The integrated three-crew concept has been used in the Norwegian Helicopter Emergency Medical Service (HEMS) for more than four decades. Norway’s entirely government-funded HEMS is necessary due to the topography of the country, characterized by high mountains, fjords, and a long coastline. Road distances may be quite substantial (road travel also often includes ferries in some areas of Norway), thus HEMS is a vital supplement for road ambulances, especially in rural areas. This importance is further underlined due to an increasing specialization of hospitals, which leads to an increase in the need for retrievals and patient transfers.
 
Norwegian Air Ambulance fleet and mission profile

The public service comprises 14 helicopters working from 13 operating bases, and covers all of Norway with consultant-delivered care. Norwegian HEMS teams respond to both primary missions (treating patients in a prehospital setting) and secondary missions (interhospital transfers/retrievals) and cover the spectrum of patients, from 600-gram neonates, to pediatric and adult ECMO (extracorporeal membrane oxygenation) and iNO (inhaled nitric oxide) transports. This broad area of responses in a 24/7/365 service is very demanding, made all the more challenging by a complex geographical environment and, during large parts of the year, difficult weather and light conditions, and non-surveyed/unknown landing sites.

Furthermore, the crew also respond to alpine incidents, including climbing and ice climbing accidents. Some missions are conducted as underslung operations with fixed-length lines (Human External Cargo (HEC) with dual hook). 

Types of aircraft currently utilised are H135 variant EC135 T3H (5 bases), H145 variants BK117 D-2 and D-3 (7 bases), AW139 Phase 7 (2 bases)

All bases have one aircraft apart from one base (Oslo), which is equipped with both an H135 and H145. Crewmembers serving on both the H145 and the AW139 must remain current on both types, which is a challenge for both scheduling and the individual crewmember. Furthermore, pilots and HEMS crewmembers (HCM) must undergo a recurrent training program every six months on both types, which means extra studying and extra time for training. 

Crew concept

For the Norwegian Air Ambulance service (NLA), a crew consisting of three people is the national standard. This crew concept has its origin in the limitations of the first helicopters used for HEMS in Norway, the Bo105 from 1978. 
The integrated three-crew concept consists of a pilot, HTCM and doctor. The professional backgrounds of the three members of the crew are shown in the table on pg 38. For all crewmembers, the compatibility of their personality with the three-crew concept is a vital part of both the selection and training process. 

Cross professionalism

One benefit of a crew that has cross-professional competencies is having the capability to assist the person who needs it most at any given time, by offering the required skills. This could include the pilot being assisted during flight by the HTCM, or the HTCM being assisted during rescue missions by the pilot and doctor. During the medical part of a mission, both the HTCM and the pilot will assist the doctor. The distribution of the areas of operational responsibilities is clearly described in the Operations Manuals and Rescue Technical Manuals.

HTCM

The HTCM assumes, for all practical purposes, the same role and duties that a pilot monitor would in a multi-pilot operation, except that they do not communicate on air band frequencies. During the ground part of the mission, the HTCM takes on a medical role with the HEMS physician. 

In Norway, there is a national standard for rescue/HEMS crewmembers, which is divided into three branches: air ambulance, search and rescue, and offshore search and rescue. Operators in the different branches must follow the standard that is current and published by the Norwegian Department of Justice. 

For HTCMs in the air ambulance field, the standard describes the levels the crewmember must meet when it comes to aircraft knowledge (theoretically, the same as an exam in PPL A or PPL H), rescue procedures and medical competence.

HTCMs in the NLA have a three-part role:

• Aviation

In the operator’s manual, the HTCM is held to the same standard as a pilot. The crewmember must meet the same requirement as a pilot when it comes to instrumental metrological condition (IMC) hours, number of instrument flying rules (IFR) approaches and night vison goggles (NVG) time during a year. The reason for these strict and high standards is that the NLA is probably the largest HEMS operator in Europe that has the most frequent requirements to fly IFR. 

• Medicine

A recent development in Norway when it comes to medicine is that more medical procedures are being done out in the field. Furthermore, medical procedures are becoming more advanced, and more invasive, with an increased use of ultrasound devices. As mentioned previously, there is also a move to hospital specialization, and, because of this, air ambulance transports for critically ill patients from rural hospitals to a university hospital are more common. The transport of intensive care patients using a device such as an incubator, or on an ECMO machine, between hospitals, increases the need for more knowledge and skills from the HTCM.

• Rescue

The air ambulance also provides a rescue service, and the HTCM is responsible for this part/type of mission. Since Norway has both urban and rural areas, the air ambulance service offers rescue in both urban and mountainous areas (rope rescue), as well as water rescue, whitewater rescue, glacier rescue, avalanche rescue and static rope rescues up to 60 meters. All these services are given on all the air ambulance bases in Norway, regardless of whether the base is in a rural or urban area.

The further HEMS missions evolve, so the demand for efficiency and safety increases in all areas in which the HEMS crewmembers perform. A particular challenge for NLA crewmembers is to maintain their skills in all these roles. 

Multiple responsibilities for NLA medics

Doctors in the NLA assist in:

• Acting as a lookout to avoid collision with other aircraft, power lines etc. and informing the pilot in command of any obstructions or hazards to flights
• Securing the area around the helicopter for personnel when rotors are turning
• Performing the function of ‘doorman’ during HEC operations
• Volunteering advice, information, and assistance to the pilot relevant to the safe and efficient conduct of the flight. This means, for example, that he/she points out any fault, failure, malfunction or defect which they believe may affect the airworthiness or safe operation of the aircraft including emergency systems. 

They also report to the commander any incident that endangered, or could have endangered, the safety of the operation, if not already reported by another crewmember. 

It might pose a challenge for the HEMS physician to operate alone in the back of the aircraft on all types of missions apart from ECMO retrievals. However, thorough training, as well as extensive clinical experience, comes in handy here. All physicians are employed on a long-term basis. The average age on some bases is over 50, with more than 15 years of HEMS experience. Simulation training is conducted for the whole crew together. 

Only two bases undertake ECMO and iNO transports, and the number of bases undertaking incubator transports are limited. However, for the bases undertaking these specialized medically complex operations, the challenge for physicians is significant. They must be prepared for, and skilled at, practising medicine alone in the back of an aircraft with extremely sick patients. This form of treatment needs planning: it is a special skill to be able to prepare the patient and anticipate their clinical development and needs for the duration of the flight. However, the physician is not ‘alone’; the pilot and the HTCM, especially, are skilled for and trained to not only assist, but to help anticipate the clinical development of the patient. In this way, the three crewmembers all assist in the medical planning of both primary and secondary missions. 

If the aviation situation allows it, the pilot contributes to the medical part of the mission by drawing up drugs, applying monitoring equipment, and even assisting in some medical procedures. This pilot contribution in the medical aspect of the mission is essential in both primary missions as well as during retrievals. 

The benefits of an integrated crew concept

Essentially, all three members of the crew are involved in most aspects of a mission. For instance, the HEMS physician as well as the pilot and HTCM have a mutual understanding of the consequences of flight level, and will accordingly communicate about this during the mission. For underslung operations, the HTCM is hanging in the static line, the HEMS physician is placed in a harness in the open door, acting as the pilot’s extended eyes, and directs the precision flying. Similarly, during a mountain rescue operation or water operation, the pilot and HEMS physician have insight and skills for assisting the HTCM. 
This integrated crew concept has multiple benefits. Having a small crew makes co-operation transparent and evident. A smaller crew facilitates rapid accommodation to changing conditions. This concept also reduces the ‘front vs back’ internal team dynamics that are occasionally seen in larger HEMS crews. Furthermore, the integrated crew concept enhances the mutual understanding of roles of all team members. The mutual understanding of medical requirements for low-level flying, or sterile cockpit during take-off and landing, are examples of this.