Flying intensive-care unit. (Aviation).

In Africa, where expert medical facilities may be thousands of miles away, the only way to get a critically ill patient to hospital is by air ambulance. TOM NEVIN took a ride in a jet which is more than an ambulance, it is a flying intensive-care unit. Here is his report.

A kind of intimacy settles in the comforting cocoon of the Falcon 10's cabin space as the jet climbs southward from Nairobi through the east African twilight to its cruising altitude of 36,000ft. The patient, aware that his condition is serious enough to warrant dispatching a multi-million dollar flying intensive care unit to fetch him, is understandably anxious and fearful.

The medical team's competence, caring and reassurance are palpable and they work quickly and efficiently, constantly telling the patient what they're doing, relaying to him information about his vital signs and assuring him that all is well. It's an elixir that quickly has the desired effect.

The patient relaxes visibly and a smile tells the team that his stress has eased. The doctor-nurse team is ever attentive and the atmosphere is quiet and restful. The lighting is soft, the hum of the engines languid. All is well in this particular world.

At Johannesburg's Lanseria airport, ZS Fox rolls to a halt beside a waiting ambulance into which the patient is transferred for a swift ride to Sunninghill Medical Centre not far away.

That rescue mission, of a cardiac patient from Nairobi, Kenya, to Johannesburg, South Africa took a total of eight and a half hours. In that time the ICU-configured Falcon 10 jet flew to Nairobi, uplifted the patient, refuelled and returned to Lanseria. Speed and medical care are the critical elements.

This was SOS Air Rescue Africa in action. It is a division of International SOS, the largest 24-hour world-wide assistance and medical evacuation network. Founded in 1974, the company employs more than 2,600 professionals in 42 countries with 25 alarm centres in strategic locations around the globe.

THE GOLDEN HOUR

In medical parlance, 'the golden hour' is that critical time between 'a health event' and highest-ability medical intervention. It's a time when the difference between life and death is counted in minutes, and even seconds.

"The 'golden hour' concept is not a reality in remote area medical evacuation," says Dr Fraser Lamonde, Regional Medical Director International SOS, "and it's for this reason that our infrastructure, particularly in Africa, allows us to use local resources to 'buy time' for critically ill people. We move such patients as quickly as possible and bypass the usual difficulties of aviation in Africa, using our own fleet of dedicated air ambulances.

"This is sometimes easier said than done and, from time to time, trying to get aircraft clearance leads to delays. Attempts to bypass these 'political' issues in the past have led to disaster, as there is little sympathy in many countries for the ill or injured.

"Safety, and our patient, are our primary concerns and through our network of representatives, we have been able to negotiate some assistance in such circumstances to expedite patient movement."

The accent is on maintaining high medical standards and focusing on performance and response times to get to people as quickly as possible and to reduce their time to care.

Historically, when there was a need to move someone by air ambulance in a fixed wing aircraft, a plane was chartered, the seats taken out, a stretcher fitted, customs cleared and the plane took off. SOS based its business on providing minimum standard, high service in aircraft that are dedicated air ambulances.

"There are other dedicated fixed-wing air ambulances in South Africa, but certainly no doctor-based jet air ambulances. The idea was to use a jet, dedicate it as a doctor-based service, concentrate on dispatch and clearance times and reduce our access time to patients in distant countries," says Lamonde.

THE SOS FLEET

The company uses three air ambulances supplied by Awesome Aviation (see panel). The two jets - a Falcon 10 and a Lear - do 99% of the work. The propeller-driven King Air 90 is used mainly domestically in situations where only dirt landing strips are available. Where SOS must use dirt strips in other countries, "we have developed a local capability using service providers to move patients to a point where the jets can land. That also helps in reducing the time to access a medical team to treat, stabilise and evacuate the patients," reports Lamonde.

A flight from Johannesburg into, say, West Africa and back costs in the region of $45,000 to $50,000. Medical rescue frequently flies to Nigeria because of the oil industry there, Client groups are large corporations working in developing world environments, and insurance companies who underwrite medical evacuation. Air ambulance evacuations average 40 a month.

"Our doctors take courses in aviation medicine to become compliant with such issues as pressurisation of cabins and how that affects patients and their physiology;" he says. "Motor vehicle accident victims undergo a variety of physiological stresses during the process of cabin pressurisation.

The minimum technical requirement we require is advanced life support training, because doctors are not generally trained in life support. We also look for doctors with an anaesthetic background. The distances we fly can present some technically challenging issues to deal with."

AFRICA'S DAUNTING LOGISTICS

The pure logistics of Africa are daunting. Aside from aircraft clearance problems, most airports outside South Africa close at dusk and will not open unless by prior arrangement and with government approval. Only the larger international airports remain open - providing the only access to a country.

"When we do fly to more peripheral or remote airstrips, most countries require customs clearance at a designated international airport prior to movement of crew and aircraft. In some countries we have dispensation," says Lamonde.

"While this is all going on, our medical team in the Alarm Centre would be assisting with preparing the patient for evacuation to reduce the time the evacuation team would require on the ground once they arrive.

"Often we fly to gravel or dirt airstrips of limited length or paved and tarred strips with no lights. This limits the type of aircraft we can use and restricts access at night. Haying to use turbo-prop aircraft and helicopters in these situations means that flight times are longer than they would be when using our air ambulance jets into and out of larger strips."

Medical facilities in Africa are limited and there are few centres that can be relied upon to provide medical care of a standard acceptable to SOS. "But this is totally dependant on the medical problem at hand. Minor medical problems can usually be managed fairly easily on a local basis but it is the major problems that require evacuation to South Africa. The key to successful medical evacuation lies in our ability to rapidly deploy medical teams on dedicated jet Air Ambulances thereby reducing time to care."

RELATED ARTICLE: AWESOME LOGISTICS

Awesome Aviation contractually supplies the aircraft for the medical evacuation missions on a crew-maintained basis to International SOS. "Typically," says Dieter Ebeling, MD of Awesome, "we'd get a call from SOS notifying us of a patient in, say, Nairobi. Russell Patterson, our operations director, would plan and pass on to SOS the operational aspects of the flight such as obtaining clearances and estimating flying times. SOS will confirm the flight and dispatch a doctor and nurse to the medical room at the airport."

General manager Sam Prentice will dispatch the flight crew and bring the aircraft into line, making sure its ready for takeoff. Chief pilot Rob Turner decides on who will fly the mission. "It all comes together in about an hour, customs are cleared and the flight is dispatched," says Ebeling. "After the flight, everything's reversed."

The company constantly keeps tabs on the political and security situation in Africa, ensuring that destinations are safe to fly into. "We monitor South African Broadcasting Corporation's Africa coverage 24 hours a day," reports Patterson. "While this does not always report on primary matters, it certainly does provide trends of what's happening at the time. Combined with that we research the internet every morning through Reuters and other news agencies. We do that daily because we're never sure of where we'll be going to next."

International SOS has a well-connected security desk in London and keeps running profiles and warning levels for different countries. "So we have plenty of access points for us to gauge security levels. We also have handling agents on the ground who verify situations for us."