major incident management has proven to optimize resource use and improve patient outcome (2). Major incident management traverses geographical and jurisdictional boundaries and involves responders from multiple rescue services. Furthermore, it involves multiple tasks such as leadership, preparation, risk-evaluation, triage, treatment and trans-

2 · 2013 I Vol. 3 I AirRescue I 96

MEDICAL CARE | 29 port. HEMS units are regularly involved in the management of major incidents. Structuring and standardising these initiatives seems essential, given the multitude of responders.

The TAS-courses have gradually evolved and the principles for disaster health education – as proposed by the World Association for Disaster and Emergency Medicine – have successively been adapted (3). Major incidents require systems that allow providers to follow their daily pattern of behaviour, the “doctrine of daily routine”. The TAS-concept focuses on training through which participants practise local inter-disciplinary cooperation and simple, field-friendly techniques. Acknowledging that triage is necessary to achieve the greatest good for the most number of people (4), the Norwegian Air Ambulance Foundation (NAAF) developed a concept for major incident triage, based on the established triage sieve and Paediatric Triage Tape (PTT) models (1, 5).

The triage Sieve is a major incident primary field triage tool designed to prioritize patients for evacuation in order to provide them with definitive medical care. Based on the assessments of the ability to walk, airway patency, respiratory- and heart rate, the triage sieve assigns four priorities (1): • P1: immediate (red) • P2: urgent (yellow) • P3: delayed (green) • Deceased (white/black) In order to increase field-friendliness, NAAF designed weatherproof action cards (see Figure 2) and slap wrap reflective triage tags (see Figure 3). Furthermore, a tape was designed that presents vital data intervals and that is placed at the side of stretchers to ensure field-friendly access to the paediatric triage algorithm. All children in need of stretchers are categorised as P2, urgent (yellow), but are upgraded to P1, immediate (red) priority, when vital signs lie outside their length-related reference values (6).

The study hypothesis was that learners would improve in speed, triage accuracy and self-efficacy after the TAScourse. This article shortly describes the feasibility of a concept for major incident triage and presents the accuracy of the modified triage Sieve in full-scale simulations of major incidents.

Methods TAS-course Local emergency service personnel (healthcare, police, fire and rescue technicians) were taught major incident self-safety, triage, patient evacuation, extrication techniques and cooperation during a two-day course (free of charge). The didactic programme combines theoretical and practical sessions and is tailored to groups of various sizes and professional compositions. A major incident was simulated outdoors using a standardised bus crash scenario, including approximately 20 patients (range 1721) and a real-size bus wreck. Every patient was given an information card with injury descriptions as well as numeric vital signs for triage purposes. Physiological parameters were dynamic to mimic de-compensation and to

2 · 2013 I Vol. 3 I AirRescue I 97

Evacuated clearing station

WALKING?

YES

INJURED?

NO

Evacuated

YES

DELAYED (P3)

NO

DECEASED

NO

BREATHING? YES 10 - 30

NO

BREATHING?

YES

< 10 or > 30

IMMEDIATE (P1)

> 120 < 120

URGENT (P2)

PULSE

visualize the need for re-triage. The patients were equally distributed between the four priorities (all categories had 25% representation). Paediatric patients were simulated with mannequins for ethical reasons. The bus-crash scenario was simulated once at the beginning of the course and once at the end of the course (with formal triage sieve competence/access to TAS-triage action cards, triage tags and paediatric triage stretcher). The didactic program was piloted and refined through 43 TAS-courses prior to the study.

Fig. 2: Modified triage sieve action card: Adult (>140 cm) triage sieve

Study design A self-report survey (before-after study) was combined with an objective quality indicator measurement. Prior to both excercises and based upon informed consent, all participants anonymously answered a written survey.

By means of the two questionnaires (that were linked without violating anonymity), self-efficacy and reaction to the training were evaluated. Each question relating to self-efficacy was scored on a 7-point Likert scale with points that ranged from “Did not work” (1) to “Worked excellently” (7). During both exercises, one instructor documented quality indicators such as over- and under-

Fig. 3: Field-friendly slap-wrap reflective triage tags in holster

30 | MEDICAL CARE 32) before and mean 10 minutes (range 5-21) in the simulation after the course was attended.

Self-efficacy and reaction to training The slap-wrap triage tags were reported to work well, median = 6 (IQR 6-7). The learners found the paediatric triage tape stretcher feasible, median = 5 (IQR 4-6).

Self-efficacy before and after the TAS-course is depicted in Table 2.

Discussion

Fig. 4: During a two-day course, local emergency service personnel were taught major incident selfsafety, triage, patient evacuation, extrication techniques and cooperation

triage rates. Triage accuracy was calculated according to allocated priority at the casualty clearing station (first simulation; without TAS-triage) and according to TAS-triage tags (last simulation; with TAS-triage). The instructors also measured quality indicator, that is the time from “scene secured” to “all patients triaged” (in minutes).

Results Descriptive A total of 110 emergency service professionals attended one of the four courses and 93 learners (85%) answered the questionnaires. Among the study-participants, 28% worked in healthcare (nurse, ambulance, other), 51% were fire fighters, 14% of the participants were police officers and 7% had “other” backgrounds. The mean participant age was 39 years (range 20-62), 84% were men and the median working experience was eight years (range 0-34).

Triage accuracy and time expenditure

Table 1: Triage accuracy with and without the use of TAS-triage

Out of the total number of learners, 48% confirmed that a system for major incident triage existed in their service, whereas 27% had access to triage tagging equipment.

Triage accuracy with and without the use of TAS-triage is depicted in Table 1. Time from “scene secured” to all patients were triaged was mean 22 minutes (range 15-

Triage accuracy with and without the use of TAS-triage Without TAS-triage

With TAS-triage

Course

Overtriage

Undertriage

Overtriage

Undertriage

1*

3/20 (15,0%)

1/20 (5,0%)

0/20 (0%)

0/20 (0%)

2

3/20 (15,0%)

3/20 (15,0%)

0/20 (0%)

0/20 (0%)

3

2/17 (11,8%)

2/17 (11,8%)

0/17 (0%)

0/17 (0%)

4

1/17 (5,9%)

3/17 (17,6%)

0/21 (0%)

0/21 (0%)

Total

9/74 (12,2%)

9/74 (12,2%)

0/78 (0%)

0/78 (0%)

Note: Triage accuracy = mistriage/total patients (n) *) Simulation was conducted without paediatric mannequins/patients, but with access to Paediatric Triage Tape Stretcher

Emergency service personnel reported a significantly increased self-efficacy in major incident triage after being taught the TAS-concept (Table 2). The modified triage sieve and paediatric triage tape stretchers were time efficient and accurate (Table 1) in allocating patient priority in simulated major incidents. It was found that the TASconcept for major incident triage is feasible for Norwegian emergency service personnel. The TAS-concept emphasizes interdisciplinary cooperation and all emergency service professionals (healthcare, police and fire fighters) are taught triage techniques. In a study of British police officers attending a tactical medicine course, Kilner et al. found that learners were able to make accurate triage decisions after being provided triage sieve decision-making material (7). Major incident triage remains a neglected field for scientific inquiry (8), and determining effectiveness of triage tools has been identified as a critical area for research (9). The optimal triage algorithm is characterized by simplicity, time efficiency, predictive validity, reliability and accuracy to minimize mistriage (10). In a review of published experience with terrorist bombings, Frykberg and Tepas found a mean overtriage rate of 59%.

They also identified a linear relationship between overtriage rate and critical mortality (11).

There are several limitations to this study, for example unrealistically high triage accuracy. In a chaotic environment, accurate measurement of vital data such as respiratory and heart rate may not be achieved. Optimally, the concept for major incident triage should not have been evaluated in simulations, as they can only serve as approximates of complex real incidents. Until real-incident experience with the TAS-concept is objectively measured, models have to be kept feasible, time efficient and accurate in full-scale simulations. Modifications of the TASconcept compared to Major Incident Medical Management and Support (MIMMS) triage sieve include: • Omission of capillary refill, as decreased temperature and dark conditions significantly impairs the field assessment of capillary refill time (12,13) • Category “dead” was renamed to “lifeless”, as jurisdictional restrictions apply to defining death in Norway • MIMMS paper tags were replaced with slapwrap reflective triage tags. Paper tags are likely to perish in the sub-arctic Norwegian climate (14, 15) and they deviate from familiar routines when stress suggests simple and field-friendly solutions.

Major incident triage is dynamic and patients are repeatedly re-triaged along the evacuation chain and through

2 · 2013 I Vol. 3 I AirRescue I 98

MEDICAL CARE | 31 the receiving hospital until definitive treatment is received.

HEMS units are regularly involved in the management of major incidents in many regions. Accordingly, they also benefit from efficient standardized multidisciplinary major incident triage. In Norway, a train accident near Aasta killed 19 people whereas 67 passengers survived. Approximately 600 personnel from 11 different services participated in the initial management of this major incident (16). Further, during a major aircraft incident in UK, the simultaneous use of several different triage-labelling systems contributed to confusion (17). A triage concept with uniform instructions and standardized triage tagging would alleviate on-scene confusion and national standards has been called for both in the US and Australia (10,18). In Norway, the lack of a standard major incident

Self-efficacy before and after the TAS-course question

before course (n)

mean

95% CI

(n)

mean

95% CI

“How did triage work?”

87

4,9

4,6–5,1

87

5,9*

5,7–6,1

“How did interdisciplinary cooperation of triage work?”

88

4,9

4,7–5,2

88

5,8*

5,6–6,0

“How did triage-tagging work?”

83

3,8

3,4–4,3

83

6,0*

5,8–6,1

triage concept that is nationally accepted, reliable and validated remains a gap in our major incident preparedness (19).

Conclusions References: 1. Advanced Life Support Group (2002) Major incident medical management and support, the practical approach at the scene. 2nd edition BMJ Publishing Group, Plymouth 2. Aylwin CJ, Konig TC, Brennan NW et al. (2006) Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 368: 2219-2225.

3. Seynaeve G, Archer F, Fisher J, Lueger-Schuster B, et al. (2004) International standards and guidelines on education and training for the multi-disciplinary health response to major events that threaten the health status of a community. Prehosp Disaster Med 19: 17-30 4. Pesik N, Keim ME, Iserson KV (2001) Terrorism and the ethics of emergency medical care. Ann Emerg Med 37: 642-646 5. Hodgetts T, Hall J, Maconochie I, Smart C (1998) Paediatric triage tape. Pre-Hospital Immediate Care 2: 155-159 6. Rehn M, Vigerust T, Kruger AJ, Andersen JE (2010) Paediatric vital sign tape on stretchers: a field-friendly triage tool? Emerg Med J 27: 412 7. Kilner T, Hall FJ (2005) Triage decisions of United Kingdom police firearms officers using a multiple-casualty scenario paper exercise. Prehosp Disaster Med 20: 40-46 8. Jenkins JL, McCarthy ML, Sauer LM ez al. (2008) Mass-casualty triage: time for an evidence-based approach. Prehospital Disaster Med 23: 3-8 9. Rothman RE, Hsu EB, Kahn CA, Kelen GD (2006) Research priorities for surge capacity. Acad Emerg Med 13: 1160-1168 10. Armstrong JH, Frykberg ER, Burris DG (2008) Toward a national standard in primary mass casualty triage.

Disaster Med Public Health Prep 2 (Suppl. 1): 8-10 11. Frykberg ER, Tepas JJ (1988) Terrorist bombings.

Lessons learned from Belfast to Beirut. Ann Surg 208: 569-576 12. Gorelick MH, Shaw KN, Baker MD (1993) Effect of ambient temperature on capillary refill in healthy children. Pediatrics 92: 699-702 13. Brown LH, Prasad NH, Whitley TW (1994) Adverse lighting condition effects on the assessment of capillary refill. Am J Emerg Med 12: 46-47 14. Knotts KE, Etengoff S, Barber K, Golden IJ (2006) Casualty collection in masscasualty incidents: a better method for finding proverbial needles in a haystack.

Prehospital Disaster Med 21: 459-464

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after course

Table 2: Self-efficacy before and after the TAS-course (Note: Each question was scored on a 7-point Likert scale with points ranging from ”Did not work” (1) to “Worked excellently” (7). *) p < 0,001)

Major incident triage skills can be effectively taught to multi-disciplinary emergency service professionals using a combination of lectures and practical simulations in a two-day course. The modified triage sieve tool discussed here provides acceptable accuracy in allocating priority during simulated major incidents and may serve as a candidate for a future national standard for major incident triage. 

15. Chan TC, Killeen J, Griswold W, Lenert L (2004) Information technology and emergency medical care during disasters. Acad Emerg Med 11: 1229-1236 16. Norges Offentlige Utredninger (2000): Aasta-accident, 4th of January. Book Aastaaccident, 4th of January, vol. NOU City, Oslo: 30 17. Staff of the accident and emergency departments of Derbyshire Royal Infirmary, Leicester Royal Infirmary, and Queen’s Medical Centre, Nottingham (1989) Coping with the early stages of the M1 disaster: at the scene and on arrival at hospital. Bmj 298: 651-654 18. Nocera A, Garner A (1999) Australian disaster triage: a colour maze in the Tower of Babel. Aust N Z J Surg 69: 598-602 19. Rehn M, Lossius HM (2010) Katastrofetriage-behov for en nasjonal standard (In Norwegian). Tidsskr Nor Laegeforen 130: 2112-3

Fig. 5: Sub-arctic climate requires field-friendly triage solutions

An earlier version of this article appeared in BMC Emergency Medicine as: “A concept for major incident triage: full-scaled simulation feasibility study”. Rehn et al. (2010) BMC Emergency Medicine 10: 17. Reprinted with permission of the authors.

32 | CASE REPORT

Fig. 1: Sikorsky S76C+ used for primary, secondary, and tertiary aeromedical evacuation (Photograph: H. Peet)

Authors: Erik N Vu British Columbia Ambulance Service AirEvac and Critical Care Operations erik.vu@bcas.ca Howard E Peet Rob S Schlamp Michael J Essery Robert T Wand British Columbia Ambulance Service Mark P Vu Department of Anaesthesiology Vancouver Coastal Health Authority Faculty of Medicine University of British Columbia John M Tallon Department of Emergency Medicine Vancouver Coastal Health Authority Faculty of Medicine University of British Columbia

A cool case: Prehospital intravenous fluid and blood warmer in aeromedical evacuation Whistler-Blackcomb ski resort is an international ski destination with highly technical and potentially dangerous ski and snowboarding terrain in the Canadian province of British Columbia (BC). A 27-yearold male skier lost control and fell more than 60 feet (20 meters) resulting in multiple serious injuries, including a suspected closed head injury, fractured pelvis and femur. Ambient temperature at the time of the crash was -12°C, and extrication from the mountain by a specialized, helicopter and alpine rescue team took over 50 minutes. The patient was air lifted to a local medical clinic where care was transferred to BC Ambulance Critical Care Paramedics (BCAS CCPs) for inter-facility transfer to tertiary care in the city of Vancouver. Patient vital signs at this time were: pulse 117 bpm, systolic blood pressure 90 mmHg, respiratory rate 24 bpm, Glasgow Coma Score (GCS) 12, SpO2 97% on an FiO2 1.0, glucose 5.6 mmol/L, and body temperature 32.4°C. Flight time to the trauma hospital in Vancouver was 24 minutes, and total out-of-hospital time was in excess of 90 minutes.

Hypothermia is one of the contributing factors to the acute coagulopathy of trauma (ACoTS) and is a significant cause of morbidity and mortality in the trauma patient (1, 2).

The perils of hypothermia, acidosis and coagulopathy in critical care (the so called “Triangle of Death”) have long been described, however, simple corrective measures to treat hypothermia are commonly overlooked, specifically

the infusion of room-temperature crystalloid solutions, and recently thawed frozen or refrigerated blood products (3, 4). Finding effective means of administering warmed intravenous fluids (IVF) and blood products has been elusive in the out-of-hospital setting. Space and weight limitations for helicopter EMS services renders the search for an ideal product even more difficult. Most recently,

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CASE REPORT | 33 BCAS AirEvac and Critical Care Operations tested a new portable IVF and blood warming device for use in patients with massive haemorrhage and severe trauma.

Methods The British Columbia Ambulance Service’s AirEvac and Critical Care Operations (A/CCO) provides HEMS for the province of BC, covering 944,735 km2 and servicing a population of just under five million people (approximately 2.5 million in the Greater Vancouver area). The BCAS A/ CCO performs approximately 8,000 to 10,000 missions per year, via both, fixed- and rotary-winged aircraft (King Air 350, Lear 31A and Sikorsky S76C+ respectively, see also Fig. 1). Yearly average temperature lows for Vancouver and Whistler are 6.5°C and 1.1°C respectively; winter average temperature lows are a chilling 2.0°C and -4.2°C respectively.

Selection criteria for an IVF warming device for use in the aeromedical and out-of-hospital setting are strict due to operational requirements. More specifically, it is important that the device be compact, portable, lightweight, robust, avionics tested, and dependable in various environmental conditions (i.e. extremes of ambient temperature, vibration, water, altitude, and shock proof). Furthermore, it is important that we have maximal compatibility between various infusion systems to optimize efficiency of patient care and patient transfer. One main challenge we encountered in the procurement process was competing with military demands for similar products.

Results Following a comprehensive product search, the BCAS A/ COO tested a relatively new product, the General Electric (GE) enFlow® and have since incorporated it into our standard practice. The enFlow® is a compact, durable, and relatively lightweight device (see Fig. 2) that allows the rapid administration of IVF and PRBC (packed red blood cells). The version tested has a rechargeable lithium battery system option (no need for power source), allowing for a portable and versatile platform. The device weighs <4lbs, allows flow rates from KVO to 200 cc/ min, monitors and maintains the infuscate temperature at a set point of 40°C +/- 2°C. It is shock, vibration, and altitude tested to 15,000 ft (Table 1). The disposable cartridges are compatible with standard IV fluid and blood product administration sets. Finally, we found the device to be easy to store and clean after use and the disposable cartridges allowed for safe handling of IV tubing contaminated with blood products. The enFlow® consists of the following elements (see also Fig. 2): • enFlow® warmer device • enFlow® portable Li-ion Battery • enFlow® disposable cartdridge

Discussion Hypothermia is a common, potentially reversible complication in trauma patients and contributes significantly to the ACoTS and patient morbidity and mortality. Unfortunately, pre-hospital medicine is consistently plagued

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Fig. 2: Elements of the enFlow® IV Fluid/Blood Warmer System, including the portable Li-ion battery (Photographs: GE Healthcare)

by challenging operational conditions and austere environments, rendering practice at-best unpredictable, and at-worst, unforgiving. As a result, trauma patients remain at risk for hypothermia in the pre-hospital time frame particularly in those EMS systems with long transport times – as is often the case in Canada.

A review of our province’s trauma registry identified both human factors and technological factors that insufficiently addressed or propagated the morbidity associated with hypothermia and ACoTS. Though discussion on the human factors is beyond the scope of this report, we have since targeted continuing medical education activities and our crew resource management strategies to focus on the cognitive and behavioural components of our practice that could help prevent ongoing heat loss in major trauma patients or those undergoing fluid or blood product resuscitation. From a technological standpoint, in-hospital experience with warming devices does not necessarily translate into the out-of-hospital setting, as these technologies are often difficult or impractical to use in the field (5). It was imperative that we find an IVF and blood product warming device that was not so prohibitively expensive or operationally cumbersome that it would impede its storage, deployment and use in the outof-hospital environment and in confined spaces, such as the back of a helicopter or jet air-craft, in particular. Likewise, we required our device to have both stand-alone battery options and power sourcing that was adaptable for all of our surface and air ambulances.

There are many other devices on the market (4, 5, 6) that can provide portable IVF and blood product warming (e.g. Ranger, Thermal Angel, FMS 2000, Level 1 series).

Balancing cost, availability, performance characteristics and versatility, our organization has incorporated the ­enFlow® into our armamentarium to combat hypothermia in our major trauma population and those undergoing aggressive volume resuscitation. Altitude and aeromedical literature describe the drop in ambient temperature of

Conflicts BCAS has no conflicts to declare. BCAS has no financial ties to, or affiliation with, the GE enFlow® or any GE product.

34 | CASE REPORT General Specifications Warmer Controller Disposable Cartridge Weight:

Warmer

Controller

Disposable Cartridge Disposable cartridge priming volume Disposable cartridge sterility Fluid Temperature Output Flow Rate Range Input Voltage Temperature Set Point Input Current

13 × 6 × 3 cm 23 × 15 × 9 cm 11 × 4 × 1 cm (w/o disposable): 275 g 1.6 kg 35 g 4 mL Gamma Sterilized 40°C ± 2°C KVO to 200 mL/min Warmer: 28 VDC at a maximum of 300 Watts Controller: 110-120 or 220-240 VAC 47 - 63 Hz 40°C 5A

Environmental/Physical Requirements Temperature, Operating Temperature, Storage Relative Humidity, Operating and Storage

-5°C to 50°C -30°C to 70°C Warmer: 10% to 90% Controller: 10% to 100% Disposable Cartridge: 10% to 90%

Altitude, Operating and Storage Air Pressure, Operating and Storage

Up to 4,572 m 570 hPa to 1,060 hPa

Compliance with Standards Water Resistance Shock/Drop Abuse Tolerance Vibration Electromagnetic Emissions Electromagnetic Immunity Magnetic Field Immunity Electrostatic Discharge

Warmer: IEC 529 IPX7 30 minutes immersion at a depth of 91.4 cm (36 in.) Controller: IEC 529 IPX1 dripping water Disposable Cartridge: IEC 529 IPX8 continuous immersion MIL-STD-810F MIL-STD-810F CISPR11 Group 1 Class A IEC61000-4-3 Level 3, 10 V/M IEC61000-4-8 Level 2, 3 A/M IEC61000-4-2 Level 4, 8 kV Contact, 15 kV Air

Safety Classifications Type of protection against electrical shock Degree of protection against electric shock Mode of operation Table 1: Modified from enFlow IV Fluid/Blood Warmer System (GE Healthcare Specification Sheet 2011)

Fig. 3: The cabin of the helicopter (Sikorsky 76C+) was heated to maximal capacity, the patient wrapped to prevent ongoing heat loss, an external warming blanket was applied, and the IVF and PRBC were administered via the enFlow® warming device (Photograph: Cpt. G. Burkholder)

Class I or Internally Powered Type BF, Defibrillation-Proof Continuous

2°C for every rise in 1,000 ft (305 m) in the troposphere (7). Even during summer months in British Columbia, it is not uncommon to be responding or flying in inclement weather conditions in sub-zero temperatures. Accordingly, the use of an IVF and blood product warming device reflects an awareness of the environment in which we work, beyond the standard challenges we face with patient exposure, cool IVF and cold blood products.

Furthermore, our working environment is relatively mild compared to some of our neighbouring provinces and many other parts of the world. As such, the main

goal of this case report is not to report on any science or theory that is new to prehospital emergency care per se, but as a focus on knowledge translation and a sharing of experience. Our hope is that the challenges we faced with this case report – combined with the success we have described with this device – will stimulate other EMS agencies to review both human and technological factors that may help in the management of major trauma patients or bleeding patients whose condition is exacerbated by hypothermia.

Case Conclusion Following initiation of transportation, BCAS CCP flight crew continued in-flight resuscitation with another 1 l of Plasma-Lyte® and two units of PRBCs provided by the local clinic. The cabin of the helicopter (Sikorsky 76C+) was heated to maximal capacity despite creating a potentially uncomfortable ambient working environment for the CCPs, the patient was wrapped to prevent ongoing heat loss, an external warming blanket was applied, and the IVF and PRBC were administered via the enFlow® warming device. Despite the awareness of ambient subzero temperatures and documented patient hypothermia, and despite our CCPs best efforts to prevent further heat loss and provide heat, the patient arrived at Vancouver General Hospital with a core temperature of 34.2°C. Vital signs remained relatively unchanged, with a pulse of 107, systolic blood pressure of 100 mmHg, SpO2 of 98%, and a GCS of 13. Patient’s admission haemoglobin was 93 g/L after a total of two units of PRBCs and his admission INR was 1.6. He was subsequently diagnosed with minor traumatic brain injury (concussion), multiple un-displaced rib fractures, unstable pelvic fracture (Tile Class C1) and a comminuted femoral shaft fracture. The patient was urgently transferred to the operating room where he received a massive transfusion (19 units PRBC, 14 units FFP, 10 units of cryoprecipitate) for the management of his haemorrhagic shock and ACoTS. Following this aggressive resuscitation, trauma and orthopaedic intervention, and a brief admission to the intensive care unit, the patient was eventually transferred to a step-down unit for ongoing recovery and rehabilitation.

Conclusion Major trauma and haemorrhagic shock are often complicated by administration of cold blood products and intravenous fluids. Strategies to mitigate coagulopathy, acidosis, and hypothermia have been identified as priorities in these clinical settings. There are few technologies available for the out-of-hospital warming of IVF and blood products. We have recently tested a device that meets our requirements for being compact, portable, durable, lightweight and operationally sound. This device is a valuable tool in prehospital emergency care and critical care transport to mitigate effects of cold IVF and blood products in the setting of haemorrhagic shock and acute coagulopathy of trauma shock.  For references, please visit:

››› www.airrescue-magazine.eu

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36 | MEDICAL CARE

Icefall climbing: ATE’s HEMS on a joint mission The crews of the Air-Transport Europe’s (ATE) Helicopter Emergency Medical Service perform missions in the mountains – mostly when tourists and skiers are injured. Injuries of mountain climbers are quite frequent as well. These incidents commonly require cooperation with the Mountain Rescue Service and the usage of technical aids. In case the ATE air rescuers are called to injury of an icefall climber, it is a unique mission. And exactly such a mission was completed successfully by the ATE crew and the Mountain Rescue Service in the “Bielovodska dolina” Valley in the High Tatras on February 17, 2013.

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CASE REPORT | 37 Icefall climbing is a discipline that requires quite a lot of experience and knowledge, as climbing unstable ice shapes and cascades is a risky way of carrying out this sport. In the “Bielovodska dolina“ Valley in the High Tatras there are also several icefalls. One of them, the so called “Air Ice”, is almost reaching down to the foot of the mountains. Some climbers have been waiting for a unique opportunity to be the first climbers on “Air Ice”, among them was also a group of experienced Slovak mountain climbers. For several days they were watching how the ice cascade was growing “drop by drop” down to the ground.

After thorough preparation and icefall mapping, the decision was made to conquer it on Sunday, February 17, 2013. The 41-year-old mountain climber, with more than 26 years of experience in climbing, explained the preparations prior to the tour: “It was necessary to tune ourselves in – mentally and physically – for this challenge and to check what the condition of the ‘Air Ice’ was like.

Four days prior to the planned task, I had climbed the ‘roof’ of an ice cave that creates the connection to the ‘Air Ice’. I put a strain on the critical spot and tested the ice stability by feet. Everything looked good and promising so that we should succeed. New challenges always motivated me. Once it gets warm, the ice fall starts disappearing and then you start asking yourself – will there be another chance? And if so; when?“ However, the plans for conquering the Air Ice didn’t turn out well.

On Sunday morning a group of three climbers took off to the High Tatras – the first climber, his friend, who was safeguarding him, and a cameraman. The first climber describes how he entered the ice: “I carefully cut a hole into the ice in waist height in order to put my foot in. Then, very carefully, I scraped little holes into the ice above my head. With a strange feeling I slowly latched myself on to a rather fragile spike of a giant icefall. Looking at emerging points of axe and crampons, I mustered the courage for another step. In snail-like pace I was getting closer to the dangerous zone. I sensed feelings of excitement and alertness ... The thicker the ice surface, the better the feeling of safety. Great, I can feel my helmet scratching the roof, I am going to make it! Now I just have to traverse to the edge and vault over to the edging ...“ Following this, the climber does not remember the subsequent seconds. Ice blocks along with the climber broke off from about 20-meter-height. The climber was very lucky that he wasn’t buried alive under the huge chunks of ice. The climber fell into steep terrain where there was about a meter of snow that dampened his fall.

Following the first crash, the ice block shattered into smaller pieces, and luckily none of these injured the climber. His friends with the Mountain Rescue Service’s (MRS) number on hand, immediately called the MRS. As the weather conditions were good, the mountain rescuers called ATE HEMS in for assistance. “We knew the terrain was difficult as well as possible injuries, but we had no idea what to expect in detail. Once we took off from ATE HEMS base at Poprad, we picked up two members of the Mountain Rescue Service and together we set out to the scene of the accident. After checking the terrain we were winched down to the spot where we treated the injured

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climber and loaded him into an evacuation bag. As the injured climber was very close to the rock, we could not evacuate him directly from this spot.

The Mountain Rescue Service members prepared a new catching tool and then we lowered the injured man about 20 meters down. From there he was evacuated along with me from the terrain by hoist. After intermediate landing and loading the climber on board of the helicopter, the injured climber was transported to Poprad Hospital.

Considering the seriousness of accident the patient was very lucky as he didn’t suffer from life endangering injuries, but he had numerous abrasions, lacerations and in the hospital a broken pelvis was diagnosed“, said Marek Rigda, ATE HEMS doctor on this mission.

Following his fall, the climber was conscious and remembered his friends and other climbers, who watched the incident and rushed to assist him. “They covered me with a foil, put rucksacks underneath me and took off my crampons. There is one thing I remember very well; when I heard the helicopter coming, I felt a great relieve, and when I saw it, I was very confident that all would end well. The rescuers were trying to find out what injuries I had, they put me into an evacuation bag and transported me – accompanied by a doctor – to the hospital by helicopter. All of them were very friendly and supportive that I could cope with the consequences of my fall. I want to express my sincere thanks to all of them.“ “When doing icefall climbing, you can be experienced and skilful, that is you know the tools, and you can have perfect equipment, but you cannot eliminate certain risks. The main risk lies in the fact that ice has its structure, including bubbles that one cannot see by looking at the surface, one cannot really scan each millimeter and analyze the ice’s complete structure of the ice. This was the major factor contributing to the climber’s fall”, said HEMS doctor Rigda.

Three months have passed since the accident and the young man feels very well, he has begun to walk after two months and now he starts training and doing sports again. “Today I am almost fit. I was really very lucky”, the climber assesses. 

Fig. 1: As the weather conditions were good, the mountain rescuers called ATE HEMS in for assistance (Photographs: ATE)

Author: Zuzana Turocˇeková Air-Transport Europe Poprad-Tatry Airport 058 98 Poprad, Slovakia turocekova@ate.sk

38 | TECHNOLOGY

Eurocopter quality assurance – testing components made of fibre-reinforced materials

Author: Julia Sailer Corporate Communications Eurocopter

Fig.1: The rotor blades of the EC135, for example, are made of glass fibre-reinforced plastic (GFRP) (Photographs: Eurocopter)

Light, robust, heavy duty – for quite a few years now, the benefits of fibre-reinforced materials have also been utilised in many areas of the helicopter construction industry. As the materials continue to be developed, further progress is also being made in the area of quality assurance. Non-destructive testing methods are continuously being applied to check the functionality and safety of the components. At Eurocopter, the world’s leading manufacturer of civil helicopters – with a market share of more than fifty per cent – these processes follow the helicopter through every step of its life cycle, from its development through to its production, overhaul and maintenance. For instance, Eurocopter uses fibre-reinforced plastics in helicopter airframes and in rotor blade production.

The helicopter manufacturer makes the rotor blades of the EC135, a well-known helicopter used for EMS and law enforcement, out of glass fibre-reinforced plastics (GFRP) and the airframe of the NH90 transport helicopter out of carbon fibre-reinforced plastics (CFRP). CFRP materials also play an important part in the development and production of aircraft doors, which is Eurocopter’s second line of business in Germany.

These high-performance fibre composites place very high demands on non-destructive testing methods in

quality assurance. Even the smallest of errors can greatly affect the strength of the components. In order to identify potential weak points at an early stage, Eurocopter applies the most up-to-date testing methods, such as computer tomography (CT) and various ultrasonic testing methods.

The choice of method is based on the materials used, and on the design and size of the components.

CT is an important non-destructive testing method that forms part of Eurocopter’s quality assurance process. It was being used in helicopter component testing as

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TECHNOLOGY | 39 early as the late 1970s, in order to detect cracks and to perform fatigue tests on GFRP rotor blades. Since 1993, Eurocopter has also been using CT for quality assurance purposes in serial production, e.g. for EC135 rotor blades.

This helps ensure the quality and service live of the components. At its site in Donauwörth, Germany, Eurocopter operates a medical CT scanner, which is used to test over 3,000 components every year.

Using computer tomography for quality assurance

Fig. 2: Computed tomography is an important non-destructive testing method in Eurocopter’s quality assurance process

us to implement new fibre-composite designs. Eurocopter therefore applies an all-encompassing approach, which constantly makes material testing part of the quality assurance process, from the design of new components and tools through to serial production checks, maintenance and repair. 

Photo Air Zermatt

Conventional ultrasound is used to test the large CFRP airframe components in the NH90 and Tiger military helicopters as well as the CFRP passenger doors on the A350 XWB airbus. The main challenge is to automate the tests at times of increased production. To this end, Eurocopter uses a series of ultrasonic sensors, which are guided by robots along the complex structures. Eurocopter’s innovation is to use air-coupled ultrasonic testing technology to test the sandwich tail rotor booms. The ultrasonic testing and medical computed tomography are supplemented by high-resolution micro CT testing methods, which are mainly used to optimise processes in the production of prototype components and to validate the ultrasonic testing results.

It is still a long way to go from realising the full potential offered by non-destructive material testing methods.

The development of testing methods goes hand in hand with the development of new products and can also help

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40 | TECHNOLOGY

Fig. 1: Gino Elia, one of P&WC’s many talented and driven assembly line technicians, hard at work on a PW200 engine (Photograph: P&WC)

Pratt & Whitney Canada: 40+ years of leadership in helicopter engines Part of United Technologies Corporation – with Pratt & Whitney headquartered in Hartford, Connecticut, USA – Pratt & Whitney Canada (P&WC), located in Longueuil, Quebec, celebrates its 85th anniversary this year. For the past 50 years, it has been a world leader in the design, manufacture and maintenance of gas turbine engines, known for their reliability, cost-effective operating metrics and environmental performance. P&WC has grown from its modest beginnings near Montreal, Quebec, to become a world leader with operations around the globe.

P&WC in HEMS

Author: Nicolas Chabée General Manager Helicopter Programs Customer Service Pratt & Whitney Canada

Given the great diversity of HEMS operations in Europe and around the globe, the 1st AgustaWestland EMS Seminar, held in Vatican City last summer (see also AirRescue Magazine 1/2013), was an excellent opportunity for P&WC to join with international HEMS experts in order to examine some of the unique challenges and opportunities in what is a complex and multi-disciplinary industry.

The PT6T twin engine, still popular today with helicopter operators around the world, was P&WC’s first engine to enter the helicopter market in the early 1970s.

This engine is based on the company’s first gas turbine engine, the PT6A, which is used in single and twinengine configurations aboard turboprop aircraft. Later helicopter engines, the PT6B and PT6C specifically, were also based on that original design and offer varying levels of shaft horse power (SHP).

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TECHNOLOGY | 41 New levels of performance The PT6 engine family is celebrating its 50th anniversary this year. This is one remarkable piece of propulsion technology. It has been used on more than 130 different types of aircraft. Over 50,000 PT6 engines have been manufactured, each new generation incorporating the latest technological advances in combustion efficiency, metals and alloys, environmental performance and controls. But what makes the PT6 exceptional, is its body of work. PT6 engines have accumulated nearly 400 million hours of flight, a record unparalleled in the industry. That flying experience has allowed P&WC engineers to build new levels of performance and reliability into the engine.

47 million hours flying time In the 1990s, Pratt & Whitney Canada introduced a new family of turboshaft engines, the PW200 light twin series.

This engine family has also proven very popular and has helped triple the number of helicopter engines delivered annually in the course of the past decade. This year, the newest family of helicopter engines, the PW210, will enter into service. Over the past 40 years, the manufacturer delivered well more than 14,000 helicopter engines that have combined flying time of 47 million hours.

A good portion of P&WC’s success in expanding the turboshaft engine portfolio is attributable to the global expansion of HEMS. In fact, more than 50% of its turboshaft engine applications are on helicopters that are routinely used for HEMS applications. While the business models for HEMS vary from country to country, the technical requirements of operators remain much the same.

P&WC has worked diligently to understand those needs and to adapt the products accordingly and developed strong business relationships with some of the largest HEMS operators in the world. Four of the manufacturer’s top HEMS operators – three located in the United States and one in Germany – account for more than 550,000 accumulated engine flight hours on P&WC products.

HEMS challenges P&WC’s commitment is to provide the HEMS industry with safe, easy to operate and effective engines. Surely, HEMS missions cannot really be planned and almost always mean flying in difficult conditions where everyone on board is expected to multitask. The modern engines are designed to minimize pilot workload. They have advanced features such as auto start, limit protections that eliminate the need for constant gauge monitoring, and automatic OEI (one engine inoperative) exceedances monitoring. The engines have greater reliability, providing for outstanding dispatch availability. Furthermore, they have rapid takeoff capability, allowing the operator to maximize time in a setting where every second counts. The Canadian manufacturer also provides computer-based diagnostics and prognostics data management. Engine performance data can be gathered and downloaded after every flight giving the ability to forecast maintenance events and plan accordingly.

Cost is always a concern and certainly fuel costs are at the top of every HEMS operator’s agenda. P&WC en-

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gines provide excellent fuel burn metrics, also offering automatic cycle counting, which recognizes fractional cycles, thus extending the life of cycle-limited parts.

P&WC Customer Service In an industry where dispatch availability is a critical factor, engine maintenance for a HEMS operator is a constant priority. P&WC offers a far-reaching customer service organization: Operations are organized around customers’ needs and their locations to create a unique service capability that responds 24/7/365 – virtually anywhere in the world.

There are 30 owned and designated repair and overhaul facilities located around the globe. When it comes to consulting with its customers, P&WC has approximately 100 Field Support Representatives (FSRs), engine experts, who are always available to assist customers with their individual needs. And there are 100 strategically located mobile repair team technicians, which can be onsite anywhere in the world in eight hours, an industry benchmark. P&WC believes that by providing its customers with effective customer service solutions – based on reliability, maintainability and capability – it is also possible for the operators to create incremental value in their HEMS ops.

Since many HEMS operators have a single aircraft, “aircraft on ground” (AOG) situations mean the job is not getting done. P&WC’s customer service network is highly responsive: Its CFirst customer response centre operates around the clock from the company’s headquarters in Longueuil, Quebec. CFirst is staffed with AOG experts whose focus is to get the aircraft back in service. In

Fig. 2: Four of the manufacturer’s top HEMS operators – three located in the US and one in Germany – account for more than 550,000 accumulated engine flight hours on P&WC products (Photograph: DRF Air Rescue)

42 | TECHNOLOGY

Fig. 3: The first in the PW210 engine family, the PW210S, will power the Sikorsky S-76D helicopter (Photograph: P&WC)

Fig. 4: When an agreement is signed, a P&WC FMP® Customer Manager is appointed to provide all the essential coordination and support required to ensure customer satisfaction (Photograph: P&WC)

2012, a second CFirst centre was opened in Singapore to better serve local customers, often in the language of their choice. Both centres are fully integrated.

There are seven parts distribution centres that can deliver parts anywhere in the world within 12 hours.

With more than 800 rental and exchange engines in the manufacturer’s inventory, it has the largest available P&WC engine pool in the industry. A rental engine can be dispatched in hours to get the aircraft back in service.

Cooperation with FlightSafety International A key element of the suite of customer service solutions is training. Through an agreement with FlightSafety International, P&WC offers training courses on all of the engine families. FlightSafety International has 12 locations

around the globe. These courses are also offered online on a self-paced basis and the latest in 3-D and animation technologies are employed. These courses are highly cost effective for operators. Since partnering with FlightSafety in May 2010, the volume of training on turboshaft engines has doubled.

Furthermore, P&WC offers pay-per-hour (PPH) engine maintenance programs that have proven quite popular with HEMS operators for whom the ability to accurately budget for maintenance costs greatly augments the business case. The Eagle Service™ Plan (ESP ® program) offers P&WC engine operators a complete range of maintenance coverage, depending on the level selected. Basic coverage includes parts and shop labour for scheduled engine overall, refurbishment and hot section inspection, basic unscheduled engine and line replaceable unit (LRU) accessory maintenance, and required product support improvements at shop visits. Other benefits include rental engine support for covered events, Engine Condition Trend Monitoring (ECTM), and an allowance for trouble shooting.

P&WC also offers Fleet Maintenance™ Programs (FMP) that allow customers to focus on their core business and eliminate the overhead and logistical issues associated with operating a maintenance facility. When an agreement is signed, a P&WC FMP ® customer manager is appointed to provide all the essential coordination and support required to ensure customer satisfaction.

Coverage under a P&WC FMP ® can be tailored to meet an individual operator’s requirements, based on the nature and mission of the fleet. All of the PPH engine maintenance programs offer peace of mind to operators who know maintenance and repair costs are established up front with no surprises.

New Engine Developments The PW210 engine family is powering a new era in the 1,000 SHP twin class. The first in the engine family, the

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PW210S, will power the Sikorsky S-76D helicopter. The engine received Transport Canada certification in October 2011, followed by FAA validation in December of that year and is expected to enter into service this year. The PW210A has been selected by AgustaWestland to power its AW169 helicopter. Certification for the engine is expected in 2013, with aircraft certification in 2014. The PW210A is now in full development. The PW210E, a third iteration of the engine, has been selected by Eurocopter to power its new X4 helicopter.

All three of these PW210-powered helicopters are capable of meeting HEMS requirements. The aircraft will all benefit from the engine’s light weight, compact size, full digital controls (FADEC), rapid take-off capability, highest power-to-weight ratio and the lowest fuel burn.

Focus on Sustainability Environmental performance has long been a priority for P&WC and for all of the companies in the UTC family. In 2006 UTC set some ambitious environmental performance targets to be achieved by 2010. The targets included a 20% reduction in non-CO2 greenhouse gas emissions and a 12% reduction in greenhouse gases (CO2 equivalent). By 2010, UTC had reduced non-CO2 greenhouse gas emissions by 66% and greenhouse gases by 23% – significantly beyond the original targets.

As an individual company, P&WC has set some equally ambitious targets to be achieved over the next 15 years in time for its 100th birthday. For the engines, those targets include 50% less fleet combustion emissions, 75% less engine oil consumption and a 10-decibel reduction in perceived noise. The manufacturer also takes a holistic approach to the life cycle footprint. It starts with materials and energy required to create the engine parts, to the way in which the engines are manufactured, shipped, used by the customers, maintained and finally disposed of/recycled at the end of their lives.

In the development of new engines – the PW210 turboshaft, the next generation turboprop for the regional airline market, and the PW800 turbofan for the business aviation market – P&WC is using new tools and materials to help make them lighter and more fuel efficient. These new tools allow to use less materials in manufacturing the parts and the new alloys can withstand higher temperatures, thus increasing the engine’s efficiency.

Serving the HEMS Industry The manufacturer’s ability to serve the international HEMS community is based on its long-term investments in new engine development, its efforts in building a global customer service network and the development of a life-cycle management framework to enable sustainable development. Understanding the needs of the HEMS industry and developing products and services that cater to those needs is a priority for P&WC. By building solid business relationships the Canadian manufacturer wants to help HEMS expand around the world in an efficient and cost effective manner while advancing medical mobile technology and the vital services it enables. 

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44 | Research

Fig. 1: It will be analysed if airborne primary rescue can be implemented as an alternative to landbased EMS (Photograph: ADAC Air Rescue)

Joint research project PrimAIR: Concept for a primary air rescue system in structurally weaker regions Authors: Gregor Ruso Research Associate Institute of Rescue Engineering and Civil Protection Cologne University of Applied Sciences Ruth Winter Research Associate Institute of Rescue Engineering and Civil Protection Cologne University of Applied Sciences & PrimAIR consortium members*

Due to demographic and structural changes, adequate medical care is becoming more and more difficult in sparsely populated areas. Cost pressure on the entire health care system also leads to centralization of hospitals and planning of specialist clinics. This change in clinic infrastructure is a challenge for pre-hospital emergency care, as hospitals are at the end of the rescue chain. Rescue helicopters have only been used as an addition to land-based EMS to get emergency physicians to the scene of an accident quickly and also to take patients to a clinic under intensive medical care as soon as possible. As a new approach, it will be analysed if airborne primary rescue can be implemented as an alternative to land-based EMS. As a consequence, air ambulances could cover larger areas and take patients directly to the appropriate hospital. The PrimAIR research project will analyse the potentials, limits and requirements of an airborne system of primary rescue.

Project background Obtaining fast and professional help in regions with low population densities and poorly developed medical infrastructure is difficult due to a suboptimal relation between hold-back time needed to provide aid in the prescribed period and the occupancy rate of rescue resources.

In principle, emergency medical services are landbased. Today air rescue mainly plays a supportive role

in Germany (e.g. 搂 3 I of the Law on Rescue Services of Mecklenburg-Western Pomerania) and is predominantly used as fast means of transport for EMS doctors and/ or patients. This results in planning-related and financial redundancy. Especially the capacities of air rescue are not completely utilized thereby (1). Area-wide medical care requires a high number of ambulance stations causing high costs per operation due to a low frequency of calls

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Research | 45 (2), whereby cost-effective provision becomes more and more difficult. Furthermore, EMS crews lack the necessary routine. Additionally, an increasing specialisation of hospitals can be observed (3), thus the patient’s way to the next suitable hospital becomes longer and adequate clinical care is delayed.

Demographic changes further exacerbate the problems mentioned above: The population density in rural areas decreases by forming agglomerations (4) and by the prevalent birth deficit, thus, the rural coverage area of EMS and hospitals has less and less potential patients.

Project aim Aim of the PrimAIR project is the development of an innovative model for EMS in sparsely populated, structurally weak regions. The developed concept shall ensure emergency medical care in a time frame that is oriented towards emergency medical demands. Furthermore the concept must take into consideration cost-effectiveness under defined framework conditions.

PrimAIR intends to shift EMS from the ground to the AIR by substituting ground ambulances with helicopters in order to create an EMS system that is exclusively based on air rescue. Due to the higher cruising speed of helicopters, this innovative concept will allow for extension of coverage areas and thus the centralisation of ambulance stations. Consequently, manpower and rescue resources can be deployed more efficiently. The new challenges will also increase the crews’ motivation and routine. Furthermore, patients can be transported directly and more quickly to a hospital that is appropriate for their pattern of injury, due to the much higher velocity of the helicopters.

Therefore, the number of secondary transports will be reduced as well. The principle is shown in Fig. 2.

Initially the determining factors of EMS were identified in the course of the project. This includes the exact demographic and infrastructural conditions under which the implementation of the new model is feasible. Legal and technical developments, which are inadequate up to now, have to be considered as well. PrimAIR aims at identifying and defining the respective demands needed for these considerations.

PrimAIR is using the example of the German federal state of Mecklenburg-Western Pomerania that provides a practical orientation for the project design. Findings gained in this model region will be standardised and published as a code of best practice. The project will thereby provide a tool enabling policy makers to adapt its results to similar regions. PrimAIR is sponsored by the Federal Ministry of Education and Research. Project management agency is the VDI Technologiezentrum GmbH (part of the Association of German Engineers, VDI).

Project status As a basis for the system developments, a status quo analysis is conducted in the following areas: • Structure of (regional) EMS (call-response patterns and structure of those facilities receiving and treating patients);

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• Demographic data (collection and analysis of data that may have an impact on EMS); • Legal framework conditions; • Meteorological and geographical influences on air rescue; • Existing systems in other countries and a possible adaptation and integration of specific elements into PrimAIR (interviews are conducted with representatives of different operators).

In the course of the previous project work, various challenges were identified. These include for example that helicopters so far cannot be deployed under all weather conditions, thus technical compensation measures or redundancy systems have to be developed for certain outage scenarios.

As helicopters cannot land everywhere, another challenge is to transport crews from the landing site to the incident scene quickly, if landing close to the scene of emergency is not possible. The same applies when the patient is carried to the helicopter for transport. The current results indicate that implementing a system that rests upon primary air rescue requires comprehensive adaptions of the statutory provisions. Due to frequent lift-offs and landings, changes in the existing infrastructure will become necessary as well, especially with respect to hospital landing sites and rescue stations.

Prospects and proceeding In the months ahead, the consortium will develop solutions for the challenges described above. Caused by the change of the EMS system and the resulting change of the rescue stations infrastructure, a comprehensive demandbased planning becomes necessary. Thereby greater incidents – such as mass casualty incidents – have to be considered as well. The new concept will also have to consider, identify and evaluate fundamental financial changes and directly compare the systems of land-based rescue and air rescue. Furthermore, the socio-economic consequences of the developed system will be identified.

Fig. 2: Routes of transportation (PrimAIR)

46 | Research providers of EMS on the other hand. The result of the project will form the scientific basis for implementation by levels of government.

Project partners and network

Fig. 3: Demographic changes further exacerbate the problems: population density in rural areas decreases (DRF Air Rescue)

Fig. 4: Patients can be transported more quickly and directly to a hospital that is appropriate for their pattern of injury

The technical requirements of the new concept will be examined, especially focusing on the demands of the existing helicopter models. Important questions to be addressed in this context are for example the possibilities of flying and landing in zero-zero conditions and the deicing capability of small aircraft. The treatment of patients has to be completely possible aboard the helicopter, if necessary even in flight. The cabin has to have appropriate dimensions, whereby attention should be paid to ergonomic aspects as well.

If the future concept of primary air rescue proves to be feasible, it will be summed up in a code of best practice.

It will be available to decision makers, who will have the possibility to check if implementing it in the area of their responsibility would be beneficial. The project will thereby take into consideration the balance between the citizens’ entitlement to the provision of medical services on the one and the necessary economic considerations of the

The partners of the PrimAIR consortium come from various scientific and practical disciplines. Besides scientific institutions specialised in emergency preparedness and response, organisations and stakeholders of the planned system are involved. Hereby scientifically validated results are ensured as well as practical relevance and acceptance of the developments.

Project coordinator is antwortING consulting company, focussing on demand-based resource planning and allocation solutions as well as consulting services for the emergency management sector, public bodies and the industry, offering support for personnel, organizational and conceptual challenges.

Fraunhofer Institute for Transportation and Infrastructure Systems (IVI) supports experts of emergency response with its software “MobiKat” which provides situational awareness as well as optimised planning of resources and infrastructure. With the aid of these experiences, IVI carries out simulations and analyses of the prospective changes that may be identified through PrimAIR. The Asklepios Hospital Group in Hamburg (Germany) is a private hospital operator. Its in-house Institute for Emergency Medicine is actively involved in designing efficient and process optimised structures. With its focus on the interface of pre-hospital and hospital settings, the institute is a very important partner of the consortium.

The Institute for Emergency Medicine and Management in Medicine (INM), University Hospital of Munich, deals with demand-based planning in the field of air rescue. The time factor and the necessity of an expansion of air rescue are of priority here. INM contributes its insights gained from its research and medical experience to PrimAIR. Third scientific partner is the Institute of Rescue Engineering and Civil Protection (IRG) of Cologne University of Applied Sciences. IRG conducts, among other things, comparative studies between different EMS concepts. The aim is to identify overriding principles that such different concepts may have in common and subsequently optimise the choice of a system. PrimAIR is also based on that systematic approach.

The research project is supported by associated partners from different fields, providing essential advice on the research: From the field of HEMS operations and air rescue, ADAC Air Rescue, German Federal Police’s flying squadron and DRF Air Rescue are also part of the consortium. AOK Nordost, a statutory health insurance fund, the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Ministry of Labour, Equality and Social Affairs of the federal state of Mecklenburg-Western Pomerania are supplying substantial data and information and deal with political and financial aspects of the project.

Emergency rescue and its framework conditions are key aspects of the project. Though effects on other fields

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Research | 47 of medical care (such as physician’s standby duties or inner-hospital structures) cannot be excluded from research in general, they are not part of this project’s examinations.

PrimAIR will however touch upon the interfaces of these areas (technical details for example are covered by other research projects as well).

Therefore many cross-cutting activities with other project-groups are promoted in PrimAIR. Examples are the projects ALLFlight, ROW and Stroke/Cardio Angel.

The project ALLFlight of the German Aerospace Center (DLR) is concerned with assistance systems for low level flight and landing of helicopters, while the research project Rescue Chain Offshore Wind (ROW), conducted by a research team at the BG Trauma Hospital Hamburg, examines the special difficulties of HEMS in offshorewind farms (see also AirRescue Magazine 3/2012). The projects Stroke and Cardio Angel of the Center for telemedicine Bad Kissingen aim at optimising the interface between EMS and hospital. This project will also contribute to a further extension and optimisation of air rescue and add to the PrimAIR research project as well. The same applies for the GNSS Low Flight Network developed by the Swiss Air-Rescue Rega and their application of the point in space procedure. PrimAIR is furthermore supported by the European HEMS and Air Ambulance Committee (EHAC), which established contacts to air rescue operators from various other European countries. 

References: 1. Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München (2009) Bedarfsanalyse zur Luftrettung in Bayern. Available online: http://www.stmi. bayern.de/imperia/md/content/stmi/sicherheit/rettungswesen2/publikationen/andere/bedarfsanalyse_luftrettung_inm_11_2009.pdf: p. 27. Last accessed: 4/06/2013.

2. Büch E, Koch B (1998) Wirtschaftlichkeit im Rettungsdienst: Effekte unterschiedlicher Organisationsmodelle; Kennzahlen für Leistungs- und Kostenvergleiche. Vol. 18. Schriftenreihe zum Rettungswesen. Verl.- und Vertriebsges. des DRK, Nottuln: 28-29 3. Bundesinstitut für Bau-, Stadt- und Raumforschung (2012) Raumordnungsbericht 2011. Bonn: 47-50 4. Bundesinstitut für Bevölkerungsforschung (2012). Binnenwanderungen in Deutschland. Wiesbaden. Available online: http://www.bib-demografie.de/DE/ZahlenundFakten/ Wanderungen/Abbildungen/binnenwanderung.html. Last accessed 04/02/2013. * Representatives of the consortium members that also contributed to this article, are: - Benjamin Käser & Benedikt Weber, antwortING consulting company - Patrick Brausewetter, Kamen Danowski & Burkhard Rammé, Fraunhofer Institute for Transportation and Infrastructure Systems - Daniel Galitzien, Hartwig Marung, Heinzpeter Moecke & Stefan Oppermann, Asklepios Hospital Group - Andreas Birk, Christian Gehring, Stefan Groß, Julian Kerth & Eva Wanka, Institute for Emergency Medicine and Management in Medicine, University Hospital of Munich - Marco Klier, Ulrike Pohl-Meuthen & Sylvia Schäfer, Institute of Rescue Engineering and Civil Protection, Cologne University of Applied Sciences - Marcus Daniels, ADAC Air Rescue - Torsten Pfeil, German Federal Police’s flying squadron - Daniel Eichler & Ernst Peleikis, DRF Air Rescue - Silvia Danke, AOK health insurance

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0 | IN PROFILE

Bond’s Jigsaw SAR: Medicine in extreme offshore conditions Pre-hospital care comes in many guises and is one of the most exciting areas of current medicine: Search and Rescue (SAR) is one such „sub-field“. Whether dealing with a medical evacuation, man overboard or the evacuation of an offshore platform, the work SAR teams do can really make the difference. Increased demands are being placed on the teams who provide this vital service, and its development is an important factor in delivering even better patient care. This article discusses the work of Bond‘s SAR teams today and looks at what the future holds for them.

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IN PROFILE | 49 Being part of a pre-hospital team In the clinical areas of SAR and land ambulances, response teams are doing all they can to save lives. A terrifying ordeal or horrific accident comes without warning at any time of the day or night. With lives at risk, the rescue and pre-hospital care teams need to work fast and in harmony with each other. Everyone has to be clear about their role, with multi-agency teams working seamlessly together. Each situation is unique and may present real dangers – not just for the patient but also for the medics, helicopter crew or land-based pre-hospital team.

Helicopter and pre-hospital care medical teams are needed in a wide variety of challenging situations.

Whether dealing with a ditched crew-change helicopter, medical evacuation, man overboard or the evacuation of an offshore platform, the work these teams do, can make the difference between life and death. Equally, land-based pre-hospital provision may be called to deal with anything from a newborn that is not breathing, to a 90 year old with cardiac problems and a complex medical history, a major incident with multiple casualties, or a serious injury following a trauma. Each situation needs to be assessed and the risks and benefits of every action carefully judged.

On one hand, the teams need to consider the patient who may have a severe injury or life-threatening illness, and judge whether the best outcome would result from the rapid clinical intervention provided by a “999” ambulance or a rotary SAR asset. On the other, they need to assess any risk to the responders who are required to work in often hazardous environments, such as dangerously bad weather conditions and other logistic constraints.

The SAR environment Land ambulances are becoming more and more focused on triage and treatment, and aim to provide transport only when it is really needed. This is a significant change from the established historic role as “transport” focused organizations and relies upon clinical competent decision-making. It does, however, hold out the prospect of improved patient care at a lower cost with unnecessary patient transportations to emergency departments increasingly being avoided.

The nature of the work done by SAR assets is necessarily different. In remote locations such as oil rigs in the North Sea, patients are almost always transported to hospital, even if their clinical condition is not as severe as initially thought when the emergency call was made. There are many examples of patients being taken to hospital who would not have been transferred to definitive care if their injury or illness had occurred on land, but SAR assets almost always transport away from the scene. This highlights the value of patient systems which offer support methods prior to the deployment of a helicopter; with effective telemedicine and triage working to minimise unnecessary call-outs and ensure more appropriate deployment of an expensive asset in what is often a high-risk role.

The nature of the SAR environment means an emphasis on transport as well as triage and treatment. Over recent years however, there has been a marked improvement in the amount of care that can be delivered en-

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route, with the teams’ skills, competencies, equipment and medications now resembling those seen in Accident and Emergency Departments, or even in Intensive Care.

Skills and operational models When there is a rescue situation, multidisciplinary and multi-agency elements are involved in the process. There are differences and similarities in the technical and nontechnical skills required to improve patient outcome between land and helicopter operations, but lessons can be learned from both. Primary retrieval gets the patient from the place of incident to a place of safety and more definitive care. Secondary or tertiary retrieval or transfer takes patients from a place of safety to more definitive care, but may still require provision of intensive care during transit to keep them stable. Can individuals attain and maintain the ideal of all of the skill sets required for primary and secondary or tertiary retrieval or transfer? This scope of practice requires all of the components in the paramedic curriculum framework, as well as additional elements including navigation, communications, principles of flight and aeromedicine – including the practicalities surrounding the treatment of patients in the confined space of an aircraft cabin. This multi-skill concept, along with the resources and requirements of a service and the type of Air Operator Certificate (AOC) needed, can be further explored while looking at the differences between SAR, HEMS and MedEvac roles. These all provide different functions, but the clinical parameters discriminating between them are not always clear and an individual service may regularly be asked to fulfil elements from across these differing roles.

Conceivably such a multi-skilled practitioner would need to be a consultant anaesthetist with extensive paediatric and intensive care experience, who has many years of experience in pre-hospital care and appropriate higher

Authors: Mark Bloch Consultant Anaesthetist Honorary Clinical Senior Lecturer Aberdeen Royal Infirmary Royal Aberdeen Children’s Hospital University of Aberdeen Andy Newton Consultant Paramedic Director of Clinical Operations South East Coast Ambulance Service Foundation Trust James Ferguson Consultant in Accident and Emergency Medicine Clinical Lead Scottish Centre for Telehealth and Telecare

Fig. 1: Pre-hospital care has a developing, ongoing evidence base that cannot always be extrapolated from in-hospital care (Bond/R. Lawford)

50 | IN PROFILE qualifications. Two different approaches to requirements are taken throughout the world and variants of both are found in UK practice: The first is a physician-delivered model and the other a physician-led model. Both of these approaches have evolved over time with structured education, training and robust, resilient governance frameworks. Both have benefits but, inevitably, both also have drawbacks. The question we should be asking is, “Which finds the best balance and which will deliver the ‘best for most’ in the future?”

A developing profession Over recent years, there have been interesting developments in the training of both doctors and allied health professionals, including paramedics: • Through the General Medical Council, the Royal College of Surgeons of Edinburgh Faculty of Prehospital Care has developed the subspecialty of prehospital care for a doctor.

• Huge advances have been made in paramedic education and training with a move to higher education institution-based diploma or degree tuition.

• Opportunities for certain allied health professionals also exist for further postgraduate study which allows for the development of tier levels of practice – a model which has been used in the physician context for decades.

• Although the Health and Care Professions Council cannot annotate the professionals register with postgraduate qualifications, the uniformity and maintenance of standards in areas with extended roles can be helped through the utilisation of voluntary registers. Two registers are currently being planned and several more considered. The first two specialist areas recognise the need to record those paramedics who are increasingly working in primary care, often called Paramedic Practitioners, and those working in critical care, Critical Care Paramedics (a program whose evolution was led by the authors of this article). Both of these registers should be in place by early 2014. These and future registers (including one which is in the context of this article) will add a level of assurance that could be of value to both paramedics and employers, with obvious benefits to the patients.

The way forward The way forward may also be the most pragmatic one: trying to overcome prejudice along with personal and traditional organisational agendas and semantics. One solution may be to use operational models that provide the best teams using the best transport modality for the circumstances at hand within the right timeframes. Such models would require systems that are both appropriately resourced, resilient and adaptable. At the end of the day, we should be striving for the best clinical care and quality assurance, without any significant geographical variation in the level of care, using finite resources in the most cost-effective way. Appropriately trained paramedics and

medics should work within a well thought-out and structured clinical governance framework, alongside effective technology and physician-led support aimed at providing resilient and high-level guidance, decision support and triage.

We, along with many others, will continue to make ourselves available to respond and provide advanced medical care in the SAR, HEMS and other pre-hospital roles.

Looking to the future, however, there are issues as to how we develop systems to improve these services, save more lives, operate more safely and work more efficiently: Just because a clinician is qualified as a doctor does not necessarily mean they will have the wide-ranging skills required for these pre-hospital arenas. Similarly, a paramedic would of course need appropriate clinical technical and non-technical skills, but also the appropriate, context-specific SAR related elements to achieve the whole package. Rather than simply continuing based on current expertise available, a better way forward might be to continue to develop the systems that support the wider body of pre-hospital practitioners, and allow them to progress both their technical and non-technical skills, including dynamic decision-making processes and generic human factors.

Pre-hospital care is an exciting area of medicine with increased demands being placed upon it. It forms an integral part in the development of numerous pathways and systems, including trauma and unscheduled care.

Furthermore, it has a developing, ongoing evidence base that cannot always be extrapolated from in-hospital care.

There have been marked developments in the systems that enable both safe and effective delivery of rescue and care, but this is still a very person-centred area of practice. Improving the care and support of the people who deliver the pre-hospital services should be a priority and will lead to even better care of the casualties and patients. 

Bond Offshore Helicopters Bond Offshore Helicopters Ltd is part of Avincis Group. Avincis Group is the world’s leading provider of mission critical aviation services. The Group’s mission is to save lives, protect the environment and provide safe transport for mission critical people and assets for public services and blue chip corporations. Mark Bloch, one of the authors, is the clinical lead for Bond Offshore Helicopters and works with Bond’s Jigsaw Search and Rescue (SAR) crews and provides voluntary operational cover for the Scottish Ambulance Service – if advanced medical care is required pre-hospital.

Avincis has a global footprint that includes the UK, Spain, Italy, France, Portugal, Ireland, Norway, Australia, Chile and Peru. The Group operates around 350 rotary and 50 fixed-wing aircraft, from 295 bases in ten countries. Avincis employs almost 3,000 people worldwide and at the end of 2011 had an annualised turnover of €521 million (£421 million). The Group is headquartered in London.

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52 | IN PROFILE

Fig. 1: Experienced military personnel who have been conducting SAR operations for many years will be a great asset to Bristow (Photographs: Bristow)

Search and Rescue in the UK: Bristow Helicopters awarded contract to deliver UK SAR Bristow Helicopters Ltd has been awarded the contract to deliver the UK Search and Rescue (SAR) service by the Department for Transport. The company, a leading provider of helicopter services to the offshore energy industry, has won the contract to provide SAR and will take over the running of the service from April 2015 and operate until 2026. The new SAR service will be delivered from 10 bases across the UK. New facilities will be established at Inverness, Manston, Prestwick, Caernarfon, Humberside, Newquay and St Athan, while existing facilities at Lee-on-Solent and Sumburgh will continue to be used, the base at Stornoway being refurbished. For more than half a century, the operation of the UK’s SAR helicopter service has mainly been carried out by the RAF and Royal Navy.

Authors: Editorial Team AirRescue Magazine

Bristow Helicopters will be introducing a state of the art Search and Rescue fleet of Sikorsky S-92s and AgustaWestland AW189s. The new helicopters will feature a raft of technology, some of which is new to commercial Search and Rescue aircraft, and shall enable Bristow Helicopters to provide unprecedented SAR capabilities.

Managing director Mike Imlach said: “In designing our Search and Rescue service we were able to start from a clean sheet and choose the best locations and helicopters to service the geographical areas we will be operat-

ing in. The base locations have been strategically selected due to their proximity to areas of high SAR incident rates and will enable the teams to respond to incidents in 85% of high and very high-risk areas within 30 minutes rather than the 70% reachable in this timeframe by the existing service.” Imlach added that Bristow crews “will provide a 24 hour a day, 365 days a year service with the ability to launch within 15 minutes in day time and 45 minutes at night time. This will enable SAR teams to get to an incident on average faster than ever before, and

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IN PROFILE | 53

we will continually work to exceed these targets wherever possible.” Regarding the service, Imlach also stated that Bristow’s services will add value to the communities in which the bases are situated. The operator intends to use local services and small and medium enterprises (SMEs) in the construction, maintenance and day to day running of the bases.

Mission equipment Two fully operational helicopters will be stationed at each base, with S-92s operating from Caernarfon, Humberside, Newquay, Sumburgh and Stornoway and AW189s operating from St Athan, Manston, Lee-on-Solent, Inverness and Prestwick.

Bristow Helicopters has gone to great lengths to obtain the necessary International Traffic in Arms Regulations (ITAR) export licence in order to invest in the best possible night vision goggles (NVG) technology available to the civil market. The Generation 3 NVG image intensifier tubes are fully integrated into the cockpit and cabin.

“Night vision capabilities are valuable for night time incidents, particularly in Scotland, where winter days are short and operations often continue into the hours of darkness”, Imlach said. Due to forward-looking infrared (FLIR), thermal imaging camera technology and high illumination lighting, the searches are said to be very effective. The new aircraft will also benefit from longrange fuel tanks to allow for operations across the vast distances that Bristow will be servicing.

Communicating with teams on the ground will be vastly improved – thanks to an advanced external public

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address system. Both helicopter types will also be fitted with Trulink ® wireless capabilities for communications between the aircraft and crew. On board, a medical intercom will also allow the cabin and cockpit to be split into isolated zones so that medical teams can work on a patient without distracting the flight crew. Improved cabin lighting including emergency white light will enable advanced medical procedures to be carried out, while the addition of 230-volt ac power outlets will support the sophisticated medical equipment. Helicopters will be fitted with dedicated medic bays with piped oxygen and medical intercom will allow crews to provide detailed medical information on casualties to hospital staff while on route.

The cockpit and cabin layout have been ergonomically designed to make Search and Rescue operations easier and safer. Newly placed and additional attachment points from which the crew will hang during winching operations will make the aircraft more balanced and make entry and exit from the cabin easier. Once in the aircraft, teams in the cabin will be able to view directional data, mapping and FLIR imaging on 20” high definition monitors positioned behind the co-pilot’s seat. Bristow Helicopters has also designed bespoke storage in the cabins to meet the specific requirements of the SAR crews.

Transition agreement Bristow Helicopters’ Search and Rescue workforce is expected to comprise around 350 dedicated pilots, crew and engineers from both the current military Search and Rescue force and Bristow’s own experienced team. A transition agreement between the company and the Ministry of Defence will give military personnel the opportunity

Fig. 2: Additional attachment points from which the crew will hang during winching operations will make the aircraft more balanced and make entry and exit from the cabin easier

54 | IN PROFILE

Fig. 3: Bristow’s Search and Rescue fleet will also include Sikorsky S-92s

to transfer to the new service and safeguard continuity of provision.

“Experienced military personnel who have been conducting SAR operations across the UK for many years will be a great asset to our teams, ensuring that local knowledge is not lost,” Imlach added. “Alongside the Ministry of Defence we have been visiting military bases throughout April and May to speak to military personnel and offer them the opportunity to come on board with Bristow.”

Bristow Helicopters also provides full in-house training facilities for all air crews and engineers. The Bristow Academy is the world’s largest commercial helicopter training service provider. Both ex-military and civilian crews will go through rigorous in-house training with Bristow Helicopters before the contract commences. The Flight Training Simulator Centre in Aberdeen will ensure that SAR crews can complete regular currency training and respond to aircraft technical emergencies in a safe environment. Stornoway and Inverness will host mission training and have additional aircraft to support this work.

The Bristow Academy will be used for much of the training, both at its UK and US bases.

As with the military service, trained paramedics will be part of the SAR crews. Bristow is working closely with medical experts to develop its own medical training capability. In response to the increase in demand for its Search and Rescue helicopter services in the UK, Bristow

Helicopters is also planning to open up opportunities for ten apprentice engineers specifically for Search and Rescue, working at one of the ten SAR bases around the UK. While applications are open to people from across the UK, the company has expressed particular interest in hearing from those applicants local to the ten SAR bases. Successful applicants will complete a four-yearprogramme of on the job training in both maintenance and flight operations, beginning at the Lufthansa Resource Technical Training (LRTT) College in Gloucester before taking on posts at Bristow Helicopters’ operational bases. LRTT is an EASA Part-147 Approved Basic Training Organisation, formed originally as a joint venture partnership between Lufthansa Technical Training and Resource Group. In January 2012, Resource Group took sole ownership of LRTT. As safety is at the heart of the business, Bristow continually strive to improve safety performance and cultivate an even stronger reputation for safety both through recruitment and in-house training. Imlach explained: “Developing talent from within the company is something we place huge value on as it allows us to instil this company culture of safety and integrity in all our recruits whether they work out on the flight deck or back in the office.”

Search and Rescue workforce will require around 103 pilots with nine located at each base. Many of these will transfer to Bristow Helicopters from the current military force, but there will also be opportunities for cadets to

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IN PROFILE | 55 join the team in the coming years. Positions will begin in September 2013 and Bristow Helicopters is working with local job centres to make information about the opportunities available.

Bristow gearing up for Gap SAR Search and Rescue has been a central part of Bristow Helicopters’ operations for many years. The company was founded in the UK in 1953 by Alan Bristow OBE and began providing SAR in the UK in 1971. The company went on to deliver SAR helicopter services on behalf of HM Coastguard from four bases, Stornoway, Sumburgh, Lee-on-Solent and Portland, until 2007.

In the UK alone, Bristow Helicopters has flown more than 44,000 SAR operational hours and conducted over 15,000 SAR missions, during which more than 7,000 people have been rescued by the company’s crews and helicopters. In that time Bristow Helicopters’ crews have won numerous awards including six Chief Coastguard’s Commendations, awarded for bravery and exceptionally meritorious service, two prestigious Coastguard Rescue Shields and three Edward Maisie Lewis Awards.

Most recently, Bristow Helicopters has been gearing up to take over the Gap SAR contract for Northern Scotland, where they will provide SAR services from bases in Stornoway and Sumburgh. Following three months of training from Inverness Airport, these teams have now moved up to Sumburgh in preparation for commencing

Fig. 4: Both helicopter types will also be fitted with Trulink® wireless capabilities for communications between the aircraft and crew

operations on 1 June 2013. The Stornoway crew will move across to their base in mid June, ready to commence ops on 1 July 2013. The company also has extensive experience of SAR delivery overseas with ongoing operations in the Netherlands, Norway, Trinidad, Cyprus, Dutch Antilles, Russia, Australia and Canada.

“Our company ethos centres on Target Zero which puts safety at the forefront of all our operations, Imlach said. “We have an enviable safety record, but we continue to push proactively for even higher standards to achieve our Target Zero goal. Not only do we want to become the safety leader in our industry, but also in the entire aviation sector.”

Return to British heritage For a number of years Bristow Helicopters has led the industry in introducing new aircraft types and technology to the civil market. Some of the SAR equipment it introduced has become the industry standard, resulting in Bristow Helicopters being recognised with the Queen’s Award for Innovation for its technical developments. Imlach added: “For us, taking over the operation of the Gap SAR contract for Northern Scotland and the UK SAR contract is a return to our British heritage. Search and Rescue has been a key area of our business for many years and we’re honoured to be providing these services in the UK once again.”

Bristow emphasizes that delivering this type of service is an exercise in “partnership working”, as pilots and crews work closely with mountain rescue, coastguard rescue teams and other emergency services every day in countries where the operator currently delivers SAR helicopter services. Imlach expressed his respect for the fantastic work done by the teams of other services as well and his will to include them in Bristow’s training exercises to ensure that “together they can be fully prepared to deliver this vital service to the UK public.”

The Gap SAR start date is 1 June, the transition of the second base will take place on 1 July. Two S-92s will be stationed at each base. 

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56 | IN PROFILE

Fig. 1: The Japanese HEMS program started in 2001 with five base hospitals; this number increases year on year (Photograph: AgustaWestland)

Realising the potential: challenges and opportunities for HEMS in Japan Helicopter Emergency Medical Service (HEMS) started in Germany in 1970 (1). Consequently many other European countries and the USA followed suit and established their own HEMS systems. However, for more than 25 years, many people in Japan regarded HEMS as useless – resulting in high costs and showing little benefit. In 1995, the Hanshin-Awaji earthquake hit Japan and killed more than 6,000 people. Buildings, houses and highways were destroyed. Search and rescue (SAR) personnel, transportation and emergency care were completely insufficient for the number of casualties. The scene was largely inaccessible by road ambulance because roads had been destroyed. Only 17 patients were evacuated and transported by helicopter during the initial 72 hours (2, 3).

Japanese HEMS

Authors: Kunihiro Mashiko Hisashi Matsumoto Yoshiaki Hara Takanori Yagi Shock & Trauma Centre Chiba-Hokusoh Hospital Nippon Medical School Chiba Japan

The Japanese government began implementing a Helicopter Emergency Medical Service (HEMS) system in 2001 – the “Doctor-Heli” scheme. It involves an emergency physician and nurse being dispatched to the scene for providing adequate treatment to the critical patient as soon as possible (4). The crew is made up of a pilot, a mechanic, an EMS doctor and a nurse. HEMS revolutionised the Japanese Emergency Medical Service system in general. The basic philosophy of HEMS is “from transport to treatment, from hospital to scene and from ground to sky” (5), and so we call the HEMS system “offensive emergency medicine”.

The Japanese HEMS program started with five base hospitals. The number of hospitals, as well as HEMS missions, increases year on year. The number of annual missions in the 2011 fiscal year was 12,923 – an increase of 37% on the 2010 fiscal year (6). By the end of 2012, there were 40 hospitals offering a HEMS program in Japan. Patient classification showed that trauma was the principle category making up 45%, followed by stroke at 15% and cardiovascular emergency at 12%. Traffic injuries made up 45% of the trauma cases. The fleet of EMS helicopters currently being operated in Japan consists of the following models: AW109SP, Bell 429, BK117, EC135 and MD900.

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IN PROFILE | 57 HEM-Net – history and activities Japanese HEMS was promoted further by strong support from the non-profit organization “Emergency Medical Network of Helicopters and Hospitals” HEM-Net (7), which was established in 1999. Mr Takaji Kunimatsu, chairman of the HEM-Net Board of Directors, was formerly president of the National Police Agency and also the former ambassador to Switzerland. HEMS progress in Japan over the last decade would not have been possible without his outstanding contribution. Thanks to the tremendous effort of HEM-Net, a special Doctor-Heli legislation was passed in June 2007 (8). The total budget for HEMS (2 million Euros in 2007) was covered 50/50 by national and local government taxes. HEM-Net funds are also generated through donations from large businesses or industrial organisations. Although the means for covering HEMS operation cost differ from country to country, in Japan, the national government and local governments had to split the total budget, half each.

Thanks to a lobbying group of assembly members from both the governing and opposition parties, who are advocating HEMS, the ratio of HEMS budget distribution changed in 2009. The national government now has to contribute 75% to 90% and local government between 10% and 25% – depending on the budget of the local government. This means, the local governments have to pay only 0.2 to 0.5 million euros per year for the HEMS program.

“Public-private Partnership” The Doctor-Heli Widespread Use Promotion Panel (DHWUPP) was formed in August 2010 (9) in Nippon Keidanren (Japanese Federation of Economic Organisations). In order to promote the nationwide deployment of HEMS, DHWUPP supports training of physicians and nurses, conducts HEMS research and holds seminars. HEM-Net started a flight physician/nurse training program in April 2010. One concept of this program is that the 10 base hospitals are responsible for providing between 2 weeks to 3 months training, depending on the trainee’s experience and knowledge as well as “on-the-job-training” supervised by the HEMS crews. The number of graduates who had participated in the HEM-Net fellowship program until December 2012 is 44 physicians and 76 nurses.

Recently, the concept of New Public Management has become popular in Japan. It means that public property should receive financial support from the government as well as the private sector. As mentioned above, the Doctor-Heli system is supported by a group of assembly members; that means the public sector and the DHWUPP of Nippon Keidanren (private sector) jointly support HEMS. Therefore, Doctor-Heli is a typical example of services established under this New Public Management principle in Japan.

Effect of HEMS Transferring the seriously ill and injured is becoming a more formalised procedure across the globe. Along with this EMS innovation, lots of studies have been conducted to evaluate the value of HEMS from various viewpoints

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(10, 11, 12, 13). The primary factor is not the speed of the transport but the helicopter medical crew administering life-saving care at the scene of the accident or at the outlying hospital.

We have already stated that HEMS has improved the outcome of life-threatening trauma patients in the Japanese emergency medical system. Kerr et al. (14) suggested rapid air transport of victims in traumatic events by specialised personnel in Maryland has a positive effect on the outcome of severely injured patients.

Annual change in traffic injury statistics in Japan shows a rapid reduction of traffic injury death since the introduction of HEMS (15). That is to say that the number of deaths has decreased significantly due to the HEMS system. The rate of traffic accident deaths (24 hour death) in Japan was 3.5 per 100,000 population in 2012.

Fig. 2: A special Doctor-Heli legislation was passed in June 2007, thanks to the tremendous effort of HEM-Net (Photograph: K. Mashiko)

Golden Hour Strategy The goal of trauma care is to get seriously injured patients into a trauma centre for diagnosis, critical care and appropriate surgical treatment within the “golden hour” (16). It recommends that EMS notification takes less than 1 minute, EMS arrival at scene takes less than 10 minutes, with hospital admittance in under 45 minutes and definitive care within 60 minutes (17). In Japan, the time

Fig. 3: In Japan, the time from HEMS call to helicopter landing at scene (response time) is 18 minutes (Photograph: K. Mashiko)

58 | IN PROFILE

Air Ambulance System Dispatched by Advanced ACN*

Call Center HEMS Alert

Call back, check response

3

Alert Information 3 Dispatch

2

1

Installed equipment

Car Crash * Automatic Crash Notification System (e-call) Fig. 4: Crash data may include information about crash severity, the direction of impact, air bag deployment, multiple impacts and rollovers (if appropriate sensors are part of the system)

Police Ambulance

lapse from a crash to EMS notification is 5 minutes. The time from EMS notification to HEMS call is 15 minutes and time from HEMS call to helicopter landing at scene (response time) is 18 minutes (18). Therefore, the HEMS doctor starts medical treatment 38 minutes after crash and the time interval from crash to the arrival at hospital is 67 minutes, which is too late to save the life of a critically injured patient.

In order to reduce the time interval from EMS notification to HEMS dispatch, the decision to call Doctor-Heli should be managed by dispatch personnel from the fire department. We created a key word system for HEMS dispatch such as fall from height, intrusion of the car, ejection, rollover, etc. for trauma, which means highimpact accident. In the case of medical emergencies, loss of consciousness, convulsion, severe headache with vomiting over 40 years old, chest or back pain with sweating over 40 years old, etc. are good candidates of the keywords (19).

Automatic Crash Notification Now it is planned to introduce the Advanced Automatic Collision Notification (AACN) system (20). The AACN sends crash data to an advisor if a vehicle is involved in a moderate or severe crash. These data include information about crash severity, the direction of impact, air bag deployment, multiple impacts and rollovers (if appropriate sensors are part of the system) and accident site information (via GPS). Advisors can relay this information to emergency dispatchers, helping them to quickly determine the appropriate combination of emergency personnel, equipment and medical facilities. This AACN information may also include injury prediction – derived from the above-mentioned information.

The dispatch centre operator may also be able to make a call to the person inside the vehicle if he or she needs ambulance help. If the answer is “yes” or if there is no answer, the operator asks the police and fire department to send a police car and a ground ambulance to the scene (21). Fig. 4 shows the usual style of the AACN and new HEMS alert pathway using AACN, which will be

added in the near future. MacKenzie et al. (22) reported that the overall risk of death is significantly lower when care is provided in a trauma centre than when it is provided in a non–trauma centre.

In December 2011, AACN simulation was performed

by HEM-Net, in which an AACN car crashes into a concrete wall at a speed of 50 km/h. An ambulance and a Doctor-Heli dispatch were performed from the call centre based on AACN information, and time from crash to initiating medical care by HEMS doctor at the scene was measured. The distance from the accident site to a HEMS base hospital was 40 km. As a result of this study, the time from crash to medical treatment at the scene was 21 minutes using AACN. It is estimated that the time taken to provide medical treatment using AACN & HEMS in car crashes is reduced from 36 minutes to 21 minutes after crash. Therefore it is clear that we can save many critically injured lives with AACN & HEMS. Key aspects for establishing AACN in Japan: system construction on national scale, institutional design with the Event Data Recorder, call centre installation from medical viewpoint which means implementing air ambulance dispatch protocol, standard real time instruction and advice to Emergency Medical Technicians.

Future Perspectives In Japan, Doctor-Heli is already recognised as an essential tool for critically injured or ill patients suffering from trauma, stroke, cardiovascular disease etc. who require critical care transport. However, in the future, DoctorHeli will have a very important role to play in disaster relief, which means medical evacuation/SAR, paediatric emergency, obstetric and perinatal emergency and rural emergency. The keywords for future HEMS are medical consolidation and hospital collaboration. The future objectives of Japanese HEMS are: • Nationwide HEMS coverage (50 to 70 bases) • System planning, such as the 15-minute-rule in Germany to improve response time • Expansion of mission times from daytime to night • Coordinated system of Doctor-Heli and fire department helicopters (25); 73 rotorcraft In the Great East Japan Earthquake that occurred on 11 March 2011, with a magnitude of 9.0, on the Pacific coast of the Tohoku Region (the north-eastern part of the Japanese mainland), and which had unbelievably devastating effects (26, 27), 18 rotorcraft out of the 26 Doctor-Heli helicopters were dispatched countrywide and promptly flew into the disaster area and saved 149 patients within the first 4 days of the MEDEVAC mission. It is possible that this stands as a best-practice example of how HEMS should work.  For more information, visit: ››› www.http://hemnet.jp For references, please visit: ››› www.airrescue-magazine.eu

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60 | HISTORY

Fig. 1: In this image taken in 1944, one of Langley Research Center’s Sikorsky YR-4B helicopters is seen in the Full Scale Tunnel while a technician sets up camera equipment for stop-action rotor-blade photos (Photograph: NASA)

Civilian helicopter air ambulance: history & future from today’s perspective Powered fixed-wing flight began in December 1903 with Wilbur and Orville Wright. The first use of aircraft for medical evacuation is described to have taken place during the First World War. The first recorded British fixed wing air ambulance flight took place in 1917 in Turkey when a soldier in the Camel Corps was flown to hospital in a De Havilland DH9. It was not until 1940 that the first documented case of a British helicopter being used to air lift injured patients, when Lt Carter Harman moved 3 wounded British soldiers fighting in Burma during World War 2 being airlifted by a US Army Sikorsky YR-4B.

Author: Dr Gareth Davies Medical Director London’s Air Ambulance Consultant in Emergency Medicine & Pre-hospital Care The Royal London Hospital & Barts Health NHS Trust

Aspirations of using aircraft with a rotary component not reliant on large runways were being conceived as early as 1928. Spanish engineer Juan de la Cierva, the gyrocopter inventor, is said to have penned the design of such an air ambulance vehicle, but it was never built as the company began to fail and pictures of the design failed to surface. In 1933 the same aspirations of using a gyrocopter for medical evacuation were documented in the March edition of the Military Surgeon – a US medical publication – for Surgeon Lt. Col. G. P. Lawrence.In it, Lawrence discusses the benefits of a transport that could take off and land in difficult terrain and weather.

Despite Lt. Col. Lawrence’s enthusiasm for the concept of the medical gyrocopter, plans were shelved. It wasn’t until 1936 that the first true helicopter design (capable of vertical take off) flew in the form of the Focke-Wulf Fw 61. By the 1940s helicopters were a regular feature of the war theatre and ad-hoc use for patient transport was taking place.

Medical helicopters during wars By 1950, helicopters dedicated to medical evacuation were present in the Korean War, notably the Bell 47 and Sikorsky. With baskets outside of the cockpit to carry patients, such aircraft were truly used following a “scoop and run” philosophy. These aircraft were eventually superseded by one of the most iconic medical helicopters, the Bell UH-1 (“Huey”) used in the Vietnam War. Despite having a spacious interior, these aircraft were initially used simply as transport with little in the way of medical intervention in flight or on the ground. However, by the 1960s, dedicated medical helicopter units, such as the 82nd Medical Detachment (Hel Amb) 1967, 68, 69 were active at the front line, moving and treating the wounded with oxygen and fluid infusions. The use of these helicopters has been cited as one of the primary reasons for the dramatic fall in the death rate of war casualties in Korea and Vietnam (4.5/100 casualties during the Korean War, 2.5/100 casualties during the Vietnam War).

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HISTORY | 61 Postwar civilian HEMS projects In the USA, in 1969 the disparity between care afforded to military personnel in Vietnam and that delivered to the public in road traffic accidents was being questioned. The military were being airlifted to hospitals by helicopters with dedicated medical personnel using “advanced” medical interventions en-route. Born of this disparity was the CARESOM project, a government sponsored evaluation of helicopters in the civilian EMS. CARESOM (Coordinated Accident Rescue Endeavour – State of Mississippi) consisted of 3 helicopters positioned around the state. The project was deemed a roaring success and at the end of the project, one of the 3 Bolkows remained in Mississippi as the state medical evacuation helicopter. In the same year, a similar project, the MAST Programme, was initiated in San Antonio, USA. This project looked at the use of military helicopters augmenting the existing land based ambulance services in patient care. Over the next two years, medical helicopters began to appear throughout the U.S.

European HEMS in the 1970s In Europe in 1970 the first civilian helicopter became operational in Germany, “Christoph 1” based in Munich. In these early years, much of focus was based on transporting the patient to an appropriate hospital, however, medical staff could see patients need medical interventions enroute, and over the next decade, these interventions spiraled into the prehospital arena in many varied ways.

Flight crews were often afforded more advanced interventions than their land based equivalents. However, flight paramedics and nurses practiced a half cooked version of medicine to fill the gap. For example, the intubation of a head-injured patient would be blind nasal intubation or perhaps just paralytic agents only, or perhaps just struggling to pass a tube against trismus or laryngeal reflexes, when in hospital a patient would be given a specific neuroanaesthetic to facilitate the process acknowledging that laryngeal stimulation had negative effects on ICP.

Transition period When the efficacy of this “prehospital medicine” was studied in the 1980s, it should come as no surprise that questions were asked about the validity and safety of certain practices, and hospital based clinician cried foul.

In a paper in the Journal of Trauma in 1985, “prehospital stabilization of critically injured patients: a failed concept”, Smith et al. suggested that “field maneuvers in critically injured patients should be minimized to decrease ultimate mortality.” During this time it is clear that patients had to fit the system. The system had helicopters, but the care that could be delivered was not congruous with hospital practice.

However, by the 1990s and 2000s we start to see the care afforded seriously ill and injured patients reflecting that of hospital practice. Head-injured patients receiving anaesthetics that focused on neuroprotection, some centres performing basic surgical procedures for pleural drainage such as thoracostomy or chest drain insertion, and in some centres, prehospital thoracotomy for penetrating cardiac injury became a standard of care.

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Bringing the hospital to the patient?

From 2010 onwards we began to see drugs manipulating the clotting cascade such as tranexamic acid and prothrombin concentrates. Some helicopter air ambulances are carrying blood on board, others use automated CPR devices or intranasal cooling with the aim of cooling the brain following cardiac arrest in order to protect it from permanent neurological injury. All of these interventions place an increasing burden on the flight crew in terms of training and implications for airframe in terms of space and weight. Looking forward it is likely the same burdens will only increase.

The use of mobile CT scanners – placed in the back of helicopters – is being considered by the Norwegian Air Ambulance. The use of profound hypothermia in EPR to treat patients in medical or traumatic cardiac arrest brings with it the need for equipment to access the central circulation, pumps and high volume 40/50/60 litres of ice cold fluid. Both will require a major re-think of crew configuration, space and power.

Many diseases attended to by HEMS are time dependent. Whilst aircraft manufacturers aim to deliver faster aircraft, the biggest gain for patients is more likely to be found in the accuracy of dispatch.

Fig. 2: In 1970 the first civilian helicopter became operational in Germany, “Christoph 1” based in Munich (Photograph: ADAC Air Rescue)

Future implications The history of air ambulances has seen the translation of procedures that were historically the domain of a specific speciality, e.g. rapid sequence induction, from anaesthetics to emergency medicine. It is likely that other procedures will also translate to the prehospital arena, such as craniotomy for acute extradural. These interventions become more normal for the flight crew, with implications for training and skill mix as well as for the size and shape of the medical cell. Engineers and manufacturers are set a sizeable challenge in accommodating more equipment and maintaining endurance and a practical size. 

This article is based upon a presentation the author gave at the London Trauma Conference 2012. This year’s conference will take place on 10-14 December at the Royal Geographical Society in Kensington. For more information, visit: www.londontraumaconference.com

62 | SAFETY

Fig.1: European operators together with manufacturers will be called to work as a team in order to ensure compliance with the new regulations and further contribute to develop new and even more encompassing safety standards (Photograph: Eurocopter)

HEMS operations: Challenges with the new Implementing Rules OPS At the end of 2012, the actual civilian registered fleet of helicopters worldwide consists of approximately 21,000 helicopters, of which about 2,000 are engaged in HEMS operations, thus representing more than 9% of the entire registered fleet. With regard to the geographic distribution, 83% of the entire HEMS fleet operates in Europe (29%) and North America (54%). In practical terms, this means that over 590 aircraft are currently engaged in HEMS operations within the EU countries.

Harmonizing European Civil Aviation

Author: Capt. Luigi Simoncini G.E.D.A. Italy Former Head of Flight Standards & Former Head of Operations and Airports Certification

Since the 1990s, the Joint Aviation Authorities (JAA) was an associated body of the European Civil Aviation Conference – ECAC, established in 1955 and consisting of 42 European states, whose objectives were to promote the development of air transport on the basis of safety, efficiency and sustainability in terms of costs.

The Joint Aviation Authorities represented the national regulatory authorities of these European countries that agreed to cooperate with each other for the development and implementation of common safety standards in the field of Civil Aviation, adopting common guidance requirements in order to harmonize the applicable aviation rules within those states.

The JAR-OPS 1 and JAR-OPS 3 constitute part 1 and part 3 of the operational agreement and contain the re-

quirements applicable to commercial air transportation by aeroplanes and by helicopters respectively. The requirements of JAR-OPS 1 and 3, having no legal force, very soon confirmed their weakness. For the above reason, a set of new rules were established, namely: • Council Regulation No 3922/91 of 16 December 1991 • Regulation (EC) No 1899/2006 of the European Parliament and of the Council of 12 December 2006 amending Council Regulation (EEC) No 3922/91 • Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February 2008 on common rules in the field of Civil Aviation, establishing a European Aviation Safety Agency, and repealing Council Directive 91/670/EEC

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SAFETY | 63 • Regulation (EC) No 1592/2002 and Directive 2004/36/EC) Basically, the aim of these new regulations was to ensure a high level of safety and to improve the functioning of the internal market by incorporating into European Union (EU) legislation the technical requirements and administrative procedures in the field of aviation, as drawn up by the Joint Aviation Authorities, thus requiring EU countries to comply with them in order to conform with community legislation and policies, taking into account its numerous implications in the economic and social field. For a better arrangement and a uniform application of common rules in the field of civil aviation safety and environment protection, an independent European body, named EASA (European Aviation Safety Agency) was also established.

EASA regulatory system EASA has legal, administrative and financial autonomy in relation to aviation-related technical matters, whose regulatory role encompasses the airworthiness and environmental compatibility of aeronautical products, parts and appliances, flight-crew licensing, operations and regulation of third country aircraft from a safety and environmental viewpoint as well as safety of ATM/ANS and aerodrome operation.

EASA’s legal powers derive from its “Basic Regulation” – Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February 2008 as amended

by Regulation (EC) No 1108/2009 of 21 October 2009.

The amended “Basic Regulation” defines the Agency’s roles and responsibilities, and establishes common rules in the field of civil aviation.

It undertakes the role through the application of a wide range of regulatory provisions, which expand upon and interpret the requirements of the “Basic Regulation” in a manner that provides sufficient technical detail and guidance to be applicable, as appropriate, by the Agency, its member states and their national aviation authorities.

EASA prepares drafts of opinions in order to assist the European Commission in its preparation of proposals for basic principles, applicability and essential requirements to the European Parliament and to the European Council.

The Agency also prepares guidance material relating to the application of implementing rules.

EASA adopts non-binding standards (decisions related to rulemaking activities) for implementing the Essential Requirements (ER) Basic Regulation (BR) and its Implementing Rules (IR). Article 17 of the Basic Regulation instructs the Agency to assist the European Commission (EC) by “ … preparing measures to be taken for the implementation of the Basic Regulation”. These measures include the preparation of draft Implementing Rules (IRs), which are submitted to the EC (under Article 18) in the form of EASA opinions. Except for draft legislation, EASA is also empowered to issue opinions on a range of other technical and operational issues.

Currently, well-established Implementing Rules are in place to support the regulation of (1) the airworthiness and environmental certification of aircraft and related prod-

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ucts, parts and appliances, as well as for the certification of design and production, as well as (2) the continuing airworthiness of aircraft and aeronautical products, parts and appliances, and on the approval of organisations and personnel involved in these tasks.

The “Basic Regulation” establishes common essential requirements to provide for a high uniform level of civil aviation safety and environmental protection; it requires the Commission to adopt the necessary implementation rules to ensure their uniform application; it establishes the EASA to assist the Commission in the development of such Implementing Rules. The Parliament and the Council a) define the scope of powers transferred from the member states to the community; b) adopt the Essential Requirements specifying the objectives to be met.

The European Commission, assisted by the Air Safety Committee, is entitled to amend the common technical requirements and administrative procedures where such amendments are made necessary by progress in the field of science and technology. Further IRs are being developed to support the ever increasing role of EASA in the field of flight-crew licensing and air operations. Table 1 gives a brief overview of the requirements contained in the new European regulations that will govern future flight operations.

Commission Regulation (EU) No 1178/2011 of 3 November 2011, amended by Commission Regulation (EU) No 290/2012 of 30 March 2012 laying down the technical requirements and administrative procedures related to Civil Aviation Aircrew pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council, consists of the following parts: • Part ARA (Annex VI to the Regulation on Civil Aviation Aircrew) • Part ORO (Annex III to the Regulation on Air Operation) • Part CC (Annex V to the Regulation on Civil Aviation Aircrew) • Part FCL (Annex I to the Regulation on Civil Aviation Aircrew)

Fig. 2: Over 590 aircraft are currently engaged in HEMS operations within the EU countries (Photograph: AgustaWestland)

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Reg. EU 1178/2011 e Reg. 290 / 2012

Reg. EU 965 / 2012

Aircrew Regulation

Air Operations Regulation

Annex I – Part-FCL

• Annex I – Definitions

Annex II – Conversion of national licences

• Annex II – Part-ARO (Authority Requirements for Air Operations)

Annex III – Acceptance of licences issued by or on begalf of non-UE Member States

• Annex III – Part ORO (Organisation Requirements for Air Operations)

Annex IV – Part-MED (Medical)

• Annex IV – Part-CAT (Commercial Air Transport Operations)

Annex V – Part-CC (Cabin Crew)

• Annex V – Part-SPA (Specific Approvals)

Annex VI – Part-ARA (Authority Requirements for Air Crew)

Annex VI – Part-NCC (Non-commercial operations with complex motor-powered aircraft (CMPA)) Annex VI – Part-NCO (Non-commercial operations with other then motor-powered aircraft (CMPA)) Annex VI – Part-SPO (Special operations, e.g. aerial Work

Annex VII – Part-ORA (Organisation Requirements for Air Crew) Table 1: European regulations requirements

• Part-MED (Annex IV to the Regulation on Civil Aviation Aircrew) • Part-ORA (Annex VII to the Regulation on Civil Aviation Aircrew) Commission Regulation (EU) No 965/2012 of 5 October 2012, laying down technical requirements and administrative procedures related to air operations pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council lays, contains detailed rules for Commercial Air Transport operations with airplanes and helicopters.

IR-OPS replaces EU-OPS This new regulation, which is generally known as IR-OPS (Implementing Rules – Operations), replaces EU-OPS (Commission Regulation) No 859/2008 of 20 August 2008, amending Council Regulation (EEC) No 3922/91 as regards common technical requirements and administrative procedures applicable to commercial transportation by airplane. IR-OPS that covers all “Air Operations” is composed of four parts, as indicated below: 1. Part OPS.ARO (Authority Requirements for Air Operations) establishes requirements for the administration and management systems to be fulfilled by the Agency and member states for the implementation and enforcement of IR-OPS. 2. Part OPS.ORO (Organization Requirements for Air Operations) establishes requirements to be followed by an air operator conducting commercial air transport operations.

3. Part OPS.CAT (Commercial Air Transport Operations) contains general requirements for commercial air transport operations, including operating procedures, aircraft performance, mass and balance, instruments and equipment requirements, etc.

4. Part OPS.SPA (Specific Approvals) contains requirements for specific approvals for airplanes operation and, for helicopters: • Operations with night vision imaging systems (NVIS), • Hoist operations (HHO) and • Emergency medical service operations (HEMS).

Entry into force of the Air Operations Regulation The Air Operations Regulation defines the general applicability, proposes grandfathering and transition measures in the form of “opt-outs”. IR-OPS started to be in effect on 28 October 2012; however, member states may decide not to apply the provisions of Annexes I to V by postponing them until 28 October 2014. Consequently, most of EASA member states have decided to delay the implementation until October 2014.

Review of procedures As a result, the implementation of the new European rules calls for a need of a comprehensive review of procedures, documentation and relevant publications in order to comply with Part ARO/ORO. At the same time, the transition to the IRs needs to be managed according to a roadmap, consisting of a number of projects, including (but not limited to) the following: • Review and amend internal processes and documents; • Review existing exemptions for airplanes and helicopters; • Prepare policies, procedures for new applicants and set up specific explanatory guidance material; • Publication of Information Notices (I.N.); • Review and amend AOC application, processes forms, National Regulations and Circulars.

Specific care will be taken to verify and monitor the ­development of the rules by accomplishing the following: • Review the latest versions of regulations at every stage and AMCs, when published, for the possible applicability; • Adjust documentation, processes and training material; • Implement Annex VI Parts SPO, Annex VII Part NCC and Annex VIII Part NCO. Taking into account the remarkable number of helicopters currently engaged in HEMS operations within EU countries, the above described ongoing processes clearly show that in the next few years, the European operators together with manufacturers (mainly AgustaWestland and Eurocopter) will be called to work as a team in order to ensure compliance with the new regulations and further contribute to develop new standards for the continuous enhancement of safety, efficiency and sustainability in aviation. 

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SAFETY | 65

Safety in HEMS: The Million-Dollar Question Last January in the U.S., the typical festive atmosphere associated with letting out the old year and ushering in the new was darkened by two fatal crashes involving medical helicopters. Each claimed the lives of all three crew members on board. The Eurocopter BK-117 operating out of Rockford Memorial Hospital in Illinois on Dec. 10, and the Bell 407 based at Mercy Medical Centre – North Iowa on Jan. 2, had each been en route to pick up patients after sunset. Weather was an uncertain factor for the team in Iowa, but a definite factor for the Illinois flight. These tragic events, like every previous HEMS crash, prompted air medical transport crew members across the nation to once again ask the question, “What went wrong?” But even though we all want to know what went wrong, the MillionDollar Question is, “How do we stop this from happening again?”

Ever since the National Transportation Safety Board (NTSB) hearings on HEMS safety in February 2009, the National EMS Pilots Association (NEMSPA) has advocated for a suite of tools to militate against preventable accidents in air medical transport. The group’s recommendation to the NTSB, titled “An Opportunity to Improve”, and other related documents can be reviewed and downloaded from the NEMSPA website at www.nemspa.org. The documents can be accessed via the homepage using the menu sequence Publications>NEMSPA Position Papers.

The following is a list of the safety enhancements NEMSPA recommended to the NTSB, and which were included in the formal recommendations put forward by the NTSB following the hearings.

• Enhanced HEMS-specific training for pilots • Implementation of a robust safety management system

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• Expanded use of flight data recording systems in conjunction with a formal flight operations quality assurance program • Enhancement/expansion of the Aviation Digital Data Service HEMS weather tool to provide better reporting for en route weather • Determination of the requirements and then implementation of a robust low-level instrument flight rules (IFR) infrastructure, to permit safe helicopter IFR operations in areas not currently supported for IFR flight • A requirement that all HEMS aircraft and pilots are equipped and qualified to use night vision goggles.

In early 2009, NEMSPA added another powerful tool to the suite of safety enhancements by proposing the use of an en route decision point protocol (EDP) for all HEMS flights.

The EDP is based on the recognized fact that a helicopter

Fig. 1: Ever since the NTSB hearings on HEMS safety, the NEMSPA has advocated for a suite of tools against preventable accidents in air medical transport (Photograph: K.D. Simpson/ Intermountain Life Flight)

Author: Bill Winn General Manager National EMS Pilots Association, Safety Officer Intermountain Life Flight Salt Lake City, Utah

66 | SAFETY

Fig. 2: The weakest link in the chain of events that might lead to an accident remains the same as it has always been: the human factor (Photograph: K.D. Simpson/ Intermountain Life Flight)

pilot will instinctively do two things to his flight profile when the ceiling or visibility, or both begin to deteriorate during flight. As the visibility drops due to fog or precipitation, the pilot instinctively slows the aircraft in order to maintain a see-and-avoid airspeed and to maintain visual contact with the terrain. And as the ceiling drops, he or she will descend to avoid penetrating the clouds. The EDP protocol uses these instinctive responses to deteriorating weather to define flight parameters that trigger one of the following mandatory actions on the part of the pilot: • • • •

Alter course to stay legal and safe Climb and transition to IFR Turn around and return to base or referring hospital Land and call for assistance

Continuing on course in conditions below the EDP limits is not an option.

The EDP is triggered whenever the pilot notes that the airspeed has dropped 30 knots indicated airspeed (KIAS) below the usual cruise airspeed for that aircraft, or whenever he would be forced to descend below the minimum en route cruise altitude established for that leg of flight.

A minimum en route cruise altitude (MECA) is required to be calculated and reported to the operations center in accordance with Operations Specification A-021, which applies to all air medical transport providers in the U.S. With a full suite of mitigations like these available for use, the weakest link in the chain of events that might lead to an accident remains the same as it has always been: the human factor. Call them errors, misjudgements, bad decisions, or simply mistakes, inappropriate actions or decisions by pilots continue to take aircraft and occupants to a point where there is no option left but to impact the ground.

It’s not that there are no mitigations for human factors. Crew resource management (CRM) and threat and

error management (TEM) are based on some very astute theories of interaction between crew members as well as between pilots and aircraft. But CRM and TEM do not operate in a vacuum, they operate in an organization.

And the culture of that organization ultimately determines how effective any safety system will be. This space will have more to say in the future on the unique culture of air medical provider organizations.

NEMSPA would like to hear feedback from HEMS pilots, or anyone else, regarding your perceptions or experiences with the EDP concept. Join the discussion on this topic in the forum at www.nemspa.org. 

The National EMS Pilots Association (USA)

AirRescue Magazine has always kept a sharp eye on safety issues, but mainly focussed on European HEMS. We would like to broaden the picture and therefore have asked William Winn, General Manager of the National EMS Pilots Association (NEMPSA) in the U.S., to sporadically contribute a column on safety matters. His column is reprinted with permission by the author and Vertical Magazine.

The U.S. American National EMS Pilots Association (NEMPSA) is a non-profit professional pilot organization that is dedicated to serving pilots involved in the air-medical transport industry. It was founded in 1984 with the focus on improving safety. This focus has not changed and safety is still number one priority. NEMSPA strives to be a voice for all EMS pilots, helicopter and fixed-wing. The association is campaigning for safe air medical transport operations, not only on a national level.

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