AirRescue Magazine 3-2014 by Verlag Stumpf & Kossendey

EC145 TANGO 2

AirRescue International Air Rescue & Air Ambul ance

M a g a zine

Regulations

European standards Benefits and challenges

Crash

â&#x20AC;&#x153;Air Ambulance 02â&#x20AC;?: Interim investigation report

Medical Care

Coagulation management: Is tranexamic acid the only option? ISSUE 3 | Vol. 4 | 2014

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.com 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, Canada, Phone: +1 905 816-4500, Fax: +1 905 858-4599, E-Mail: info@karlstorz.ca www.karlstorz.com

Editorial

Dear Colleagues, After some time, I have again been asked to write an editorial for our AirRescue Magazine. One of the reasons is that my term as EHAC President is coming to an end. However, I still have a few months of work ahead so it is not yet time to look back or to say goodbye. Nevertheless, I was spurred to comment on one other thing; why I said at the outset that I will be President just for one term. This is as follows; I realized that it is necessary for EHAC to be led by someone who knows our everyday work very well. Such a person is usually fully utilized by his or her employer, however, and it is very difficult to commit to such fairly extensive volunteer work for our organisation. The compromise lies in limiting the term of commitment and I think that a three-year period is manageable. This path can permanently ensure high quality management for EHAC together with an appropriate dynamic direction where new people will bring new ideas and values. The current period is not only summer with all that it brings to our work but also the time following AIRMED 2014 in Rome. The second day after my return from Rome, my son was born. He is already surrounded by cuddly toy helicopters from the major HEMS operators, so I believe he will soon be an expert and our community need not worry about a lack of young blood :-). Due to the holiday season, we still don’t have enough findings to comprehensively review the Congress that recently took place in Rome. However, we do know that the high-quality professional program and the motivation of the speakers were accompanied by things that were not entirely successful. And it is also evident that the traditional Congress will undergo future changes. AIRMED will be held in conjunction with Helitec International. I know that not all who hold AIRMED dear find this idea appealing but we have no choice but to respect the reality in our field. I

3 · 2014 I Vol. 4 I AirRescue I 139

am convinced that our Congress will retain its highly professional and revered standing. I wrote about summer and so I should now mention autumn. As of October this year, we will have to meet the conditions of the new regulations known in short as EU OPS. This won’t be easy and in this last phase of implementation I would like to invite all parties concerned to cooperate and share their experiences. At this point I would like to thank EASA for allowing NewEHA and EHAC to actively participate in the expert content of the 8th Rotorcraft Symposium, which will take place on 3rd and 4th December 2014 in Cologne. If you have any suggestions or recommendations for the scientific program of the Symposium, please send them to us; we will bear these in mind when preparing the content. Last but not least, I would like to mention that a few days ago I made my first HEMS flight using NVG. The fact that our company implemented NVIS was largely initiated and carried out thanks to the EHAC spirit. In this particular case, the EHAC spirit manifested itself amongst a few operators and people. And I believe that little by little, it will positively affect our entire community.

Pavel Müller President of the European HEMS and Air Ambulance Committee

Kind regards to you all,

Pavel Müller President of the European HEMS and Air Ambulance Committee

I3I

AirRescue

“Tango 2” in HEMS:

AirRescue Magazine joined the handover ceremony of the first EC145 T2 to German DRF Luftrettung – the world’s first EC145 T2 helicopter to be commissioned.

International Air Rescue & Air Ambulance

agazine

ISSN: 2192-3167

First EC145 T2 in action for DRF Luftrettung

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 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 Subscription Rate: Europe: 35  (Shipping included) World: 40  Price per Issue: 9  (Shipping not included) Bank Account: Postbank Hannover BLZ 250 100 30 Kto.-Nr. 2837300 IBAN: DE08 2501 0030 0002 8373 00 BIC: PBNKDEFF

12 Interview:

Massive bleeding:

“Point of care for professionals”

Prehospital use of hemostatic

An interview with Hans Morten Lossius, Chair of EHAC Medical Working Group, about efforts to facilitate and foster dialogue among medical HEMS experts.

Battlefield experience in Vietnam, Iraq and Afghanistan led to the introduction of hemostatic bandages with different working mechanisms.

Rapid Sequence Intubation (RSI):

Introducing RSI in Hungary Hungarian HEMS tested the feasibility of introducing RSI SOP and elements of clinical governance before applying it to the whole EMS system.

Production and Design: Bürger Verlag GmbH & Co. KG Frank Lemkemeyer Rathausstraße 1 26188 Edewecht | Germany

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

I 22 I

46 3 · 2014 I Vol. 4 I AirRescue I 140

CONTENTS

Contents

EHAC

Medical Care

14 Interview with Hans Morten Lossisus,

Chair EHAC Medical Working Group T. Bader

18 New EHAC member Elitaliana: Commit

ment to serving the community Elitaliana P.O.

News

43 “Change in cerebral oxygenation du

CRASHes

48 “Air Ambulance 02” crash:

TEchnology

12 First EC145 “Tango 2”:

ring high altitude flights – First study conducted in non-simulated flights U. Ehlers-Busse, M. Paul, O. Seiler, L. Held

BFU interim investigation report P. Poguntke, T. Bader

Regulations

In action for DRF Luftrettung P. Poguntke

50 Future HEMS operations –

Medical care

22 Interhospital transports of critically ill

patients – the hospital perspective A.J. Krüger, O. Uleberg, P. Klebstad

28 Massive bleeding: The prehospital use

of hemostatic bandages J.H. Peters, E.C.T.H. Tan

32 Aeromedical Point-of-Care Ultrasound

J.G. Yates

36 The introduction of prehospital Rapid

Sequence Intubation (RSI) into the Hungarian EMS system P. Temesvári

40 Coagulation management in multiple

trauma – is tranexamic acid the only option? H. Lier

3 · 2014 I Vol. 4 I AirRescue I 141

legal frameworks B. van der Weide

European standards – benefits & challenges P.K. Andersen

training

58 Medical simulation training of

helicopter-supported mountain rescue situations U. Pietsch, V. Lischke

in Profile

62 The future of HEMS in Finland

A. Kämäräinen

65 Off the beaten track: AMS with most

demanding rescue operation C. Woo

Cover image: Airbus Helicopters/DRF Luftrettung

I5I

NEWS

AeroAmbulancia/ Helidosa: Third fixedwing installation Spectrum Aeromed completed the sale of a Short Box Advanced Life Support system and accessories including an IV pole and manual loader. This is the third aircraft Spectrum Aeromed has equipped for AeroAmbulancia/Helidosa and the second time they have used Fargo Jet Center for this customer’s installation. AeroAmbulancia is the first and only company in Dominican Republic, which offers the most complete and modern air ambulance service 24/7. AeroAmbulancia has a crew equipped with everything needed for intensive care to manage health issues in critical conditions. The rural areas of the Dominican Republic lack optimal health centers to care for patients with severe trauma from accidents or critical medical conditions, so air ambulance offers the fastest access to the best medical care available.

Spectrum Aeromed

“We are elated to have them as customer again, especially knowing the impact their service has on the rural community in the Dominican Republic,” said Spectrum Aeromed Vice President Matthew Christenson. “We know this equipment will dramatically impact their ability to complete life-saving missions.” The first two fixed-wing installations were in a Citation 500. AeroAmbulancia also operates a Bell 212 with a Spectrum Aeromed system and is currently working on the installation of a fourth fixed wing system in a Cessna 560XL Citation Excel. AeroAmbulancia will have a total of 5 aircraft with Spectrum Aeromed equipment by the end of 2014. �� www.spectrum-aeromed.com I6I

Pilatus

First Pilatus PC-24 prototype leaves production hangars A world premiere took place on Swiss National Day, 1 August 2014, when Pilatus Aircraft Ltd unveiled its first ever PC-24 prototype. Some 25,000 spectators watched as the show took place at Buochs airfield in central Switzerland. The ceremony got underway at 12.35 when a team of 24 horses, chosen to symbolise the number appearing in the PC-24 product name and its future mission profile as a “workhorse”, pulled the first prototype out of the production halls. The rollout was preceded by a fly-by of all the aircraft which have ever reached series production in the company’s 75 year history. Oscar J. Schwenk, Chairman of the Board of Directors of Pilatus, expressed his enthusiasm about the new PC-24 and the event: “Today’s celebration is a clear sign of our commitment to Switzerland as a centre of vision and action. Our company was established

here in Stans exactly 75 years ago. We have seen our activities grow and expand here in Stans […] It’s wonderful that so many guests have made the effort to be with us here today, to celebrate this event together. The PC-24 marks a really important milestone in our history.“ The PC-24 is equipped with the kind of performance specification that allows it to operate in and out of very short runways or even unmade strips. A total of three prototypes will be produced for the PC-24 test flight programme. The maiden flight of the first prototype, which was presented at the rollout, will go ahead in spring 2015. Final certification and start of deliveries to customers are planned from 2017. �� www.pilatus-aircraft.com

Héli-Alpes to enter HEMS The Valais company Héli-Alpes SA has purchased a new Bell 429 helicopter that will be used for interhospital transfers and rescue flights as the company announced during the official presentation of the new helicopter on 2 July 2014. Héli-Alpes has previously focused mainly on helicopter VIP flights, heli-skiing and on business flights. CEO and Chairman of Héli-Alpes, Francis Sermier, will go even further: With a second Bell he wants to enter into the HEMS segment. The second chopper will also be equipped with a winch. Héli-Alpes cooperates with Air-Glaciers as HEMS operator. In a first step, Air-Glaciers will be provided with the Bell 429 helicopter and crew. The medical staff will be provided

by Air-Glaciers. In addition, Air-Glaciers-pilots can be trained at Heli-Alps. �� www.helialps.ch

Heli-Alpes

3 · 2014 I Vol. 4 I AirRescue I 142

NEWS

World’s first prehospital REBOA performed

LAA

patient is then transported rapidly to the Royal London Hospital to undergo further vital interventions. Gareth Davies: “We believe the use of REBOA can lead to a reduction in the number of patients who quite simply bleed to death before they have the chance to get to hospital where there are highly developed systems for stabilising and preventing blood loss.” London’s Air Ambulance has worked closely with The Royal London Hospital to deliver REBOA safely in A&E before embarking on the surgery outside of hospital. Speaking about this partnership, Professor Karim Brohi, Consultant Vascular and Trauma Surgeon at Barts Health NHS Trust,

Please visit Aerolite, March 4 – 7, Las Vegas, Nevada

Tailor-made Medical interiors that fit your mission

Performance Lightweight equipment and excellent handling

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

said: “We have to stop people bleeding to death – it’s one of the world’s biggest killers. Over 2.5 million people bleed to death from their injuries each year around the world.” It is an extremely difficult technology to deliver; in the emergency department in hospital and even more so at the roadside. According to Brohi, the success of REBOA “represents nearly 2 years of development work by our staff. We are excited about the potential for REBOA to reduce death and suffering after trauma and will continue to evaluate and develop the technology into the future.” �� www.londonsairambulance.co.uk

Photo Air Zermatt

London’s Air Ambulance (LAA) has performed the world’s first prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This technique, used to control haemorrhage in trauma patients, was first applied in the UK at The Royal London Hospital. Many of the patients attended to by the LAA are suffering from catastrophic bleeding. Tragically, some die at the scene as a result of their severe blood loss and never make it to hospital. LAA can now perform REBOA on patients suffering severe pelvic haemorrhage, an injury most commonly associated with cycling incidents and falls from height. Commenting on the use of REBOA to treat trauma patients, Dr Gareth Davies, Medical Director for London’s Air Ambulance, said: “Our aim is to provide our patients with the world’s most innovative and effective pre-hospital care. Being able to effectively manage blood loss at the scene is a significant advancement in pre-hospital medicine.” REBOA works by controlling or preventing further blood loss. The balloon is fed into the bottom end of the aorta and then inflated, temporarily cutting off blood supply to damaged blood vessels. The

Flexibility Quick change capabilities for different missions

Completion Center | Ueberlandstrasse 255 8600 Dübendorf | Switzerland Phone +41 44 823 60 70 | www.aerolite.ch

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

NEWS

First Bell 429 for HEMS in France and first two in the Middle East Bell Helicopter has announced a signed purchase agreement with INAER France for a Bell 429 in HEMS configuration. The aircraft, the first Bell 429 sold in France, will be equipped with a fully customized EMS interior and state-of-the-art avionics. INAER will take delivery of the aircraft in 2014, which will support medical rescue missions in the West region of France. “Medical missions are very demanding and require modern aircraft and the highest standards of safety,” said Martin Whittaker, director of fleet & engineering at Avincis. “The Bell 429’s advanced technology and performance will allow us to provide safe and rapid transport to those most in need of care.” Patrick Moulay, Bell Helicopter’s managing director for Europe, said: “We are thrilled to introduce the Bell 429 to France with long-time customer INAER.” INAER France is a leader in HEMS rescue, with almost 20 years of operating aerial surveillance assistance and parapublic missions. INEAR France provides aircraft maintenance and pilot type ratings. The Bell 429 for HEMS in the Middle East will be delivered in 2015 to support medical rescue missions throughout the region. “We are excited to bring the Bell 429 to the Middle East for HEMS operations,” said Steve Suttles, Bell Helicopter’s managing director for the Middle East. �� www.bellhelicopter.com

Bucher Leichtbau: Interior concept for the EC145 T2 Airbus Helicopters recently celebrated the official handover of the EC145 T2 to DRF Luftrettung (see also pages 12-13). This was the green light for Bucher Leichtbau to begin the first installation in an EC145 T2 of their totally redesigned and developed helicopter emergency medical system (AC70). Bucher regards this as “the culmination of two years of intensive collaboration” with its customers and partners, the air rescue organizations ADAC Luftrettung and DRF Luftrettung, both with more than 40 years of experience. The modular and flexible structure of the new generation of HEMS equipment makes conversion from one mission profile to another very easy. The AC70 can be used for the following missions: HICAMS (patient transportation between hospitals with full intensive care equipment; maximum configuration), HEMS (emergency mission with the equipment for emergency care; similar to ambulance), SAR (winch lift missions in mountain regions or over water; equipment is further reduced to create space for mountain rescuers, rescue divers etc.) and disaster management (major incidents; two stretchers are fitted for the transportation of a second patient). Among other things, a so-called Center Cabinet provides storage space for the emergency backpack that used to be affixed to either a seat or the stretcher. In the past, the removal of material and medication was somewhat difficult, but the new location means that handling the emergency backpack is now more ergonomic and getting ma-

terial out of the backpack is also easier. As a result, weight can be saved. At the rear of the helicopter, a modular cabinet is also installed, which can be assembled according to the specific application. It provides room for oxygen tanks, consumables, bags of modules and medical equipment, etc. For patient transport, various stretcher configurations are available that can be adapted to different patients and mission requirements. The seats can be rotated and positioned at various positions in the cabin. Another progressive feature is the “Roof-Rail” system: medical devices attached to standard brackets can slide and swivel on the rail system, giving the flexibility to meet any need. A full-scale mockup of the AC70 will also be on display in Amsterdam at the Helitech, 14 to 16 October 2014. �� www.bucher-group.com

Bucher

Airbus Helicopters wins tender in Russia As recently announced by the Moscow Health Department, following an open tender, Airbus Helicopters Vostok was awarded a contract to supply two medical helicopters for the Health Department’s Scientific and Practical Centre of Emergency Medicine. The preferred rotorcraft among two other bidders was the EC145. “Our EC145 has already been very successful as a medical helicopter in Moscow, with three operated by Moscow Aviation Centre, saving around 600 lives each year,” said Laurence Rigolini, Airbus Helicopters Vostok General Manager. “The Airbus Helicopters story in Russia actually started with a medical helicopter we delivered for the EMERCOM back in 2006, and we are very happy that our products have remained the backbone of the local medevac fleet over these years. We look forward to delivering two more EC145 helicopters to Moscow, and we thank our customers for their

long-lasting confidence in our team”, Rigolini commented. The tender documentation requires two new medical helicopters to be delivered in 2015 and to be equipped with an oxygen tank, resuscitator, and defibrillator, as well as with a reanimation complex and neonatal intensive treatment (including incubator and lung ventilator for newborns). The deliveries are expected as early as next year. Worldwide deliveries of the multi-purpose light twin-engine EC145 exceed a total of 650 units, of

I8I

which the medical fleet accounts for about 30%. The EC145 is equipped with two powerful and reliable Turbomeca Arriel1E2 engines and a hingeless rotor system, which together provide “outstanding performance and vital power reserves, even in one-engine-inoperative scenarios. Its spacious cabin allows transportation of up to two patients on stretchers and accompanying medical personnel with all necessary emergency equipment.” �� www.airbushelicopters.ru

3 · 2014 I Vol. 4 I AirRescue I 144

Airbus Helicopters Vostok

NEWS

KSSAAT & DSAA select AW169 for HEMS

AgustaWestland

Two UK HEMS operators have selected the AW169 helicopter for HEMS operations: The Dorset and Somerset Air Ambulance (DSAA) and Kent, Surrey & Sussex Air Ambulance Trust (KSSAAT). The DSAA aircraft will start operations from its base at Henstridge on the Dorset/Somerset border in South West England in 2016 and will be able to reach any point in the two counties faster than ever, due to its maximum cruise speed and quickly transport patients to hospitals and major trauma centres in the South West. The AW169 was selected following an extensive evaluation process by the Charity and its clinical partners. According to AgustaWestland, this contract “continues the success already achieved by the AW169 in the UK helicopter market and marks the first EMS tender win in the UK for this new generation helicopter.” The new aircraft at KSSAAT will be operated by Specialist Aviation Services (SAS). KSSAAT, a prime HEMS provider and the first, and presently only, air ambulance in the UK to fly 24/7 throughout the year, will be the first customer in HEMS to introduce the AW169 into service in the UK in autumn 2015. Henk Schaeken, Managing Director of SAS said: “We selected the AW169 two years ago at the previous Farnborough International Air Show, as it offered the best capabilities and performance in its class and we felt that it could greatly enhance the operations of our customers. We underlined this belief by taking orders and options on six aircraft.“ Bill Sivewright, Dorset and Somerset Air Ambulance CEO, said: “Dorset and Somerset Air Ambulance’s vision for the future assume one of clinical excellence. The capability and flexibility offered by the AW169 made it a clear winner in our selection process. We are looking forward to the point in time when we can start operating this fantastic helicopter.” The AW169 is suited to both primary and secondary air ambulance missions, it can accommodate one or two stretchers. The large unobstructed cabin can also accommodate wheeled stretchers and can be configured with a full suite of advanced life support equipment. �� www.kssairambulance.org.uk �� www.dsairambulance.org.uk �� www.agustawestland.com 3 · 2014 I Vol. 4 I AirRescue I 145

I0I

NEWS

Prince William to join EAAA as a pilot His Royal Highness Prince William Arthur Philip Louis, Duke of Cambridge, will join the East Anglian Air Ambulance as helicopter pilot in spring 2015, as the charity recently confirmed. “He will join our highly skilled team of pilots and clinicians who ensure that we provide the highest standard of pre hospital emergency medicine to the scene of accidents and medical emergencies across the region”, as EAAA stated in a press release. Mr Andrew Egerton Smith MBE, Chairman of EAAA, said: “Having the Duke of Cambridge as one of our pilots is marvellous news as he brings much experience to the charity after his successful career as a search and rescue pilot. We have an outstanding track record of attending people in the hour of need which is recognised and generously supported by our local communities.”

EAAA

Kensington Palace also confirmed that Prince William will join the East Anglian Air Ambulance flying both, day and night shifts. BBC quoted a spokesman saying the duke was “hugely excited and motivated” by the new role. “The duke sees this as a true form of public service, helping people in their most difficult times,” he said. Prince William left his role as SAR pilot with the Royal Air Force last year. “He regards his work with the RAF search and rescue force as having been an exceptional privilege and the duke wanted to make his own contribution to the outstanding work of the air ambulance service.” The charity’s chief executive, Patrick Peal, was also quoted: “We‘re delighted His Highness has decided to fly with us. We are confident this will help raise the profile of the charity and other air ambulance charities in the region and across the UK.”

ASU

ASU: new white phosphor goggles Aviation Specialties Unlimited (ASU) unveiled their new white phosphor night vision goggles (NVG) at the Airborne Law Enforcement Agency (ALEA) annual convention in Phoenix. “The new white phosphor night vision goggle is the first technological breakthrough in aviation goggles since the Generation III goggle was introduced,” said President Jim Winkel. ASU’s Director of Pilot Training and Retired Army National Guard Pilot, Justin Watlington said, “I have been flying with night vision goggles for 27 years and would characterize the new white phosphor system as a distinguished milestone in NVG technology. In all aspects of flight, from the highly illu-

minated urban environment to the darkest regions of the Idaho mountains, the white phosphor NVGs outperformed the traditional green phosphor NVGs. It is not enough to say the white phosphor NVGs outperformed the GP NVGs, they significantly outperformed the traditional green phosphor NVGs.” ASU was established in 1995 to meet the growing demand for aviation night vision systems. Since that time, the company has earned a reputation as a leading innovator in aviation night vision imaging system design, manufacturing, installation, certification, sales, training and service. �� www.asu-nvg.com

FinnHems and LAA: joint thoracotomy masterclass FinnHEMS (FH) together with London’s Air Ambulance (LAA) had organized a thoracotomy master class in Finland in April 2014. The course was held at Tampere University Hospital and consisted of lectures and cadaver training (half day respectively) in the hospital’s new surgical training unit. Tampere is also home to the “FH 30”-base (see ARM 4/2013 for further details). Doctor-paramedic teams from each FH-base participated in the course.

Course instructor was Dr Gareth Davies from LAA and the course provided the participants with an excellent opportunity to get a thorough understanding of the theoretical and clinical background of the procedure. Course feedback was very good and FinnHEMS sees this as an excellent example of cross-national cooperation between different HEMS services. Participants welcome the idea to continue meeting for joint trainings on a regular basis. �� www.finnhems.fi

�� www.eaaa.org.uk I 10 I

3 · 2014 I Vol. 4 I AirRescue I 146

T. Martilla

NEWS

AirMed partners with MedAire AirMed has selected MedAire’s aviation travel safety solutions for its air ambulance operations. “Over the past few years, our geographical reach has expanded considerably. We regularly fly into higher-risk and remote destinations to evacuate patients,” says AirMed’s director of business development, Jane Topliss. “Due to the nature of our work we regularly receive very short notice to fly to a variety of destinations, some of which may be in areas with potential safety risks. We chose the MedAire travel risk management solution for the analysis and advice it provides about the destinations where we travel so we can provide the utmost duty of care to the patient and our medical and flight crews.” AirMed will use the information from MedAire “Trip Ready”, an aviation travel risk management app, and MedAire’s online resources to support their safety management system. In addition, AirMed

may speak with MedAire security analysts about any specific concerns and to request Aviation Travel Security Briefs. “The information we receive from MedAire allows us to save a considerable amount of time, allowing us to focus on providing quality medical care for our clients and the patients we fly.” MedAire is providing AirMed with a complete security and health update for any region in the world 24/7. All of AirMed’s crews have direct access to this information so they may stay apprised of rapidly changing health and safety situations. “We have found that by giving the crews quality, vetted information from MedAire as part of our internal risk assessment, our crew and medical teams are confident they have the information and advice to reduce their travel risk,” continues Ms Topliss. �� www.airmed.co.uk �� www.medaire.com/bga

DRF Luftrettung: contract with Matrix42 German HEMS operator DRF Luftrettung now employs the Workspace Management Solution by Matrix42. Along with this, iPads now serve as electronic flight bags (EFBs) and replace – in combination with Matrix42 Mobile software solution – the “hard cover” flight manuals in paper form that had to be carried on board so far. This saves weight and space in the aircraft: With the introduction of EFBs, 35 kg of weight could be saved. In order to get all the necessary approvals, DRF Luftrettung had to equip the aircraft with fireproof containers for the iPads. The devices contain all the information necessary for flight operations, such as the flight ops manual, the flight maps and other programs. According to Matrix42, the Workspace Management Solution also gives a “comprehensive overview of all the tools in use” and thus, “a better overview of the costs”. In addition, the IT staff and systems can rely on a self-service portal, where the user can retrieve information directly from the knowledge database. �� www.matrix42.com

NEWS

Fig. 1: Handover ceremony: Johann Haslberger and Franz Ahollinger, both pilots with DRF Luftrettung, Manfred Merk, EC145 Programme Director, Dr Hans Jörg Eyrich, DRF Luftrettung, Chairman, Dr Wolfgang Schoder, CEO Airbus Helicopters Germany, Steffen Lutz, DRF Luftrettung, Chairman, and Thomas Hein, Airbus Helicopters, Vice President Customer Relations and Sales Europe (Airbus Helicopters)

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

I 12 I

First EC145 “Tango 2”: In action for DRF Luftrettung It may have been a hot summer’s day at the runway of Airbus Helicopters’ Donauwörth plant, but not even the sweltering heat could spoil the fun of those guests gathered to celebrate the handover of the first EC145 “Tango 2” (T2) helicopter as they watched the aircraft take flight. The T2 helicopter – to be delivered to DRF Luftrettung – is also the world’s first EC145 T2 helicopter to be commissioned. The EC145 helicopter features a number of upgrades and DRF Luftrettung has ordered a total of 20 models, which they hope to phase in gradually to replace their BK 117 and Bell 412 models. This means the commissioning of the “Tango 2” represents not only a milestone in the overall development of helicopter technology, it also marks a generational shift in DRF Luftrettung’s service fleet.

The most striking feature of the “Tango 2” is its size, as this aircraft is visibly larger than the basic model. The sliding doors are considerably wider and the increase in fuselage size has allowed for greater on-board capacity, which means the EC145 T2 is particularly well-suited to HEMS missions. During the handover ceremony, Steffen Lutz, Chairman of DRF Luftrettung, explained that in the coming years his organisation is expecting a marked increase in the number of flights involving patients in a critical condition – which will require more on-board equipment – as well as in night-time HEMS missions. That is why this new helicopter is the organisation’s “air rescue aircraft of choice”. He went on to say that the

helicopter also met all requirements stipulated by the European Aviation Safety Agency (EASA). Dr Wolfgang Schoder, CEO of Airbus Helicopters Germany, stressed the importance of HEMS operations, stating that they formed part of a “core mission” to further advance helicopter technology. The “Tango 2” reinforces this claim more so than any other helicopter that has gone before; it features a completely redesigned avionics suite with four-axis autopilot as well as improved satellite-supported navigation and the FLARM collision warning system. All of the on-board systems play a key role in facilitating the pilot’s task. The “Helionics” digital avionics suite is a core component of this upgraded set-up. 3 · 2014 I Vol. 4 I AirRescue I 148

NEWS

Alexander Neuhaus, experimental test pilot at DRF Luftrettung, explained that, with the four-axis autopilot, even if the pilot were to remove his/her hand from the cyclic stick, the aircraft would still fly steady in the air. Even in the event of engine failure, hovering is still possible. In addition, the EC145 T2 has been fitted with more powerful and quieter Turbomeca Arriel 2E engines, featuring two-channel digital control (Dual FADEC), making it significantly quieter than its predecessor. The aircraft also requires less maintenance thanks to an extended time-between-overhaul on main components and optimisation of processes, which considerably improves the T2’s availability and efficiency. A full-flight simulator will be available for pilot training from 2016. Before this first EC145 T2 model commences operations, replacing the key “Christoph München” EMS helicopter, the aircraft will be taken to DRF Luftrettung’s hangar located at the Karlsruhe/BadenBaden airport where medical equipment will be installed in line with a brand new concept. This concept was developed by T2’s medical-sector-based project partners, Swiss company Bucher Leichbau AG, as well as the German ADAC and DRF Luftrettung air rescue services. Together they created an innovative medical interior layout (used for the very first time in this model) which is designed to ensure uniformity during the installation of medical equipment. “For the first time, each piece of equipment will have its own designated place”, explained Stefan Neppl from DRF Luftrettung’s specialist medical team. Ergonomic and 3 · 2014 I Vol. 4 I AirRescue I 149

functional features that simultaneously enhance patient safety were the main focus during stretcher layout design and the positioning of the medical crew’s seats within the aircraft. Since 2009 nighttime rescue operations starting from Munich’s Klinikum Großhadern 24-hour HEMS base have been carried out using night vision goggles (NVGs). “Demand in this sector is set to grow”, stressed Steffen Lutz, “and I am delighted that we have taken decisive steps at such an early stage to ensure this technology’s availability for the civil sector.” It will take a few months until the aircraft can go into operation. DRF expects the commissioning of the aircraft to take place at the end of the year. After the fitting, the EASA approval process will follow which, due to the fact that it is an initial fitting, will take some time. “Simultaneously, the theoretical and practical training of our pilots will be running for the new helicopter type. Our technicians, who will take over the regular maintenance of the EC145 T2, will also undergo training”, said Dr Hans Jörg Eyrich, Executive Board of DRF Luftrettung. Overall, 85 orders from HEMS operators across the whole of Europe have been placed for this latestgeneration rescue helicopter. Thanks to its modular and therefore flexible design, the “Tango 2”, is also a worthwhile investment for organisations working in other fields: the German Military has ordered 15 aircraft for its special forces operations, and one German police helicopter squadron has also expressed an interest. 

Fig. 2: Bucher’s new and innovative medical interior layout will be used for the first time in the EC145 T2: Ergonomic and functional aspects were in the foreground, also with regard to arrangement of the seats for the medical crews (Bucher) Fig. 3: The “Helionics” digital avionics suite is a core component of this upgraded set-up (Airbus Helicopters/C. Abarr)

I 13 I

EHAC

“Do the right thing with the right patient at the right time!” An interview with Hans Morten Lossisus, Head of Research and Development at the Norwegian Air Ambulance and Chair Medical Working Group, EHAC Norway is in the vanguard of research and expertise on prehospital critical care and Helicopter Emergency Medical Service (HEMS). Professor Hans Morten Lossius, Head of Research and Development at the Norsk Luftambulanse (Norwegian Air Ambulance), is one of the driving forces behind this development: The Norwegian Air Ambulance Foundation, a not-for-profit member organization, runs one of the largest Research and Development programs in Europe within prehospital critical care with more than 25 PhD research fellows as well as 10 professors and associate professors. Tobias Bader, editor of AirRescue Magazine (ARM), talked to Hans Morten Lossius, who is also Chair of the Medical Working Group of EHAC, about the focus of his research, his efforts to facilitate exchange and dialogue among HEMS experts in Europe through the EHAC working group, about the challenge of working with “alpha males of both sexes” and his visions for HEMS of the Future.

service in line with the newly established national air ambulance service. As the chief medical officer it was my job to carry out the reorganization, in fact sawing off the branch that I was sitting on. I therefore chose to specialize in anesthesiology myself – which I completed after serving in Northern Norway, Stavanger and Oslo getting board-certified in 1999. ARM: How long did this specialization take?

Fig. 1: “Prehospital medicine is rapidly developing. It is more and more about diagnosing, treating and monitoring pathophysiological processes.” (Norwegian Air Ambulance)

Author: Tobias Bader Editorial Team AirRescue Magazine

I 14 I

ARM: Hans Morten Lossius, you are Head of Research and Development at the Norwegian Air Ambulance Foundation, Stiftelesen Norsk Luftambulanse. Could you tell us a bit about your professional career and about your current positions at the Foundation as well as in EHAC? Hans Morten Lossius: I started off as a general practitioner, GP, way back in 1986 and moved to Northern Norway, where I joined SAR helicopter services at Banak as chief medical officer, also responsible for setting up the medical manning. The manning was based on GPs, but very soon I experienced that this was not a job for a GP, much rather a job for an anesthesiologist. So I initiated a discussion with the regional health authorities and some time after the authorities decided to change it into an anesthesiologist-manned

Hans Morten Lossius: This specialization took six years. I kept on working as a flight physician while doing the specialist training, both at Banak, and in Stavanger and in Arendal with the Norwegian Air Ambulance, along with calls on the physician manned ground ambulance at Ullevål University Hospital, and international retrieval services for the Norwegian Air Ambulance. Parallel with this, I started an academic career with a PhD-project, supervised by Professor Petter Andreas Steen, and defended the thesis in 2003. From 2003 I carried on as a part time flight physician, but my main post was as the Medical Director firstly for the Medical Dispatch Centre at Ullevål University Hospital, and later for the Emergency Department at Stavanger University Hospital. Parallel to this, research projects and organizing international medical conferences filled most of my spare time and in 2006 I was re-recruited by the Norwegian Air Ambulance Foundation with the task to build up the Research and Development Department, because they had decided to build such a department. 3 · 2014 I Vol. 4 I AirRescue I 150

EHAC

ARM: Could you tell us a bit more about the Foundation’s R&D work? Hans Morten Lossius: Yes, the Foundation is 35 years old and is the largest idealistic member organization in Norway. The Foundation had a tradition for funding research, but in 2006 they decided to make Research and Development – R&D – a more central part of the Foundation’s activity. I got the task to set up the R&D program and with a lot of support from the Foundation and several competent and dedicated national and international colleagues we have now reached the level of 25 PhD-students and 10 professors/ associated professors with a budget of 10-12 million Euros. ARM: You are still an active researcher yourself; what is the focus of your research? Hans Morten Lossius: Actually I am focusing on three different aspects: First of all it is airways. I have always been interested in airways. It all started with airways, you know, because once, when I went out with the SAR helicopter into the Barents Sea – as a general practitioner – there was a man on a trawler with a head injury. We got him into the helicopter and as a GP I did not have the competence or skills to secure his airways adequately. When we arrived at the university hospital in Tromsø several hours later, the anesthesiologist on call immediately took care of his airways, but then, off course, it was too late. I thought: ‘This intervention should have been done three hours earlier!’ That would really have made a difference for the poor patient. Securing sufficient airways and ventilation when needed must be the main focus of prehospital emergency medicine. The second topic is traumatology; looking into systems and the precision of systems and especially looking at Air Ambulance or HEMS systems part in a modern trauma system. The third subject is the effect and efficiency of Air Ambulance services in general. Parallel with that, I have been working with research methodology, trying to adjust common methodology to emergency medicine. ARM: You are also Chair of the EHAC Medical Working Group. What is the focus of this working group? Hans Morten Lossius: Yes. I have been watching EHAC from the sideline for some years, particularly because the Norwegian Air Ambulance has been involved in EHAC. I have seen how important EHAC is in helping HEMS organizations in giving the right input to the authorities. It is so important to have a strong organization behind you while negotiating and 3 · 2014 I Vol. 4 I AirRescue I 151

Fig. 2: Almost one-fifth of the Norwegian population supports the Norwegian Air Ambulance Foundation through membership – and it is highly valued to be a member (Norwegian Air Ambulance)

discussing with the authorities. This is also important for the medical part of HEMS. So when Stefan Becker, Managing Director EHAC, asked me to take on the task, I was honored and happy to get the possibility to take part in the important work. As HEMS crews and operators, we serve the seriously ill or injured patient and must continuously improve our operations for the best for these patients. ARM: What will be the focal points of the group? Hans Morten Lossius: I have been discussing that very much with Stefan and first of all I am really impressed with EHAC and what they are doing today. I think, what I might bring into EHAC is a large European medical network. Because of all these years with research and conferences etc., I am lucky to have got so many good and highly competent friends all over Europe. My hope is to build a strong medical working group by bringing the medical decision-makers from the member organizations together with researchers and clinical trendsetters. Together, they can give important inputs into EHAC. And as I understood from the EHAC board and other projects of EHAC, that’s how we work within the organization, but also attracting experts from outside to make the processes better. ARM: What are your plans for the activities of the working group? Hans Morten Lossius: My vision is that by producing sound recommendations, producing a good standard for HEMS and Air Ambulance, EHAC will add quality to HEMS and Air Ambulance services in Europe. Making such recommendations is not the work of a leader of the medical working group or of the medical director of a service – it is the work of selected experts within the specified area. Therefore my most important task will then be to make the experts cooperate, produce and contribute to the EHAC mission. So it is my task to facilitate the processes. I 15 I

EHAC

ARM: Coming back to the Foundation, could you tell us about the structure of the Norwegian Air Ambulance Foundation and how the funds are being generated?

Fig. 3: “My vision is that by producing sound recommendations, producing a good standard for HEMS and Air Ambulance, EHAC will add quality to HEMS and Air Ambulance services in Europe.” (Norwegian Air Ambulance)

Hans Morten Lossius: It started off in 1978 as a charity and is now the largest idealistic and non-profit organization in Norway. And it is almost as large as the Labor Union. We have almost one-fifth of the Norwegian population as members. That is quite a few. And in Norway it is highly valued to be a member of Norwegian Air Ambulance Foundation. You put a sticker on your car, you always tell somebody. The charity has done a wonderful job all these years and I believe, it may be the demography and the geography of Norway that make people so interested in Air Ambulance Services, because they are all really dependent on it. So with all this funding, the organization is really powerful and the organization has been the driving force behind the development of the Norwegian Air Ambulance Services. It is now a national service and has been so since 1988. But we are still pushing the service forward, and with all that funding, we really have the power to do that. The charity decided in 2006 that pushing the service forward should be more evidence-based, and some of the most important improvements would be increasing the evidence level and the academic level within the service. So that is why they initiated a Research and Development program. ARM: What it the perception of HEMS in Norway? Is it seen as an integral part of the national EMS or is it regarded as something “nice to have”, an add-on?

Hans Morten Lossius: HEMS is now a core part of the national EMS. As an illustration of the authorities’ change of attitude to the service; when the first base was established the Director of General Health proclaimed “luxury medicine!” Today, if the national HEMS operations in any way are threatened by internal factors like labour disputes or external factors like ash clouds, the Minister of Health will intervene making the necessary measures to keep the service going. Today, the Foundation has different important tasks: Through our subsidiary company, Norsk Luftambulanse AS, or NLA in short, we run HEMS operations. NLA is the main contractor in Norway and now also the only contractor in Denmark. Another important task for the Foundation is to run the Research and Development program. This is by far the largest part of the Foundation. But we also do a lot of layman education, projects on ‘first responder’, other educational programs and campaigns. So we do a lot of other things as well. ARM: What about the training as well as the Research and Development parts of Norwegian Air Ambulance; they are quite interconnected, right? Hans Morten Lossius: Yes, but we are not all there yet. We are striving to get one professional line through the company, putting the head of medicine in charge of quality control of everything that we deliver. But with all these really engaged, proactive people, it is not always easy to keep everybody under control. So we say, we have a lot of alpha males of both sexes. ARM: Do you also cooperate with HEMS operators from other European Countries? Hans Morten Lossius: As a charity, we get funding from people from the whole of Norway. That’s why we also support the three bases within the Air Ambulance System run by our ‘competitor’, so to say, Lufttransport. NLA runs nine bases and Lufttransport runs three bases. Meaning we are putting money into our competitor to make the whole service better. We cooperate with them, obviously. They take part in our training programs and we do not like it, but we like it [Laughs]. And of course, in my opinion, and in the charity’s opinion, you cannot improve without cooperating with others and you have to keep a national perspective. So, the cooperation is a fundamental part of especially the Research and Development program, not at least on an international level. As a charity, we are not willing to spend money on other countries’ services – only Norwegian – but we can spend money to cooperate, if that cooperation can improve our na-

I 16 I

3 · 2014 I Vol. 4 I AirRescue I 152

EHAC

tional services. Therefore, we have a formal contract or agreement on cooperation with the London’s Air Ambulance. We are also running the EUPHOREA network and we are willing to spend some money on the EHAC cooperation, and conferences like the SHARE meeting and other things. EUPHOREA stands for the European Prehospital Research Alliance and it is an informal voluntary and no precedence alliance; there are no ‘presidents’ and the Foundation runs the administration. The main purpose of the network is to cooperate on research projects with common interests. I think there are 11 countries that are part of the research alliance, but not all delegates meet each time. Participation at the meetings is voluntarily. We cooperate on several projects, like the AIRPORT study where we collected data on prehospital advanced airway management from 16 bases from five countries in Europe. So for our PhD students this network is like a gold mine. And I believe for the other countries as well. ARM: What about the first SHARE conference? Could you identify any hot spots for future HEMS? Hans Morten Lossius: I think a main challenge to HEMS and Air Ambulance Services is the variation in competence and skills of the medical personnel. There are some really good doctors out there, but the quality is not equal among all doctors and we do not have sufficient control of the medical delivery. The quality improvement, with tools like clinical governance, should be focused. We have much to learn from the pilots. ARM: So EHAC’s Aeromedical CRM, ACRM, is one such tool to achieve quality improvement? Hans Morten Lossius: Yes, it is one important tool and we should implement several other projects similar to that. Further, pre-hospital medicine is rapidly developing. It is more and more about diagnosing, treating and monitoring pathophysiological processes and I think EHAC will be really important here. So far the focus of pre-hospital EMS has been an anatomic and technical one with algorithms and practical measures, like cervical collars etc. The future will be ‘individual and structured point of care medicine with focus on pathophysiology’, including advanced diagnostics and advanced interventions. And this will also challenge the technical part and environment in the helicopter. ARM: Talking about future HEMS: Do you think there is a general tendency of “bringing the hospital to the patient”? 3 · 2014 I Vol. 4 I AirRescue I 153

Fig. 4: “A main challenge to HEMS and Air Ambulance Services is the variation in competence and skills of the medical personnel.” (Norwegian Air Ambulance)

Hans Morten Lossius: Yes, for the right patients and, like Prof. Wolfgang Voelckel says, you need competence out there to understand when the patient should be brought directly to the right hospital and when you should intervene. Because with the same type of patient it could be, in one situation a perfect solution to take him directly to the right hospital, but in another situation to perform an advanced intervention. The choice is depending on the transportation time, on the temperature, on the environment, on the qualifications of the receiving hospital – there are so many factors. ARM: So its not like either “stay and play” or “load and go”? Hans Morten Lossius: I say ‘algorithms for amateurs’ and ‘point of care for professionals’. Point of care does not necessarily mean ‘stay and play’. Point of care means ‘play and go’ or ‘play while you go’. It means doing the right thing with the right patient at the right time. And then you need the competence, skills and experience of a specialist doctor. It is within the first hour the really dangerous pathophysiological processes start and you need to cut them off. What is needed is not Basic Life Support, but Advanced Life Support in the right sense of the words. This includes advanced diagnostics, like echo sonography, advanced interventions and drug therapy, and advanced monitoring. This may include invasive procedures, like heart-balloon-pump, REBOA, ECMO or thoracotomy. That’s Advanced Life Support. And for those really critically ill patients, you need highly qualified specialists in the field. ARM: Hans Morten Lossius, we thank you for the interview.  I 17 I

EHAC

Fig. 1: Elitaliana became an official member of the EHAC; it was included in the membership board during the 2014 AIRMED (Elitaliana)

Elitaliana: Commitment to serving the community

Author: Elitaliana Press Office Elitaliana S.p.A. Base Roma Fonte di Papa Via Salaria 2061 00138 Rome Italy

I0I

Elitaliana S.p.A. was established in 1964. It is Italy’s oldest helicopter company and its core business is focused on Helicopter Emergency Medical Service (HEMS). Furthermore, Elitaliana carries out other types of missions of aerial work: from operations with the cargo hook to freight transport, up to offshore missions, aerial firefighting, and services linked to agriculture and environmental monitoring. The Elitaliana Group includes: Elitaliana Helicopter Company, Elitaliana Training Academy (Elitaliana’s flight school), Freeair Helicopters S.p.A (committed to helicopter maintenance), and Ground Aviation Maintenance, which designs and produces helipads, as well as providing the management and supply of firefighting services for helipads. The Elitaliana Group is based in Rome, at the air base in Fonte di Papa in Via Salaria 2061; besides, it has another two air bases in Roma-Urbe and Roma Ciampino. Furthemore, in the Italian region of Lazio, Elitaliana has three HEMS “118” air bases in Rome, Viterbo and Latina, as well as an operative base in Tarquinia. Elitaliana became a member of EHAC in June 2014.

3 · 2014 I Vol. 4 I AirRescue I 154

EHAC

Since 2009, Elitaliana has been the leading company in HEMS services in the Italian region of Calabria, where it owns two air bases in Lamezia Terme and Cosenza. Pushed by the requirements of the current medical regulations, as well as by several internal and external requests, Elitaliana is going to launch an Aeromedical Center (AeMC) in the coming months, the first private structure in aviation medicine to release and renew the medical certificates required for student pilots, pilots in command, co-pilots, technicians, and HEMS crew members, in compliance with the medical requirements EASA PART-MED, which apply to international civil pilots.

Part of Elitaliana’s fleet: • Robinson R22 • Robinson R44 • AgustaWestland AW 109E “Power” • AgustaWestland AW109S “Grand” • Bell 206AB • Bell 412 • Eurocopter EC130 cockpit and next generation avionics and both are deployed for HEMS missions.

Elitaliana’s key figures Elitaliana’s history Elitaliana’s path dates back to the middle of the 1960s, at the very beginning of the Italian helicopter rescue history. From the legendary “Jota” Agusta Bell AB47Js, passing through the Helicopter Support to the Eulex Kosovo Mission in 2011-2012 (mandated by the European Union), up to the use of the most modern technological aerial instrumentation, Elitaliana’s commitment to serving the community has exponentially increased throughout the years. A simple number can prove it: 40.000 missions in four decades. Elitaliana started its helicopter rescue activity in a period when the Italian HEMS and SAR operations were still an exclusive prerogative of a few. The experience gained by Elitaliana over the past fifty years in helicopter rescue, freight transport, offshore operations, aerial firefighting, environmental monitoring services, has turned the Italian Company into a highly reliable figure in both the Italian and the European rotorcraft industry.

Most modern fleet Elitaliana’s fleet consists of 18 twin and single-engine helicopters, committed to Elitaliana’s flight training operations and activities. Along with the Robinson R22 (two-seat helicopter) and the R44 (four-seat helicopter), there are also the twin-engine AW109S and AW109E helicopters, both equipped with a glass

3 · 2014 I Vol. 4 I AirRescue I 155

Elitaliana was founded in 1964. Among its activities today are helicopter rescue, aerial work, people and freight transport, offshore operations, wildfire fighting, aerial supervision, assistance, design, production and management of helipads, whereas its main field of activity is HEMS. During its 50 years of existence, 25,000 hours were flown and 40,000 HEMS missions were accomplished in Italy and Europe. Elitaliana has ordered 6 new AgustaWestland AW169 helicopters to be delivered this year. 120 employees work for the operator, out of which 32 are pilots, carrying out missions from 9 operative air bases, 5 of which are dedicated to HEMS services.

Training at Elitaliana Taking into account the need to maintain a high standard of safety for the flight crew, the Elitaliana Training Academy (ETA) was founded. ETA also acquired a flight simulator FNPT II MCC for the EC135, which allow to recreate certain flight or mission scenarios as well as certain weather conditions. The following courses can be taken at the ETA: Private Pilot LicensePPLH,Commercial Pilot License-CPLH, Pilot LicenseLine ATPLH, Course for instrumental helicopter-IR, Instructor Course for helicopter-FI, CRM courses (Crew Resource Management), MCC (Multi-Crew Cooperation) and FNPT II simulator and mountain flying, just to name a few.

Fig. 2: During its 50 years of existence, 25,000 hours were flown and 40,000 HEMS missions were accomplished in Italy and Europe (Elitaliana)

EHAC

Fig. 3: Elitaliana started its helicopter rescue activity in a period when the Italian HEMS and SAR operations were still an exclusive prerogative of a few (Elitaliana)

For more information, visit: www.elitaliana.eu

I 20 I

“You need mental alertness and a lot of training!” Graziano Lorenzi, Elitaliana’s HEMS captain, who also went through various trainings and conducts courses himself, told ARM his career path, from AVES (Aviazione Leggera dell‘Esercito, Italy‘s Army Aviation) operations with the CH-47 to HEMS: Etna, March 1992. A sultry weather, and the lava trickling down the volcano walls. It’s a moon-like scenario. A Chinook CH-47 disengages a 5-ton mass in one of the ephemeral mouths, the crevices that fill the volcano’s sides. First Marshal Graziano Lorenzi, who would later become Elitaliana’s HEMS pilot in 2004, is in the cockpit. Graziano’s story began with the Italian Army Aviation. “After achieving the licence, I worked for more than 15 ears at Antares First Regiment in Viterbo”, he told ARM. Such experience gave him the opportunity to pilot one what he defines as “the most beautiful helicopter in the world, the CH-47”. As a pilot in command of his Chinook, Graziano lived different experiences, from public calamities to international missions. It’s quite easy to figure out how the relationship between a pilot and a helicopter is, like a fraternal bond almost, a trust that is hard to explain. “In detail, I remember a mission in Kosovo, between 1999 and 2000. We used to carry 35 soldiers each time from one point to another. That experience shaped me. I saw war in people’s eyes and emptied buildings, that war that had just ended. Those scenes are engraved in my memory.” Later in his career as a pilot, however, Graziano needed new incentives. He found new and satisfying challenges in HEMS, thanks to Elitaliana’s call (the company where he became HEMS commander). It was the beginning of a new adventure in the civil field for him.

The operative scenarios changed, but the feelings remained the same. “I am happy when I see that I can make a difference. Like that time we intervened in the Italian region of Calabria to rescue a pregnant woman. I was about to take off and head to the hospital, but the physician told me to stop: the woman was about to give birth to her child. Therefore, the baby was born there, in front of the heli. We brought the woman to the hospital immediately after. A few years later, that woman found me on facebook and thanked for what I did. It was a great satisfaction for me.” Obviously, a pilot with such a CV tries to instil his knowledge to new pilots. It’s almost a natural instinct, a common feature for many experienced pilots. According to Lorenzi, experience and the ability to decide in a extremely short period of time does make the difference. “On the helicopter, you learn from the very start that it is essential to opt for the best solution as quick as possible, both before and during flight. You constantly need to consider the variables; therefore, you also need mental alertness and, most of all, a lot of training. When you fly, you have to learn how to change the situation and take your own decisions: it’s a crucial point that could change the mission outcome.”

The “H” in HEMS Giovanni Niro, responsible for Elitaliana’s training courses, spoke about helicopter rescue, focusing on the role of “118’s” HEMS services in the Italian region of Lazio, and also considering the pros and cons of the “H” in HEMS operations. “Helicopters are mainly used to accelerate operations. Furthermore, they can intervene in complex situations while hovering or using the rescue hoist. Once the patient is on board, physicians can use the medical equipment on the helicopter to stabilize him.” The helicopter has several advantages, but also some limits due to its peculiarity. “Of course, we cannot fly in difficult weather conditions with low visibility. However, helicopters remain a versatile vehicle, crucial for reconnaissance; besides, it can land anywhere, provided there is a suitable emplacement. Furthermore, the new EU Regulation 965/12 allows helicopters to land also outside the sanctioned helipads.” The key word used in HEMS operations is safety. Risk reduction is only possible through constant training. “Both pilots and medical staff must be constantly updated,” concludes Giovanni Niro. In detail, the medical staff must achieve the IML (Istituto medico legale, responsible for medical certification) qualification, pass the physical test, attend both a theoretical and practical training and rescue hoist training, and, finally, attend the HUET course.”  3 · 2014 I Vol. 4 I AirRescue I 156

Dedicated

Dedicated to the mission. Just like you. Completing the mission is the only acceptable outcome and the new customer support team at Breeze-Eastern lives by that same standard â&#x20AC;&#x201C; we are dedicated to delivering the best support for the most important mission. Yours. Call us today to see the difference that focused customer support brings to your mission success. 1.973.602.1165 Breeze-Eastern is the worldâ&#x20AC;&#x2122;s only dedicated helicopter hoist and winch provider.

breeze-eastern.com

Medical Care

Fig. 1: ICU transports are needed from higher to lower level of ICU care in order to free ICU beds in specialized hospitals, to continue long-term care closer to the patients’ home and family and to enable smaller hospitals to have an adequate volume of ICU care (Norwegian Air Ambulance)

Authors Andreas Jørstad Krüger Dept. Anesthesiology and Intensive Care Medicine St. Olav’s University Hospital Trondheim Norway Oddvar Uleberg Dept. Prehospital and Emergency Medicine St. Olav’s University Hospital Trondheim Norway Pål Klepstad Dept. Anesthesiology and Intensive Care Medicine St. Olav’s University Hospital and Dept. of Circulation and Medical Imaging Norwegian University of Science and Technology Trondheim Norway pal.klepstad@ntnu.no

I 22 I

Interhospital transports of critically ill patients – the hospital perspective Patients treated in intensive care units (ICU) are usually connected to a ventilator, are sedated, receive multiple drug infusions and need close monitoring of vital signs. Therefore, in the ICU, at all times, trained nurses observe patients, and physicians trained in ICU medicine are immediately available. Despite this high level of observation and frequent need for immediate interventions, ICU patients are often transferred between hospitals. The transports are either medically indicated for patient transfers to a hospital that is able to give the needed therapy (e.g. neurosurgical interventions) or are repatriations to a similar or lower level of ICU care indicated by organizational causes. Interhospital ICU transports are widespread: In 2013 alone, 117 transports were conducted during on-going therapy at the 9-bed ICU of St. Olav’s University Hospital.

Ground ambulances staffed with paramedics and an anesthesiologist from the involved hospitals usually perform short distance Norwegian interhospital ICU patient transports. However, in Norway many interhospital transports involve long transport distances making ground ambulances not feasible. These transports are performed by the “National Norwegian Air Ambulance Service”. This organization includes both helicopters (rotor wing, RW) and airplanes (fixed

wing, FW). Scheduled interhospital transports are usually done by the FW service. ICU transports are staffed with an anesthesiologist and often also a specialist nurse. Usually the FW service performs only the transport from airport to airport, while the local ground ambulance and an anesthesiologist from the hospital perform the transports between the airport and the hospital.

3 · 2014 I Vol. 4 I AirRescue I 158

Medical Care

A large number of Norwegian ICU transports can be considered as a service delivered by the Air Ambulance System to the hospital ICUs. As in all interactions, this interplay may include some conflicts of interest between the involved parties. In this short commentary we present a discussion where one intensivist, Pål Klepstad (PK), presents what he consider are the preferences for the delivery of ICU interhospital transports based upon the ICU perspective. Each statement is commented by an air ambulance physician, Oddvar Uleberg (OU), and one researcher involved in organization of prehospital specialist medical care, Andreas Jørstad Krüger (AJK).

Statements 1. Inter hospital ICU transports are needed PK: From the hospital perspective there is no doubt that interhospital ICU transports are needed. An absolute indication is transport to specialized treatments, which in the scattered and small population of Norway can only be performed at selected hospitals. Some treatments, such as severe burns or transplant surgery, are only delivered at one center. ICU transports are also needed from higher to lower level of ICU care in order to free ICU beds in specialized hospitals, to continue long-term care closer to the patients’ home and family and to enable smaller hospitals to have an adequate volume of ICU care. OU: Since 1988, when the National Air Ambulance Service was established, there has been a substantial reduction in the number of hospitals treating critically ill or severely injured patients and in the number of available ground based ambulances (1). Advanced medical procedures and therapeutic options cannot be offered at every hospital. Therefore, there is a need for ICU transports and the demand is most likely to increase in the future. AJK: Living in a political climate, where the mantra is “we need to centralize what we must, and decentralize what we can”, it is not possible to give definitive or complex treatment for all patients in all hospitals. Typically the sickest patients will need to be transferred to a centralized ICU, and therefore, some kind of transportation solution must be present. One paramount principle in Norwegian health legislation is that all citizens should have access to equal care. To achieve this goal, transportation measures must be available for those living in rural districts. For the centralized ICU, overcrowding represents a challenge. Typically, the centralized and larger hospital will have a regional (or national) specialization, in addition to being a hospital for local inhabitants. In our hospital, 3 · 2014 I Vol. 4 I AirRescue I 159

an overcrowding of ICU beds will reduce the capacity for major scheduled surgery due to lack of ICU beds for postoperative care. Cancelling selective major surgery severely affects the patients involved and represents a threat to patient rights as well.

Fig. 2: ICU transports are associated with risks such as limited access to the patient because of the physical conditions during transports (P. Klebstad)

2. Inter hospital ICU transports are risky PK: It is well recognized that ICU transports are associated with risks. Some examples of risks are tube dislocations, tube occlusions, loss of i.v. access, interruption in vasoactive drug infusions, and limited access to the patients because of the physical conditions during transports. In addition, all sorts of complications that could occur during in-house ICU therapy can also occur during transport. OU: Advanced medical treatment including invasive procedures in the pre-hospital setting is considered a high-risk operation due to the operational setting. This is due to factors such as confined and noisy working environment, potential difficult access, effects of weather (i.e. temperature, rain and wind), the patients physiologic response to temperature, stress, noise, vibration and acceleration forces, which all can lead to negative patient related effects (3). These are all factors, which add to the more “expected” risks involving treatment of severely ill and injured patients. Although the risks are obvious, the numbers of reported serious adverse events in the aero-medical setting are still rare (4, 5). Hopefully, this is the result of a well-structured transport system, including sufficient pre-transport coordination and communication, adequate accompanying personnel, and adequate equipment (6). I 23 I

Medical Care

fety issues should always be the first priority. Timely transfer can be lifesaving, but should never compromise the safety of the aircrew. It is essential that there is a continuous exchange of needs and possibilities between those requesting the service and the providers. In order to provide full coverage, there should also be ground-based alternatives with the same high quality standards.

Fig. 3: Ongoing treatment is complex and must be continued during transport (P. Klepstad)

AJK: Transportation of critically ill or injured patients is dangerous. It must be regarded as a responsibility for the critical care community to reduce the exposed time in this austere environment. The ICU patient is not able to express his/her opinion and we as critical care physicians act on the patientsâ&#x20AC;&#x2122; behalf, both in direct management of vital functions and logistical decisions. As such, patient autonomy is absent implying a responsibility to take all precautions for the safety of the patient. 3. The hospital needs the transports to be performed in due time PK: For emergency transports to specialized treatment there can be an immediate need for transport such as in patients transferred for emergency neurosurgical interventions. Therefore, the air ambulance system must be able to deliver transports as an emergency mission at all times. Also transports between similar or to lower level of care need to be performed within a reasonable timeframe. The indication for this timeframe is not each patientâ&#x20AC;&#x2122;s medical outcome. However, in Norway, as in most other countries, the capacity of ICU beds in specialized hospital is limited and patients need to be transferred in order to free ICU beds for incoming patients. OU: As stated by the intensivist, an all-time accessibility of the air ambulance system is requested. In order to achieve this, it is important that the service is able to provide full-time night and day operations. In Norway this coverage exists today at all RW- and FW-bases. This emphasizes the need for a reliable operator to provide the helicopter and airplane aviation operations. In a country where weather, winter and night conditions can be extremely challenging, the sa-

I 24 I

AJK: Effectiveness of novel emergency medical interventions is usually time-dependent (7). For instance, time to restoration of adequate blood flow is important for interventions such as thrombectomy for thrombotic stroke or opening of an occluded cardiac vessel. In a scarcely populated country as Norway, with long distances between specialized hospitals, rapid transport with dedicated personnel is a prerequisite for equal care for the population. Some of these patients might even require advanced critical care interventions en-route emphasizing the importance of not only a rapid transportation means, but also a competent liaison. 4. The air ambulance should perform ICU-to-ICU (door-to-door) transports PK: ICU patients interhospital transports often include three transport teams: hospital to airport, airport to airport and airport to hospital. A three-leg transport is time-consuming and includes two in-transport changes of stretchers and reestablishment of infusions, ventilator, and monitoring devices. Complications are often related to such procedures. It is safer to perform these interventions in a controlled environment in the delivering and receiving ICU than in an ambulance or at the airport tarmac. The three-leg transport will also include three handovers of information with an obvious risk of loss of information. OU: Every transfer situation with handover of information, re-establishment of complex and advanced procedures inherits the potential for an adverse event. The ability to reduce these situations is of paramount importance, even though the in-flight time might be shortly longer. Door-to-door transport by means of helicopter has several advantages to airplane in this perspective. AJK: From the medical perspective the importance of door-to-door transportation capacity is two-dimensional. Firstly, being able to transport the patient directly to the receiving facility reduces time to definitive care. Secondly, such transport implies less manipulation of the patient, which reduces potential hazards. As such, both related to medical outcome, and patient safety, a door-to-door system is preferable 3 Âˇ 2014 I Vol. 4 I AirRescue I 160

Medical Care

for the critically ill or injured patient (8). Medical emergency interventions are usually time-dependent, and future planning of retrieval systems should ideally aim to maximize the infrastructure for door-to-door transportation. 5. ICU competencies must be present also during transport PK: The ICU patients are still ICU patients during interhospital transports. Therefore, emergency physicians that are competent in treating ICU patients or ICU physicians that are trained in transports must be involved in patient care. The physician must be competent in therapy of typically ICU related conditions and in the use of ICU equipment. Control of severe respiratory failure with ICU ventilators, control of circulation with volume and vasoactive drugs, control of raised intracranial pressure, and sedation are all examples of ICU issues relevant during transport. OU: Aeromedical transport has evolved from being a mode of transportation to an advanced platform for applying state-of-the-art-medicine on scene and during transport. Although time is of essence in many cases, the ability to initiate, provide and continue advanced medical interventions started in the local hospitals is also important. The backbone of the national Norwegian Air Ambulance System is the highly trained anesthesiologist with special competence in critical emergency- and transport medicine (9). Ongoing cooperation within pre- and in-hospital competencies should be continued to provide best practice medicine for the ICU patient outside the hospital. AJK: Critical care is a concept, not a location. The patientsâ&#x20AC;&#x2122; needs must be evaluated, acted upon and maintained throughout the complete episode of care. I think it is a must that personnel with competency in critical care have to be present at all times. In our system, this translates to a physician with enough experience and skills in basic airway, breathing and circulation manoeuvres, as well as complex technical equipment. Sometimes, anesthesiologists in training minimal critical care experience perform interhospital transfers. It can be argued that such a policy is not best practice. At least, a formal education in retrieval medicine must be in place to achieve the desired patient safety. Given the need for professional competencies during intensive care unit (ICU) transports, there is a paradox in Norwegian emergency medicine. This service includes research in prehospital treatments (i.e. cardiac arrest) and in the delivery of primary missions, while a similar interest in research in interhospital transfers is lacking. 3 Âˇ 2014 I Vol. 4 I AirRescue I 161

6. We want one organization that organizes transfers and one address for referrals to ICU transports PK: There are many hospitals, dispatch centers, ground ambulances and air ambulance services involved in ICU patient transports. It is impossible for the ICU physician at one hospital to have an overview of how transports are best performed and resources best utilized. Therefore, in order to coordinate interhospital transports efficiently, all such transports should be organized at a national or regional level and each participant should have one dedicated address for all questions. OU: Efficient uses of a costly and advanced resource rely on effective coordination to meet the demands and utilize the available resources. In Norway there are 11 emergency dispatch centers responsible for 12 air ambulance helicopters, 2 Joint Rescue Coordination Centers responsible for 6 search and rescue helicopters, and 3 dispatch centers responsible for 9 air ambulance airplanes. The large number of coordinating centers potentially leads to a lack of oversight of available resources and delay in the transport of patients. AJK: ICU transports must be regarded as a complex intervention (10). Such complex interventions typically involve multiple providers and several steps. Planning is key for successful performance. All ICU transports consist of several subsequent steps: a need, planning, preparation, handover, transfer and handover at the receiving hospital. All these steps require different competencies. Centralisation of organisation might prove beneficial for all these steps. Moreover, ICU transports are expensive and a centralised dispatch center for ICU transportation might facilitate maximum resource utilisation. For instance, the RW services usually do not provide non-emergency transports in flights back-to-base after delivering emergen-

Fig. 4: Critical care is a concept, not a location: the patientsâ&#x20AC;&#x2122; needs must be evaluated, acted upon and maintained throughout the complete episode of care, including transport (Norwegian Air Ambulance)

I 25 I

Medical Care

low number of such transports the service needs to be either regional – or nationally organized (11). AK: Such need is rare and it must be questioned if such a service would add enough value in a time with economical constraints and increasing costs. On the other hand, as medical knowledge and technology refines and grows, the clinical benefit of treatment modalities might increase. Having a specially trained national retrieval unit, keeping competencies on a few physicians might presently be the most appropriate solution in Norway.

Fig. 5: Ground ambulances staffed with paramedics and an anesthesiologist from the involved hospitals usually perform short distance interhospital ICU transports – long distance transports in Norway however, are carried out by helicopter (Norwegian Air Ambulance)

Fig. 6: From the archives: Loading of a patient for a RW mission (Norwegian Air Ambulance)

cy patients. The argument for this practice is to be prepared for new emergency missions. This policy does not lead to maximum resource utilisation. Moreover, a national central coordinating ICU transports could also coordinate the use of ICU beds, directing flights to an ICU with available ICU beds at that time. 7. We need a service, which also delivers very specialized transports PK: Some ICU patients have very specialized treatments, which need special competencies or equipment. Examples are patients receiving nitrous oxide, ECMO, aortic balloon pump therapy or very small infants. National or a regional ICU transport services must be organized so that even such specialized treatments can be administered safely during transports. OU: Technological advances within the field of medicine are leading to increased interventions and treatment options. In many cases, the best option will be to identify and transport the patient before the need arises (e.g. prenatal transports with congenital heart disease, respiratory insufficiency before need of ECMO). Still, in cases where the need arises prior to transport, the outcome of the patient relies on specially advanced transport options. Considering the

8. We want an air ambulance service that is an essential part of the health care system PK: All emergency hospitals in Norway are organized within a national health care system. The use of ICU beds is based upon a shared responsibility for the patients. Interhospital ICU transports is a needed part of the health care region’s ICU services. We need air ambulance physicians to be continuously updated in ICU medicine, and we need in- and pre-hospital doctors to interact. Thus, an understanding of shared goals is vital and we advice to avoid a development where emergency services are uncoupled from in-hospital medicine. OU: In Norway, the National Air Ambulance Service is an integrated part of the specialized health care system. Increased demand, increased complexity and more advanced treatment modalities require active cooperation between the hospitals and the transport services involved. AJK: Norway has a governmentally funded air ambulance service (12). Missions are based on a national dispatch policy, and there is no pay-for-mission system for the operators. As such, there are no incentives to lower the threshold for dispatches, and it is believed that this contributes to a very low accident rate in the air ambulance system in Norway. For the critically ill or injured patient, a highly flexible air ambulance system staffed with specially trained physicians is crucial for being able to maximize the treatment potential. Nevertheless, the Norwegian air ambulance system should increase its quality assurance work. The dispatch system has not been validated for efficiency, and we currently have little knowledge of the quality of care provided.

Limitation An obvious limitation with this commentary is that it represents the views from three individuals based in one health care region. For a more comprehenI 26 I

3 · 2014 I Vol. 4 I AirRescue I 162

Medical Care

www.http://lovdata.no/dokument/SF/forskrift/2005-03-18-252 (accessed 8 June 2014). 3. Soreide E, Grande C (2001) Prehospital Trauma Care Marcel Dekker: 690-95. 4. Seymour CW, Kahn JM, Schwab CW, et al. (2008) Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care 12: R71. 5. Fan E, MacDonald RD, Adhikari NK, et al. (2006) Outcomes of interfacility critical care adult patient transport: a systematic review. Crit Care 10: R6. 6. Warren J, Fromm RE, Jr., Orr RA, et al. (2004) Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 32: 256-62. 7. Ghosh R, Pepe P (2009) The critical care cascade: a systems approach. Curr Opin Crit Care 15: 279-83. 8. Thomas SH (2009) On-site hospital helipads: resource document for the NEMSPA position paper on on-site hospital helipads. Prehosp Emerg Care 13: 398-401. 9. Kruger AJ, Skogvoll E, Castren M, et al. (2010) ScanDoc Phase 1a Study G. Scandinavian pre-hospital physician-manned Emergency Medical Services – same concept across borders? Resuscitation 81: 427-33. 10. Campbell M, Fitzpatrick R, Haines A, et al. (2000) Framework for design and evaluation of complex interventions to improve health. BMJ 321: 694-6. 11. Coppola CP, Tyree M, Larry K, et al. (2008) A 22-year experience in global transport extracorporeal membrane oxygenation. J Pediatr Surg 43: 46-52. 12. Kruger AJ, Lossius HM, Mikkelsen S, et al. (2013) Pre-hospital critical care by anaesthesiologist-staffed pre-hospital services in Scandinavia: a prospective population-based study. Acta Anaesthesiol Scand 57: 1175-85

sive analysis of the performance and needs of ICU patient transports, observational prospective studies or formal expert opinion processes using the Delphi methods are needed.

Summary We observe that between the three rapporteurs in this commentary there is a shared understanding of the major goals and ambitions for interhospital ICU transports. ICU transports are needed, the transports represent special medical challenges, health care professionals must have special competencies, the transports must be delivered timely and preferably be door-to-door ICU transports, and transports should be coordinated by a joint dispatch center. Therefore, the obstacles from achieving an optimal service is more based upon tradition, organization and funding. 

Bibliography: 1. http://www.norskluftambulanse.no/wp-content/uploads/2013/09/ SNLA-Kapasitet-og-basestruktur-rapport-sept2013.pdf (accessed: 8 May 2014). 2. Regulation on pre-hospital emergency medicine services in Norway. Forskrift om krav til akuttmedisinske tjenester utenfor sykehus:

#1 for

Dauphin Parts

We own and stock the largest inventory of independently held Dauphin helicopter spare parts available on the market today. Rotables, hydraulics, avionics & instruments ready to ship worldwide. Parts for exchange and outright sales.

Phone Fax US-Phone E-Mail Web

3 · 2014 I Vol. 4 I AirRescue I 163

: : : : :

+41 52 345 3605 +41 52 345 3606 +1 207-513-1921 mail@alpine.aero www.alpine.aero

I 27 I

Medical Care

Massive bleeding: The prehospital use of hemostatic bandages Data presented in this article were previously published in Dutch: Peters JH, Tan ECTH (2014) Prehospitaal gebruik van hemostatische verbandmaterialen. Ned Tijdschr Traum 22: 36-41.

In the Netherlands, approximately 3,500 people die because of trauma related injuries annually (1). Non-controllable bleedings are a major cause of death in these patients (2). In the military setting, exsanguination is the most important cause of death (3). Battlefield experience in Vietnam, Iraq and Afghanistan led to the introduction of hemostatic bandages for massive bleeding. These bandages have different working mechanisms. Certain bandages concentrate the patient’s own clotting factors by an exothermic reaction and fluid absorption to enhance clotting (QuikClot®). Other bandages contain materials that adhere to erythrocytes in order to create a firm cloth (HemCon®, WoundStat™ and Celox). Some bandages include clotting factors to promote cloth formation, for example Combat Gauze®. Animal studies show better and faster hemostasis for these bandages than conventional bandages (5-11). These better hemostatic results are also suggested in human military studies (12-16).

Four helicopter emergency medical teams (HEMS) are available to support ambulances in Dutch setting. These teams consist of an experienced nurse, and a physician (consultant level anesthesiologist/surgeon). These teams are deployed in trauma and non-trauma cases. Patients with potentially life-threatening blood loss with need for immediate intervention are frequently seen. Quick hemorrhage control prevents loss of clotting factors and erythrocytes. This contributes, in addition to the optimization of the oxygenation, to the prevention of oxygen debt, acidosis, hypothermia, and thereby further coagulation disorders. This phenomenon is known as the “Trauma Triad of Death” (21). Nijmegen HEMS uses HemCon® hemostatic bandages since 2009. We questioned the additional value of these bandages in traumatic bleeding and evaluated the hemostatic effect of HemCon® after a minimal application time of five minutes. We also reviewed the usability, bleeding time and possible side effects. Fig. 1: HemCo® – mechanism of action (HemCon® Benelux)

I 28 I

The armed forces of the Netherlands use HemCon® hemostatic bandages since 2009. HemCon® contains the biological polysaccharide chitosan, derived from crustacean exoskeletons. Chitosan has a positive charge contracting the negatively charged erythrocytes, forming a cloth that covers the damaged surface. This shortens bleeding time and in theory also forms a barrier to bacteria. Chitosan also activates platelets function and vasoconstriction enhancing wound closure (19, 20). Chitosan function is not influenced by body temperature and it is also useful in patients using anticoagulants (16-18). No side effects of chitosan or anaphylactic reactions to this products have been described.

Methods Nijmegen HEMS uses HemCon® ChitoGauze™, a flexible folded bandage measuring 10 centimeters by 3.7 meters in a package of 12 x 14 cm. These bandages cost approx. 55 €. We use these hemostatic bandages in bleedings that are suspected to be difficult to control using conventional bandages. This includes life threatening bleeding form lacerations, penetrating trauma and traumatic (partial) amputations. We also applied HemCon® after unsuccessful use of conventional bandages. After HemCon® use, the HEMS team completed a questionnaire, which were collected in a database. 3 · 2014 I Vol. 4 I AirRescue I 164

Medical Care

We scored patient and dispatch parameters, degree of bleeding control and usability in the prehospital field. To review the possible side effects of HemCon appliance, we analyzed the discharge papers from the receiving hospitals after prehospital HEMS treatment. Fig. 2: ChitoGauze™ is a flexible folded bandage, measuring 10 cm by 3.7 m in a package of 12 x 14 cm

Results Between April 2009 and July 2013 we applied HemCon® in 24 patients. (22 male and 2 female). Mean age was 41.3 years (12-80). In 18 of the 24 patients (75%) the bleeding was stopped after a minimum of 5 minutes of HemCon® application. In 6 patients the blood loss was not completely stopped but was considerably less than prior to the use of these bandages. No patients had a bleeding that could not be efficiently treated with HemCon® (see Table 1). Three patients (12.5%) received cardiopulmonary resuscitation (CPR) at hospital arrival. The effect of hemostatic dressings in patients receiving CPR is less clear compared with patients with spontaneous circulation. These patients should be represented in a separate ta-

Tab. 1: HemCon® application, “Lifeliner 3” Sex

Age (y)

Mechanism of injury

Arterial/venous

Location

Result

Fall bicycle

Veneus

Groin

Dry

Car accident

Veneus

Head

Dry

Arm trapped

Combi

Arm

Controlled

Car accident

Combi

Head

Dry

Fall height

Veneus

Head

Controlled

Car accident

Veneus

Head

Controlled

Fall horse

Combi

Mouth

Controlled

Train

Combi

Legs

Controlled

Fall height

Veneus

Head

Dry

Gunshot

Veneus

Groin

Dry

Car accident

Combi

Leg

Dry

Gunshot

Veneus

Head

Dry

Car accident

Combi

Abdomen

Dry

Bicycle vs car

Combi

Head

Dry

Authors:

Car accident

Combi

Groin

Dry

Car accident

Veneus

Head

Dry

Fall height

Veneus

Head

Dry

Joost H. Peters Department of Surgery Raboud University Medical Center Nijmegen, HEMS Nijmegen „Lifeliner 3“ The Netherlands

Leg trapped

Combi

Leg

Dry

Car accident

Combi

Head

Controlled

Gunshot

Veneus

Head

Dry

Arm trapped

Combi

Arm

Dry

Car accident

Combi

Head

Dry

Knife

Veneus

Head

Dry

Car accident

Veneus

Neck

Dry

3 · 2014 I Vol. 4 I AirRescue I 165

Edward C.T.H. Tan Department of Surgery Raboud University Medical Center Nijmegen, HEMS Nijmegen „Lifeliner 3“ The Netherlands

I 29 I

Medical Care

HemCon (n=24)

Died on scene (n=3)

Incomplete documentation (n=3)

Follow-up HemCon in receiving hospital (n=18) Fig. 3: Application of HemCon® and follow-up

ble. However, due to space limitations, these patients cannot be presented here. A complete follow-up from hospital admission till discharge was available in 17 patients (Fig. 3). When the three patients without spontaneous circulation are excluded from follow-up, we have complete data from 18 of 21 patients (85.7%). In these 18 patients there were no complications noted after HemCon usage. There were no problems regarding the removal of the gauzes in the hospitals. No rebleedings after bandage removal were reported. Three infections were found in these 18 patients, none of these were in the area were the hemostatic bandages were used.

Discussion

Notes The authors did not receive any funding/ support for this research. The first ten HemCon bandages were provided free of charge by HemCon Benelux. HemCon®, ChitoGauze™: HemCon Benelux, Parkweg 17A 2585 JD The Hague, the Netherlands.

I 30 I

In these cases all bleedings were controlled after the use of the HemCon hemostatic bandages. In the follow-up no complications or problems were reported that were relatable to the HemCon appliance. Three patients had a circulatory arrest prior to HemCon administration. In these cases it is difficult to relate the use of hemostatic bandages to the cessation of blood loss. No follow-up was available in three patients. These patients were not traceable in the administration of various receiving hospitals. It is therefore not possible to draw definitive conclusive conclusions regarding the long-term complications of this hemostatic bandages. Hemostatic bandages are more expensive than conventional gauzes. Reducing blood loss result in less blood transfusions and hypovolemic complications, and therefore less costs. With the results of this study it is difficult to justify the additional costs of the hemostatic bandages. Further research is necessary. In conclusion we see the additional value of these hemostatic bandages in our prehospital setting in severe traumatic bleeding. A prospective study is currently conducted in two Dutch regional ambulance services. This study will give further data regarding the cost efficiency of these novel products. 

References: 1. Cijfers ‘Gezondheid en welzijn’. Heerlen: Centraal Bureau voor de Statistiek (2010). http://www.cbs.nl/nl-NL/menu/themas/ gezondheid-welzijn/cijfers/default.htm 2. Sauaia A, Moore FA, Moore EE, et al. (1995) Epidemiology of trauma deaths – a reassessment. Journal of Trauma-Injury Infection and Critical Care 38/2:185-93. 3. Champion HR, Bellamy RF, Roberts CP, et al. (2003) A profile of combat injury. Journal of Trauma-Injury Infection and Critical Care 54/5: S13-9.4. 4. Granville-Chapman J, Jacobs N, Midwinter MJ (2011) Pre-hospital haemostatic dressings: A systematic review. Injury – Int. J. Care Injured 42: 447-459. 5. Maclntvre AD, Quick JA, Barnes SL (2011) Hemostatic dressings reduce tourniquet time while maintaining hemorrhage control. Am Surg 77/2: 162-165. 6. Arnaud F, Teranishi K, Tomori T, et al. (2009) Comparison of 10 hemostatic dressings in a groin puncture model in swine. J Vasc Surg 50: 632-639. 7. Kozen BD, Kircher S, Henao J, et al. (2008) An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot. Acad Emerg Med 15/1: 74-81. 8. Ward KR, Tiba MH, Holbert WH, et al. (2007) Comparison of a new hemostatic agent to current combat hemostatic agents in a Swine model of lethal extremity arterial hemorrhage. J Trauma 63/2: 276-283. 9. Clay JG, Grayson JK, Zierold D (2010) Comparative testing of new hemostatic agents in a swine model of extremity arterial and venous hemorrhage. Mil Med 175/4: 280-284. 10. Kheirabadi BS, Edens JW, Terrazas IB, et al. (2009) Comparison of new hemostatic granules/powders with currently deployed hemostatic products in a lethal model of extremity arterial hemorrhage in swine. J Trauma 66/2: 316-326. 11. Kheirabadi BS, Scherer MR, Estep JS, et al. (2009) Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine. J Trauma 67/3: 450-459. 12. Wedmore I, McManus JG, Pusateri AE, et al. (2006) A special report on the chitosan-based hemostatic dressing: experience in current combat operations. J Trauma 60: 655-658. 13. Pozza M, Millner RW. Celox (chitosan) for haemostasis in massive traumatic bleeding: experience in Afghanistan. Eur J Emerg Med 2010. 14. Rhee P, Brown C, Martin M, et al. (2008) QuikClot use in trauma for hemorrhage control: case series of 103 documented uses. J Trauma 64/4: 1093-1099. 15. Millner RW, Lockhart AS, Bird H, et al. (2009) A new hemostatic agent: initial life-saving experience with Celox (chitosan) in cardiothoracic surgery. Ann Thorac Surg 87/2: 13-14. 16. Tan ECTH, Bleeker CP (2011) Eraringen uit het veld met een bloedstelpend verband: chitosangaan. Nederlands Militair Geneeskundig Tijdschrift 64/2: 45-49. 17. Schwaitzberg SD, Chan MW, Cole DJ, et al. (2004) Comparison of poly-N-acetyl glucosamine with commercially available topical hemostats for achieving hemostasis in coagulopathic models of splenic hemorrhage. J Trauma 57: S29-32. 18. Klokkevold PR, Fukayama H, Sung EC, et al. (1999) The effect of chitosan (poly-N-acetyl glucosamine) on lingual hemostasis in heparinized rabbits. J Oral Maxillofac Surg 57: 49-52. 19. Thatte HS, Zagarins S, Khuri SH, et al. (2004) Mechanisms of poly-N-acetyl glucosamine polymer-mediated hemostasis: platelet interactions. J Trauma 57: 13-21. 20. Fischer TH, Thatte HS, Nichols TC, et al. (2005) Synergistic platelet integrin signaling and factor XII activation in poly-N-acetyl glucosamine fiber-mediated hemostasis. Biomaterials 26: 5433-5443. 21. Mikhail J (1999) The trauma triad of death; hypothermia, acidosis, and coagulopathy. AACN Clin Issues. Feb 10/1:85-94. 3 · 2014 I Vol. 4 I AirRescue I 166

Defibrillator, pacemaker, patient

Smallest pocket

monitor and 12- channel ECG in one

defibrillator

ARGUS PRO LifeCare® 2

FRED easyport ®

SCHILLER’s reliable solutions for extreme needs on land, at sea or in the air. Headquarters: SCHILLER AG, Altgasse 68, CH-6341 Baar, Phone +41 41 766 42 42, Fax +41 41 761 08 80, sales@schiller.ch, www.schiller.ch

Medical Care

Fig. 1: The continued development of vastly improving, highly portable devices now allows for out of hospital use and the realm of Point-of-Care Ultrasound (POCUS) is expanding (Denise Baylous)

Aeromedical Point-of-Care Ultrasound Point-of-Care Ultrasound (POCUS) is quickly moving towards the upcoming standard of care in aeromedical transport of patients experiencing significant traumatic injury. Many studies have been successfully conducted on the feasibility of using ultrasound in the pre-hospital environment and each has supported its use. Areas of potential use have included fixed and rotor-wing aircraft, advanced life support ambulances as well as in austere environments frequently encountered by military special operations units and police special weapons and tactics (SWAT) teams. This article will focus primarily on the use in aeromedical rotor-wing aircraft – however its application is fairly synonymous in the other areas.

Author Jeffrey G. Yates, MPA, PA-C Assistant Professor and Senior Physician Assistant Eastern Virginia Medical School EVMS Medical Group – Surgery Norfolk, Virginia yatesjg@evms.edu

I 32 I

Ultrasound technology is well established as a primary diagnostic and therapeutic modality when conducted at the bedside and also during formal studies conducted in an ultrasound suite. The continued development of vastly improving, highly portable devices now allows for out of hospital use and the realm of Point-of-Care Ultrasound (POCUS) is expanding. It is important to recognize that POCUS is a limited, goaldirected examination performed to answer a specific clinical question, such as is free fluid present in the abdomen. More simply said, it provides the examiner an anatomical “view” of only what is directly under the probe and nothing else. It is the responsibility of the examiner to incorporate their working knowledge of anatomy along with its structure and function to identify the problem. This is then followed with rapid concise medical decision making to implement the best modality for treatment of the identified condition.

A very common question concerning POCUS deals with what it is capable of doing. To properly answer to that question it frequently involves the review of nearly fifty potential uses related to examinations and procedures, but referring back to a question that has more utility is more germane. What should you do with POCUS to make it a valuable tool in your clinical practice? The potential use of POCUS is so vast that very few providers would be required, or able to, master all of its applications. All aeromedical services have a well-established and successful patient care protocol and by reviewing the potential uses of POCUS and electing what applications enhance your patient care requirements allows you the greatest benefit of this device. A significant benefit for those considering implementing an ultrasound program is that it will make little impact to the common pre-flight and post-flight procedures conducted by most rotor-wing flight crews. 3 · 2014 I Vol. 4 I AirRescue I 168

Medical Care

Initially most flight crews immediately recognize the patient assessment and care benefit that it provides, however, you may find that it also allows you to modify some of your existing Standard Operating Procedures (SOPs) or protocols related to patient care. This is truly a secondary benefit of the device but can certainly be responsible for the enhancement of the assessment and care that is provided to the patients. POCUS provides a very valuable tool in your regimen for the assessment and care of critically injured patients. The enhancement of your physical examination skills beyond the cardinal techniques of Inspection, Auscultation, Percussion, and Palpation is the most significant utility provided by POCUS. Termed the “Visual Stethoscope” by some experts, POCUS allows you to now see past the surface of the skin during your patient care assessment. As with everything in medicine, POCUS does have some down-sides: 1. The initial cost of the device can be quite expensive. 2. There is a significant amount of initial training required to become proficient and a dire need for occasional continuing education and review. 3. Some examinations are very difficult because of patient size, accessibility, and available positioning inside an aircraft. 4. Examinations are very operator-dependent and are based upon the skill and ability to identify specific anatomical landmarks. 5. From a technology standpoint: Not all devices are created equal. It is essential that you identify the device that provides you with what you need. 3 · 2014 I Vol. 4 I AirRescue I 169

The negative aspects of POCUS are far overshadowed by the positive ones however. The most significant benefits of POCUS are: 1. The examination is safe, non-invasive, and very effective in assisting the provider in obtaining a thorough patient assessment when performed properly. 2. Previous research by military and civilian flight crews shows that this ultrasound technology does not interfere with fixed or rotor-winged aircraft operations or avionics. 3. POCUS is a great adjunct to provide spectacular patient care in the prehospital environment that was not technologically available until recently. 4. Providing enhancement of the physical examination allows for the identification or confirmation of clinical conditions. This has shown to reduce iatrogenic injury from unnecessary procedures, such as needle decompression and has also allowed the early identified life-threatening conditions that was previously not available.

Figs. 2 & 3: POCUS can aid in decreasing iatrogenic injury resulting from “blind” procedures along with increasing the sensitivity of obtaining the proper diagnosis of several life-threatening conditions

One of the most common applications of POCUS is applied during the evaluation and care of blunt and penetrating trauma patients. During the extended Focused Abdominal Sonography in Trauma (eFAST) examination examiners evaluate the patient for the presence of a significant amount of “free fluid” in the dependent areas of the abdomen and pelvis, observe for the presence of free pericardial fluid along with a gross evaluation of cardiac activity and function, and lastly interrogate the thorax for the presence of pleural (lung) sliding in the evaluation for pneumothorax I 33 I

Medical Care

sibility of PreClinical Cardiac Output and Systemic Vascular Resistance in HEMS in Thoracic Pain – The Ultrasonic Cardiac Output Monitor”). During the evaluation of a patient’s hemodynamic status the Inferior Vena Cava (IVC) can be visualized and its variability can be assessed to assist in determining a patient’s volume status. All of these potential uses of POCUS are helpful in assisting in the evaluation of a patient’s clinical condition, but also require an increased proficiency on the part of the evaluator. Although some feasibility studies suggest a minimal amount of education is required to obtain proficiency with a POCUS device, experienced evaluators suggest a specified curriculum that involves both didactic and clinical education. One suggested curriculum would be: Fig. 4: POCUS provides a tremendously enhanced assessment during the evaluation and care of patients undergoing aeromedical care and transport (Denise Baylous)

I 34 I

(PTX) and hemothorax (HTX). The detection and confirmation of pneumothorax (PTX) by ultrasound is far more accurate and sensitive than chest radiography, not to mention auscultation, which is generally not a modality available during aeromedical transport because of extensive ambient noise. With plain chest radiography a minimum of 200 ml of blood is required for detection of hemothorax however with ultrasound that volume is decreased to 50 ml and the duration of the examination is significantly shorter while providing “real-time” data. It is generally accepted that 200 ml of intraperitoneal fluid must be present to be identified by ultrasound as “free abdominal fluid”. Th[e eFAST examination is certainly the standard of care in the evaluation of traumatically injured patients, but the thorax component offers so much to the prehospital community for the detection of PTX and HTX that it nearly stands alone to show its benefit. By providing early confirmation of these potential life-threatening conditions we may also find a reduction in iatrogenic injury from procedures such as unnecessary needle thoracentesis. The application of POCUS may also be instituted during incidents, involving multiple or mass casualties or where there is a significant limitation of available resources as an aid in the triage and transport of these victims. There are several other modalities where POCUS proves to provide significant application in the aeromedical environment. In patients that are experiencing acute myocardial infarction (AMI) providers may find it helpful to determine the presence or extent of cardiac wall motion abnormalities so the treatment provided during transport to definitive care specifically addresses their condition. The identification of cardiogenic shock can be improved with the use of POCUS and appropriate treatment modalities may be instituted more quickly, which should theoretically improve patient outcomes (see K. Knobloch: “Fea-

1. Didactic education (8 hours): This includes both a lecture and “hands-on” clinical component. 2. Supervised Clinical Practice (4 hours): This involves performing Point-of-Care Ultrasound examinations on standardized patients under the close observation and direction of an experienced evaluator. 3. Observed Standard Clinical Examination (OSCE): During this one (1) hour examination the novice evaluator is provided a clinical scenario during which time they must successfully complete an entire patient evaluation and treatment protocol, to include a POCUS examination. This reinforces the integration of POCUS into established patient care protocols. 4. Continuing Medical Education (CME): Upon completion of the above curriculum, providers are required to perform a minimum of five (5) POCUS examinations per month with an experienced provider. In addition to the basic didactic and clinical education training, OSCE and CME components, there is also a Quality Assurance/Quality Insurance (QA/QI) or more commonly, a Performance Improvement (PI) package associated with Aeromedical POCUS. The POCUS examinations performed by the flight crews are saved, by flight number, onto the hard-drive of the device and reviewed for quality and accuracy. A very helpful component of the PI project is that the Trauma Service conducts the same eFAST US examination, with the same model device, upon the patient’s arrival in the trauma bay which allows for comparison between two independent studies performed by different providers. Although the US examination conducted in the prehospital setting is generally more physically and technically demanding, it offers a good comparison to the examination conducted in the controlled 3 · 2014 I Vol. 4 I AirRescue I 170

The extended FAST examination includes

2 4

1. The Perihepatic Region “Morrison’s Pouch” 2. The Perisplenic Region 3. The Pelvic Region 4. The Pericardial Region The Lung windows for pleural slide atmosphere of the hospital’s trauma bay. When the results of this comparison are presented with the proper demeanor, it can be a very valuable educational tool for all of those involved.

Summary In summary, Point-of-Care Ultrasound (POCUS) provides a tremendously enhanced assessment during the evaluation and care of patients undergoing aeromedical care and transport. Establishing a specific curriculum of didactic and clinical education along with an organized continuing medical education program will allow providers the ability to become and maintain proficiency with the device. The most significant benefit is achieved when the flight crews augment their already established patient care protocols with the use of POCUS in a systematic patient care assessment protocol, such as the ABCDE (Airway and Arterial Bleeding, Breathing, Circulation, Disability, Exposure/Environment/eFAST) primary survey for trauma. What has allowed POCUS to take such a strong foothold in the assessment and care of patients, are the technological advancements that have taken ultrasound evaluations out of the hospitals and into the prehospital environment. As these advancements continue, we should expect to see small, lighter, and more technologically advanced devices with much improved resolution. We would also expect that manufacturers will develop multiuse devices capable of EKG, pulse oximetry, blood pressure, EtCO2, and ultrasound in a single unit. The future of POCUS is revolutionary and very exciting.  3 · 2014 I Vol. 4 I AirRescue I 171

MEDICAL CARE

Fig. 1: Hungarian HEMS tested the feasibility of introducing a paralytic Rapid Sequence Intubation (RSI) SOP and elements of clinical governance (Balazs Sebok)

The introduction of prehospital Rapid Sequence Intubation (RSI) into the Hungarian EMS system Emergency Medical Service (EMS) in Hungary has a history of over 125 years. From the beginning, physicians responded to incidents using different kinds of transport platforms, from horse drawn carriages to helicopters in the modern days. Land-based EMS was always physician staffed on part of the ambulances. The National Ambulance Service (NAS) today is the biggest and basically the only EMS provider in the country. NAS has over 7,000 employees, operates basic and advanced level ambulances from 240 stations around the country. The Hungarian Air Ambulance provides HEMS support for the land-based units from 7 bases. Hungarian HEMS tested the feasibility of introducing a paralytic Rapid Sequence Intubation (RSI) SOP and elements of clinical governance before applying it to the whole EMS system.

Author: Dr Péter Temesvári Medical Director National Ambulance Service Hungary

I 36 I

Basic ambulances respond with 2 providers with Basic Life Support (BLS) level competences. NAS operates around 550 of these units. Advanced level ambulances respond with either a physician or a paramedic with a college degree. Doctors and paramedics are helped

by an assistant and a driver for a 3-person crew in an ambulance, or by an assistant-driver in a response car. There are around 180 advanced level units operated by NAS. Paramedics in Hungary have a minimum of 4 years of training. They are allowed to give various 3 · 2014 I Vol. 4 I AirRescue I 172

MEDICAL CARE

medication and they are competent in performing advanced interventions. Paramedics have almost equal competences as doctors in the prehospital setting. Although prehospital intubation remains a controversial procedure with conflicting evidence, prehospital doctors and paramedics always had intubation in their skill-set. This means drug-assisted intubation as well as intubation in cardiac arrest. Hungarian prehospital medicine traditionally followed the model seen in many countries in continental Europe. This means the so called “stay and play” model and physicians and paramedics having a limited number of guidelines or protocols to follow. Most of the on-scene medical work has been based on individual knowledge and experience with very few elements of clinical governance to improve patient safety. There have always been guidelines to help prehospital work, but clinicians had freedom of choice regarding diagnostic procedures, medication and interventions in the field.

Prehospital intubation then and now The Hungarian Air Ambulance and the NAS realized that the traditional method for drug assisted intubation in Hungary left room for improvement. Beside the general feeling and feedback from receiving hospitals that things could go better, there is some data suggesting that our results were not up to the international standard. The method for drug assisted intubation had a few characteristic features: 1. There was no standard operating procedure to guide clinicians 2. Practice varied greatly regarding choice of drugs and methods 3. This has led to the lack of a standard to follow when training clinicians 4. The method was a non-paralytic RSI, meaning that clinicians have never used muscle relaxants to facilitate intubation. We believe that one good indicator to measure the quality of prehospital drug assisted intubation is the rate of intubations that are successful at first attempt compared to all drug assisted intubations. We have collected data from several audits showing first attempt success rate to be around 65%. This value is lower than what we can consider the international standard. Data from London HEMS for example suggests an 85% first attempt success rate is achievable in a service with good clinical governance and highly trained clinicians. Other audits have shown a substandard practice regarding oxygen administration and the use of capnography for patients who received drug-assisted intubation in Hungary. 3 · 2014 I Vol. 4 I AirRescue I 173

RSI indicated? Preoxygenate Prepare for RSI Optimise first attempt Perform standard induction

Cannot see cords

Intubate Confirm tube position

30 second drill Retry

Ventilate Transfer

Fail Rescue plan

Towards more clinical governance

Fig. 2: Rapid Sequence Intubation (RSI) algorithm

It was decided that Hungary needs to change the method of prehospital drug assisted intubation and this included complex intervention into the system. There is data to support that intubation can be harmful, and we can conclude that in order to provide benefit for our patients, the system needs elements of clinical governance in place. These include a robust and proven standard operating procedure, training of staff, continuous audits to follow practice and regular revisions of the SOP and training based on the data collected. The RSI model developed by London’s Air Ambulance (London HEMS) seemed to be a very effective template to base Hungarian practice on. The model developed by London HEMS was a proven, robust system with high success rate and excellent quality patient care. In addition, a few Hungarian physicians have had the opportunity to receive training and experience working with UK prehospital services, where drug assisted intubation was based on the London model. Clinical leadership of London HEMS was happy to share experience with the Hungarians and has helped greatly to develop the Hungarian SOP.

Standard Operating Procedure Key elements of the SOP include an absolutely standardized approach to preoxygenation, positions, preparation of the equipment, tube position confirI 37 I

MEDICAL CARE

ts being away from scene in an environment where they were emotionally less involved. Data collection started immediately with a separate sheet to collect Cormack-Lehane grades, number of attempts and complications. Results from the HEMS pilot project were very encouraging with overall intubation success rates over 99% and first attempt success rates over 90%. There were no incidents of hypoxia or loss of airway associated with the new RSI system.

Implementing new RSI in land EMS

Fig. 3: “Key elements of the SOP include an absolutely standardized approach to preoxygenation, positions, preparation of the equipment, tube position confirmation and post-intubation care as well as rehearsed procedures in case of failed laryngoscopy or failed intubation” (Hungarian Air Ambulance)

mation and post-intubation care as well as rehearsed procedures in case of failed laryngoscopy or failed intubation. The RSI algorithm is shown in Fig. 2. In the patient group requiring drug assisted intubation, we intended to base patient safety mostly on the simplicity and the standardized approach of the SOP as well as the training and experience of the clinicians.

The pilot project In Hungary, we have used Hungarian HEMS to test the feasibility of introducing a paralytic RSI SOP and elements of clinical governance before applying it to the whole EMS system. The process started in 2011 with consultations with the Society of Emergency Medicine and leading Anesthesiologists in Hungary. Parallel to this, a 2-day training program was set up for HEMS clinicians and a Hungarian version of the London HEMS SOP was developed. After approval for the pilot project to continue, trainings have begun and some additional equipment and drugs were provided for the helicopters. HEMS units in Hungary fly single pilot operation with a doctor-paramedic or a doctor-assistant medical team. The 2-day training consisted of minimal theoretical lectures, skill stations for failed laryngoscopy and failed intubation situations and other skills as well as complex low-tech and high-fidelity simulations. To facilitate decision making mostly in establishing the indication, an on-call telephone consultation system was set in place. This means that before every prehospital RSI, on-scene clinicians are asked to seek telephone advice before committing to drug-assisted intubation. We have found this method to improve patient safety as in many cases consultations had a significant added value to on-scene decision making with telephone consultan-

I 38 I

After 2 years of the successful pilot project, steps were made in 2013 to widen the range of clinicians who use RSI for drug-assisted intubation. This new project was significantly larger in volume, as land EMS employs around 300 doctors, 800 paramedics and over 2,000 assistants on their advanced level ambulances. Training of the clinicians involved proved to be one of the biggest challenges. The program had a very tight schedule with only 8 months to complete the 2-day training for the intubating clinicians (doctors and paramedics) and the 1-day training for the assistants. Even with this volume, there needed to be no compromise in the quality of training given. We have completed the countrywide training with over 150 dedicated and enthusiastic RSI instructors, who were selected at the beginning of the program. Failure rate proved to be around 20% with each clinician group. Competence to perform prehospital RSI was given only to those who have successfully passed the exams. The SOP was slightly modified after the lessons learned with the HEMS pilot project. Ketamine was identified as the only choice of induction agent to simplify the SOP and we’ve excluded the general use of fentanyl as a premedication agent. Another challenging part of the project was to provide extra equipment for the RSI capable units. With the new SOP, a very welcome increase in oxygen use and the use of equipment like simple airway adjuncts can be witnessed. As the NAS is a huge organization with lots of momentum, it is slow to respond to such challenges and as a result today only about half of our advanced ambulances have the equipment needed to perform RSI according to the new SOP. We hope to achieve 100% equipment cover within 2-3 months.

First experiences in land EMS Initial results with the land EMS extension are promising. Overall success rate with the first few months of data collection is over 97% and first attempt success rate is also very good with around 85%. We’ve recorded no failed airways associated with the RSI system, our pre-determined plans for failed intubation were 3 · 2014 I Vol. 4 I AirRescue I 174

MEDICAL CARE

successful with most of our patients who had a failed intubation attempt receiving a supraglottic device (Laryngeal Mask Airway) and some receiving a surgical airway to provide oxygenation and ventilation. Within the first few months after introduction of RSI to the NAS, several new problems surfaced. First was the inability of receiving hospitals to cope with paralysed ventilated patients. There were no formal complaints, but informal feedback was significant about hospitals having problems with neurological assessment of paralysed patients. Some doctors voiced their opinion about the legal aspects of paramedics performing prehospital anesthesia. Other concerns included administration of muscle relaxants to patients with organophosphate poisoning. There is also general concern from doctors about the ability of prehospital clinicians to perform RSI safely. We take every feedback seriously and we are working closely with the Hungarian College of Emergency Physicians to identify areas where intervention into the system is needed. We have no major concern at this point based on our audit data, but we will continue to be vigilant. We have identified a few areas where minor changes to the SOP are needed. We have also pointed out the need to increase the frequency of recurrent training for clinicians. To respond to some legal drug administration requirements, we are going to re-introduce etomidate as an alternative induction agent for cases where the Hungarian drug manual identifies ketamine as contraindicated. We will also introduce extra measures into the SOP and the training manual to facilitate preoxygenation of medical patients with ventilatory failure. To help hospitals with the neurological assessment of ventilated patients, we will target the dose of the long lasting muscle relaxant to keep the effect as much to the pre-hospital phase as possible. All this means that we are trying to establish a thinking where feedback is important and is acted on, and where we are working together with our partners to optimize patient care, and make the transition from the prehospital to the hospital phase as smooth as possible.

Human factors As expected with an organization the size of the NAS, response to the changes introduced was very diverse. Most of our colleagues agreed, that the area of prehospital drug assisted intubation needed improvement and that the training program organized was necessary and effective. We had a high positive feedback rate regarding the 2-day course from our colleagues. Most of them embraced the idea of following an SOP for this procedure. However, some of our colleagues think that any SOP will limit their freedom of choice. 3 Âˇ 2014 I Vol. 4 I AirRescue I 175

Some also think the traditional non-paralytic drug assisted intubation has worked perfectly in their case. We can say that to change the thinking of clinicians and to change organizational culture is a difficult and slow process. The problem remains that if some clinicians refuse to see the value of a standardized and well governed system, their adherence to the SOP will be poor. Poor SOP compliance could lead to sub-optimal patient care results. This, together with a variable quality of documentation presents a huge challenge to clinical management in an organization with the size of the National Ambulance Service.

Fig. 4: Hungarian land EMS employs around 300 doctors, 800 paramedics and over 2,000 assistants on advanced level ambulances (National Ambulance Service)

Future tasks We will definitely need to continue monitoring the results of the new RSI SOP. Our continuous audits should be the source of information on which to base our plans regarding training, consultations, and SOP revisions. This project should be supported by another one that is currently on-going within the Ambulance Service, namely the introduction of a new electronic patient documentation and database system. This later project will hugely influence the success of our other efforts at building a robust clinical governance system. We also need to continue to ask for feedback from clinicians inside the service and from receiving hospitals as well as other medical bodies in Hungary. We plan this discussion to be an on-going process and we expect it to lead to better SOP compliance and good quality patient care from dedicated and skilled clinicians. Based on our findings so far, we are confident that the introduction of RSI into Hungarian prehospital care was successful and will continue to be of benefit to our patients. ď&#x201A;¤ I 39 I

Medical Care

Fig. 1: TIC is now considered to be an early, acute, “endogenous” coagulopathy, which is independent of the secondary factors hypothermia, acidosis and dilution (P. Knacke)

Coagulation management in multiple trauma – is tranexamic acid the only option? Ever since trauma-induced coagulopathy (TIC) was described by Brohi et al. (1), this clotting disorder in patients with multiple injuries has been seen in a new light. In the past, the “triad of death” – consisting of hypothermia, acidosis and loss/consumption/dilution – has been used as a pathophysiological explanation for this often life-threatening bleeding disorder. However, TIC is now considered to be an early, acute, “endogenous” coagulopathy, which is independent of the secondary factors hypothermia, acidosis and dilution (2), but dependent on the severity of the injury (3). Hyperfibrinolysis is at the centre of these considerations: the clot forms normally, but its physiologically limited dissolution is excessive. Author: Dr. Heiko Lier Department of Anaesthesiology and Intensive Care Medicine University Hospital of Cologne Germany Heiko.Lier@uk-koeln.de

I 40 I

The therapy for this non-surgical, diffuse bleeding from the mucous membrane, serous membrane and from wounds (4) is determined by the principles of damage control resuscitation: after the quickest possible start of therapy (clear A1 recommendation with

high-grade evidence [5]), „permissive hypotension“ (high-grade 1C recommendation with weak evidence [5]), re-warming (high-grade 1C recommendation with weak evidence [5]), acidosis compensation (highgrade 1C recommendation with weak evidence [6]) 3 · 2014 I Vol. 4 I AirRescue I 176

Medical Care

and the following sophisticated coagulation therapy is attempting to avoid a complete collapse of the “organ system” coagulation. As hyperfibrinolysis plays a key role, using a drug that blocks this should be very effective in patients with TIC. Tranexamic acid (TxA) is such an antifibrinolytic drug. This drug was first described in 1966 and is (similarly to the markedly less effective ε-aminocaproic acid) a synthetic lysine analogue: it blocks the lysine-binding sites of plasmin. It also blocks the binding of α2-antiplasmin and prevents inflammatory reactions. It has a delayed onset of action compared to aprotinin, as the activity of free plasmin is still effective. Only a small fraction of TxA is metabolised, only 3% binds to plasma proteins and it is completely excreted via urine (7). To date, there is no evidence of critical side effects such as thromboembolic events (myocardial infarction, myocardial ischaemia, apoplexy, pulmonary embolism, venous thrombosis) or multiple organ failure (5). The adverse effects are limited to temporary vision disorders, nausea, headaches or dizziness (8) and hypotension when the drug is administered intravenously too quickly. Post-operative seizures have only been described in high dose ranges during cardiosurgical operations with a heart-lung machine or during direct intrathecal use (9). On a European level, since 2013 there have been high-grade 1A recommendations for the use of TxA in traumatic (5) and perioperative (6) bleeding. These recommendations are based on the CRASH-2 study (10), which was published in the Lancet in 2010. Within 8 hrs after trauma, trauma patients aged over 16 years with (a risk of) “significant haemorrhage” (defined as RRsys <90 mmHg and/or HR >110/min.) were double-blinded and randomised tested in 274 hospitals in 40 countries. One of the inclusion criteria was the “uncertainty principle”, i.e. the attending physician was not certain whether TxA was indicated or not. 10,060 patients received 1 g TxA in 10 min. plus 1 g over 8 h, the control group of 10,067 patients received NaCl 0.9%. The total mortality was 15.3% (35.8% of these on day 1). A significant reduction in the total and haemorrhage-related mortality became apparent (total: TxA 14.5% vs NaCl 16.0%, risk ratio [RR] 0.91, 95% confidence interval [CI] 0.85–0.97, p=0.0035; haemorrhage-related: TxA 4.9% vs NaCl 5.7%, RR 0.85, 95% CI 0.76–0.96, P=0.0077). This absolute reduction in total mortality by 1.5% corresponds to 70,000 lives saved each year on a global scale (11). Although TxA is a drug used to promote coagulation, an increased rate of thromboembolic complications was not registered (heart attack, stroke, pulmonary embolism, deep vein thrombosis).

3 · 2014 I Vol. 4 I AirRescue I 177

One year later, further analysis of the data (12) showed that TxA should preferably be administered within 1 h after the trauma, as then the haemorrhagerelated mortality can be reduced by 32% (TxA 5.3% vs NaCl 7.7%, RR 0.68, 95% CI 0.57-0.82). This advantage was reduced between the first and third hour (TxA 4.8% vs NaCl 6.1% RR 0.79, 95% CI 0.64–0.97). After more than 3 hours, the administration of TxA was harmful (TxA 4,4% vs NaCl 3,1%, RR 1.44, 95% CI 1.12–1.84). In the third edition of the European trauma guidelines (5), this data resulted in the suggestion to consider administration of the first dose of TxA en route to the hospital. The randomised, controlled examination of this suggestion is currently under way in Australia (PATCH study [13]). Considering the current cell-based model of coagulation (14), it seems logical that the administration of TxA and, if necessary, subsequent administration of fibrinogen can only be successful when carried out at an early stage so that a sufficient number of thrombocytes and coagulation factors are present and the enzymatic reactions can take place (15). Therefore, TxA and fibrinogen are increasingly considered to be crucial components needed to prevent the complete collapse of the “organ system“ coagulation in severely injured patients. The analysis of over 20,000 patients in 40 countries in this impressive study shows a considerable advantage of administering TxA for trauma, without the risk of thromboembolism. On closer inspection, some points of criticism must be noted: • No measurements of coagulation, or at least fibrinolysis, parameters were made in a laboratory. • Most of the hospitals were in developing and emerging countries. Can the data be transferred to developed countries?

Fig. 2: It seems logical that the administration of TxA and, if necessary, subsequent administration of fibrinogen can only be successful when carried out at an early stage (R. Schnelle)

I 41 I

Medical Care

• Reduction in mortality from 16 to 14.5%, i.e. absolute reduction of mortality by 1.5% in 20,211 patients. Is this overpowered? • Only 50.4% of the patients received a blood transfusion: 6.06 (±9.98) on average, but a median of 3 (2–6) units. Is this a massive transfusion? • Despite the significant reduction in haemorrhagerelated mortality, no blood products in the TxA group could be saved (TxA 50.4% vs NaCl 51.3%, not significant). • There were, in fact, 20,211 patients and 3,076 deceased (15.3%). However, the analysis of the deaths caused by haemorrhage is only confined to 1,063 (TxA: 489 = 4.9% vs NaCl: 574 = 5.7%; p = 0.0077). • In 20,211 patients, only 369 thromboembolic complications were noted (TxA: 168 = 1.7% vs NaCl: 201 = 2.0%; n.s. and DVT: 0.4%). This is a staggeringly low number: in high-risk patients, deep vein thrombosis is expected in 11–44% and approximately 3% of all multiple trauma patients with DVT suffer a pulmonary embolism (16). • The thromboembolic rate of NaCl in comparison to TxA was not significant, but still higher. Up to now, physiological saline solution has not been considered as thrombogenic. The administration of TxA in CRASH-2 led to an absolute reduction in the risk of mortality by 1.5%; therefore, the number needed to treat (NNT) is 67 patients. In the case of military traumas with considerably severe injuries, the reduction was 6.5% and the NNT was 15 (MATTERS [17]). Only taking massive transfusions into consideration, it was 13.7% (NNT 7). The more severe the injury, the more effective TxA seemed to be. For over ten years there has also been clear evidence that, in the case of perioperative bleeding, the application of TxA can reduce the probability of a blood transfusion by about a third (18). For subarachnoid haemorrhages, the results are still inconsistent, i.e. a benefit has not been clearly proven, while there is no indication of potential damage (7). Despite the above-mentioned points of criticism for CRASH-2, according to the current body of knowledge, the administration of TxA at a dosage of 1 g over 10 minutes (20–25 mg/kg body weight), if necessary followed by 1 g over 8 h (5, 6), in patients with (severe) multiple traumas should be made at an early stage, and in the emergency departement at the latest. A theoretical risk for thromboembolism cannot be confirmed by current literature. At an actual cost of about EUR 8 to 12 per gram, TxA is also very cost-effective (6). I 42 I

Conflict of interests: H.L. received lecture fees and travel costs from the German Red Cross (DRK) Blood Donation Service West, CSL Behring, Ferring Pharmaceuticals, Mitsubishi Pharma, NovoNordisk and Tem International.  Bibliography: 1. Brohi K, Cohen MJ, Davenport RA (2007) Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 13(6): 680–5. 2. Kashuk JL, Moore EE, Johnson JL, et al. (2008) Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma packed red blood cells the answer? J Trauma 65(2): 261–70. 3. Floccard B, Rugeri L, Faure A, et al. (2012) Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury 43(1): 26–32. 4. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF, Association of scientific medical societies in Germany), German S3 Guideline 012/019 ‚Polytrauma/Schwerverletztenbehandlung‘ [Multiple trauma/ severe injury treatment]. Online: http://www.awmf.org/uploads/ tx_szleitlinien/012-019l_S3_Polytrauma_SchwerverletztenBehandlung_2011-07.pdf. Last accessed: 6 July 2014 5. Spahn DR, Bouillon B, Cerny V, et al. (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17(2): R76. 6. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. (2013) Management of severe perioperative bleeding: Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 30(6): 270–382. 7. McCormack PL (2012) Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 72(5): 585–617. 8. Ducloy-Bouthors AS, Jude B, Duhamel A, et al. (2011) High-dose tranexamic acid reduces blood loss in post-partum haemorrhage. Crit Care 15(2): R117. 9. Pusateri AE, Weiskopf RB, Bebarta V, et al. (2013) Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Shock 39(2): 121–126. 10. Shakur H, Roberts I, Bautista R, et al. (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376 (9734): 23–32. 11. Sydenham E (2011) Thousands of lives could be saved using tranexamic acid for patients with bleeding trauma. Injury prevention: journal of the International Society for Child and Adolescent Injury Prevention 17(3): 211. 12. Roberts I, Shakur H, Afolabi A, et al. (2011) The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 377(9771): 1096–101, 101. 13. Gruen RL, Jacobs IG, Reade MC (2013) study PA-T. Trauma and tranexamic acid. The Medical journal of Australia 199(5): 310– 311. 14. Hoffman M, Monroe A (2001) Cell-based Model of Hemostasis. Thromb Haemost 85: 958–965. 15. Tanaka KA, Esper S, Bolliger D (2013) Perioperative factor concentrate therapy. Br J Anaesth 111 Suppl 1: i35-49. 16. Holley AD, Reade MC (2013) The ‚procoagulopathy‘ of trauma: too much, too late? Curr Opin Crit Care 19(6): 578–586. 17. Morrison JJ, Dubose JJ, Rasmussen TE, et al. (2012) Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. ArchSurg 147(2): 113–119. 18. Ker K, Edwards P, Perel P, et al. (2012) Effect of tranexamic acid on surgical bleeding: systematic review and cumulative metaanalysis. BMJ 344: e3054. 3 · 2014 I Vol. 4 I AirRescue I 178

Medical Care

Fig. 1: The study was conducted with crew members during flight to investigate if the change of oxygen concentration has an influence on cerebral oxygenation (Rega)

Change in cerebral oxygenation during high altitude flights – First study conducted in non-simulated flights During high altitude flights, oxygen partial pressure drops to 76% of oxygen partial pressure at sea level and causes a drop of 3-4% in oxygen saturation. This study was conducted to evaluate the effect of changing oxygen concentration on cerebral oxygenation. Over the last years, around 1.5 billion passengers have been transported between the 30 largest airports of the world (1). Airports in Europe reported new record levels of passenger transport. Munich Airport, for example, recorded an increase of 13% in traffic over the first half of 2011 to hit 18 million passengers – the highest number the airport has ever handled (2).

In recent years, our knowledge of environmental conditions and mechanisms of physiological adaptation to high altitude has expanded. Hypoxia is one of the most important consequences of high altitude exposure (5). The aim of this study was to explore what 3 · 2014 I Vol. 4 I AirRescue I 179

happens with cerebral oxygenation saturation during high altitude flights. At sea level with a barometric pressure of 760 mmHg and air oxygen concentration of 21%, the arterial pressure of oxygen (PaO2) in a healthy individual is approx. 98 mmHg. As airplanes

Authors Ulrike Ehlers-Busse, MD Surgical Intensive Care University Hospital Zurich Rämistrasse 100 8091 Zurich Switzerland u.ehlers@bluewin.ch Michaela Paul, PhD Institute for Social and Preventive Medicine Division of Biostatistics University Zurich Hirschengraben 84 8001 Zurich Switzerland Olivier Seiler, MD Swiss Air-Ambulance, Rega PO Box 14148058 Zurich-Airport Switzerland Leonhard Held, PhD Institute for Social and Preventive Medicine Division of Biostatistics University Zurich Hirschengraben 84 8001 Zurich Switzerland

I 43 I

Medical Care

Fig. 2: During 10 high altitude flights, cerebal oxygenation measurements of 10 healthy male pilots were collected by Equanox™ NIRS technology (Rega)

ascend, cabin pressure is kept to a cabin altitude of 5,000 to 8,000 feet, depending on the route and type of aircraft. This corresponds to air oxygen concentrations at sea level of approx. 17.1% and 15.1%, respectively. During cruise cabin pressure is maintained at 8,000 feet and passenger oxygen saturation will drop to 90%, caused by a drop of PaO2 to approximately 55 mmHg (6). For each additional 1,000 feet, PO2

decreases approximately a further 5 mmHg (5, 7). As the tension around a PaO2 of 60 mmHg corresponds to the higher, flatter part of the oxyhemoglobin dissociation curve, the saturation decreases by only 3% to 4% compared to sea level and is not noticeable unless oxygen demand is increased by physical exercise (8). This study was conducted with crew members during flight to investigate if the change of oxygen concentration has an influence on cerebral oxygenation. We monitored regional cerebral oxygen saturation during 10 flights of 10 pilots of Swiss Air-Ambulance (Rega) between July 2011 and August 2012 with patented near-infrared spectroscopy (NIRS) technology of Nonin® (Equanox™), Model 7600® Monitor and Sensors. This technology measures the balance of oxygenated and deoxygenated hemoglobin (HbO2 and Hb) in the target tissue of this study – the brain (9). Measurement within cerebral blood vessels is possible because the skull is translucent to infrared light (10, 11). With Equanox™ sensors dual emitters alternately create pairs of reflected light paths through surface tissue to the shallow receiver and through the cerebral cortex to the far receiver (9). According to the guidelines of the manufacturer, it is a clear indication that a patient may be in a critical oxygen reserve condition and immediate intervention should be considered when rSO2 values are below 60% (12). Due to ethical

Fig. 3: Cabin pressure (sinosoidal approximation and measured values) for one of the pilots

ground level

difference

flight level 25 mins

25 mins

take-off

landing

time

landing

time

cabin pressure [mbar] 1000 950 900 850 800 25 mins take-off

I 44 I

25 mins

3 · 2014 I Vol. 4 I AirRescue I 180

Medical Care

flight level

difference

pilot

ground level

–8

–6

–4

–2

Estimates

aspects we did not want to examine invasive paO2 in crew members. Similar standard values seemed to apply in a study of Heringlake et al. (13). Here the rSO2 was 62% when patients were breathing room air with a median arterial oxygen saturation (SaO2) of 97%. With oxygen-enriched air the rSO2 was 66% with a SaO2 of 100%. The authors concluded that a rSO2 equal or below 50% is an independent predictor of short- and long-term mortality in patients undergoing on-pump cardiac surgery and might serve as a refined marker for perioperative risk stratification in cardiac surgery patients. Other studies concluded that a baseline rSO2 below 50% acts as pre-emptive marker for patients requiring more intensive monitoring and expectant care in the postoperative period (14, 15). Thus, NIRS is a technique that can be used as a non-invasive and continuous monitor of the balance between cerebral oxygen delivery and consumption, and sensitively indicates global cerebral hypoperfusion (16, 17, 18).

Methods During 10 high altitude flights, cerebal oxygenation measurements of 10 healthy male pilots were collected by Equanox™ NIRS technology. We have taken only male pilots, because Swiss Air Ambulance has only one female pilot. The use of her data would have preserved no anonymity. All pilots were piloting the aircraft. We made our measurements on the flight to the rescue location. The purpose of this study was to collect data from healthy persons, which may serve as a base for further investigations of ill persons during air travel. All pilots have given written informed consent to publish these case data anonymously. We also got ethical approval to publish our data by “kantonal ethic committee” Zurich, Switzerland (KEK-StV-Nr. 49/13). 3 · 2014 I Vol. 4 I AirRescue I 181

We continuously monitored rSO2 in 10 Rega crew members during flight, including take off, cruise and landing. After reaching maximum cruising altitudes, cabin altitudes ranged from 4,900 ft to 6,600 ft. This corresponds to a barometric pressure of 85 kPa (641 mmHg) with 84% of the oxygen available at sea level and a barometric pressure of 80 kPa (604 mmHg) with 79% of the oxygen available at sea level respectively. There were no significant turbulences during these flights. Using the commercially available Equanox™, Model 7600® monitor, rSO2 was measured. Sensors were taped on the forehead before take-off and removed after landing. Equanox™ measures the concentration changes of oxyhemoglobin and deoxyhemoglobin. As in the application of pulse oxymetry to measure systemic arterial oxygen saturation, the development of cerebral oxymetry monitoring is based on the different absorption characteristics of near-infrared spectrum (NIRS): oxygenated hemoglobin absorbs less red light (600-750 nm) and more infrared light (8501000 nm) than deoxygenated hemoglobin does. As a result, hemoglobin has an absorption peak at 740 nm while oxygenated hemoglobin does not (19, 20). Measurements were recorded every 4 seconds from 5 minutes before take-off until 5 minutes after landing. All flights took more than one hour. Depending on the length of the flight, this resulted in 975 to 6,000 measurements per pilot. Cabin pressure has been approximated using a sinusoidal form depending on start and landing time (see Fig. 3). This form correlates very well with the actual cabin pressure, which was available for three flights (correlation between 0.95 and 0.99). The rSO2 ground and flight levels have been estimated using this sinusoidal form. To account for temporal correlation of the rSO2 measurements, time series methods have been used (21). Specifically, Autoregressive-Moving

Fig. 4: Ground level, flight level and difference between the two with 95% confidence interval for each pilot

I 45 I

Medical Care

flight level

p = 0.94

p = 0.04

–6

–5

–4

–3

–2

80 70 60

parameter estimates

–1

p = 0.02

difference

ground level

age

Fig. 5: Regression analysis of ground level, flight level and difference between the two, versus age of the pilot

Average – ARMA – (p, q) models have been fitted to the residuals separately for each time series, where the order (p, q) has been selected based on the Bayesian information criterion (BIC). Appropriateness of the selected model has been checked by inspection of residual autocorrelation functions. The rSO2 ground and flight levels are reported with 95% confidence intervals taking into account the estimated correlation. Significance of the difference between ground and flight rSO2 levels has been assessed based on a type I error rate of 5% using two-sided P-values obtained from the ARMA models. Adjustments for multiplicity have been made using Bonferroni-Holm (22) corrections. Linear regression analysis has been made to investigate a possible association between age of the pilot and rSO2 ground and flight levels. All analysis were done using R (23) using the package forecast (24) to fit ARMA models.

Results Ten male pilots of Rega were monitored during separate flights on board a Challenger CL604 between July 2011 and August 2012. They were between 28 and 53 years old, had a BMI between 22 and 30 and were all ex- or non-smokers. All pilots were in good clinical condition without serious illnesses and did not use any medication. All flights lasted more than one hour with a maximum of 6.6 hours. For all 10-time series, the residual autocorrelations were smaller than 0.1 in absolute value, confirming the appropriateness of the selected ARMA models. The rSO2 ground level (95% confidence interval in brackets) varied between 56.5% (55.4 to 57.7) and 82.8% (81.9 to 83.6) among the 10 pilots (see Fig. 4 for details). The rSO2 flight level (95% confidence interval in brackets) varied between 54.4% (53.6 to 55.2) and 82.4% (81.8 to 83.0). The I 46 I

drop in rSO2 level, i.e. the difference between ground and flight level values, was between 0.3 and 5.3 percentage points and significant for 7 pilots without and 6 pilots after multiplicity corrections. There was evidence that both ground (p=0.02) and flight level (p=0.04) rSO2 decrease with increasing age of the pilot. But there was no evidence that the difference between ground and flight level rSO2 depends on age (p=0.94), see Fig. 5. The regression analysis predicts a drop of rSO2 ground levels of 0.64 percentage points for each additional year of age of the pilot (0.63 for flight levels).

Discussion The results of this study reaffirm several data of other authors, who demonstrated that oxygen concentration declines due to exposure to higher altitudes (25, 26, 27). But most authors, who examined subjects under hypoxic conditions, simulated high altitudes with hypobaric chambers (6, 28, 29). Only one author described cerebral oxygen saturation monitoring during real flights (30). However, these measurements have been conducted with three fighter pilots under special conditions in fighter jets and took only about one hour. Thus our study is one of the first, in which the measurements have been taken during non-simulated flights and to our best knowledge it is the first study conducted in non-simulated flights, in which rSO2 has been measured over several hours. Even if the number of subjects is low, this study clearly indicates that healthy persons can have a decline of rSO2 to a range, which is declared as nearly pathological (12, 13), even in flights that have not yet reached the maximum cabin altitude of approximately 8,000 feet. Muhm’s study showed a decrease of mean oxygen saturation with increasing altitude, but clinical mani3 · 2014 I Vol. 4 I AirRescue I 182

Medical Care

festations became apparent after 3 to 9 hours (31). As the type of aircraft operated by Rega is a Challenger CL604, refuelling is necessary about every six to seven hours. The influence of longer exposures to hypoxia could therefore not be studied. Another point of interest would have been how other parameters change during high altitude flight and if there is a correlation (in particular with regard to circulation). However, it was not possible to monitor the circulation of crew members continuously. Intermittent measurements were stable and inconspicuous. All pilots have felt fine. So even if some of them had rSO2 in a pathological range, is it relevant? But if pathological rSO2-values already exist in healthy crew personnel, the question of the effects on cardiopulmonary unstable patients or patients with head trauma or cerebrovascular ischemia arises. This should be examined in further studies.

Summary A considerable variation in ground and inflight regional cerebral oxygen saturation (rSO2) levels (54.4% to 82.4%) between pilots was found. A drop from ground to flight level of 0.3 to 5.3 percentage points was noted and considered to be significant in 6 out of 10 pilots. Ground and flight levels of regional cerebral oxygen saturation significantly decreased with progressing age of the pilots. Using NIRS, reliable data can be collected regarding regional cerebral oxygen saturation. This study is one of the first to demonstrate a decline in regional cerebral oxygen saturation due to exposure to higher altitudes in aircraft. It is the first study monitoring regional cerebral oxygen saturation during real flights with a duration exceeding one hour. We have shown that healthy subjects can show a drop in rSO2 to an almost pathological range without any discomfort during high altitude flights. Patients with respiratory, cerebral or cardiac limitations may benefit from oxygen supplementation. 

References: 1. Airports Council International (2011) Passenger Traffic 2010 Final. www.aci.aero (accessed: 20 May 2014). 2. Airport World (2011) European Airports Break Records. www. airport-world.com (accessed: 20 May 2014). 3. Coker RK, Partridge MR (2000) Assessing the risk of hypoxia in flight: the need for more rational guidelines. Eur Respir J 15: 128130. 4. Delaune EF, Lucas RH, Illig P (2003) In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med: 74/1: 62-68. 5. Mortazavi A, Eisenberg M, Lengleben D, et al. (2003) AltitudeRelated Hypoxia: Risk Assessment and Management for Passengers on Commercial Aircraft. ASMA 74/9: 922-927. 6. Dine CJ, Kreider ME (2008) Hypoxia Altitude Simulation Test. CHEST 133: 1002-1005. 3 · 2014 I Vol. 4 I AirRescue I 183

7. Stoller JK (2000) Oxygen and Air Travel. Respir Care 45/2: 214221. 8. Skjenna OW, Evans JF, Moore M-S, et al. (1991) Helping patients travel by air. Can Med Assoc J 144/3: 287-293. 9. Nonin® (2009) Regional Oximetry Technology. www.noninequanox.com (accessed: 20 May 2014). 10. Edmonds HL, Ganzel BL, Austin EH (2004) Cerebral oximetry for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth 8: 147-166. 11. Murkin JM, Arango M (2009) Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br J Anaesth 103/1: i3-i13. 12. Nonin® (2011) www.noninequanox.com (accessed 20 May 2014). 13. Heringlake M, Garbers C, Käbler J-H, et al. (2011) Preoperative Cerebral Oxygen Saturation and Clinical Outcomes in Cardiac Surgery. Anesthesiology 114: 58-69. 14. Murkin JM (2011) Cerebral Oxymetry – Monitoring the Brain as the Index Organ. Anesthesiology: 114/1: 12-13. 15. Slater JP, Guarino T, Stack J, et al. (2009) Cerebral Oxygen Desaturation Predicts Cognitive Decline and Longer Hospital Stay After Cardiac Surgery. Ann Thorac Surg: 87/1: 36-45. 16. Denault A, Deschamps A, Murkin M (2007) A Proposed Algorithm for the Intraoperative Use of Cerebral Near-Infrared Spectroscopy. Seminars in Cardiothoracic and Vascular Anesthesia 11/4: 274281. 17. Fischer GW (2008) Recent Advances in Application of Cerebral Oximetry in Adult Cardiovascular Surgery. Seminars in Cardiothoracic and Vascular Anesthesia 12/1: 60-69. 18. Nemoto EM, Yonas H, Kassam A (2000) Clinical experience with oximetry in stroke and cardiac arrest. Crit Care Med 28/4: 10521054. 19. Casati A, Spreafico E, Putzu M,et al. (2006) New technology for noninvasive brain monitoring: continous cerebral oximetry. Min Anestosiol 72: 605-617. 20. Koike A, Itoh H, Oohara R, et al. (2004) Cerebral Oxygenation During Exercise in Cardiac Patients. Chest 125: 182-190. 21. Diggle PJ (1990) Time Series. A Biostatistical Introduction. Oxford University Press. 22. Holm S (1979) A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics 1979/6: 65-70. 23. R Development Core Team (2012). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria: www.R-project.org (ISBN 3-90005107-0). 24. Hyndman, RJ and Razbash S (2011) forecast: Forecasting functions for time series. R package version 3.16. URL http://CRAN.Rproject.org/package=forecast. 25. Aldrete JA, Aldrete LE (1983) Oxygen Concentrations in Commercial Aircraft Flights. South Med J 76/1: 12-14. 26. AMA Commission on Emergency Medical Services (1982) Medical Aspects of Transportation Aboard Commercial Aircraft (1982) JAMA 247/7: 1007-1012. 27. Cottrell JJ (1988) Altitude Exposures during Aircraft Flight: Flying Higher. CHEST: 81-84. 28. Dillard TA, Berg BW, Rajagopal KR, et al. (1989) Hypoxemia during Air Travel in Patients with Chronic Obstructive Pulmonary Disease. Ann Intern Med 111: 362-367. 29. Christensen CC, Ryg M, Refvem OK, et al. (2000) Development of severe hypoxaemia in chronic obstructive pulmonary disease patients at 2438 m (8000 ft) altitude. Eur Respir J 15: 635-639. 30. Kobayashi A, Miyamoto Y (2000) In-Flight Cerebral Oxygen Status: Continous Monitoring by Near-Infrared Spectroscopy. ASMA 71/2: 177-183. 31. Muhm JM, Rock PB, McMullin D, et al. (2007) Effect of AircraftCabin Altitude on Passengers Discomfort. N Engl J Med: 357/1:18-27.

I 47 I

CRASHES

“Air Ambulance 02” crash: BFU interim investigation report Following the crash of “Air Ambulance 02” on 28 February 2014 over the Baltic Sea, an interim report has now been published by the German Federal Bureau of Aircraft Accident Investigation (Bundesstelle für Flugunfalluntersuchung, BFU) This report ruled out a technical defect, instead coming to the conclusion that most probably human error was to blame for the accident that left three people dead. According to the report, the DRF Luftrettung’s BK117 C-1-type helicopter rapidly lost height, which went unnoticed by the crew, collided with the surface of the water on approach to the “Theo Fischer” lifeboat and sank. The multiple approaches were part of a joint winch training session between the German Maritime Search and Rescue Service’s (DGzRS) lifeboat and helicopter crews. The four-man crew of the DRF Luftrettung helicopter agreed the exercise with the crew of the rescue lifeboat in advance. The pilot, emergency doctor and winch operator (HHO-CM) died in the crash. The copilot survived the accident.

Fig. 1: The BFU report ruled out a technical defect, instead coming to the conclusion that most probably human error was to blame for the accident that left three people dead (DRF Luftrettung)

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

I 48 I

The BFU investigation report describes the way in which the accident unfolded in a great degree of detail: after completing the winch manoeuvre, the crew discussed the exercise they had just completed during the flight, the Pilot In Command (PIC) steered the helicopter to the left and asked the HHO-CM for the position of the vessel. However, the HHO-CM had lost sight of the vessel during the discussion about the winch manoeuvre. A further attempt was then made to turn to the left and re-establish visual contact with the lifeboat. “Once the lifeboat’s position had been identified by the copilot (COP) and the HHO-CM, the PIC started the approach flight to the vessel despite it not being in sight. The PIC turned to the left and reduced the altitude to approximately 150 feet height above mean sea level (AMSL). When visual contact was re-established with the liefboat, the helicopter had ascended to 500 feet again unnoticed. Since the pilot then felt that this was too high, he aborted the approach and started a new approach by circling left.

The HHO-CM then communicated the position of the vessel as being left of the helicopter using the clock face. The report also states: “in the downwind approach, the helicopter was at an altitude of approximately 500 feet AMSL. The copilot informed the PIC that he should not fly so far out and should turn 15 degrees to the left. The HHO-CM then reported the vessel was at a right angle to the helicopter and the copilot informed the PIC that he could now turn.” Approximately 20 seconds before the accident, the COP said to the PIC: “slower and we have to descend”. Approximately twelve seconds before the submersion the PIC indicated the course as “170” and the COP responded: “turn now”. The PIC then gave the course as “150” and at the same time the signal for the radio height detector sounded: “decision height”. The COP confirmed “150” four seconds before the accident, and the PIC in turn reported “100” three seconds before the submersion. The final voice recording was of the HHO-CM shouting “ey, ey, ey”. The helicopter then hit the surface of the water at approximately 6.37 p.m. The lifeboat crew had watched the approach and believed that the helicopter was turning in the direction of the lifeboat from a distance of approximately one nautical mile (NM) and rapidly lost height before making contact with the water.

Multi-use helicopter BK117 C-1 The helicopter that crashed, a twin-engined BK117 C-1, is a multi-use helicopter for up to 8 (11) passengers. It has two engines (Turbomeca Arriel 1E2), a hingeless four-blade rotor, a cell constructed as a half shell and a skid landing gear. The helicopter model 3 · 2014 I Vol. 4 I AirRescue I 184

CRASHES

was authorised in 1992 in accordance with FAR 29. The minimum occupancy is one pilot in the right hand seat of the cockpit. The optional winch is on the left hand side of the fuselage. The winch must be swivelled out on one arm to increase or decrease the wind load on the skid. According to information from the Federal Bureau, the helicopter in question, built in 2002, was authorised for use by the Federal Aviation Office. “The dry operating mass was approximately 2,336 kg, the take-off mass on the day of the accident with approximately 470 kg of fuel, four people on board and the additional equipment was approximately 3,335 kg. The last Airworthiness Review Certificate (ARC) was issued on 29 August 2013. At the point of the accident, the helicopter had a total operating time of approximately 2,954 hours.” The helicopter was also equipped for HEMS in the offshore area. As well as the additional medical equipment, it also had an autopilot system, a radar height detector with an acoustic warning, weather radar, a collision avoidance system (TCAS), a Health and Usage Monitoring System (HUMS) and a rescue winch. An emergency floatation device was installed on the skid landing gear. On board there was also a life raft for up to six people, a one-man rescue boat and an emergency local transmitter (ELT).

Experienced crew The 53-year-old pilot who was responsible for the helicopter travelled to the air rescue base on 22 Febru-

3 · 2014 I Vol. 4 I AirRescue I 185

ary 2014 for seven days of on-call duty. The accident occurred on the last working day before a planned holiday. The BFU report gives the total flying experience as approximately 7,000 hours. In total, he had approximately 236 hours of night flying experience and approximately 215 hours of instrument flight experience. He was authorised to fly the BK117 and EC135/635 models. He was also licensed for flights in accordance with instrument flight rules. He was also a qualified TRI instructor for the BK117 and EC136/635 models. The 47-year-old copilot, who survived the crash, is also authorised to fly the BK117 model as a pilot and licensed for flights in accordance with instrument flight rules. He was also a qualified TRI instructor for the BK117 model and was authorised to train private and professional pilots and instruct night flight training. He is also a recognised examiner (TRE) by the Federal Aviation Office for the model authorisations AS350/350B3 and HU269. The document indicates total flying experience of approximately 9,500 hours, and in total since he started flying in 1982 he has approximately 434 hours of night flight experience and approximately 107 hours of instrument flight experience. The co-pilot travelled to the base on 23 February for seven days of on-call duty. All of the crew members – the two pilots, the 45-year-old paramedic who was also on board as the winch operator and the 47-year-old emergency doctor – had completed the company’s internal basic training for offshore flights and winch manoeuvres and sea survival training. [With Material from BFU.] 

Fig. 2: The aircraft that crashed was a twinengined BK117 C-1, a multi-use helicopter with a winch (DRF Luftrettung)

I 49 I

RULES AND REGULATIONS

Fig. 1: Since there was a drive for a high safety standard for HEMS ops, the decision was taken to look at the set of requirements for CAT and determine in which areas adaptations were considered necessary (T. Bader)

Future HEMS operations – legal frameworks The overall aim of aviation regulations is to permit the widest spectrum of operations with the minimum risk. In general, these regulations can be divided into three groups: those providing protection to third parties (persons and property on the ground), those providing protection to passengers (both “farepaying”, including patients, as well as “non-fare-paying” passengers) and lastly to crew members. In Europe, this aim is embedded as objectives in the Regulation establishing EASA, the European Aviation Safety Agency (1).

The principal objective of the Regulation (EC) No 216/2008 is to establish and maintain a high uniform level of civil aviation safety in Europe. Additional objectives in the areas covered by this regulation are as follows:

Author Bas van der Weide Standardisation Team Leader European Aviation Safety Agency (EASA) Approvals and Standardisation Directorate Standardisation Department – Air Operations Section

I 50 I

• To ensure a high uniform level of environmental protection; • To facilitate the free movement of goods, persons and services; • To promote cost-efficiency in the regulatory and certification processes and to avoid duplication at national and European level; • To assist Member States in fulfilling their obligations under the Chicago Convention by providing a basis for a common interpretation

and uniform implementation of its provisions, and by ensuring that its provisions are duly taken into account in this Regulation and in the rules drawn up for its implementation; • To promote community views regarding civil aviation safety standards and rules throughout the world by establishing appropriate cooperation with third countries and international organisations; • To provide a level playing field for all actors in the internal aviation market. In the 1980s and early 1990s, Europe experienced some helicopter incidents and accidents in the HEMS community. Therefore, a need arose to regulate those types of operations. At that time, the Joint Aviation 3 · 2014 I Vol. 4 I AirRescue I 186

RULES AND REGULATIONS

Authorities (JAA) was founded and a common set of requirements for Commercial Air Transport (CAT) had just been drafted. Because there was a drive for a high safety standard for HEMS operations, the decision was taken to look at the set of requirements for CAT and determine where adaptations were considered necessary to fit the HEMS operations. This would also avoid duplication of efforts and HEMS requirements could be developed in a relatively short timeframe. A solution was found in addressing all those variations to the CAT requirements in a separate Appendix. A specific approval then ensured that the required mitigations were checked by the authority and put in place by the operator before HEMS operations were commenced. In simple terms, there are three areas in HEMS operations where risks (beyond that allowed in CAT) are identified and accepted, due to the fact that these operations are conducted in the public interest. Some examples of those variations are: 1. The en-route phase of flight – alleviation is given for height and visibility rules (operating minima) 2. Operations to/from elevated hospital sites (in congested hostile environment) – alleviation is given from performance requirements 3. Operations to/from accident site (the primary pick-up sites for patients) – alleviation is given from performance requirements, and contrary to “normal” CAT operations, this is also allowed at night. However, mitigation is required in all those cases, which make multi-crew operations (two pilots or one pilot and a HEMS technical crew member) and additional specialist training necessary (such as instrument training in order to compensate for the increased risk of inadvertent entry into cloud). In addition, HEMS crews and medical personnel carried as passengers are also expected to operate in accordance with good crew resource management (CRM) principles. Furthermore, aviation risks should be proportionate to the task. Therefore, the following specific policy was implemented (analogous to road transport):

This policy was not intended to contradict/complement medical terminology, but it was considered that none of the risk elements of HEMS should be existent and therefore, none of the additional requirements of HEMS need to be applied. In regulatory terms, air ambulance is considered to be a normal transport task, where the risk is no higher than for “normal” CAT operations. It is for the medical professional to decide between HEMS or air ambulance – not for the pilot. For that reason, medical staff that carry out aeromedical operations should be fully aware of the additional risks, which are potentially present under HEMS operations (and the pre-requisite for the operator to hold a HEMS approval). For example in some countries, hospitals have principal and alternative sites. The patient may be landed at the safer alternative site (usually in the grounds of the hospital) thus, eliminating risk – against the small inconvenience of a short ambulance transfer from the landing site to the hospital. Once the decision between HEMS or air ambulance has been taken by the medical professional, the pilot-in-command makes an operational judgement regarding how to conduct the flight. Simplistically, the above type of air ambulance operations could be conducted by any operator holding an Air Operator Certificate (HEMS operators are required to hold an AOC) – and usually are when the carriage of medical supplies (equipment, blood, organs, drugs etc.) is undertaken as a planned activity (air ambulance), rather than responding to an accident (HEMS). Lastly, risks should be inversely proportional to the use of the site, i.e. the higher the utilisation, the lower the risk that is considered acceptable. In this regard, there are three different classifications of operating sites:

Fig. 2: HCM medical that carry out aeromedical operations should be fully aware of the additional risks that are potentially present under HEMS ops – and the pre-requisite for the operator to hold a HEMS approval (T. Bader)

1. If called to an emergency, a ground ambulance would proceed at great speed, sounding its siren and proceeding while ignoring traffic lights – thus matching the risk of operation to the risk of a potential death (= HEMS operations); 2. In case of patient transfer, where life and death is not an issue: the journey would be conducted without sirens and within normal rules of motoring – once again matching the risk to the task (= air ambulance operations). 3 · 2014 I Vol. 4 I AirRescue I 187

I 51 I

RULES AND REGULATIONS

1. HEMS operating base from which all operations will start and finish: There is a high probability of a large number of take-offs and landings at this HEMS operating base and for that reason, no alleviation from operating procedures or performance requirements are allowed. 2. HEMS operating site: Because this is the primary pick-up site related to an incident or accident, its use can never be pre-planned and therefore attracts alleviations from operating procedures and performance requirements, when appropriate.

Fig. 3: The number of take-offs and landings from hospital sites depends on their location and facilities (T. Bader)

Fig. 4: The pilot is responsible and decides on operational safety aspects, i.e. how to conduct the flight, based on the urgency determined by the medical staff (ADAC Luftrettung)

I 52 I

3. The hospital site: Is usually at ground level in hospital grounds or, if elevated, on a hospital building. It may have been established during a period when performance criteria were not a consideration. The amount of use of such sites depends on their location and their facilities; normally, it will be greater than that of the HEMS operating site, but less than for a HEMS operating base. Such sites therefore attract some alleviation. However, during implementation of the original HEMS requirements in the late 1990s, a number of states had encountered problems with the impact of performance rules in the case of EMS helicopter operations. Although states accepted that progress should be made towards operations, where risks associated with a critical engine failure are eliminated or limited by the exposure time concept, it is still not possible to carry out operations in performance classes 1 or 2 at a number of landing sites. This resulted in creating an alleviation in the performance requirements for those hospital sites that were not used as an operating base, which were located in a congested hostile environment, firstly on the hospital grounds or secondly on hospital buildings. This alleviation is referred to as the Public Interest Site approval, as otherwise it would seriously curtail a number of existing operations. However, the requirements also assumed that the approval would only be given by member states subject to a site-improvement programme, where such improvement would be feasible. At the same time, it is not very well understood, for those that have no aviation background, that helicopter performance is strongly dependent on environmental conditions, especially air pressure. Bad weather is generally understood as a reason not to fly (e.g. thunderstorms and mist/fog), whereas good weather (e.g. a nice summer day with temperatures above 20°C) may also be a reason not to fly (although it is generally not perceived as risky), as it is putting a severe penalty on the operating masses of helicopters. In some cases, an increase in temperature from 21° to 31°C can lead to a mass penalty of around 150 kg to remain within the certified performance limitations. In general terms, we speak of degraded performance under “hot and high” conditions (i.e. low air pressure, due to high temperatures or high altitudes or a combination of both), which are manifesting itself in reduced operating masses during higher temperature or at higher altitudes. The aforementioned drive to improve helicopter performance by using more appropriate helicopters (capable of meeting the required performance criteria) and by improving operating sites, is often being jeopardised by recent technological advancements, 3 · 2014 I Vol. 4 I AirRescue I 188

RULES AND REGULATIONS

as they translate in more modern equipment being carried on board assisting the pilot (e.g. additional equipment for navigation, obstacle avoidance as well as changing from analogue instruments to a fully digital system – the glass cockpit), but also the medical crew (e.g. more advanced monitors, pumps, etc.) in fulfilling their tasks. Such additional equipment goes hand in hand with extra batteries to mitigate the risk of electrical failures. In some extreme cases this amounts to an increased operating mass of around 500 kg. This technological advancement is progressing much faster than the development of new helicopter types or the upgrading of their performance. It is therefore no longer only a matter for the aviation regulator to come up with a solution. We are currently approaching a level, where all possibilities in the aviation requirements have been explored. It requires the coordinated approach and understanding of all those involved in the provision of HEMS operations, and to act in accordance with their responsibilities. In order to improve the obstacle environment around hospitals, not only the hospital management, but also local government bodies (in particular those responsible for planning urban development) are to ensure that such obstacle free areas are being maintained, especially when issuing building permits in those areas below the predominant approach and departure directions. Health care providers, when tendering out contracts, should also take into account the current helicopter performance capabilities, especially with regard to all weather and “hot and high” conditions (in terms of equipment, medical staff and minimum fuel loads to be carried). This will ensure that bids from operators will be more realistic, and do not merely reflect helicopter performance under the most favourable conditions. Right now, those bids often meet the expectation of the tender, knowing that in fact in a majority of circumstances the operation cannot be conducted within the legal framework. Looking into the future, there are also other challenges to overcome in order to expand HEMS operations and services. Technological advancements do not only have a negative impact as illustrated above. They also provide improvements in the HEMS environment we should embrace. The increase in the use of NVIS to assist in safety enhancements – when it comes to providing HEMS services at night – is one major example. Currently both, operations and technology, are predominantly based on the presumption of visual operations under Visual Meteorological Conditions (VMC) and Visual Flight Rules (VFR) and in this area, technology that may assist in expanding the capabilities in all-weather operations is emerging. 3 · 2014 I Vol. 4 I AirRescue I 189

Evolving technology in relation to satellite-based navigation may make helicopter operations less dependent on ground-based equipment. Historically, airspace infrastructure also does not cater for low-level all-weather operations, other than to established airfields, and therefore Air Traffic Services are not well established for those lower altitudes. Typically HEMS operations are conducted in unclassified airspace, i.e. where no Air Traffic Services are provided at all. Technological advancements can also make a difference in terms of solutions now coming into sight, whereas several years ago, such solutions were not considered feasible at all. In this respect, we still have a long way to go. 

Fig. 5: HEMS crews and medical personnel are also expected to operate in accordance with good CRM principles (T. Bader)

References: 1. Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February 2008 on common rules in the field of civil aviation and establishing a European Aviation Safety Agency, and repealing Council Directive 91/670/EEC, Regulation (EC) No 1592/2002 and Directive 2004/36/EC. 2. “Hostile environment” is defined as an environment in which: • A safe forced landing cannot be accomplished because the surface is inadequate; • The helicopter occupants cannot be adequately protected from the elements; • Search and rescue response/capability is not provided consistent with anticipated exposure; or • There is an unacceptable risk of endangering persons or property on the ground. In any case, the following areas are labelled as “hostile”: • overwater operations, the open sea areas north of 45N and south of 45S designated by the authority of the State concerned; • those parts of a congested area without adequate safe forced landing areas.

I 53 I

Regulations

Fig. 1: Beach King Air B200 operated by Lufttransport AS, part of National Air Ambulance Services of Norway (Lufttransport AS)

European standards – benefits & challenges Standards are practical and suitable tools for setting quality levels in medical equipment and HEMS as well as air ambulance operations. Safe operations and safety in treatment of patients and for the air ambulance crews are essential. Standards are setting guidelines for how to reach a level of quality and get a basis for quality assessment. In contrast to directives, national law and requirements, standards are, as defined by the European Committee for Standardization (CEN), merely a tool “that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context”.

What is a standard?

Author: Per Kristian Andersen Senior Adviser, RN Norwegian Directorate of Health Convener of CEN TC 239, Rescue systems working groups for Road and Air ambulances and their equipment

I 54 I

Standards have been used over years. They are important tools for quality enhancement and assessment of health care services. Standards are used and understood differently due to tradition, education, training and experience. A certain standard of quality can be expressed in requirements in directives, national laws and regulations, as in JAR/FAR/EASA – requirements. CEN – European Standardization Organizations and ISO – International Standardization Organizations are making standards for a wide range of equipment, services and processes in various industries. In addition, there are national standards (National Standardization Bodies) and business sector or industry

standards. Operational handbooks and procedures are detailed documents to point out “the way we do it here”. It is important to know the different status of the different types of normative documents. Directives, national law and requirements are strong regulatory documents to be strictly followed, while standards are a tool “that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context” (Definition by CEN). It is vital to realize that standards are established by consensus between relevant stakeholders within a professional area or industry and approved by a recognized body (National Standardization Bodies). 3 · 2014 I Vol. 4 I AirRescue I 190

Regulations

How to participate If you are interested in taking part in the standardization work, contact your National Standardization Organization (NSO) for advice. The NSO will provide you with more information on standards in your field of work. More about standardization can also be found at www.cencenelec.eu

How are standards made? Participation in a standardization process is voluntary. Every interested stakeholder can be a part of the process. Normally a potential new standard is proposed by stakeholders in a member country to the relevant National Standardization Organization (NSO). Related to CEN, every EU/EEC country’s NSO is part of the CEN-organization. Proposals are distributed through the NSOs and voted for by all member organizations. If the work item is accepted, the task is given as a Work Item to a Technical Committee (TC) and normally worked out in details in a TC working group. Representatives in working groups under CEN TC 239 Rescue Systems dealing with air ambulances are manufacturers, operators, medical personnel, medical engineers and representatives from governmental bodies. After finishing a standard proposal, there is an enquiry period and voting process within CEN, in which the NSO is an important element.

Relevant standards for air ambulances Three types of normative documents regulate the main parts of air ambulance operations. First of all, there are the JAR/FAR/EASA-requirements which regulate the aircraft, airworthiness and operations. The operational manuals are detailed descriptions of the way to do operations, and finally there is a set of standards and guidelines giving advice on how to reach an expected level of quality for the medical part of the service. When setting requirements for the aircraft as an ambulance, it is important to have a distinct separation between the JAR/FAR/EASA-requirements and the standards for the aircraft as an ambulance and its equipment. When setting requirements for the latter, it is important that these do not collide with the JAR/ FAR/EASA-requirements. Presently, CEN TC 239 has worked out the following standards for use in Rescue Services: • EN 1789: medical vehicles and their equipment – road ambulances; • EN 1865: stretchers and other patient handling equipment (5 parts); 3 · 2014 I Vol. 4 I AirRescue I 191

• EN 13718: medical vehicles and their equipment – air ambulances – part 1: medical device interface requirements; • EN 13718: medical vehicles and their equipment – air ambulances – part 2: operational and technical requirements of air ambulances; • EN 13976: transportation of incubators – part 1: interface conditions and • EN 13976/AC 2004: rescue systems – Transportation of incubators – part 2: system requirements. Additionally, there is a wide range of standards related to medical devices in order to guide manufacturers and end users of how to comply with the requirements in the Medical Device Directive 93/42 EEC. A very important new standard, recently adopted is: IEC/FDIS 60601-1-12 Medical Electrical Equipment – part 1-12: General requirements for basic safety and essential performance – requirements for medical electrical equipment and medical electrical systems used in the emergency medical services environment. Most of the medical devices used in the emergency medical services environment to this date are not intended for use outside hospitals. It can cause problems when these devices are used in a rough emergency environment. This new standard sets criteria related for the use under such conditions (such as vibration, bumps, ingress of water and other important elements). Such requirements have been set in EN 13718 part 1, but the new particular standard will have better impact on manufacturers. EN 13718 part 1 has been revised according to this new standard and has been accepted in Final Vote. EN 13718-2:2008 part 2: operational and technical requirements of air ambulances have been technically revised. The following points represent the most important changes in the revision:

Fig. 2: The standardization process

Preliminary stage (Preliminary work item)

Implementation (National standard)

Proposal stage (NWIP)

Publication stage (European standard)

Preparatory stage (Working draft)

Approval stage (Final draft)

Committee stage (Committee draft)

Enquiry stage (Enquiry draft)

I 55 I

Regulations

Fig. 3: EC135 of Norwegian Air Ambulance AS, the most common EMS helicopter in Norway (Norwegian Air Ambulance)

Fig. 4: Air ambulance standards are made for air ambulances in general and they have elements for both, fixed and rotor wing aircraft as well as dividing into HEMS operations/primary missions and secondary air ambulance transports with rotor and fixed wing aircraft (Norwegian Air Ambulance)

I 56 I

• Clarification of previously unclear issues in this part of the standard and between the two parts of the standard (for example requirements for patient’s compartment illumination); • Changed text dealing with enhancement of safety related to the risk from helicopter rotors; • Clarified the requirements for the patient treatment area/cabin. The revision of this standard has been a difficult task. The difficulty has been focused on requirements for the patient treatment area. In the 2008 version the design of the patient compartment is described. In the revised version that will be out on Final Vote this autumn, the compartment as such is no longer important. The purpose is to have a patient treatment area with space enough to treat the patient according to internationally accepted medical guidelines. One manufacturer of a helicopter not complying with the generally accepted requirements has filed a complaint through the respective national body. The complaint

has been treated within the CEN regulations and a common proposal was worked out as a proposed solution to the CEN Technical Board. They have accepted the proposal and part 2 is now ready for Final Vote. The air ambulance standards are made for air ambulances in general and they have elements for both, fixed wing (FW) and rotor wing (RW) aircraft as well as dividing into HEMS operations/primary missions and secondary air ambulance transports with RW and FW aircraft. The requirements are based on how to have enough space for patient and medical personnel and how to design an environment where it is possible to perform monitoring and treatment according to international medical guidelines. This has been a great challenge in the last revision because one manufacturer has a specific helicopter type without enough space to fulfil the space requirements. This has created a lot of discussion about alternative ways to perform medical procedures. It would have been an advantage if manufacturers would accept the guidelines given from the medical profession and designed the aircrafts accordingly or put the energy into an alternative type from an excellent range of helicopters. The manufacturer and NSO have filed a complaint about the process to CEN. The complaint has been sorted out, and EN 13718 part 2 is now ready for Final Vote.

Standardization benefits We should come back to the question “what is a standard?” Standards are all around us, even though we are not always aware of them. One example of a widely-used standard is the A4 size for sheets of paper. A standard is a document that sets out requirements for a specific item, material, component, system or service, or describes in detail a particular method or procedure. Standards facilitate international trade by ensuring compatibility and interoperability of components, products and services. They bring benefits to businesses and consumers in terms of reducing costs, enhancing performance and improving safety. Standards are developed and defined through a process of sharing knowledge and building consensus among technical experts nominated by interested parties and other stakeholders – including businesses, consumers and environmental groups, among others. The formal definition of a standard is a “document, established by consensus and approved by a recognized body, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context”. Standards are voluntary, which means that there is no 3 · 2014 I Vol. 4 I AirRescue I 192

Regulations

automatic legal obligation to apply them. However, regulations may refer to standards and even make compliance to them compulsory.

Standards in (H)EMS In emergency services standards enhance safety, interfaces and interoperability and a safe use of medical devices. In the case of vehicles and aircraft it is important to have a certain quality related to electromagnetic interference in order to ensure that the electromedical devices do not interfere with the systems in the vehicle or craft and that the vehicle or craft does not interfere with the medical device so functions or readings on monitors are disturbed. Medical devices shall work according to the intended use and shall be safe to use for patients and personnel. The term “intended use” is important to describe what and in which environment the manufacturer has designed the medical device for. If products are used differently, not congruent with their intentions, it is not necessarily safe to use for neither patients nor personnel. Safe use of medical devices in aircraft focuses on specific and environmental conditions and performance, mainly for electrical power driven medical devices. Attention is also given to gas supply and fixation of medical devices in air ambulances.

Challenges in the use of standards The use of standards is voluntary. Within six months after being accepted on Final Vote, the (CEN) standard shall be implemented as national standard in countries within CEN. In spite of this, the standard does not have to be used. When stating this, it is important to mention that a standard is an easy way to bring state-of-the art quality into the service. Without the use of a standard you will always have to consider the level of safety and quality you need and perform risk assessments yourself. That might be an expensive and time-consuming task – even if you have the knowledge. The voluntary use of standards can be looked at as a disadvantage from some, but in real life the overall practice is to use a standard if it is known and applicable. Knowledge about the existence of standards is a challenge in itself. When setting up a service or designing or searching for products to use, it is important to search for relevant standards. Use the information provided by your National Standardization Organization. The time it takes to develop a standard can be long, especially when it is done for the first time. Members of working groups find themselves in long discussions influenced by different educational backgrounds, culture and common practice in different 3 · 2014 I Vol. 4 I AirRescue I 193

Fig. 5: Medical devices shall work according to the intended use and shall be safe to use for patients and personnel (Norwegian Air Ambulance)

countries. This is not necessarily problematic, but it takes some time to get through it and to create a common platform for the discussions to come. Many elements are solved using standards, but we still have challenges to work on. As an example, we still lack important interface elements, i.e. connectors for electricity, standardized connectors for test probes and one common stretcher fixation system. This is partly caused by technical challenges and partly by a lack of willingness from manufacturers.

Successful standards It is a general experience that the standards in the air ambulance environment are widely used. We have seen them in Europe and in other parts of the world. These standards – to a larger extent – guide the development of (H)EMS. The road ambulance as well as stretcher and patient handling equipment standards are widely used with great success. Standards for the transport of incubators are not widely used. One major reason for this might be a lack of knowledge about the standard. If the quality of the standard is insufficient, it is important to urge experts to join the ongoing revision in order to work for a higher quality level. Finally, there are a lot of successful business area standards. Examples are Norwegian standard for physicians in RW air ambulances, Norwegian standard for FW flight nurses and Norwegian standard for rescue men. The last standard is applicable for rescue men in air Ambulance operations (HEMS crew members), SAR-operations (government/Air Force), SAR-operations (offshore oil industry) and is also applicable to rescuemen in the Coast Guard helicopters. Overall, the use of standards have been a great success as a contribution for performing high quality services for our end users – the patients, and to make safer workplaces for our crews. Standardization work is a dynamic business and experts with experience, knowledge and interest are always welcome to participate in developing high quality services.  I 57 I

Training

Fig. 1: The mock-up helicopter fuselage is also fitted with a rescue winch as well as a double hoist hook, allowing teams to train the full range of high-risk rescue manoeuvres (Olga v. Plate/Bergwacht)

Medical simulation training of helicopter-supported mountain rescue situations Authors: Dr. Urs Pietsch Anaesthesiology and intensive care unit Cantonal hospital of St. Gallen Switzerland; Air Zermatt AG Zermatt Switzerland; German Mountain Rescue Service Prof. Volker Lischke Air Zermatt AG Zermatt Switzerland; German Mountain Rescue Service; Anaesthesiology and Surgical Intensive Care Unit Hochtaunus-Kliniken gGmbH hospital Bad Homburg Germany

I 58 I

The delivery of preclinical care to patients presenting complex symptoms and injuries during alpine air rescue operations requires advanced medical knowledge and competency in mountain rescue techniques from all involved parties. Professionals from different fields, such as pilots, HEMS doctors, paramedics and mountain rescuers, often have to work together on an ad hoc basis. Until recently there was no training programme in place to develop the team skills needed for such an operation. In order to train complex and critical responses in a way that incorporates Crew Resource Management (CRM), a “medical simulation training” (MedSim) workshop for emergency doctors and mountain rescuers was developed at the mountain rescue training centre (Bergwacht-Zentrum für Sicherheit und Ausbildung”, BW-ZSA) in Bad Tölz/Germany. A rescue helicopter simulation unit is operating at the BW-ZSA which can be used to simulate rescue work involving winches. The basic principles and content of this training workshop can, in part, be applied internationally, e.g. as recommendations given by the International Commission for Alpine Rescue (ICAR).

Challenges in alpine air rescue The use of EMS helicopters in rescue operations involving severe trauma can improve the outcome for the patient by reducing the intervention timeframe and the time needed to transport the patient to a suitable hospital (1). Given the long ground-based rescue times that are naturally associated with mountain rescue,

this is an area where time-saving measures would be particularly beneficial (2). This is the reason why an increased use of helicopters in mountain rescue operations has been observed across the entire European alpine region since helicopter-supported mountain rescue began in 1966. Operations that involve rescue helicopters are a classic example of work within a sociotechnical sy3 · 2014 I Vol. 4 I AirRescue I 194

Training

stem (i.e. the interaction between individuals with different professions/tasks and a single aviation device). Sociotechnical systems are particularly susceptible to human error. This type of error can have fatal consequences, especially in operations involving rescue winches or MERS (operations with Human External Cargo, HEC). During complex rescue operations, a HEMS doctor is often deployed together with other rescue personnel; however, these teams can often only be formed on an ad hoc basis after the operation has commenced. For this reason, there is an increasing need for these teams to undergo training processes that include not only practical skills, but also nontechnical skills, such as communication, situation awareness, decision-making as well as stress and resource management (3). In order to ensure these skill demands are met, managerial staff at the Bavarian Mountain Rescue Service in Germany have worked together with the German Red Cross Mountain Rescue Service (DRK) to develop a joint training concept for mountain rescue in Germany. This new training concept was based around the planning, construction and opening of the new “Mountain rescue training centre” (BW-ZSA) in Bad Tölz in 2008. Simulation was placed at heart of the new education and training structures, and the concept was adapted to the field of mountain rescue for the first time. The centrepiece of the BW-ZSA is a helicopter rescue simulation unit: a specially-developed crane unit suspends a full-scale mock-up helicopter fuselage (Eurocopter BK117), allowing it to “fly” within the approx. 20-metre-high facility. The helicopter fuselage is also fitted with a rescue winch as well as a double

hoist hook, allowing teams to train the full range of high-risk rescue manoeuvres under standardised conditions (see Fig. 1). An additional aerial cableway, with a chairlift and a gondola lift, along with various “terrain structures” – e.g. a boulder, rock ridge and uneven surfaces – allows a wide range of rescue operation scenarios (Fig. 3) to be simulated (Fig. 4). Such realistic scenarios are reinforced by the creation of standardised procedures in helicopter-supported mountain rescue established by a group of mountain rescue experts and various aviation operators (Mountain Air Rescue Advisory Board), the addition of further, nationally-recognised training documentation (e.g. for mountain rescue services’ basic training in emergency medicine) as well as the distribution of this information within all German regional sections of mountain rescue associations.

Course structure The course layout is currently structured as follows: the theoretical introduction to the course consists of topic-specific presentations regarding “Team Resource Management” (TRM) in the field of mountain rescue, the S3 guideline on the treatment of polytrauma/ severe injuries and paediatric emergencies in difficult terrain under consideration of the recognised ABCDE approach that forms part of the Prehospital Trauma Life Support Course® (PHTLS). Participants then act out a number of different simulated scenarios. The supervising course trainer holds a debriefing for the rescue team, immediately after completing the simulated rescue scenarios. This session allows team members to give an assessment on the handling of the Fig. 2: An additional aerial cableway, with a chairlift and a gondola lift, along with various “terrain structures” allows a wide range of rescue operation scenarios (Olga v. Plate/ Bergwacht)

3 · 2014 I Vol. 4 I AirRescue I 195

I 59 I

Training

Fig. 3: The course covers topics such as “Team Resource Management” in the field of mountain rescue, the S3 guideline on the treatment of polytrauma/severe injuries and paediatric emergencies in difficult terrain under consideration of the recognised ABCDE approach (Olga v. Plate/Bergwacht)

operation, team communication, recognised errors, as well as any other impressions they may have, and to reflect on them in light of the theoretical training given the previous evening. For the trainer, this is a time to address procedural errors in terms of recognised rescue practice which may pose a risk to safety, to examine how medical care was delivered to the patient in consideration of an optimised PHTLS algorithm and to look at CRM content. The MedSim training workshop ends with a final, moderated discussion involving all participants and trainers. This entails further group discussion of the individual training stages and operational scenarios, as well as the strengths and weaknesses of the team’s simulation performance. MedSim training workshops are currently being held for German HEMS crews that operate alongside mountain rescue services. The first international simulation training workshop was also held this year.

Discussion Alpine HEMS teams must be able to carry out challenging rescue operations involving complex emergency medical procedures quickly and efficiently within the “golden period of trauma” (4) during deployment in difficult terrain/operational locations, often at considerable personal risk. These teams are often only formed once the operation has begun and frequently comprise individuals from different organisations or professions. A crucial shortening of the intervention and rescue timeframe in mountain rescue operations is achieved through increased and (during suitable weather conditions) extensive use of EMS helicopters, in some cases in combination with rescue winches or ropes. Emergency doctors with training in alpine rescue and professional experience in the administration of emergency medical care in extreme conditions/terrain are also being increasingly deployed. The combined use of helicopters and qualified emergency medical I 60 I

care personnel offers substantial evidence to support the meaningfulness of intensive cooperation between mountain rescue and air rescue teams. This new, required interaction between mountain and air rescue teams, associated flight risks and the particularities of operations involving HEC, whereby the rescue operator’s life often “hangs by a thread”, all increase the risk of human error within the system. Operational routines, responses and team interactions, which are already complex under normal conditions, are vastly complicated when unforeseen events occur (e.g. acute deterioration in the condition of the patient, technical problems involving the helicopter or a sudden change in weather conditions). For this reason, it is essential for the team to communicate effectively to address the problem (5). In essence, three steps can be taken to help ensure the required high level of operational competency and speed is reached: • Establishing rules can shift operations away from knowledge-based behaviour towards rulesbased behaviour. By reflecting on real-life rescue scenarios and repeating training exercises as part of targeted continued and further education, mountain rescuers are able to assign memories to certain (environmental) stimuli and call upon memorised rules on how to tackle specific tasks/ problems. These rules may appear in a form that is standardised (e.g. algorithms, guidelines, SOP) as well as with or without the individual’s awareness, i.e. in a heuristic manner (“It has always worked this way previously ...”) . Heuristics are important to us all, and we make use of them constantly, but for others they can often seem non-transparent, and conceal the risks associated with fixation. Actions, which are required multiple times and have a critical impact on safety, must therefore be subjected to external standards. • A briefing before the operation can essentially safeguard rule-based behaviour (e.g. by helping to avoid misunderstandings) as well as accelerate its implementation. The briefing helps establish which operational plan and which specific rules/ standards shall to be adhered to, which critical influential factors, in the opinion of the operators, may have an impact on the chosen plan (weather, patient’s likely medical care needs) and at which foreseeable points during the operation further decision-making or process review steps may be required. This leads to the creation of a type of collective “mental map”. • Repeated training can also help operators execute manual skill-based actions with increased speed and safety. Here experiences gained from specific, previously-executed action plans 3 · 2014 I Vol. 4 I AirRescue I 196

Training

(e.g. emergency medicine practice in daily professional life, alpine skills gained through repeated exposure to mountain conditions, repeated real-life operational experience in mountain rescue) can be enhanced through practice in the simulator. A pre-rehearsed set of actions can then follow, often within a fraction of a second, as the direct consequence of certain (environmental) stimuli. The aim should be to integrate all three levels of behaviour. The steps outlined regarding the safeguarding and acceleration of processes can be ideally developed and trained in the simulation unit. The more accurately training conditions mirror the reality of situations faced by operators (e.g. in a simulation unit), the more intensively acquired knowledge can be applied to specific operational situations and compensate, at least partially, for any lack of experience (5). 

References: 1. Galvagno SM Jr, Haut ER, Zafar SN, et al. (2012) Association between helicopter vs ground emergency medical services and survival for adults with major trauma. J Am Med Assoc 307: 1602–1610.

2. Tomazin I, Kovacs T, International Commission for Mountain Emergency Medicine (2003) Medical considerations in the use of helicopters in mountain rescue. High Alt Med Biol 4: 479–483. 3. Petri M, Friedrich L, Hildebrand F et al (2012) Simulator training: reducing risk in helicopter rescue. Air Med J 31:117–12 4. Berger E (2010) Nothing gold can stay? EMS crashes, lack of evidence bringing the golden hour concept under new scrutiny. Ann Emerg Med 56(6): A17–A19. 5. Lischke V, Berner A, Pietsch U (2014) Medical simulation training of helicopter-supported mountain rescue situations (MedSim-BWZSA) Notfall Rettungsmed 17: 46–52.

Fig. 4: Alpine HEMS teams must be able to carry out challenging rescue operations involving complex emergency medical procedures quickly and efficiently within the “golden period of trauma” (Olga v. Plate/ Bergwacht)

SUBSCRIBE NOW! 1-year subscription 4 issues – 30 €*

2-year subscription 8 issues – 55 €*

www.airrescue-magazine.eu/subscribe *shipping not included (Europe 5 E, World 10 E)

EC145 TANGO 2

Airrescue InternatIonal aIr rescue & aIr ambul ance

M A g A zine

Regulations

European standards Benefits and challenges

Crash

“Air Ambulance 02”: Interim investigation report

Medical Care

Coagulation management: Is tranexamic acid the only option? ISSUE 3 | Vol. 4 | 2014

AirRescue International International Air Air Rescue Rescue & & Air Air Ambul Ambulance ance

M a g a zine

In Profile

Fig. 1: With the close co-operation and tight network of personnel involved, the vision is to develop common SOPs, standard level of medical care and standard criteria for HEMS operations throughout the country (FinnHEMS)

The future of HEMS in Finland Six HEMS bases. Almost 14,000 annual missions. Over 150 lives saved annually. A budget of 27 million Euros per annum. Finland has not been left untouched by the global state of economy. Thus – to many, the most interesting figure of the ones described above is the one of costs. Money will play a central role the following years when not only HEMS, but rather the whole organization of emergency medical services will be evaluated in Finland.

Piece of history

Author: Antti Kämäräinen, MD, PhD Emergency Medical Services FinnHEMS 30 (“FH 30”) Tampere University Hospital Tampere, Finland

I 62 I

Since the launch of the first base in 1992 (later followed by five additional ones), the Finnish HEMS bases were run by distinct support organizations of local coordination and low national co-operation. Funding was mainly based on charity and sponsors with associated risks involved. In 2011, after several processes all the six bases with their distinct background organizations were finally brought under the same umbrella of FinnHEMS – a government funded, non-profit company coordinating the HEMS bases in co-operation and under the ownership of the five University Hospital Districts of Finland. As the funding of HEMS operations became government based,

the subject of fund raising subsided and more focus could be directed on more uniform national basis of operations. Areas of development, conducted by FinnHEMS, have been described in more detail in the 4/2013 issue of AirRescue Magazine.

Strengths Under central coordination, not only the monetary issues have been settled for now, but also the operational concepts and codes of conduct have been scrutinized on a national level. Involved are the aspects of aviation, grounds of HEMS operations and – to a certain degree – emergency medical issues. The coordinating medical board of the FinnHEMS 3 · 2014 I Vol. 4 I AirRescue I 198

In Profile

includes emergency medical professionals involved in active fieldwork from all Hospital Districts, giving rise to the opportunity of developing national HEMS standards. Also, as the flight operations are provided by only two operators, the network of communication and development is not overwhelming with regard to the pursuit of common background of operations.

country, there are at least two geographical areas in Finland that would necessitate a HEMS unit. However, financial aspects and a certain degree of parochialism have not given in to enable the development of a more encompassing HEMS network. At present, 70% of the Finnish population can be reached by the HEMS units within 30 minutes.

Opportunities Weaknesses Tradition dies hard and culture eats strategy for breakfast. In a country of only 5 million inhabitants and six HEMS bases run by a handful of people, it is astonishing to see how different a culture of HEMS operations could be comparing one base to another. Years of local autonomy, distinct geographical characteristics and also local hospital policies have shaped the form of Finnish HEMS since the 1990s. A couple of years certainly is a short time to change the course – and nothing new comes without resistance. Ever wondered why medicine is called an art? Does that make a doctor an artist? Well, imagine trying to tell 60+ (critical) artists they should paint a similar masterpiece out of the same topic, using the same colours and brushes … Despite updated legislation aiming for equal availability of emergency medical services throughout the

The future should be perceived with opportunities in mind. The opportunities of Finnish HEMS are founded on the described strengths and them overcoming the current weaknesses. With the close co-operation and tight network of involved personnel, the vision and opportunity is to develop common standard operating procedures, standard level of medical care and standard criteria for HEMS operations throughout the country. Regarding standard, it should not be understood as a rigid form of accredited nature but rather a common goal or mode of operation, designed in national co-operation and reflecting present day evidence and experiences from local and international sources. However, it is notable that what works in a mainly urban area, does not necessarily fit in to the setting of a more rural area or frank wilderness. Some of the topics – regarding the quest for common practices – include the question of all weather-

AirRescue ance Ambullance Air Ambu & Air ue & Rescue Air Resc Inter nal Air national Internatio

M a g a zine

for download! Any past issue on your mobile device – for EUR 6 only.

www.airrescue-magazine.eu/shop/

In Profile

Fig. 2: The Finnish visions regarding the future of HEMS do not greatly differ from those of neighbouring countries (FinnHEMS)

Disclaimer: The article represents only the individual opinion of the author.

HEMS, dedicated HEMS dispatching and dispatch criteria, medical guidelines and uniform training of medical personnel. What is crucial for this work is the information extracted from the FinnHEMS mission database. Data from all HEMS missions operated in the country enable evaluation of not only medical but also tactical and flight information. Best practices can be shared and areas of non-ideal performance identified.

Tab. 1: HEMS operations in Finland – visions for the future Aviation

• All-weather HEMS • Improved safety management; all crew resource management; fatigue management; multidisciplinary co-operation

Medicine

• Prehospital blood transfusion • Aggressive management of traumatic cardiac arrest • Improved management of neurological/neurosurgical time-critical events

Threats As noted above, the most relevant threat concerns the funding of HEMS. Currently, government funded basis is under political re-evaluation. There are visions that gross funding and expenses would be allocated to the communal level. In all likelihood, this would cause several HEMS bases to be run down due to preexisting economic struggles already faced by many Finnish communities. At the moment, the current model of government funding will continue until 2017. Another threat associated with the insecure funding of HEMS operations is related to the still unappreciated role of the HEMS unit as a regional coordinator of the EMS system in general. The media, lay public and even EMS professionals – in many parts of the country – still perceive HEMS as a sole transporter of the patient, rather than a dedicated link in the EMS chain.

• Focused prehospital surgical interventions • Improved prehospital diagnosis; ultrasound, point of care testing • Extracorporeal membrane oxygenation • Resuscitative endovascular balloon occlusion of aorta • Cardiac arrest – improving the chain of survival & the role of hypothermia General

• Criteria for HEMS dispatch – dedicated HEMS dispatcher • Location and number of HEMS bases – nationwide availability • Uniform patient transport criteria • Stable funding

I 64 I

Summary The Finnish visions regarding the future of HEMS do not greatly differ from those of neighbouring countries as described in the last SHARE meeting in Oslo, Norway. International innovations as well as domestic export products are shared as the co-operation within the European HEMS community remains close. Some key visions and contemporary issues are described above.  3 · 2014 I Vol. 4 I AirRescue I 200

Case Report

Off the Beaten Track: AMS with most demanding rescue operation A call to evacuate a small group of stranded employees from Mapungubwe National Park turned into the largest and most gruelling rescue mission conducted in the history of the South African Red Cross Air Mercy Services (AMS). Captained by rescue pilot Johan Stone, the organization’s EC130 B4 rescued 89 people in just over nine hours. It was a small group of South African National Parks personnel stranded in a remote corner of Mapungubwe National Park, Limpopo Province, South Africa.

The scene that greeted South African Red Cross Air Mercy Services (AMS) pilot Johan Stone as he peered out the window of the helicopter to the rising Limpopo River below was dire: “People were stranded on patches of high ground holding blankets, clothes and whatever was left of their belongings. Bridges were swept away, and there was water everywhere.” The AMS helicopter and medical rescue team had been dispatched by the Limpopo Department of Health & Social Development to evacuate a small group of South African National Parks personnel stranded

in a remote corner of Mapungubwe National Park, which is home to lions, rhinos, leopards and other wild animals. Instead, the rescue team discovered dozens of people in need of evacuation. “The weather intensified as we arrived at the site. We feared additional flooding due to broken dams, not to mention the threat of free-roaming wild animals, so we immediately escalated the scale of our rescue operation with a focus on getting everyone out to a safe gathering point,” recalled Mr. Stone. The EC130 B4 recorded 9.3 hours of flight that day

Author Courtney Woo Freelance journalist France

Fig. 1: In just over nine hours, AMS rescued 89 people, a small group of South African National Parks personnel, stranded in a remote corner of Mapungubwe National Park (Johan Stone)

Case Report

Fig. 2: “Given the heavy rain and uneven terrain, the only way to load passengers was through vertical lift with partial and slope landings, full power on” (Johan Stone)

For more information, visit: www.ams.org.za

I 66 I

– a record for AMS on any rescue mission in its 46 years of existence – in extremely difficult weather and landing conditions. “Given the heavy rain and uneven terrain, the only way to load passengers was through vertical lift with partial and slope landings, full power on”, added Mr. Stone. He and the team of two rescue coordinators and flight paramedics successfully evacuated 89 people. The helicopter was configured to transport people in a trooping arrangement, and all seats were removed – except the pilot’s and the two in the rear to accommodate as many as 11 individuals per trip. “It was about halfway through the first trip that I realized we were 11 up: one crew member, four mothers, five children and me. I had never completed a mission of this scale before, flying at an altitude of between 1,500 and 2,000 feet with 300 kg of fuel, but I had faith in the chopper and knew it wouldn’t let me down,” said Mr. Stone. The helicopter flew the stranded people to safety, where they were further treated and assisted by the Limpopo Emergency Medical Services ground teams. Mr. Stone expressed his admiration for the helicopter: “The size, reliability and power of the EC130 B4 are critical for this line of work. The helicopter amazes me on a daily basis – it’s strong, spacious, very powerful, yet small enough to get into those tight spots. But the most important thing that stands out is its reliability and low pilot workload. Once you’ve completed your pre-flight inspection and everything is in place, you can concentrate on the mission ahead.” That concentration paid off for Mr. Stone: “The people were stranded for more than one day without any idea that a helicopter would come to their rescue. As a pilot, nothing is more rewar-

ding than when you look back and see those happy faces.”

About Air Mercy Service, S.A. Established in 1966 by the South African Red Cross Society and formed into an independent trust in 1994, the Air Mercy Service (AMS) shares the principles and creed of the South African Red Cross Society. The AMS is a non-profit organization with bases in the Western Cape (Cape Town & Oudtshoorn), Northern Cape (Kimberley), KwaZulu-Natal (Durban & Richards Bay), Mpumalanga (Nelspruit) and the Free State (Bloemfontein) that provides an air ambulance network, rural health outreach and emergency rescue service to metropolitan areas and remote rural communities. In a land characterised by vast distances, the AMS has become a vital conduit for delivery of regular healthcare services to peripheral areas. The organization works closely with the Provincial Departments of health and community health workers to assess needs, identify backlogs and implement appropriate healthcare programmes. The AMS plays a vital role in providing not only emergency rescue and air ambulance services, but also a community outreach programme taking critically needed healthcare to impoverished communities. The AMS air ambulance and fixed wing services provide emergency medical services and inter-hospital transfers to hundreds of critically ill or injured patients. Each aircraft is equipped with an Advanced Life Support (ALS) medical interior. Besides the EC130, from Airbus Helicopters, there is an AS350, an Augsta 109 (twin), an AW119Ke (single), and a Pilatus PC-12 fixed wing part of the AMS fleet.  3 · 2014 I Vol. 4 I AirRescue I 202

Have a Smartphone? Download the mobile app

In association with

14-16 OCT 2014 AMSTERDAM RAI

Be part of Europeâ&#x20AC;&#x2122;s largest 100% dedicated helicopter exhibition INTERESTED IN EXHIBITING? Contact Elex van Rensburg, Sales Manager Tel: +44 (0)20 8910 7810 elex.vanrensburg@reedexpo.co.uk

JOIN US 14-16 OCTOBER 2014 AMSTERDAM RAI

Join & follow us Organised by

Search for helitechevents on these social media channels