It was during the Vietnam War that attitudes towards battlefield casualty evacuation shifted enormously. In 1968, the US Air Force introduced the McDonnell Douglas C-9A Nightingale, based on the DC-9 twin-jet airliner, as the world’s first long-range jet air ambulance with advanced medical facilities. This flying ambulance and ICU was quickly dubbed the ‘Cadillac of Medevac’ because of its state-of-the-art pre-hospital care and emergency medical systems. Since then, the lessons learned from the C-9A have trickled down to the 21st Century commercial aeromedical transport scene, where the benefits of the ultra-long-range jet air ambulance are plain to see.

Demand for long-range jets

The Covid-19 pandemic has been a driver in seeing demand change worldwide for long- and ultra-long-range jet air ambulance provision. “The need has certainly grown during the peak time of the pandemic due to the many operating restrictions,” commented Volker Lemke, Managing Director of FAI Aviation Group’s Air Ambulance Division. “By using long-haul aircraft, some hurdles, such as the lack of landing permits for certain countries, could be circumvented,” he declared.

FAI, with its headquarters in Nuremberg, boasts a fleet of 11 aircraft comprising Learjet 60, Challenger 604 and most recently, its large-cabin Bombardier BD-700 Global Express. The BD-700 offers among the fastest speeds in the industry of Mach 0.85 and an unrefueled range of up to 6,180 nautical miles, giving truly trans- and inter-continental range – covering routes such as Dubai to Toronto and Buenos Aires to London.

In the last few years, Luxembourg-based European Air Ambulance (EAA) identified a need to expand its capabilities with a longer-range jet aircraft that offered a larger cabin. “This need was specifically reinforced during the Covid-19-related lockdowns,” said EAA’s Business Development Manager Tom Hienckes, “since many countries had imposed severe travel restrictions, with increased protocols for landings – even if only for a fuel stop. By eliminating the need to stop, and therefore bypassing these restrictions, we were able to avoid many potential problems and a significant amount of complicated and time-consuming administrative work,” he explained.

There are obvious cost savings to be made in multiple patient transportation by using long-range aircraft with larger cabins and space for up to four stretchers

“Recently, we also experienced problems with fuel shortages at airports, especially in Western Africa,” he disclosed. “In such cases, we have operational limitations with our Learjet 45XRs, whereas the longer-range Challenger 605 gives us more flexibility when it comes to fuel and flight planning.”

EURAMI’s insight

Claudia Schmiedhuber is Managing Director at EURAMI, the European Aeromedical Institute, whose mission is to advocate for the highest standards among providers globally. “We at EURAMI have seen a great change in fleet composition over the last few years and especially since the Covid-19 pandemic started in March 2020. Many of our providers have added additional long-range and even ultra-long-range capacities to their programs,” stated Schmiedhuber. “Part of the reason for the changes in aircraft types were the difficult circumstances when it came to transporting Covid-positive patients directly, along with the fact that many countries did not allow aircraft to land for a fuel stop, which made direct flights between the destinations much more necessary than pre-pandemic,” she confirmed.

As well as the logistical benefits from non-stop flights already mentioned, there are obvious cost savings to be made in multiple patient transportation by using long-range aircraft with larger cabins and space for up to four stretchers. “This has been a great cost-saving factor for assistance and insurance companies and was often demanded in the last few years,” observed Schmiedhuber. “Whilst a couple years back long-range aircraft were seldom used by travel assistance companies due to the high costs, we can now see that these aircraft are utilised much more, either due to the demand of combining patients, or that the patient needs to be isolated or flown without fuel stops due to medical reasons.”

Finding the right long-range jet

Finding the right long-range jet has depended on geographical region as well as target market and clientele. “Generally speaking, most assistance companies were shy to use a long-range aircraft in the last few years,” Schmiedhuber disclosed. “While this has significantly changed during the pandemic, it remains to be seen if the trend to use long-range aircraft continues that way as, typically, long-range patient transports with long-range aircraft were usually more focused on government and corporate missions,” she explained.

Investing in new aircraft

When it comes to acquiring long-range jets, what does an operator look for, and when is it worth them making the investment? EAA made the decision to add the first long-range jet to its fleet during Covid when worldwide air travel had been stripped back to a minimum. When EAA acquired a new Bombardier Challenger 605 long-range jet in 2021, it was not simply a knee-jerk response brought on by the sudden changes caused by Covid. “We took the decision to give us the capacity to operate longer-range missions. It was the culmination of a long process that included examining case studies, doing our market research, deciding on the right aircraft type, and finally identifying when the opportunity was right to make the purchase,” explained Hienckes.

“Of course, our first Bombardier Challenger CL-605 was a significant investment for us,” proclaimed Hienckes. “Its acquisition involved a lot of work for our dedicated team, but we believe that investments in the future are now more important than ever,” he maintained. With a range of eight flying hours and some 4,000 nautical miles, the CL-605 can cover routes non-stop, ranging from London to Cape Town, and Dubai to Sao Paulo.

Hienckes went on to outline three key attributes that EAA considered essential when it came to buying the long-range CL-605: speed, capacity, and space. He continued: “Speed – the quicker the repatriation, the sooner a patient can be transferred to a medical facility that offers the appropriate level of care for their needs. Capacity – the CL-605 enables us to carry more patients, with flexible configuration options that include more patients simultaneously, even those needing intensive care and treatment during the flight. Space – the additional onboard space means more room dedicated for medical equipment and for accompanying passengers and luggage,” he said. “One advantage, of course, is also that the medical team has much more space in the cabin to treat complex and challenging cases in the air, which is a beneficial factor for everyone involved,” concluded Hienckes.

In 2021, FAI reconfigured one of its two Bombardier Global Express jets as an ultra-long-range air ambulance. Volker Lemke related what prompted them to do this: “Of course there is only a very limited request for this type of aircraft, but we sometimes have the situation that a patient should have no – or as few – fuel stops as possible for medical reasons, even on ultra-long-range sectors,” commented Lemke.

“Or maybe a wealthy private customer would like to use one such aircraft with this cabin interior – the reasons can be varied, but the inquiries are rare. Nevertheless, we decided to optimise the medical configuration and equipment of the Bombardier Express in order to be prepared for such cases and to be able to deliver the ideal product. However, these aircraft are not generally used as dedicated air ambulances, but for mixed use.”

Cabin configurations

Lemke described the medical interior options for FAI’s Global Express jet: “The aircraft is traditionally operated in a single-stretcher configuration with space for the medical crew and up to 10 additional passengers. A double or maybe a triple stretcher would basically be possible, but it’s generally never used with this type of mission,” he explained.

EAA’s Challenger 605 will be able to take up to three patients (two high-comfort stretchers and one logistic stretcher), as well as additional relatives. The cabin configuration will also allow the privacy of each patient individually. “We will be able to fly two full intensive care units – ICU monitoring and ventilator, video laryngoscopy, ultrasound device, blood gas analyser, cardiothoracic drainage system, thorax compression device, plus ECMO capability,” outlined Hienckes.

Hienckes outlined three key attributes that EAA considered essential when buying the long-range CL-605: speed, capacity, and space

For neonatal transfers, the Challenger 605 will also be able to fly up to two patients together (including neonatal ventilators with heated and humidified gas) accompanied by a team of neonatologists and specialist nurses. “The 605 will, of course, also offer infectious diseases capability with different options based on the cases analysis, different infectious diseases module,” revealed Hienckes.

“Obese patients’ flights will also be much easier with wider stretchers and dedicated equipment. The redundancy of vital medical equipment, and electrical power supplies, plus a reserve of oxygen with different independent sources, are other major improvements. As with all our aircraft, the patients will be taken care of by physicians specialised in anaesthesiology/ICU and Emergency Medicine, and flight-nurses specialised in ICU and Emergency Medicine,” he announced.

Accreditation

When it comes to the accreditation and quality control of long-range jet aeromedical transport, EURAMI does not differentiate between the types of aircraft, explained Schmiedhuber: “Our auditors look at the whole operation and fleet very thoroughly. What we do look at – regardless of the type of aircraft – is, for example, the maintenance records, the Supplemental Type Certificates, how the equipment is equipped as well as the overall condition of the aircraft and the kit onboard.

One thing that is different when it comes to long-range jets is that these are often used for multiple patient transports, which means that during an audit, we also look at the configuration of multi-stretcher missions to ensure that every patient can be cared for safely and adequately. Generally speaking, I can say that we have seen an increase of long-range aircraft fleet compositions in both primary and re-accreditations, over the last three years,” she revealed.

Looking to the future

What does the future hold for the continuation of long-range jet air ambulance missions? FAI’s Lemke remarked that the need for such missions had certainly grown during the peak time of the pandemic, due primarily to operational restrictions, but today, he believes the number of long-range operations is actually declining.

“We are basically back to normal operationally,” he said, “but, of course, a renewed flare-up of the virus problem could lead to higher demand again in the short term, but in general the market should not change that much in the future and there should only be limited demand for long-range.

Through these difficult and uncertain times ... air ambulance operators have adapted their business models

“The current capacities in the long-range sector are, in my opinion, sufficient for today’s needs and also for developments in the near future due to the relatively large number of Challenger aircraft on the market. Our investments in our long-haul fleet over the last 10 years were certainly in line with the market as there was a relative under-capacity at the time, but we currently see no need for further expansion and the associated financial efforts.”

From the viewpoint of EURAMI, it has seen a lot of companies around the world invest in longer-range aircraft as an addition to their current fleet, which was mostly focused on mid-haul or even short-haul flights. Schmiedhuber said the market has to be watched carefully before we can decide whether or not these investments have been worthwhile: “During the pandemic, the demand for such long-range and ultra-long-range flights had risen dramatically, which might have been an incentive for some companies to add these jets to their fleet.

To confirm that such an investment pays off is difficult to assume as the market trends are still very fragile and can change quickly, as the current summer season shows very clearly. In general, I believe that investing in long-range aircraft allows for a provider to enhance and widen their client portfolio and assures a true global reach, which is attractive to many clients that might not have been interested in working with a company focused on mid-haul flights beforehand.”

Ready for change

The message coming out of the past two years is that through these difficult and uncertain times, when the whole world has been so enormously affected by the Covid-19 pandemic, air ambulance operators have adapted their business models and operating profiles to include long-range air ambulance transport. “We want to be ready for whatever the future may bring, with enhanced and more flexible options for our clients,” concluded EAA’s Tom Hienckes.