You became Chief Medical Officer for HALO Aviation in 2017; what made you want to join the company?

I have always had a passion for aviation, and after finishing basic training, I had the opportunity to join HALO on a part-time basis. I immediately fell in love with every aspect of aeromedical care. The clinical environment is unique, and it is quite difficult not to fall in love if you are able to work in a beautiful aircraft, treating patients and thinking critically under pressure. It admittingly was very challenging with a steep learning curve in the start, but I was welcomed with open arms by some highly skilled and experienced mentors, to whom I will eternally be grateful.

You could be servicing a complex neonatal interfacility transfer from a rural facility in the morning, and then a high-speed road traffic collision in an urban area in the afternoon. It fits in very well with my constant need for adrenaline and making sure there is a never a dull day in the ‘office’. Couple this with amazing co-workers, a reliable working platform, and incredible aerial views.

Gaining some practical experience in prehospital medicine as an undergraduate medical student and junior doctor certainly equipped me with a whole bunch of technical and non-technical skills to ease the transition from a strict controlled clinical environment to a dynamic one such as HEMS. Because of experience gained at HALO, it led me to the successful completion of the prestigious Diploma in Retrieval and Transfer Medicine at The Royal College of Surgeons in Edinburgh in 2019, the first person in Africa to do so.

Have you introduced any major procedural changes since you’ve been with HALO? 

Absolutely, yes. We have managed to bring all the different spheres of the operation together under one roof, to break down perceived ‘silos’ of operation. Our emergency center agents, pilots, paramedics, doctors, administration, support, and managerial staff all know each other well and are like family. At HALO, there has always been a strong emphasis on continuous quality improvement and rugged safety systems. Never losing focus on the patient allows us to provide quality healthcare instead of quantity. This, for us, meant having to focus on the basics, making sure we execute those flawlessly, and focusing on small but impactful gains every day. It initially took quite a financial and personal investment to put all the systems we currently have in place, with our CEO’s (Ryan Horsman) support and visionary leadership making it possible all the way.  

Staffing models in a low-to-middle income country such as South Africa is an area of hot debate, but we take pride in the fact that up to recently, we were the only doctor-led HEMS in South Africa. Our paramedics are incredibly skilled and are more than able to care for critically ill patients, but as previously mentioned, we are not complacent, and believe that patients deserve the best you have to offer in their time of greatest need. I firmly believe that having another practitioner onboard leads to advanced decision making, transfer of clinical skill, and an expanded scope of interventions that is not currently catered for by our health profession’s regulatory body. 

Bringing our emergency call center, with an advanced computer-aided dispatch platform, in house means that we are able to have clinical input literally when the first call comes through. It helps us to significantly decrease dispatch times and tailor our response if need be, as we know where the call for help is coming from by the time the phone rings.

We have recruited some of the brightest young talent while not neglecting the invaluable input and wisdom the more experienced practitioners bring to the team.

Our pilots come from a variety of aviation backgrounds, and are able to perform amazing feats. They have created and live what I’d like to call the ‘HALO way’ and their focus on technical skill, proficiency, currency and safety far surpasses what is legally required.  Not once have they neglected the immense responsibility that comes with our unique position. More than 55,000 combined flying hours, and more than 135 years of combined aeromedical experience, certainly shows in this aspect.

How have your past medical positions influenced you in your current role with HALO, either in terms of standard operating procedures, or culture?

Breaking down barriers of communication and perceived power differentials are key to running a smooth operation. Not having mutual respect, and having a disconnect between management and ground staff, is a mistake I have learnt not to repeat from other organizations. I can proudly say that no job is too big or too small for anyone at HALO.  

Clinically, we prefer not to have a punitive approach, but would rather encourage growth using reflection in a variety of formats. Operationally, I encourage accountability and responsibility as tangible actions, with trust being the foundation of it all. Although I think it is important to have well written standard operating procedures, these should be revisited frequently in response to feedback received until clinical excellence can be achieved whilst remaining pragmatic. 

HALO has seven aircraft in its fleet, including three different helicopter models; why is variety in the aeromedical evacuation fleet key to your operation?

Variety means that we are able to adapt to different missions in South Africa’s unique geography, and to dynamic patterns of demand. By owning a reliable fleet, down-time for scheduled or unexpected maintenance does not lead to an interruption in service. Our fleet serves us well, and we think we have found the perfect mix of reliability, robust operational capacity, and cost-effectiveness.

Do all the helicopters have the same equipment onboard? 

Over the years, we have opted to standardize certain pieces of critical equipment, such as patient monitor/defibrillators, ventilation equipment and airway kit. This happened after rigorously testing equipment that we found to be superior to others. This also allows us to optimize our in-service training and logistical support for these key items. Although there are disposable items that are stock standard across the fleet, the aircraft are stocked and packed uniquely to each base, owing to the difference in pathologies encountered at each one.  

How has HALO been affected by Covid-19? 

During its peaks, Covid-19 was certainly very challenging, and we had to adapt, not only to new disinfection protocols, but also with our own personal fears and anxiety. During the first wave, we created a dedicated Covid-19 HEMS unit with its own isolation chamber, set of medical equipment, dedicated PPE and procedures. As the situation changed and knowledge regarding the virus grew, we adapted our protocols accordingly. It was quite funny initially to have crew being showered down outside in disinfectant after a mission and then make their way inside. We quickly found that certain items of PPE were not conducive in the aeromedical environment, and it was sometimes a process of trial and error to ensure a relatively comfortable working environment while ensuring staff safety is not compromised. Certain basic measures, such as strict hand hygiene, and mask wearing in the HEMS base and office, remain in place. We also had to suspend certain training activities and limit access to the HEMS base to limit exposure to certain staff members only. We saw a significant drop in primary trauma calls during the first wave, so therefore staffing was fortunately not the big concern that we initially anticipated. It was inspiring to see how quickly all members of the HALO team were able to adapt to this unprecedented scenario and learning whilst we go along.

What does the Level 1 BEE status mean for HALO and its patients?

The major benefit we see in achieving and maintaining this status is that we have made a lifelong commitment to bring the aeromedical sector within reach of each and every South African, not just a fortunate few. This status allows us to develop and give ownership to a whole generation of pioneers and previously disadvantaged persons.

Night flying certification can be difficult to obtain, and the NVIS equipment is costly. Why did HALO make the decision to invest in this capability?

Having previously mentioning the strong focus on safety and not being complacent, this is strategically the next technological frontier that allows us to safely and comfortably be able to operate in conditions where otherwise it would not be possible. Unfortunately, Covid-19 has slightly delayed us in the goal of having this capability universally accessible across our fleet, but we will remain determined to do so even in the face of adversity.  

South Africa is covered by a patchwork of independent HEMS operators, how does HALO Aviation fit into the pre-hospital emergency medicine provider network?

HALO is the first, independent aeromedical owner-operator of its kind in South Africa (and Africa from what we know). Having access to both fixed-wing and rotary-wing platforms makes us able to serve not only the whole of South Africa, but in fact the whole Sub-Saharan Africa. We currently have several strategic bases as determined by operational need and other factors. There is a major paucity of scientific evidence for the optimal positioning of bases in low-to-middle income countries, but we believe we have been successful so far in expediently delivering a high level of quality clinical care to places where it was not before.

Do all HEMS providers work on the same communication platform to ensure safe operations within sometimes crowded airspace? How is asset management cohesive during an emergency response to a large-scale incident where multiple helicopters might be responding?

It is, fortunately, quite infrequent, but certainly, we have been faced with it before. We do not solely rely on a single form of communication, and it depends on the clinical scenario. Most of the time, our flight desk is able to liaise with other provider’s call centers should we be aware that other providers might be responding to the same incident. Pilots are also able to talk to each other directly via air band radio in uncontrolled airspace or via air traffic control in controlled airspace. In our monthly safety meetings, this is frequently a topic of discussion and is an eventuality that everyone is prepared for. The ideal scenario of everyone using the same platform and style of communication is not feasible currently. 

How would you like to see emergency medical provision improved in South Africa in the future, whether through public investment in HEMS, or more private operators?

The only way HEMS can be sustainable and address the disparity in healthcare in South Africa is by finding a hybrid solution. Making decisions with regards to whom the population is we should be servicing without any vested interest from government and academia would lead to high healthcare expenditure without perceived public health benefit. I do believe there is a lack of technical aeromedical capability and ‘know-how’ in the public sector, which could be supplemented with an experienced and capable private sector at a reasonable and fair cost to benefit the whole population. I know that certain key personnel at the National Department of Health are currently vesting significant effort to make this possible, and I am positive that we will have positive changes in the industry in the near future.