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Wednesday, October 1, 2008

EMS Down Under: Australia Taking Care of Its People

Barney O’Shea, Melbourne

EMS helicopters Down Under serve a sparse population of citizens and visitors who hunger for adventures that often leave them in dangerous predicaments.

May 17 is a significant date in Australian aviation. On that date 80 years ago, the first flight of what was to become the Royal Flying Doctor Service was made, carrying a doctor to attend an outback patient.

This was a dream come true for the Rev. John Flynn, who saw the airplane as a means of providing medical service to the people in the outback, to cover those who are few and far between in the vast distances where — after cyclones, storms or the rare heavy rain — the first driver through makes the road.

These people are very special who make the decision to live in the outback providing services, exploring, doing the 1,001 things that outback Australia provides, not the least of which are raising great herds of cattle and sheep. The initial Royal Flying Doctor Service was made possible by the bequest of Victor McKay for the first aircraft. It now has 47 aircraft, with 700 staff to cover about 80 percent of Australia. The service has a very interesting and informative Web site: www.flyingdoctors.org.

A major change for medical services in the field was the arrival of the helicopter, which could go where no ambulance or fixed-wing aircraft could, take a medical team in and bring a casualty or patient out.

All states in Australia have a responsibility to their citizens to provide medical and ambulance services. Today, most have incorporated helicopter into their state medical services. If Flynn was alive today, he would be astonished how far his dream has gone, with the Royal Flying Doctor Service able to link up with the state medical services that now are using helicopter-borne teams to treat and move patients to the nearest place that the service can land one of its fixed-wing aircraft and pick up patients for transport to a medical facility that can provide the necessary emergency treatment. Residents of cities also benefit from EMS helicopters that can overfly road problems and speed up transfer during the important "golden hour," especially trauma victims of accidents invariably cause roadblocks.

If one lays a map of Australia over one of the U.S., it is clear that the nations are similar in size. Yet Australia has only 20 million people and a coastline of about 16,000 mi (25,760 km), compared to the U.S. population of more than 300 million and coastline of 12,383 mi (19,924 km). One does not talk of how many Australians there are per square kilometer but how many kilometers there are per Australian. When it comes to how many animals can feed from an acre, again it is how many acres per animal! The population’s distribution does not help, either. About 70 percent lives within 20 mi (30 km) of the coast, and 70 percent or more of that again lives within the areas of the state capitals. Those capitals, like Sydney and Melbourne, and major towns naturally attract industry and people and become the place to build the big hospitals that house the limited numbers of specialists and equipment such as trauma centers. The Royal Flying Doctor Service flies doctors to the people and brings patients back to the specialist centers. The ever-growing and mobile Australian population is outstripping natural resources, even essentials such as water, and there are fewer major hospitals to serve it.

Due to the limited facilities, helicopters are now accepted as essential for providing emergency services with back-up from the stretched ambulance and medical services. To achieve this, state governments have incorporated helicopters with medical teams to work with the ambulances to retrieve casualties from locations too far for ambulances.

People in population centers accept as normal calling for an ambulance and going off to the hospital. But with the increase in people comes the increase of vehicles that enable people to live farther away. Even new freeways between big towns have trouble handling with the higher volumes of traffic.

Australians, especially newcomers living close to the coast or cities, consider all the country open for them. Scratch an Australian and out comes the bronzed bushman who can live anywhere, go anywhere, never get lost in the bush, get stuck on a cliff, whose boat never breaks down and, of course, who has no problem with natural phenomena. How many of these do you know? Therefore, there are now more people — new Australians and city dwellers — who will go where experienced people fear to. This means there will always be someone needing help or rescue.

Australia has established a nationwide fleet of helicopters to make rescues, find the lost, save the gallant voyagers, attend the isolated, and provide one of the world’s most advanced patient-retrieval services. The helicopter filling the spaces that the Royal Flying Doctor Service cannot reach, brings a medical team to retrieve a patient to the local hospital, or — when no specialist or trauma facility is available — to the nearest landing place for the service to pick up and carry over long distances that are impractical for rotorcraft. This is not perhaps ideal, but what an improvement from even 10 years ago. (The tilt-rotor has had the first operational trials and, in time, may be available but has yet to be tested in Australia.)

The birth of helicopter emergency medical services here was again typically an Australian experience. The Mornington Peninsular is a vacation spot for Melbourne. The community took their problem to Tyabb Airport, where a local helicopter pilot and owner got together and made the Angel of Mercy the peninsula’s emergency rescue helicopter. The peninsula stretches 45 mi (75 km) from Melbourne, with the sea on one side and Port Philip Bay on the other. The sheltered waters and beaches combine with a selection of nature and wildlife reserves to lure vacationers in part because they are easily accessible — until you fall down a cliff, get cut off by the tide, have your boat sink under you. All coastal areas like these create a steady need for emergency services.

In 1971, when the Angel of Mercy was launched with a Bell Helicopter JetRanger, travel into the city by road took hours. The peninsula’s attributes attracted a growing aging population, for which a quick emergency response was needed.

The community accepted the responsibility to find the necessary funding to finance the operation for the Angel of Mercy, the helicopter being flown and provided by the Tyabb Co. The value in lives saved and quicker recovery by winning the essential golden-hour race was apparent to all.

The state government of Victoria was approached to help finance the Angel of Mercy, and helped maintain the service and prove the value of an EMS helicopter. A Helicopter Ambulance Task Force was formed in the early 1970s to advise and develop that helicopter service in the state and formulate actual requirements. Especially as compared to greater Melbourne, the Mornington Peninsula is barely a suburb.

With much foresight, the decision was made to acquire a twin-engine turbine helicopter capable of carrying 6 – 10 passengers. It also was decided to base the helicopter in Melbourne and to have it flown by the Victorian police with a police officer and ambulance paramedic making up the crew. The choice of helicopter was driven by the assessment that the major duties, police support and rescue, demanded a twin turbine. Opting for a single-engine helicopter would restrict low-altitude work in populated areas. Likewise, a single-engine aircraft would carry limitations on overwater operations. and other marginal conditions in which the crew might be called upon to operate. The safety of the crew was imperative.

This was seen in the 1988 Sydney Hobart Race, when the race was decimated by a violent storm and 55 casualties were rescued by helicopter, all by individual winch rescues. Much heroism was seen that day, with helicopter crews operating in winds at times exceeding 50 kt (100 kph) and waves of more than 80 ft (25 m). Film footage shows the effort to hoist each individual casualty took 20 min, and sometimes three or more approaches were required to rescue one casualty. Each hook-up missed meant the helicopter had to go round again and hover in high winds over the massive waves.

Twin engines also were necessary to permit the rescue of an average family of two parents and two children and carry the weight of inert, soaking wet bodies plus the emergency equipment required.

The first Eurocopter AS365 Dauphin came in, tasked to fly within a radius of 80 nm (150 km) from Melbourne — and elsewhere in the state as needed by police or ambulance.

Upset at losing the Angel of Mercy, the peninsula community nonetheless had proved the need for an EMS helicopter. It subsequently helped form the Southern Peninsula Rescue. The new team from the start insisted on being completely independent, so that there was no bureaucratic interference or sponsors using the rescue service to promote their activities to the detriment of the rescue team activities

This independence meant not even using sponsors, but unconditional gifts or donations for such essentials as fuel, servicing, medical volunteer personnel doctors and nurses, etc. The reason was to enable the rescue team to fly and carry out rescues as required. Basically, the ambulance service had to be on call over a far greater area and was tasked by the ambulance controller. Getting a casualty with broken bones up the rocks from the beach to an ambulance was not seen as a helicopter function since the injuries are not life threatening. Tell that to a distraught parent seeing a helicopter flying away without her seriously injured son, who is left far from hospital.

Southern Peninsula has been operating since the mid-70s and is still going strong, with support from the community and vacationers. It has managed to upgrade to a new, single turbine helicopter and is on call all year round.

The need was established again for a helicopter by the community in the Latrobe Valley. Just about on the limits to fly casualties to Melbourne, this also has become a full state responsibility. The Police Air Wing went to three twins with the purchase of two more similar model Dauphins. These served well for more than 20 years and the replacement helicopters were obtained on lease from CHC: two Eurocopter N3 Dauphins for Melbourne, a Bell 412 for the Latrobe Valley, and a Bell 412 for City of Bendigo.

The recent amalgamation of the Melbourne and rural ambulance services has focused attention on rural needs and a further two EMS helicopters. A new location at Warrnbool, not as far from Melbourne as the Latrobe Valley, is suited for covering the West Victorian coast. A third N3 for the Police Air Wing gives it an on-site standby capability, as one N3 is allocated to and fitted for ambulance and rescue work and the other for police work. A certain amount of overlap is possible, but the dedicated machine provides the best operations.

A separate contract with Australian Helicopters has been let to provide Melbourne and Victoria neonatal and infant coverage and patient retrieval and transfer, enabling the police to be committed with the N3s to ambulance and police work. The new contract also provides an EC135 as light back up and training of aircrew.

The Victoria state policy is not to own high-cost assets or to burden specialist operations with anything other than their duties. This ensures that the specialist helicopters and crews will be available as required, equipped and trained for the task, with the helicopters and equipment correctly maintained by qualified personnel.

This is just Victoria, not the largest state, but quite highly populated. As EMS helicopter contracts have been let, each state has a different approach, the aim of all to provide a helicopter ambulance capability where needed. All states and territories now have EMS helicopters in place. Smaller places have only one, like Tasmania. Western Australia has only one government helicopter, but has access to the offshore-support helicopters, mainly twins. Queensland is a large state but thinly populated. It maintains a review system for regularly analyzing operations and future requirements. The Queensland Emergency Service is completing an upgrade from a Bell 412 to three new AgustaWestland AW139 medium twins. The first AW139 has been used for crew training and has been refitted by the Queensland Emergency Service’s own engineers with compatible ambulance and medical treatment.

New South Wales and Queensland, upon contract renewal, have been raising the standards of their EMS helicopters by changing from community-supplied and -crewed helicopters to fully maintained and flown helicopters. Previously, the states had included mandatory conditions to ensure operations and maintenance were to an accepted standard. This has been hard for some community groups to accept after years of community effort to provide helicopter coverage and with organizations like CareFlight that has developed crewing to include trauma specialists (and the only aircraft unit with accredited trauma training). CareFlight lost the EMS contract, replaced by a contractor providing larger, newer aircraft. At the same time, CareFlight’s expertise has been recognized by continuing the head injuries work with a dedicated A109.

In Queensland, due to the area covered, EMS helicopters have been stationed at overlapping intervals along the coast, with larger twins at the major centers like Queensland, Townsville and Cairns.

Queensland and New South Wales are among the leaders in the improved ambulance service, using EMS helicopters for patient retrieval since it is impossible to ensure medical staff are everywhere with the people. The helicopters are crewed with doctors and paramedics who can assess, treat and transfer patients.

CareFlight has the contract to provide doctors for both Queensland and New South Wales. With the introduction of commercial operators on state contracts, the standard of helicopter has been improved. Queensland, for instance, has the new AW139s as well as EC135. New South Wales has some AW139s coming in to replace older, lighter twins. Australian Helicopters replaced a LongRanger with an EC135 and is also acquiring an AW139. The community organizations that have remained, as well as most EMS helicopter services, are planning to update current older twins and the odd single.

The atmosphere around the EMS helicopters has changed completely since inception, mainly through increased government support and the fact that there is a wider selection of helicopters to choose from. All services are planning to update. For instance, one can presume that Bell 412s being replaced could well be shifted to replace smaller machines in other organizations.

When the patients cannot be treated within reach of a helicopter, it is arranged for the helicopter to deliver the patient to the Royal Flying Doctor Service for transport to major trauma hospitals.

Flynn would be very happy to see what started with that one aircraft bequest 80 years ago now numbers 47 aircraft of their own, with availability throughout Australia for a comparable number of helicopters to cover the areas not able to be supported by the Royal Flying Doctor Service.

All states have limitations on a dedicated EMS helicopter capability, mainly in the form of funding or staffing for the smaller states. The capability of all helicopters within each region is known and helicopters can be hired as required to ensure that the Australian people are supported where ever possible.

The Australian helicopter fleet is now well more than 1,500, with Robinson dominating the single-engine, piston machines. Single-engine turbines in larger numbers are Bells and Eurocopters, with Hughes, MD and AgustaWestland filling specialist niches. The number of twin turbines has increased markedly to provide for EMS, with AgustaWestland having a sideline in twin training while the army and navy are waiting for their new twins. EC135s are increasing in number for short range service, general utility and training for the large twins.

When one sees what has been accomplished in the Royal Flying Doctor Service’s 80 years, one can rest assured that the flexibility of the Australian community will ensure that the EMS helicopter will be developed to cope. The service began as the Flying Doctors, the title Royal approved by Queen Elizabeth II in recognition of its superhuman efforts to serve the outback.

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