ITIJ 212, Air Ambulance Review, September 2018
Medical crews flying around the world to collect critically injured patients are subject to fatigue, So ensuring proper rest times for them is an essential part of a company’s duty of care. Tatum Anderson reports
It’s a long-distance flight between Bangkok and Paris on a CL604. A patient, perhaps under mechanical ventilation, is monitored by a physician. A member of the patient’s family accompanies the patient. A second member of the medical team is preparing hot dishes in an oven. Chances are the crew has flown into Bangkok from Paris to pick up the patient. Usually, while the flight crew is resting in Bangkok, the medical crew gets to work. “We manage three periods for our doctor and registered nurse team,” said Dr Hervé Raffin of French air ambulance firm Medic’Air International. “First, they go to see the patient, meet the local treating doctor and start treatment. Second, they make sure they get around four hours sleep in the nearest comfortable hotel. Lastly, they return to the hospital to take the patient on the road to the airport for boarding.” If the patient is unstable, there must be a very quick turnaround, Dr Raffin says: “For these acute patients, our target is to take off from Paris at a moment’s notice, even during the night, to project our ICU team to the patient’s bed in the shortest time possible.”
Dr Raffin says his company uses planes with wide cabins to help maximise crew and patient rest times. “For these long flights (12 to 24 hours), there must be room for one of the team to have real rest time on board when the two others are monitoring the patient,” he said. Such an aircraft has toilets, a galley with an oven to eat hot meals at any time and space for the team and a family member.
Marcy Phipps, Chief Flight Nurse at Global Jetcare, which specialises in long-haul repatriations, told ITIJ that it is detailed forward planning and logistical support that make such flights successful. “Long-haul air ambulance flights require advance planning for crew configurations and pilot changes,” she said. In addition, medical crews must conduct pre-trip visits to assess and evaluate patients and allow ample time for collaboration with the sending team. “That ensures all medical preparations, including transport from the hospital to the aircraft, are in place,” Phipps said. The team must also procure scheduled medications, food, additional oxygen stores and other elements vital for long distances.
Feelings of fatigue
Excessive stress and fatigue experienced by the crew has a direct impact on the patient. Fatigue, defined by the UN’s International Civil Aviation Organization (ICAO), is: ‘a physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crewmember’s alertness and ability to safely operate an aircraft or perform safety-related duties’. Fatigue can be dangerous – it can lead to slower reaction times, poorer co-ordination, difficulties sustaining attention, fixation and less creative problem-solving. Sleep is the only effective fatigue countermeasure because it allows the brain to recover, ICAO said.
Flight crew rest times are extremely well regulated – for example, by the Federal Aviation Administration (FAA) in the US and in Europe by the European Aviation Safety Agency (EASA). The rules stipulate exactly how long breaks must be for pilots and other staff flying the plane depending on the number of time-zones they cross and in which direction.
However, no such rules exist for medical crews. It’s up to the air ambulance company to stipulate just how much doctors, nurses and other medical staff get to rest on a plane.
So, how does an air ambulance firm ensure both flight and medical crew have sufficient rest before flying a patient?
Solutions, not problems
Some use bigger planes, as the more powerful a plane is, the less frequently it will need to stop for refuelling. Dependent on completion, weight, balance, and extras such as wing tips and extra fuel tanks, generally speaking, most of the mid-size jets like the Hawker 800/100, Gulfstream 280/550, Falcon 2000 or Challenger 604 can cover 11 hours with a single stop. Smaller planes may require two or even three stopts for scheduled refuelling. Each stop takes time because it involves landing, taxiing to the refuelling depot and then a wait for take-off. So, whereas a commercial flight may take 11 hours, the same journey could extend to 15 hours by air ambulance.
Some firms will state rest times, but may expect their crews to spend quite a lot of that rest on the plane. Robert J. Starr, Director of Medical Services at Air Ambulance Worldwide, said that’s not ideal. “Being on the plane and resting is not getting rest, because you are still feeling the effects of altitude when you are flying even though the cabin is pressurised,” he explained. “On an aeroplane you have a lot of noise and vibration and a lot of stressors. You have environmental, physical and psychological stressors.”
it’s up to the air ambulance company to stipulate just how much doctors, nurses and other medical staff get to rest on a plane
A few companies even treat the medical crew in the same way as flight crew, said David Ewing, Executive Director, Global Market at Canada’s Skyservice Air Ambulance. “Government rules only apply to the flight crew and not the medical crew, though we try to follow the same rules for both groups, when possible,” he explained. “Also, the medical crew are encouraged when the patient is stable to have controlled rest within the cabin during long flights. That means taking turns closing their eyes and resting.”
Another option is to change the medical team completely on the way. Medic’Air International said it recently evacuated a patient from Abidjan, Côte d’Ivoire to Montreal, Canada with a fuel stop in Paris, France to change pilots and the medical team. This is a strategy that helps with ultra-long flights, such as those from Africa to North America, for example.
Take another ultra-long flight: a crew based in Florida is taking a patient from Perth, Australia to Florida, US, via Bangkok. The air ambulance company could use two teams. They might send the first ahead on a commercial flight a day before the second crew, which flies the air ambulance itself. The pre-positioned crew could rest in a Bangkok hotel and then pick up the plane when it arrives 24 hours later, taking it to Perth and then back to Bangkok, where they are able to hand over to the original crew who have had time to rest.
Alternatively, a wing-to-wing agreement could be struck with another carrier. Here the flight to Bangkok is met by another carrier which has brought the patient from Perth, so that the patient can fly in more or less one flight back to Florida.
Or both teams might be expected to travel on the same flight from Florida, and swap in Bangkok, and are expected to rest while on the plane.
However, not all ambulance firms will want to entail increased costs – such as pre-positioning pilots – because that involves commercial plane tickets, hotels and taxis, or employing a wing-to-wing carrier. They will also have to get governmental permits and visas for flight and medical crews.
How much is it worth?
Cost is inevitably a key consideration when planning a repatriation mission, and ensuring optimum crew rest can nudge costs up. “It is an increased cost for the insurer, so choosing wisely the company to undertake the mission in the first place is essential to a successful transport,” said Ewing. “Typically, shortcuts taken are those to save money for the client and don’t always work out. The saying ‘the cheap becomes expensive’ is often applied here.”
Christoph Ullrich, Senior Manager, International Network, for Germany’s travel club ADAC, which operates its own air ambulance service, agreed. “It really depends on the philosophy of the operator,” he said. “Although all the stakeholders in aeromedical transportation have to focus on costs, there are still some topics not to compromise on, like qualification of the medical teams, proper insurance and proper usage of your aircraft performance. A flight, for example, with a Learjet 35 with more than three technical stops with a patient on board would be a no-go for my company.”
Hotels must be well chosen too, said Ullrich. Some firms will automatically choose an airport-based hotel. So, while the aircrew can reach their beds quickly, the medical crew will have to travel to the treating hospital after a long flight. If the hospital is based inside one of the world’s megacities, the distances covered will be large. Plus, there’s a high chance of travel problems, which will curtail the amount of rest the medical crew gets before the flight takes off again. “In huge cities like Bangkok, Mexico City or São Paulo, if you hit the rush-hour, the time from the hotel to pick up the patient can be three or five times as long compared with [the same journey] out of rush hour,” he said.
If weather isn’t factored in, that can lead to more problems too. “If you go to Ho Chi Minh City in the rainy season, for example, you can’t forecast the rainfall, but you have to take it into account because the traffic comes to a halt,” he explained. “And nobody cares if you have a patient onboard or whether you’re going to the airport.”
Journeys may be particularly gruelling. A patient may have a back or spinal injury, for example, so the journey to the airport by road may well take longer, in order to minimise discomfort.
A key strategy to ensure the wellbeing of a crew is to foster strong relationships between the members, said Global Jetcare’s Phipps. “Because we are rather a small company, our crew members fly together frequently and know one another very well. This results in our family-type camaraderie with all team members. They are sympathetic to the needs and idiosyncrasies of the others,” she said. During long trips with stays in foreign, and occasionally remote, locations, support among crew members is vital to the wellbeing of all. That helps emotional support when far away from home. “It directly impacts the care of the patient and the success of the trip,” Phipps said.
Trust amongst crew members and management is just as important, said Starr. The crew must be confident enough to declare when they are, for example, taking any medication or have consumed alcohol. “If it makes them drowsy, the medical director reviews that and make sure they are always fit to fly,” he said.
A key strategy to ensure the wellbeing of a crew is to foster strong relationships between the members
Take, as an example, a last-minute flight, in the early hours. The crew would be expected to declare exactly how much they may have drunk in the early evening. Some companies impose the so-called eight hours from bottle to throttle rule, to make sure they are fit to fly at the last minute.
Air ambulance firms also tend to outsource food provision. Some will provide nutritious meals, fresh fruit, plenty of water and snacks for their crews and others, the odd sandwich and chocolate bar. Some encourage their crews to eat smaller meals and often, because larger meals are likely to make them drowsy.
Choose wisely, or the costs could rise quickly
The philosophy of an air ambulance firm, therefore, is vital when choosing one for a long-haul flight. “The insurer/assistance company needs to choose the right company, for the right mission at the right time for an uneventful, successful transport of their clients,” said Skyservice Air Ambulance’s Ewing. “We provide our clients with options and are transparent about those options in order for them to make an educated decision for the transfer.”