Over the past seven years, Europe has been presented with a perfect storm of geopolitical issues. From the UK voting to leave the European Union (EU) to the Covid-19 pandemic, and now the ongoing conflict between Russia and Ukraine, the world has become incredibly complicated. However, air ambulance services and assistance companies have simply had to weather the storm, adapting to new operating environments and regulatory changes.
Brexit means bracing for change
On 24 June 2016, 51 per cent of the UK electorate decided to leave the EU. This was an unprecedented situation, affecting more than just those directly involved in politics. But how was the work of air ambulances and assistance companies affected by the monumental decision of one country?
For air ambulance service UNICAIR, based in Germany, the uncertainty around Brexit had a direct impact. “The fact that Britain withdrew from the EU made aviation operations more difficult and added a certain level of uncertainty for foreign air operators wishing to base a non-UK registered aircraft in the country,” UNICAIR Chief Commercial Officer, Eva Kluge, explained.
The fact that Britain withdrew from the EU made aviation operations more difficult
However, Kluge also noted that all of UNICAIR’s aircraft operate in a floating base system, ‘to offer clients more competitive pricing, to reduce environmental impact and minimise activation times’, so the closure of the company’s UK operations in Birmingham has not affected it significantly.
For Johannes Hoischen of Malteser Aeromedical and Philipp Schneider at Quick Air, reacting efficiently has been key. “By exiting the EU, the UK also left the European Union Aviation Safety Agency (EASA), which has led to direct consequences in patient and passenger transport for all carriers,” they said. “Quick air was granted a permanent foreign carrier permit, which allowed for us to continue operating into the UK. In addition, Quick Air also obtained a block permit, which enables us to fly into UK airspace, even with short notice.
“Generally speaking, the administrational efforts to maintain these permits and thus continuing to operate into the UK is significantly higher than before, as British authorities have high expectations when it comes to the quality criteria and documentation of operators. At Quick Air and Malteser Aeromedical, we do think, though, that this is worth the effort, in order to assure a seamless operation into the UK for national and international clients,” they concluded.
Volker Lemke, Managing Director of Germany-based Flight Ambulance International (FAI), reported little to no impact on air ambulance operations: “Strictly speaking, the issue of Brexit has hardly hindered us in any way,” he said.
However, Lemke admitted that some processes have become complicated. “Landing permits, for example, are a bit more difficult to obtain and we suddenly became aware of the issue of cabotage (transportation of goods between two places in the same country) and the conditions in the aircraft insurance market changed,” he said.
Lemke added: “Of course, administrative processes have become more complex due to changed rules and regulations, but after a short period of getting used to it, everything was managed well.”
FAI were not the only ones largely unaffected by the UK’s departure from the EU. Dr Finn Morgan, Group Medical Director of UK assistance services company Healix, said, ‘Brexit has thankfully had no significant effect on air ambulance operations’.
Quarantine requirements limited how long crews could stay in certain countries
So, administrative changes have been identified as the obvious challenge, yet these have been addressed and continue to be managed. As summarised by Lemke: “I don’t think our part of the aviation industry has had any major negative impact from Brexit.”
The World Health Organization (WHO) declared Covid-19 a global pandemic on 11 March 2020 – and the effects are still being seen today. Everyone suffered, but in particular hospitals, ambulances, doctors, nurses and healthcare workers across the world, overwhelmed by what they had to face.
Air ambulances and assistance companies, who support people in medical emergencies, had to change the way they worked. Although there was a global crisis, individual accidents and emergencies could still occur and operators had to be ready. Indeed, many air ambulance operators have reported in the past two years that they were extra busy during Covid lockdowns, due to the lack of commercial flight options for medical repatriation.
FAI adapted quickly to get their Covid-related transportation operations under way. Lemke explained that this was possible because the changes they had to make weren’t extensive or unusual: “The set-up for our Covid transports does not deviate greatly from our standard configuration; only the floorplan with the positions of the base units had to be adjusted. However, this is a process that we carry out for a wide variety of transport types, such as extracorporeal membrane oxygenation (ECMO) missions or bariatric patient transfers, and is therefore part of our daily business,” he said.
Dedicated trained medical teams at FAI used EpiShuttle Portable Medical Isolation Units (PMIUs) to transport patients throughout the pandemic. These offered capabilities for those with confirmed cases of SARS-CoV-2 and negative serology test results, but that had been in contact with a positive case of the virus, as well as those with unrelated diagnoses.
The war in Ukraine obviously prevents air ambulance missions from taking place in that country
Because of the PMIU, FAI could ‘immediately increase transport capacities for infectious patients if necessary’. Lemke explained: “The PMIUs in the medical store are of course maintained, equipped and ready for use at any time.”
Despite having the equipment to continue to treat and transport patients, this did not mean air ambulances were exempt from other regulations. Quarantine requirements limited how long crews could stay in certain countries and where they could go. Kluge said: “As an immediate 14-day quarantine was required by many countries for our crews once they passed through immigration, we performed most of our missions as tarmac only, with direct turnaround to avoid immigration.” An additional measure by UNICAIR to mitigate this issue was the use of three Challenger 604 heavy jets. “These have a range of up to 3,500nm, with plenty of space for crew, meaning they could cover longer distances without a stop and carry additional crews, heeding the legal duty times.”
But now the periods of lockdown and other restrictions have significantly reduced, one ‘post-Covid effect’ that has challenged European air ambulance operators is the return to leisure travel, explained Dr Morgan. The sudden increase in demand has not been matched by capacity in staffing levels across the travel sector, whether for airlines or air ambulances: “Our understanding is that this is not a lack of aircraft, but rather shortages of personnel to staff those aircraft. This mirrors issues which have been very apparent in other travel-related businesses, such as airports and hospitality,” he said. However, Dr Morgan doesn’t believe this will be ‘long-lasting’.
Kluge also highlighted how the trend of ‘revenge travel’ post-pandemic has now led to the return to UNICAIR’s ‘classic’ European destinations, as well as the service of intercontinental routes. She said: “We have been four times to Australia in September 2022 only, transported an ECMO case from Mexico to the Netherlands, and several newborn babies for treatment across the Atlantic.” The demand for air ambulances has jumped substantially since May 2022, especially when compared to 2021 and pre-pandemic levels, according to Kluge. She explained that travel was only half the story, though: “A substantial part of the increase is also down to the fact that commercial carriers still have reduced capacities for patients, and some will be transported by air ambulance as no commercial carrier is available,” she said.
Procedural change is part of the new landscape for Hoischen and Schneider: “As of today, most patients still need to be tested for Covid-19 before being granted admission into a local hospital, so they are aware and prepared. However, the European and international regulations in regards to when a patient needs to be isolated, and what measurements a hospital need to take upon receiving an infectious patient, vary greatly, which makes it difficult for an aeromedical operator and assistance company to adjust,” they stated.
As is often the case, prior knowledge goes a long way. “Both Quick Air and Malteser Aeromedical have gained extensive experience in handling these cases and ensuring that a patient can be safely admitted at their destination. Generally speaking, we observe a more relaxed approach from hospitals and airports which – combined with fewer travel restrictions – allows for an almost normal operation these days, Even before the pandemic, Quick Air had strict regulations and sanitary proecudres in place, so we could rapidly respond to the many demands for repatriation right from the beginning,” they concluded.
The air ambulance sector adapted and created solutions to support the global medical effort related to Covid-19, continuing to transport patients with other conditions, and these changes have resulted in improved preparation for the next event that impacts the industry – whatever it may be. Dr Morgan concluded: “I believe our experience of dealing with Covid-19 has prepared us very well for whatever may lie over the horizon.”
A conflict with no end in sight
On 24 February 2022, Russia invaded Ukraine. Global media coverage, political condemnation, heavy economic sanctioning on Russia and support in favour of the Ukrainians on various platforms followed… continuing into the second year of the conflict.
Industries and businesses worldwide had to adapt, by changing suppliers, moving offices and even being forced to cut ties. Air ambulances and assistance companies have also had to change. The need for patient care and transport is still required in these countries, in spite of, and also because of, the situation.
“The war in Ukraine obviously prevents air ambulance missions in that country,” said Dr Morgan. “But it has also reduced the number of air ambulance providers able to operate into Russia and Belarus.”
Ukraine has closed its entire airspace to all civil traffic. Russia and neighbouring countries Belarus and Moldova have also closed large sections of their own airspace near to the flight information region (FIR) boundaries with Ukraine. Some nations – including the US, UK, Canada, France and Germany – have issued total flight bans for Ukraine, due to the risk of military activity at all levels. The US and Canada have also banned operators from Russian airspace along FIR boundaries with Ukraine, while Germany has recommended that its operators do not to enter certain FIR zones in Russia and Belarus within 200nm from Ukrainian airspace and territory.
Lemke explained that these restrictions don’t just impact operations to those nations alone, but ones that would normally fly through this airspace: “The No Fly Zones are operationally a real limitation, because the connection from the Far East to Europe, for example, traditionally went through this area,” he said. But they now ‘just take a detour, which is of course still feasible’. Michael Diefenbach, Managing Director of UNICAIR, explained the consequences: “At present, we do not enter Ukrainian, Iranian and Russian airspace, which means that we need to plan alternative routes when going east. This can cause more fuel stops and longer flying hours, especially to destinations such as China, Japan or Korea.”
Lemke also admitted that Russia was never a major market for FAI, so at the beginning of the conflict, the company didn’t experience any decline in volume, giving them time to adapt to the new situation. Conversely, FAI actually has a larger number of ambulance flights than before the war, with Lemke believing this was ‘due to the fact that we are one of the few operators who fly to Russia at all’. He explained: “It was amazing for us how easy and fast the approval process was in the end, but of course you have to make sure that sanction regulations are fully complied with.”
UNICAIR, although not collaborating with companies in Russia, is allowed to transport Russian nationals. They recently transported a Russian patient to eastern Finland, after which he was taken by a Finnish ground ambulance to the Russian border, then transferred to a Russian ground ambulance on the other side. “Our foremost commitment is to help all who depend on medical care – regardless of nationality,” stressed Diefenbach.
Quick Air and Malteser Aeromedical also have a desire to keep helping: “As part of our daily operations, we still transport wounded Ukrainian citizens to Germany and other European states. Due to the flight restrictions, these patients need to be picked up from neighbouring countries before being brought back for further treatment,” they said. “In addition to not being able to land in Russian and Ukraine territory, mission planning also includes a no-overflight zone of the same region, thus any missions must be planned with additional flight time, increasing the duration and costs.”
Adaptations are being made by air ambulance operators to continue, or even expand their operations in and around the areas of Russia and Ukraine affected by the conflict.
No one can ever predict geopolitical situations and the ensuing fallout, but having processes in place is vital. Professor Dr Alex Veldman, Medical Director of UNICAIR, has already warned of another potential issue: “All experts agree that the next pathogen is lurking around the corner, and flare-ups of Ebola in East and Central Africa seem to confirm such sobering perspectives,” he said. But the past seven years have shown how air ambulance and assistance companies were able to handle unpredictability, so there is confidence in the sector that it can cope with inclement weather.