2010

International Travel Insurance Journal

Air AmbulanceSUPPLEMENT

AIRAMBULANCE2

contents

Stand out from the crowd 4

Spotlight on Pilatus PC12 10

Spotlight on Eurocopter EC135 11

Wing-to-wing transfers: Dream or reality? 12

Call of the wild 14

Care in the air 18

Profi le – David Ewing 20

Fasten your seatbelts! 22

Tractor triage 24

Eastern promise 28

Number crunching 31

Extreme evacuation: The Himalayas 32

Biggles jet giggles 34

Regulation update 35

International Travel Insurance Journal

Publisher: Ian Cameron

Copy editors: Mandy Aitchison

Charlotte Hodgman

James Wallis

Designers: Eli Butler

James Elliott

Production manager: Helen Watts

Sales: David Fitzpatrick

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Would you like to make a comment?Are you interested or involved in any aspect of the travel insurance industry? Whether you are a professional journalist or an industry professional we would love to hear from you.

Call Ian Cameron at the ITIJ offi ces or email: editorial@itij.co.uk

Front page image by Airteamimages.com/FyodorBorisovPublished on behalf of Voyageur Publishing & Events LtdVoyageur Buildings, 43 Colston Street, Bristol BS1 5AX, UK

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or fi rm mentioned, is hereby excluded.

Printed by Pensord Press Limited Copyright Voyageur Publishing 2010 Materials in this publication may not be reproduced in any form without permission.

INTERNATIONAL TRAVEL INSURANCE JOURNAL ISSN 1743-1522

welcome

Welcome to the fourth annual Air Ambulance Supplement, published in conjunction with the International Travel Insurance Journal. This year, we have cast our net even farther around the world to see what sort of provision is made in Japan for emergency medical evacuation, as well as checking the plans in place for tourists heading to South Africa for the 2010 football World Cup.

Elsewhere, we chat to one of the industry’s most-recognised fi gures about developments he has witnessed in the air ambulance sector over the past 20 years, while elsewhere, we give our readers an update into the viability of wing-to-wing transfers. Case studies of extreme rescues – including a tourist trekking high up in the Himalayas – are also included in this year’s Supplement, giving readers a peek into how its done.

We have, of course, the usual suspects as well, in the form of aircraft spotlights – this year we have looked in depth at the Eurocopter EC135 and Pilatus PC12, both of which are used extensively around the world as air ambulances.

The ITIJ team would like to take this opportunity to thank all the contributors to the Supplement this year. We couldn’t do it without you!

AIRAMBULANCE - FEATURE4

Stand out from the crowdhe men and women who staff air ambulance companies are providing a vitally important service. They are hardworking

and highly skilled, without question. But, how do they measure up when it comes to marketing and branding their businesses? What seemed like a simple request – write an article about the impact, if any, caused by so many similarly named companies in a single business segment – turned out to be anything but. Kyle Davis reports on the importance of choosing the right name for your air ambulance fi rm

While it would be easy to brand air ambulance marketers as an unimaginative bunch who simply mix and match a handful of names over and over, that would be doing all of us a disservice. In truth, there are valid reasons for overlap,

and sometimes surprisingly few negative consequences for those who fail to differentiate themselves. At the same time, the consequences, when they occur, can be quite serious. With all this in mind, it becomes clear that entire issue is worth a closer look.

Oops, I meant the other air life ambulance companyAn informal review of more than 460 air ambulance company names worldwide reveals much duplication and little originality. Here’s a snapshot (right) of the top 10 overused words and phrases, followed by the number of companies using them.We’ve clearly established that the industry has lots of similar sounding company names, which raises a series of questions, such as ‘why is there so much similarity?’, ‘so what?’, ‘is this actually causing confusion?’, ‘do customers care?’, ‘is it

affecting business?’, and ‘what steps can be taken to make things clearer?’ In adopting names that use terms like air ambulance, companies are being

smart marketers, as they are conveying the nature of their businesses to their customers quickly and clearly. This is especially important for fi xed-wing T

AIRAMBULANCE - FEATURE 5

operators, as they often have considerable contact with the general public, who may find them via a search engine or phone book. Let’s say grandpa is vacationing in Mexico, has one too many margaritas, falls on the dance floor and breaks a hip. If he’s not physically able to fly home commercially, and insurance does not cover the cost of the trip, then the family is left to make arrangements and cover the cost. Chances are, the family will start its search for an air ambulance on the Internet.It’s quite a different story if an assistance company is involved in helping bring grandpa home. While the assistance company will have existing contacts or relationships with air ambulance companies, the overlap in brand names could make it challenging for personnel to recognise and distinguish one company from another. A delegate at last year's International Travel Insurance Conference

in Athens, Greece, raised this very concern during a session. It’s hard to misunderstand a term like air ambulance, which is certainly why it is used in the names of 49 separate companies. It’s different for rotorcraft operators. A first responder is not at the scene of an accident, paging through a phone book to find an air ambulance provider. They already work with companies they know and trust, and they’ll keep calling until they find someone available to respond. There is one critically important issue that could potentially impact all air medical operators, and it goes straight to the heart of your reputation and brand – what if there’s an accident?

Bad PR can be fatalSafety issues in the air medical community, especially among helicopter operators, are being scrutinised at

Stand out from the crowd

an informal review of more than 460 air ambulance company names worldwide reveals much duplication

and little originality

AIRAMBULANCE - FEATURE6

ITIJ found a selection of similarly named air ambulance organisations:

AirMed (Air Medical Ltd), Oxford, UK, FWAirMed International, Birmingham, Alabama, US, FWAirMed El Paso, El Paso, Texas, US, FWEagle Air Med, Blanding, Utah, US, FWAirMed (University of Utah), Salt Lake City, Utah, US, FW+RAirMed, Martinez, Georgia, US, RAir Med 1 (Superior Ambulance Service), Elmhurst, Illinois, US, RLife Flight International Inc., Sidney, British Columbia, Canada, FWCla-Ore Life Flight, Brookings, Oregon, US, FWSierra Lifeflight, Bishop, California, US, FWMeritCare LifeFlight, Fargo, North Dakota, US, FW+RLife Flight Network, Aurora, Oregon, US, FW+RLife Flight, Wellington, New Zealand, FW+RRio Tinto Life Flight (Royal Flying Doctors Service), Western Australia, Australia, FWLife Flight (Intermountain Helath Care), Salt Lake City, Utah, FW+RLife Flight (Saint Francis Medical Centre), Peoria, Illinois, US, RLife Flight (Geisinger Health System), Danville, Pennsylvania, US, RLifeFlight Miami Children’s Hospital, Miami, Florida, US, RLifeFlight of Maine, Bagnor, Maine, US, RLifeFlight (Allegheny General Hospital), Pittsburgh, Pennsylvania, RMemorial Hermann Life Flight, Houston Texas, US, RTulsa Life Flight, Pryor, Oklahoma, US, RDuke Life Flight, Durham, North Carolina, US, RLifeFlight (University of Massachusetts), Worcester, Massachusetts, US, RLifeFlight Eagle, Kansas City, Missouri, US, RStanford Life Flight, Stanford, California, US, RVanderbilt Life Flight, Nashville, Tennessee, US, RPortneuf LifeFlight, Pocatello, Idaho, US, RLife Flight (St. Patrick Hospital), Missoula, Montana, US, R+FWNorth Country Life Flight, Saranac Lake, US, RSt. Mary’s LifeFlight, Evansville, Indiana, US, RBaptist LifeFlight, Pensacola, Florida, US, RMountain Lifeflight, Susanville, California, US, RLife Flight (Iowa Methodist Medical Center), Des Moines, Iowa, US, REHS Lifeflight, Enfield, Nova Scotia, Canada, RSouth West Life Flight, New Mexico, US, R+FWNRMA CareFlight / Careflight International Air Ambulance, Westmead, New South Wales, Australia, R+FWTriState CareFlight, Bullhead City, Arizona, US, FW+RSt. Mary’s CareFlight, Grand Junction, Colorado, US, R+FWFlightCare (Enloe Medical Centre), Chico, California, US, ROchsner Flight Care, New Orleans, Louisiana, US, RCare Flight REMSA, Reno, Nevado, US, RCare Flight (Miami Valley Hospital), Dayton, Ohio, US, RAvera St. Luke’s CareFlight, Aberdeen, South Dakota, US, RCareFlite, Grand Prairie, Texas, US, R+FW

It’s hard to misunderstand a term like air ambulance, which is certainly why it is used in the names of 49 separate companies

What is a brand?The American Marketing Association defines a brand as a “name, term, sign, symbol or design, or a combination of them, intended to identify the goods and services of one seller or group of sellers and to differentiate them from those of other sellers.” Here are five reasons branding matters to your business:• Brands enable customers to remember your product service.• Brands build customer loyalty and lead to repeat purchases.• Brands make it easier for current clients or customers to refer you to others.• Brands send a message as to what your customers can expect.• Brands add value.The bottom line? Care for and protect your company’s brand, and it will return the favour.

the highest levels of government and the news media, not least in the US, where the number of fatal helicopter air ambulance crashes have made national headlines. If you share a name, or even part of a name, with a company that has a high-profile accident, the negative fallout could be serious and long lasting. What if AirMed provider ‘A’ has a sterling safety record, while AirMed provider ‘B’ does not – but the audience can’t distinguish one from the other? The reputation your team has painstakingly built over many years could be wiped out in a second. For a publicly traded company, the consequences could be financially devastating. Is it worth the risk?

What should air ambulance companies do?Once again, there is no pat answer. Researching the levels of brand awareness among your customers and prospects is a good first step. If you’ve built considerable brand equity over the years, changing your name now could do more harm than good. In this case, you may want to consider tweaking your brand to make it more distinctive and memorable through the use of colour or a tagline. In discussing this topic, several people actually quoted taglines that have made a lasting impression on them, such as ‘every second counts’. There is no shortage of research on the subject of branding, and nearly all of it suggests that branding is one of the most important aspects of any business. That’s because your brand represents your

All the above companies include the words 'Life Flight' in their company name.

Key: FW – Fixed-wing air ambulance operatorR – Rotary air ambulance operator

Rod Dermo

Jonathan Rankin

Hector Rivera

Ralph Duenas

Kevin Boyoston

Ben Wang

Yauhen Patsel

AIRAMBULANCE - FEATURE8

Kyle Davis started her career in journalism, moved into marketing communications with The Boeing Company, and has been actively involved in aerospace ever since. She co-founded BDN Aerospace Marketing in 1999. The company works exclusively with aerospace companies to meet their marketing and sales objectives and deliver measurable results. Services include: research and audits; strategy development and implementation; and integrated marketing plans. BDN

implements programmes using advertising; print materials; trade shows; digital media; public relations/thought leadership/social media; and more.

From the front lines

An online discussion about this subject elicited a range of comments and opinions. Here are some excerpts:

From a line pilot: “In the field, people always get us mixed up with other companies. When they refer to us by another name we correct them, point out our logo/paint scheme and then let the Outreach Department know what is happening in the community.”

From a mechanic: “I don’t think the person needing our assistance cares what our name is as long as we do our job.”

From a firefighter/EMT: “It really depends on what target you are appealing to. A great marketing scheme that works for one many not work for the other.”

From a chief executive: “Having gone through the branding exercise myself, I understand the dilemma. It’s not just negative attachments you need to be concerned about. There are those who will try to attach themselves to your name to hijack business.” Also, “HEMS is a serious business and serious consideration should be given to the name, use of colour, the logo and overall visuals created to help do that.”

From a marketing consultant: “Don’t give up! Your brand is one of the most valuable things about your company. It’s the recognisable image of your relationship with customers, and your reputation among potential customers and the public.”

promise to customers, and consistent strategic branding leads to strong brand equity, which adds value to your company and your products.If you are going through a rebranding process, or establishing a new air ambulance service, consider this subject very carefully. With research, imagination and perhaps the help of a marketing professional, you can establish a brand name that is unique from everyone else while still capturing the essence of who you are and what you do — and that’s what great branding is all about. n

If you share a name, or even part of a name, with

a company that has a high-profile accident, the negative fallout could be serious and long lasting

AIRAMBULANCE - SPOTLIGHT10

Pilatus PC12 NGHistoryThe Pilatus PC-12 is a King Air class and size turboprop aircraft aimed at corporate transport and regional airliner operators. It is the latest in a line of single-engined PT6 turboprop powered Pilatus products. Pilatus announced that it was developing the PC-12 at the National Business Aircraft Association’s annual convention in 1989. The initial flight of the first of two prototypes occurred in May 1991. Certification was originally planned for mid-1993, but a redesign of the wings, including the addition of winglets to ensure that performance guarantees were met, pushed the date back, with Swiss certification awarded in March 1994 and US Federal Aviation Administration certification following in July 1994. The first customer to receive an aircraft was the Royal Flying Doctors Service in Australia.Compared to the King Air 200 twin, the PC-12’s main competitor, the Pilatus’s most significant design feature is the single engine. Internally, the PC-12’s cabin is also longer and wider than the King Air.Most PC-12s built so far have been for corporate clients, but recent regulatory changes in Australia, Brazil, Canada and the US have cleared single-engine turboprops for Instrument Flight Rules Regular Public Transport operations in those nations. The move has opened up new potential markets for the PC-12 as a regional carrier, replacing older King Airs and elderly piston twin aircraft such as the Cessna 400.The PC-12 Spectre is based on the PC-12, but is equipped with a retractable FLIR system, which allows for surveillance tasks to be carried out efficiently and discretely.

Specifications

Pilot: One or twoStretchers: TwoMax. rate of climb: 585 m/sMax. cruise speed: 519 km/hMax. range with three passengers: 2,889 kmMax. operating altitude: 9,144 mMax. take-off weight: 4,740 kgMax. payload: 1,024 kgCabin width: 1.53 mCabin headroom: 1.47 mEngines: Pratt & Whitney Canada PT6A-67P, flat rated at 1,200 SHPWC? Yes

Did you know?

Nearly 1,000 PC-12s have been sold as of June 2008. Its pressurised 330 cubic feet cabin can accommodate up to three patients in addition to life support equipment and medical personnel. When the PC12 was originally developed, the needs of air ambulance operators were considered an important element of cabin design, so the aircraft has a large, motorised cargo door, making stretcher access much easier.

The Pilatus PC-12 is the aircraft of choice for the Royal Flying Doctor Service of Australia (RFDS) in South and Central Australia. It has a number of advantages over its nearest rival in the class, most significantly higher range and payload capabilities. These advantages have been extended again, and in the latest model the maximum take off weight has been increased by 200 kilograms.For the pilot, the cockpit is ergonomically excellent. It has been designed from the ground up with the human interface as the priority, rather than being a stock standard cockpit with after market add-ons. Visually, the layout is simple and switching is on the ceiling rather than cluttering the panel, as most switches are used only at the start up and shut down. The aircraft is simple for a pilot to prepare for flight, which is a great comfort to safety given our medical response time requirements.Automated systems such as engine start and environmental control enhance safety in our round-the-clock operations. They also cut back on turn around times, which is beneficial to patient care.The Central Advisory and Warning System monitors all the aircraft’s systems and issues cautions and warnings only when there is a problem. The primary flight display is electronic, a significant improvement on the old analogue style. All of these aspects make the aircraft easy to fly and it follows that the Training and Checking Program is easy to manage.For medical and flight crews, the aircraft provides a user-friendly layout. The ‘airstair’ door forward of the cabin means that the pilot does not

have to negotiate the medical team, equipment and patient to get to the cockpit. Similarly, the large cargo door is standard to the aircraft and allows the fitment of various designs of stretcher-loading devices.An added bonus is that it is pneumatically and electrically operated, requiring no physical exertion to open or close. Flight nurses report that the cabin is relatively quiet because the engine and propeller are out the front and the cabin slightly larger than similar aircraft. The climb and glide performance coupled with GPS navigation systems, the airfield database and the simplicity of the cockpit display mean that a potential emergency landing area is reachable most of the time. In fact you could say that from initial lift off (rotation) to 1,000 feet is the only phase of flight where a prepared landing area cannot be reached following an engine failure. This window lasts for 30 seconds or less each flight. We should also not ignore statistics that show controlled flight into terrain and other human factors cause most accidents, rather than engine malfunctions. Pilatus goes a long way to design out the potential for pilot error, as can be seen clearly in the cockpit.I have flown several aircraft types in aeromedical operations, and the Pilatus PC-12 is equal and, in some ways, superior in overall safety. Flying into the outback in the dark, diverting around thunderstorms I would much rather have the spare fuel that it offers than the added weight of a spare engine. Added to that the excellent payload and cabin features, and it becomes the obvious choice for this type of work.

Testimonial – Alan Benn, chief pilot of RFDS Central Operations, spoke to ITIJ about why the organisation uses a Pilatus PC-12

RFDS

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Eurocopter EC135The EC135 is a light, twin-engined, multi-purpose helicopter of the two to three-ton class with space available for up to eight seats for pilots and passengers. Underlining its multi-role capabilities, it can even be operated by single pilots under Instrument Flight Rules as an option.The helicopter uses the latest technologies, such as advanced cockpit design, modern avionics, anti-torque devices and an all-composite bearingless main rotor system, giving impressive manoeuvrability. Optimised main rotor blades with advanced tip geometry and unequal blade spacing make the EC135 the quietest helicopter in its class, bringing it 6.5 dBA below the ultra-induced International Civil Aviation Organization limit. The built-in anti-resonance system filters rotor-induced vibrations and this enhances flying comfort to a maximum.In September 2009, Lotnicze Pogotowie Ratunkowe (LPR), the Polish state air rescue service, took delivery of the first of 23 new EC135 helicopters. The aircraft boast completely new medical cabins and high performance parameters. This new fleet signified a revolutionary change for LPR, whose fleet consisted of 17 Mi-2 Plus helicopters and one Agusta 109 Power.The new EC135s will all be in operation by 2011, with the first aircraft taking to the skies in early 2010.

Specifications

Pilot: One or twoLength: 12.16 mWidth (rotors extended): 10.2 mStretchers: 1 pilot,1 litter, 5 seats 1 pilot, 2 litters, 4 seats 2 pilots, 1 litter, 4 seats 2 pilots, 2 litters, 3 seatsMax. take-off weight: 2,910 kgFuel capacity: 560.4 kgEngines: 2 Pratt & Whitney turbine engines or 2 Turbomeca turbine engines

Did you know?

Eurocopter's EC135 is a very powerful lightweight twin-engine multipurpose helicopter and is operational worldwide. Over 800 have been delivered since the helicopter entered service in 1996 with German Air rescue company Deutsche Rettungsflugwacht and the helicopter is flown by over 100 customers in 27 countries. A military version, the EC635, has also been developed and has entered service with the Royal Jordanian Air Force. As of December 31, 2009, a total of 823 EC135s (all versions) were in service with customers worldwide.

“There are currently 826 EC135s in service worldwide today – of these, 46 per cent are involved in emergency medical services. The very first aircraft to come off the production line did so in 1996 and we took delivery of our first EC135 in June 2000. Our decision to operate the EC135 was based on a careful evaluation of mission features, performance capabilities and the costs of the light twin engine helicopters available on the market.Bond now operates 19 EC135s throughout the UK, with 14 of these operating in dedicated Helicopter Emergency Medical Services (HEMS) and Emergency Medical Retrieval roles. Bond Air Services opted for the Arrius 2B2 power plants, which give us a maximum takeoff weight of 2,910kg, a maximum range of approximately 320nm and a cruise speed of 135kts. This speed and agility lends itself very well to HEMS operations. The 135 can be airborne within two minutes, enabling rapid activation to calls, while its small external footprint and powerful engines enable access and egress to difficult HEMS sites. The skidded undercarriage allows us to land on a variety of terrains and the high set main rotor and enclosed tail rotor ensure a safe working environment to those working around the aircraft. As well as HEMS operations, the aircraft is also used extensively for demanding and complex inter-hospital transfers where specialist consultants are delivered to a patient who is then stabilised and prepared for transport to the definitive medical care centre.The EC135 was designed with EMS in mind. The aircraft is equipped with a specifically designed aero medical interior fitted with lifesaving equipment such as a cardiac monitor, a defibrillator and a ventilator. It is also equipped with an integral medical outlet panel that features electrical and medical gas outlets. The internal fit-out can also be configured quickly and easily to support an additional stretcher, a maternity stretcher or a neonatal incubator, and the height and size of the side and rear clamshell doors all contribute to the ease of patient loading. The cabin size itself allows for medical equipment and drugs stowage, whilst still providing a comfortable environment for both the patient and the medical team working onboard.”

AIRAMBULANCE - SPOTLIGHT

ITIJ spoke to David Bond of Bond Air Services about the EC135

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Wing-to-wing transfers –reality or wishful thinking?Volker Lemke of FAI rent-a-jet details the ongoing development of the wing-to-wing transfer phenomenon in the international fixed-wing air ambulance industry

Wing-to-wing transports have been a subject of much controversy within the air ambulance industry for a while already, but the consensus over the years seems to be that the advantages quite obviously outweigh the risks. During the last few years, FAI rent-a-jet AG (Flight Ambulance International) has carried out an average of between five and 10 wing-to-wing transports a year, and this year has already added another four flights together with its partners. Discussions with other air ambulance providers have shown that while the volume is not huge, this operational configuration is routinely seen as an available – and viable – option. A close co-operation between a few providers on different continents have essentially demonstrated the existence of a real need for such a service, and wing-to-

wing transports can now be seen as part of the reality in today’s air ambulance market.Several considerations make wing-to-wing transports attractive for both the clients and the operators – they include the following:

The time factorIn most cases, the possibility of saving time on long-distance flights is the deciding factor in planning wing-to-wing transports. The time saving is related to several considerations:-Faster arrival at the patient’s bedside through the involvement of a regional provider and the ability to immediately proceed with the initial flight, since there is no crew rest time involved. The wing-to-wing partner can use the same period of time to position its own aircraft and, immediately after changeover, bring the patient to their final destination. This is particularly true of critical, time-sensitive missions out of medically under-serviced areas. Using wing-to-wing transfers can,

for instance, allow a saving of up to a full day in bringing a patient from Central Africa back to Europe.-For less critical cases, wing-to-wing transportation can allow companies to circumvent operational hurdles that can hinder the organisation of an air ambulance flight. While as a rule some sort of time buffer is available, nevertheless, transports in or out of the US can only be undertaken by European air ambulance carriers with an advance notice of five to seven days because of the waiver regulation. Such an operational arrangement is, quite understandably, not acceptable for most clients.-In the case of extremely long-range missions, both flight and medical crews must normally be pre-positioned, so that the plane can only be used, and the patient only transported, after the required crew rest time has elapsed. Significant time gains can also be achieved in such a scenario by organising the mission as a wing-to-wing transport. n

Volker Lemke is director of sales and marketing for FAI rent-a-jet. He joined the FAI board of directors in 2004 after 15 years of practical experience as a paramedic working for ground and helicopter emergency medical services. Volker brought with him a professional background and comprehensive market knowledge, strengthening FAI’s position as a worldwide provider of air ambulance services.

A snapshot of a recent wing-to-wing transfer at FAI's hangar FAI

AIRAMBULANCE 13

AIRAMBULANCE - WORLD FOCUS14 AIRAMBULANCE - WORLD FOCUS14

Call of the wildWith the 2010 World Cup only a couple of months away, ITIJ asked South Africa’s Red Cross Air Mercy Service if visitors setting foot on South African soil, along with South African citizens, are in safe hands should they need medical treatment

Established in 1966 by the South Africa Red Cross Society and formed into an independent Trust in 1994, the South Africa Red Cross Air Mercy Service (AMS) is a non-profit organisation with bases in the Western Cape, KwaZulu-Natal, Northern Cape, Mpumalanga, Free State and Polokwane that provides an air ambulance network, rural health outreach and emergency rescue service to metropolitan areas and remote rural communities. The AMS works in partnership with the Department of Health in each of the provinces in which it operates. AMS’s mission is to contribute to the improvement in the quality of life of all communities, facilitate access to

equitable and effective healthcare and the provision of aero-medical and other associated humanitarian services. Over the past 40 years, AMS has grown into a remarkable aeromedical organisation, notwithstanding the challenge of skill shortages that the organisation faces, and has proven its commitment to serving communities in need.

Rescue serviceDuring the last summer season, the AMS helicopters were kept busy with mostly mountain and sea rescues in the Western Cape – the Western Cape operation operates two AgustaWestland 119Ke single engine helicopters based at Cape Town and Oudtshoorn respectively. The aircraft are used for air ambulance and rescue work and are fully equipped with dedicated, mobile intensive care-type interiors, complete with sling and winch capacity and emergency floatation gear for operations over the sea – the aircraft each have the capacity for two pilots, three crew members and one stretcher.

With the extensive experience in the aeromedical environment across many different aircraft types, AMS has custom designed a medical interior for both the AgustaWestland 119Ke and the Eurocopter EC 130 B4 helicopter – the medical interior is a South African product that has been developed to meet world-class standards. The medical kit is

produced through a local manufacturer for a number of reasons, some of which include investing in the country’s economy, but it was also important to have local support from the manufacturer, which enables further refinement and customisation throughout the development phase. The medical interior is developed to allow for two pilots,

AMS has custom designed a medical interior for both the AgustaWestland 119Ke and the Eurocopter EC 130

B4 helicopter

Cape Town, South Africa

AIRAMBULANCE - WORLD FOCUS 15

a single stretcher/incubator and two medical crew members and also allows for a rescue capability.

Rural health outreach serviceThe heartbeat of the organisation is providing healthcare to all communities in need. The Rural Health Outreach programme provides effective and appropriate delivery of healthcare to the rural communities in and around KwaZulu-Natal (KZN) and the Northern Cape.At the break of dawn the PC 12 fixed-wing aircraft is pulled out of the hangars, packed and checked to start work for the day – the aircraft can accommodate nine seating patients or three stretcher patients and is utilised for air ambulance work and transporting healthcare personnel on the outreach service. Each morning at 7:00 am, the plane takes off with doctors and healthcare specialists onboard to fly to the outlying areas of each province in which it operates.Doctors and healthcare specialists contribute to the outlying healthcare facilities with specialist patient clinical consultations, surgery, teaching ward rounds and other capacity building efforts. Rural communities are afforded the services of specialists in the fields of surgery, optometry, ophthalmology, obstetrics & gynaecology, paediatrics, orthopaedics, plastic surgery to mention a few. With this programme, access to specialist healthcare is afforded to indigent communities and also helps to decrease mortality and morbidity rates of our people. The KZN service has also extended to operate a ground support unit. The ground support unit has access to areas that do not have landing strips and which are in close enough proximity to drive. Not only do patients benefit from this system, but the healthcare practitioners in the outlying areas receive training and support. The health referral system is refined and strengthened.

Roger Sedres Photography

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Air ambulance serviceThe air ambulance service compliments the local road ambulance services by providing rapid emergency aero-medical transportation of patients who are critically ill or injured. Both the PC-12 fixed wing aircraft as well as the helicopter fleet nationally (Eurocopter EC 130 B4’s and AgustaWestland aircraft) perform daily air ambulance services. The complete AMS programme has been formally evaluated through a Cost Benefit Analysis Study conducted by a health

economist – these studies were ratified by the National Department of Health. In a land characterised by vast distances, the AMS has become a vital conduit for delivery emergency and critical healthcare services to rural and urban areas. We work closely with provincial departments of health and health workers in the communities to assess needs and implement appropriate healthcare programmes. Our commitment to saving lives and changing lives knows no boundaries! n

Case Studies

While the sunset was slowly fading into the horizon of the Mother City, a call was received from the town of Stellenbosch. Two rock climbers had injured themselves while rock climbing in the Jonkershoek Mountains. One had fallen and sustained facial fractures, while the other was uninjured. Both came to rest on a surface no bigger than one metre in diameter where they found themselves underneath an overhang approximately 100 metres from the top of the mountain and secured themselves with safety lines against the rock face. Due to fading light and the patient’s profuse bleeding and inability to climb further, a request for help was sent out via mobile phone. AMS, together with

the Wilderness Search & Rescue (WSAR), immediately responded to the call for help. On arrival at the scene, the patient was in such a position where the helicopter had to hover a metre away from the cliff face – this left no margin for error! A rescuer was hoisted out of the aircraft, where he had to be pendullumed back and forth until he could reach the patient – this took about three attempts. The patient was secured on the scene and hoisted into the aircraft using a similar pendulum technique and taken to a secure location to receive medical attention. The helicopter then returned to pick up the rescuer and second climber, performing the same technique, during which both rescuer and climber were hoisted together. This was a rescue operation that would have

taken hikers five hours by foot to reach the patient and proves that quick and effective aeromedical evacuation can mean the difference between life and death, as well as save many hours getting professional medical help to patients.On another rescue mission, just off Seal Island, the owner and captain of a yacht was having a heart attack. Five people were onboard, of which only one person was qualified to steer the boat (the Captain) and CPR was administered by one of the vessel’s passengers while waiting for the helicopter to arrive. The yacht was spotted by the helicopter crew and under extremely difficult conditions (the yacht was pitching and rolling) the rescuer (who also happens to be a skipper) was hoisted onto the yacht to

manage resuscitation and steer the craft in the right direction. On initial assessment by the paramedic he found the patient already deceased. The rescuer secured the sails of the yacht while waiting for further assistance from the National Sea Rescue Institute (NSRI). The remainder of the passengers were taken off the yacht. NSRI placed another skipper onboard and our rescuer was hoisted back into the aircraft. While the life of one person could not be saved, the lives of four were saved. Teamwork plays a vital role in the existence of the AMS. The AMS works in partnership with the Department of Health in each of the provinces in which it operates, and various rescue organisations, to provide efficient and effective healthcare to all those in need.

Venessa Horn is the public relations officer for the Red Cross Air Mercy Service (AMS), an orgnisation that has grown into a remarkable and unique aero-medical service since its introduction in 1966. Working closely with the provincial departments of health to assist with delivery of healthcare services, the AMS has flown 6,521,334 kilometres and transferred 12,849 patients via its fixed and rotor-wing air ambulance service.

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Roger Sedres Photography

How important is the type of aeroplane used by your air ambulance provider? Is a jet always best, or do you just opt for the cheapest quote? Do comfort, safety and medical care feature in the decision? Mark Ponsford, general manager of CEGA Air Ambulance, compares the capabilities of three popular air ambulances and concludes that the choice of aeroplane can have a significant impact both in terms of service and cost. Coming under his scrutiny are: a jet – the Learjet 35, a turboprop – the King Air 200, and a piston engine – the Piper Chieftain

The basics – flight range and critical care capabilityWith varying flight ranges, these three aeroplanes, between them, will meet most transfer needs. At the budget end, the Piper Chieftain, whose range would roughly cover the distance from the Alps to central England, is not pressurised, so is normally unsuitable for intensive-care transfers. However, the Chieftain has the lowest operating costs of the trio. This makes it an economical choice for the short transfer of non-critical patients, who cannot be accommodated on commercial flights. In the mid-range category sits the King

Air 200, with a maximum flight range that covers the distance from the south of Spain to central UK, or comfortably further with a fuel stop. A popular choice for critical-care transfers, with large internal cabin space, the King Air is pressurised and can offer a sea level cabin pressure. This provides a safe air pressure for the most severely ill; such as a patient with a head injury or a respiratory illness.Like the King Air, the Learjet 35 is suitable for critical-care patients and offers a sea level cabin pressure. It can be used for mid-range transfers, but is considerably less economical than the King Air on its fuel

consumption. Its strengths lie in its long flight range – and it is the only one of the three aeroplanes that is able to carry out long-haul transfers.

Time in the air and flexibility on the groundFaster than the King Air 200 and the Piper Chieftain, the Learjet 35 is the clear winner in terms of flight speed; offering the patient the shortest time in the air. However, the Learjet’s speed advantage in the air can be counteracted by its inflexibility on the ground. Its reliance on large airstrips restricts its use to major airports, which

may not be close to patients or hospitals, and can necessitate lengthy and stressful road transfers. In contrast, the King Air and Piper Chieftain both have the flexibility to land in smaller spaces and on grass; allowing them to gain greater proximity to patients and receiving hospitals. Not only can this minimise patient stress, but it can also help to cut down on total journey time.But how important is time in the air to critical-care patients and does the King Air put these patients at risk by exposing them to a slightly longer flight time than the Learjet?

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Which aircraft

Aircraft Good for: Weaknesses:

King Air 200 Mid-range critical transfers; internal space; fuel economy; flexible take off and landing options; sea level cabin pressure

Not as fast as Learjet 35; limited flight range

Learjet 35 Mid and long-haul critical transfers; speed; sea level cabin pressure

Lack of internal space; high fuel consumption; need for large take off and landing space

Piper Chieftain Short, non-critical transfers; low operating costs; flexible take off and landing options

Not suitable for critical-care transfers; short range; relatively slow

King Air 200

Care in the airArpingstone

A good air ambulance service should not be defined by the length of time that a patient spends in the air, but by the qualityof his or her journey and of the care available while he or she is in transit. The effective transfer of care from one clinical team to another (for example hospital to air ambulance medics), the skills of the flight medical crew and the level of escort that the crew can offer – such as a hospital ‘bed-to-bed’ service – will be fundamental to a patient’s wellbeing.

Providing that the quality of this care is good, increased time in the air will not equate to an increased risk to the patient – particularly since (except in extreme emergencies) a patient will need to be in a medically stable condition before being able to fly anyway.

The inside storyWhat sort of environment do these aeroplanes offer to patients and their medical crews? Internally, it is space that

sets the Learjet 35 and the King Air 200 apart. With its wide cabin, the King Air can comfortably accommodate a critical-care patient, medical crew and relative with luggage (the latter both comforts the patient and saves the underwriter the cost of a commercial flight home). This still leaves space for medics to move freely around

the patient and for ventilators, monitors or bulky medical equipment to be loaded and operated with ease. Even in its twin stretcher configuration, the King Air does not feel cramped; with a curtain between the stretchers to provide patient privacy. In contrast, the sleek body that helps the Learjet cut through the air at speed comes at the price of reduced cabin space. This inhibits free movement around the patient and can hinder medical intervention, particularly around the back of the patient’s

head. The narrow cabin also makes it difficult to load and operate bulky intensive care equipment, while space for the relative may depend on the doctor’s decision on the day. When loaded with two stretchers, space inside the Learjet 35 is extremely cramped and, for this reason, not all operators choose to configure their Learjet

35s in double stretcher mode.Used for short, non-critical transfers, the Piper Chieftain does not rely on space in the same way as its more sophisticated counterparts, since in-flight medical intervention is not typically necessary. However, with the capacity to carry two stretchers, it is a low-cost solution for the double transfer of those who have sustained more minor injuries; such as skiers with broken bones, who can be accompanied by a nurse. n

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The facts at a glance

LEARJET 35 KING AIR 200 PIPER CHIEFTAIN

Max Speed:* 510mph/820kph 280mph/450kph 175mph/280kph

Max flying distance:* 2,485mi/4,000km 1,677mi/2,700km 745mi/ 1,200km

Stretcher capacity: Two Two Two

Pressurised: Yes Yes No

Landing distance: 1500m 800m 800m

*Disclaimer: These figures are manufacturers’ claimed figures. In reality, the claimed flight speeds are the aircrafts’ top speeds and if the

planes are flown at top speed their range will decrease dramatically. The maximum range is also dependent on maximum fuel in the tanks.

In reality, once the aircraft has been loaded with a patient, doctor, nurse, relative, medical equipment and baggage, the aircraft cannot take

off with maximum fuel in the tanks. This will obviously reduce their range.

Mark Ponsford’s interest in aviation was awakened at an early age by his father and uncle – CEGA’s sibling founders whose initials

gave the group its name (Clive Edwin and Graham Andrew). Today, after a decade with CEGA, Mark is the general manager of the group’s air ambulance division, operating from Bournemouth International Airport. He also holds a commercial pilot’s licence.

Faster than the King Air 200 and the Piper Chieftain, the Learjet 35 is the clear winner in terms of flight speed

In contrast, the King Air and Piper Chieftain both have the flexibility to land

in smaller spaces and on grass

Piper Chieftain

Learjet 35 Royal S King

John Olafson

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You’ve been with Skyservice for 17 years – what significant changes have you observed both in the company itself and in the air ambulance industry as a whole during this time?It has been an exciting journey. When I joined Skyservice, we had one base of operations in Montreal, one Learjet 35 and one Citation jet, and primarily flew from Baffin Island (also known as Iqualuit), Northwestern Territories, Canada, back to Montreal. This is where we developed our expertise in neonatal, paediatric and adult critical care transport, in addition to our flights from Florida, California and Arizona, repatriating sick and injured Canadians back home. As the company grew, we added an

additional base in Toronto and four additional medically dedicated Learjet 35s. Our ventures abroad introduced us to the international travel insurance marketplace and we have spread our wings across the Atlantic and Pacific. Through our association with McGill University Skyservice has developed and implemented aviation medicine programmes and a fellowship in aviation physiology.The industry continues to grow and evolve with new players emerging in all four corners of the globe. This growth affords the assistance and insurance marketplace options in parts of the world that did not exist previously, which is excellent for them, giving them better services and options for their patients. In the North

American market, when new providers enter the marketplace, they drive the pricing down for a short period of time and do not necessarily deliver a high-quality product, and then eventually grow or disappear totally after a few years.

How do you see the recent acquisition of Skyservice Air Ambulance by American Medical Response affecting operations (assuming it is given the go-ahead by Transport Canada) and do you envisage the two air ambulance specialists merging or remaining in competition with each other?The proposed acquisition would not affect the medical and aviation operations of Skyservice Air Ambulance in the initial phase; both parties would remain independent. Over time, we will evaluate synergies to enhance our service, improve air medical transport and our offerings to both the travel insurance

industry and our customer base. This will only happen over time. As a point of clarification, Skyservice Airlines was sold in August of 2007 to an investment group – Skyservice Air Ambulance is a business unit within Skyservice Business Aviation and was not part of that purchase agreement.Your company introduced the first fuel efficient Boeing B-757 in Canada in 2007 – what else is planned reduce the firm’s carbon footprint?In 2008, we outfitted 60 per cent of our fleet with the ZR light kits, which created increased fuel efficiencies of approximately five per cent. We also upgraded our engines from 2B to 2C models; these engines can run at higher temperatures, which helps improve engine performance. The preferred aircraft in the air ambulance industry today remains the Learjet 35 – a 30-year-old aircraft design. There are more modern aircraft out

Clear skies aheadITIJ spoke to David Ewing, vice president of international business development for Skyservice Air Ambulance, about how the industry has developed over the years, as well as weightlifting and winning the lottery

I love Law and Order, I guess I am lucky as there’s always a marathon of them on when I am ready

for some TV time

AIRAMBULANCE - PROFILE 21

there, which are more fuel efficient with at least a four times the cost of acquisition but, unfortunately, this situation does not make this business model viable.

In less than 25 words, what is Skyservice all about?Quality, safety, respect, commitment and efficiency are the core values guiding the company to build and continue its reputation as an industry leader.What aircraft do you operate and what benefits do these provide clients?

Skyservice Air Ambulance operates a fleet of five Learjet 35s, which are all permanently dedicated to air medical operations. The aircraft have all had extensive modifications, including radio and satellite communications, and are equipped to offer clients a safe, cost-effective means of transport – from the smallest of neonates to the ventilator-dependent, aortic balloon pump patient. Skyservice Air Ambulance also has access to, and has used, aircraft as large as an Airbus A-320, Challenger, and Global Express as and when required.

How did you come to work in the air ambulance industry and how did you end up in your current role at Skyservice Air Ambulance?My jump into the air ambulance industry was a natural progression from careers in the fire-rescue service and as a supervisor of a large metropolitan land ambulance operation. Prior to my current position, I worked for another air ambulance provider, which at that time was owned by a European travel insurer and assistance company. From that opportunity I met Russell Payson and Peggy Zafiris, the owners of Skyservice, and was offered an opportunity to join the company.

Where do you see the company in another 20 years?The first 20 years have been exciting, fun and unpredictable; we hope the next 20 will be even more so. We want to continue to be innovators within the air medical transport community, and as technology evolves, we hope to be capable of real-time telemetry of patients in flight, which will enhance and improve patient care. We’d also like to expand our physical footprint across the globe.

Where were you born, where were you educated, and where do you live now?I was educated in Pittsburgh, Pensylvania, and have lived in Toronto and Ontario in Canada. I currently reside in Miami Beach, Florida, with my pug dog, Fitch.What are you most proud of – personally and professionally?Professionally, I am proud to be part of a team that makes a difference every single day to someone, somewhere, in need of our help to either get them to a higher level of medical care or back home; our teams work hard day in and day out to make that difference and playing some small part in that is very fulfilling. Personally, my accomplishments in school and the volunteer work I did, which led me to bigger and better accomplishments in my life.

If you could work in any other role or marketplace, what would you be and why?I think I would return to the emergency services. I live in the city and when I see the fire engines, rescue units and EMS helicopters responding to accident scenes, I do miss the adrenaline rush.

What is your guiding philosophy?I have a ‘how I can help?’ attitude. For me, changes present opportunities and

those surprises along the way make things more interesting. What do you like to do in your spare time?I enjoy college football, basketball and weightlifting. Living on the beach presents many opportunities for those activities, as well as plenty of restaurants, shops, and interesting people and, of course, lots of celebrity watching. I try to get to Honolulu, Hawaii, every year for some quality rest and relaxation time.

What’s the worst job you’ve ever had to do, and how long did you last? That would be a short, eight-hour shift as a health food store clerk. One stock of the shelves and I knew it was not for me!

What’s the first thing you would do if you won the lottery tomorrow?It would be to find a great financial advisor first, purchase a dream home/condo – probably in Miami Beach and Los Angeles … and then to become an investor in my company.

What’s your favourite TV series? I love Law and Order, I guess I am lucky as there’s always a marathon of them on when I am ready for some TV time.

What is the first single you ever bought?I think it was the Pet Shop Boys … don’t know the song though! n

The industry continues to grow and evolve with new players emerging in all four corners of the globe. This growth affords the assistance and insurance marketplace options in parts of the

world that did not exist previously

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I was so excited about starting my new position as an in-flight nurse that I hadn’t even considered the challenges of coming from the UK’s National Health Service (NHS) to the private sector and into a

completely different aspect of nursing. The main difference I have found from the NHS is that you are more autonomous. On a repatriation flight, no-one else can see the patient. People on the ground

are relying solely on your judgements, so can only offer advice based on your findings (for example, the company doctor by phone), but at the end of the day it’s your decision and your actions

that determine the patient’s outcome. For me, this is part of the excitement of the job: being autonomous gives you more responsibility, although it can also bring additional stresses.

One-to-one careOn the positive side, you are able to do a lot more for your patient on a level that is not possible on a busy ward. You have time to care for your patient on a basic level and listen to their worries and concerns. The culture abroad is often different, and in a lot of countries, it is left to families to do the basic care. So, especially if your client is alone, there is so much a nurse can do for the patient that will make a big difference to how they feel – for instance, you can help wash a patient, wash their hair or even just comb it.Another significant difference is that patients are always pleased to see you and so appreciative of your work, even if you feel like you haven't assisted much. It means so much to them to be able to go home. I have had patients say to me: “Thank you so much for coming all this way, especially for me.” As we all know in the NHS, more often than not it is the complaints that we hear about most!

Getting to grips with logisticsIssues that may arise on a repatriation flight are often logistical rather than medical. NHS work does not prepare you for this – it comes with experience! Much of the time, you cannot do what you would ideally like to and an alternative or compromise needs to be found, which can be especially tricky when dealing with foreign authorities.Also, a lack of equipment or resources can result in having to improvise to achieve the best level of care possible. Things that are readily available to you in a hospital are not there on repatriations, so you have to put your thinking cap on.

A question of insuranceThe other side of flight nursing is the office-based assistance. We are governed by what the patient’s insurance policy covers them for, and this can limit what you can do for them. It can be extremely difficult, especially when you have relatives crying down the phone to you, begging you to do

Fasten your seatbelts!The challenges of making the transition from ground to flight nurse are part of the fun. Joanne Mayhew,

a flight nurse with AXA Assistance UK, writes of her experience of moving into a new field of practice

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what they wish for their relative, whereas in the NHS we will be doing everything we can for the patient regardless. Tying in with that is having to deal with clients who for some reason or another are not covered at all by their policy – for example, they didn’t realise they had to declare their past medical history or were injured or became ill under the influence of alcohol or drugs.

Also, in the assistance company office, one of the main differences from the NHS is the amount of computer work. The whole day in the office is computer based, so you need to have basic computer literacy skills.In the NHS, we know how hard it can be sometimes to track down a doctor – now, as an in-flight nurse, I have to factor in thousands of miles and foreign languages! Yes, this is an extremely challenging area of nursing, and once you get the doctor on the phone you have to make sure you ask all the relevant questions to enable the case to move forward, anticipating what information our doctors require.

ConclusionIt’s been a huge learning curve for me, especially when an evacuation needs to take place, to decide where the nearest centre of medical excellence is, knowing what facilities are available and where. Now, thankfully, a few months later, it is becoming a whole lot easier.But of course, the challenges are all part of the excitement of taking on the role of an in-flight nurse. I have enjoyed every minute of it so far and look forward to many more adventures in the future! n

Article courtesy of RCN Critical Care and In-Flight Nursing Forum

Joanne Mayhew began her nursing career working in trauma and orthopaedics and medical admissions, later moving to a vascular and general surgical ward. After working on a cardiac ward, she moved to the intensive care unit. For two and a half years, she has been working for AXA Assistance as a flight nurse, and has completed the Clinical Considerations in Aeromedical Transport (CCAT) course and the Immediate Life Support (ILS) course, updated yearly.

Issues that may arise on a repatriation flight are often logistical

rather than medical

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Tractor triageCaroline Pearman examines the problems faced by ground ambulance providers when administering aid in a third-world country

It is extremely difficult to explain to anyone from a first-world environment that there are areas in the world where the concept of ‘emergency’ does not exist, or why

such a concept is actually inconceivable. It seems unimaginable that there are places where ambulances can make more money and are busier carrying the dead than saving the living. One only has to spend some time in the hot, crowded and overwhelmed outpatients department of any hospital in Africa to realise that there is no point in hurrying urgently to get

someone to a place where they will have to wait indefinitely in order to get the help and treatment they require. Twelve years ago on a street in Ghana I saw someone drag a person away from a car accident victim while he was trying to perform CPR, saying that dying is God’s will. Now, 12 years later, the local Red Cross in Ghana is running a campaign

in small local villages to train people in basic CPR techniques along high-risk locations where many highway accidents occur. These are hopeful signs that Ghana is developing a healthy and much needed consciousness of emergency care, but the country still has a long way to go.The government of Ghana has done an excellent job in arranging the well-

equipment anyway for continued care. The West Africa Rescue Association (WARA), although a private ambulance service, has been, and continues to be, involved in the training of the National Ambulance team to help it reach first-world standards of emergency care as far as possible. WARA’s fleet of nine vehicles is currently alone in providing patients with advanced life support and care to an intensive care unit (ICU) level. Ghana is, in fact, the only country in West Africa besides Senegal that can provide the safe and reliable transportation of fully ventilated patients. WARA’s paramedics are internationally trained in advanced life support and are equipped with the 'full monty' of medical

and rescue equipment from abroad to be able to do their job. WARA has also been requested to provide ICU transportation for many government and military personnel between major hospitals; most of the company’s ground ambulance services include 24-hour rescue response to registered members who are affiliated to WARA privately, or through

large corporate organisations, embassies, schools and hotels. Unfortunately for the general public, one can expect little else in the average ground ambulance in West Africa other than a fairly empty vehicle with a stretcher and little else. Sadly for highly critical cases, this places patients requiring urgent transportation to hospitals at a high risk. Traffic congestion creates huge challenges for many of the local ambulances services and, being ill equipped, little stabilisation can be performed before, or during, transportation. However, despite the lack of facilities available, it would be completely mistaken to assume that current local ambulances

services in West Africa do not save lives. In fact, many areas have come up with highly unique solutions for local challenges, which are very area-specific, such as that seen at the small hospital I visited in the northwestern area of Ghana, in a village called Bole. In this village, many women inadvertently tread on a Carpet Vipers while they walk through the fields to collect

AIRAMBULANCE - WORLD FOCUS 25

Tractor triageorganised Ghana National Ambulance Service, with its fleet of over 40 ambulances, to assist in developing a professional public ambulance service. They have strategically placed ambulances at various key positions at remote high risk roadside villages for rapid responses. Road traffic accidents are responsible for an overwhelming number of deaths in

Ghana. While the National Ambulance team of medics is well trained, it lacks sophisticated equipment to be able to achieve advanced levels of emergency care. At this stage even if the team was equipped with defibrillators, monitors and ECG equipment, for example, the emergency rooms medics transport their patients to are mostly lacking in such

Unfortunately for the general public, one can expect little else in the average

ground ambulance in West Africa other than a fairly empty vehicle with a

stretcher with little else

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water – this viper is potentially lethal as it causes hemolytic symptoms and patients begin bleeding out within 24 hours of a strike. Because the environment is underdeveloped and most of the attacks occur in the fields where no roads or infrastructure exist, the best ambulance response is a tractor with a trailing box, which transports the snake’s victim to the very poor, but highly helpful, district hospital. Here, an average of 50 cases of snakebites are seen every year, of which there are usually one or two fatalities.

Field ambulances It is without question, however, that in comparison to the highly sophisticated ground ambulance rescue services found in first world environments, West Africa, like most of Africa, has a long way to go. The concept of WARA was founded six years ago with the goal of proving that it is possible to operate a highly sophisticated ground ambulance rescue service in a third- world environment. It was the company’s hope that having such a service in a largely medically deprived environment would act as a lever to launch a better

concept of emergency care and what people should strive towards. Not only has WARA proved an extremely successful business model, but it does constantly fulfil this goal by providing a launching board for local training and skills sharing opportunities through the corporate responsibility and training programmes, which we are involved in. In addition, WARA has extended its services over the last few years to include operating emergency air rescue services throughout Ghana and into nine countries in the West African region. Until now, there were no official bodies to regulate and standardise emergency care, ambulance response or workers, but even this is now advancing and changing in Ghana and the country will certainly be moving in the right direction with regards to the development of ambulance services.One of WARA’s biggest challenges is the unavailability of reputable ground ambulance services in the poorer countries surrounding Ghana from which we regularly evacuate people by air rescue. Moving

any patient is extremely risky, and if this is done inadequately or incorrectly, can be uncomfortable, but can also jeopardise the safety of the patient. For this reason the WARA team does not frequently take the risk of relying upon local solutions for unstable cases in Ghana’s foreign surrounding countries unless there are no other solutions available to move patients safely within these environments. In these cases the team takes a full set of equipment with it so that they can be prepared to fully equip the local ambulance provided at remote hospitals, and then accompany the patients using WARA equipment back to the airport where they can then fly them out of the country to Accra for further treatment.Currently, WARA is the only reputable ground ambulance service provider that can provide international insurance companies with the reassurance of standards in both equipment and medical personnel, as well as providing immediate ground ambulance response within Ghana, 15 minutes after a guarantee of payment has been issued. n

It is without question, however, that in comparison to the highly sophisticated

ground ambulance rescue services found in first-world environments, West

Africa, like most of Africa, has a long way to go

Caroline Pearman has worked in the West African region for the past 12 years, gaining significant experience in local healthcare challenges. She has a nursing diploma, a BSc degree with honours in education, and a Canadian Masters in counselling psychology. Caroline is head of the counselling department with West African Rescue Association, where she sees patients for psychotherapy, crisis management and trauma counselling.

AIRAMBULANCE 27

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EASTERNPROMISE

Steve Earle takes a closer look at air ambulance provision in Japan and the problems faced by the industry

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Air ambulance services in Japan, as is the case in most other countries, rely predominantly upon private operators to supply and operate the required aircraft; yet relative to the size of Japan’s population and its economy, the number of such operators and their aircraft is surprisingly small. By way of illustration, the UK, which has 64 per cent of the land area, 48 per cent of the population, and 55 per cent of the gross domestic product of Japan, has approximately five times the number of private aircraft – this does not include air ambulance aircraft. This comparison, however, is less surprising when viewed within a regional context, for private aircraft are equally few and far between among Japan’s East Asian neighbours, as well as within Asia in general – even in China, a country whose vast territory and enormous population place high demands on air travel (the International Air Transport Association currently lists some 21 China-based commercial passenger carriers – exclusive of Hong Kong-based carriers). Emergency Assistance Japan’s (EAJ) Beijing operations report a total of only seven lease operators and approximately 25 civilian aircraft suitable for medical air transport purposes.Japan’s shortage of private aircraft is partially due to historical and social factors, but it is especially tied to geography. Viewed from the air, Japan’s major population centres fall one after the other like a single string of dots, making for some of the most heavily travelled air traffic lanes in the world. Meanwhile, on the ground, its airports are almost all operating at or near the upper limits of their capacities, and the premium on hangar space makes the costs of keeping and maintaining smaller aircraft for private business use almost prohibitive.The leader among Japan’s charter aircraft providers is Nakanihon Air Service, operating out of the Aichi Prefectural Nagoya Airport. The company owns and operates 57 helicopters and 17 winged

aircraft, including two Cessna Citation V business jets. Nakanihon plays a major role in the delivery of emergency medical services by helicopter. Maintaining helicopters in 16 locations from Hokkaido to Okinawa, it has landed doctors and medical teams in earthquake and typhoon disaster areas, as well as participated in highway, mountain, and other rescue operations. Nakanihon’s Citation Vs are dispatched to pick up and transport patients both within Japan, and from international locations back to Japan under the co-ordination of Emergency Assistance Japan and with qualified medical teams from Japanese hospitals. As is to be expected, most of Nakanihon’s international pickups occur in China, Korea and Taiwan.According to Misao Nagae, general manager of Nakanihon’s International Business Aircraft Enterprise Division, the challenges facing his industry are not so different from those facing other Japanese, or for that matter, other global industries. They include rising energy and fuel costs; rising compliance costs associated with increasing regulation; the effects of economic deflation (although this has had a stabilising effect on the cost of aircraft); employee training, retention and motivation; and the pressures of international competition.The small aircraft industry, Nagae further explains, is affected by technological and regulatory changes to aviation at large. The advent of GPS-based navigation and Japan’s MTSAT-based aviation control has greatly reduced the mandated above-below, right-left, and forward-aft clearances between aircraft, making it possible to put even more aircraft in already heavily trafficked air lanes. Just to stay abreast of such advances requires major capital expenditures in aircraft retrofitting and pilot training from small aircraft operators.Likewise, the forces of globalisation present constant challenges. The bar has been raised on the qualifications of pilots flying

internationally, especially with regard to English communication skills, g and Nakanihon is constantly upgrading its communications and staff capabilities to better accommodate quick and accurate assimilation of flight and landing-related information, even from the more remote corners of the Asian continent. They are also working towards ever-higher levels of readiness and shortening of response times around the clock.Use of Nakanihon’s aircraft in medical

transports is typically precipitated by a call from either a hospital doctor or an assistance company, such as EAJ. Its Citations are readily convertible into air ambulances by removal of seats and installation of stretchers, oxygen, and other medical equipment. Doctor/nurse escort teams and their equipment are provided by the hospital or by EAJ, which has performed over 800 medical transports, including over 90 involving the use of private aircraft.

patient care while airborne requires skills that can only be gained through special

training and experience

Nakanihon Air Service’s Bell 430 descending for landing at Yao Airport, Yao, Osaka Prefecture, Japan Jo/wikipeda commons

AIRAMBULANCE - WORLD FOCUS30

Patient care whilst airborne requires skills that can only be gained through special training and experience. Conditions such as sudden and unpredictable aircraft movement and variable cabin pressure, as well as space restrictions and equipment limitations, can test the medical judgment of the most seasoned medical professional. EAJ participates actively with Japanese university hospitals to provide opportunities for such training and experience to their staff, and as a result the company can now count 33 physicians and 57 registered nurses on its ready-to-fly roster.In closing, a recent development worthy of note is the decision by Japan’s Ministry of Economy Trade and Industry (METI) to take up the cause of making Japanese medical institutions more accessible and more user friendly to potential non-Japanese users. Under the METI-sponsored initiative, a number of prominent Japanese hospitals, together with EAJ as a key service intermediary, have joined together under a consortium whose purpose is to establish Japan as a regional player in the growing medical tourism market. This development is likely to contribute to an increase in demand for medically assisted transports, including air ambulance transports, from China, Korea, Taiwan, Mongolia, and the Russian Far East to Japan, as patients in those areas seek specialised medical care not readily available to them at home. n

Doctor/nurse escort teams and their equipment are

provided by the hospital or by EAJ, which has performed over 800 medical transports, including over 90 involving the use of private aircraft

Steve Earle is executive vice president of Emergency Assistance Japan (EAJ), a Tokyo-based medical assistance company with operation centres in Asia, Europe, and North America. Steve has almost 40 years of business experience in Japan and Asia. He currently works out of EAJ’s North American operations centre in Richmond, Virginia, US.

PROFILE 31

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Himalayan challenge: The Zanskar ValleyEvery year, thousands of international tourists head to the mountainous regions of India for the stunning scenery and unique adventure holiday experience. Dr Pradeep Bery of Meera Rescue details the challenges of operating a rescue service in the region, and gives his own insight into two different retrievals

The challengeTo evacuate seriously ill or injured tourists from the Himalayas.The geographyNorth Western Himalayas. Leh (Ladhakh) on one side; the Zanskar Valley in between and Manali on the other side.Average altitude13,000 feet-14,000 feet.Who goes thereAdventure holidaymakers are really the most common tourists – backpackers and trekkers, in particular elderly French trekkers who want to walk the frozen rivers of Zanskar!What goes wrongAmong the most common illnesses we see are gastroenteritis, acute mountain sickness, cerebral edema, headaches diagnosed as cerebral edema (the most expensive type of headache!), fractures

(rare for some reason), and sadly, we do see the occasional death.Medical facilitiesThere are some few district hospitals along the way – although most have little or no facilities. There is one hospital in Leh, which is government-owned, free, and has virtually no equipment, although it does have oxygen and lasix equipment and staff who know how to use it. Manali has a basic hospital.Available transportationDonkeys, human backs, some trucks if you are near a small town with roads to it, no ambulances, no taxis.

Case study – The army lends a helping hand:The tourist in this case was part of an organised tour that, thankfully, had travelled with a satellite phone. The patient was 74 years old, had just come out of remission from prostate cancer, and had decided to do a trek on the frozen rivers in the region, which are spectacular. He was suffering from acute mountain sickness, a sprained ankle and, of course, he did not speak a word of English. He was in the middle of the trek, with the nearest road over 60km away and the porters were needed for helping the other trekkers. Consequently,

the only way to evacuate him was by helicopter. We could not send a normal commercial helicopter, as the pass to enter the valley is at an altitude of between 15,000 and 17,000 feet. So, we needed the help of the Indian Army. There is a swift procedure already in place whereby we contact the Embassy, the Military attaché contacts the Ministry of Defence, who clears it with the Ministry of External affairs and then the Army is activated. We then pay the Army for the use of their equipment.

The only helicopters the Army uses are Cheetahs, which can fly at the high altitude required. We could not send any medical crew in the helicopter as they won't fit, but they do carry oxygen. Two Cheetah helicopters have to fly together for operational reasons and they cannot stop the engines when they land, as they may not start again at such a high altitude. Of course, this is dependent on the weather, which has to hold, and even then the evacuation can only be done early morning!

An Indian Army Cheetah helicopter Erwin van Dijkman/Airliners.net

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The helicopter located the patient after one hour of flying over the valley. He was dumped at the Leh airfield for us to do basically what we thought was best for him. He was frost bitten, as well as having both a pulmonary and cerebral edema. Luckily, we had an aircraft waiting to bring him to Delhi. If there had been bad weather, a delay in finding this patient, or for some reason having to admit him in Leh, would have led to a different outcome. We have had a few such cases deposited at the airfield wrapped in gunny bags; that is the risk!

Risky flyingThis case involved a young Spanish boy who had been riding on top of a bus in Kargil, when he fell off it, suffering multiple subdural haemorrhages. It was the days of militancy – during the Kargil conflict in 1999, Indian and Pakistani troops clashed in the Kargil district of Kashmir.I took a Bell 407 from Delhi, which happened to be coloured green. When we were coming in to land in Kargil, though, they thought we were a military aircraft and started taking pot shots at us. However,

having just about landed safely and explained who we were, we put the patient onboard the helicopter. Just to add to the concerns, as soon as we hit the pass, the pilot told me that this was the first time he had taken this chopper to this altitude ... and then suddenly the patient had a seizure. So, in between the clouds, the turbulence and the fear that the engine might stall, we were also trying to control the patient's seizure.In India at the time, you could not land a helicopter after sundown and we were running out of time. If we flew the regular route we would not make it. However, we were lucky enough to have an ex Air Force pilot flying the aircraft, who obtained permission to overfly the strategic airfields to land in Delhi, a mere two minutes after sundown.The good news is when I went to Barcelona for the International Travel Insurance Conference a few years later, the patient came to my hotel with his family, one full leg of Serrano ham and six bottles of red wine!

Moral of the story: There has to be a god. n

Dr Pradeep Bery is the director of Meera Rescue in India, and has been in the assistance business for 17 years. During this time, he has had many happy adventures thanks to the wonderful people who travel to India. He hopes to retire in eight years and spend the rest of his life on a beach with his wife, and smoking vintage cigars.

When we were coming in to land in Kargil, though, they

thought we a military aircraft and started taking pot shots at us

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Free strip searchITIJ spoke to Chris Connor of Lifeflight who reported on an interesting experience at airport security recently.One of the company's medics was sent to Phoenix from Vancouver for medical

escort duties. At the airport he was stopped and swabbed for explosives – nothing special in these times of paranoid security. Trouble is, he tested positive. Consequently, the explosive doctor was taken aside and taken apart for a thorough explosives hunt – inside and out. However, they found nothing because they were looking in the wrong place(s). The test was positive

because, at work that morning, the Doc had sprayed his hands with medical nitro spray, giving an identical test result to nitro-based explosives. Still, the story gave his colleagues a lot of entertainment, which was very generous of him…

NoxiousBakersfield airport in California was recently closed for a similar explosives alert. Examination of a passenger’s suspicious lemonade bottles gave positive results for explosives, and staff reported feeling ill from the fumes given off by the contents. Medics were called and the staff and bottles’ contents thoroughly investigated. Quite a buzz had been created by this time. Which wouldn’t bee

surprising – since it turned out the bottles contained honey, being taken to relatives. In spite of this sticky ending, the nausea of the staff remains a mystery.

Buzzing offA medic had arrived in Spain in order to bring a heart attack patient back to the UK. He found his patient, and went off

to sort out the paperwork and drugs for the journey. When he returned, his patient was gone. Nothing remained but an empty bed. He hadn’t seemed that ill. Spontaneous combustion, perhaps? Passing aliens? Or perhaps he’d been blown up by exploding honey. Ignoring such reasonable possibilities, our medic rushed out of the hospital just in time to

see the doors of an ambulance closing and his patient speeding off down the road. But where to? Rejoice. There’s a double happy end to this one. Not only was the patient found at the airport, but the medic was able to hail a passing taxi and say the deathless words “follow that ambulance…” Haven’t you always wanted to do that?

Devastatingly AttractiveAnd finally ... important attributes. And Captain Dominic James has both. First off, he’s Australia’s devastatingly handsome pin-up pilot, voted Bachelor of the Year by the country’s Cleo Magazine. The perfect person to fly jets in a caring way, wouldn’t you say? And the devastating part? Well, not long after he received the magazine’s ultimate award, he was in the left-hand seat of a Westwind jet on a night ambulance flight from Western Samoa to Norfolk Island. Weather on arrival at Norfolk was atrocious and after four aborted landing attempts, he decided fuel was too low to risk an engine failure and ditched in the sea. Which he did with complete success, not killing anyone at all and breaking his aeroplane into only two parts. So, two things you need to handle a jet ambulance: be devastating, and attractive. Oh, yes – and use all your charm on your Civil Aviation Authority, because they’re currently asking why he didn’t have enough fuel. Ah well, nobody’s perfect.

Biggles Jet GigglesThis column normally tells of things that happen to colleagues who beat up the sky with aerial egg-whisks. This special edition explores the different world of the jet jockeys. How different? Well, clearly the world of jet ambulance flying is not one for mere everyday mortals

Ian Lewis is a writer and film maker. He has had four books published and regularly writes for magazines on subjects including aviation. As a film maker, he has written and directed over 350 different productions, including training and promotional work for aviation, medical and military clients.

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EuramiAt last year’s International Travel Insurance Conference (ITIC) in Athens, Greece, six air ambulance providers received accreditation documents during the members’ meeting, which was attended by more than 50 people. An increase of annual accreditations – 18 accredited providers worldwide, several providers for audits in the pipeline and 86 members – demonstrates the increasing attractiveness of EURAMI accreditation for air ambulance providers. Two providers have been audited since the ITIC in Athens and the board’s decision is expected in April.The following companies have current accreditation, which began in 2010, many of which are outside the European continent:

Norsk Luftambulanse AS•REGA Schweizerische •Rettungsflugwacht FAI rent-a-jet AG•AMREF Flying Doctor Service•International Medevac Services•Skyservice Aviation Incorporated•American Care Air Ambulance•ADAC Ambulance Service•Bangkok Airways / Bangkok •HospitalAir Ambulance Professionals Inc.•Aero Jet International•MedCareProfessionals GmbH•Air Ambulance Worldwide•Fox Flight Inc.•Air Med International•JET ICU (Worldwide Aircraft •Services Inc.)

Some of the providers have held their accreditation for more than three years and therefore re-accreditation is necessary – all of these providers are now in the process of re-accreditation. The re-accreditation programme should not exceed one day and the main focus will be on findings, including suggestions for improvement identified during the previous accreditation process.It might be questioned why EURAMI accreditation became so popular on almost all continents of the world – nobody really likes to do paperwork for quality management, being assessed by external auditors, receiving advice from someone else or paying money. During the members’ meeting some of these advantages became apparent and are summarised briefly below:

audits by experts in the field;•acceptance of internationally accepted •certifications;constant improvement process;•quality assessment based on the •patient’s needs;reduction of visits by clients;•advantages in international business;•co-operation with other EURAMI •certified companies, like wing-to-wing transports, exchange of medical crews, etc; andbetter acceptance in tenders•

Differentiation of accredited providers and membersThe differentiation of accredited providers and pure EURAMI members has been

identified as a crucial area of examination by the board members, as abuse of accreditation seems to be common in the industry. Some members try to infer that they are accredited providers by using just the EURMAI logo. To avoid this, the logo will be used in a different style in future, with an additional phrase added to it mentioning accreditation.

Website relaunchThe relaunch of the EURAMI website went live at the end of March. The new version, which includes a world instead of a European map, provides more information on accredited providers, including a map spot with accreditation date, fleet information and web link. In addition, accredited providers have the opportunity to create their own specification sheet for download purposes. Members will receive a password for the member’s area only after payment of the annual member’s fee.With the support of Dr Laurent Taymans, two online tools are now available:

accreditation 4.0 (online self •questionnaire); ande-learning tool on aero-medical topics •(added after input from members and affiliated international experts)

These new tools will improve the accreditation process and will allow members to train their medical crews in a standardised way, across the world.

The next members’ meeting with elections will be held at this year’s ITIC in Istanbul, between 8 and 11 November. Members’ meetings are open to the public and non-members are invited to attend to find out about the spirit and advantages of EURAMI membership. n

Dr. Michael Weinlich is chief executive office of Med Con Team, Germany, president of the European Aero-Medical Institute (EURAMI e.V.) as well as a general surgeon and emergency physician. Weinlich has been president of EURAMI, a worldwide accreditation body for air rescue providers, since 2000. In summer 2007 he founded Med Con Team, an independent assistance company with a special focus on medical quality and consultancy. He holds a teaching position at the university hospital in Frankfurt, Germany, and was co-founder of the simulation centre at the university hospital.

CAMTSITIJ spoke to Eileen Frazer of CAMTS to catch up on what the organisation has been doing over the past year.

In 2010, we added two new member organisations to our board of directors. One of those was US Transcom, the division of the US Air Force that arranges for fixed-wing transports with civilian companies. The US DOD requires CAMTS accreditation as a pre-requisite for contracting with US Transcom. The other organisation is the Air Medical Operators Association (AMOA) – an organisation made up of EMS aviation operators in the US.

In 2010, we will publish our 8th Edition of the Accreditation Standards. The drafts have been posted on the website since October 2009 and the Standards Committee plans to bring the suggestions for change to the full Board of Directors at the April 2010 meeting in San Antonio. All comments and suggestions are welcomed.CAMTS is a non-profit organisation dedicated to improving the quality and safety of air medical transport services through a voluntary accreditation process. The Commission believes that the two highest priorities of a medical transport service are patient care and safety of the transport environment. n

Angel One – Little Rock, AR (FW/R/G)Air Ambulance Specialists, Inc. – Englewood, Co (FW)HealthNet – Charleston, WV (R)Life Air Rescue – Shreveport, LA (R) Life Flight – Pittsburgh, PA (R/G)Life Flight of Main – Bangor and Lewiston, ME (R/G)Northwest MedStar – Spokane, WA (R/FW/G)St Mary’s FlightCare – Saginaw, MI (R/G)

New accreditations:Dove Flight – Indianapolis, IN (R)LifeMed Alaska – Anchorage, AK (FW/R/G)Miami Children’s Hospital LifeFlight – Miami, FL (FW/R/G)PANDA Transport – Portland, OR (FW/R/G)University Hos§ pitals MedEvac – Cleveland, OH (R)

Eileen Frazer RN, CMTE, CLNC, is executive director of the Commission on Accreditation of Medical Transport Services. In the past, Eileen has served as chair of the ASHBEAMS (now the Association of Air Medical Services), and served on its safety committee from 1984 to 1990.Key – FW= Fixed wing; R=Rotary;

G=Ground transportation