the flying hospital: when healthcare arrives by jet

June 11, 2020

Marc Grangier provides a glimpse into the air ambulance service market, keeping up to date on the latest medevac modifications in the industry


Air ambulances are not new. Their first documented use occurred during the Siege of Paris in 1870 when balloons were used to evacuate more than 160 soldiers from the besieged city. However, the first true air ambulance flight happened during World War I, when a Serbian officer was flown from the battlefield to a hospital by a plane operated by the French Air Service. According to French records, if casualties could be evacuated by air within six hours of injury, the mortality rate among the wounded would fall from 60% to less than 10% – a staggering reduction!

The First Ambulance Jets

The first ambulance jets, as we know them today, coincided with the arrival of the first business jets at the end of the 1960’s. Two of the most popular models for medical evacuation (medevac) missions were the Learjet 35 and 36, both of which offered the advantage of high speed and service ceiling. As air ambulances, they were configured to carry one full stretcher, two medical staff and one to two traveling companions. Thanks to their high cabin pressure differential limit, sea level pressure could be maintained up to FL 250, and even FL 280 on the latest models. Their doors were not only tall, but more importantly, they were much wider than those of other light-medium sized jets in the segment. And the installation of a slightly larger ‘cargo’ door, wider than the standard Learjet door, allowed for even easier loading and unloading of patients. Also, the door was close enough to the ground that a stretcher ladder was usually unnecessary.

Today, there are a total of 474 Lear 35 and 36 jets in operation, with more than two-thirds still used for medevac missions. LifePort, based in Woodland, WA, USA, produces a range of equipment for Learjets, including multi-mission medical interiors. These interiors are built around the company’s Patient Loading Utility System (PLUS), which includes an Advanced Life Support (ALS) base unit, manual loading system, and AeroSled stretcher. Designed for a wide range of mission profiles, its ALS systems offers low-maintenance standard packages that include oxygen, compressed air, vacuum and electrical inverters. To keep critical backup systems functional during an emergency, the company designed backup power sources, such as J.E.T. Brand Emergency Power Supplies and Power Conditioning equipment, which provide mission-critical functions and enable operators to power two to three essential systems for more than an hour.

Multi-Mission Aircraft?

Most medevac aircraft are now dedicated specifically to these missions, for the simple reason that when a flight is requested, it is very often urgent, and reconfiguring the aircraft from executive to medevac takes time. Another reason is that air ambulance missions can have a negative impact on the aircraft’s interior as doctors and nurses taking care of patients in emergency conditions have more important things on their minds than not scratching ceilings and seats.

Beechcraft has built more air ambulances than any other manufacturer. Its King Air series is particularly well-equipped to handle medevac missions. The aircraft feature cabins that can be fitted with medical equipment either on a permanent or temporary basis, thanks to medical floor covering and easily cleaned sidewalls, allowing for an easy transition from air ambulance to VIP transport. Furthermore, their optional large cargo door facilitates the loading and unloading of patients on stretchers.

“The ability to quickly convert VIP charter aircraft for medical evacuation purposes offers significant benefit to aircraft operators who want to extend the serviceability of their business jets,” says Erik Vandegrift, Director Maintenance Operations at Jet Aviation in Basel.

Transporting Intensive Care Patients

Defibrillator, infusion pump, oxygen tank, stretcher, heart rate monitor. All this equipment is usually found in a hospital. However, they are also the basic items found in medevac aircraft, which are equipped to help patients in critical health conditions or who need to be transported under medical care.

Standard on board medical equipment includes heart monitors, mechanical fans, infusion pumps, mobile blood analysis devices (COPD), ultrasound equipment, external pacemakers, portable incubators. Specialized and advanced devices, such as Extra Corporeal Membrane Oxygenation (ECMO) and Intra-Aortic Balloon Pumps (IABP), can also be installed. It is even possible to adjust cabin pressure to the air pressure on the ground, providing a so-called “sea-level flight”, which is necessary when transporting patients with certain medical conditions like anemia, pneumothorax or intestinal injury.

Most cabins feature easy-to-clean vinyl sidewalls and floors, and most medical systems are bought as standard items by the aircraft manufacturers that then proceed to retrofit the air ambulances. The only main modification is generally the power supply, which must be independent of the aircraft power supply. Its electrical system must also support hospital equipment that requires a lot of power, like the defibrillator, for example.

Air Ambulance Transport Options for Covid-19 Patients

After purchasing a portable medical isolation unit manufactured in Norway by EpiGuard AS, known as the EpiShuttle, Germany’s FAI Air Ambulance, based at Nuremburg, has started transporting patients with confirmed Coronavirus infection. For this purpose, the company installed a customized stretcher configuration on its Challenger CL604s, with specific EpiShuttle equipment and accessory modules ready to deploy. It also positioned dedicated teams of four ICU Flight Doctors and eight Flight Paramedics, all of whom are trained in accordance with the ECDC European Center for Disease Control Technical.

Following numerous requests from clients, FAI carried out repatriations of infected patients, working around the clock and averaging around six missions per day with its 10-strong fleet of five Learjet 60s, four Bombardier Challenger 604s, and one Global Express air ambulance aircraft. At the time of going to press, the demand was such that FAI had a backlog of three days.

Epiguard AS, mentioned above, has developed the EpiShuttle, a medical transport isolator system designed to carry infected patients. Aircraft that transport highly infectious patients within this system do not have to be disinfected afterwards. This saves time and money and ensures that aircraft can remain in operation as much as possible.
The EpiShuttle is reusable and can be safely disinfected and re-assembled in less than two hours. This significantly reduces the cost per transport, compared to single-use transport isolators. Glove ports provide medical personnel access to the patient’s entire body. The patient can be intubated and mechanically ventilated during transport, and IV-lines and monitoring equipment can be attached.

To deal with the health crisis linked to COVID-19, Dassault Aviation recently made two Falcon business jets, a Falcon 8X and a Falcon 900, available to the French Defense Ministry as part of the Operation Resilience intended to supply logistics and medical support for civilian coronavirus control activities. The first mission took place on Sunday, April 5th, where the aircraft transported a team of 26 doctors and other medical personnel from Brest, Brittany back to Paris. The team had accompanied COVID-19 patients to Brest on a special medical train. The two Dassault aircraft were equipped for 15 and 13 passengers respectively.

SARS, Avian Flu, Ebola, and now Covid-19 – epidemics regularly threaten human lives. A unique kind of aircraft is necessary to transport and treat such highly infectious patients just as safely as on the ground. 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. In 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. Two exterior tents, also airtight, served as buffers so that the treatment tent could be entered and exited safely. Disinfection procedures ensured absolute hygiene, and waste management was also taken into account.

Many more specific requirements also had to be met, such as electrical connections for the intensive care systems, separate ventilation systems for the air inside and outside the tent, the disinfection system and, last but not least, a special system for communication between the aircraft crew and the medical staff in the isolation unit.

Air Ambulance Retrofitting

Because it is a niche market, a limited number of companies modify standard business jets or helicopters into medevac aircraft. At the beginning of the year, Bombardier sold two Learjet 75 Liberty aircraft to North Dakota-based Fargo Jet Center (FJC). The aircraft are to be converted to dedicated medevac configuration and delivered to air ambulance service provider Lotnicze Pogotowie Ratunkowe (LPR), based in Warsaw, Poland. Fargo Jet Center is expected to take delivery of the aircraft from Bombardier in late-2020, then deliver the converted EMS aircraft to LPR in Poland in 2021.

With a flat floor and the longest cabin in its class, the Learjet 75 Liberty aircraft has room to accommodate up to three stretchers and sophisticated medical equipment, as well as seating for medical staff. The auxiliary power unit is also certified for unattended operation and can continuously supply power to key life support equipment.

Spectrum Aeromed, also based in Fargo, has been selected as the air medical equipment provider on the project. Since 1991, the company has designed medical interiors and equipment for all kinds and sizes of aircraft. But the company can also create unique solutions for individual clients. For example, Life Flight Network, one of the largest not-for-profit air medical transport services in the USA, liked the Bell 429’s interior but wanted a few customizations. These included a single Pivot Stretcher, forward medical cabinet with a liquid oxygen 10-liter orb, medical pivoting seat, ceiling valance, medical lighting and a lightweight floor protection kit.

These additional components would provide a variety of benefits, specifically in the areas of accessibility. The Pivot Stretcher’s rotating, extension and locking capabilities would allow for a better ease of loading and handling patients, in addition to safer patient access in-flight. The cabin would have capacity for up to three medical seats, including a rotating seat with patient access. Medical equipment could be secured by the mounted Stretcher Bridge. For neonatal missions, an Infant Transport Deck could instead be secured to the base deck. For neonatal missions, an Infant Transport Deck could be secured to the base deck.

To meet these expectations, Spectrum Aeromed sent the interior kits to Bell, which will perform the installation and deliver the helicopters to LFN. The Pivot/Articulating Stretcher and base deck, medical swivel seat, and medical mounts are established designs, while the floor adapter attachment is an update to an existing product.

Spectrum Aeromed is currently at work on four other STCs. The current available STC is a Dual-Patient solution for the Leonardo AW139 helicopter. The other STCs concern the Pilatus PC-24 light jet, the Embraer Phenom 300 light jet and the Leonardo AW169. Spectrum also designed two loading systems. Its Manual Patient Loader fits any smaller aircraft and allows patients easy access aboard the aircraft, while its Electric No-Lift Patient Loader allows crew to load any patient or incubator safely into the aircraft without any lifting at all.

Jet Aviation Dusseldorf has performed the first Medevac conversion of an Embraer Legacy 600. The company converted it to serve both as a Medevac aircraft with four patient stretcher systems, and as a VIP charter aircraft accommodating up to 14 passengers. The Medevac conversion was supported by the company’s EASA-approved Part-21 organization and ensured short reconfiguration cycle periods – within just one working day – and extreme flexibility in the operation of the aircraft.

In 2017, Jet Aviation was awarded two medical evacuation conversions at its maintenance facility in Basel. An Embraer Legacy 600 was converted for a customer in Asia and an Embraer Legacy 650 conversion for a customer in the Middle East. Jet Aviation developed and owns an STC that ensures short reconfiguration cycle periods and extreme flexibility in the operation of Embraer Executive Jets. With Jet Aviation’s modifications, it is possible to convert the aircraft from VIP charter aircraft to medical evacuation aircraft within just a few hours. As VIP charter aircraft, the two Legacy’s each accommodate up to 14 passengers. When converted for medical evacuation, the Legacy 650 presents four patient stretchers and loading systems, while the Legacy 600 supports two.

Air Ambulance Technology (AAT), based in Ranshofen, Austria, has been designing “Quick Change Interiors” for over 25 years. With a maximum installation time of under 30 minutes for a complete interior (depending on the aircraft), these kits allow operators to carry out multi-missions (EMS, SAR/Medevac) with a single aircraft. Presently offered for various aircraft, including the Beechcraft 300/350, the Citation 550/5460, the Learjet 45/55/60 and the Dornier 328, AAT kits can be installed and easily removed without any structural changes to the aircraft structure. They are built in a modular system and can cater for one patient requiring intensive and non-intensive care treatment.

LifePort, which equipped the first Learjets, has extended its portfolio. It now ranges from integrated line replaceable units (LRUs) that exclusively equip Gulfstream G-Vs, to multi-mission systems for the Airbus H125 AStar helicopters. According to the company, its systems are designed to be compact, maximizing the available space in the aircraft. LifePort also has the internal capability to design and certify liquid or gaseous oxygen systems for extended range aircraft or multiple patients that need to be supported at the same time.

Two years ago, LifePort collaborated with Piaggio on the design of its Avanti EVO Medevac aircraft, with an enlarged cabin door as an option. Around 25 Avanti in Medevac configuration or equipped with the quick-change stretcher kit, are presently operated. Last January, the Italian government ordered five medevac Avanti, but the future of the manufacturer, now operating under receivership, remains uncertain after the withdrawal of Abu Dhabi’s sovereign fund Mubadala.

Lufthansa has also developed an in-flight intensive care system, the PTU Next Generation (NG), to transport an intensive care patient on a large aircraft. The PTU NG complies with all applicable airworthiness and medical regulations. It can be installed within minutes via seat track adapters in any aircraft. As it is equipped with different adapters, the same unit can be used in a fleet of different aircraft types. The units are small and light enough to be easily handled by two persons.

Recent Deliveries

Last year, Bombardier delivered a third Challenger 650 aircraft to Swiss Air-Rescue Rega, a long-standing Bombardier customer that took possession of two other Challenger 650 aircraft earlier in 2018. This trio of aircraft replaces Rega’s Challenger 604 fleet. In addition to repatriating patients from abroad with its three ambulance jets, Rega also carries out air-rescue operations in Switzerland with a fleet of 17 helicopters.

Rega’s ambulance jets are extremely versatile. Up to four patients – two of them intensive care patients – can be transported lying down at the same time. A team of Rega pilots, medics and engineers collaborated with a group of external specialists to design the new cabin fit-outs, carried out by Bombardier in Montreal. Equipped like an intensive care unit, they feature two mobile ICU respirators, one ECG monitor, defibrillator, external pacemaker, intravasal BP, NIBP, capnometer, SaO2, transport monitor, syringe pump, blood glucose analyzer, suction unit, ultrasound system, non-invasive cardiac support pump, fiberoptic intubation system with monitor, infusomat and integrated cuff pressure controller. Additional standard equipment includes vacuum mattresses, cervical spine immobilization collars, surgical kits for minor interventions, surgical dressings and thoracic drainage sets.

Pilatus Chairman Oscar J. Schwenk was delighted to see the Royal Flying Doctor Service of Australia (RFDS) return to his company again as a customer when the PC-24 was launched. Pilatus joined forces with a Swiss company, Aerolite AG, to design and build a medevac interior to meet the mission requirements of the RFDS. The PC-24s underwent their aeromedical fit-out at Pilatus’ factory in Stans, Switzerland.

“We have improved the stretcher design, creating a lightweight design with 1.95m length and an extra comfortable mattress,” says a spokesperson from RFDS. “Additionally, we’ve added a specially engineered auto-stabilizing stretcher-loading device that loads patients in a horizontal position, as opposed to other aircraft with inclined stretcher slides.”

The interior, accessed by the PC‑24’s standard 1,295mm x 1,245mm cargo door, also boasts an enhanced load capability medical electrical system with both 28VDC and 240VAC supplied. Wall-mounted supply panels are coupled with ceiling rails that support IV-hooks, enhancing the care delivery on board. Further improvements see a separate cabin intercom system that allows hand-held Satcom and VHF access for medical staff. Three PC-24 are currently in operation with RFDS.

Aerolite also announced a further order of six full EMS Medical Interiors for the Pilatus PC-24 EMS Aircraft. These aircraft will be delivered to the Swedish National Air Ambulance Organization (Kommunalförbundet Svenskt Ambulansflyg). This will allow Aerolite and Pilatus Aircraft Ltd to gain a foothold in the European market, which has been traditionally dominated by US manufacturers.

Gulfstream Aerospace recently delivered a Gulfstream G550 medevac aircraft to the Beijing Red Cross Emergency Medical Center. The aircraft features a dedicated medical bay outfitted by Gulfstream with advanced equipment to sustain and stabilize critically ill patients, including: 360-degree in-flight patient access, a medevac first; advanced life-support capabilities (extracorporeal membrane oxygenation); a bed designed to accommodate an infant incubator; a powered gurney loading system on aircraft stairs; X-ray viewing equipment; refrigerated medical storage cabinets; fold-out nurses’ seats for individual patient care; and crew rests with berthing.

The Beijing Red Cross Emergency Medical Center is already operating a medevac Dassault Falcon 2000LX. The cabin conversion work was conducted by Dassault Aircraft Services in Wilmington, Del. The aircraft is equipped with an electrical patient loading system, a full medical suite and an electrical power supply sized for a complete medical module. This module includes a stretcher with dedicated lighting, a three-bottle oxygen supply, and monitoring and analysis equipment. It also incorporates special devices like defibrillators electrocardiographs, echographs, a blood bank and an ECMO (Extracorporeal membrane oxygenation) unit.

Concerning Embraer, the Brazilian manufacturer has seven aircraft whose internal setup can be changed for medevac missions: the Phenom 100EV, Phenom 300E, Legacy 450, Legacy 500, Legacy 650E, Praetor 500 and Praetor 600. The Phenom 300E stands out among the models configured for this purpose. One of Embraer’s customers, Amil Saúde (Amil Resgate Saúde), has transported people on a Phenom 300 throughout Brazil and South America since 2012. Over the course of seven years, the company carried out an average of two flights per week with this aircraft, involving poly-trauma patients, pregnant women, people with organ transplants, burns and serious infections.

Textron Aviation recently announced a purchase contract with Pel-Air, based in New South Wales, Australia, for five Beechcraft King Air 350 air ambulance turboprop aircraft. The aircraft, configured by Textron Aviation for multi-stretcher operations, will be equipped with the aft cargo door and heavy weight options for additional performance capabilities. Deliveries are expected to begin later this year and run through 2021. The five King Air turboprops will be used by Pel-Air to provide contracted air ambulance service to NSW Air Ambulance, a government agency providing emergency services in New South Wales as part of NSW Health Service. The new aircraft, which will be based in Mascot at Sydney Airport, will replace the current mixed fleet of King Air B200 and B350 aircraft that have been used to support NSW Ambulance to date.

A year ago, Textron received an order from RFDS’ South Eastern Section for two modified Beechcraft King Air 350 cargo heavyweight aircraft, which are scheduled to begin delivery in the third quarter of this year. The new turboprops will replace King Air B200 aircraft in order to modernize the organization’s patient transfer and air ambulance fleet. The RFDS currently operates more than 35 Textron Aviation aircraft, including the South-Eastern Section’s fleet of 18 King Airs.

The two new King Air 350 are scheduled to be delivered with an 11 passenger, high-density seating configuration to transport passengers from rural and remote communities to their regional health care facilities. The organization plans to take advantage of the flexibility of the King Air 350 by converting it from its high-density seating to air ambulance configurations and back as needed for each mission. Other modifications include an added cargo door for easier patient loading and offloading as well as heavyweight landing gear that support a higher maximum takeoff weight for increased payload capabilities.

During EBACE 2019, Textron showcased its first air ambulance configuration of the Citation Latitude. The aircraft was purchased by Babcock Scandinavian Air Ambulance for medevac operations in Norway. The production-certified interior configuration offers compatibility with a wide range of medical equipment. The medevac Citation Latitude on display featured a single-sled stretcher, expanded cabin door and a SATCOM radio system for emergency communications. A number of medevac Citations are already in operation all over the world, including in Africa, where AMREF Flying Doctors, based in Nairobi, Kenya, successfully operates a Citation Bravo, a Citation XLS and a Citation Sovereign, plus a Pilatus PC-12 and several helicopters.

Comlux has lent its Crystal Air Cruises B777-200LR VIP aircraft for vital cargo flights, taking advantage of its exceptionally long-range to link distant destinations as part of the fight against the coronavirus. After demand for air cruises and private charters vanished in early March, Comlux Aviation decided to convert the wide-body jet’s ultra-luxurious cabin into a belly cargo hold. Crystal Skye, as the twin-engine luxury liner is called, can carry up to nearly 50 tons of cargo and has a range of over 16 hours (depending on the load). The aircraft has already begun flying cargo missions as part of the COVID-19 airlift, starting with delivering essential medical supplies (mainly masks) from Shanghai to Indianapolis. To keep up with regulations, four pilots were onboard, but thanks to Comlux’s extensive experience, approvals for the 13 hour flight were quickly obtained.

In early April, Comlux KZ used its Sukhoi Business Jet SBJ (completed earlier by the Comlux Completion) to transport 19 Chinese doctors from Karaganda to Almaty, where they supported Kazakhstan hospitals in their fight against coronavirus.

“Comlux is getting more and more requests for medical flights, but also repatriations of patients,” says Comlux CEO Andrea Zanetto. “Our VIP aircraft, with their roomy cabin configurations, are ideal for facilitating the social distancing necessary to avoid the spread of the disease.”