Air ambulance services in India.A Mehra
Indian Aeromedical Services Pvt. Ltd., Mumbai, India., India
Keywords: Air Ambulances, organization &administration,Human, India,
19th September 1783, Lyons, France, preparations were being made for a journey, a journey that will eventually take man from his secure environment of terra firma into the hostile environment called atmosphere.
The vehicle to be used was a hot air balloon. The brainchild behind this trek was a wealthy paper maker named Joseph Montgolfer. There has been much speculation over just how Montgolfer made the discovery of the hot air balloon. The most commonly believed legend has it that his wife was standing too close to a fire and that the smoke caused her skirt to be inflated and lifted above her knees. This caused Montgolfer to wonder, if the smoke, and its magical lifting powers, could be captured in a large container, it my rise and lift a person along with it. So Montgolfer went about building the first hot air balloon and the first flight passengers in this balloon were a chicken, a sheep and a duck. The balloon attained an altitude of 518 meters above main sea level and fell to the ground a mile and half away. Upon examination of the occupants for any ill effects, it was discovered that duck had a broken wing, could this be due to atmospheric effects, was the question. Actually many observers had noticed that the sheep in anxiety had kicked the duck.
Montgolfer had reasoned that it would be safe for human beings to ascend to altitude. Thus, on November 21, 1783, the first manned balloon flight carried Pilatre de Rozier, a young scientist and physician from Metz. Jean-Pierre Francois Blanchard, a great balloonist, considered balloon flight because of purer air (rarefied air).
First air evacuation was done in 1870, 33 yrs. before the historic Kitty Hawk flight when 160 wounded casualties were evacuated by air balloons during Prussian siege of Paris, by French Physiologist and Father of Aero medicine, Paul Bert. In 1909, Capt George Gosman thought of using fixed-wing aircraft as air ambulance. In 1917, French aircraft, Dorand AR II, was used as the first such air ambulance. During World War II nearly 1 million causalities were evacuated by air w ith a death rate of 4/100,000.
It was not until 1933 that the first British Civilian Air Ambulance Service was started, serving the Scottish Isles; the descendants of this service still operate today, carrying the sick and the invalids from the remote islands of Scotland to the Midland.
Long distance high altitude aeromedical evacuation was however pioneered by the Luftwaffe during the Spanish Civil war and the Second World War. In the later years of the war more than 90% of allied causalities were evacuated by air from all the sectors.
One month after the start of the Korean conflict the first medical evacuation was made on August 4, 1950. The helicopter, a Bell 47 with externally mounted litters, was flown by Marine Corps pilots of VMO-6 squadron to the hospital ships Repose and Consolation, as they were equipped with a special helicopter landing pad.
The Military Assistance to Safety and Traffic (MAST) system began opertions in 1969 at Fort Sam Houston in San Antonio, Texas. MAST was started as an experiment by the Department of Transportation to study the feasibility of military helicopters augmenting existing emergency medical services. In the first ten years of operation MAST expanded nationally and transported more than 16,000 patients casualties.
The US Army MAST program probably provided the first stimulus for health care facilities to transport patients by helicopters. Later, during the Vietnam and Gulf conflicts helicopter air ambulances proved their worth in evacuating a large number of casualties.
Air ambulance services were used during the wars India has had with Pakistan. Air evacuation of civilian casualties has been done by the Indian Air Force at the time of national calamities, but no such service existed exclusively for the civilians until the India Aero medical Services was started in 1995.
Transfer from military evacuation to today’s sophisticated EMS (Emergency Medical Services) programs for all concerned did not occur overnight. Australia, a land of vast distances and scattered population, probably deserves the credit for being the leader in integrating the airplane into the health care delivery system. The air ambulance industry all over the world, from the early MAST type operations to today’s increasingly sophisticated programs in the western countries has only one goal: “Get the patient to the best medical care available as rapidly and as safely as possible, a rewarding goal with proven medical benefits.”
Today medical evacuation and rescue operations by air are being carried out by both military and civil organisations in most of the countries because of the availability of flying machines. There are dedicated and fully equipped aircrafts available for air evacuation in many countries. In India this service was only available in the military, but none in civil due to lack of finances and non-availability of suitable aircrafts. With the onset of liberalisation in our country during the early years of the last decade, it became possible to commence a dedicated Air Ambulance Service, leading to reduced morbidity and mortality during evacuation.
An air ambulance is specifically designed to accommodate the aeromedical needs of person’s who are ill, wounded, injured or otherwise mentally or physically incapacitated or helpless, who may require emergency medical care in-flight, and who, in a physician’s opinion, cannot be safely transported on a standard commercial flight. Use of air ambulance services can be particularly valuable when time is of the essence, when ground transportation is an uncomfortable or even a life-threatening mode of transportation, and/or when no other means are available to transport the patient.
In transportation of patients by air ambulance, flying time, distance and condition of the patient are significant factors. Critically ill and injured patients in remote areas may require rapid transportation to large tertiary care centres, similarly stable patients with certain unusual and critical problems may need transportation to super-specialised tertiary care medical centres.
The major questions that must be answered are:
1. Is the risk to the patient in being transferred less than the risk of not being moved?
2. What is the risk to the patient flying at high altitudes?
3. Is the patient adequately stabilised?
4. Are the benefits of the move real, and do they justify the clinical and fiscal costs?
5. Is the move medically necessary or being driven by non-medical or emotional concerns or the family’s concerns?
6. Is the equipment on board capable of handling the anticipated and unpredictable emergencies?
There are a few clinical conditions in which aero medical transportation may not be safe and none is an absolute contraindication. However a knowledge and understanding of physical, physiological and psychological constraints, imposed by the flight environment, will allow anticipation and therefore, prevention of clinical problems that may arise in flight or at any other stage of transfer.
The upper troposphere is a hostile place. As air pressure declines, less oxygen is available for cellular metabolism. Gases trapped within the body cavities also expand with ascent due to changes in barometric pressure. There are other factors like motion sickness, vibration, noise, cold, fatigue, effects of G forces, dehydration and the psychological fear felt by someone who can imagine nothing worse than being locked in metal carriage tube flying at 805 kph (500 mph) at an altitude of 10,670m (35,000 ft.). Most healthy individuals can readily compensate these stresses; however, a sick and injured patient is placed at risk, depending upon the nature and severity of the medical condition.
To protect these patients from these stresses following points must considered very carefully:
1. Pre flight medical assessment of invalid passenger / patient.
2. Specialised training of the medical staff and flight crew.
3. Availability of airworthy portable medical equipment.
4. Type of aircraft being used for carriage.
5. Flying Time.
6. Considerations of the potentially adverse effects of the Cabin environment.
7. Need of a specialist doctor on board.
Currently, two types of air ambulances are available:
Helicopter air ambulance. Because of its unique capabilities such as of flying into otherwise inaccessible areas and taking off from and landing at narrow spaces, flying over difficult terrain, it is the primary mode of emergency operations. However its range of operation is generally limited to 150 to 300 miles, depending upon the type of helicopter. The helicopter offers great advantages over road transport, especially, inbeing able to approach incident or accident site where access by road may be very difficult or where roads may not even exist. Confined spaces (particularly in urban areas) are not necessarily a problem and when time is of essence, critical patients can be air evacuated to the most appropriate hospital for further medical treatment. The helicopter therefore, becomes not just a means of transportation but also an airborne intensive care unit, thereby, diminishing the duration of the therapeutic vacuum. The result is not simply a reduction in mortality or morbidity but also reduction in disability.
Fixed wing air ambulance. It can transfer the patients long distances, but must load and offload them at the airports or existing airfields. Since hospitals are rarely located near the airports this necessitates ground transfer at either ends of the flight.
The type of air ambulance which is optimal in a particular situation will depend upon distance, terrain, patients’ condition, diagnosis, flying time and Civil Aviation rules and regulations.
In the confines of an aircraft, the major functional disadvantage for practice of critical care medicine is one of space. A patient (and possibly relatives) plus flight crew and medical team, with the equipment and baggage, consume a large part of the available space within the cabin. Even simple things like opening a box or bag containing medicine / equipment may prove difficult, let alone major medical interventions. As such, prior planning and positioning of essential airworthy, portable, medical equipment is very essential, but there is no substitute for frequent practice and mock-up training in the aircraft cabin itself.
While considering the effects of long haul International transportation of invalid passengers and patients, awareness and planning for logistic factors such as total out-of-hospital time, ground transfers, airport formalities, time zone changes, actual time of arrival at the destination and the facilities available at destination is absolutely vital and essential. In addition, consideration must be given to the timing of feeding and administration of medications in transit and to the availability of suitable clothing or protection while travelling between one climate zone to another. Other equally important considerations are: availability of emergency funds in suitable currencies, passports, visas and documents for the import/export of controlled drugs.
The overall aim is to transfer the patient safely from point of origin to destination, without further deterioration in his condition. Essentially, the quality of medical care should not fall short of that which could be available on the ground in an ICU. This is a tall order when consideration is given to the constraints already listed, but providing adequate medical equipment and medications can ensure its achievements. During air transportation of casualties all the members of the medical team and cockpit crew must be thoroughly familiar with the usage of all equipment on board and they should have the knowledge and skills to deal with both, the predictable and the unexpected emergencies.
Minimum requirements for an air ambulance are a suitable aircraft, trained medical staff and flight crew and airworthy medical equipment.
Medical help that can be given to the patients during air evacuation falls into three categories:
A. Basic life support services involve transportation of stable patients who have no serious emergency conditions and are not critically ill, and for whom no major in-flight stabilisation is needed and anticipated.
B. Advanced life support includes basic life support services, cardio pulmonary resuscitation including cardiac monitoring, defibrillation, trauma care and other life support measures like provision of continuous oxygen supply, monitoring of blood pressure & temperature, IV and central lines etc.
C. Specialised life support requires specialist doctors on board, highly sophisticated medical equipment like Aortic balloon pump or Portable infant transportation systems and any other electronic instruments needed for arterial or pulmonary catheter monitoring. It also needs highly experienced medical and flight crew necessary to provide a level of tertiary care as found in the intensive care units of major medical facilities.
Aero medical transportation missions can be divided into three categories:
A. Primary: This includes search and rescue, transportation of skilled personnel to scene of accident, transportation of equipment and medical material to scene of accident and evacuation from scene of emergency.
B. Secondary: Inter-hospital or intra-hospital transfers
C. Tertiary: This includes inter-hospital transfers to tertiary care centres, national or International repatriation, and transportation of donor organs and drugs.
Of the many controversial issues surrounding the use of helicopters in the EMS (Emergency Medical Services) role, there are two fundamental concepts, each of which has vociferous proponents. The first concept is much the same as was applied in Vietnam, namely, to reach the trauma victims quickly and transport them, equally rapidly to a nearby centre with full medical facilities and excellence. The other perhaps more controversial concept is one of “stay and play”. If the patient is critically injured and the evacuation time is likely to be long or delayed, it is suggested that advanced trauma life support skills be moved to the site of incident or accident. In this way, medical personnel with the appropriate equipment will be able to resuscitate and stabilise the casualties who might otherwise die before arrival at hospital and are at risk from transportation by air.
On dedicated aero medical flights the mission object is the safe transport of the patient. The medical team will specify to the pilot the medical requirements - such as origin and destination of flight, personnel and equipment needs (payload weight), and the pilot will plan to meet all these needs to the extent that it is operationally feasible. The pilot or flight operator will need to consider aviation matters – is the available aircraft appropriate for the task/crewing and duty hours/ endurance/re-fuelling/weather/terrain/national orders/etc. There may be issues to which the medical team may contribute by request or advise but which are nevertheless operational issues – such as choice of aircraft – helicopter or fixed wing, jet or turbo-prop, pressurised or non-pressurised. Coordination between the two teams is very essential. Ultimately the mission and planning of the dedicated aero medical flight is centred on the safe medical transportation of the patient.
The receiving hospital and the attending physician must be fully aware of the evacuation plan and be fully prepared. Ground support at the origin and destination must be available and adequate to fully support the patient, equipment and transport team.
1. Restrictions by the AAI.
a. Private road ambulances cannot be taken inside the airport, up-to the aircraft for loading and offloading the casualties.
b. No priority given to the medical emergency flights.
c. No airport passes for doctors and other staff working for Air Ambulance Companies.
2. There are no guidelines issued by DGCA. regarding Air Ambulance services.
3. Air evacuation of casualties in India at the present is an expensive proposition due to high price of the ATF (Air Turbine Fuel) and aircrafts. Since this service is not covered by the medical insurance as yet, it becomes very difficult for potential customers to pay for the service. Until such time as this service is brought under the insurance scheme or subsidised by the state govt., it will be difficult for a common man to avail of this life saving facility.
4. There are no helipads at most of the major hospitals in India, but there are open places near these major hospitals where one can land a helicopter after taking permission from the concerned authorities which may take a long time.
5. Several aircrafts are available now for air ambulance duties but there is no denial to the fact that there should be dedicated aircrafts for this purpose, but looking at the cost of buying and maintaining, a venture like this deserves support, encouragement and mobilisation of resources from charitable bodies or corporate houses.
In India the reasons for using air ambulance transport seems very appropriate; namely to provide rapid transport of the patients to specialised centres of tertiary medical care. India being such a large country with nearly 80 % of its population living in the rural area, this type of specialised medical service can save many precious lives, only if there was a health insurance plan available to cover this service for a common man. Air Ambulance services must make efforts to provide all emergency critical care to patients being transported by air of the same level as provided by the ICU ground ambulances. The fact that a patient is being transported by air does not alter his patient status. Our aim should be to provide modern, safe and convenient air transportation to patients, keeping in mind that patients are not cargo, patients are not passengers, and patients are patients.