When the call comes in saying that the only way to get your insured back home is via an air ambulance, the next decision that has to be made by the assistance company is: which aircraft can get the patient home with the best level of care in the optimum time? Mandy Langfield discusses the considerations to be made when an air ambulance is called for
Getting what you want
Nobody wants to pay for what they don’t need, and it’s important that insurers and assistance companies are not bamboozled into paying for an aircraft that does not match the client’s requirements. An unscrupulous air ambulance provider or broker might seek to take advantage of the opportunity of an insurance company paying the bill to suggest that a bigger plane might be more suitable for the patient when, in fact, a smaller, cheaper aircraft might be adequate for the mission at hand.
For air ambulance companies, then, having a mixed fleet with different sizes of aircraft can be an advantage, meaning they can offer a suitable aircraft to the assistance company or insurer to cater to a wider range of illnesses/injuries and locations. While the cost of running a fleet of different aircraft types can be a more expensive option, as parts cannot be swapped between planes if needed, by giving the assistance company different options, the air ambulance operator makes sure that they are doing everything they can to secure the business.
There are several different elements that need to be considered by the payer – whether it is the insurer or the assistance company – before they decide to use a particular aircraft:
The first priority should always be the patient’s condition and medical care needs. Does the aircraft on offer allow the patient and physicians the space they need? For example, with more bariatric patients being moved by air ambulance, ensuring that the patient and their larger-than-normal stretcher can fit through the door of the smaller aircraft is essential to avoid cancellation of the mission at the airport when the patient is stuck in the cabin door.
The Learjet 35 is known as a workhorse in the air ambulance industry, and is much praised, but it is not perfect. For instance, the height of the cabin – around 1.3 m (4 ft 3 in) can mean that the environment feels quite cramped, with the medical crew unable to stand up straight. This can be a problem in the event that a patient suffers a cardiac arrest. While CPR can be performed in the Learjet 35, said Patrick Schomaker of European Air Ambulance (EAA), it is not an ideal position for the medic – should CPR need to be carried out for a period of time longer than around 15 minutes, then an automatic chest compression device is used on the patient. There is also the lack of toilet facilities, which can affect the comfort of the medical crew, if not the patient! Luggage restrictions also mean that an insured could be separated from their belongings, causing more paperwork and headaches for the assistance company.
Considering larger patients and small aircraft, the patient’s height, width and weight must all be considered. EAA, for example, transports patients of significant weight (up to 130 kg) in the Learjet 35, but patients must not measure more than 60 cm in width, otherwise they cannot fit through the door. There have been occasions where this has happened, said Schomaker, because the assistance company did not obtain the patient’s height and width measurements before employing the services of the air ambulance – thus, when the patient was unable to fit through the door and the plane returned to base empty, the cost of the flight was borne by the assistance company. This raises another important issue that ITIJ has looked at on many occasions – that of the assistance company obtaining, and passing on, up-to-date and accurate information about the patient. The problem of flight medics arriving to collect a patient and finding their medical condition differs from what they had been expecting can be dealt with by medics carrying more kit in the expectation of using it. If the patient’s measurements have not been taken into account, though, there is no medical kit that will be able to force an obese patient into a Learjet 35. Reasons like these, said Schomaker, are why EAA is changing its fleet to Learjet 45 aircraft, which are capable of handling larger patients, and multiple patients with all the necessary medical crew to attend them. Using the latest Learjet 45XR configured as a dedicated air ambulance, EAA can transport two patients or a single patient and passengers. Indeed, the 45XR’s unique flexible cabin can accommodate up to four passengers – such as relatives of the patient – in a fully equipped cabin, complete with bathroom facility, which can be separated from the medical unit by a curtain.
The patient’s condition can also influence the aircraft choice. Seriously ill patients who are transported via air ambulance could need a larger aircraft to accommodate the equipment needed to maintain a high level of treatment throughout the transfer. For example, putting a patient who is undergoing ECMO (extra corporeal membrane oxygenation) in a small aircraft may not leave enough space for the necessary attendant medical crew. Similarly, transporting a patient with an infectious disease can necessitate a larger aircraft in order to accommodate the patient isolation bubble in which they are being transported – in French air ambulance provider Medic’Air’s case, a Falcon 50 jet is used to transport patients suffering from infectious diseases.
Pressurised versus non-pressurised aircraft choice should also be dependent on the patient’s status, as there are occasions where patients need to be moved at sea level, or just above. Terry Martin, medical director of Capital Air Ambulance in the UK, described in Waypoint AirMed & Rescue the pros and cons of using unpressurised aircraft: “Undoubtedly, unpressurised aircraft are often noisier and may be subject to turbulence at lower levels. There may be a higher likelihood of route restrictions due to weather or terrain, and the patient’s oxygen status will require closer monitoring. However, on the plus side, such aircraft need much less runway for take-off and landing, can be flown from unpaved surfaces, and are ideal for small hops during which there is little time to climb to high altitude.” He further added: “Piston-powered unpressurised (PPUnp) aircraft certainly cost less to both lease and purchase, and also to operate over short distances. Although cost should never be the predominant factor in deciding on the mode of patient transport, when budgets are tight, the only choice might be unpressurised – take it or leave it. It goes without saying that if better care can be given in the air than is found on the ground, then there is no absolute contraindication to aeromedical transport. Similarly, in time-critical transfers, a transfer in a PPUnp aircraft is eminently superior to leaving the patient where he or she is, when the treatment needed is in a distant place.”
Where is your patient, and what is the most efficient way to get them where they need to be? This situation is where the ‘horses for courses’ approach to air ambulance selection becomes clearest. If your patient is in the middle of the outback in Australia, for example, then your plan to get them out of the remote region and repatriate them to the UK via Learjet may not cut it. Instead, the assistance company should break down the journey into two parts – the first is evacuating them from the remote region, most likely with an aircraft used by the Royal Flying Doctor Service (RFDS) that can cope with the potentially uneven and shorter-distance landing terrain, and the second is moving the patient internationally from an airport with ‘proper’ runways.
The RFDS makes used of Pilatus PC-12, Beechcraft King Air 200, Cessna Grand Caravan and Hawker 800XP2 models, with each aircraft used for different mission profiles. For example, RFDS Western Operations medical director Dr Stephen Langford said of the Hawker: “The jet can fly non-stop from any location in Western Australia to Perth within three hours and it can undertake interstate transfers without refuelling stops in most circumstances. It can also undertake faster Flying Doctor retrievals from offshore locations, such as the Australian territories of Cocos and Christmas Islands, and has the advantage of a dedicated aeromedical layout to help us treat and care for almost any patient. Seriously ill babies also benefit as this jet can easily load and carry the specialised Mansell Neocots used by Princess Margaret Hospital and, when requested, we will be able to take babies to specialist medical care interstate. Importantly, the addition of the Rio TintoLife Flight jet to the State’s disaster response resources enhances WA’s capacity to respond quickly and effectively to mass casualty incidents, of which we’ve had several in recent times.”
AMREF Flying Doctors, based in Kenya, makes use of smaller turboprop aircraft such as Cessna Caravans or Beechcraft King Airs, which are more flexible when it comes to landing on unpaved surfaces that can often be significantly different in length and width – not to mention full of wildlife. The patient is then taken to a larger airport where jets can land safely and the patient can continue that part of the journey in the most appropriate aircraft. It also, though, carries patients onboard Cessna Citation Excel and Bravo aircraft, allowing for longer-range missions to be undertaken. The AMREF Flying Doctors’ website states that the choice of aircraft is dependent on ‘the location, airstrip, time of day and the condition of the patient’. Both AMREF Flying Doctors and the RFDS are reliant on the local populace to maintain their remote airstrips.
Getting a patient out of a remote area can involve some out-of-the-box thinking. A case managed by FrontierMEDEX last year, for example, saw the evacuation of a patient with a hip fracture from Antarctica. The transportation logistics were, for obvious reasons, complex. The choices were between a King Air 100 pressurised turboprop aircraft (small and cheap) or a BAE 146 jet (a 99-seater aircraft). The King Air was further away from the patient, and had a longer flight time, so FrontierMEDEX opted for the BAE 146 – despite the fact it was only one patient on an enormous plane, it reached the patient sooner and transported him more quickly, meaning that in this case, the more expensive option was selected for the patient’s wellbeing in terms of the speed of his evacuation.
Where there is more than one patient, it is often preferable to use a larger aircraft in order to make the air ambulance flight more efficient from a cost point of view. There are a variety of aircraft that can take more than one stretcher – from the Learjet 35 that can take two, to the Dornier 328 (up to 12 patients), which is often used for transporting large numbers of patients from popular winter sports destinations back to their home nations during ski season by ADAC Ambulance Service and Tyrol Air Ambulance. The ‘plaster flights’, as these flights filled with winter sports victims are known, are a common way for an insurer to benefit from the economy of scale that results from carrying multiple patients onboard a flight.
So, in answer to the question that was mooted at the start of this piece – why are there so many different air ambulance aircraft on the market? – it is quite simply because each case that is dealt with via the air ambulance, assistance and insurance company is unique, and the industry has responded by making sure that no matter what your patient needs or where they are, there is a plane and a medical crew waiting to be deployed.
The next time you’re on the phone to the air ambulance company and they are offering to fly your client home onboard one of their aircraft, consider which aircraft will best fit the needs of the patient, the needs of the plane – for example, the runway length needed – and finally, of course, how much the whole thing is going to cost you. ITIJ is not expecting every assistance company claims handler to become an expert in aviation, but it would certainly mean a more educated decision could be made by the company if the significant differences between the aircraft on offer were more clearly understood.
While this article is about why air ambulance firms will have several different aircraft on offer to assistance companies, it is worthwhile noting that the expense of operating a varied fleet can often be far more than if an operator were to choose just one model of aircraft for its missions. The economy of scale that can be achieved by an air ambulance company in this case can be significant – the aircraft maintenance costs are vastly reduced, a saving which should then be passed onto the payer. Patrick Schomaker, director of sales and marketing for European Air Ambulance, which operates a dedicated fleet of Learjet 35 and 45 fixed-wing aircraft, said of the fleet: “The advantages of operating aircraft from the same manufacturer – in our case Learjet 35As and Learjet 45XRs from Bombardier – are numerous. Firstly, it keeps the cost of additional training for pilot and crew to a minimum, as well as providing synergies regarding the maintenance. It is also important to note that Bombardier provides an excellent support network that includes worldwide access to spare parts and constantly upgraded sub-systems, and that sticking to one manufacturer, in our case Bombardier, maintains a good relationship with a trusted manufacturer.”