Effective management of a patient involves professional diagnostics, appropriate therapy and medical transportation, which is often neglected. Medical transportation services are divided into emergency transport from the incident scene to hospital and inter-hospital transport. For these purposes, ground and air ambulances are used. Air transportation is carried out using helicopters or planes. In Poland, these two types of medical air transportation are accomplished by the Medical Air Rescue (MAR) operating all over the country from 17 bases of the Helicopter Emergency Medical Service (HEMS) and one air base located in the military section of the Okęcie Warsaw Airport.

Besides medical transportation, MAR also delivers emergency medical services.

The services of MAR are regulated by the National Emergency Act of September 8th 2006. The article 37.1 of this Act states: “The air medical rescue team consists of at least three people: one professional pilot, a physician and a paramedic or a nurse” [1]; these are the helicopter crew members. In the plane team, two pilots are needed. The funding of air medical rescue teams is described in the article 48 and is based on the contract between the proper minister of health and the dispatcher of air medical rescue teams. The Minister of Health finances fully emergency rescue activities carried out by air medical rescue teams, i.e. flights to accidents and emergency cases. In 2009, emergency helicopters performed 5896 flights, including 4359 to incidents and 1537 inter-hospital emergency transports (Fig. 1).

Emergency helicopters are at disposal of dispatchers of emergency services and of teams of these services at the incident site [2]. Additionally, in agreement with the MAR regulations, the entitled ones include the National MAR Dispatcher, ambulance and medical emergency dispatchers, dispatchers of emergency notification centres and, in special cases, physicians-coordinators of medical emergency.

The indications for ordering an emergency helicopter include the following emergency conditions:

• loss of consciousness,

• sudden cardiac arrest,

• acute cardiac conditions,

• hypertensive crisis,

• cerebral stroke,

• traffic accidents,

• height falls,

• burials, avalanches,

• multi–organ injury,

• head injury requiring neurosurgical intervention,

• spine injury with paraplegia, tetraplegia or lateralization symptoms,

• penetrating injury of the neck, thorax, abdomen,

• fracture of two or more long bones,

• severe pelvic injury,

• traumatic amputation of the limb,

• II and III degree burns affecting more than 20% of the body surface, suspected airway burn, electrical burn, explosions and fires,

• hypothermia,

• drowning.

This list of cases is not closed and it should be assumed that an emergency helicopter might also be ordered for other medical emergency conditions requiring urgent intervention of the rescue team, if the medical dispatcher finds is well grounded.

The criteria of inter-hospital air transportation are completely different. The only person with the authority to order air medical transport is a physician. Financing of air medical transport teams is also slightly different and is based on the article 70, section 1 of the Act of August 30th 1991 on the medical health care institutions.

The team standby, as in the case of air medical emergency team, is financed based on the agreement of the proper minister of health and the medical health care institution owning the air medical rescue teams. On the other hand, direct costs of using the team (fuel costs, possible flight and landing fees) are covered by the health care institution ordering transport [3].

Helicopters or planes are used for medical transportation. The helicopter is used when medical transport is emergent, within the operational region of a given base or on a scheduled basis – under special circumstances and medical indications resulting from the patient`s condition. Plane transport is used when the distance between the present and target airports registered in the “Air Information Book” exceeds 250 km (according to road maps) or in agreement with the written contracts [4]. In 2009, medical planes performed 589 medical transport flights and 196 rescue flights (Fig. 2).  

Medical equipment of the air medical ambulance team in a plane enables the transport of any patient, including those requiring intensive therapy. Medical transport with the use of an incubator is also possible, both in planes and in some helicopters.

Air medical transport performed by the helicopter or plane team is usually proceded by the history taking carried out by the MAR dispatcher to gather possibly broadest information about the patient`s condition, thus to prepare adequately the team for accomplishing the task. Medical history is taken in the form of a medical report, which is delivered to the suitable MAR team (Fig. 3).

An important element of preparation of patients for air medical transport is an early consultation with the National MAR Dispatcher, which enables rational planning of flights and provides the physician ordering transport with the knowledge concerning operational possibilities of a helicopter or a plane on a given day.

Medical Air Rescue, the heir of the long-term tradition of medical aviation in Poland, was established in 2002 by combining the teams of medical air transport into one medical health care institution. The services were started with Mi-2 helicopters; yet it was well known that the whole fleet would have to be replaced with new machines as the operational capacities of old planes and the European Union regulations imposed substantial limitations on their exploitation.

After many efforts, in 2005 a new act was passed, which enabled the purchase of new helicopters. In June 2008, the act for delivery of 23 modern emergency ambulance helicopters EC 135 was signed. This was a complete breakthrough in the history of Polish air rescue; after 20 years of exploitation of Mi-2, new aircraft were introduced with extremely modern medical equipment, which will ensure the long-term accomplishment of tasks of emergency medical services and transport.

EC 135 (Fig. 4) is a lightweight, twin-engine aircraft with the skid landing gear produced by the German-French Eurocopter consortium.

According to the producer, the aircraft constitute about 80% of HEMS equipment worldwide, which makes it the leader on the rescue helicopter market. The helicopter fulfils all requirements of air transport regulations, is adjusted to visual flight rules (VFRs) and instrumental flight rules (IFRs), at day and night, with one- or two-person crews. The cruise speed of EC 135 is 230-240 km h-1, and its operation range with the crew and a patient on board is 350 km and 445 km in IFR and VFR flights, respectively.  Such parameters increase the operational range of individual HEMS bases and the national area of services from 60% to over 90%. Moreover, EC 135 has very extensive and modern technical devices, including the CMA 9000 system, moving Map, Polycom system of cordless communication between the crew members, the system enabling night vision with the camera installed under the helicopter visualizing monochromatically the ground below and in front of the flying helicopter, and an autopilot [5]. Additionally, the beam is installed on the starboard, which enables high manoeuvres; once pilots have suitable flying hours, such manoeuvres will be performed during emergency rescue operations with the National Fire Brigade and Mountain Voluntary Emergency Service. A new helicopter will be operating at night, which was not possible with Mi-2.

The key element of an ambulance helicopter is its modern medical cabin (Fig. 5). Realizing how important it is for medical services provided, its construction was based on professional experience of many physicians and rescuers working in HEMS for many years. Numerous analyses and trials were performed to design functionally the medical cabin, considering the major medical activities during the life-saving procedures, e.g. cardiopulmonary resuscitation or endotracheal intubation. To define accurately the parameters of space for cardiopulmonary resuscitation, the ergonomic analysis was extremely helpful. The analysis was ordered by the Ministry of Health and carried out in the Ergonomic Laboratory of the Wroclaw Technical University. The key medical procedures were analysed ergonomically to determine the suitable space for individual body parts of the patient and members of the medical team. It was assumed that the medical crew consisted, in ergonomic terms, of adult individuals belonging to the European population. The gender of providers of health services in the medical cabin was not accounted for [6].

The medical cabin of EC 135 is equipped with the latest medical devices: a transport ventilator, a defibrillator, a set of infusion pumps (3), including two syringe pumps and one flow pump, suction and the other necessary medical equipment. The transport defibrillator has the following modules: 12-lead ECG (tele-transmission possible), ETCO2, SpO2, non-invasive pressure measurement, resuscitation metronome. Defibrillation may be carried out in the full range of two-phase energy (up to 360 J); moreover, cardioversion, transcutaneous stimulation and automated defibrillation are possible. The transport ventilator can work in a variety of lung ventilation modes: IPPV, A/IPPV, SIMV, SVV, CPAP, BILEVEL, PCV, ASB, SPV. The rescue ventilation module enables controlled ventilation, is easy to operate, intuitive, even for those who did not work with a ventilator before. The second ventilation module provides all ventilation modes and additionally enables the imaging of curves of respiratory parameters. Such a ventilator has the system to regulate the respiratory rate in the limits of 0 – 60 min-1, VT 50 – 2000 mL, FIO2 40 – 100%, PEEP 0 – 30 cm H2O, inspiration/expiration ratio within the range from 4:1 to 1:4, sound and light (important in helicopters) alarm signals plus text messages informing about the alarm reason.

Furthermore, the medical cabin is unique as the paramedic, who is the member of the helicopter crew, is capable of moving from the pilot to medical cabin during the flight, if need be.

The purchase of helicopters with modern avionic and medical (medical cabin and equipment) configuration ensures high quality services of MAR for further twenty years to come. The range of possibilities of emergency medical services and air transport services has been markedly extended, including an important increase in landings in places earlier unavailable for Mi-2 [7].

..............................................................................................................................................................

REFERENCES

1.    Ustawa z dnia 8 września 2006 roku o Państwowym Ratownictwie Medycznym (Dz. U. Nr 191 poz. 1410),

2.    Jakubaszko I: Ratownik Medyczny, Wyd. Med. Górnicki, Wrocław 2003.

3.    Ustawa z dnia 30 sierpnia 1991 r o zakładach opieki zdrowotnej (Dz. U. Nr 91 poz. 408, z późn. zm.

4.    Regulamin Porządkowy SP ZOZ Lotnicze Pogotowie Ratunkowe.

5.    Gałązkowski R: Śmigłowiec EC 135 – nowa latająca karetka. Ogólnopolski Przegląd Medyczny 2010, 3: 47-49.

6.    Marcik D: Ratownictwo z powietrza dla pasjonatów – cz. III. Na Ratunek 2008, 4: 60-62.

7.    Marcik D: Ratownictwo z powietrza dla pasjonatów – cz. IV. Na Ratunek 2008, 4: 60-64.

8.    Grobelny J, Michalski A: Analiza ergonomiczna. Laboratorium Ergonomii Politechniki Wrocławskiej, Wrocław 2007.

9.    Gałązkowski R: Kabina medyczna w nowoczesnych śmigłowcach ratunkowych – trudny kompromis. Ogólnopolski Przegląd Medyczny 2010, 7: 23-27.

10.   Briggs SM, Brinsfield KH: Wczesne postępowanie medyczne w katastrofach. Podręcznik dla ratowników medycznych. PZWL Warszawa 2007: 20-24.

..............................................................................................................................................................

Address:

*Robert Gałązkowski
Lotnicze Pogotowie Ratunkowe
Zakład Medycyny Ratunkowej,
Warszawski Uniwersytet Medyczny
ul:  Lindleya 4, 02-005 Warszawa
e-mail: r.galazkowski@elpr.com.pl

Received: 05.02.2010
Accepted: 10.07.2010