AirRescue Magazine 3/2013

TRAINING

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

Medical Care

Transatlantic ECMO Retrieval

Training

Helicopter Crew Course Medical Module

In Profile

“Medevac 112”: Ireland’s EAS

ISSUE 3 | Vol. 3 | 2013

AN 43 06/2013/A-E

Proud to Support Saving Lives

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

E di tori a l Dear Readers, Many people in Europe nowadays are worried about healthcare. One of the main concerns is the notion of a “two-tiered healthcare system”, meaning that the full range of medical options is only available to those who can afford the treatment. It is however fair to say that cost pressure can be felt all over the healthcare sector, and that hospitals and the medical healthcare infrastructure are changing.

Aside from making considerable investments in technology, HEMS operators and air rescue organisations such as ours are equally affected by this trend. We are faced with the challenge of maintaining our high quality standards at all times, standards which are based on our safe working practices and the safety of our patients.

At the same time, every effort should be made to keep HEMS affordable. The emergency medical services are undergoing a dynamic process, as new intensive care methods are being proposed and backed by scientific studies. At the same time, the requirements for ensuring safe flight operations are constantly being heightened by new official regulations. These two factors combine to create a high cost pressure in the HEMS and air rescue sector.

In order to maintain the latest quality standards in many different countries across Europe and the western world, the EHAC is often asked if there are suitable solutions to the current problems. Although the effectiveness and efficiency of the aeromedical service can be proven by evidence-based evaluations, methodological factors make it difficult to meet this demand for answers at the prehospital stage. It is therefore necessary to start

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designing new research projects in order to find answers to the complex questions, which are troubling many of our members, too. A step in the right direction will also be made at the 15th Air Rescue Symposium – hosted by ADAC Air Rescue – which will be held in Mainz from 29 to 31 October, bringing together the German-speaking HEMS community.

However, the AIRMED conference is and will remain the measure of all things and “the place to be”. It is the world’s only air rescue event of its kind and is designed to stimulate intense and extensive discussion in order to find such answers. The programme for next year’s AIRMED – to be held from 3 to 5 June 2014 in Rome – has been prepared with great care and input from all the major international associations and their representatives, providing us with an essential platform for knowledge transfer and discussion. We would like to invite you to attend this outstanding event and hope that you, together with all the aforementioned representatives, will get the answers that will at least suggest some general trends and help us all set our course for the future.

We hope you enjoy reading this edition!

Erwin Stolpe Medical Director EHAC

140 | 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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HUET and Rescue Training: Petrofac’s STASS course for HEMS crew members

A. Kippen

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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ADAC HEMS Academy: Training in an evolving environment T. Gaßmann

52

“ Medevac 112”: Ireland’s Emergency Aeromedical Service (EAS) D. Figgis

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

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Transferring casualties en masse: Aeromedical missions with large jet aircraft

S. Curnin

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CONTENTS | 5

06

News

EVENTS

12

1 st Hamburg ROW Symposium: A fresh breeze for the Offshore Rescue Chain

14

M. Nielsen, D. Hory, D. Dethleff, et. al

DRF Luftrettung celebrates 40 years: Ambitious plans for future offshore HEMS P. Poguntke

16

AMTC celebrates 30 years: Ö “Yellow Angels” providing EMS from the sky

R. Schüller

17

“ Every tier of the supply chain”: Helitech International 2013 in London

18

“ Unhealthy Dependency”: UK Air Ambulance Charities in Crisis?

T. Bader

TRAINING

24 26

Training requirements within an

aeromed environment: A South African perspective

C. Pedersen Technology

44 46

“ As close to reality as it can get”: Rega’s new Full Flight Simulator Editorial Team

I naer’s SIMULHEMS: University Qualification Course with Simulation

J. Sinisterra

28

Fixed rope procedures: Long line training at Norwegian Air Ambulance

D. Halvorsen

33

“Communication is paramount”: Interview with P. Fauchère on HHO & HEC trainings

Editorial Team

36

NVG-Training: EAAA with UK’s first ever night HEMS mission

A. Rooney, P. Cummings

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“ Bacoban for Aerospace”: Disinfectant for aircraft interiors

K. Bishop

SferiSense: Obstacle and terrain collision avoidance system M. Mämpel

J. Hyde

POLITICS

38 40

UK HEMS: Helicopter Crew Course Medical Module

N. Sinclair, J. Proctor, R. Lyon

In Profile

48

Saving lives in Denmark: Nordic Air Ambulance provides high quality HEMS

R. Buckley

54

T he BARS Program: Risk oversight & management

G. Marshall

Review

58

Stroke Study: HEMS and its influence on thrombolysis rates

V. Reiner-Deitemyer, M. Brainin Case Report

60

Snake on board: Hitch-Hiking on an EMS helicopter

Z. Turocˇ eková Fixed-Wing

65

ECMO retrieval: New opportunities in fixed-wing aeromedical transport

H. Ruge, A. Parasta, U. Krivec

Cover Image: Philipp Franceschini

6 | NEWS SAR contract award: Bristow celebrates Bristow Helicopters marked their successful bid for the UK SAR helicopter service with a celebration event at the Royal Aeronautical Society in London. The event was attended by Bristow Helicopters’ senior management team, staff and a wide range of partners who have assisted the company with their bid and preparations to take over the service. Also in attendance was Heather Bristow, wife of the late Alan Bristow, who founded the company in 1953.

AAA: National Conference 2013 The Association of Air Ambulances (AAA) of UK announced that on 18 November 2013 the National Conference and Awards of Excellence will be held at the Millennium Gloucester Hotel in Kensington, London, giving delegates the chance to engage with others in elegant surroundings. The function will be a one-day event (9 a.m. to 5 p.m.) and will be divided between a main speaker’s room and two plenary rooms in which workshops and additional presentations can take place. Exhibitors will also be taking their place at the event.

The National Conference is “the pinnacle in the annual calendar of events for the air ambulance community.” The event aims to brief, incite debate and inform. Speakers are leaders in their field and always topical, with opportunities for group debate in workshops. The Conference is seen as a chance for the air ambulance industry to come together and network, share ideas and build partnerships. Key Notes will be given by Prof Christopher Moran („Major Trauma Networks in

England: Results From the First Year“), Dr David Rowney („Paediatric Air Transport – The Future“) and Alistair McLean („Ethical Fundraising“). Visit the “speakers” page to see the other topics and interesting discussions that will be going on throughout the day. The Millennium Gloucester has also given delegates of the event a discounted room rate.

››› www.associationofairambulances.co.uk/ event/3/

Bronco crash pilot to thank air ambulance

Bristow SAR

Mike Imlach (middle), managing director Bristow Helicopters, said: “We are honoured to be returning to our British heritage of delivering SAR helicopter services in the UK and celebrating here at the Royal Aeronautical Society, where Alan Bristow was a fellow, seemed a fitting way to mark the occasion. We’re grateful to our fantastic team who have worked hard to deliver the bid, and who are already making the preparations for a smooth transition. We are committed to delivering a world class service here in the UK and look forward to doing so in the coming years.” Mark Duncan, senior vice president (left), and Peter Gay, business development director, Bristow Helicopters (right), also joined the event.

The company was awarded the contract by the Department for Transport in March 2013 and is due to take over the service on behalf of the Maritime and Coastguard Agency from April 2015 onwards. Bristow will operate from ten strategically located bases across the UK until 2026.

Great Western Air Ambulance Charity (GWAAC) is to receive a donation of 5,000 UK-Pounds from a former patient who has gone on to raise funds for the cause. On Tuesday 10 July 2012, Bronco pilot Tony de Bruyn required the services of GWAAC after the plane he was flying crashed at Cotswold Airport near Cirencester. Tony suffered a broken back and severe burns as a result of the accident, and was anaesthetised by GWAAC’s Critical Care Doctor and Critical Care Paramedic at the scene before being transported to Frenchay Hospital in Bristol in the Wiltshire Air Ambulance.

On Friday 14 June 2013, as part of a day of visits to thank the different emergency services

that went to his aid that day, Tony visited Great Western Air Ambulance Charity’s base in Filton, Bristol, to pay thanks to the pilot, Critical Care Doctor and Critical Care Paramedic that went to his aid, and also presented a cheque of 5,000 UK-Pounds to the cause, which was well received by the charity’s Chief Executive John Christensen.

Speaking of his visit, de Bruyn said: “The reason for our visit was to thank all of the people and rescue services who have played such a vital role in my survival after the unfortunate aircraft accident last year at Cotswold Airport.” ››› www.greatwesternairambulance.com

››› www.bristowsar.com

Make your ad space reservation for the upcoming

AirRescue International Air Rescue & Air Ambulance

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GWAAC

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NEWS | 7 New DAA helicopter at the Air Tattoo Visitors to this year’s Royal International Air Tattoo (RIAT) that took place from 20 to 21 July, were in for a special treat as they saw the first public flight of the latest Devon Air Ambulance (DAA), an EC135, which went into service in Devon on 1 September. The Devon Air Ambulance Trust (DAAT), the charity which has funded the purchase of the new aircraft replacing the leased helicopter, and the helicopter manufacturer Euro-

DAA

copter UK had agreed upon that the new helicopter was to be delivered to the Cotswolds to take part in an emergency services role demonstration which involved not only the DAA EC135, but also the Police and Fire & Rescue Service.

In a dramatic recreation of an emergency scenario, the National Police Air Service (NPAS), London Fire Brigade (LFB) and Devon Air Ambulance (DAA) demonstrated their capabilities to the Air Tattoo audience. The mid-day demonstrations at RAF Fairford simulated a major road traffic accident, with an EC145 deploying a specialist crew of the London Fire Brigade and their heavy tooling to remove the car’s roof. Monitoring of the accident scene and downlinking of real-time information to a command base station was provided by a Police EC135 helicopter, while the Devon Air Ambulance performed casualty evacuation from the scene. ››› www.daat.org

Jersey and Guernsey with joint air ambulance Jersey and Guernsey are to have a joint air ambulance facility following the signing of a shared contract on 9 July 2013. According to a news report, the Health and Social Services departments in both Islands have agreed a joint approach for the service to fly critically ill patients to the UK for

NASA

treatment, culminating in signing of the contract with supplier Capital Air Charter. The move, it is said, will save money and ensure continuity for the essential flights for at least three years.

Although Jersey and Guernsey will use separate planes to provide the emergency air transfers, it is estimated that the joint saving will be in the region of 245,000 UK-Pounds per annum for both the Islands. The contract is worth approximately 1 million UK-Pounds per annum for Jersey, and 500,000 UK-Pounds a year for Guernsey. The service to both islands will be provided by Capital Air Charter and was awarded following a tendering process. Capital already holds the contract in Jersey, but will be a new provider for Guernsey for this service. According to the report, figures show that in 2012 Jersey carried out a total of 346 emergency air transfers to the UK, while Guernsey transported 174 patients.

Open heart surgery “at the roadside” The 16-year-old Rayan could have been yet another teenager to die from a knife attack in London. Instead, earlier this year – when he was stabbed in the chest and his heart stopped beating – a London’s Air Ambulance doctor and paramedic were by his side in minutes to perform open heart surgery and administer a blood transfusion at the roadside, literally giving him life when he was clinically dead.

Rayan is one of 100 patients to have received immediate blood transfusion. In March 2012, London’s Air Ambulance became the first air ambulance in the UK to carry blood and administer blood transfusion to critically injured people, suffering from catastrophic bleeding, on scene.

Dr Anne Weaver, Lead Clinician and Emergency Medicine Consultant at Barts Heath NHS Trust, said: “We were confident that carrying blood would make a big difference to our patients but it has exceeded our expectations. Our teams continually push the boundaries in medicine to save lives. London’s Air Ambulance also pioneered prehospital roadside open-heart surgery and we have the world’s highest survival rates from this procedure.” Kent, Surrey and Sussex and Thames Valley Air Ambulances followed the lead and are using LAA’s operating procedures to deliver this procedure to critically injured people in their areas. ››› www.londonsairambulance.co.uk

LAA

Milestone closes deal with Bristow Milestone Aviation Group, a global helicopter operating lease company, announced that it has closed a new 300 million US-Dollars credit facility. The company will use the proceeds to acquire and lease helicopters valued at 400 million USDollars to affiliates of Bristow Group Inc. The assets include Sikorsky S-92’s, Eurocopter EC225’s and AgustaWestland AW189 and AW139 aircraft.

The Milestone facility is the largest-ever for a helicopter leasing company. Lloyds Bank, acting through its Corporate Asset Finance division, was Mandated Lead Arranger and Facility Agent while Lombard, asset finance arm of The Royal Bank of Scotland Group, and Barclays Bank served as Original Lenders for the credit facility. “We are delighted to have closed this innovative, single

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lessee transaction with Lloyds, Barclays and Lombard,” said Richard Santulli, Milestone’s Chairman and CEO. “We structured this transaction with Bristow and worked together to bring it to completion. The proceeds will allow us to continue to support Bristow and grow this important relationship while diversifying our sources of capital.”

Milestone has over 500 million US-Dollars in equity capital and has raised 1.8 billion USDollars in debt commitments from leading banks in North America, Europe and Asia as well as insurance companies and the US capital markets.

The company partners with helicopter operators globally and offers 100% operating-lease financing. In its first year of operation, Milestone had already closed deals with Aeroservicios Espe-

cializados S.A. de C.V. (ASESA), CareFlite, Global Vectra Helicorp, Helijet International Inc., Omni Taxi Aereo and Inaer. ››› www.milestoneaviation.com

8 | NEWS APPGAA: Lobbying for Air Ambulances The first annual reception for the All Party Parliamentary Group for Air Ambulances (APPGAA) of the UK took place at the House of Commons on 11 June 2013. The APPGAA, supported by the Association of Air Ambulances (AAA), aims to raise the quality of care, effectiveness and efficiency of the Air Ambulance Services for patients through closer engagement with political leaders and policy makers. The reception, also an opportunity for the air ambulance community to come together and to network, was opened with speeches by Chair of APPGAA, Guy Opperman (MP for Hexham), and Lord Howe, Parliamentary Under Secretary for Department for Health. Their speeches addressed some of the key objectives of the APPGAA, including the current application of VAT on aviation fuel and access to quality helicopter landing facilities at major hospitals. The AAA lobbies towards establishing helipads suitable for 24-hour-operation and against high VAT rates on aviation fuel.

AAA

Earl Howe also in his speech praised the Air Ambulance Charities who raised in 2010/2011 Fiscal Year £76.6M through public donations.

He went further by recognising the shortage of helipads at major trauma centres and the need for centres to recognise “the important part of the local provision.” Jane Gurney, CEO of Essex & Herts Air Ambulance Trust (right, together with David Amess, MP for Southend West, and Pam Withrington, EHAAT Fundraising & Marketing Director), said: “This event was a great opportunity for the Community to come together and network with MP’s from across the UK about real issues that affect individual charities and the wider issues often faced in the air ambulance world as a whole. The Charity team found the reception to be very beneficial and we look forward to continuing to engage with our local MP’s over the coming months.” ››› www.associationofairambulances.co.uk/ appgaa

Inaer

Spain’s first all-female HEMS crew The Malpartida medical base in Cácares, operated

by Inaer Spain, is now the home of Spain’s first all-female medical helicopter crew. Cácares is a province of western Spain, in the northern part of the autonomous community of Extremadura. The Malpartida crew is made up of pilot Beatriz Parera, medic Gloria Palacios and paramedics Salobrar Sánchez as well as Rocio Ramos from the Extremadura Health Service, and flies an EC135.

Pilot Beatrix Parera says that “the gender of the crew doesn’t matter; what matters is the way the crew and the health professionals work together to ensure successful missions, like those we have seen over the past few days.”

Inaer operates a total of 27 medical aircraft in Spain. In 2012 the company completed 8,228

medical emergency missions and treated 6,658 patients suffering from conditions like trauma, heart attacks, strokes and sepsis, as well as providing neonatal care and transport. Besides medical services, Inaer also focuses on mountain and maritime search and rescue, coastal and fishing surveillance, firefighting, training and aircraft maintenance. Inaer is part of the Avincis Group, the world’s largest provider of aerial services for mission critical operations. The group is based in the UK and serves local markets and customers in Spain, Italy, France, Portugal, Chile, Peru, UK, Norway, Australia and Ireland. ››› www.inaer.com ››› www.avincisgroup.com

ICAR-CISA conference on helicopter rescue The 2013 conference of the International Commission for Alpine Rescue/Commission Internationale du Sauvetage Alp (ICAR-CISA) will be held in Croatia from 15 to 19 October in Bol, on the island of Brac, the third largest among the Croatian islands. Host is the Croatian mountain rescue service, and the gathering’s main focus will be on helicopter rescue procedures. During the 4-day-event, attendees will have the chance to participate in several demonstration sessions, theoretical presentations, showcases and discussions in order to share knowledge, experience and the spirit of the mountain rescue.

On the preconference day, international experts for mountain rescue will deal with the “interface between ground and air rescue”. During the Assembly of Delegates the “future of ICAR” will also be discussed. ICAR president Gerold Biner: “We also need to take some decisions about changes in the statutes.” Vinko Prizmic´,

Head of the Croatian Mountain Rescue Service (CMRS), emphasizes that „although we live in a country that does not have high mountains, the CMRS has developed its maximum capacity and rescue techniques and as such is the vanguard of the region and is a proud member of IKAR-CISA that contributes to the development of the world’s mountain rescue service.”

››› www.ikar-cisa2013.hr

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NEWS | 9 NLR and DLR: joint development of Composite Structures

EHAC and EHA meet in Munich

The lightweight construction of aircraft with carbon fibre reinforced polymers (CFRP) is a dynamically developing field of research. On 17 June 2013 at the Paris Air Show, the German Aerospace Center (DLR) and the National Aerospace Laboratory of the Netherlands (NLR) signed a Cooperation Agreement in the field of Fibre Reinforced Composites. Bas Oskam (NLR Division Manager), Rolf Henke, Michel Peters (General NLR), Horst Hüners (DLR aeronautics programme director) joined the “signing ceremony” (from left to right). Together, both partners will develop production techniques for lightweight components for use in the aviation and transport sectors, which will contribute to a reduction of fuel consumption and the associated carbon dioxide emissions. Rolf Henke, DLR Executive Board Member for Aeronau-

EHAC and EHA experts held a joint meeting on 3 September at Munich Airport. They focussed on the ongoing rulemaking tasks that might affect HEMS operators. In particular, the challenges and potential solutions on FTL for EMS operators (RMT.0346), HEMS performance (RMT.0325/.0326), H-V performance (RMT.0132/.0515) were discussed constructively. EHA president Dr Morassi and EHAC president Dr Müller were pleased with the meeting. It was agreed to continue following the joint path and to adopt resolutions and interventions for improving the actual rulemaking situation for the industry.

tics research: “The focus of the cooperation will be in the areas of automated fibre placement/tape laying techniques, robot assisted manufacturing processes, autoclave technology, high-volume components, and virtual process planning and control.” Both partners operate laboratories and large research facilities for the development and production of lightweight components. Within the cooperation agreement, the partners agree to the mutual opening and provision of research facilities for further development of CFRP technology.

Close cooperation is also envisaged in the field of computer simulations of fibre reinforced polymer production processes. ››› www.dlr.de ››› www.nlr.nl

››› www.ehac.eu ››› www. eha-heli.eu

Part of Weinmann renamed Virtus

meteorological conditions (IMC), day or night and over any kind of terrain.

Tools such as the EDP protocol and technology such as NVGs and Helicopter Terrain Avoidance Systems (HTAWS) are only effective in a culture of cooperation, communication, and compliance. Cultural malignancies in air medical provider organizations have been implicated in too many CFIT, and other types of preventable accidents. NEMSPA’s Cultural Health Assessment and Mitigation Program for Safety (CHAMPS) is a survey-based assessment of an organization’s safety culture, developed specifically for air medical provider organizations. The results of the CHAMPS assessment can reveal weaknesses in a culture that could make an organization more vulnerable to the risks inherent in helicopter EMS operations (Bill Winn, General Manager, NEMSPA).

Weinmann, Business Unit Emergency, was renamed Virtus Emergency Medical Technology. Virtus was set up as an independent company and started operations on 1 July 2013. Virtus comprises of the same team and the same products, and will focus more intensely on the market segments of emergency and disaster medicine as well as medical transport services – not only in Germany, but also on international markets. Virtus Emergency is a family business, owned and operated by the Griefahn and Feldhahn families. An international team of 220 employees work for Virtus Emergency in Research & Development, Production, Administration as well as Sales and Marketing.

The Weinmann brand, logo and products remain unchanged. Well-known Weinmann devices such as the transport ventilator Medumat Transport, the ventilator Medumat Standard or Easy, the defibrillator Meducore Standard, etc. will continue to be marketed under the same names, and also the well-known quality will remain the same. André Schulte, managing director of Virtus Emergency, said: “The only real changes regard the address and telephone numbers for contacts.” Virtus Emergency takes over the production facilities in Henstedt-Ulzburg near Hamburg.

“Thus, we continue to guarantee highest quality for our products and best service,” added Philipp Schroeder, the co-managing director.

››› www.nemspa.org

››› www.virtus-emt.com

NLR

NEMSPA campaigns for CHAMPS The U.S. National EMS Pilots Association (NEMSPA) is mounting an aggressive campaign to eliminate preventable accidents from helicopter air medical transport operations. Controlled flight into the terrain (CFIT) is a recurrent tragedy in air medical flights and NEMSPA’s two-pronged attack is designed to provide the tools and the changes needed to effectively prevent these tragic crashes: NEMSPA is currently seeking additional funding to conduct an empirical validation study of the optimum trigger conditions for the Enroute Decision Point (EDP) protocol that they introduced in 2009. The study will utilize experienced HEMS pilots in a Level D helicopter simulator to observe the pilots’ instinctive adjustments to their flight profile as the visibility and/or the ceiling are progressively degraded in simulated flight. The data gathered will be used to fine-tune the original parameters of the EDP protocol to ensure that use of the protocol by helicopter pilots will prevent inadvertent entry into instrument

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10 | NEWS First five EC135 for HEMS in Turkey THK Gökçen Aviation, the commercial company of the Turkish Aeronautical Association THK, has received the first five EC135s to provide medical airlift duties throughout Turkey. The new helicopters started operations in August. THK Gökçen Aviation and Saran Holding had placed an order for a new fleet of 17 EC135s and the contract was signed in May this year. The purchase agreement was signed by Prof. Dr Ünsal Ban, Rector of the University of THK, Aeronautics & Astronautics; F. Volkan Yilmazer, General Manager of THK Gökcen Aviation; Osman Yildirim, President of THK as well as Vice President of FAI; and from Eurocopter’s Luisa Alberti, Marquard Heimhofer, Peter Feyerabend and Reiner Heimbach (from left to right).

THK Gökçen Aviation and Saran Holding will deploy a fleet of 17 EC135 to ensure HEMS in the framework of a five-year contract with the Turkish Ministry of Health. The remaining helicopters will be delivered in spring 2014. Eurocopter has

Eurocopter

been present in HEMS operations of the Ministry of Health in Turkey since 2008. A total of more than 1,100 EC135 have been delivered worldwide, and more than 500 of these helicopters are in the EMS configuration. The EC135 combines a wide, unobstructed cabin with good performance,

range and payload capacity – along with lownoise operations. The helicopter’s large sliding side doors and rear clamshell doors enable fast loading/unloading of patients. ››› www.eurocopter.com

Flying Doctors India launches service

Flying Doctors India launched its first air ambulance service on 8 June 2013 in the national capital New Delhi. The dedicated chartered aircraft is equipped with ICU equipment. The goal is to provide critical care to patients on air ambulance and repatriation flights. The air ambulance medical crew is the same

team of doctors who flew the Delhi gang rape victim to Singapore in December 2012. “Earlier, whenever we got a call, we would take a private aircraft, tape off the chairs and fit our equipment in. It was basically a temporary fix. Now we have a dedicated air ambulance ready for all emergency services,” Dr

Naresh Trehan of Medanta Medicity told the Delhibased Indian News Channel NDTV. With the air ambulance, Flying Doctors has taken a leap. According to the news report, the “response time” now “is just 20 to a maximum of 90 minutes”. Before that, it took doctors and medical crews three hours to prepare the aircraft. Another timesaver is the aircraft’s longer endurance level of up to seven-and-a-half hours, unlike earlier, when the aircraft would have to stop after 3 hours for refuelling. “This could perhaps mean a matter of life or death for a patient”, Dr Trehan says. However, hiring the aircraft it still not at low cost. It can cost at least 50,000 Indian Rupees per hour (approx. 600 Euros). The aircraft can cater to patients even in smaller cities with the air ambulance having rough field capability so that landing on unprepared landing sites is also possible. ››› www.flyingdoctorsindia.com ››› www.medanta.org

Nepal’s Shree Airlines with 8 Ecureuil orders Nepal’s Shree Airlines has placed an order for eight Ecureuil helicopters – comprising five AS350 B3e and three EC130 T2 – for use in SAR, aerial work, disaster relief missions and heli-tourism.

Shree Airlines, a leading helicopter operator in Nepal, is increasing its fleet of Ecureuil helicopters after successfully operating one AS350 B3e which arrived in February this year. With the additional orders, Shree Airlines becomes the biggest operator of the Ecureuil fleet in the South Asia region with a total of nine aircraft, comprising six AS350 B3e and three EC130 T2.

The AS350 B3e will be used in SAR, aerial work and disaster relief missions, whereas the

EC130 T2 is to perform tourism operations. First deliveries of the Ecureuil family aircraft for Shree Airlines will begin from early 2014. Both the AS350 B3e and EC130 T2 are members of Eurocopter’s rugged and proven Ecureuil family, and also are the latest members of their respective helicopter types. The AS350 B3e evolved from the high-performance AS350 family. Today, approximately 5,350 Ecureuils have been delivered in 130 countries to some 1,600 operators. These aircraft have accumulated close to 25 million flight hours. ››› www.eurocoptersea.com.sg

EC / J. Deulin

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NEWS | 11 New flight rules for Australian air ambulances The Civil Aviation Safety Authority (CASA) of Australia proposed new flight rules for air ambulances. Rescue flights then will have to adhere to better safety standards. Under the new proposals, air ambulance services like CareFlight HEMS will be included in the aviation safety regulations covering passenger transport operations. So far, Australian air ambulance flights are only covered by aerial work regulations. CASA says higher safety standards are needed, given the “passenger-carrying nature of their operations”. The proposal has

CareFlight

been welcomed by CareFlight’s executive director of flight operations-commercial, Jeremy Ovens: “We are still reviewing the proposal and CASA has asked all air ambulance operators for feedback.”

Mr Ovens went on saying, “the proposed changes are seen to be a positive move for the industry as a whole, as it “puts more onus on the operators to make sure their crews are better trained and that safety standards for all aircraft are at a consistently high level.” The move would not require more work from CareFlight, as the service “already operates in accordance with these rules” with the medical helicopters and jets, but it will help improve and standardise the air medical industry across the board. CASA argues the benefits of the proposed changes include ensuring a “higher level of training and checking for pilots” as well as “fatigue risk management” that is so specific to aeromedical operations. ››› www.casa.gov.au

Norway SAR bid Norway currently procures a new fleet of SAR helicopters. It had shortlisted two bidders for SAR procurement contest and invited them to further negotiations for the replacement of the current Sea King fleet. The two bidders selected are AgustaWestland and Eurocopter. The procurement includes up to 16 new SAR helicopters with an option for additional 6. The project target is that the contract will be awarded by the end of this year and the last Sea King phased out by end 2020.

The administration is due to make a decision this autumn on a proposed 17 billion Norwegian Krones (2.8 billion US-Dollars) investment to replace the Sea King aircraft, which are more than 40 years old. According to a report on Norwegian state TV channel and other sources, there are three alternative models the administration regards as suitable for Norwegian SAR operations: the AW101 (Canada operates a variant of the AW101 in SAR), the EC225 Super Puma and the

AgustaWestland

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AW189. The AW189 SAR is an 8-tonne helicopter capable of long-range, deep water missions, it has capacity of 2 stretchers, 6 seated persons and additional standing persons. The SAR configuration of the EC225 allows for the SAR equipment with an operator seat, hoistman seat and up to 8 rescue seats as well as 3 stretchers.

The continued inclusion of the Super Puma (the same model that was involved in a fatal crash off the UK end of August) in the ongoing helicopter tender evaluation process has fuelled some concerns. Officials however stated that the different models are still under “intense evaluation” and suggested the latest accident – the third incident involving a Super Puma in just over a year – would not materially affect the process: “The way we see it, the Super Puma is a safe helicopter with millions of flying hours behind it, so this has no real bearing at the moment.” ››› www.agustawestland.com

Wysong completes Hospital Wing’s first EC130 B4 Wysong Enterprises announced the completion of Hospital Wing’s first EC130 B4: “We started our relationship with Hospital Wing two years ago,” said Vice President Rodney Wysong: “We take pride in our role in making sure they are equipped with high quality products and were thrilled to be selected to complete their first EC130 B4.” The installation work is one of several EMS aircraft to pass through Wysong’s shop in 2013. So far, Wysong has delivered five 407s and has another 3 in-house and two more scheduled.

Wysong

Hospital Wing is a nonprofit air medical transport organization, which provides interhospital transfers as well as emergency scene calls within a 150-mile-radius of Memphis. “The first aircraft Wysong refurbished for us in 2011, was on one of our AS350 B3s”, said Director of Maintenance, Glen Wilson. “We chose Wysong because they exceeded our expectations with the first aircraft. There’s just no comparison to their quality of work.” The chopper was equipped with a full medical interior and several avionics and safety modifications. Some of those modifications include Cobham HeliSAS 2 Axis Auto Pilot, Garmin G500H EFIS System, an Aviation Specialties Unlimited Night Vision Modification, Avidyne Traffic Advisory System and a KRA-405B radar altimeter. ››› www.wysongusa.com

OEAMTC chopper “under fire” An EMS helicopter operated by Austrian OEAMTC drew a gunshot recently. Another chopper had to replace “Christophorus 9”, which was hit by a 9 mm projectile. The bullet had pierced one rotor blade of the helicopter. Crew members did not notice the incident that luckily did not cause any major damages and did not leave anyone injured.

Ralph Schueller of OEAMTC said that the incident must have occurred most probably during a HEMS mission on the day before the bullet hole was discovered. The pilot of “Christophorus 9” in Aspern, Vienna, did not notice anything suspicious either. Police is currently investigating the case.

A replacement helicopter from Wiener Neustadt (Vienna New Town) was in service substituting the damaged chopper. During another incident, an EMS helicopter had been attacked by laser pointers in March this year while transporting a neonatal patient to Donauspital in Vienna. ››› www.oeamtc.at

12 | EVENTS

Fig. 1: Research findings, also discussed at the symposium, show that environmental and marine parameters in the North and Baltic Sea have a strong influence on the offshore rescue chain (Bond)

1st Hamburg ROW Symposium: A fresh breeze for the Offshore Rescue Chain The BG Trauma Hospital Hamburg (BUKH) hosted the 1st Symposium on the research project “Offshore Wind Rescue Chain” (ROW) on 26 and 27 April 2013. The overall aim of the ROW project is to develop a multidisciplinary rescue chain for trauma patients and acutely sick workers in offshore wind farms, specifically tailored to the requirements of the offshore wind energy operating area.

Authors: Maja Nielsen Dorothea Hory Dirk Dethleff Markus Stuhr Klaus Seide Nils Weinrich Christian Jürgens Berufsgenossenschaftliches Unfallkrankenhaus Trauma Hospital Hamburg Germany

Researchers from different scientific fields are part of the ROW project, which also serves as an independent platform for exchange of information and discussing current challenges as well as to set up new benchmarks in offshore medical care. Funded by the Institution for Statutory Accident Insurance and Prevention for Trade and Merchandise Distribution (BGHW), various departments – like the Department of Trauma Surgery, Orthopedics and Sports Traumatology, the Department of Anesthesiology, Intensive Care and Emergency Medicine, Centre for Pain Therapy as well as the Laboratory for Biomechanics – contribute to the project under the leadership of the BUKH medical Director, Prof. Dr. med. Ch. Jürgens.

The research project commenced in spring 2012.

Preliminary results were presented at the VDI Knowledge Forum in Bremerhaven in October 2012 on “Health, Safety & Environment at Offshore Wind Farms”. Now, after one and a half years of intense networking and interdisci-

plinary research, the ROW team invited experts from all offshore fields to critically analyse first results and to give prospects on future challenges. Participants of the symposium in Hamburg at the Trauma Hospital, presented their research projects and also proposed concepts for current offshore challenges and approaches for future solutions to the offshore community. The presentations covered medical, technical, logistical as well political topics. On the second day, the ROW team summarized current rescue concepts and gave an overview on scientific tools found in emergency medicine.

Telemedicine and ALLFlight system The opportunities of telemedical devices in supporting first responders in complex emergency scenarios was intensely discussed. Teleconsultancy is also regarded as a feasible alternative to consulting the “family doctor” in case offshore employees fall ill with minor ailments. The

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EVENTS | 13

Aachen research project called TemRas was also presented. This concept aims at encountering the decreasing numbers of doctors in less populated areas in Germany by the use of an innovative telemedic paramedic system that was introduced in 2012. Additionally, PrimAir, a research project funded by the German Federal Ministry of Education and Research, analyses, if airborne primary rescue in remote areas is a feasible alternative to land-based EMS in order to provide a quick and efficient way to transport EMS doctors to the incident scene. Nevertheless, one has to bear in mind that onshore rescue strategies are not seamlessly transferable to the offshore context.

Theoretical and empirical scientific research findings show that there is a strong influence of the environmental and marine parameters in the North and Baltic Sea on the offshore rescue chain: High waves and water salinity, high wind speeds as well as wind turbulences, floating ice, darkness, fog, rain and hail may potentially endanger water- as well as air-bound rescue scenarios. Rescue vessels and helicopters respectively show different degrees of durability under such specific environmental conditions.

This still needs to be evaluated, also in order to define their suitability in different rescue scenarios.

The German Aerospace Center (DLR), Institute of Flight Systems, launched a research project that investigates questions regarding operational helicopter flight systems, which technically support pilots and on-board rescue teams during risky flight manoeuvres (ALLFlight). Such systems may be used to identify the exact distance between the rotor and the wind turbine tower and may help to increase safety in low distance operating procedures, for example rescue procedures from a wind turbine. Furthermore, landing on uneven ground and safe hoisting of patients or HEMS crew members (downwash) are subject of current investigations.

Slip, trip and fall accidents Moreover, the patterns of injury play an important role in the choice of live saving devices. The ROW team presented first research results on patterns of injury in onshore wind parks and compared them to potential offshore scenarios. In summary, most accidents involve the upper and lower limbs in terms of slip, trip and fall accidents.

The time gap between accident and professional medical

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aid plays an important role in remote offshore working environments.

In this context, it was also discussed if it is possible to bridge this gap by deploying highly qualified and specially educated offshore personnel or rescue-professionals that are based “offshore”. However, to make a valid statement concerning exact circumstances of accidents, patterns of injury and currently practiced rescue operations, it is essential to implement an offshore workflow database.

The ROW team pointed out that a centralized registration of all medical wind park incidents could be a useful tool for a scientific evaluation of offshore accidents as well as acute diseases. This approach should subsequently lead to a significant enhancement of emergency treatment and to specific prevention of illness and accidents offshore in the long term.

The ROW team is also involved in the development and advancement of algorithms and guidelines covering the entire rescue chain, from first aid to transportation and rescue via helicopter and/or by vessel to a coastal clinic. The ROW team suggests introducing a “competence network” of all potentially involved coastal clinics at the North and Baltic Sea to increase the awareness for offshore accidents by a constant exchange of information.

The network may spearhead the implementation of the above mentioned offshore database. Furthermore, it was emphasized that efficiency of the therapy, when dealing with offshore accidents, would allow particular hospitals to highly benefit from this.

Rescue procedures in the offshore industry surely are a challenge to the German social and health in­ surance system. In this context, viabilities of a health insurance for workers from non-European countries have to be discussed and realistic scenarios have to be developed. The offshore work field, which is geographically defined by the German 12nm-zone and the Exclusive Economic Zone (EEZ) of both the North and Baltic Seas, holds many judicial obstacles that will take a long time to be resolved.

The symposium closed with a vivid and beneficial discussion that again highlighted the complexity of the offshore wind energy business, but also illustrated a major aspect of the work in the offshore community: “Offshore is teamwork”. 

Fig. 2: “Offshore is teamwork”: Dr. Nils Weinrich, ROW project coordinator, discussed first results as well as prospects for future developments (BUKH) Fig. 3: The 2nd symposium on the research project „Rescue Chain Offshore Wind (ROW)” will be held on 24 and 25 February 2014 (BUKH)

For more information, visit: ››› http://tinyurl.com/pdyy9up You may also contact row@buk-hamburg.de

14 | EVENTS

DRF Luftrettung celebrates 40 years: Ambitious plans for future offshore HEMS It wasn’t just past successes, but also ambitious future plans which took centre stage at the ceremony marking the 40-year anniversary of the German DRF Luftrettung. In the press conference, chairman Dr Hans-Jörg Eyrich pinpointed the new business areas, which DRF Luftrettung will be focusing on as part of efforts to obtain additional funding for the air rescue service. One of the key ambitions is to break into the emerging offshore rescue market. DRF already has a base in Husum on the North Sea coast. Eyrich stressed that this initiative will be limited to air transport of patients from oil rigs and offshore wind farms and will not provide any further medical support for these facilities. now been conducting a cross-border joint venture with the rescue service provider Falck. “DRF will not participate in any more tenders there,” stressed Eyrich and, in response to questions regarding the partnership with Falck, he stated, “You can expect some changes to take place.”

EC145 T2 and Learjet 45 Fig. 1: Interior minister of the state of Baden-Württemberg, Reinhold Gall, stressed that the government had succeeded in setting aside a further 3.2 million Euros of state funds for the air rescue service (DRF Luftrettung)

The Learjets owned by DRF Luftrettung will in future be used to perform calibration flights for the purpose of radar flight testing, when not needed for their original purpose.

In line with this initiative, the number of technical services – which DRF Air Rescue has integrated into its Operations Center at Baden Airport near Karslruhe – should also be made available to far more external customers.

For example, the 14 docks there could also be used for maintenance work on police helicopters.

Author: Dr Peter Poguntke Editor-in-chief AirRescue Magazine

Withdrawal from Denmark Many people were surprised by the announcement that DRF intends to pull out of Denmark, where it has up to

Indeed, DRF Luftrettung’s future plans require a clear focus on the most essential aspects. One of these priorities is the purchase of a large number of new EC145 T2 helicopters. This new version of the EC145 offers far more and unobstructed cabin space. It is being developed by DRF in partnership with ADAC Luftrettung and Bucher, the Swiss HEMS interior specialist. The plans furthermore envisage an increase in the number of stations in 24-hour operation. Up till now, only eight of the 31 DRF bases provide a 24/7 service. The importance of having such stations in the state of Baden-Württemberg was emphasised in a speech by interior minister Gall, who is responsible for the ambulance and EMS services. Seven of the eight HEMS bases in Baden-Württemberg are operated by the DRF alone. A further high-cost project is the renewal of the fixed-wing fleet, which comprises three aircraft. These aircraft will be fully converted into Lear 45 jets. It therefore comes as no surprise that Stuttgart-based DRF will in future also focus on consolidating its various subsidiaries and acquiring more sponsoring members – currently it has around 362,000 sponsoring memberships.

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EVENTS | 15 Technological pioneers DRF Luftrettung would not have been possible without its founder, Dr Siegfried Steiger and his wife Ute, described in a speech by the chairman of the organisation’s Supervisory Board as “visionary and resolute campaigners of an idea.” Once again, he looked back to the organisation’s modest origins, to a time when many people still considered the idea of a nationwide air rescue service in Germany to be quite extraordinary. Just 300 missions were undertaken in 1973, by what was to become DRF Luftrettung in the first year of its existence. In the past year, there have been 38,000 missions. “DRF Luftrettung has played a special pioneering role throughout the past four decades”, said Nanz, alluding to developments such as the DRF Rescue Track system. This system allows all control centre dispatchers to locate helicopters and see their readiness for deployment. However, Nanz also recalled the problems which the air rescue service is currently facing: “Ever-increasing demands, including those from Brussels, are making our work difficult, they increase costs and create masses of red tape.” Other factors are the 170% rise in the cost of jet fuel over the last 10 years and the conversion to digital radio, which costs 100,000 Euros for each helicopter.

State funds for DRF Demographic growth and its ramifications are matters which minister Gall addressed in his speech: “It will take lasting efforts – particularly in less developed areas – to meet the needs of a healthcare situation which is increasingly deteriorating due to the lack of doctors and the focus on the hospital sector.” The minister stressed that BadenWürttemberg had succeeded in setting aside a further 3.2 million Euros of state funds for the air rescue service.

From this sum, large investments have been made into the air stations in Leonberg and Villingen-Schwenningen.

A review of the rescue service plan in Baden-Württemberg is expected to bring about further improvements.

“The rescue time is just a performance indicator; what’s equally important is the optimum use of resources by dispatchers in the integrated control centres, a high level of care at the scene and fast transfer times and treatment in the right hospital,” explained Gall. He added that there will be new regulations to govern the dispatch of air rescue resources: “It is necessary to ensure that air

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rescue resources are only dispatched in situations where they are the most suitable option.”

Facts & Figures: DRF Luftrettung

The Operations Center – an economic factor

• A total of 700,000 missions undertaken since 1973

Anyone who had not yet seen DRF Luftrettung’s Operations Center, which was only commissioned in January 2013, had this opportunity at the ceremony. “Our centre has been expanded by over 5,000 m2 to become an important economic hub within the region,” stressed DRF Chairman Steffen Lutz. The DRF headquarters at Baden Airpark is where all the EMS helicopters and air ambulances are maintained and where all the pilots are trained.

Aircraft mechanics are trained on the site and further education programmes are offered for both internal and external technicians. DRF Luftrettung has invested around 9 million Euros into this facility, which includes the following departments: • The technology department with its 14-bay hangar, design team and CAMO (responsible for the airworthiness of aircraft equipment); each section of this department has been approved by the European regulatory body EASA; • Helicopter operations; • Quality management; • Air ambulance operations; medicine, aircraft and alarm centre for coordinating global operations; • Central coordination office in Baden-Württemberg (commissioned by the interior ministry in conjunction with the German Red Cross) for providing both groundlevel and airborne intensive-care transport in BadenWürttemberg.

Who better to give an account of the air rescue service than those who put their heart and soul into their work, those who owe their lives to the air rescue service and those who have given decades of fully committed support.

A selected group of these people were invited to speak at the 40th anniversary. These were a Bremen-based pilot, the head of Medical Technology, the head of Design at the Operations Center and four patients who described their experiences. Some of them were brought to tears as they thanked their rescuers, who also attended. On behalf of all the organisation’s members, Helmut Nanz expressed his gratitude to three members who have supported DRF Luftrettung ever since it started 40 years ago. 

• 700 EMS doctors, 300 paramedics, 160 pilots, 80 technicians • 31 bases in Germany, Austria (ARA) and Denmark • 51 helicopters (23 BK117, 17 EC135, 7 EC145, 4 Bell412) • 3 jets (2 Lear 35A, 1 Lear 45) • 362,000 members

Fig. 2: Without its founder, Dr Siegfried Steiger and his wife Ute, DRF Luftrettung would not have been possible Fig. 3: On behalf of all the organisation’s members, Helmut Nanz expressed his gratitude to three sponsors who have supported DRF Luftrettung ever since it started 40 years ago (DRF Luftrettung)

16 | EVENTS

ÖAMTC celebrates 30 years: “Yellow Angels” providing EMS from the sky The Austrian Automobile, Motorcycle and Touring Club (ÖAMTC), Austria’s largest automobile club, has a large fleet of mobile roadside mechanics in yellow cars that assist motorists in trouble - the “Yellow Angels”.

Just like the ADAC automobile club in Germany, ÖAMTC has always been known as a rescue organisation, too, as it operates a large fleet of EMS helicopters, the “Christophorus” choppers, also known as “Yellow Angels”. The EMS provided from the sky is in keeping with the vision of a “Yellow Angel” coming to people‘s aid. The main reason behind the club‘s involvement in this field was mainly the rapid increase in the number of road traffic accidents three decades ago and the challenges posed by salvage operations and emergency aid in the Alpine regions.

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

Author: Ralph Schüller ÖAMTC Schubertring 1-3 1010 Vienna Austria

It is not about how quickly the patient is taken to the hospital, but rather how quickly the EMS doctor reaches the patient; this principle of modern-day emergency care prompted the commissioning of the first ÖAMTC EMS helicopter in 1983. Nowadays, it would be hard to imagine rescue services in Austria without these airborne emergency operations.

However, 30 years ago, it took some strong and forthright words from the Austrian university professor Dr Gerhard Flora, who at that time criticised the prevailing situation in the accident rescue service to spur the ÖAMTC into action. On 1 July 1983, Austria’s first EMS helicopter, “Christophorus 1”, was stationed at Innsbruck Airport, marking the start of a rapid development process.

Two years later, the Austrian interior ministry and ÖAMTC combined their HEMS resources to provide a nationwide air rescue service and the terms “EMS doctor” and “Critical Care Paramedic” became established as professional titles.

In 2001, the “Christophorus” Air Rescue Association (Christophorus Flugrettungsverein) took over the government-owned airbases. On 23 July 2002, “Christophorus Europa 3” was commissioned for operations on the German-Austrian border, becoming the first ever EMS

helicopter to serve two different countries. With “Christophorus 15”, which is based in the small town of Ybbsitz in Lower Austria (operational since 25 June 2005), and “Christophorus 16”, which is based in the town of Oberwart near the Hungarian border (officially commissioned on 1 January 2006), the ÖAMTC air rescue service has now expanded to operate 16 airbases all year round.

In good visibility, the ÖAMTC EMS helicopters can now reach almost any location in Austria within 15 minutes. As of late 2010, the cooperation agreements which ÖAMTC had maintained with the interior ministry since 2001 were discontinued due to sky-rocketing costs.

In early 2012, solutions were outlined for all nine Austrian states to safeguard the middle-term financial future of HEMS. Around 249,000 missions have been undertaken since 1983, providing aid to almost as many patients.

These missions have saved many lives and prevented a large number of people from suffering long-term health problem. The effective provision of EMS “from the sky” is underpinned by the highly professional teams in various organisations – ÖAMTC, the mountain rescue service, the Red Cross and the Vienna ambulance service – who work together day in day out to help people in their hour of need. 

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EVENTs | 17

“Every tier of the supply chain”: Helitech International 2013 in London Helitech International, the largest dedicated helicopter exhibition in Europe that represents every tier of the supply chain, is a must-attend event for anyone involved in the rotary wing industry. Taking place at ExCeL in London from 24 to 26 September and organised by Reed Exhibitions, Helitech International is being staged in association with the European Helicopter Association (EHA) and is supported by the British Helicopter Association (BHA) as well as leading industry primes, such as AgustaWestland, Bell Helicopter, Eurocopter, Russian Helicopters, MD Helicopters, Pratt & Whitney, Sikorsky, Rolls Royce and Turbomeca.

Author: John Hyde Helitech International Exhibition Director

Overcoming “hours of darkness” More than 220 companies – including operators and HEMS providers – from 23 countries will exhibit at the Helitech International in London. One of the HEMS providers is the East Anglian Air Ambulance (EAAA), which operates in the UK across the counties of Norfolk, Suffolk, Cambridgeshire and Bedfordshire. The EAAA will promote its service as the first in the UK to be granted permission to fly HEMS missions at night, which was confirmed in May 2013 (see also the article on pages 36-37). Following 18 months of hard work from EAAA and its aircraft operator, Bond Air Services, the charity is now flying to incidents which occur during the hours of darkness using Night Vision Imaging Systems (NVIS) and 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 during dark as well as daylight hours. In order to operate at night, the aircraft is specified with an instrumentation system and external lighting, compatible with Night Vision Goggles.

Reducing stray light Trakkacorp will use Helitech International to extol the benefits of its Trakkabeam A800 steerable searchlight. The product, also used by the EAAA, utilises a Xenon lamp half the size of traditional searchlights to deliver a more intense and consistent beam. The precision design of the optical element in relation to the arc source is responsible for the effective collimation and reduction of stray light.

This eliminates the black hole that obscures the centre of vision of conventional searchlights. The Trakkabeam A800 has no black hole and provides an even beam with energy at the edges to avoid lost targets.

The Helitech International Conference will open on the afternoon of Tuesday 24 September and run through until the afternoon of Thursday 26 September. Building upon the success of 2011, Reed Exhibitions has researched the market and expanded the conference in order to enhance its appeal to international audiences, creating an unrivalled educational forum for the helicopter industry.

Key themes to be addressed include • • • • •

Fig. 1: More than 220 companies – including operators and HEMS providers – from 23 countries will exhibit in London at the Helitech International at ExCeL (Helitech International)

The future of the rotorcraft sector; Night-time HEMS; Rule making – open Issues; Business challenges and opportunities and Financing the future.

CE approval for Lite Flite Danish company Life Flite, will use the exhibition to promote its complete range of rescue equipment used for helicopter rescue operations. Life Flite was the first company to obtain CE approval of its equipment back at the beginning of the year. The equipment includes all belts and straps used by rescue crew aboard helicopters as well as the classic orange rescue sling strop used to rescue injured people.

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In addition to the Helitech Conference, for the first time there will be a series of free-to-attend workshops on safety. The foci will be on on training, maintenance, health usage monitoring as well as on developments in SMS, flight safety and flight data monitoring. The European Helicopter Safety Team and International Helicopter Safety Team will host these in conjunction with the Global Helicopter Flight Data Monitoring Steering Group. 

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

18 | POLITICS

Fig. 1: London’s Air Ambulance (LAA) responds only to major trauma incidents, whereas other HEMS operators also undertake inter-hospital transfer (LAA)

“Unhealthy Dependency”: UK Air Ambulance Charities in Crisis?

The Association of Air Ambulances (AAA) of the United Kingdom responded to a critical article published in The Guardian mid-July by reassuring the British general public that air ambulances are not in crisis.

The article “Emergency services: air ambulances charities in crisis” by Guardian journalist David Brindle had stated that air ambulance charities “have been set up across the country with no overall planning, no agreed funding and no clear, bespoke system of regulation.” Brindle criticizes that consequently there “is an imbalanced patchwork of services, heavily skewed towards southern England, all relying to some degree on charitable donations but some receiving much more state support than others.

Unsurprisingly, there are tensions and rifts.”

The AAA refutes this position and emphasizes “air ambulance operations across UK have never been stronger or more effective.” Since the introduction of the Major Trauma Network, survival rates had improved and “air ambulances have played a significant part in that success”, the AAA argues and refers to a recent report commissioned by the National Health Service (NHS).

Role of services varies widely

Author: Tobias Bader Editorial Team AirRescue Magazine

It is however undeniable that the “precise role of the individual services varies widely”, as London’s Air Ambulance (LAA) for example responds only to major trauma incidents, whereas other HEMS operators also undertake inter-hospital transfer. Crew member configuration also varies: whereas LAA always has a paramedic and a HEMS doctor on board as well, most other services carry only a paramedic.

The article in The Guardian also quotes Andy Williamson, chief executive of the Air Ambulance Service (AAS) which operates two services, one for Warwickshire and Northamptonshire and another for Derbyshire, Leicestershire and Rutland, who estimates that the NHS is putting around 60 million UK-Pounds per year into air ambulances, in spite of the fact that some charities are “sitting on big cash reserves” and still taking state aid. He suggests pulling together “to use some of this money better.”

The “Matthew effect” The “Matthew effect” also holds true in the case of the air ambulance scene in the UK: Eminent services often get more credit and funds than comparatively smaller and less known charities, even if their quality of work and outcome is similar. Williamson (AAS) also criticizes “unacceptable practices” elsewhere and argues in favour of joint operation of services by one organisation “which is more efficient and cost-effective and brings demonstrable patient benefits.”

The article in The Guardian gives the example of LAA, “which in the past has had sponsorship from Express Newspapers and Virgin, had 18 personnel seconded from the NHS in 2011/2012 at a value of more than 1.2 million UK-Pounds. In addition, the charity received an NHS grant of almost as much again, representing more than a third of its cash income.”

The Association of Air Ambulances, which is representing three quarters of air ambulance services and the leading helicopter leasing operators across the United Kingdom, was disappointed with the article and responded by stating that air ambulance charities “work very closely with their local ambulance services to provide a first class, innovative and coordinated service, ensuring that the needs of the patient remain the number one priority.” 

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15. Fachtagung Luftrettung October 29th – 31st 2013, Rheingoldhalle Mainz, Germany HEMS –– EMERGENCY Part of BasicMEDICINE Emergency Medical Service 24 / 7?!

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Safety management, safety culture and crisis management in high reliability organizations

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Staff qualification in HEMS and ambulance flights

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Updates in emergency medicine – hot topics

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Offshore Emergency Medical Services

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Evidence-based medicine – presentations on research projects

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For further information please contact: MCN Medizinische CongressNeuwieder Str. 9 organisation Nürnberg AG 90411 Nuremberg, Germany

Or visit us online: www.fachtagung-luftrettung.org

Please note that the entire program will be held in German.

+49 (0) 9 11 393 16 21 +49 (0) 9 11 393 16 78

fachtagung-luftrettung@mcnag.info

ADAC-Luftrettung GmbH Gemeinnützige Gesellschaft

20 | TRAINING

Fig. 1: The HUET trainers, built to resemble the inside of a helicopter cabin with seating, harnesses and windows, are hoisted over the pool and used to simulate a helicopter ditching, sinking and capsizing (Petrofac Training Services)

HUET and Rescue Training: Petrofac’s STASS course for HEMS crew members Petrofac Training Services provides a host of different courses for the marine industry, ranging from Survival and Rescue training to Health and Safety and Emergency Management. Petrofac Training’s European sector, based in Aberdeen, Scotland, provides courses for workers travelling worldwide.

The Petrofac Training Survival Centre provides a number of courses for those working offshore within the oil and gas industry and renewables sector, for those working with Helicopter Emergency Medical Services (HEMS) and if required by clients, bespoke survival courses. These courses cover a number of theoretical and practical areas of self-rescue and survival to ensure trainees become competent in the use of survival equipment, helicopter escape and safety procedures.

Author: Adam Kippen Survival and Marine Instructor Petrofac Training Services

Petrofac Training’s excellent facilities allow them to run a number of courses every week. Fully equipped classrooms allow for extensive theoretical work to introduce the delegates to emergency survival equipment, sea survival techniques, basic first aid procedures and the safety procedures relevant to their workplace.

The pool hall, which consists of two large three-metre deep pools, is where the delegates first put their theoretical knowledge to practical use. They will use the survival equipment, practice survival techniques and carry out their helicopter escape assessments. The Helicopter Underwater Escape Training (HUET) forms a large part of the courses at Petrofac Training. In order to simulate a ditching scenario the HUET trainers are used. These trainers are built to resemble the inside of a helicopter cabin with

seating, harnesses and windows. These are then hoisted over the pool and used to simulate a helicopter ditching, sinking and capsizing. Each of these is designed to represent different scenarios where the delegates will have to follow practiced procedures to use emergency equipment, jettison windows, release harnesses and escape from the given situation. This is perhaps one of the most challenging assessments within the courses.

Safety is the top priority at Petrofac Training and all the instructors are trained to deliver the theory and practical modules safely, in a controlled environment. The instructors come from a variety of backgrounds, ranging from medical staff to divers and ex-military personnel.

Furthermore, each instructor has an individual training programme that he or she follows to allow him or her to

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TRAINING | 21 deliver each of the course modules. This staff training programme and the wealth of knowledge and experience among the staff allows the instructors to deliver course material to the highest standard.

The Training Courses Petrofac Training offers a number of different survival courses depending on the needs of the customer. Basic Offshore Safety Induction and Emergency Training (BOSIET) and Further Offshore Emergency Training (FOET) are the two primary survival courses required by offshore oil and gas workers. These courses are based around selfrescue in terms of helicopter escape, sea survival and fire/smoke filled environments. Petrofac Training also provides the Short Term Air Supply System (STASS) course that is attended primarily by the doctors and medics that make up the HEMS teams. The threads that are repeated in all of these courses are the helicopter escape assessment, the use of emergency breathing Systems (EBS) and the use of sea survival techniques.

Short Term Air Supply System (STASS) The STASS course is a self rescue course aimed at providing those who are part of the HEMS crews with the skills and knowledge needed to escape a ditched helicopter and maintain themselves until picked up by SAR. Delegates spend half of the day-long STASS course learning the theoretical knowledge behind procedures and equipment, while the second half of the day consists of a practical in-water session where they are assessed on their sea survival and helicopter escape skills. The day begins with the theory session for the STASS. The STASS theory consists of different pieces of equipment and procedures that they would be required to use in the event of a ditching on water. The delegates are required to use STASS, often introduced as Helicopter Emergency Egress Device (HEED), an emergency breathing system that consists of a compressed air cylinder, regulator and mouthpiece, a small compacted SCUBA (Self-Contained Underwater Breathing Aparatus) system.

The system specifications are also introduced, 200 bar pressure and 48 litres of air, which provides trainees with just 30 breaths available for escape. The delegates at this stage are also introduced to the components of the system including the regulator, pressure gauge, exhaust port and purge button. Delegates are responsible for inspection of the system prior to flight; hence they are introduced to these checks during the theory and assessed on this during the practical. Once the delegates are comfortable with the Short Term Air Supply System theory, they are taught the procedures for using the system. This includes: how the system is deployed from the life jacket, how to clear the regulator if it has filled with water and how to keep a good seal around the mouthpiece.

Petrofac Training Services teaches safety as a matter of the highest importance and breathing compressed air at depth presents a number of hazards. Therefore the delegates are introduced to basic gas laws, diving theory and the potential diving related injuries and methods through which these injuries can be avoided.

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The theory then moves onto the procedures that should be taken in the event of a helicopter ditching.

First of all looking at their initial actions in the event of a problem with the aircraft; delegates should make sure that their harness is secure, that they can locate the STASS unit and that they can also locate their life jacket inflation toggle. Once these checks are done, they should adopt the “Brace” position until touchdown on the water when they will adopt the “Locate” position which consists of immediately finding the harness release with one hand and the nearest exit point with the other. This position should then be maintained as long as is needed to ensure that the passenger stays orientated should the aircraft submerge.

The delegates will then cover in detail the theory of the four exercises that they are required to carry out in the water. Each of these exercises requires the delegate to follow the previously mentioned processes to allow them to escape through a window in the HUET trainer each time. The first exercise is a surface evacuation where they step from the HUET into a life raft, the second is a submersion where no STASS is used and they hold their breath while escaping, the third is a submersion where the STASS is used to escape and finally a capsize submersion using STASS, where they are turned upside down in the water and once again must escape. Each of these exercises is designed to equip the delegates with the knowledge to escape from a variety of different situations: an aircraft stable on the surface, a rapid submersion of an aircraft, a steady submersion of an aircraft and if the aircraft was to submerge and rotate.

The afternoon’s practical pool session begins with a brief assessment. This ensures that the delegate is comfortable with donning the life jacket and carrying out the appropriate checks on the STASS system. The assessment then moves into the water. This begins with the use of the STASS system before getting inside the HUET trainer. Delegates must show that they can breathe from the STASS on the surface of the water. They must also show that they can breathe from the STASS system with

Fig. 2: The STASS, Short Term Air Supply System, is an emergency breathing system that consists of a compressed air cylinder, regulator and mouthpiece (Petrofac Training Services)

22 | TRAINING

Fig. 3: The STASS course is a self-rescue course aimed at providing those who are part of the HEMS crews with the skills and knowledge needed to escape a ditched helicopter and maintain themselves until picked up by SAR (Petrofac)

Fig. 4: Delegates learn how to deal with a variety of different situations: an aircraft stable on the surface, a submersion and if the aircraft was to submerge and rotate (training at Falck Nutec in Germany; Falck)

their face submerged in the water. In many cases this is the first time that delegates experience the sensation of “breathing underwater.” The delegates are then asked to demonstrate that they can move through the water using the system and get themselves into an inverted position to undergo the final HUET capsizing exercise. The assessment then moves inside the HUET. From this point there are four exercises that the delegates must complete with little or no prompting from the instructor inside. The first exercise is the surface evacuation. Delegates will hear a series of commands: “Stand by for ditching,” at which point they must carry out their initial checks and “Brace Brace Brace,” when they must adopt the brace position. As soon as there is impact with the water they must then adopt the ‘locate’ position.

Delegates will then deploy the STASS system, release the buckle and make their way out the main exit into the life raft. The second exercise consists of the same actions but this time will not stop on the surface of the water. The HUET trainer will rapidly submerge, not giving enough time to deploy the STASS system. They should maintain their ‘locate’ position, which keeps them orientated underwater. Once they are submerged, the delegates release the buckle, making sure that all of the latches have disengaged, so there is no hindrance when escaping. Delegates must then pull themselves towards their nearest exit, out of the HUET and to the surface. The third exercise follows a similar pattern, but this time they stop on the surface of the water and they will have time to deploy the STASS. They will then submerge, release the buckle and escape from the HUET. Delegates often find this exercise easier or more comfortable than the others due to the use of the STASS, which allows them to breathe while carrying out these processes. The final exercise is the capsize. Once again the delegates will continue through the process, on the surface deploying the STASS. The command “Standby” will be heard. This means that the HUET will submerge and then roll over.

This is perhaps the most challenging of all of the exercises; the delegates are in an awkward inverted position, possibly disorientated and must escape.

On completion of the final HUET exercise they inflate the life jackets and are introduced to some sea survival techniques: the most efficient way to move through the water wearing all of this equipment, towing casualties through the water, moving in a survival chain, maintaining warmth, protection of airways and creating the survival circle.

The STASS assessment is fully practical and these are the assessments that make up the course. If there are areas that the delegates feel that they would like to cover again, or other scenarios they wish to try, then this can also be arranged to give the delegates the best possible understanding and experience of the processes and equipment.

BOSIET/FOET courses The BOSIET and FOET are another two courses that are offered by Petrofac Training that are tailored towards offshore workers. On top of helicopter safety and escape, the BOSIET also offers training in offshore safety, sea survival techniques, fire safety and first aid over a three-day course. The FOET is a shorter one-day course for those refreshing their BOSIET certificate which covers helicopter safety and escape, fire safety and first aid.

The HUET training for the BOSIET/FOET and the STASS are similar in many respects, but there are some differences in procedures and also in the equipment used.

First of all, the emergency breathing system used is a ‘re-breather’ system. This Emergency Breathing System (EBS) is incorporated into the life jacket known as the Lifejacket Air Pocket Plus (LAPP). This system consists of a mouthpiece, a flexible hose that is attached to a counter-lung inside the jacket that can receive the user’s exhaled air and allow them to re-breath from the EBS.

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The time that the delegates can spend breathing from this system is limited in comparison to the time that they could spend breathing from the STASS system. This is due to oxygen depletion and carbon dioxide build-up from continuously re-breathing the same air. This system is designed to allow the user to overcome cold-water shock and lengthen escape time from the aircraft. During training exercises delegates use only their own exhaled air to rebreathe, whereas in operational LAPP jackets there is a small air cylinder that will inflate the counter lung with a few litres of air on immersion, giving users an increased escape time.

This type of EBS system often presents challenges of its own. With the STASS system there is no difference breathing at depth as there is at the surface. However, with the LAPP system breathing becomes more laboured as the user moves deeper in the water as the water pressure squeezes the counter lung further. Therefore there is detailed training on LAPP system use to ensure all delegates are comfortable using it before their helicopter escape assessment.

In terms of the exercises that will be carried out during the BOSIET, there are a few extras. As with the STASS, there is a surface evacuation, a rapid submersion and a submersion using the EBS system. Windows are then added to the HUET trainer. This time the delegates must use the EBS system and upon submersion jettison the windows, release the harness and escape from the HUET. Once all delegates have completed these escape assessments, they move onto the capsize assessments that follow the same format. The first capsize is a rapid submersion where delegates must hold their breath, in the second they use the EBS system and in the third they will use the EBS system and jettison the HUET windows as necessary while inverted and potentially disorientated.

During each of these scenarios the delegates must follow certain procedures: they must carry out their initial checks, adopt the brace position, adopt a position on impact where they can locate their harness release and exit and finally escape the HUET trainer unassisted.

The assessment for the Petrofac Training BOSIET and FOET helicopter safety and escape module is all-practical.

The instruction and assessment is designed to give the delegates a complete understanding of the equipment used during their transit flights and the procedures to follow if they were to experience a ditching scenario.  Helicopter Underwater Escape Training Acronyms STASS

Short Term Air Supply System

HUET

Helicopter Underwater Escape Training

BOSIET

Basic Offshore Safety Induction and ­Emergency Training

FOET

Further Offshore Emergency Training

EBS

Emergency Breathing System

LAPP

Lifejacket Air Pocket Plus

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24 | TRAINING

Fig. 1: The FFS helps pilots to familiarise with the latest technology found in the AW109 SP new cockpit (Screenshot: Rega video)

“As close to reality as it can get”: Rega’s new Full Flight Simulator Swiss Air Rescue Rega recently inaugurated its new flight simulator of an AW109 SP. The simulator was designed and produced by AgustaWestland in Sesto Calende in Italy and has been certified by the Swiss National Aviation Authority (SFOCA) in February 2013. It is now fully operational and will meet the training requirements for Rega’s new fleet of Da Vinci and GrandNew light twin helicopters. This Full Flight Simulator will enable crew training under true-to-life conditions.

Authors: Editorial Team AirRescue Magazine

The simulator is dually certified as a Full Flight Simulator (FFS) Level B and a Flight Training Device (FTD) Level 3. The FFS includes all the instruments and equipment necessary to operate the helicopter; it is equipped with a visual system and a motion platform, which replicates the corresponding flight movements in a very realistic way. The letter “B” stands for the certification category, whereby “D” is the highest level. In the FTD, all aircraft instruments, equipment, panels and controls are replicated in an enclosed cockpit mock-up.

The FFS helps pilots to familiarise with the latest technology found in the AW109 SP new cockpit, which features Flight-Logic Synthetic Vision EFIS (Electronic Flight Instrument System) with a Flight Management System (FMS), Helicopter Terrain Awareness Warning System (HTAWS), Highway In The Sky (HITS) as well as embedded flight recording functions.

“Closest-to-reality” training Highly trained crews are crucial for the safety and success of EMS flights. In addition to “regular” flight training, a helicopter simulator makes it possible to practise accident scenarios in extremely demanding and exceptional situations (e.g. in the case of malfunctions) realistically and efficiently – without danger, noise or polluting the environment. In future, Rega crews can practise certain situations that until now have not been possible.

Level “B” certification means that the simulator can also be used for compulsory check flights that previously were only possible in real aircraft. This training apparatus also permits simulation of emergency scenarios, including tail rotor failure or engine fire. Training pilots in instrument flying (IFR) is also of importance, as flights to be carried out in poor visibility demand a high level of training, especially in the case of IFR routing and GPS-supported

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TRAINING | 25 approach flights to hospital helipads. A large proportion of that training – a pilot requires a minimum of 55 training hours to gain an IFR licence – can be completed in the simulator. All pilots as well as HEMS crew members (medical) have to complete up to eight simulator training exercises per year.

Cooperation agreement with SAT The simulator is operated and maintained by Swiss Aviation Training (SAT), a subsidiary of Swiss International Air Lines. SAT is an internationally active training organisation, fully licensed as Type Rating Training Organisation (TRTO) and has approvals from JAR-FCL1/EUOPS1, JARFSTD A, and JAA – among others. It already manages various simulators (fixed-wing) in its training centre at Zurich-Kloten. Training services will also be available for other customers operating GrandNew light twin helicopters, with courses being conducted at the SAT training centre. Type rating, refresher and recurrent courses as well as instructor training – comprising theoretical ground training in the classroom and/or via distance learning – will also be delivered. SAT and AgustaWestland also plan to create mission training courses together, with the opportunity to benefit from Rega’s extensive knowledge as an experienced HEMS operator.

The only one of its kind

a Level B-certified simulator – for training and check flights. The AW109 SP simulator however, is the only one of its kind in the world and enables the pilots of the Da Vinci helicopter fleet to also carry out exercises and training flights under simulated conditions. Rega operates 10 Da Vinci single pilot cockpit-equipped aircraft plus 1 GrandNew helicopter, featuring Rega dedicated mission kits. The Da Vinci, a highly customised variant of the GrandNew, was specifically developed to meet Rega’s HEMS requirements. 

With information provided

by Rega media service and AgustaWestland communications.

Photo Air Zermatt

Rega also operates the EC145 at its lowland bases and its pilots travel to Germany – where Eurocopter operates

Fig. 2: The AW109 SP simulator is the only one of its kind in the world and enables the pilots to also carry out exercises and training flights under simulated conditions (Rega)

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26 | TRAINING

Inaer’s SIMULHEMS: University Qualification Course with Simulation Inaer Spain has been providing EMS services as part of its operations since 1986, when it launched the first helicopter-operated medical service. Since then, it has become an industry standard, using up-to-date resources and the highly qualified personnel. In order to maintain a high standard, professionals need to be trained. Inaer has developed a state-of-the-art training model that includes both theory and practice, aimed at obtaining professionals with high qualifications. This EMS University Qualification Course also includes exercises on INAER’s simulator SIMULHEMS. The course has a total of 10 EMS medical instructors (6 doctors and 4 nurses). All must have at least 10 years of work experience as EMS paramedics and a proven capacity to teach. Furthermore, they must have conducted research and published articles about the EMS environment. The faculty consists of Dr. José Manuel Gutiérrez Rubio, Inaer Medical Manager and Associate Professor, Dr. Juan A. Sinisterra Aquilino, Coordinating Doctor and Associate Professor Inaer and Dr. Enrique Nogueroles, Operations Manager Inaer Spain. The course has a total of 18 teachers coming from human resources personnel, commercial, operations, aeronautical engineers and EMS doctors. The “target group” of the course consists of doctors, nurses, pilots and flight technicians.

Outline of the course

Fig. 1: Some training sessions are also conducted in the SIMULHEMS, the special simulator created by Inaer’s Research & Development department, employing its own technology and resources (Inaer)

Author: Juan Sinisterra HEMS doctor, EMS training appointee Inaer Spain

The EMS University Qualification Course offered by Inaer was created jointly with the University of Zaragoza in 2008 in order to provide specific EMS training, offering all the benefits that a large and respected university can provide, in line with the Bologna requirements. The course is offered to doctors and nurses with the aim of training them on how to attend to critical patients in an EMS environment. It meets the training requirements contained in JAR-OPS 3 on EMS helicopters.

The course is unique in Europe, because it is the only one endorsed by the European Credit Transfer System with 5 ECTS at a University education degree level. Inaer has conducted nine courses since its commencement in July 2008, and has trained a total of 163 doctors and 382 nurses in EMS. The course has three main objectives.

Participants should: • Learn how to efficiently apply lifesaving medical services to critical patients during EMS operations; • Learn how to provide the highest standards of care effectively and • Fully understand the concept of safety and apply this to all of their future operations.

• Duration: 145 hours • 5 ECTS • On-line phase: 90 hours, duration 7 weeks • In-person phase: 55 hours • Seminars: 4 days • Practice sessions: 2 Days in EMS units • Operation of a 15 minute accommodation flight/student with tutoring by an instructor EMS • Operation within the EMS Static Simulator SIMULHEMS

Contents The EMS University Qualification Course covers topics such as elementary theory of the helicopter (helicopter types: models), phases of flight (critical moments), helicopter and ground security, internal and external communication, night flight, mission responsibilities, human behaviour, air resource management, prevention of occupational risks during the mission, thoracic trauma and the EMS flight, anesthesia and analgesia in the EMS mission as well as alterations during flight EMS. Sessions also include patient flight assistance (pediatric, newborn as well as amputation injuries), defibrillation protocol flight, assisted mechanical ventilation, management of respiratory failure in flight and protocol of hypothermia after PCR, just to name a few.

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TRAINING | 27

Fig. 2: The University of Alicante will offer the EMS course from February 2014 onwards, it will comprise of 145 hours, including practices in INAER EMS helicopters

SIMULHEMS The course covers all the different types of medical emergency situations in an EMS environment and the practical sessions include a 15-minute flight and sessions in the SIMULHEMS, a special simulator created by Inaer for this purpose. The SIMULHEMS was created by Inaer’s Research & Development Department, employing its own technology and resources.

SIMULHEMS provides for real life EMS situation simulation, replicating the space and volume limitations found in an aircraft and the medical equipment found on board a helicopter. SIMULHEMS “simulates” the exact conditions found inside an aircraft, including a dummy with which exercises are carried out. SIMULHEMS is super-

vised from a control cabin, where the instructors constantly monitor all the variables and the physical signs of the simulated patient as well as the flight details – thanks to dedicated software. SIMULHEMS is very adaptable and can be transported to other areas where EMS training is needed.

Future courses Thanks to a new agreement, the University of Alicante will offer the EMS course from February 2014 onwards, together with the Nursing Master university degree – the first of this kind. This course will comprise of 145 hours, 90 of which are on-line and 55 hours in person, including practices in Inaer EMS helicopters. 

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28 | TRAINING

Fig. 1: The ropes used by Norwegian Air Ambulance (10, 20 and 30 m) are connected to the double hook bracket with a Y-sling that has two steel rings (NLA/Aage Kirkestuen)

Fixed rope procedures: Long line training at Norwegian Air Ambulance From day one, Norwegian Air Ambulance (NAA), which was established in 1978, gave priority to trainings in fixed rope procedures and the “H-Net”. The pioneers of this rescue technique were trained in Switzerland with Swiss Air Rescue Rega that had already accumulated some expertise

on this operation. Even with the small helicopters used at that time, the BO105, it was not always possible to land near the patient, and the rescuers had to be flown into the terrain and had to use the “H-net” (similar to a fishing net), invented by the Swiss legendary rescuer Fritz Bühler.

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TRAINING | 29 Since the implementation of this procedure in Norwegian HEMS in 1978, many lives were saved – and are still being saved. It is a rather simple concept: The pilot flying the aircraft receives instructions from the HEMS doctor who is sitting at the sliding door and “transmitting” the flight instructions from the rescuer by using hand signals to carefully descend and enable the rescuer to get off in difficult mountainous terrain that is sloppy or steep.

When Norwegian Air Ambulance started to renew its helicopter fleet in 2000 by introducing the EC135, it also implemented a rope-down device, which was replaced in 2002 by a double hook attachment. This system consists of a bracket with two hooks mounted under the helicopter for the attachment of the fix rope. It has been approved by the Norwegian national civil authorities for human external cargo (HEC) operations. In emergency cases, the pilot can open the hooks electrically or manually.

Equipment Norwegian Air Ambulance uses ropes of three different lengths: 10, 20 and 30 m. They can be used separately or, when needed, linked together to a 60 m rope. The ropes are connected to the double hook bracket with a Y-sling that has two steel rings. The 30 m rope is used the most.

Only steel safety carbines are used for the system. The patient can be lifted from the terrain with a triangle harness. It is a comfortable lifting system for patients with minor hurts or injuries like ankle fracture, arm or shoulder damage. The triangle harness is not suitable for patients with multiple trauma. In such cases, HEMS teams use the vacuum mattress and the rescue bag. Lifted on vacuum mattress, the patient is well stabilized and protected. It is also possible to transport an intubated patient in the rescue bag. The rescuer will then take care of the ventilation during the “flight”. The doctor is secured by a harness and a retention lanyard when he sits at the door guiding the pilot through the operation.

In 2012 the Norwegian Air Ambulance implemented Polycon (Axnes) to improve communication between the rescuer and pilot. However, hand signals are still used as primary means of communication – via the HEMS doctor in the doorway. Polycon is a wireless intercom extension for aircraft and operational platforms. This system enables the rescuer to follow all the communication on the intercom system and get verification that the doctor observes the rescuer’s hand signals correctly. The rescuer can also immediately rectify orders if needed; he is “on the intercom” system working on ground in noisy surroundings.

“Training is the clue!”

Rope operations are not an “every day business”, in fact the number of such operations is quite small. Nevertheless, they do occur and for these cases, HEMS crews at NAA are prepared. Norwegian Air Ambulance carries out trainings based on a fixed schedule. Within a time frame of 90 days, each crew member has to have completed at least five training cycles of rope operations over land and over water. The annual training camp is another occasion to improve and streamline the HEC operation.

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HEMS in the mountain and ski regions In Hemsedal and Kvitfjell (popular ski resorts in Norway), the ski patrols are also equipped with rescue bags and vacuum-mattresses that can be used for patient lift. In the future, this concept may be implemented in other ski resorts as well. The ski patrol is professionally trained to ski downhill to the patient, do the necessary first aid and stabilize the patient in the rescue bag. Then the helicopter crew can do a reckon flight, communicate with the ski patrol, and, after preparing the rope system, fly the rescuer to the site and directly lift the rescuebag with the patient from the steep terrain.

There is an increase in all types of mountain activities and “extreme- sports” in Norway, and consequently, the need for increased technical rescue missions. Also in the areas with high trees and no open spaces to land the helicopter, the HEC operation is a proper way to bring the rescuer to the patient, treat her or him and then evacuate the patient to a landing place nearby.

Water rescue with rope For water rescue the rescuer is dressed in a dry suit and is flown to the victim in the water, hanging on a 10 m rope and using a pickup sling for the rescue. Water rescues are quite common in the spring when people are on the lakes or fjords and the ice is not longer to trust. A fast rescue from ice-cold water is definitely a lifesaving operation.

This rescue system is limited to be used close to the shore lines. For sea rescue it is the Westland Sea King helicopter of the Norwegian Air Force that does the job.

Other rescue specialists can also be flown into terrain where it is too steep to land or put a skid on the ground.

When other rescue specialists are involved in the HEC operations, the rescuer is always connected to the rope to take care of the operation.

To summarize, rope operation is used world-wide, it is an effective rescue method for small helicopters when hoist is not needed. The clue to a successful lifesaving HEC operation is a solid procedure and proper training. 

Fig. 2: Pulling out a rescuer from the sea during a water rescue training exercise at the annual training camp (NAA)

Author: Dan Halvorsen HCM Paramedic/UIAGM Guide Norwegian Air Ambulance Member of IKAR Air Rescue Commission dan.halvorsen@norsk­ luftambulanse.no

30 | TRAINING

Fig. 1: ADAC’s HEMS Academy provides state-ofthe-art training capabilities, valuable for all EC135 and EC145 operators, from law enforcement and HEMS to offshore and VIP transport (ADAC HEMS Academy/C. Papsch)

ADAC HEMS Academy: Training in an evolving environment A few years ago, when simulator training for small helicopters was almost unknown, ADAC Air Rescue (ADAC Luftrettung) took a bold decision and implemented a rather unique concept: A fully-fledged training academy with full flight simulators and medical training facilities was built in Bonn Hangelar with the purpose to create a global training platform for the entire HEMS crew. ADAC extended its outreach to other operators all over the world and adapted the Academy’s concept to provide state-ofthe-art training capabilities, valuable for all EC135 and EC145 operators, from law enforcement and HEMS to offshore and VIP transport. In the meantime, several other training centres around the globe acknowledged this idea by developing similar concepts.

Why simulation?

Author:

Lower costs are one major reason to turn to simulation instead of flying a real aircraft. The cost reduction ratio in the fixed wing business is however much larger. Comparing simulation for mid-size helicopters like the EC135 and EC145 with the real helicopter, the ratio is as high as 1:3 and 1:4 respectively. This means that the cost of one flight hour on a real helicopter is equal to the costs of three flight hours in a full flight simulator (FFS). The following reasons make the use of an FFS even more feasible:

Thomas Gaßmann Director Business Development & Sales Accountable Manager ADAC HEMS Academy thomas.gassmann@hemsacademy.adac.de

• Training for critical scenarios that cannot be demonstrated in “real life” or are too dangerous to fly on a real aircraft; • Training in a full flight simulator does not depend on certain weather conditions and is less restricted

through time constraints; • FFS allows close-to-reality simulation of IMC (instrumental meteorological conditions); • Training is virtually possible „around the clock“; • There is no fuel consumption and no noise (pollution) – the simulator is environment-friendly, carbon dioxide emissions were reduced by now by more than 3.000.000 kg, compared to trainings on real aircraft.

Electricity used for the simulators is accounted and already subtracted in this calculation; • Simulation leads to a reduction in maintenance costs; • Flight time to training sites is not needed, the simulated helicopter can easily be placed everywhere in the simulated environment; • There is a large number of operating scenarios – mission training is getting closer to reality as ever before.

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TRAINING | 31 Full flight simulator in helicopter training: the undisputed role The International Helicopter Safety Team (IHST) has recommended 10 ways to prevent helicopter accidents. This also includes improved technical installations like cockpit recorders and risk management programs. But other recommendations explicitly mention helicopter training. Most of these recommendations can be turned into reality in a full flight simulator: • • • • •

Improve autorotation training; Add advanced manoeuvres to simulator training; Emphasize critical issues awareness in training; Enhance aircraft performance & limitation training and Strengthen emergency procedure training.

This was also unanimously recommended by the participants of the Royal Aeronautical Society’s mission training rehearsal in London 2012, who agreed that training in a full flight simulator is the best solution for psychomotoric training, skill and mission training.

“Flight training beyond limits” With the introduction of highly sophisticated full-flightsimulation for the small- and mid-size helicopter segment, the training situation for helicopter pilots has changed dramatically (for the better) in the last years and will continue to improve. Pilots need to train in a surrounding simulation that appropriately reflects the dynamically changing environment of a helicopter pilot, whether that is in terms of helicopter systems, environmental influences, flight procedures or corporate culture. The simulation has to guarantee that proficiency is maintained at the highest level, as it is indispensable on real missions, especially for rarely practiced skills like handling emergency situations.

It is paramount that today’s helicopter pilots train and demonstrate proficiency in the integration of cognitive and motoric skills in realistic scenarios. Real-life challenges are used to enhance the simulation and the training benefits. The simulation must assure that, besides training, cognitive and motoric skills are being tested. However, one has to keep in mind that the main target of all trainings and simulations is accident prevention.

All-weather capability There is one major topic that will be paramount for the HEMS-community, law enforcement agencies and offshore operators in the near future, which is all-weather capability. This capability is almost fully established in the case of large vessels unlike for helicopters, where deicing and 3D-imaging are in development. For small size rotary wing aircraft, used on the above-mentioned missions, de-icing is yet impossible due to weight and power limitations. There are other usages, where improvement is possible and feasible, for example NVG/NVIS, use of electronic flight bags to reduce pilot’s workload, development of low level GPS approaches, etc. For all these new features and technologies, appropriate training is fundamental and the HEMS Academy, as a training innovator, stays one step ahead in the effort to support the pilots in

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this rapidly changing field. In order to keep up-to-date, a constant renewal process, listening to the necessities of the operation and adaptation of the capabilities will make the difference in training.

EC145 T2 likely to become the “game changer” It is very likely that the EC145 T2 will conquer the European market during the next decade. The additional power available, combined with a remarkable low sound signature (due to the Fenestron), a 4-axis autopilot and the latest technology glass cockpit solution, are very convincing arguments for HEMS (intensive care transport) operators and law enforcement agencies. ADAC Luftrettung, among other European operators, already ordered 14 new helicopters EC145 T2 to replace the aging BK117 B2 in its fleet. Consequently, ADAC HEMS Academy will adapt the training possibilities at its premises to the benefit of all international customers. In order to accommodate the future training needs, a new EC145 T2 Full Flight Simulator is considered for 2016 – in addition to the already existing EC145 and EC135 FFS at the Academy.

Fig. 2: The transportable mock-up, equipped as a regular EMS helicopter, enables not only for flight crews and pilots, but also paramedics as well as (H)EMS doctors to conduct realistic and mission specific training (ADAC HEMS Academy/C. Papsch)

Fig. 3: The Academy decided to convert its EC135 analogue FFS into an EC135 EFIS (digital) FFS, to get the approval in the second quarter of 2014 (J. Rosenow)

32 | TRAINING customers’ needs for special mission training: NVGs, visualization of special areas in several countries and offshore scenarios in different landscapes.

Paramedics and HEMS doctors training The Academy introduced a second full-scale mock-up for the BK117 to offer additional medical simulation capabilities. Up to date, professional, realistic and mission specific training is required, not only for flight crews and pilots, but also for paramedics as well as (H)EMS doctors.

They are being trained on this transportable mock-up that is equipped as a regular EMS helicopter. Through this transportable mock-up simulation opportunities can be delivered to medical personnel at the Academy as well as at HEMS bases or during special (public) events.

Along with the existing EC135 full-scale mock-up and the shock-room, the new BK117 trainer is especially equipped to train for intensive care transports and to practice loading and unloading of patients.

Strong effort Fig. 4: ADAC HEMS Academy delivers dedicated trainings for flight as well as medical crews in order to provide professionals with more knowledge and tools helping them to cope better with day-to-day challenges and unpredictabilities (ADAC HEMS Academy/C. Papsch)

The new glass cockpit solution (three multifunction displays on the T2) is a completely different system that pilots will have to deal with, compared to the ones used today in small-size helicopters. The time of analogue instruments seems to be over, now digital monitors deliver the information required, connected to an intelligent program that decides, which information is needed in the current flight situation.

ADAC HEMS Academy aims at providing dedicated trainings for flight as well as medical crews. These trainings shall provide professionals with more knowledge and tools helping them to cope better with day-to-day challenges and unpredictabilities. The helicopter business is a fast developing field and forces training organisations to constantly investigate the best training options and aspects related to the formation of flying personnel.

Training and safety have never been “cheap”, but as the author’s former instructor said: “The best safety device in any aircraft is a well-trained crew.” 

New technologies – new risks?

Increasing automation also increases the need for the pilots to correctly analyze the situation and for the trainings to enhance the pilot’s situational awareness skills in order to prevent mishaps or even accidents. Social scientists have long recognised that (further) automation poses a risk to safety. It is vital that pilots are given the necessary skills, knowledge and information to face these new challenges.

One of the measures taken is to design a wellequipped EC145 T2 training device to fulfil the advanced needs for the professional pilots. This system is currently being developed (it will also include web-based trainings) and will be available mid 2014. All EC145 T2 customers are invited to participate in the development and customization of the respective full flight simulator and the T2 system trainer.

EC135 FFS going digital: EFIS The majority of the renowned European HEMS organizations send their staff for training on the EC135 and EC145 full flight simulators at the HEMS Academy. In order to fulfil the increasing customer demands for training on EC135 P2+/T2+ FFS, the Academy decided to convert its EC135 analogue FFS into a Eurocopter EC135 EFIS (digital) Full Flight Simulator, to get the approval in the second quarter of next year. In addition, customized vision databases are being developed to respond to the

ADAC HEMS Academy The ADAC HEMS Academy has its roots in ADAC Air Rescue, one of the major air rescue and air ambulance operators in Europe. With 50 helicopters, type EC135, EC145 as well as BK117 and more than 150 pilots, ADAC Air Rescue flies almost 50,000 missions a year, accumulating over 25.000 flight hours. ADAC Air Rescue is responsible for 36 HEMS bases throughout Germany. Starting end of 2013, ADAC Air Rescue will continuously renew its fleet by replacing the aging BK117 with the new EC145 T2.

The ADAC HEMS Academy was established in 2009 to provide a state-of-the-art platform for professional flight training on EC135 and EC145 full flight simulators, open for all operators on these helicopter types. As a unique feature, in addition to flight training on the simulators, HEMS Academy provides specialized integrated trainings for pilots, doctors and paramedics in close-to-reality, simulated medical scenarios.

International customers from Argentina and Brazil to Japan and Australia rely on the expertise and knowledge of a well-established operator like ADAC Air Rescue with more than 40 years of experience in HEMS. Besides teams from the major air rescue and air ambulance operators in Europe, several law enforcement units and offshore operators are among its customers.

The Academy is conveniently located and easy to reach via 3 international airports within less than an hour’s drive: Frankfurt Airport, Cologne-Airport and Düsseldorf Airport.

Participants can also fly directly to the Academy’s doorstep at Bonn-Hangelar Airfield with a small plane or helicopter.

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Fig. 1: “In the case of HHO, the first training session is carried out with a hoist cable of 25 m length at maximum altitude of 3,000 m, in the second session, a hoist cable of 50 m length is used, at a maximum altitude of 3,500 m” (Air Glaciers)

“Communication is paramount” – Interview with Patrick Fauchère, Air Glaciers, on HHO & HEC trainings Air Glaciers, one of the largest helicopter operators in Switzerland with its headquarter in Sion, Valais, regularly conducts trainings for its HEMS in heli hoist operations (HHO) as well as in human external cargo (HEC). Patrick Fauchère, helicopter pilot and flight operations manager, spoke to AirRescue Magazine about the training procedures, the syllabus and about the importance of communication.

Patrick is a person of great expertise in this field, also stemming from his position as Chairman of the Air Rescue Commission of the International Commission for Alpine Rescue (ICAR).

ARM: Patrick, Air Glaciers regularly conducts longline and cable hoist trainings – how many trainings do you have to accomplish as pilots at Air Glaciers?

Patrick Fauchère: We have to complete the initial training as requested by the FOCA, the Federal Office of Civil Aviation in Switzerland, which has three steps for heli hoist operations, HHO, and three for human external cargo, HEC.

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ARM: Are longline and cable hoist trainings conducted separately?

Patrick Fauchère: Yes, FOCA requirements say that human cargo sling, HCS, and HHO are two different syllabuses and our trainings also reflect this. The same applies for the rescuers. On the hoist, 2 persons are the maximum load. In the case of HCS, the load can be up to 5 persons at a time.

Patrick Fauchère, helicopter pilot and flight operations manager at Air Glaciers, is also Chairman of the Air Rescue Commission of the International Commission for Alpine Rescue (ICAR)

34 | TRAINING

Patrick Fauchère: The terrain in which the trainings are held clearly reflects the one we have in mission. So we train in mountains and canyons. Chairlift and cabin cars are also part of the trainings, glaciers and crevasses are part of the natural setting as well as the altitude in which we have to operate.

ARM: Who participates in and who conducts these trainings?

Patrick Fauchère: The pilots’ training has to be conducted by a flight instructor, and a member of the mountain guide team – who works as an expert and instructor for the particular course – gives the rescuers’ training. Air Glaciers has its own team of mountain guides and they are all providing training to ground crews. They regularly conduct joint trainings with the departement of Valais during cantonal courses as well.

ARM: Are there certain elements that are mandatory – and if so, for whom?

Patrick Fauchère: As already mentioned, for the pilots the syllabus is quite all-encompassing and surely requires some particular training. For the rescuers, the goal is to get familiar with all different aspects of the work that may become relevant in any rescue situation. A rescue mission always includes surprises and through training you want to give rescuers the maximum of knowledge to deal with these. A well trained rescuer will cope with all sorts of surprises.

ARM: What are the main characteristics of the trainings?

Fig. 2: Hoist operations are limited to 2 persons, whereas HCS takes up to 5 at a time and is fixed below the helicopter (Air Glaciers)

ARM: What are the characteristics of the respective trainings?

Patrick Fauchère: In the case of HHO, which means the transfer of persons and loads by means of a hoist cable, the first training session is carried out with a hoist cable of 25 m length and at maximum altitude of 3,000 m. In the second session, we use a hoist cable at the length of up to 50 m and at a maximum altitude of 3,500 m. The final session is without any limits – unlimited length and altitude. During trainings with HCS, the steps are identical.

Once the initial training is completed, we are “cleared” and, as we fly sling load regularly, we do not have other training sessions dedicated to pilots. HCM medical have their own training system and they carry out a “refresher” training at least once a year. This means more opportunities also for pilots’ training.

ARM: Where are the training courses being conducted?

Patrick Fauchère: For pilots, a part is done as dual training and another part is done alone, but under supervision.

First we use ‘dead weight’ before flying ‘human cargo’.

For the rescuers, the training is carried out as terrestrial training involving them in close-to-reality rescue situations. The rescuers, who are all mountain guides, have a tremendous amount of knowledge.

ARM: What kind of challenges do you as a pilot, but also hoist operators face?

Patrick Fauchère: The real challenge is the surprise effect. Even if we know where and what we will have to expect, on a real rescue mission a certain amount of uncertainty always remains. The ability of coping with the situation is our strength. We abide to the rule that ‘there is a solution to every problem’. Flying HCS is daily business for us, as our main job is to fly sling load, so the training is always accurate. The challenge of mountain rescue is the altitude, combined with particular weather conditions and the situation of the patient. Each rescue is different and brings along its own peculiarities and surprises. A crevasse accident or an avalanche can require more helicopters on the same place which may increase difficulties.

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ARM: Which equipment is used? What are the technical details that are relevant?

Patrick Fauchère: At Air Glaciers we use two types of hoists: A 25 m cable on the Alouette 3 and a 50 m cable on the AS350 B3. For HCS, we use steel cable as well as textile line from 10 m up to 100 m. For more, we add lines together up to 220 m. This longline technique is used at least 10 to 15 times a year.

ARM: Patrick, how do you and your colleagues communicate? How does the crew coordinate a mission while on a flight?

Patrick Fauchère: Communication is paramount. Lack of communication affects the whole rescue mission. We use a two-way communication radio system between the pilot and the ground rescuers. They are equipped with helmets, mikes and earphones and the system works on FM frequencies. On the ground, the same equipment is used for the rescuers and they are always connected with each other.

ARM: What, in your opinion, are the respective advantages of hoist cable and long line rescue procedures?

Patrick Fauchère: Hoist is the ability of being quick. You get to a rescue site, and without landing you can hoist down a first rescuer. The HCS system, however, needs a ‘pit’ stop first. You get to the site, you assess the situation, define and calculate the length and you land nearby.

Then you can start the mission. Hoist procedures also allow to bring the rescuer and patient near the helicopter whether the longline is fix. Hoist procedures are more reliable during night missions, for sure, and may also be more appropriate during difficult weather conditions. Hoist is limited to 2 persons, HCS takes up to 5 persons at a time and is fixed below the helicopter. Hoist costs and maintenance are also expensive, compared to those of the HCS system. The HCS system is the best solution for sling pilots, as this enables us to carry out daily training flights, and as the load is always centered, we can take the whole crew at the same time, which is consequently time saving.

ARM: For what kind of missions are hoist cables and longlines being used?

Patrick Fauchère: We use hoist or HCS in case landing nearby the patient is not possible. On a total of around 1,800 missions a year we fly something of around 300 hoist or sling missions. Around 100 missions require the use of HCS. HCS missions are mostly technical and they require a longer line or are used to evacuate some blocked chairlift or cabincars.

ARM: Is Air Glaciers also cooperating with other operators and organizations for training purposes?

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Patrick Fauchère: Here in Wallis in the south of Switzerland there is another operator besides us. Different languages separate us, as Swiss German is their first language and ours is French. Crews of both the companies work in the same kind of environment and do the same job every day. We are both commercial operators and rescue providers. There is a regional rescue center and all emergency calls land there. The dispatch center will then dispatch the nearest helicopter to the patient.

Cooperation is good, very good in fact, and during wintertime it is not rare to see helicopters from one operator helping the other HEMS team to cope with high numbers of patients at the same time, for example if there is a ski accident with many people involved.

A high season wintertime rescue day can have as many as 30 missions. In winter, we respond with up to 4 helicopters from the Sion homebase each day and we can dispatch another 3 within minutes. During winter, up to 4 helicopters are dispatched daily from the other 3 bases. This system is surely unique, where commercial operators with their fleet are dedicated to initiate a rescue mission right after the call. Some examples: In the case of an avalanche accident, we had dispatched 11 helicopters at the same time and, at another incident, there were 8 helicopters on a mission during a tragic car accident in a tunnel at night.

These examples are not stand-alone missions. Several times per year we have such cases and because of this unique system here in Wallis, we are able to cope with these very particular situations. This is a real challenge for the dispatch center, but it works, thanks to a splendid cooperation between all rescue forces. It is a pleasure to work in such a system where the patient is put first.

ARM: Patrick, we thank you for the interview.



Fig. 3: “Communication is paramount, and the lack of communication affects the whole rescue mission” (Air Glaciers)

36 | TRAINING

NVG-Training: EAAA with UK’s first ever night HEMS mission In May of this year, the East Anglian Air Ambulance (EAAA) was given the all clear to start the first UK night HEMS missions. Being able to operate at night means that the air ambulance is able to fly HEMS missions in the dark in the same way that it does during daylight hours – flying to an incident, landing close by, treating patients at the scene and taking them to the most appropriate hospital when necessary. The use of Night Vision Goggles (NVG) is something not being done by any other air ambulance in the UK, and is an advance in service that EAAA believes will allow it to carry out approximately 30% more missions, helping an estimated 300 more patients a year.

“MissionSafe” strategy Highest levels of safety require a detailed and thorough safety assessment – whether it be related to equipment, training or safety procedures. Bond is focussed on making safety an inherent part of every aspect in its daily operations. It is also part of its MissionSafe strategy – an integrated approach to safety management, which is shared by all the operating companies in the Avincis Group to which Bond Air Services belongs.

The aircraft used by EAAA, a Eurocopter EC135 T2e, spent almost 18 months being equipped and tested inhouse by experts at Bond (see also AirRescue Magazine 1/2013). This process began at the start of 2012 when the Bond Flight Operations Team submitted a safety case to the UK Civil Aviation Authority (CAA), outlining the challenges and risks, as well as the mitigations that they felt would allow night operations to be as safe as daytime missions. This strategy revolved around the use of night vision goggles, and also included previously unavailable digital data regarding obstructions such as wires.

Legal requirements and safety directives

Fig. 1: Dr Lazslo Hetzman in flight on one of the first night HEMS missions of the East Anglian Air Ambulance (EAAA)

Authors: Andy Rooney Senior Pilot Scotland Pete Cummings Director of Operations East Anglian Air Ambulance

Most air ambulance and helicopter emergency medical services (HEMS) operations in the UK are – with the exception of Scotland – led and financed by charities who depend on raising substantial sums in their local area. Until recently, no charity or ambulance service had identified the definite need for operations during “hours of darkness” and naturally shied away from the extra financial input that was required. The EAAA took a bold decision to implement night operations within their area and asked Bond Air Services as its operator to develop a way to make this possible.

At that time, there was no legal framework covering night HEMS operations since existing regulations (JAR-OPS 3, soon to be replaced by the EU Air Operations Regulation), do not distinguish between day and night missions. Their only stipulation was that the HEMS operating site must be lit, either from the ground or from the helicopter.

Bond went further, proposing a level of equipment that they felt would secure the safety of the helicopter and crew when landing at adhoc or unlit night sites and proposed a method of operation, backed up by a training regime. This met with general acceptance by the Civil Aviation Authority (CAA) and was only modified by the inclusion of a steerable searchlight.

In July 2012, the Authority issued a safety directive that laid out the terms under which they would grant approval for night HEMS operations, which closely followed the proposals and requirements of Bond’s original proposal. In order to fly at night, the aircraft was fitted with an instrumentation system and external lighting, which was

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TRAINING | 37 compatible with the use of night vision goggles. These modifications required certification by both the European Aviation Safety Agency (EASA) and the CAA. Chris Greenhill, Managing Director, Bond Air Services said: “We are delighted to be the first UK air ambulance operator to have received both European and CAA certification to operate night HEMS flights. To achieve this we drew on extensive in-house expertise at Bond, as well as the experience from other Avincis Group companies operating night HEMS flights across southern Europe”.

Trained, tested and certified Flying missions during the night is very different to flying during the day, and the pilots and crew who would be operating the aircraft had to be trained, tested and certified in order to use the required equipment. Training for crews started shortly after the aircraft was commissioned, with Bond working with the EAAA, the CAA and East of England Ambulance Service to ensure that crew members were fit and ready for night-time HEMS missions.

The training to prepare for night-time HEMS missions was conducted by Bond’s own trainers, all of whom are drawn from a military background, and was structured in several stages. Firstly there was ground school, which took eight hours in total to complete. This theory-based training was conducted in classrooms at Cambridge Airport, and each crew member was required to complete it – from pilot to paramedic. They were not just trained on how to operate the NVG, but on the physiology of the eye, understanding light levels and how light affects the equipment, as well as what to do in the event of an NVG failure and the rules and regulations that govern this type of emergency service.

Three NVG flights every 90 days Then came flight training, which took place on an air ambulance helicopter operating out of Cambridge Airport. Pilots and paramedics received individual training and then trained together, with both the pilot and the paramedic acting as crew whilst supervised by a Bond trainer. In total the flight training took five hours for the pilots to complete and three hours for the paramedics.

The pilot and the ‘front-seat’ paramedic are required to use the FENNS NG 2000 night vision goggles that have been certified as safe to in the EC135 by EASA. Both of these crew members therefore had to be specially trained in the use of this equipment.

At the end of the training the crew undertook a flight test, which simulated a night HEMS mission. Going forward, each crew member is required to carry out three night flights every 90 days to ensure that their training and experience remains current.

sion in Essex. The patient required immediate transport to the nearest Major Trauma Centre after an anesthetic and chest surgery was carried out at the scene. The aircraft landed in a field nearby and transported him to Addenbrooke’s Trauma Centre for treatment.

In June 2013, EAAA ran “Operation Night Owl”, a simulated exercise involving all emergency services in a major incident. The event was hailed a success by the other emergency services taking part. These exercises will be rolled out to the other three counties served by EAAA. Later this year, the Charity will take delivery of a further NVG capable helicopter which is slightly larger than the one currently in operation and will allow the Charity to carry up to two patients if required. The current night capable helicopter based at Cambridge Airport will be relocated to Norwich Airport, giving the Charity the option of operating two helicopters at night should the service be required. 

East Anglian Air Ambulance East Anglian Air Ambulance (EAAA) is a local charity, funded by the public and receives no direct government funding. It operates two dedicated air ambulances across Norfolk, Suffolk, Cambridgeshire, Peterborough, Bedfordshire, Central Bedfordshire, Bedford, Luton and Dunstable. By January 2014 the fundraising target will be £6 million a year to maintain the helicopter fleet and the extended service into the hours of darkness. EAAA works in partnership with the East of England Ambulance Service NHS Trust (EEAST) and with Essex and Hertfordshire Air Ambulance to provide a comprehensive service across all six counties. The crew consists of specially trained NHS doctors and critical care paramedics.

“Operation Night Owl”

Bond Air Services

It was perhaps fitting that Captain Dave Nicholls, one of the Bond training captains who put so much effort into the training of Bond pilots and EAAA paramedics, was the pilot on the first ever UK night HEMS mission. A male motorcyclist had sustained life-threatening head and chest injuries after being involved in a road traffic colli-

Bond Air Services is the largest operator of air ambulance aircraft in the UK. Using mainly EC135 and BO105 helicopters, it operates from 23 bases around the UK and has two major maintenance facilities, Staverton and Glasgow.

It is part of the Avincis Group, the world’s leading provider of mission critical aviation services.

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Fig. 2: When landing at unlit night sites, a steerable searchlight (Trakkabeam A800), compatible with the use of NVG, is used (EAAA)

38 | TRAINING

UK HEMS: Helicopter Crew Course Medical Module The Glasgow-based Emergency Medical Retrieval Service (EMRS) is a consultant-delivered service providing critical care and safe secondary transfers of patients to definitive care for the population of remote and rural Scotland. In addition to this, the EMRS also provides a prehospital service, predominately covering the West of Scotland, to assist with the treatment of critically ill and injured patients in the prehospital environment. Transport is either configured for a HEMS system or by road in a fast response car, optimising the service’s ability to reach patients in both urban and rural areas 24-hours a day. Team configuration consists of a consultant-grade physician specialising in retrieval and prehospital medicine and either a registrar or critical care practitioner (CCP). The service’s CCP team were keen to have further specialist training and guidance in order to be as effective as possible. This lead them to the UK experts in the field and the UK HEMS Helicopter Crew Course (HCC) medical module, delivered by London’s Air Ambulance.

Authors: Neil Sinclair BSc DIMC DRTM Jeff Proctor BSc (Hons) DIMC Richard Lyon MBChB (Hons) MD MRCP DIMC Emergency Medical Retrieval Service 110 Stobcross Road Glasgow G38QQ UK

The team will bring critical care interventions to the polytrauma patient in both rural and urban areas throughout the West of Scotland. Such scenes can often present with a complex range of issues and challenges such as geography, human factors and scene management. These all need to be dealt with effectively before embarking on complex patient extrication plans or high-risk interventions such as emergency anaesthesia. The CCP team therefore participated in the Helicopter Crew Course (HCC) medical module, delivered by London’s Air Ambulance.

HCC as a benchmark The HCC is a specialist training course run for prehospital clinicians which started, in its current form, in 2005. The course is widely recognised as a benchmark for clinicians with an interest in working within the UK’s pre-hospital air ambulance services and attracts applications from all over the world. The HCC is a 7-day-course, aimed at prehospital clinicians who already possess a degree of prehospital experience and who are actively involved in, or

about to be involved with prehospital medical teams and the UK air ambulance services. The HCC medical module is delivered by prehospital care consultants and flight paramedics from London’s Air Ambulance and is based at the Royal London Hospital in Whitechapel, London.

Pre-course reading was provided in the form of standard operating procedures (SOP), these are an essential part of any service’s clinical governance structure, and allowed an insight into the level we would be working at and what would be expected of us. The reading and learning of these SOPs gives an important level of underpinning knowledge, allowing you to work effectively when under pressure throughout the week.

The course at LAA The course is located at London’s Air Ambulance helipad base at the Royal London Hospital. The HCC consists of lectures in the morning, delivered by experienced doctors and paramedics with the afternoons having a more practical element with skill stations and moulages. There are

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TRAINING | 39 end of course assessments on the final day of the course with feedback, support and guidance given throughout the course.

Lectures Lectures covered a wide range of clinically focussed topics including emergency anaesthesia, head injury, chest trauma, traumatic cardiac arrest and more. London’s Air Ambulance have a rich and unique experience which allows for important and informative lectures on the epidemiology of trauma, major incident management and emergency dispatching from the ambulance control centre. Each lecture is delivered by a paramedic or doctor, depending on their area of speciality. Personally, coming from a paramedic background, it was aimed at a good level and delivered in a comfortable environment where questions could be easily asked.

Skill stations There is a large practical element to the course, which usually followed the morning classroom-style education lectures. Practical equipment skills station sessions were held at various points. These had no disparity between designations of candidates, everyone needed to be competent with all equipment used. Areas covered range from emergency anaesthesia equipment kit dump, patient packaging and fitment of femoral and pelvic splints to facial splinting for max-fax injuries.

Moulage The moulage assessments took place in and around various locations across the hospital grounds. We were provided with flight suits to wear and told we would be getting dirty! The scenarios were consistently challenging and expanded with complexity throughout the week, as our knowledge grew with the lectures and skill stations.

The moulages used a large selection of low fidelity mannequins and many props, including the use of artificial vomit and blood, simulated vehicles and train tracks.

A large group of volunteers at the base allowed for elaborate pre-hospital environments to be replicated. The size and intensity of the scenarios was a new experience, there were many factors to deal with alongside clinical

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treatment, including communication at the scene, distressed relatives, other emergency services and realistic complex extrications. There was a focus on completing a job from initial arrival on scene to having the patient packaged for moving, not just passing an endotracheal tube.

These situations are designed, focussed and successful at placing you in a stress zone, similar to those faced in real time incidents. This allowed for valuable reflection on your clinical and cognitive performance whilst under pressure.

The assessment The Friday of the course is assessment day. Pulling together all that candidates have learnt and experienced in the week, into a morning of examinations. This begins with a one hour written exam paper, followed by a practical focus with a 30-minute viva and skill station. Lastly there is a 30-minute moulage station where you join an emeritus paramedic or doctor to be involved in the treatment of a patient and are assessed on your performance.

Personal thoughts This is an intense and focused course, educating and training you to effectively stabilise and treat critically ill or injured patients. Lectures were very informative, delivered by the people who have actually been there and done it.

This was especially true of areas such as major incidents and experience from the exposure to critically ill or unwell patients, which the service has seen over their many years of activity. The moulage and training is some of the most realistic I have done in my career, pushing my cognitive bandwidth during training as it feels in real life situations.

The lessons learnt from the skill stations have sharpened my skills and ability when using equipment I considered myself competent with.

Aside from the intensity and the seriousness of what we were doing, there was a very social and friendly atmosphere to the course with the team having a social drink after a hard day’s training, the obligatory course meal as well as a barbeque on the Saturday morning. This course has seen us return to our service in Glasgow with a heightened appreciation and understanding of the skills and knowledge required to treat critically ill and injured patients across Scotland. 

Fig. 1: The HCC medical module is delivered by London’s Air Ambulance (LAA) Fig. 2: Each lecture is delivered by a paramedic or doctor, depending on their area of speciality (LAA) Fig. 3: “An intense and focused course, educating and training you to effectively stabilise and treat critically ill or injured patients (LAA)

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Fig. 1: The crew, their skills, knowledge, experience, and the equipment on board, are all the resources available to deal with unforeseen events (Photographs: AMS)

Training requirements within an aeromed environment: A South African perspective Aeromedical training requirements pose some significant challenges: The industry is a combination of fallible human beings qualified in two different, highly specialized professions and who are expected to operate as one cohesive team. This plays out in an inherently hostile, high risk environment. Once the aircraft doors close and until the aircraft lands, allowing the doors to open, there is no access to any outside assistance. The crew, their skills, knowledge, experience, and the equipment on board, are all the resources available to deal with any unforeseen event. In order to minimize disaster “up there”, one has to think ahead and pre plan “down here”.

Author: Cheryl Pedersen Lead Trainer for South East Coast Ambulance Service Ashford, Kent, UK Former Training Manager Red Cross Air Mercy Service Cape Town South Africa cheryl.pedersen@gmail.com

Training assumes a vital role in effective aeromedical operations and covers many different aspects. It covers knowledge of the legislative and regulatory requirements and an understanding of operations in an aviation environment, from oversight of the different disciplines to unpacking the different pathologies and the specific handling of each. Included is the real need for safety, quality, and human factors (soft skills) training. Aeromedical operations can be divided into the various types of aviation health care services available. The South African Red Cross Air Mercy Service (AMS), with its Head Office in Cape Town and numerous operational bases around South Africa, offers the following Aeromedical Service Models:

• Rescue - Mountain and water • Air Ambulance - Primary scene • Inter Facility Transfer - Transfer of critical or stable patients from rural hospitals to tertiary hospitals for definitive care • Outreach Flying Doctor Service - Taking the medical expertise and equipment to the rural areas Each of these services would need specialised and specific training geared towards the requirements of each.

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TRAINING | 41 In addition to the above, aeromedical training would encompass the following aspects: • • • • •

Aviation, Technical, Medical, Regulatory and Human Soft Skills

The training is assessed, verified and – if required – remediated. Let us look at a few of these in more detail.

This could be either helicopters or fixed-wing aircraft, or a combination of both.

Aviation The aviation part of aeromedical operations consists of pilots, engineers and their operational support staff. Both crews, aviation and medical, require an introduction to and type rating on the specific type of aircraft in which they will be working. Therefore the training is directed at the type of aircraft fleet that is being utilized. This could be either helicopters or fixed-wing aircraft, or a combination of both.

Pilots ➜ Pilot-training is regulated with stringent oversight by the South African Civil Aviation Authority (SACAA).

This regulatory body is guided by its promulgated regulations and technical standards, a part of which stipulates training requirements. Crew training is in compliance with CAA requirements, AMS policy and procedures, and includes: • Type rating conversions onto new types of aircraft; • Flight and proficiency checks at regular laid down intervals; • Recurrent training at regular laid down intervals: Crew Resource Management (CRM) Dangerous Goods (D G), technical quizzes; • Regulatory Part 138 (Aeromedical Operations) requirements for operating in an aeromedical environment. The purpose is to provide pilots with an understanding of the role and responsibilities of the medical team. This includes, but is not limited to, an understanding of the medical equipment used, its uses, limitations and dangers. Also included are transport of highly infectious patients, the dangers of infection and contamination, patient transport considerations, overview of what medical crew are taught about aviation.

Engineers ➜ Maintenance technical engineers operate under Part 145 CAA regulations that include: • • • • •

License currency – renewable every two years; Regulatory recurrent training; Technical updates; Type rating conversion onto new types of aircraft; Time on type before being allowed to certify maintenance procedures and

3 · 2013 I Vol. 3 I AirRescue I 177

• Annual competencies – towing aircraft, ground runs, emergencies, special tools, safety practices and human factors.

Medical Aeromedicine is a unique specialty requiring specific knowledge of procedures and processes necessary to operate safely and effectively in an environment that for most is way out of their comfort zone. Training for Intermediate and Advanced Life Support paramedics, flight nurses and medical doctors has as its purpose to prepare health care providers with the necessary skills, knowledge and understanding to safely & effectively manage patients in an aeromedical environment. This includes: Aeromedical specific training consists of the AMS Health Care Provider/Flight Medical Attendant AHCP course. This is an intense short course which encompasses required and elective modules designed to equip the clinician or practitioner with the skills needed to operate in a high risk, high reliability aeromedical environment. The course duration is two weeks for Advanced Life Support (ALS) and one week for Intermediate Life support (ILS).

Requirements Minimum requirements for ALS Health Care Provider/ Flight Medical Attendant AHCP: Current registration with the relevant professional body as a Medical Practitioner or Paramedic or Nurse with ICU, trauma or emergency care experience, or relevant emergency care short course training. In addition, a minimum of six months full time post qualification clinical experience or 1,000 hours clinical experience in a recognised service as a registered practitioner.

Minimum requirements for ILS Health Care Provider/ Flight Medical Attendant AHCP: Current registration with the relevant professional body as an Intermediate Life Support Practitioner. In addition, a minimum of six months full time post qualification clinical experience or 1,000 hours clinical experience in a recognised service as a registered practitioner is required.

Fig. 2: The training is directed at the type of aircraft fleet that is being utilized

42 | TRAINING Type of Training

Additional Information

Regulatory training

CAA regulations and policies of company or organization; Standard Operating Procedures (SOPs); Safety Management Systems (SMS)

Safety orientation

Intended for medics who may be accompanying patients on a single trip, but do not have aeromedical certification. They are not considered part of the crew and do not have regulatory responsibility, but still require vital safety and equipment knowledge

Equipment

Equipment knowledge is vital

Continued training

Courses like ACLS, APLS/PALS, ATLS, ITLS or similar

Rescue training

Hoist operation, mountain and water rescue

Aeromedical specific

Aviation Health Care Provider/Flight Medical Attendant (AHCP) ALS/ILS; Advanced Airway Management & Ventilation; Emergency Medical Dispatch; Aeromedical Rescue & Hoist Training

Referring medical facilities

Safety issues and patient packaging

Table 1: Types of training

Fig. 3: Aeromedicine is a unique discipline requiring specific knowledge of procedures and processes necessary to operate safely and effectively

Medical Team Crew Resource Management Medical Team Crew Resource Management (MTCRM) is the exciting new kid on the block. It has been sourced from the aviation industry and was introduced in the 1980s, in order to reduce the high rate of aircraft accidents. It was determined that about 80% of the accidents were attributed (in part) to the negative attitudes of human beings and their inability and unwillingness to work effectively as a team.

Crew Resource Management (CRM) in aviation, in the decades since, has proven to be effective in enabling humans to modify and improve their interpersonal skills, in order to work harmoniously and synergistically with each other with the goal of safe, appropriate and effective outcomes. A team is most effective when its members understand and compensate for each other’s weaknesses, thereby maximizing strengths and minimizing any weaknesses. “Teams can lead to superior performance in Emergency Medicine where multi-component decisions in ambiguous situations can result in harsh consequences for miscalculations and mistakes.” (Croskerry et al. 2011,

Course Outcomes • Knowledge of the history of Aeromedicine • Basic understanding of the principles of flight, aerodynamics, aircraft types, fixed wing and rotary • An awareness of the laws, regulations and bodies that govern and have oversight of aviation • An awareness of related disciplines and their interaction with aviation • An understanding of the importance of safety and risk control related to safe aeromedical operations • An awareness of working in a challenging environment and operating according to CRM and Just Culture principles • An understanding of the basic principles of survival • Skills to prepare and manage a landing zone or air field • A knowledge of the physical and physiological stressors of flight • Knowledge of the gas laws and their effects at altitude • Knowledge of specific patient management strategies according to different pathologies • Understand effective patient packaging and in flight care • Knowledge of the requirements for accurate legible record keeping and documentation EJOST 21/5: 180) In this field, teams could very well consist of multidisciplinary specialties who work in a silo environment with little if any communication between them. This could lead to costly errors.

Interaction of the human component of any organisation is of prime importance. Colleagues who are unable or unwilling to work harmoniously with each other can bring an organisation down. Are the people who do the work skilled in handling interpersonal relationships? Skills can be taught in communication, situational awareness, assertiveness, conflict resolution, teamwork, handling of stress and fatigue, emotional intelligence, cultural differences, decision making, briefing/debriefing, use of checklists, attitudes, leadership and complacency.

MTCRM is also in part an error-prevention programme, that: • • • • • •

Effectively manages risk, instills an organisational (just) culture, creates safe systems, actively seeks out error traps, provides free lessons through error reporting, puts systems in place to mitigate errors once they occur.

To sum up, the aim of MTCRM is to improve patient and team safety, while achieving the best expected outcomes, by utilizing all available resources, within the best possible systems, to achieve an efficient, cost-effective and safe service delivery. The medical profession are thankfully now promoting soft skills training as the safety and cost reduction benefits are realized. 

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At AMTC 2013, you’ll find: • 2500 attendees representing over 250 international emergency medical transport programs.

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44 | TECHNOLOGY

Fig. 1: “Bacoban for Aerospace” has especially been developed to protect aircraft interiors (T. Bader)

“Bacoban for Aerospace”: Disinfectant for aircraft interiors Conventional disinfectants have a limited duration of active infection control, and reduction of infectious foci has become an important task lately. However, a problem arises using conventional disinfectants.

Although these are effective immediately, the effect is short-lived. The microorganisms are killed for only a few minutes during the continuous exposure. Then, the disinfectant evaporates and when it has, the previously treated area is again exposed to microbial infection. Therein lies the danger of re-infection. Until the next disinfection occurs, there is a hygiene gap in which there may be a new settlement of micro-organisms and pathogens. “Bacoban for Aerospace” fills this gap, as it has been developed not only to protect medical environments such as hospitals and surgeries (class 2 medical product), but also aircraft interiors.

Author: Kevin Bishop Technical Manager Frasers Aerospace contact@ frasersaerospace.com

“Bacoban for Aerospace” is a long-term, anti-viral, antibacterial and anti-fungal nano-thin coating, which can be applied to any surface via spray or wipe. Unlike most surface protection products, which once applied only last minutes, “Bacoban for Aerospace” remains active for up to 10 days after application and is resistant to the most common germs and viruses including MRSA, HIV, hepatitis B & C and norovirus. Bacoban is a water-based surface disinfectant that contains a polycondensate, a quaternary ammonium compound and sodium pyrithione. The disinfectant is free from aldehydes and phenol. It is available exclusively from Frasers Aerospace.

Bacoban disinfection and cleaning of various areas and aircraft is in accordance with European Medical Devices Directive 93/42/EEC and all types of surfaces in hospitals, doctors’ practices, rehabilitation centres and old people’s homes. It is especially useful in areas demanding effective and long-lasting hygiene and particularly suitable for areas where unpleasant odours, caused by microorganisms form, such as toilets and sanitary facilities.

“Bacoban for Aerospace” is microbiologically effective against bacteria, fungi, hepatitis B and C viruses, HIV, influenza virus, including H5N1, rotaviruses and adenoviruses. The solution (100 g) is composed of benzalkonium

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TECHNOLOGY | 45 chloride (26 g), sodium pyrithione (2.5 g), polycondensates, perfume substances and purified water. It has also been tested in accordance with German DGHM (Deutsche Gesellschaft für Hygiene und Mikrobiologie) guidelines for high organic load (see Table 1).

Effectiveness

5 min

15 min

Tested in accordance with DGHM guidelines:

2%

1,5 %

Limited virucidal effect (according to RKI/DVV recommendations), incl. HBV, HCV, HIV, influenza, BVDV and vaccinia

1%

Rotaviruses

Recent case study Over the last 18 months, Pauline Bradshaw, who is the Associate Director, Infection Prevention and Control at Alder Hey Children’s Hospital (UK), has been trialling the product. In essence, this technology allows the user to coat almost any object with a layer of invisible, durable anti-pathogen glass, which is 500 times thinner than a human hair. Pauline found that the Alder Hey trials confirmed that it created easy-to-clean-surfaces, which significantly reduced contamination.

Double blind trials have proven the efficacy of the technology. The coating procedure is very straightforward – it is a matter of wiping it with a tissue that is impregnated with the product. The procedure takes two minutes and then the item becomes protected for the next 10 days. During “Infection Control Week “ at Alder Hey, staff with stethoscopes, pagers and mobile phones were given the opportunity of having the coating applied to them.

Pauline Bradshaw went on to note “having evaluated the ease with which the items are coated, we are now going to examine the possibility of providing the product to

0,1 %

Adenoviruses

2%

Effectiveness

5 min

DIN EN 1040

0,25 %

DIN EN 1275

0,25 %

DIN EN 1276

0,75 %

0,5 %

DIN EN 1650

0,5 %

0,25 %

DIN EN 13697

0,5 %

Rotables, hydraulics, avionics & instruments ready to ship worldwide.

Parts for exchange and outright sales.

3 · 2013 I Vol. 3 I AirRescue I 181

: : : : :

Table 1: Tested in accordance with DGHM

Table 2: Tests* in accordance with EN guidelines * Long-lasting antimicrobial and virusinactivating effect for up to 10 days, tested according to ASTM E 2180.

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doctors and nurses who can use to protect their phones and stethoscopes on a regular basis. We are of course always examining ways in which to enhance infection control.” Pauline and the team are keen to continue this work by using a cohort of staff and following them for a week post coating and testing the phones, stethoscopes and pagers for levels of contamination using ATP testing, a well recognised marker for cleanliness. 

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46 | TECHNOLOGY

SferiSense: Obstacle and terrain collision ­avoidance system Author: Marcel Mämpel Sales Director Mission Avionics Cassidian

There are numerous accident-reports giving examples of controlled flight into terrain (CFIT) and obstacle strike accidents of helicopters flying under visual flight rules (VFR). Some of these accidents are preceded by unintended flight into instrumental meteorological conditions (IMC). A few examples of challenging flight situations that bear an increased risk of CFIT are limited visibility, darkness, changing weather conditions in combination with complex obstacle environments at remote locations and demanding mission requirements. tabases typically include just a fraction of all man-made obstacles. One new obstacle class the Federal Aviation Authority (FAA) was pointing out lately, are so-called MET towers (Meteorological towers). They can be erected very rapidly and are extremely difficult to see. The most serious threat comes from almost invisible wires within the helicopter’s flight path. However, database coverage of wires and cables is close to zero.

Patented LADAR technology Fig. 1: German HEMS “Christoph 17” with SferiSense – the system has demonstrated that its design features enable the operator to cope with influence of adverse weather, such as direct or indirect solar illumination, rain, fog, cloud and snow fall (www.helipictures. de)

Fig. 2: Intuitive visualization of power lines in flight path of the helicopter (Cassidian)

Flying around the clock and/or flying in unknown environments with obstacles like cables, poles and trees are major risk factors for flight safety. Timely detection of dangerous terrain approximation and obstacles may be hindered and the potential risk of a collision increases.

This is especially true taking into account the high workload of the crew for example during HEMS or other rescue operations. For a reliable CFIT and obstacle strike avoidance for helicopters, it is essential to detect any obstacle at any location within the flight path of the helicopter. This can only be done through the use of an accurate active sensor on board. In the case of Terrain Awareness and Warning Systems (TAWS), the technology relies solely on database information and therefore has intrinsic limitations on accuracy in height and position, completeness and actuality.

The typical absolute height accuracy of the ground surface of a database is approx. 60 ft. Additionally, these databases are missing completeness of non-ground obstacles as they do not include, for instance, large trees, small power lines and aerial cableways. Nowadays da-

SferiSense applies LADAR (Laser Detection and Ranging) technology to detect objects like almost invisible cable in a distance of more than 1,200 m in front of the helicopter. It visualizes all obstacles in real-time according to their threat level on a Multi Functional Display (MFD) or a Helmet Mounted Sight Display (HMSD) and warns the pilot timely in case of a likely collision. Thus, SferiSense, product of Cassidian’s (defence and security division of the European Aeronautic Defence and Space Company, EADS) Situational Awareness product family SFERION, considerably reduces this risk and maximizes the safety of pilots, passengers, helicopters, and payload. LADAR detects all obstacles independent from their materials or surface characteristics in the complete field of view and achieves a detection probability of ≥ 99.5% within the first second of the obstacle appearance. During thousands of flying hours, for example on HEMS operations in Germany, SferiSense has demonstrated that its design features enable the operator to cope with influence of adverse weather such as direct or indirect solar illumination, rain, fog, cloud and snow fall.

Furthermore, SferiSense has proven its capability to withstand the effects of self-blinding (caused by close and reflecting objects such as dust and bugs on the optical window) enabled by certified eye-safe binocular system layout. This guarantees insensitivity to self-blinding and minimizes scatter effects from objects close to the helicopter. The SferiSense Obstacle Warning System is the result of more than 25 years experience in 2D and 3D laser radar system and line scanner technology as well as 15 years background in range data processing and obstacle detection/warning algorithms. 

3 · 2013 I Vol. 3 I AirRescue I 182

EMSSA 2013 incorporating

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48 | IN PROFILE

Fig. 1: The Nordic Air Ambulance of Denmark was granted permission to operate HEMS in 2010 (NAA)

Saving lives in Denmark: Nordic Air Ambulance provides high quality HEMS Night-time in Denmark: A woman in her forties experiences chest pain. She decides to call an ambulance, but wonders if she is exaggerating the whole thing. When the ambulance arrives, she insists on walking to the vehicle. With the ambulance crew on the scene, the medical coordination centre dispatches the helicopter emergency service – to be on the safe side. The helicopter meets them at the nearest airport in mainland Denmark. Again, the woman wants to walk, this time from the ambulance to the helicopter. When the helicopter is about to lift off, the flight crew hears the doctor in the back yelling, “Stop! Stop!” This surprises the flight crew. What is going on? Are they supposed to stop? Quickly, they realise that the doctor definitely did not want them to stop – he was referring to the patient’s heart that had stopped beating.

Author: Randi Johannessen Buckley Norsk Luftambulanse randi.johannessen.buckley@ norskluftambulanse.no

The story of Nordic Air Ambulance began only recently, in 2010. Danish health authorities wanted to establish a Helicopter Emergency Medical Service (HEMS) project as an addition to the existing health services, with the base to be located at Karup airport on the mainland. The objective was to verify if HEMS operations 24/7 was beneficial to Denmark’s population, both on mainland and on the islands close to shore.

At the time of the tender process, Norwegian Air Ambulance (NLA) did not have the opportunity to make an offer. However, the subcontractor to the company that won

the tender failed to deliver and had to establish a new operation. As a result, Norwegian Air Ambulance was approached in April 2011 and asked if they were interested in stepping in. This time, Norwegian Air Ambulance was able to say “Yes”. Lasse Dahl, CEO and accounting manager of Nordic Air Ambulance: “We had helicopters and crew available at this time. Having 35 years of experience operating air ambulance services, we knew how to implement and run this kind of service. We worked extremely hard for many weeks, 24 hours a day, and two months later we had a full-scale operation running.”

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IN PROFILE | 49 Permission by the Air Aviation Administration The process moved forward quickly: Norwegian Air Ambulance was given permission by the Danish Civil Air Aviation Administration (DCAAA) to commence operations in Denmark, despite the fact that it is normally required to be a Danish registered company to operate such a service. Hence, Nordic Air Ambulance (NAA), a subsidiary of Norwegian Air Ambulance, was established in Denmark in May 2011. Only a few months later, NAA fulfilled all requirements, was approved by the DCAAA and was fully operational, taking over the operation from their mother company Norsk Luftambulanse, the Norwegian Air Ambulance (NLA). Pilot, HEMS Crew Member and an anaesthesiologist specializing in emergency medicine and trauma, recruited from university hospitals in the area, make up the team providing the Danish population with quality care 24 hours a day, 365 days a year. “The whole principle is to provide the patient with optimal care, no matter where and when. We always work with our vision in mind: “No one can say we could have done more”, says Dahl.

The woman is suffering from a sudden cardiac arrest – she is clinically dead. The team starts treatment immediately. The helicopter lifts off and heads towards the nearest suitable hospital. It would normally take an ambulance between 50 minutes and an hour to get there, the helicopter lands after just 25 minutes. A trauma team is ready on arrival, and the patient is taken to surgery immediately.

Despite the fact that HEMS operations were established in a record time, no shortcuts have ever been taken, as quality and safety is key in every aspect of the operation of Nordic Air Ambulance. A highly skilled and experienced team is on duty every hour of every day, all year long. They must meet high competency requirements and go through the most extensive training programme in Europe.

Requirements for HEMS crew In order to maintain safety at a highest level, (H)EMS professionals are hired on a full time basis and the company works hard to maintain a high continuity of pilots, who are trained to handle the most demanding tasks in extreme weather conditions. The requirements include: • • • • • •

CPL/H – ATPL certification Flight commander, time minimum 2.000 hours Experience flying in darkness Experience flying instrumentally and visually Relevant experience Suitable personality

The crew conducts emergency training twice a year in an EC135 simulator. Training of non-technical skills like leadership, communication, situation awareness, teamwork and decision-making are equally important, and the crew has access to unique training facilities at Camp Torpomoen (fully funded by the Norwegian Air Ambulance Foundation) in Ål, Norway. The training programme focuses on realistic human factor aspects in the HEMS team (Aeromedical Crew Resource Management).

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Nordic Air Ambulance has chosen an EC135 for its operations, a chopper regarded as being the optimum for HEMS. Due to its medium size, it can land in the most confined areas, very close to the patient. Its tail rotor construction – the Fenestron – decreases noise and improves safety, making it suitable to land in narrow spaces. The medical interior can be reconfigured to meet different needs. The treatment and procedures given on board the EC135 almost equals that of a trauma centre or an intensive care unit. The patients are taken to the nearest hospital, which is best suited to deal with the acute illness or injury.

Using state-of-the-art equipment and advanced technology, Nordic Air Ambulance aims to provide the best, most reliable and safest service. The EC135 has an impressive average reliability above 99.5% on an annual basis. “Our assignments are typically located in mid mainland Denmark and regional islands around the mainland.

The helicopter is usually in the air within 2 to 3 minutes after receiving the alarm call and short pre-flight planning, and we can reach most of the emergency distress within 25 minutes”, explains Dahl.

Two days later, as the crew brings another patient to the university hospital of Aarhus, they find the woman enjoying a hospital dinner. She only remembers bits and pieces from the dramatic incident that had occurred two days earlier. Now she is in a good physical condition after surgery, and tells them she expects to be back at work in 14 days.

Nationwide HEMS in 2014 Three years in operations, Nordic Air Ambulance is faced with yet another short deadline: The Danish parliament has decided to establish nationwide HEMS, starting October 2014. Three bases will be situated in Ringsted (West of Copenhagen), Billund (Central Mainland) and Skive (South West of Aalborg).

“These are very exciting times. We are offering to run the three bases, and we absolutely want to be present in Denmark. We want to provide the Danish patients the same high quality treatment that we have been providing Norwegians for 35 years, using the right type of helicop-

Fig. 2: Nordic Air Ambulance has chosen an EC135 for its operations that – due to its medium size – is ideal as it enables HEMS in the most confined areas as well (NAA)

50 | IN PROFILE

Fig. 3: Three years in operations, NAA’s total number of missions in 2011 was 527 and rose to 1,117 in 2012, with a tendency to increase even further in 2013: until 28 August 2013, there were 780 HEMS missions (NAA)

ter, the right equipment and the right competence. There is no faster and easier way to do this, says Dahl.

Shortly after meeting their patient in the hospital, the flight crew receives a card from the woman, expressing her deepest gratitude. The crew however was downplaying their efforts: “We were just doing our job. However, it feels really good to be able to help, especially when the end result seems to turn out so well, says Jens Vilman, the manager for Flight & Ground Operations in NAA as well as pilot.

Implementing a new technology A breakthrough for the HEMS crew has been the implementation of NVIS (Night Vision Imaging System) in 2012.

Nordic Air Ambulance is the first civilian air operator to get approval in Denmark for using this kind of a system. The NVIS, originally used by the military, is mounted on the pilot’s and HEMS Crew Member’s helmets. NVIS improves flight safety and enables the crew to land closer to the patient during night time. The system has proven to be extremely useful: During the first month, the Night Vision Goggles were in use 32 times. “The goggles have been crucial in many situations. We are able to fly on more primary assignments – even when it is not clear if we are needed. Our pilots say they can’t imagine flying without them, says Vilman.

The next step to ensure even better service is implementing PinS (Point in Space Navigation), a system developed by Norwegian Air Ambulance, which presently has 35 approaches certified in Norway. This system is in use at airports, but has so far not been an implemented part of the HEMS operation in Denmark. Using pre-pro-

grammed GPS-routes to hospitals, the helicopter is able to fly and land in weather conditions that would normally lead to altered and more inconvenient landing sites. There is no doubt this system is of great importance, improving safety and regularity of the service. “We are currently cooperating with the authorities to test and develop PinS. Five approaches are being developed at this point. It is an extensive process, but it looks very promising”, says Vilman.  Nordic Air Ambulance – Facts and Figures

• Nordic Air Ambulance (NAA) is a subsidiary of Norwegian Air Ambulance (NLA) • NAA operates on assignment from the Danish health authorities and is government funded • NLA runs the air ambulance helicopter service on assignment from the Norwegian health authorities, and runs 8 of Norway’s 11 air ambulance helicopter bases • The company is renowned for its experience and expertise in the field of HEMS and is a significant driving force in R&D • Norwegian Air Ambulance is a subsidiary of the Norwegian Air Ambulance Foundation (SNLA) • SNLA is Europe’s largest research facility in pre-hospital emergency medicine

3 · 2013 I Vol. 3 I AirRescue I 186

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52 | IN PROFILE

Fig. 1: “Medevac 112” on-scene in rural Co. Roscommon for an agricultural incident (Medevac 112)

“Medevac 112”: Ireland’s Emergency Aeromedical ­Service (EAS) For the past 14 months, two separate Irish government departments (Department of Health & Children and the Department of Defence) have been working closely together to evaluate the need for, and requirements of, a full-time helicopter air medical service for the island of Ireland. The Emergency Aeromedical Service (EAS) has been operated by the Irish Air Corps in support of the National Ambulance Service (NAS) under a Memorandum of Understanding (MoU) signed between the Minister for Health, Dr. James Reilly TD, and the Minister for Justice, Equality and Defence, Mr. Alan Shatter TD. To date, the service has performed around 300 missions in support of the NAS since being officially launched by both ministers at a ceremony at Custume Barracks, Athlone, on 21 May, 2012.

Author: Darren Figgis Advanced Paramedic EAS Flight Paramedic National Ambulance Service, Ireland

Flying under the call-sign “Medevac 112”, EAS uses dedicated helicopter assets of the Irish Air Corps, with in-flight clinical care being performed by speciallytrained paramedics from the NAS. Initially utilizing a Eurocopter EC135 (later an AgustaWestland AW139) airframe, the service has provided invaluable support to patients and paramedics, where distance to definitive care has been increased due to reconfiguration and centralization of specialist medical care and hospitalbased services, including interventional cardiology and trauma services.

Although no long-term decision has yet been made regarding the future of the project, the first fourteen months of EAS have been welcomed as a success, and demonstrated the need for a full-time helicopter service.

History of Helicopter Air Ambulance Services in Ireland The Irish Air Corps have played a vital role in providing air support to the ambulance service since 1965, when a

formal arrangement was established whereby the Department of Defence provided air ambulance transport (both rotary and fixed-wing) to the Health Boards (now National Ambulance Service) for emergency cases when available.

Up until the establishment of the EAS, air ambulance missions were defined as a purely “secondary role” for the Air Corps as an aid to the civil community.

Prior to the implementation of the EAS, Air Corps helicopter activity in support of the NAS was limited to approximately 150 air ambulance missions annually. This number of missions diminished, partly due to responsibility for the island medevac service being transferred to the Coast Guard, and an aging fleet of helicopters, which was long overdue for replacement.

Over the intervening years, several government reports were commissioned to review the potential benefits of a full-time helicopter emergency medical service (HEMS), but all found that the provision of such a dedicated service would be very costly relative to the health gain which could be achieved at a lower cost by continu-

3 · 2013 I Vol. 3 I AirRescue I 188

IN PROFILE | 53 ing the improvement of ground ambulance services to a standard required.

Establishment of EAS “Pilot” Project Under the joint direction of the two government ministers responsible, the Irish Air Corps and National Ambulance Service worked closely together to establish a pilot feasibility project, which would be used to determine the type and level of service required to support the day-to-day activity of the National Ambulance Service, nationwide.

This involved the selection of aircrew (both military and civilian), and specific training relevant to their new roles operating as EAS personnel. Senior Air Corps personnel visited other helicopter air ambulance operators to learn from them about their newly adopted role, and exchange information. Advanced paramedic practitioners from the NAS were chosen to provide appropriate in-flight clinical care, and received a month-long introduction to their new roles and responsibilities operating as part of the helicopter crew.

From a central location at Custume Barracks in Athlone, the AW139 helicopter is approximately 50 minutes flying time from any part of Ireland, and for this reason it was chosen as the ideal base of operations. Tasking of the aircraft is provided by dedicated dispatchers at the National Aeromedical Coordination Centre (NACC) based at the NAS Communications Centre in Tullamore, Co. Offaly. NACC dispatchers also provide in-flight communication between the helicopter crew, NAS personnel on the ground and receiving hospitals, as well as flight following.

First Mission The first EAS mission was performed on 4 June 2012, when a 26-year-old woman injured in a farm accident and was flown from rural Co. Roscommon to specialist trauma services at Galway University Hospital in just 11 minutes. Prior to the implementation of the EAS, an equivalent 90-km-journey by ground ambulance would have taken approx. 90 minutes to drive. Since then, EAS missions have been diverse in nature, with the majority (around 45%) being in support of the National Acute Coronary Syndrome Programme (NACSP), which sees patients with new or evolving acute myocardial infarctions being brought directly to dedicated centres for emergent percutaneous coronary intervention (PCI). The first of

3 · 2013 I Vol. 3 I AirRescue I 189

these dedicated centres for ambulance service referral was established at Galway University Hospital, and since the establishment of EAS, approximately one-third of all patients requiring emergent PCI have arrived there by helicopter.

The majority of EAS missions have involved response in support of the NACSP (including patients post-ROSC) for which the AW139 is ideal, as it provides ample room for the treatment and transport of patients with multiple medical conditions. Incidents involving traumatic injuries have also resulted in a significant number of missions, with approx. 30% resulting from serious road traffic collisions, industrial, agricultural and other causes of serious trauma.

Initially, the pilot project was designed to provide helicopter support to NAS activities along Ireland’s Atlantic seaboard, where the population density and rural road means an increased length of time for ambulance service response, as well as transport to definitive care. However, such has been the success of the project that EAS operations have encompassed the entire country, flying patients from many remote rural locations to specialist medical care in a fraction of the time it would have taken for them to be driven by ground ambulance. Since the EAS pilot project’s inception, approximately one-third of patients requiring emergent PCI at GUH have arrived at the hospital via helicopter.

Future for EAS Although no formal announcement has been made, the EAS, or its successor, will undoubtedly have significant influence on the development of a National Transport Medicine Programme for Ireland. This will seek to enhance the current level of pre-hospital, critical care and transport medicine designed to optimise the use of resources at local and national level, with a view towards providing cost savings to the health service overall, by reducing the length of stay in acute hospital beds. EAS has demonstrated a significant overall improvement in the quality of care, and has enhanced the outcomes for many of those patients who have been flown directly to specialist care.

It is hoped that EAS will provide the building blocks for a clinically effective national retrieval system and support the implementation of national clinical programmes for adult, neonatal and paediatric specialties. 

Fig. 2: The majority of EAS missions have involved response in support of the National Acute Coronary Syndrome Programme for which the AW139 is ideal, as it provides ample room for the treatment and transport of patients with multiple medical conditions (Medevac 112) Fig. 3: Since the EAS pilot project’s inception (image shows EAS aircrew with staff from the Interventional Cardiology Unit at Galway University Hospital), approximately one-third of patients requiring emergent PCI at GUH have arrived at the hospital via helicopter (Medevac 112)

54 | In Profile

The BARS Program:

Risk oversight & management

Risk oversight and management are key elements of governance for any organization and not just from the commercial perspective. Whilst safety risk management has for a long time been at the forefront of high-risk industries, the manner in which third party providers of services, including aviation, are measured in terms of safety, can be somewhat variable. Aviation has become an integral part of the resource sector in providing services such as the transport personnel, exploration support, aerial survey and other operational activities often conducted in remote regions of the globe. These types of operations pose a high material risk for personnel. If not managed appropriately, they can manifest themselves with tragic results.

Author: Greg Marshall Managing Director BARS Program Flight Safety Foundation Melbourne, Australia marshall@flightsafety.org

The global demand for raw materials has seen an exponential growth in mining operations and along with this has been an equivalent level of growth in the aviation support sector. For many smaller aircraft operators, this growth has resulted in an increase in operating capacity

through increased flying frequency or the introduction of larger and more complex aircraft types. Such growth may represent significant organizational change with concurrent new or increased levels in risk.

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In Profile | 55

Fig. 1: The Basic Aviation Risk Standard (BARS) is also tailored towards the resource and mining sector aviation operations, onshore as well as offshore (Bond)

Market growth has also seen a number of new aircraft operators enter the aviation support sector, and not all may be adequately prepared to meet the challenges posed by operating in these new environments. Resource companies need to apply prudent governance measures to ensure that the operators providing these services meet standards that often exceed that of respective regulatory authorities.

BAR Standard During 2009, the mining and resource sector approached the Flight Safety Foundation to help with the development of a common global standard that could be applied to resource sector aviation operations. The product of that development is the Basic Aviation Risk Standard (BARS) that

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is framed against the actual threats posed to resource and mining sector aviation operations. These threats have been identified from both normal operations and from experience gained by the sector over many years. It directly links these to control, recovery and mitigation measures in a risk-based manner. Together with an auditing and training program, BARS has been operational now for over two years and is already yielding positive improvements in operational safety.

The BAR Standard is subject to continual review and has resulted in refinements and the addition of new elements to the standard, including for Medevac and NVG operations. A technical advisory committee, comprising of representatives of each of the member organizations, meets on a six-monthly basis for the purpose of ensuring

56 | In Profile Audits

Fig. 2: The BAR Standard is subject to continual review and has resulted in the addition of new elements to the standard, including NVG operations (G. Marshall)

the BAR Standard remains contemporary and relevant to resource sector aviation operations. A summary analysis of findings from BARS audits is a part of the review process to promote awareness of any trends identified through the program.

Program tools

Fig. 3: BARS is a growing program that is contributing to an incremental improvement in aviation safety in some very challenging environments, including Medevac and repatriation flights (G. Leonhardt)

The program has also seen the introduction of a number of tools to assist organizations with the management of their aviation risk. The BARS implementation guidelines suite of documents provide additional details on the elements that make up the BAR Standard. Volume 1 was introduced earlier this year, volume 2 was released in July. Further volumes will be added and all will be subject to continual review to ensure they remain contemporary.

For resource sector member organizations, an intranet safety portal has been developed that can be “plugged in” to a company’s existing intranet. The portal contains template aviation risk policies, procedures and processes that can be used as a starting point by those companies that have not yet developed these. New resource sector member companies also receive a BARS member organization induction pack that includes the intranet safety portal.

BARS is essentially a two-step process. Firstly, it involves a two-person two-day audit of the aircraft operator to ensure that the threat controls embodied within the BAR Standard are established. Secondly, separate operational reviews are carried out of identified end-point high-risk activities to validate the effectiveness of these controls.

Rather than conduct a typically broad-based audit once per year, a BARS audit of the aircraft operators systems is conducted annually. However, operational reviews are conducted during the year at a frequency dictated by risk.

All audit findings categorized as P1 and P2 are tracked to close within a defined period of time. Unlike some other audit programs, these findings have to be closed and cannot appear as a repeated finding. The status of audit findings and corrective action taken is updated within BARS to enable member resource companies to track their progress.

BARS audits are carried out through one of 8 accredited audit companies and there are currently over 60 auditors accredited under the BARS Program. Before auditors can achieve a BARS audit accreditation, they must have a considerable level of experience as either a pilot or an aircraft maintenance engineer and possess Lead Auditor qualifications with a prescribed level of auditing experience. Auditors then undergo a course designed to inform them of auditing to the BAR Standard.

It is important to note that a BARS audit is not a pass-or-fail type of audit. It is an objective audit ­devoid of subjective comments, conducted to an industryderived standard. It serves to identify any opportunities for improvement that may be identified for an operator to achieve conformance with the Standard. Today, more than 100 aircraft operators across the globe have been audited against the Standard with a number of these having achieved the Gold category within the last month.

Findings With a growing number of audits comes a wealth of data that can be used to the benefit of stakeholders, both within and outside of the Program. This data can be used to identify key findings by region that may prove useful in identifying, where efforts may be required to assist in enhancing safety. Some preliminary assessment of the data gained thus far was conducted late last year and involved a review of over 3,000 findings conducted of 87 aircraft operators. Some of the results of the data assessment are as follows: Profile of aircraft operators audited by type: • Fixed-wing 58% • Rotary-wing 28% • Fixed- and rotary-wing 14%

Profile of aircraft operators audited by company size: • 15% are classified as small with less than 20 employees • 43% are classified as medium with between 21 and 100 employees

3 · 2013 I Vol. 3 I AirRescue I 192

IN PROFILE | 57 • 42% are classified as large with more than 100 employees

Findings summary: • 25% of operators had a non-conformity against stabilized approaches • 36% of operators did not have a “no fault” go-around policy • 20% of operators did not have documented hand-over procedures for multi-crew aircraft • 40% of operators had non-conformities associated with passenger safety briefings • 56% of operators had non-conformities associated with Crew Resource Management training • 11% of operators did not provide training for TCAS or TAWS (where this equipment was fitted to their aircraft) • 20% of all findings are associated with SMS deficiencies • 5 operators did not have a no-transit policy regarding external load with a short line and no load attached • 15% of operators did not have documented guidance associated with thunderstorm avoidance

The good news is that in all of the findings that formed a part of this review have been corrected and closed.

In a number of cases, the findings reflect that there is inadequate understanding of how to implement elements of SMS, particularly those involving change and risk management. Whilst there is a wealth of information available in this area, smaller operators appear to have trouble interpreting what is specifically relevant for their size of operation.

Training courses The Onshore Aviation Coordinator (AVCO) training course was the first to be developed to meet a need for training of resources personnel in aviation hazards and risk.

This two-day course covers aviation risk for fixed and rotary aircraft in addition to other aviation facilities typically used and managed by resources sector personnel.

A variation to this course is nearing finalization and has been tailored to meet the needs of the offshore sector.

The first beta course is expected to be delivered during October this year.

Helicopter external load operations are conducted within many industries in most countries globally. At present, there is little standardisation in procedures, equipment or training for personnel engaged in these activities. A new “Helicopter External Load Operations for Ground Personnel” course has been developed by the Flight Safety Foundation to provide standardisation and basic training for personnel engaged in activities involving under-slung loads. This two-day course includes the use of 3-D animations, graphics and video, and has been developed for resource sector application, however it can be tailored to meet the specific needs of other sectors that engage helicopters in similar support roles such as fire-fighting, humanitarian support and flood and famine relief. A further course on “Aviation Risk for Managers” has also been developed.

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BARS Program Application to other markets The BARS Program was established to address a need of the onshore resources sector. This sector typically involves fixed and rotary wing operations that often occur in remote regions and over hostile terrain. With this in mind, BARS can equally be applied to other operations outside of the resources sector that possesses the same operational risk profile. For this reason, a number of other stakeholders, including government, are currently reviewing the use of the BARS Program to support their activities.

Gold Status A new Gold registration status has been introduced and the first to achieve this in the world is National Airways Corporation, which is based in Lanseria, South Africa.

Other aircraft operators to have achieved the Gold registration status include Solenta Aviation (also based in South Africa), Execujet Australasia (based in Sydney) and Alliance Airlines (based in Brisbane) and Cobham Aviation Regional Services (based in Adelaide). Alliance Airlines are the first aircraft operator in Australia to have achieved the Gold registration status.

Summary The BARS Program provides a level of risk assurance for organizations by utilizing an industry-derived global standard to assist in the management of safety for company personnel. It is supported with tools and training courses designed to assist member resource sector organizations with the management of aviation risk.

Globally, more than 100 aircraft operators are currently BARS registered.

The BARS Program continues to mature with new products under continual development. The number of resource sector organizations wishing to join the Program also continues to grow, as do the number of aircraft operators opting to undertake BARS audits. BARS is a growing program that – in its own way – is contributing to an incremental improvement in aviation safety in some very challenging environments, including Medevac and repatriation flights. 

Fig. 4: The Onshore Aviation Coordinator two-day training course covers aviation risk for rotary and fixed-wing aircraft (DRF Luftrettung)

58 | REVIEW

Fig. 1: Minimization of pre-hospital time delays is a highly critical issue in acute stroke management (Photograph: ÖAMTC)

Stroke Study: Helicopter transport of stroke patients and its influence on thrombolysis rates In May 2011, a noteworthy article about the relevance of helicopter transport of stroke patients and its influence on thrombolysis rates was published in the journal of the American Heart Association (1). The study group is from Austria’s Center of Clinical Neurosciences, Danube University Krems and Department of Neurology, Danube Clinic Tulln under Michael Brainin. The author Dr. Veronika ReinerDeitemyer received the Presidential Award 2012 from the Austrian Society of Stroke Research (ÖGSF) for this article.

Authors: Veronika ReinerDeitemyer, MD, MSc Attending physician Department of Neurology Danube Clinic Tulln e-mail: neurologie@ tulln.lknoe.at Michael Brainin, MD, FESO, FAHA Head of the Department for Clinical Neuroscience and Preventive Medicine, Head of the Center for Neurosciences, Danube University Krems, Head of the Department of Neurology, Danube Clinic Tulln

Time is brain! As we all know, a stroke is an emergency.

Rescue teams are trained to recognize stroke symptoms like numbness, weakness and problems with speech.

Stroke patients have to be transported to a specialized center (stroke unit) as fast as possible in order to receive efficient thrombolytic therapy. Thrombolytic therapy in patients with ischemic stroke has been recommended for use within four and a half hours (2). The earlier the patient receives this treatment, the better the outcome. The first hour is considered the “golden hour” concerning thrombolytic therapy. Therefore, minimization of pre-hospital time delays is a highly critical issue in acute stroke management. In some instances, when ground transport is considered too time-consuming, patients are transported by helicopter to minimize pre-hospital delays. Helicopter transport is thus used either in rural areas or in very large cities with chronic traffic congestion in order to provide rapid transfer to a tertiary care centre (stroke unit).

Until now, experience has been very limited regarding helicopter transport in association with acute stroke management. Most studies are based on small numbers of helicopter transports only to single centers (3-6). This current study was aimed at including a large number of helicopter-transported ischemic stroke patients (n=905) treated within a national network of stroke units. The specific question of this study was to find out whether helicopter transport effectively reduced pre-hospital time delays and significantly increased rates of thrombolysis.

Data from the Austrian Stroke Unit Registry from 32 stroke units in Austria were analyzed between January 2003 and May 2009. During this time period 21,712 ischemic stroke patients were admitted to 32 stroke units in Austria. Of these patients 905 (4.1%) were transported by helicopter, 752 (3.4%) by direct air transport from the site of stroke onset and 153 (0.7%) by inter-facility air transport.

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REVIEW | 59

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stroke patients and thrombolysis in a nationwide setting.

It shows that helicopter transport is most efficacious for short pre-hospital time management enabling time-dependent therapy with thrombolysis for a large number of patients.  Time from stroke onset to admittance

Door-to-needle time

N=13329*

N=2086*

median

inter­ quartile range

median

inter­ quartile range

90 175 85 162 120 240

60-125 105-257 60-145 90-348 65-274 125-540

45 30 48 40 50 46

30-60 10-68 35-70 15-73 35-74 25-75

HEMS direct HEMS indirect AMBP direct AMBP indirect AMB direct AMB indirect

35 30 25 Percentage

In Austria an emergency call is answered by a trained dispatcher at the rescue coordination/dispatch center, who decides – based on telephone triage and availability – which type of transportation is sent out. If necessary, an ambulance with EMS physician or HEMS can be requested. In Austria (as in many other European countries) the accompanying HEMS physician is a certified emergency physician with a high level of expertise. Other persons such as paramedics have a lower level of expertise and formal training. Thus patients come either by ambulance (AMB) accompanied by emergency paramedical stuff only, or by ambulance accompanied by an EMS physician (AMBP), or by HEMS, which is always accompanied by an EMS doctor. Within these three means of transportation we distinguished between patients coming either directly from home to a hospital with a stroke unit and those transferred from a peripheral hospital without a stroke unit (indirectly).

In this study, transport times were similar for direct helicopter transport and direct ambulance transport, provided the ambulance was equipped with an EMS doctor.

The shortest transport times (90 minutes or less) from stroke onset to hospital arrival were achieved with direct ambulance transport accompanied by an EMS doctor and direct HEMS transport. Only in these two groups did more than 70% of patients arrive within two hours of stroke onset (see Table 1).

The most striking result of this study was the high rates of thrombolysis in patients transported by helicopter (see Fig. 2). Of 21,712 ischemic stroke patients, 2,501 received thrombolysis. 180 of 745 patients (24%) transported by direct HEMS were treated with thrombolytic therapy. In the indirect (inter-facility air transport) HEMS group, the rate of thrombolysis was even higher with 29% (44 of 153 patients were treated with thrombolytic agents).

In Austria, almost all patients receive thrombolytic therapy in stroke units served by neurologists. The multidisciplinary care of stroke patients in stroke units is of enormous value regarding the management of these patients. In the future not only fast treatment with thrombolytic agents is of importance, but also possible endovascular procedures in case of carotid t occlusion or middle cerebral artery occlusion. So, fast access to endovascular treatment has to be established for patients in all regions.

Thus the reduction of pre-hospital time delays and fast interfacility transfer are essential.

This study showed the effectiveness of helicopter transport regarding pre-hospital management of ischemic stroke patients and subsequent time-dependent therapy with thrombolysis. Indeed, 89% of all direct and 95% of all indirect HEMS transports to stroke units had a confirmed diagnosis of acute stroke. This and the high rates of thrombolysis in the helicopter groups indicate that preselection of ischemic stroke patients and assignment to a certain mode of transportation during pre-hospital management is a successful process offering fast access to therapy with thrombolysis.

In conclusion, this study is the first with high numbers of helicopter transports in association with ischemic

44/153

180/745

165/1,102

10

978/11,289

5 0

% 74.2 34.2 70.3 39.5 51.7 24.6

Fig. 2: Percentage of thrombolyzed patients according to transport mode

1,050/5,842

15

N=13329* Transports arrived within 2 hours of total transports 389 of 524 38 of 111 2,668 of 3,794 280 of 708 3,499 of 6,767 351 of 1425

Table 1: Pre- and intrahospital time periods of ischemic stroke patients according to transport mode (*due to missing values data are reduced from a total of 21,712 ischemic stroke patients to 13,329 and 2,086)

(n = 2,501 thrombolyzed patients)

20

Arrival within 2 hours

84/2,442

HEMS

AMBP

AMB

direct / indirect

direct / indirect

direct / indirect

References: 1. Reiner-Deitemyer V, Teuschl Y, Matz K, et al. (2011) Helicopter transport of stroke patients and its influence on thrombolysis rates – data from the “Austrian Stroke Unit Registry“ Stroke 42 (5): 1295-300. Epub Mar 24 2011.

2. The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Group (2008) Guidelines for management of ischemic stroke and transient ischemic attack 2008. Cerebrovasc Dis 25: 457-507 3. Silliman SL, Quinn B, Huggett V, et al. (2003) Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 34: 729-733 4. Conroy MB, Rodriguez SU, Kimmel SE, et al. (1999) Helicopter transfer offers a potential benefit to patients with acute stroke. Stroke 30: 2580-2584 5. Thomas SH, Kociszewski C, Schwamm LH, et al.

(2002) The evolving role of helicopter emergency medical services in the transfer of stroke patients to specialized centers. Prehosp Emerg Care 6: 210-214 6. Konstantopoulos WM, Pliakas J, Hong C, et al. (2007) Helicopter emergency medical services and stroke care regionalization: Measuring performance in a maturing system. Am J Emerg. Med. 25: 158-163

AMBP: ambulance with accompanying physician AMB: ambulance without accompanying physician Direct (blue column): patients transported directly to a center with a stroke unit Indirect (grey column): patients transferred from another hospital to a center with a stroke unit

60 | CASE REPORT

Fig. 1: A poisonous snake had crept out of the patient’s jacket – luckily only after the helicopter had landed and all crew members and the patient were out of reach (ATE)

Snake on board: Hitch-Hiking on an EMS helicopter A stowaway snake got on board an EMS helicopter operated by Air-Transport Europe, Ltd. (ATE) in Slovakia during one of its missions in May 2013. Well hidden, none of the helicopter crew members were aware of its presence on board during the flight. The snake stowaway hidden and carried in one of ATE’s EMS helicopter turned out to be a 30-centimetre long viper. Not even the patient who was accidentally carrying it in his jacket during the whole transport to hospital had any idea about how it got there.

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

On 11 May 2013 the helicopter crew of HEMS Air-Transport Europe was called on a mission in the village of L’ubotín. The forlorn village, situated in the north-eastern part of Slovakia, is surrounded by beautiful nature, meadows and fields. However, local people say that snakes are a very common sight in this area. Bitten by a poisonous snake while working on a meadow, it was a 41-year-old local, who was awaiting the help of the HEMS crew. The man’s swollen leg required an urgent helicopter transport to a hospital. A crew of the HEMS ATE base in Poprad was sent on the mission. The flight took 16 minutes and the helicopter landed on a meadow close to the injured man. After necessary treatment the ATE helicopter crew took the patient to the nearest hospital in Stará L’ubovña.

The patient was handed over to the doctor on duty in the Accident & Emergency department. The doctor – with the assistance of a nurse – examined the patient and provided basic treatment after the snake bite. While putting on his jacket after the surgery with the intention to leave

the operating theatre, a 30-centimetre long snake jumped out of it. “First we got a bit scared, but then we succeeded in keeping a cool head and I noticed that it was a viper,” the doctor said. The snake was creeping under the bed in the operating theatre, heading for the window. The doctor, the nurse and the patient got out of the room and called in the security. A security guard managed to catch the snake, took it out of the hospital and packed it into a box. This would not have been an option for the HEMS crew if the poisonous snake had crept out of the patient’s jacket during the flight. The “what-if” scenario not only struck the helicopter crew that got to know of the snake’s presence in a helicopter from the hospital staff, but also the media that became interested in this “rarity on board”.

Mr. Viliam Krivák, the chief pilot of ATE helicopters flight operations commented: First of all it is necessary to stay cool, “keep a cool head” so to speak. An overreaction, stress response, seems to be the worst thing to do. In my opinion, the outcome of such a scenario would have

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CASE REPORT | 61 been determined by the site where the snake was located inside the helicopter, i.e. in which part of the cabin the snake appeared and how it would have reacted. It is more likely to believe that the snake itself would have been under more stress than all the members of the helicopter crew together, so most probably it would have stayed “unnoticed” in some hidden place. If this would have been the case, then it is better just to keep an eye on it rather than provoke it. To minimize its activity or just to keep it calm, it is recommended to cover the snake with some jacket or a blanket. In case it starts moving in a random way, it cannot get to the pilot, namely close to the pedals. In any case – depending on the patient’s health condition – landing in a proper surface in nature and releasing or forcing out the uninvited guest into the countryside would be the most proper solution. One important fact has to be taken into consideration: Even if the worst comes to the worst, meaning the pilot is bitten by a fully grown-up viper, the poison takes effect after several minutes depending on the quantity of poison. Until then, every experienced pilot should have been able to land safely in a proper place.

How come the patient did not realise the presence of the snake in his jacket and how did it get into his pocket at all? Ján Korˇínek, a doctor working for ATE HEMS, explained: After we landed on the meadow, the injured man was waiting for us, sitting on the ground, his jacket laid next to him on the meadow. His leg was swollen, tingling and he was feeling weak. I gave him a medicine to ease

Fig. 2: Bitten by a poisonous snake while working on a meadow, a 41-year-old local from the north-eastern part of Slovakia was awaiting the help of the HEMS crew (J. Slivinsky)

allergic reaction and consequently we transferred him on board the helicopter. He took the jacket lying on the ground and kept it with him all the time during the flight.

Nobody noticed the snake hidden in his jacket.

Oddly enough, some other snake had got into the injured man’s jacket while he was waiting for help. “We often land on high-grass meadows during our primary missions, but we have never experienced this kind of a situation before. However, having experienced this, we have become aware that something similar may happen quite easily. Sometimes it is not possible to foresee all potential risks. It is this experience that is a good lesson for us,” Mr. Krivák summed up. 

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62 | FIXED-WING

Transferring casualties en masse: Aeromedical missions with large jet aircraft Fig. 1: Boeing C-17 of the US Air Force in an aeromedical evacuation configuration (Master Sgt. S. Reed)

Author: Steven Curnin Faculty of Education & Australian Bushfire Cooperative Research Centre University of Tasmania Steven.Curnin@utas.edu.au

Disasters requiring the repatriation of victims to their home country will invariably necessitate an aeromedical platform capable of transferring casualties en masse. These missions often require the aircraft to have long-range capability that invariably requires the utilisation of large jet aircraft. However, the configuration of large jet aircraft for aeromedical capability can be challenging due to logistical and financial constraints. This article describes three diverse European solutions for configuring large jet aircraft into an aeromedical platform that are currently in use and have been applied in previous disasters.

As society becomes increasingly susceptible to both natural and man-made disasters, governments are faced with multiple challenges. Modern day disasters are characterized by complexities that may frequently require governments to provide assistance to their citizens that are outside of their jurisdiction. If the disaster results in casualties, this may require governments to repatriate citizens injured as a result of the disaster using aeromedical services back to their home countries. The large number of European tourists on holiday in Southeast Asia during the 2004 Indian Ocean Tsunami required numerous European Governments to stage multiple large scale aeromedical missions to transfer the injured back to their home countries (1, 2, 3, 4 & 5). Similarly but on a lesser scale, man-made disasters such as the 2002 Mombasa terrorist attack in Kenya (6) and the 2008 Mumbai terrorist attacks in India resulted in the aeromedical transfer of casualties back to their respective countries.

Due to the extended flying distances involved with all these aeromedical missions, the chosen mode of transport was large jet aircraft. Nevertheless, the aeromedical transfer of multiple casualties over extended distances

using large jet aircraft is challenging. This discipline is commonly reserved for the military environment. Historically the United States Air Force has successfully used C-141 and C-17 Globemaster III jet aircraft for aeromedical operations in the Middle East (7). The German Air Force has successfully used and continues to use the Airbus A310 for aeromedical missions (8). Finally, the Israeli Defense Force (6) and the Italian Air Force (5) have both used Boeing 707 aircraft for aeromedical missions.

The use of large jet aircraft as an aeromedical platform has proven beneficial when transferring multiple casualties’ over greater distances due to the increased speed and range of jet aircraft compared to non-jet aircraft.

However, not all governments have access to military aeromedical assets. Even those governments that do have the ability to use these resources may not be able to draw upon them in a suitable time frame to respond to the event due to existing operational deployments.

The temporal challenges of disasters often necessitate a rapid response and subsequently governments may have to draw upon civilian options in the quest for a large-scale aeromedical solution.

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FIXED-WING | 63 Aeromedical solutions for large jet aircraft The following section describes three very diverse solutions used for the configuration of large jet aircraft as an aeromedical platform. These findings are based on a tour of three European countries that have previously used large jet aircraft configured for aeromedical missions.

The first solution is from Finland and describes the rapid and temporary makeshift configuration of a large civilian jet aircraft for an aeromedical mission. The next solution draws upon a Swedish aeromedical system that utilizes specially designed modules that can be used in large civilian jet aircraft to provide an aeromedical platform.

The third solution from Germany describes a permanently configured aeromedical system used by the military on large jet aircraft.

oxygen cylinders were used for this purpose. This requirement also provided difficulties due to the weight of the cylinders and requirements to safely secure them in a cabin environment. A further challenge associated with an extended aeromedical transfer was the lack of electricity supply available in the aircraft and the necessity to bring extra batteries for all electrical medical equipment used for the mission. However, despite these encounters the mission successfully transferred 14 critically ill patients with 2 demanding intensive care treatment. In

A Finnish perspective Following the 2004 Indian Ocean Tsunami, the Government of Finland used a civilian Boeing 757 jet aircraft temporarily configured for aeromedical missions to transfer multiple casualties from the affected areas (3). Due to the infrequency of disasters requiring the aeromedical evacuation of multiple casualties, many countries do not have the resources readily available to respond to such events. The use of military assets may not be an option for some governments due to unforeseen logistical issues and the potential unavailability of aircraft and personnel. The associated costs of procuring specialized civilian aeromedical platforms for use in dedicated aircraft may also be financially unobtainable for many governments.

The temporary makeshift configuration of a large civilian jet aircraft for an aeromedical mission may be the only option in a time critical scenario.

A Boeing 757 aircraft used by the Finnish Government after the 2004 Indian Ocean Tsunami was configured to carry 7 intensive care patients, 15 stretcher patients and 13 health staff (3). This was achieved only 8 hours after the decision was made to send and configure a large civilian jet aircraft for aeromedical evacuation. What was noted from this experience was the need for good and intuitive logistical support when temporarily configuring a large civilian jet aircraft for aeromedical missions using nonstandard aeromedical equipment. An important consideration during the Finnish mission was the use and securing of stretchers in the aircraft. The Boeing 757 aircraft used by the Finnish Government had seats that were able to lean forward. This enabled stretchers to be secured to the seats for transport. This method was also demonstrated – following the 2004 Indian Ocean Tsunami – by the Icelandic Government (2) which also used a rapidly converted Boeing 757 to transport multiple casualties, and the Swedish Foreign Ministry that used the services of a corporate jet (1) to the same effect.

In the event of a rapid temporary reconfiguration of any aircraft using non-certified aeromedical equipment, the medical equipment used for the mission has to be adapted to make it safe for flight. Challenges during the Finnish mission included the provision of medical oxygen to ventilated intensive care patients over a prolonged period. Subsequently, a total of twenty-two 10-litre medical

3 · 2013 I Vol. 3 I AirRescue I 199

this instance the aeromedical configuration did not meet Finnish aviation requirements, so a special exemption was granted by the Finnish aviation board and Finnish Government that allowed the aircraft to fly.

A Swedish civilian system Following the Mumbai terrorist attacks in India in 2008, the Swedish Government used the Swedish National Air Medevac System on a large civilian jet aircraft to repatriate 6 critically injured casualties back to Europe. The aim of the Swedish National Air Medevac System was to develop a lightweight aircraft reconfiguration system that met regulatory transport requirements, was functional without the need for technical aircraft modification and could provide sophisticated levels of aeromedical care.

The result is a temporary modular configuration system that can be used on a range of civilian jet aircraft. Utilising the Swedish National Air Medevac System on a Boeing 737-800 jet aircraft means that the aforementioned aircraft can be converted for aeromedical use within 6 hours and be capable of transporting multiple patients (8). This can include up to 6 intensive care patients, 12 stretcher patients and up to 23 walking wounded patients with a crew of 18 staff. The Swedish Government has an unwritten agreement with European Union countries to transfer European Union citizens if requested. The Swedish National Air Medevac System medical crew all work at Umeå Hospital north of Stockholm and are all trained in aviation medicine. The crews exercise annually with civilian and military personnel. The medical equipment and aircraft technicians are located at Arlanda airport in Stockholm, home to Scandinavian Airways. The modular system uses existing aircraft systems, which mean that

Fig. 2: Swedish National Air Medevac System configured for a Boeing 737-800 aircraft (Photograph: S. Quigley)

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Fig. 3: One of the six intensive care systems available on the Luftwaffe Airbus A310 aircraft (Photograph: S. Curnin)

Acknowledgements The study tour and subsequent article would not have been possible without the author being awarded the Responding to Major Events Fellowship provided by the Nursing and Midwifery Office in Western Australia. The author would like to thank Tom Silfvast, Dag Henriksen and Guido Rademacher for sharing their expertise.

that can provide long-range capability with the availability to transport casualties en masse. A suitable platform for this role is large jet aircraft. Large jet aircraft have been in used in a military context for a number of years with great success. However, in recent years the use of large civilian jet aircraft as an aeromedical platform has increased. The catalyst for this was the 2004 Indian Ocean Tsunami disaster. The three diverse solutions described in this article provide an overview of some of the current solutions used for configuring large jet aircraft for aeromedical capability.

Large jet aircraft permanently configured for aeromedical capability such as that operated by the Luftwaffe would be the gold standard. However, this is a very costly solution and most other military organizations throughout the world do not follow this model. Instead, they provide an aeromedical platform based on temporary configurations usually on a pallet system. any aviation technician can complete the task, as no formal training is required.

The German military option The German Air Force or Luftwaffe, effectively repatriated approximately 160 European casualties from Thailand using 3 flights following the 2004 Indian Ocean Tsunami.

The Luftwaffe uses a permanently configured modular system in an Airbus A310 jet aircraft. The aircraft is based in the military section of Köln/Bonn International airport.

This permanently configured aeromedical large jet aircraft has the capacity to transfer 6 intensive care patients and 38 litter patients with 25 health staff. As the aircraft is permanently configured, the reaction time of the aircraft in an emergency event is approximately 6 hours. The response time varies as not all the health personnel are stationed at this base and – depending on the number of casualties and size of the operation – health staff may need to be transferred from other military medical facilities throughout Germany. Therefore the response time may be much quicker if the health personnel are already on the base.

The aircraft is not only used for military missions. As part of the German Government Katastrophenplan, the aircraft can be called upon to assist in civilian disasters.

The Luftwaffe aeromedical Airbus A310 aircraft has been in operation since 1999 and assisted in countless civilian emergency events requiring the transfer of multiple casualties. These missions include, but are not limited to the European floods that caused widespread destruction in Eastern Europe in 2002 (8). During this mission, the Luftwaffe transferred over 100 casualties to various medical facilities across Germany over a period of 3 days.

In 2002 the Luftwaffe transferred 10 German nationals with critical burn injuries following an incident in Tunisia to multiple hospitals in Germany. Also in 2002 the Luftwaffe was contracted by the French Government to repatriate 12 French nationals that received critical injuries following an incident in Pakistan.

Aviation requirements to be considered Using this modular pallet system, the military can still provide a rapid aeromedical platform but the large jet aircraft can still be utilized for other roles. This system has also been demonstrated in the civilian setting as described in the Swedish example. This is another very effective option and offers a very rapid response time. However, this option may be beyond the financial means of many governments, especially when considering the infrequency of use. The temporary and rapid makeshift configuration of a large civilian jet aircraft for aeromedical missions has proven successful during previous disasters. However, this solution cannot be relied upon routinely for aeromedical missions, as the equipment used in the configuration does not normally fulfil aviation requirements. This option consequently relies on that country’s aviation board and government to provide a special exemption allowing the aircraft to operate. However, this is in no way guaranteed.

Need to adopt numerous approaches An understanding of recent disasters requiring largescale aeromedical missions has highlighted the need for governments to adopt numerous approaches to transfer multiple casualties from the affected area. Recent disasters have confirmed the effectiveness of using large jet aircraft equipped for aeromedical missions. However, the cost implications of procuring aeromedical solutions capable of performing long range missions may be beyond the means of many governments. A limited amount of literature has demonstrated that the configuration of large jet aircraft for aeromedical missions should be considered in any disaster health arrangements (9). Therefore, government strategies need to include a greater flexibility in planning for an aeromedical response which may include pooling assets and resources to develop systems that can be used by multiple jurisdictions. Nevertheless, this can be challenging when a synergistic approach is required by both civilian and military operators potentially involving multiple countries. 

Recommendations for the future The long-range aeromedical transfer of multiple casualties is challenging. Governments ultimately rely on assets

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

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Fixed-Wing | 65

ECMO retrieval: New opportunities in fixed-wing aeromedical transport On 30 April 2013, a team of German doctors successfully completed the first international transatlantic transfer of a 26-year-old patient – who was suffering from global heart failure – by means of an external heart and circulation support through ECMO/heart-lung machine. In the past, transport of patients requiring extra-corporeal membrane oxygenation (ECMO) had only been performed over short distances – if at all – and in most cases only as the “last resort”. Pulmonary problems were almost exclusively the primary concern in maintaining an intact heart function. The young patient from Dubai with advanced toxic cardiomyopathy and global heart failure was in desperate need of an aeromedical transport to Chicago (IL, USA) for a heart transplant. During the flight, all the cardiac functions were taken over externally (ECLS).

Anamnesis Severe and irreversible heart failure is taken care of by highly specialised medical centres. This applies not only to Central Europe, but also to those highly developed countries in the newly industrialising world, such as the United Arab Emirates (UAE). A heart transplant is often the only possibility for young patients, and this further restricts the choice of possible clinics worldwide.

We report on a 26-year-old patient from Dubai, who, following successful chemotherapy in 2000 on an osteosarcoma in the right proximal tibia, was suffering from pronounced cardiomyopathy with an ejection fraction of less than 10%. Thanks to sport and a healthy lifestyle, the young patient had been able to lead a normal life for the last 13 years, despite a permanently deteriorating heart function. At the beginning of March 2013, when his condition began to deteriorate rapidly, the supervising clinic of the University of Chicago decided to immediately go for a heart transplant. At that time, a journey from Dubai to Chicago with a scheduled airline flight was envisaged.

The intended intensive-care transport on a scheduled airline flight was called off due to flight delays. The patient was admitted to hospital in Dubai on 24 April with an acutely deteriorating condition after a chest infection.

His condition further deteriorated within 24 hours until after all the complete picture of Acute Respiratory Distress Syndrome (ARDS) as well as global failure of the heart and circulation system was presented. His condition and circulation system could not be stabilized, even by maximum inotropic support. The situation of the young patient was further exacerbated by a tricuspid valve failure, caused by his pronounced cardiomegaly.

In order to stop the patient from rapid deterioration, the doctors in Dubai decided to attempt a stabilisation with the aid of extracorporeal circulatory support aiming at compensating for the heart function, which by then had ceased almost completely. The mobile CardioHelp© system (Maquet) was used, which was placed in the left

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groin by means of arteriovenous access with a femorofemoral bypass. A satisfactory circulation situation could be achieved by maximum machine support.

Fig. 1: Previously, transport of patients requiring ECMO had only been performed over short distances (epitop medical)

Transportation indication The German team of doctors under the guidance of the authors got involved in the case just several hours before the installation of the Extra Corporal Life Support (ECLS) for days prior to departure. The team began with all preparations for an intensive care transfer to Chicago immediately after placing the ECLS. Due to the acute deterioration of the patient’s condition and the lack of international experience in the case of long flights with a mobile heart-lung machine, colleagues from the German Heart Centre in Munich (Germany) and experts from Maquet immediately joined the team for the intensive care transport flight.

Authors: Dr Hendrik Ruge German Heart Center Munich Dr Amir Parasta Ulrike Krivec Epitop medical GmbH Lichtenbergstr. 8 85748 Garching Germany info@epitop.com

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Fig. 2: A converted Boeing 737 BBJ was deployed for the flight and the medical staff consisted of a team of doctors from epitop medical Germany (epitop medical)

As an alternative to the transfer in an ambulance plane, joint discussions were also held with the doctors in Dubai and with other colleagues in London about the feasibility of an implantation of auxiliary pumps (LVAD/ RVAD) as a bridge operation for the purposes of intermediate stabilisation. Since the patient would however have required biventricular auxiliary pumps due to the global heart failure, and since there was no experience available in this regard, the responsible team decided to undertake the complete transport with extracorporeal circulation. For this purpose, a heart surgeon and a cardio-technician from Maquet joined the team as well. All steps were carried out in close cooperation with the Department of Cardiac Surgery at the University of Chicago Medical Center.

Transport A converted Boeing 737 BBJ was deployed for the flight and the medical staff consisted of a team of doctors from epitop medical Germany. The aircraft offered sufficient space for the equipment and for the optimum care for the young man as well as enough room for relatives who were accompanying the patient. The aircraft was provided by the charter operator Royal Jet from Abu Dhabi that caries out exclusive flights between the UAE and Europe.

Medical equipment on board the aircraft (analogous to a fully fledged intensive care unit) included standby ventilation systems, monitoring equipment, a blood analyzer system (i-STAT, Abbott) for measuring coagulation values, as well as a Vscan ultrasound system (GE Healthcare). An additional CardioHelp® system enabled the extracorporeal support system to be exchanged without complications, and the care of the patient to be provided throughout the entire transfer without interruption. The patient transfer to Dubai airport by ground ambulance was challenging because of the size of the ambulance car and its rudimentary equipment. The medical team had to be prepared for all eventualities on the 45-minute-journey – including a possible power supply and oxygen supply failure, something that would be rather unimaginable, say in Germany.

The patient was placed on an integrated stretcher inside the aircraft and appropriately positioned with an upper body elevation angle of ca. 20° to 30° and facing forward. The ECLS system was installed near the patient’s feet. The journey from Dubai to Chicago took 21.5 hrs, with an intermediate stop in Glasgow (Scotland). Close

monitoring and adjustment of the blood readings and of the circulation parameters were carried out.

Aspects that need to be emphasized here are the significant changes in virtually all the circulation parameters as well as necessary major interventions in the support settings of the extracorporeal system during take-offs and landings. Especially because of the several take-offs and after cruising altitude had been reached, a significant increase in extracorporeal support was necessary as well as increased medication. In contrast, volume of the extracorporeal flow was reduced in order to stabilise acceptable circulation and blood parameters. The team was also able to take advantage of CO2 elimination through the lung during cruising time at 39.000 feet. CO2 was still available – much to the crew’s surprise.

When the aircraft landed in Chicago, the team was awaited by three intensive care ambulances from the University of Chicago with their own team of doctors. The remaining journey to the ICU Unit in Chicago, where the patient was transferred to another ECLS system, took place without complications.

Outcome In Chicago, the medical team succeeded in gradually weaning the patient from the ECMO/ECLS system. As the lung function steadily increased, the experienced team was able to implant biventricular auxiliary pumps. According to latest information, the patient has since become completely awake and oriented as well as mobile and cooperative, and he is in a stable condition waiting for a transplant organ.

Conclusion The successful ECMO retrieval may serve as a best practice for countless other patients. There are only very limited therapeutic possibilities for most severe heart illnesses if there are no specialised medical centres available. The transatlantic transfer shows that intensive care air transport with an operating ECLS system can be very successful. An experienced team and also high-quality equipment as well as a suitable fixed-wing aircraft are key factors to success. In contrast to the smaller aircraft deployed by regular air ambulances, the Boeing 737 BBJ, which was used in this case offered sufficient space for the best possible patient care. 

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