The operational needs of helicopter emergency medical services (HEMS), air ambulance and SAR worldwide vary greatly, including the technologies being used. AirMed&Rescue spoke to medical providers all over the world to get their thoughts on equipment and communication standards:

• In Haiti, rescue efforts are made to safely reach and transport patients within a timely manner, with often older equipment and latent communication or geographically tricky landing zones
• In Italy, for many years, technology was adapted from ground-use ambulances, with much air ambulance improvisation in the case of neonatal emergency transport (NETS)
• In Guatemala, SAR technology plays multiple roles, and providers serve in rescue positions and as education and aviation experts on film production crews
• In the UK, newer technologies and innovations are prevalent, including tools to monitor physiology, serve bariatric patients and utilization of enroute video-linking
• In Germany and other European locations, providers may offer improved ultrasound and therapeutic interventions, newer ambulance interiors and Wi-Fi-enabled monitoring, in addition to other technologies
• Finally, as an (original equipment manufacturer) OEM, Bell Helicopter UK recognizes turnkey solutions at a base level for customers and custom helicopter platforms per requirements.

Air ambulance SAR perspective

Haiti Air Ambulance is a Long Island, New York-based charity, the only provider of this free service since 2014. They fly a Bell 407 helicopter and plan to put another aircraft into service soon, according to Program Director Cory Oaks. The challenge for the operation is that they aren’t allowed to fly at night.

During the day, they attend to three-to-five flights, with two-to-three scheduled flights for the next day. There are designated landing zones and security concerns for medical staff.

Regarding communication between flight staff and hospitals, Oaks said: “If someone at a clinic calls us, we will go to a predetermined landing zone. Our comms people find a local ambulance to bring them to the air ambulance that is waiting.”

We are a step backward with communications – regular VHF radio and SAT phones are limited

He added: “We are a step backward with communications – regular VHF radio and SAT phones are limited.” They use WhatsApp to communicate. “Everything is analog only, which is a higher output that works for us. There is no digital infrastructure there.”

Oaks noted that with some equipment when they need updates, it is hard to get it into the country. They often have to carry it through customs and onto the airplane and hand deliver it to the location. “We can’t ship things in and out of Haiti. If there is a problem, people need to carry it out and back in.”

However, they still operate to all US standards, clinically and in aviation. They offer pre-hospital ultrasound and blood gases with EPOC, and before the end of the year, will carry blood onboard also.

In contrast to HEMS and SAR in Haiti, Air Ambulance Charity Kent Surrey Sussex (KSS) in Rochester, UK, is ‘concentrating on ways to improve patient care, both on scene and in transit to hospitals’, according to Dr Duncan Bootland, Medical Director. They have purchased intra-arterial blood pressure monitoring equipment, while also trialing video-link from the HEMS and dispatch desks for emergency 999 callers. He said: “The benefit of both innovations will be better discrimination in identifying and responding to the patients who need us most, and in allowing us to shorten the time to the hospital for those patients requiring emergency surgery.”

Online training has made it cheaper and more accessible for those in developing countries

Finally, Black Wolf Helicopters of Guatemala provides operational SAR, with deployments to Central and South American countries. They also offer training in FAA or DGAC (Central and South American equivalent) for compliant aircrew survival, underwater egress, CRM and remote jungle helicopter operations. One of the most significant technology changes for them is online training. Chief Aircrewman Chris Sharpe said: “It has made it cheaper and more accessible for those in developing countries.” They can now fund Black Wolf Helicopters non-pilot aircrew SAR management courses.

Medical Doctor or Director perspective

Dr Bootland said they are exploring new technologies to provide better on-scene patient care and in-hospital transit. “Video laryngoscopes, used widely in-hospital for intubating patients as part of pre-hospital anesthesia, have some aspects such as screen reflection in bright light that make them more challenging to use outdoors. We are exploring ways in which in-hospital technology can be adapted to benefit our pre-hospital patients.”

Dr Simon Forrington, Medical Director at Gama Aviation (UK) who also works with the European Aero-Medical Institute (EURAMI), shared the many advances in their work:

• Ultrasound for diagnostic and therapeutic interventions
• Navigation by iPad (HEMS and fixed-wing) and iPad/tablet-stored procedures and guidelines that can be used in-mission (in the air) by flight medical crew
• Automatic/mechanical chest compression devices (e.g. Lucas) for HEMS
• ECMO CPR for HEMS – a patient in cardiac arrest is quickly put on a heart-lung bypass machine in a hospital, or potentially even at the roadside
• Wi-Fi-enabled monitoring: patient monitor connected to Wi-Fi 4G/5G to allow staff at the base to monitor observations in real-time.

“With my EURAMI hat on, our new version 6.0 Standards for Fixed-Wing Air Ambulance Transports [became] a consensus document with expert input from across the industry and the globe,” Dr Forrington said.

Their standards leveraged worldwide expertise, which he said was ‘the first time this has been attempted in our industry’. He added: “The new standards were launched in October 2022 at the International Travel and Health Insurance Conferences (ITIC). In 2023, we will work on similar new consensus standards for commercial airline medical escort transports and rotary wing transports.”

In Italy, neonatal mortality (up to 30 days) does not exceed three per cent, reaching the best levels in the world

Other technology adaptions occurred over several decades in Italy, with Giannina Gaslini Hospital dealing with neonatal emergency transport for babies from birth to 30 days of life. Director Carlo Bellini said that during the pioneering period of neonatal transport, they had to modify equipment because it wasn’t included on air ambulances. “At the time, we had an incubator that worked at 12 volts, typically used for cars, while in aeronautics, 24-26 volts were used. Very simply, we disassembled our incubator and handcrafted [it] to work at 24 volts, and it is not damaged if connected to a helicopter.” They’ve modified hydraulic systems to operate two ventilators consecutively for twin transport. Bellini added: “Currently in Italy, neonatal mortality (up to 30 days) does not exceed three per cent, reaching the best levels in the world.”

Original equipment manufacturer (OEM) perspective  

“Bell fully recognizes that there is no one-size-fits-all approach to customizing its HEMS and SAR aircraft,” said Key Systems Specialist Terry Miyauchi. “Whereas Bell offers turnkey solutions with its mission-ready configurations, baseline trends have undoubtedly remained constant with unique custom completions requests for the HEMS and SAR segment operators. Bell strives to provide proven helicopter platforms with multiple specialty equipment options based on the customer’s needs.” They are working on the trend towards lighter, more compact reliable mission equipment. Miyauchi added that Bell partners with HEMS and SAR providers.

Now ‘open architecture’ has become necessary for direct access while airborne.

A major area is flight storage, especially for HEMS and SAR aircraft. On most of them, baggage compartments are isolated or closed. Now ‘open architecture’ has become necessary for direct access while airborne. “This not only allows for expanded critical mission equipment and supply utilization, but also greatly expands the total open cabin space.” This is currently on the Bell 429 and will soon be certified on the Bell 525.

Other modifications coming to the forefront consider more oversized or bariatric patients. Dr Bootland said: “The stretcher fit in our AW169 does not have a specified weight limit, and we are mostly limited by the width of the stretcher and our ability to move patients on and off the aircraft, which is done manually.” He said that they recognize larger body mass patients and that ‘those weighing more than 100kg are estimated to have nearly doubled in the past 10 years’.

For Miyauchi, wider door openings are a solution. “With the value of open baggage compartment engineering, so is access to the cabins as a whole. For example, a wide cabin door opening not only allows for a side-loading option for a patient on the ground, but a more efficient dynamic hoist uploading in an SAR operation. HEMS and SAR hoist uploading demand both time efficiency and minimal patient movement.” Bell offers the widest cabin door openings for larger patients, stretchers and equipment uploads, ‘in each class of aircraft offered’.

Communication perspective

From an in-transit communications viewpoint, KSS is clear. “Standard communication remains using handheld radios via the Airwave Network, and I don’t see that changing in the near future,” said Dr Bootland. They are working better to support on-scene crews with staff at a distance by also utilizing live streaming of the patient’s physiological observations through a Tempus monitor and Philips IntelliSpace Corsium technology.

Sharpe at Black Wolf Helicopters said communications have improved since ‘the removal of just hand signals by the winchman’. He said in discussion with Bob Cockell at ARS and Trevor Abraham at Air Rescue (UK), they moved to head signals, ‘a revelation’. 

Communications have improved since the removal of just hand signals by the winchman

“Freeing up an operator’s hands (yes, some hand signals are still used), through the integration of this system and the subsequent training of crew and pilots has been a challenge (as nobody wants to change), but has eased the workload and capabilities of the winchman dramatically,” said Sharpe.

Summary

New technologies and methods of communication vary by location. Some entities are more advanced than others, but it seems that all groups are working to improve – whether for special circumstances like newer equipment, in-flight blood banks, or special equipment for bariatric patients. Miyauchi said it best in reflecting that one of the most essential facets of HEMS and SAR are operational aircraft. “What is perhaps interesting is at a baseline, the medical crews also emphasize the need for confidence in aircraft safety systems and operational readiness. In the life-saving service of HEMS and SAR, an aircraft in the hangar due to lack of manufacture support is just as critical as not having the asset.”