Flying nurses

Royal Med, part of Abu Dhabi's Royal Jet Group, is the region's only licensed air ambulance service provider. Flight nurse, Caitlin Picker explains how it works.

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By  Neil Denslow Published  April 1, 2004

|~|royalmed_m.jpg|~||~|When Royal Jet began operations last year, it took over the role of providing air ambulance services for Abu Dhabi from the Emirate’s Amiri Flight, one of the company’s owners. These services, which are run through its Royal Med subsidiary, have now become a key revenue stream for the aviation service provider — the company racks up an average of three medevac flights a week, which account for over half its total flight operations. Royal Med has become a success, as it is the only fully insured and registered air ambulance service in the Middle East. Furthermore, leveraging on its Amiri Flight history, the company also has a long experience of providing medevac services and strong governmental connections in Abu Dhabi. However, while the UAE, especially Abu Dhabi, accounts for more than 70% of Royal Med’s medevac flights, the company is developing its presence across the region in both the private and public sectors. “This is not only for the government of Abu Dhabi,” says Ammar Balkar, director of sales & marketing, Royal Jet. “This is for any individual, any entity, any insurance company or any medical centre; we can always do a flight for them. Being a Middle East-based company, Royal Med is able to offer a number of advantages over its competition. Most obviously, the fact that it is based here means that there is no need to fly an aircraft to the region, which cuts costs and speeds up response times. “If Royal Jet was not here, [patients] would have to take an aircraft from Europe, which would take 12 hours to arrive,” notes Balkar. Furthermore, because the company is targeting the region, its services are specifically designed for the needs of the Middle East market. Noticeably, this means that family members are able to accompany patients on medevac flights, which is not always possible with other companies, and that the service onboard is specifically designed for the region. “We do provide a very high-level of inflight service, not only for the patient... but also for the relative or person accompanying them,” says Caitlin Picker, aeromedical co-ordinator, Royal Med. “[Other companies] usually have very small aircraft and family members have to travel commercially and meet the patient at the other end; however, it’s important in this region that people can all travel together.” Royal Jet currently has three aircraft, a Boeing Business Jet and two Gulfstream 300s, all of which can be transformed into air ambulances. However, because of the work involved in doing this, the company tends to use one of the Gulfstreams exclusively for medevac flights and it only uses the BBJ when transporting more than one patient at a time. The company is also able to use the helicopters operated by Abu Dhabi Aviation, another part owner of Royal Jet, when collecting patients from rural areas, such as Al Ain or the western part of Saudi Arabia. In terms of personnel, Royal Med has its own inhouse aeromedical staff that currently comprises of two doctors, two flight nurses and one flight paramedic; another doctor and nurse are due to join the team shortly. The company also draws on personnel from Abu Dhabi hospitals if it needs additional resources to support its flights. The number of personnel onboard a particular trip depends upon the level of care that the patient needs. “For one patient, we will have one doctor and one flight nurse or flight paramedic [onboard] depending on the condition of the patient we are flying,” explains Picker. “If we have two or three patients on a flight then we increase that number depending on the needs of the patients. Some patients might be critical and require full intensive care facilities; others might be ward patients that just require stretcher facilities, so they don’t need intensive medical treatment, just general medical care,” she adds.||**||II|~||~||~|The patients flown on Royal Med services suffer from a wide range of conditions, including babies with heart problems, road traffic accident victims and geriatric patients. “We are able to cater for neonatal, paediatric patients and adults, and we go right across the spectrum,” says Picker. “We can [also] do basic general care up to intensive care, and most people who require an air ambulance facility are usually quite sick, so they do require high preventative care at a minimum,” she adds. The Royal Med service has flown patients to and from destinations across the Middle East, and has even been as far as the United States and Singapore. However, most patients are taken to London, with Geneva and Munich also frequent destinations. These cities are most commonly chosen as they have facilities in place for quickly receiving and processing patients from abroad, as well as the specialists the Middle East lacks because of its smaller population base. “For example, for some complicated cardiac surgery, especially for children, the specialists who are doing the condition all the time are in major European institutions… For the less complex procedures, surgeons are available here, so we don’t see those patients,” says Picker. Flying patients in an air ambulance provides a number of challenges for the medical staff. Firstly, just moving a critically ill patient out of a hospital environment, into a road ambulance, and then onto an aeroplane involves a lot of lots of coordination between the hospital, Royal Med and the destination to ensure that ambulances arrive on time and with the right equipment. For the patient, the main part of the preparation is medical assessments from both a Royal Med doctor and flight nurse to ensure that they are up to making the trip. “The key to our function is the medical report,” says Picker. “We will not accept any patient without having done a thorough medical assessment, and if that means we [Royal Med staff] have to fly commercially to Kuwait, for example, then that is what we will do.” Based on the assessment, a decision is made about whether or not the patient is suitable for a Royal Med flight. In some cases, they may be able to fly commercially or in a standard business jet, while in other cases the patient may require a few more days to recover from surgery, for instance, before being moved. “Most of the patients [referred to us] are suitable to fly on an air ambulance, but a small number are not,” says Picker. “There may be difficulties with flying or the benefits for their treatments might not be there, so we will give that information.”||**||III|~||~||~|This preparation work can be undertaken in as little as four to six hours, but the majority of cases take two or three days to prepare because of the need to process visas, or passports for newborns, and to find a hospital bed at the other end of the journey. “You cannot just take a patient to another country without systems in place for them to be received,” notes Picker. Patients need the medical assessment before being transported in an air ambulance, as flying clearly places a number of stresses on the body, especially for people who are seriously ill anyway. Taking the patient out of the hospital environment is a challenge in itself, as they are then cut off from equipment and personnel. In the air, however, this problem is compounded, so the Royal Med planes are kitted out with essentially all the equipment that would be found in an intensive care unit, and the aeromedical staff are specially trained to deal with any inflight emergencies. “While you are up in the aircraft, it’s just yourself, the doctor and your equipment; and you have got to be able to deal with whatever happens, which is why you need specialist equipment. The patient might deteriorate, for instance, so you need to have staff that can deal with that,” says Picker. “If they need to be put on a ventilator [on the patient], for instance, you need to have somebody who can actually do that.” These types of challenges are also found when moving a patient on the ground, but flying adds extra difficulties because of the effects of altitude. For instance, the cabin temperature must be closely regulated and ventilation circuits need to be humidified to ensure that the patient can breathe easily. The higher pressure found at altitude also causes gases to expand, which can have an effect on instrumentation filled air, as well as on the patient. “If we have a patient that has had recent bowel surgery, for instance, then we will know that during that operation they normally use carbon dioxide,” notes Picker. “If there is still carbon dioxide left inside the patient, then when we go up to altitude it is going to expand and it can cause severe discomfort, if not a separation... This is not general medical knowledge; you don’t know it until you have done specialist training,” she adds. Royal Med aircraft are also connected into the MedLink service from MedAire. This 24x7 centre can provide medical advice if needed, but more importantly, it is also able to assist the Royal Med staff in the event of an emergency. Firstly, it can advise on whether or not to divert and then, if needs be, it can say which is the closest hospital on the ground with the necessary facilities and where the aircraft should land. “This is nice to know when we are out there dealing with a patient, as we need to concentrate on that patient and give them the best attention and treatment that we can,” says Picker. “We don’t want to be working out where would be the best place to land — that is something MedLink would be able to advise the pilot.” The same service can also be contacted on Royal Jet’s regular passenger flights via the Tempus 2000s from RDT that are installed on all of its planes. This medical monitoring device can be used by non-medical staff to send health readings to MedLink in the event of a passenger being taken ill. This provides reassurance for regular passengers, as well as for patients returning from medical treatment in Europe, for instance, who don’t need a medevac flight. “The Tempus 2000 is available onbard, and [ill passengers] can link up to a doctor during the flight,” explains Balkar.||**||

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