For the majority of women, pregnancy is an uncomplicated and generally smooth process, other than the obvious pain and discomfort involved in delivering a baby. This is quickly forgotten, or at least temporarily placed to the back of the mind, when both parents finally get to meet their ‘healthy’ newborn for the very first time. Unfortunately, this is not the case for all.

The harsh reality is that the unpredictability of the onset of labor will mean that many infants are left requiring transportation to more appropriate facilities

It is currently estimated that one in 7 newborns, premature or term, will require admission to neonatal services. Gestation dependent, this can mean an extensive hospital admission for both baby and parents, with the possibility of complications, and the potential for challenges later in life. To place this into perspective, a neonate born at 23 weeks (17 weeks earlier than their term counterpart), should expect a hospital stay of a minimum of three months. This of course will be dependent on clinical needs and vary according to hospital policy. During this time, the challenges the newborn will face can feel like a never-ending roller coaster, with tasks that would ordinarily be simple, such as establishing feeds, taking weeks to fine tune. Whilst this is not the case for every admission, most babies requiring an escalation in care will need ongoing observation and/or management for an undefined period.

Neonatal Services in the UK

As a result of the current structure of neonatal service provision across the UK, many babies will require transportation to specialist units. Currently the UK has three levels of care, and a neonatal unit will be classified in accordance with these levels, dependent on which services it offers. The Special Care Baby Unit (SCBU) provides care to infants who require low level interventions such as oxygen therapy, phototherapy (used for the treatment of neonatal jaundice), and antibiotics, just to name a few. Staffing acuity will be significantly lower than that of the Neonatal Intensive Care Unit (NICU) and therefore the equipment available will be limited. Most SCBU will not accept babies below 32 weeks gestation, as well as those who require prolonged invasive or non-invasive ventilation.

The next step on the ladder of neonatal services is the Local Neonatal Unit (LNU). Here infants will generally be from 28 weeks gestation and requiring short term, low level intensive care. Staff acuity will be increased, and the specialist facilities and equipment more freely available. With the ever-increasing pressure on intensive care units, it is becoming more and more prevalent for Infants to be transferred from the SCBU to a LNU. Historically, most babies who required an uplift in care would be transferred to the NICU, however, with advances in treatments and technology to support this fragile patient group, the NICU is now under immense pressure.

The NICU is our third step up on the ladder, providing care to the sickest newborns, across a vast geographical area. Supporting infants from the viability of life (23 weeks onwards), the NICU offers a vital lifeline to those who require high level intensive care, one-to-one nursing support, and specialist interventional services. In an ideal world, all babies who ‘may’ require such a high level of care would receive antenatal support and subsequent delivery at a NICU providing hospital.

. With this is in mind it can be concluded that transport services will be allocated the task of moving the sickest and most complex of babies.

Transport services

Neonatal transport services across the UK are divided up according to geographical area and operational networks. Most teams will operate using road ambulances, often meaning long transfers and poor road conditions. Whilst this form of transport is adequate for most, many babies in rural or poorly accessible areas may require the use of rotary or fixed wing transportation. As an organization providing specialist aeromedical neonatal retrieval services, we are one of only a handful of teams in the UK able to facilitate the immediate aeromedical evacuation of some of the sickest newborns, providing a lifeline to the most remote of areas. The fleet of Beechcraft King Airs are specifically adapted to support the medical team in providing NICU level care in the air. Each aircraft has been internally modified to encompass a life-port system with oxygen, suction, and power in which the retrieving team can securely mount the incubator during transfer. This equipment is essential to the success of the mission, as each part plays a role in maintaining life to the fragile and often unstable newborn.

The transport team itself is lead by a senior neonatal consultant, who is contactable 24/7 for advice and support, throughout the transfer process. On referral, clinical coordinators, all with in-house neonatal training, will take basic clinical details and liaise with the neonatal consultant. A permanent neonatal nurse is also on hand to aid and support in the logistical planning of neonatal missions. The team itself will consist of a Senior Neonatal Registrar or Advanced Neonatal Nurse Practitioner (ANNP) and a Neonatal Nurse. Depending on the level of care required, special care and high dependency babies, on low level ventilation may be transported using two Neonatal Nurses, with the ongoing support of the consultant at all times. Like their medical colleagues, neonatal nurses undertake intense post-graduate training in neonatology, vital to provide the level of care required to this complex patient group.

Transport Rig

Altered and approved for aeromedical use, the transport rig is by far the most important piece of equipment that the neonatal transport team possess. Mounted onto an AeroSled for stabilization in the aircraft, the rig is made up of an incubator, ventilator, fluid pumps, suction, and a resuscitation device. Each piece of equipment is carefully arranged to ensure accessibility throughout the transfer, whist also taking into consideration weight distribution in-flight, as well as loading and unloading. The incubator, fixed to the most forward-facing part of the AeroSled, is designed to provide a warm environment to a patient group in which hypothermia can have a detrimental effect on neurodevelopmental outcomes later in life. With a maximum internal temperature of 38 Degrees Celsius this ‘hot box’ provides a safe and secure environment, whilst minimizing heat loss through radiation, conduction, convection, and evaporation. The neonate is secured using a specially designed system of restraints that connect to the internal fixings of the incubator. A double walled design also minimizes some of the noise associated with aeromedical transportation. Whilst the incubator can’t provide the same level of protection as the womb, its development has undoubtedly led to a significant decrease in morbidity and mortality.

Training

Continuing Professional Development (CPD) is vital for safe and effective practise. More so in the aeromedical environment where a confined space, physiological changes from altitude, and unpredictable turbulence are part of daily practice. All neonatal team members undertake an initial training program, introducing them to neonatal flight physiology, the aircraft, equipment, and clinical simulation. To facilitate the learning experience, we offer delegates the opportunity to train in our purpose-built King Air simulator. Team members can practice scenarios such as aircraft ditching and smoke in the cabin, whilst also enhancing their clinical skills in an unpredictable and challenging environment.

As part of ongoing training and development, the neonatal team will be required to undertake yearly refreshers, whilst also keeping up to date with mandatory training courses and Neonatal Life Support (NLS).

Case Review

. Transport providers are often tasked with moving infants in the peak of their decline, highlighting the importance of pre-departure optimization and stabilization. Tasked with moving a baby at 25 weeks gestation, weighing 800 grams (less than the average bag of sugar), the neonatal team commenced their mission and departed base. A short flight, the team arrived on the island and were transported via road ambulance to the receiving hospital. Whilst this seems like an easy task, the unloading of an incubator from an aircraft using an electronic loading system is a time consuming and delicate procedure; one that is fine-tuned with experience and practice. On arrival to the hospital the team take handover and examined the baby. Connected to ECG wires, temperature and oxygen saturation monitoring, blood pressure cuffs, as well as the Endotracheal Tube (ET) and in line suction device, there is often very little of the baby to be seen. It is perhaps this fact that makes neonatal care so challenging, creating a surreal and upsetting environment for parents and care givers.

It’s a well-known fact amongst neonatal health care professionals that respiratory distress syndrome will progressively worsen in the first 12 hours of life

As is often the case, the most recent blood gas requires an adjustment in ventilation. A severe respiratory acidosis is still present following the administration of surfactant via the ET tube. The decision was made to commerce ventilatory support on the transport teams Hamilton, therefore minimizing the need for further change when the respiratory status has improved. The team continued to optimize care, inserting umbilical lines, reducing the need for a bulky blood pressure cuff on such a tiny arm, and started to move the baby into the transport incubator. A drop in blood pressure is immediately noted and whilst improvement is seen after a couple of minutes it is decided to have inotropes at the ready. The aircraft environment is less than satisfactory to be drawing up lifesaving medications, therefore pre-empting the need for further support is always at the forefront of the transport team’s mind.

Both parents are updated prior to departure and consent to the flight is taken. Unfortunately, the ability to transport mum and baby is often restricted by the mothers own clinical needs. Post caesarean section, the neonatal team are not best placed to provide maternity care, as well as the obvious restricted space. A short 10-minute journey back to the airport and the baby is loaded into the aircraft and the team take five minutes for a pre-flight briefing. This informal chat involving the pilots and medical team is essential to the outcome of the mission. Adjustment such as a slow ascent and descent, or a sea-level transfer may be required for the success of the mission.

The flight was uneventful, and the baby required minimal interventions. A slight adjustment to the ventilation and an increase in the oxygen to compensate the effects of altitude is all that’s required. As requested, the pilots do their best to avoid any known turbulent spots, however this is slightly more difficult when flying at night and in the winter. The team arrived at the receiving airport and the ambulance was already waiting to assist with the unloading. Oxygen is transferred from the aircraft supply back to the transport rig and the clip deck (a specially designed base for incubator), was secured onto the ambulance stretcher.  Hand over is given to the receiving team and parents are updated on the progress of their baby. The team continue to follow up on their progress and look forward to reuniting the family in the not-so-distant future.

Conclusion

The transportation of neonates using fixed wing aircraft is a complex process, requiring highly trained professionals with extended skills in aeromedical transport. Each mission requires complex planning and should involve the multidisciplinary team for its success. Whilst the movement of sick neonates is less than desirable, the current service provision across the UK means that transport services are often vital for the survival of this delicate patient group. Therefore, transport services have a duty to provide high quality intensive care, including in the air.