air ambulances – when lives are in the balance

September 12, 2019

For International SOS, a renowned specialist in medical evacuations, the best way to ensure that people abroad stay healthy is to establish robust preventive programs. But for the rare instances when prevention is not possible, a safe and rapid evacuation is vital to saving lives. Que the Air Ambulance. Marc Grangier reports

The history of aviation and emergency evacuation traces its roots to 1925, when a medical section of the US Army Air Corps began using converted De Havilland fixed wing aircraft. Although know nearly synonymous with medical evacuation (medevac), helicopters were not used for this purpose until 1944. For medium to long distance evacuations, most air ambulances are now specially equipped business jets capable of using more airports than commercial airlines. They are also to fly more direct routes, picking up a patient from the closest airport to the treating hospital and landing at the closest airport to the receiving hospital.

As more people move around the world seeking jobs, visiting family and traveling to far-away destinations, the need for medical evacuation services has become indispensable. To serve this need, the last 50 years has seen the launch of a number of medevac companies. Many of these companies are headquartered in developed countries so they can easily bring back sick or wound expatriates or tourists to a hospital in their home countries or, for large countries like United States or Canada, to an adequate trauma center.

Concerning a continent like Australia, the situation is slightly different. For the many rural communities located across the isolated bush, medevac is a lifeline to a town hospital. The Royal Flying Doctor Service (RFDS) is one of the world’s largest aero-medical organizations, providing comprehensive basic medical assistance across Australia. The first civilian air medical transport was completed in 1928 when a De Havilland Fox Moth aircraft in the service of Australia’s Royal Flying Doctor Service took off on its first mission. At present, its fleet is 71 planes strong, and includes 31 Pilatus PC-12, 30 Beech King Air B200 and 200C, two King Air B300 and three Pilatus PC-24.

OEM Medevac Options

Most business aircraft manufacturers have a foot in the medevac door. One of the very first was the Learjet Company, taken over in 1990 by Bombardier. Due to their cabin length, Learjets, from the 25 to the 35/36, were for several years the only aircraft in their segment modified to accommodate tandem stretchers. The auxiliary power unit was also certified for unattended operation and could continuously supply power to key life support equipment.

Another good reason why Learjets have been very popular was their high cabin pressure differential limit, which allow sea level pressure to be maintained up to FL250 (25,000 feet pressure altitude), while a quite low cabin altitude could be maintained at higher levels. For normal commercial flights, this doesn’t matter too much, but when you are carrying patients with medical problems, the partial oxygen pressure can be vital – even a question of life or death.

A number of Learjet 35, 45, 55 and 60s are always used for medevac operations. For example, in Europe, European Air Ambulance, based in Luxembourg, coordinates a fleet of five LearJet 45XRs, which replaced its Lear 35As in 2017.

Bombardier also offers specially outfitted Challengers. Its newest air ambulance is based on the new Challenger 650, which can be configured to transport up to four patients with incubator support for newborns or fly a mix of patients and seated passengers while still having room for core medical staff. Equipped with GE CF34-3B MTO engines, the Challenger 650 benefits from greater thrust, an increased payload capacity, the ability to take off from shorter runways (take-off distance of 5,640 ft (1,720 m), and a range of 4,000 nm (7,408 km) at Mach 0.74 – all features critical to medevac missions. To ensure greater patient attention and comfort, medical beds in the cabin are customized with special sliding mechanisms and patients can be taken on board by means of an electrically actuated platform elevator or by a folding ramp, both of which can be stowed on the aircraft.

A typical Challenger operator is the Swiss air-rescue organization Rega, which owns three Challenger 650s (they replaced three CL-604 in 2018), each of which feature a specially designed, multifunctional stretcher. Rega also operates 19 helicopters – seven Airbus H145s, 11 AgustaWestland Da Vincis and one Airbus H125 used for training purposes.

Last July, the organization presented a new type of aircraft for search and rescue missions: a newly developed drone that can autonomously scan large search areas and is equipped with various sensors, such as a thermal camera. Further comprehensive test flights are necessary before the drone system can be used in search operations, which are expected to launch in 2020.

Over the years, Dassault Aviation has customized many Falcons for medevac missions, from the Falcon 20 to the Falcon 2000. In 2015, the French manufacturer delivered a fully outfitted Falcon 2000LX medevac aircraft to the Beijing Red Cross Emergency Medical Center. The wide body twinjet was the first fixed wing aircraft in China fully equipped to perform air medevac services. Since it began operation, it has provided pre-hospital rescue and medical treatment service for over three million patients.

The Falcon 2000LX medevac aircraft is equipped with an electrical patient loading system and a full medical suite, along with an electrical power supply sized for a complete medical module. The medical module includes a stretcher with dedicated lighting, a three-bottle oxygen supply, and monitoring and analysis equipment. It also accommodates special devices like defibrillators, electrocardiographs, echographs, a blood bank and an ECMO (extracorporeal membrane oxygenation).

Several other medevac companies around the world also operate Falcon aircraft. One of them is Medevac.Flights. Based in Perth, it provides emergency evacuations throughout Australia, the Pacific and Asia, operating one Falcon 2000, two Falcon 50s, two Falcon 20s, a Learjet 60, and a number of other aircraft.

At the last AirShow China in Zhuhai, Gulfstream displayed a G550 medevac aircraft recently delivered to the Beijing Red Cross Emergency Medical Center. Powered by two Rolls-Royce BR 710 engines, each of which has a rated takeoff thrust of 15,385 lb/68.40 kN, the G550 has a cruise range of 6,750 nautical miles/12,501 kilometers The aircraft, modified by Gulfstream, provides new in-flight medical capabilities, including 360-degree in-flight patient access, X-ray viewing, advanced life-support equipment (including ECMO), and a bed designed to accommodate an infant incubator.

“Demonstrating its demanding capability, the Beijing Red Cross Emergency Medical Center aircraft recently conducted two very complex rescue missions involving varied weather conditions and mountainous terrain, with operations out of one of the world’s highest altitude airports, Lhasa Gonggar Airport in China,” says Gulfstream President Mark Burns.

Beijing Red Cross Emergency Medical Center is currently considering adding a longer range Gulfstream G650ER to its fleet for the same missions.

Evacuation Aircraft for Epidemics

At the height of the Ebola epidemic, Lufthansa Technik was commissioned by Germany’s Federal Foreign Office to convert an Airbus A340 into an evacuation aircraft for transporting and treating highly contagious patients. As there was no existing solution for the conversion of such an airplane, Lufthansa Technik built and installed a special isolation unit in the cabin: the middle and rear section of the airplane, passenger seats, galleys and luggage bins were removed to make room for a patient transport isolation unit surrounded by an airtight tent with negative pressure. At the front of the cabin, there were seats for up to 19 passengers such as doctors, scientific staff and isolation tent technicians.

At EBACE 2019, Textron Aviation showcased the first air ambulance configuration of its Citation Latitude, highlighting the company’s strength in special mission capabilities across its wide range of Beechcraft and Cessna aircraft. The Latitude, purchased by Babcock Scandinavian Air Ambulance for aero-medical operations in Norway, delivers the first custom OEM interior solution for medevac missions on the platform. The production-certified interior configuration offers compatibility with a wide range of medical equipment.

Plans for interior certifications on other aircraft, including medevac options for the Citation CJ4 and Citation XLS+, are underway, without forgetting the popular Cessna Caravan. Future aircraft, notably the Denali and the SkyCourier, are progressing through design phases to incorporate medevac mission capabilities.

Beechcraft, which claims to have built more air ambulances than any other manufacturer, is also very active in this field. Last June, the Norwegian Luftambulansetjenesten ANS organization took delivery of the 10th King Air 250 it had ordered for its medevac missions.

Pilatus is also involved in medevac operations, thanks to its PC-12. Partly at the request of the Royal Flying Doctor Service of Australia Western Operations, the Swiss manufacturer developed a medevac version of its new PC-24 twinjet. The very first unit was handed over to the RFDS last November.

“The PC-24 will become the emergency ward in the sky and will nearly cut the time for long-haul critical patient scenarios in half,” says Pilatus Chairman Oscar J. Schwenk. “I am positive that the PC-24 will ideally supplement the existing fleet of PC-12s of the RFDS.”

The interior was installed under a supplemental type certificate procedure in partnership with Aerolite AG, a Swiss company specializing in aircraft medical interiors. The large cargo door and bespoke electric stretcher-loading device facilitate safe, ultra-easy loading and unloading of patients. For Schwenk, the PC-24 is the world’s first jet to offer this possibility, thanks to the cargo door, which comes as a standard fit from the factory.

Helicopter Emergency Medical Service (HEMS)

Over 2,500 helicopters are in service worldwide for HEMS missions. Around half of them are in North America, where the air ambulance industry is booming due to medical advances, rural hospital closures and loose regulations. The most common models are the Airbus AS-350/EC130 and the Bell 206/407 for single-engine aircraft. For multi-engine, the industry utilizes the medium-sized Bell 222/230/412/429, Airbus BO-105/BK-117/EC-135/EC-145/AS-365, Agusta A-109/139 and the Sikorsky S-76.

Since the 1970s, the Airbus H125, H130, H135, and H145 have captured more than half of the global HEMS market, serving more than 300 customers. Earlier this year, Air Medical Group Holdings (AMGH), based in Lewisville, Texas, ordered a total of 21 Airbus helicopters, consisting of a mix of single-engine H125 and twin-engine H135 helicopters. AMGH is one of Airbus Helicopters’ largest customers, with a current Airbus fleet of nearly 85 helicopters, out of a fleet of over 300 medically equipped helicopters.

Established in 1980 to provide air medical transport, Air Methods is the largest provider of air medical transport services in the United States. Based at Centennial Airport in Englewood/Colorado, but operating from 306 bases of operations in 48 states, it has a fleet of 488 aircraft, of which 94% are helicopters, making them the largest helicopter operator in the world, transporting roughly 130,000 patients per year. Air Methods has been the first operator to fly first Airbus H125 (formally known as AS350) with FAA-certified crash resistant fuel systems (CRFS).

The Bell 206 is one of the oldest original designs used in HEMS today. A variant on the Bell 206, the Bell 206L LongRanger is commonly used by air ambulance services because of its ‘stretched’ cabin that provides more space to accommodate a patient, air medical crew, and needed equipment. Also, the Bell 429 was developed primarily for use in emergency air medical services. It has a flat floor and, in some variations, a set of rear clamshell doors underneath its tail boom to allow for easier loading of patients.

Sikorsky Aircraft Corporation’s S-76 is a fairly large dual-patient helicopter with sliding doors and a rectangular cabin capable of carrying about 14 passengers in its standard configuration. It has enough room to carry one or two stretchered patients.