While it is more frequent in countries characterized by wide, expansive spaces, such as the US, Canada, and Australia, long-distance neonatal emergency transport (NETS) is extremely rare. Instead, they generally operate locally; hub-and-spoke facilities are designed for short distances, on the order of a hundred miles at most, often located in metropolitan contexts. As such, NETS rarely need to call on fixed-wing aircraft, instead routinely employing ground ambulances and occasionally helicopters. That said, the percentage of NETS in Europe by helicopter hovers around two per cent.

It is generally private companies or military air forces that conduct long-distances neonatal transport, generally for repatriation purposes and still in small numbers. However, with the prevalence of tourism – especially for citizens of rich western countries – the possibility of an unexpected premature birth, or accidents involving newborns or very young children are now relatively frequent events.

With the infrequency of NETS, medical personnel usually develop their skills through daily neonatal intensive care, then develop specific skills for air travel. However, this creates a unique problem to confront: it is not the quality of care of teams involved, but rather the lack of available, routine planning, practice, and experience with these types of transports. In other words, it is much more of a logistical problem than a medical one.

It is for this reason that the the Advanced Training School for Neonatal Transport was recently established at the Gaslini Institute in Genoa, Italy. It is specifically dedicated to neonatal air transport, addressing medical, organizational, logistical, and safety aspects, and, we believe, a global first for dedicated training and preparation.

Healthcare and transport in Italy

As in many places around the world, long-distance, non-stop neonatal transfer flights in Italy require flying with a private company or through the Italian Air Force. Healthcare in the country is completely free of charge and includes the transfer of patients, although the physician treating the patient must ascertain whether both the need and conditions are met; the most important being whether transferring the patient risks their life.

The local Prefecture, delegated by the National Government, will authorize the intervention of the Italian Air Force. Examples of NETS includes infant cardiac patients from the major Italian islands, Sardinia and Sicily, to the main Italian pediatric hospitals, in particular Gaslini in Genoa and Bambino Gesù in Rome, Vatican City. The Italian Government also authorizes the use of military aircrafts for the repatriation of Italian citizens abroad if specific conditions are present, for example technicians of important companies or diplomats engaged in contracts abroad.

More importantly, in the case of intervention by the Air Force, while the aircraft and flight crew are provided, medical personnel must be provided by the hospital and assumes responsibility for the transfer. This is one of the principal challenges for NETS: while the team is certainly the best available for the treatment of the sick infant, they are generally unfamiliar with the specific needs of neonatal transport.

Selecting the right aircraft

The aircraft most frequently used as ambulance aircraft in Italy, and many western territories, are the Hawker 400, the Beechcraft King Air 200, the LearJet 35A, the Cessna Citation I, and the Cessna Citation II. In all cases, the interior is small and of limited height, therefore unsuitable for long-distance transport, particularly when considering the additional medical equipment needed for neonatal transport. Additionally, their limited range makes them unsuitable for long flights and certainly burdened by many stops for refueling.

Compared to these, the Falcon 900 is wide, comfortable and above all has a significantly wider range – 4,750 nautical miles, making it more suitable for long non-stop flights. But while Falcon aircraft are supplied to the Italian Air Force for intercontinental passenger transfers, the available space and access present challenges for use as an air ambulance. While the Italian Air Force makes them available for medical use, the medical team is similarly responsible for converting them for use as air ambulances.

As such, choosing the best medical team for long-distance neonatal air transport is not easy. Besides the essential clinical experience, I believe personnel must be able to sustain themselves over extremely long periods of work, often largely exceeding the usual hours of shifts; the ability to adapt to non-optimal conditions, such as the cramped cabin of the plane; and be able to deal with difficulties beyond the medical, such as the management of travel documents or confrontations with regional authorities or local police that may operate in a very different way than what the team is used to. If you’re not well organized, leaving without a credit card or cash could become a far worse problem than treating a pneumothorax.

Fourteen days from Shanghai to Genoa

These logistical considerations were all tested with a recent repatriation of a seriously ill 14-day-old newborn in need of continuous mechanical ventilation in flight, transported from Shanghai, China to Gaslini Hospital in Genoa. The flight itself presented very little trouble; with the exception of two stops for refueling in Novosibirsk, Siberia on both legs of the journey and landing in Shanghai for the patient pick-up, it occurred without stopping.

The greatest difficulty was in equipping the Falcon 900 airplane for use as an ambulance and bringing onboard all the technical equipment necessary to assist the newborn. We needed to disassemble the transport incubator down to every single component to allow passage through the small access hatch. Once onboard, we reassembled and reorganized the equipment. Loading the medical gas supply was a further complicated aspect, both for the calculation of the theoretical gas consumption during the return flight, and, above all, for the weight of the 18 cylinders – both air and oxygen – of 10 liters each, and their relatively difficult stowage.

The other complex aspect was to establish alternate airports along the route beyond Extended-range Twin Engine Operations Performance Standards (ETOPS). Flying over large deserts or uninhabited areas, such as Siberia, Mongolia, and the Gobi desert, greatly reduces the possibility of having a secure foothold and additional considerations must be made. In case of a forced landing due to medical problems related to the newborn, it was necessary to identify airports located in cities that offered the presence of hospitals with active neonatal intensive care units and could offer a transport system from the airfield to the hospital.

The figure (below) shows the ETOPS circles that are connected to the stopovers that we have identified as useful alternate aerodromes. To overcome the problem of possible night closures, not unusual in such areas, we planned the return flight so that it would take place completely in daylight. Despite all these obstacles, the medical management of the patient was straightforward. If entrusted to expert teams, neonatal air transport over long distances is safe and feasible even if newborns in serious clinical conditions are involved.