tiltrotor may 2015

Tiltrotors and Australian Aeromedicine – Project Thunderbird

Author – Dr Paul Adams (May 2015) 1 of 42

Contents: 1. Overview/Outline 3 2. Introduction/Disclosures 4 3. Queensland’s Rural and Remote Medical Environment 5 4. Aeromedical Systems 6

4a Existing services 7 4b Helicopter costs to the State Government 8 4c Aircraft 4d Types of operations 9

5. The V22 Osprey Tiltrotor 11 5a Aeromedical applications 5b Military & other applications 12 5c Military doctors as retrieval medicine specialists 13

6. The AW609 Tiltrotor 15 7. Aviation Pioneering in North-‐Western Queensland 2017 16

7a The North West Hospital and Health Service 7b North Queensland Helicopter Rescue Service 7c Approximate area of operation 18

8. A Vision for Australia – 100% responsive vertical lift coverage: “nowhere out of reach”

20

9. Aeromedicine in Special Circumstances 25 9a Bariatric Patients 9b Obstetric Transfers 26 9c Neonatal Retrieval 9d Major Trauma 9e Critical Care Retrieval 27 9f Multiple Casualties 9g Organ Donation 28

10. Technology and Aeromedicine 29 10a Anaesthetic Excellence 31 10b Ultrasound and other imaging 10c Telemedicine 10d “Treat and Transport” – the deteriorating patient 32 10e The retrieval team 10f Emergency/Last-‐resort Surgical Techniques 10g Accommodating future medical breakthrough 33

11. Attributes of the ideal aeromedical aircraft 34 12. Counting the Cost (investing in vertical lift capabilities) 36

12a Life is sacred and priceless 12b Sustainable aeromedicine – how can it be done? 37 12c Multi-‐tasking assets & potential non-‐aeromedical

applications



12d Future Infrastructure considerations 38 12e Disaster preparedness – in the national interest

13. Political Relevance – Rural Generalism 39 14. Project Blueprint 40 15. References/Further Reading 41



1. Overview/Outline Rural and remote medical service delivery in Australia is an

issue of current political importance at state and national levels. There is potential for improved aeromedical service capability into the future.

Tiltrotor aircraft represent a remarkable development in aviation. They can both fly like a plane and land like a helicopter.

An introduction of tiltrotors to use for aeromedical purposes in Australia should be coordinated.

It is inevitable that tiltrotors be applied to search and rescue operations – they are perfect for the task. This aircraft will save lives if applied to aeromedicine – but we need proof.

The potential benefits of an Australian tiltrotor program are numerous. This might occur in conjunction with the Australian Defence Force and/or existing aeromedical organisations.

The US Military is currently operating hundreds of these aircraft, and acquiring more in developing amphibious capabilities. [1]

AgustaWestland is developing a version for the civil aviation market that will be available within a few years. [2]

Queensland’s successful Rural Generalist Program is evolving as a national approach and is receiving international attention. In this era of rural health innovation, the stage is set for the debut of the tiltrotor in outback Australia.

It is most likely that Agusta Westland’s AW609 will be the suitable model to attend Australia’s aeromedical needs into the future.



2. Introduction/Disclosures

This document advocates an introduction of tiltrotor aircraft to Australian aeromedicine. Such an approach could save lives in rural and remote Australia.

The advanced capabilities of these aircraft are unique in comparison to any other currently operated in Australia. Tiltrotors are a platform to better healthcare for Australians. Implementation would represent innovation and reform to the aeromedical environment nationally.

One might consider tiltrotors a cutting-‐edge new development in aviation – something formerly of science fiction. Hundreds of V22 Ospreys have been in production for the US Military since the late 1990s. Prior to this, the Osprey had an extended and difficult period of development. Experience in operational use of the V22 Osprey began at the turn of the new millennium, whereas prototypes for the AW609 are still under trial. [1,2]

The “long and short” of this document is that one could consider an introduction of this aircraft to aeromedical application in Australia inevitable -‐ it is perfect for this environment.

Queensland could be the setting for a “world-‐first” if the implementation of a tiltrotor trial was initiated in a timely fashion.

Disclosure

This is a work purely of personal initiative.



3. Queensland’s Rural and Remote Medical Environment

Delivery of rural and remote medicine in Queensland is complicated by the tyranny of distance. This country is vast, and rural health workers find themselves physically isolated from major centres.

Tiltrotor aircraft are perfect for rural Australia's aeromedical needs in the future because these distances won't change.

In the context of critical care and inter-‐hospital retrieval medicine, precious time and effort is used moving people to and from airports or landing strips. In rural areas outside the capable range of metropolitan-‐based rotary wing services, transport options are limited to fixed-‐wing aircraft only.

“Road legs” to and from a suitable runway complicate long distance transport and significantly increase transport times. Clinicians have historically accepted this as unavoidable. Tiltrotor technology now exists to fly long-‐range at high speed directly to a hospital helipad or an accident scene.

Development of biomedical technology enables improvement in the quality of critical care retrieval medicine. The ability to “treat and transport” simultaneously can make a difference between life and death. Current focus in pre-‐hospital and retrieval medicine involves maximizing this ability. As the “standard of care” continues to improve, more carrying capacity (and interior space) is needed of transport vehicles to empower progress.

Finally, an epidemic of obesity brings increased operational necessity for bariatric medical transport capabilities (especially in rural areas).



4. Aeromedical Systems The current Australian Aeromedical landscape is a complex

maze of services of various types. Different organisations vary by structure, size, scope of operations, agenda and funding arrangements. “Community based” or sponsor-‐run services play a key role in effective delivery of aeromedical infrastructure, supplemented to varying degrees by Government funding. Government funding is intimately related to workload capability and relative operational usefulness. Exclusively owned and run State Government services are growing and increasing in workload. Different services inevitably find themselves set against each other as they compete for workload and funding in order to survive. “Turf wars” and entitlement by tradition are unavoidable concepts that require consideration in bringing any type of change to what is a dynamic service delivery system.



4a. Existing services

The existing arena of retrieval medicine in Queensland is a mosaic of services dependent upon sponsorship. Medical transport methods utilised apart from commercial aircraft include small fixed wing aircraft and rotary wing aircraft.

Royal Flying Doctors Service

The Royal Flying Doctors Service is a large organisation responsible for fixed-‐wing aeromedical work in Australia. In Queensland it has bases in Cairns, Townsville, Mount Isa, Longreach, Rockhampton, Bundaberg, Charleville and Brisbane. [3]

Emergency Management Queensland Run by the State Government,

the Emergency Helicopter Service operates out of Brisbane, Townsville and Cairns. [4]

Community Helicopter Providers

Sponsor-‐based helicopter rescue organisations exist around the country in different highly populated locations. In Queensland this includes Careflight (Gold Coast, Sunshine Coast, Toowoomba, Bundaberg), Capricorn Helicopter Rescue Service (Rockhampton), and CQ Helicopter Rescue (Mackay). These services receive an annual grant from the Government. [5]

Source: [6]



Other Providers

The North Queensland Helicopter Rescue Service (Mount Isa) is contracted to the Government as required. The Surat Basin Rotary Wing Aeromedical Evacuation Service is based in Roma and is available for 100hours per annum free of charge. Another oil and gas company-‐funded helicopter is being established in Gladstone. [6]

Angel Flight should be acknowledged as part of the aeromedical system, albeit for non-‐urgent transfers of disadvantaged persons on a charitable basis.

4b. Helicopter costs to the State Government [5] • Emergency Management Queensland 2012-‐2013 22.714M • Emergency Management Queensland 2013-‐2014 23.796M • Community Helicopter Providers 2013-‐2014 13.46M

4c. Aircraft Aircraft Payload Speed (Cruise) Range Fixed Wing in use (RFDS) PC-‐12 Pilatus 549kg 519 km/hr 2889 km [7] King Air B200 1064kg 535 km/hr 3095 km [8] Hawker 800XP2 850kg 745-‐828 km/hr 4232-‐4854 km [9] Cessna Grand Caravan C208

1501kg* 345 km/hr 1726 km [10]

Rotary Wing in use (Careflight & NQHRS) AW139 2650kg* 305 km/hr 786 km [11] Bell 412 2239kg* 240 km/hr 622 km [12] BK117, Eurocopter AS 350 BA, Bell 230, Bell 206 L1, Sikorsky S76A (are all smaller helicopters than the above) BO 105LS (NQHRS)

921kg 229-‐259 km/hr 505-‐757 km [13]

Tiltrotors for comparison V22 Osprey 9071kg 443 km/hr 1444-‐2222 km [1] (20000lbs) Mission radius 390-‐600nm (24 troops) AW609 2495kg* 510 km/hr 1296 km [2] *Max useful load



4d. Types of operations

Short-‐range aeromedical operations focus on rapid response and optimisation of the pre-‐hospital phase of emergency medical care. Service provision is best tailored to population or workload requirements. Small or medium helicopters are ideal for para-‐metropolitan short-‐range rapid response work. Tiltrotor aircraft may become more suitable to this work if readily available because of their high speed.

Medium to long-‐range aeromedical operations predominantly involve retrieval medicine and inter-‐hospital transfers. This is usually in the context of the tertiary referral of a patient to a specialist centre (or returning such patients to local hospitals). Fixed wing aircraft are occasionally called upon to perform primary pre-‐hospital response to the scene of illness or injury. Classically this is limited by the availability of a suitable landing strip/runway close to the scene. Other roles include international repatriation or retrieval operations.

Clinical co-‐ordination is an important aspect of aeromedical operations. Long distance retrieval operations are best coordinated centrally (or at a national level) as adequate service provision should accommodate the need for geographical coverage.

Tiltrotors are not the “complete aeromedical solution”, and as such will not surpass locally based small and agile helicopters or long range fixed wing jet aircraft for certain aeromedical tasks. Tiltrotors are rather the “missing puzzle piece” for an intermediate service deficit exposed by the very existence of tiltrotor technology.

Australian patients especially could clearly benefit from a vertical lift capability with ranges exceeding that provided by any rotary wing aircraft currently in aeromedical use. Long range helicopters may offer ranges near that provided by tiltrotors but are clearly inferior when it comes to speed over such distances.

As such, tiltrotors are not here to replace existing aircraft mentioned above. Alternatively, as part of the ideal complete



aeromedical fleet, tiltrotor aircraft will excel in attending to an all-‐important intermediate capability requirement where fixed wing aircraft are relatively suboptimal.

As part of this “hybrid model” of ideal aeromedical service delivery, and owing to their versatility, tiltrotors will provide an excellent ability for contingency planning and stability of coverage when it comes to dynamic emergency service delivery. For example, a well-‐placed tiltrotor might supplement both metropolitan-‐based rotary wing services and regional fixed-‐wing services by “filling in the gap” if multiple conflicting tasks arise.

The “hybrid model” of service delivery might further expand to metropolitan built up areas to combine rotary wing and tiltrotor services for complex retrievals. For example, a rotary wing may transport a retrieval team to the patient location before a tiltrotor transports the stabilized and packaged patient to definitive care (with the ability to bypass facilities). This model would be more suitable if a large tiltrotor was in operation, such as the V22 Osprey with cargo-‐door/ramp for loading.



5. The V22 Osprey Tiltrotor [1]

The V22 Osprey Tiltrotor’s first flight occurred on March 19, 1989. Hundreds are currently in operation. Its custom design meets the needs of all four US Armed Services.

Tiltrotors take off and land vertically. Once airborne, the engines nacelles with their propellors are rotated forwards and the aircraft becomes a turbo-‐prop airplane. Large distances can be covered via high speed, high altitude flight. As a 30-‐ton military workhorse the Osprey is versatile to nearly any task.

Being able to “fly like a plane” and “land like a helicopter” gives the V22 a remarkable operational capacity. Since the late 1990s, America has been building its fleet. Purpose-‐built ships have been created that function as mobile launch platforms for multiple Ospreys. This arrangement provides an enhanced amphibious assault capability.

Rapid self-‐deployment (ability to fly internationally without stopping) is possible due to a capacity for air-‐to-‐air refueling. It has a mission radius of 722-‐1111km if carrying 24 troops without refueling. Mid-‐air refueling enables a range of 3892kms (from Australia’s east to west coast). Up to three auxiliary fuel tanks may be carried, increasing fuel capacity by approximately 25% each.

5a. Aeromedical applications The V22’s versatility is perfectly suited to aeromedicine:

1. Large payload/interior: good for military and medical uses (a spacious interior enhances the delivery of world-‐class emergency medical care during transport).

2. Flies like a plane: capable of timely long-‐range journeys and suitable for mid-‐air refueling.

3. Lands like a helicopter: doesn't need a runway to land and this cuts out extra legs of a journey as it can fly “A to B" like a rotary wing aircraft.



Flying “A to B” directly is of great advantage in a medical context. If a patient's clinical status is “time critical”, effective treatment requires arrival at the treating facility as soon as possible.

Capable of winch operation: suited to all aspects of aeromedical workload (primary response, retrieval medicine and routine transfer). Major pitfalls:

• Not pressurized • Large in size and weight – limiting urban landing options • Significant downwash

5b. Military & other applications

This aircraft is custom designed for military combat use. The ADF could be capable of providing support for maintenance and infrastructure associated with operation. This includes staffing of pilots and mechanics and may expand to include clinical co-‐ordination and logistics.

The V22 Osprey has also been trialed for use as a tanker to refuel other aircraft mid-‐air. This ability might be exploited for use in firefighting (i.e. “waterbombing”).

Current aeromedical aircraft have a limited military crossover capability – they are customized exclusively to aeromedical and rescue operations. Owing to their versatility, tiltrotor aircraft are a platform to new funding models. Tiltrotors are “the ultimate multi-‐tasker” or utility asset.

Potential military applications of tiltrotors according to Bell-‐Boeing include: Special Warfare Special Operations Electronic Warfare Antisubmarine Warfare Mine Warfare



Theater Operations Assault Medium Lift Tactical Mobility Advanced Rotary Wing Attack Gunship/Close Air Support Aerial Refueling Recovery Search and Rescue Combat Rescue Medical Evacuation

Joint Emergency Evacuation of Personnel Communications Forward Air Control

Surface, Subsurface, Surveillance Coordination

Over-‐the-‐Horizon Targeting Surface Combatant Airborne Tactical System

Intelligence Observation Armed Reconnaissance

Airborne Early Warning-‐Surface Combatants Signal Intelligence Battle Group Surveillance-‐Intelligence

Transport Fleet Logistics

Carrier/Surface Ship On-‐Board Delivery Operational Support Airlift Mid-‐Air Retrieval System Light Intratheater Transport National Executive Transport

Support Missile Site Support Range Support

[14]

5c. Military doctors as retrieval medicine specialists

Military exposure to civilian retrieval medicine is a recipe for enhanced capability and competence. Civilian medicine could benefit from the application of superior organisational and logistical abilities that the military are renown for.



Retrieval medicine is emerging as a specialist entity in itself. If ADF medical personnel permanently staffed Australian V22s, a niche would exist for military doctors to become specialists in retrieval and critical care transport medicine. It might even be that the Australian Defence Force becomes the home of retrieval medicine as a medical specialty.

Military management of retrieval medicine in Australia could translate benefits beyond wartime to international, repatriation and humanitarian operations.

Military involvement with civilian critical care transport will also serve to improve integration with military medicine. This is especially excellent for improving trauma management, whereby most major medical advances in trauma medicine are derived from evolving contemporary military “battlefield medicine” experiences.



6. The AW609 Tiltrotor [2]

The AW609 Tiltrotor can take off and land vertically and fly above adverse weather conditions at twice the speed and range typical of helicopters. It commences operation in the commercial market place in 2017 in civil (both private and commercial operators), government and para-‐public roles.

AgustaWestland is making preparations to guarantee existing order fulfillment immediately after FAA type certification in 2017.

The AW609 can be configured for passenger transport, search and rescue, law enforcement, maritime surveillance, training and government applications. It will be certified for instrument flying in known icing conditions and features an advanced glass cockpit and full fly-‐by-‐wire digital controls. New levels of performance, reliability and affordability will be realized by future operators.

The hallmark of the AW609 (as for the V22) is fast and efficient point-‐to-‐point transport in all weather conditions rendering it an unrivalled asset to government or private search and rescue operations. Improved response times and fast connectivity when transferring patients between facilities will be of much benefit in time-‐critical scenarios. Vertical rescue will be available to clients in areas previously out-‐of-‐reach.

Four medical staff and two stretcher patients may be accommodated in a medically equipped and pressurized cabin (or two pilots and nine passengers).

The AW609 has a maximum demonstrated speed of 616km/hr, and a maximum cruise speed of 510km/hr. Its maximum range on standard tanks is 1296km with an operational ceiling of 25000ft and a cabin pressure altitude of 8000ft. High OEI (One Engine Inoperative) performance coupled with a low noise footprint results in a platform suited also to flying over densely populated areas.

As a smaller aircraft compared with the V22, the AW609 is better suited to pure aeromedical operations. It enables access to tiltrotor technology for aeromedicine without military involvement, if affordable.



7. Aviation Pioneering in North-‐Western Queensland 2017

A trial would need to occur in some capacity before the concept of using tiltrotors in aeromedicine is solidified for further funding. North-‐Western Queensland has a rich history of aviation pioneering, with Longreach being the home of Qantas and Cloncurry the birthplace of the Royal Flying Doctor’s Service. This proposal originally focused on promotion to champion a trial of tiltrotor aircraft for aeromedical use in North-‐Western Queensland.

7a. The North West Hospital and Health Service

With all the challenges of the Australian outback, North-‐Western Queensland is an accurate microcosm simulating key environments found around the country. Remote populations exist at great distances to each other and are serviced by rural public health facilities with a ceiling of care. It would be the perfect place to prove the usefulness of this aircraft in the Australian setting.

For example, the nearest referral centre to Mount Isa is roughly 900 kilometres away in Townsville, and the large specialist hospitals in Brisbane are 1800 kilometres away.

7b. North Queensland Helicopter Rescue Service

One possibility includes trialing a tiltrotor by North West Helicopter Rescue Service (out of Mount Isa). The current aircraft is small and has not been supported by state government as openly as other services because its range is limited. North West Queensland has a population density much less than other parts of the state. An aircraft based in Mount Isa needs a large operational range to offer a justifiable service platform compared to metropolitan-‐based helicopters. This applies to all aspects of aeromedical workload. Up until now, fixed wing aircraft have been the only real option for North West Queensland. [15-‐16]



The “RACQ NQ Rescue” Helicopter Service was established in 2008 as a commercial enterprise. Service delivery and safety standards are formalized via a fee for service agreement with Queensland Health which expires 30 June 2017. [17] Indications have been that the fee for service arrangement is unlikely to change if the service capability doesn’t change. [18]

Lately, a merger has been announced with CareFlight from 1 July 2015.

Serious consideration should be given to trialing an AW609 tiltrotor out of Mount Isa – as the aircraft is expected to be available to the civil aviation market around this time. Local benefits/”wins” via a trial of the AW609 include:

• The future of a Mount Isa based vertical lift rescue service is promoted

• Increased publicity on the national and international stage • Expanded service capability/workload platform (increased utilisation justifies more funding)

• Queensland leads the nation in the application of tiltrotor technology



7c. Approximate area of operation – AW609

The above model is based on a mission radius of 600kms and

flight originating out of Mount Isa with potential transport destinations of Mount Isa, Cairns, Townsville and Mackay. It is important to remember that this operational range represents a vertical lift capability unlike anything ever seen before. Roma might



also be considered a suitable location out of which to prove the effectiveness of tiltrotor technology for aeromedicine in Queensland.

If a trial is successful, the use of tiltrotors might be considered for implementation on a larger scale. As an exercise in rural innovation, it is only fitting that this originates in North-‐Western Queensland in proximity to the emerging era of the Rural Generalist.

Queensland has some of the best civilian specialists in pre-‐hospital and retrieval medicine. It would seem logical to engage these personnel in a trial of this aircraft in order to promote success. One could see opportunity to showcase on an international stage the quality of our emergency medical service professionals in Queensland.

Australia has an opportunity here to be a “trendsetter” as the first country to apply tiltrotors to civilian rescue. It would be most satisfying to publish “ground-‐breaking” research by using tiltrotor aircraft to push the boundaries of previous possibilities in healthcare delivery.



8. A Vision for Australia – 100% responsive vertical lift coverage: “nowhere out of reach”

The below diagram titled “National primary response vertical

lift tiltrotor coverage with bare bones fleet/minimum aircraft” is for illustration purposes only. It is based on the AW609 tiltrotor on a single-‐task mission with an operational range no less than 1200km (600km mission radius). It also requires that refueling be available at the listed transport destinations.

National primary response vertical lift tiltrotor coverage with bare bones fleet/minimum aircraft*

Halls Creek Tiltrotor Destinations -‐ Darwin -‐ Jabiru -‐ Katherine -‐ Tenant Creek -‐ Alice Springs -‐ Newman -‐ South Hedland -‐ Broome -‐ Halls Creek

Mount Isa Tiltrotor Destinations -‐ Nhulunbuy -‐ Weipa -‐ Cairns -‐ Townsville -‐ Mackay -‐ Longreach -‐ Alice Springs -‐ Tenant Creek -‐ Katherine -‐ Mount Isa

-‐ Esperance -‐ Albany -‐ Margaret River -‐ Perth -‐ Geraldton -‐ Carnarvon -‐ Karratha -‐ South Hedland -‐ Newman -‐ Leonora Leonora Tiltrotor Destinations

Coober Pedy Tiltrotor not drawn *based on AW609 on a single-‐task mission with operational range 1200km (600km mission radius) and refueling available at transport destination

Green lines represent division of long-‐range zones

-‐ Longreach -‐ Rockhampton -‐ Bundaberg -‐ Brisbane -‐ Gold Coast -‐ Coffs Habour -‐ Newcastle -‐ Sydney -‐ Canberra -‐ Melbourne

Bourke Tiltrotor Destinations

-‐ Adelaide -‐ Port Augusta -‐ Whyalla -‐ Port Lincoln -‐ Bourke

Tiltrotors and Australian Aeromedicine – Proposal Document

Author – Dr Paul Adams (July 2014) – Supplementary to Version 2.0 22 of 42

The green lines featured delineate separate “long range zones”. This incorporates the general principle that if a mission requires movement from one zone to another, this is not possible via tiltrotors (if based as indicated) without refueling or using auxilliary fuel tanks. Such long distance transfers would be better suited to jet aircraft. Please note that a green line has been omitted which should divide Victoria and Tasmania.

The diagram illustrates unprecedented vertical lift capability on a national scale with a relatively small fleet of tiltrotors. Five tiltrotors cover the Australian mainland, with the assumption that Tasmania is completely serviced by existing rotary wing services (and transport to the mainland occurs via fixed wing).

Realistically, it is clear that five tiltrotors are insufficient for a nationally operational fleet providing such coverage on a 24/7 basis. As such the diagram does not accommodate the need to bring aircraft offline for maintenance, or contingency coverage that is required when one or more assets are unavailable due to workload (tasked with a mission, refueling, restocking or returning to a base of operation).

The diagram also illustrates a need to address the following question:

“Where is the best base of operations for tiltrotors?”

For example, if tiltrotor aircraft exclusively replaced rotary wing services in Queensland, it is true that less total aircraft would be needed and this would favour a coastal-‐based service. However, without refueling mid-‐task or using auxillary fuel tanks, the current operational range of tiltrotor aircraft precludes complete state coverage from an exclusively coastal based service.

It is also useful to highlight that state borders serve to limit the operational efficiency of tiltrotor technology -‐ more ground could be covered if asset placement was planned independent of state borders (in terms of coverage and operational mission scope). This is why a



national network is the most cost efficient model for maximum pure geographical coverage using tiltrotors.

This model illustrates why housing tiltrotor aircraft inland enables better operational coverage and a smaller fleet.

A significant number of the transport destinations listed are not tertiary centres. Including them as potential transport destinations however serves to improve the operational range of tiltrotor aircraft. As the Rural Generalist Program strives to support rural centres in the provision of high quality healthcare to local populations, these locations become more suitable as primary transport destinations.

Such an awesome coverage potential as illustrated suggests that tiltrotors may overtake turboprop services for rapid response and urgent aeromedical workloads.

Existing helicopter arrangements in Queensland services 97% of the population. Response times are not just about population however geography must be considered. It is useful to ask the question -‐ Where are the other 3% (135,415) of people located? [19]

Enabled with tiltrotor technology a goal of 100% geographical coverage will ensure vertical lift services to 100% of the population.

This is nearly achievable with as little as five tiltrotors nationally.

Other hypotheticals – Sydney or Mackay

If such a service were based in Sydney, it could theoretically cover NSW, Victoria, and probably Tasmania with a slice of south eastern SA and QLD. Using Sydney as a base could attract more Government (even federal) funding than a Queensland service via population coverage, especially if the aircraft was pitched as being suitable for multiple federal and state Government purposes (police, diplomatic, etc.)

If an AW609 were operating from Mackay, the



combined population and geographical coverage would be enormous. Coverage could extend easily to Cairns, as far south as the Gold Coast, easily Longreach, and even Mount Isa (with refuelling). The capability of this aircraft provides unprecedented vertical lift rescue coverage (including winch operations). There shouldn’t be a shortage of tasks to justify the use of an AW609 in central Australia.



9. Aeromedicine into the future -‐ Special Circumstances

Aeromedicine incorporates multiple medical specialties. This demands versatility of personnel and aircraft. It is useful to consider specifically the key patient groups and what each requires of aeromedical technology. If a large tiltrotor, such as the V22 Osprey could be pressurized and made available for aeromedical purposes there would be huge implications for patient care. Beyond the increased payload and spacious cabin, simply being able to stand up and move freely inside the aircraft around the patient would revolutionise our ability to “treat and transport”. Emergency surgical techniques for example might become an option to clinicians mid-‐flight. Functionally speaking, the interior of a tiltrotor could be a blend of ambulance, intensive care unit, trauma room and operating theatre.

9a. Bariatric Patients

Australians are amongst the most obese in the world. [20]

Existing road-‐based bariatric services are specially designed and equipped to transport our largest patients. Size alone can disqualify a patient access to certain aeromedical resources. Transport of the bariatric patient poses significant logistical difficulty which can significantly delay arrival at the receiving facility. This is especially realized when it comes to bariatric transport in rural areas.

A large tiltrotor such as the V22 may provide the complete aeromedical solution when it comes to medium or long distance bariatric transport. Being able to land proximal to the bariatric patient’s location, load via a large cargo door and carry significant payload in a spacious cabin directly to the receiving facility could dramatically simplify what can be a problem-‐solving nightmare.



9b. Obstetric Transfers

Aeromedical transfer of the laboring mother is historically fraught with challenge and avoided. The issue is multifactorial. If in-‐flight surgery became possible this would have significant implications for the management of trauma and obstetrics. This in addition to being able to carry more equipment and personnel might allow emergency transfer of the laboring mother. The mother might also be afforded a support person during the transfer.

9c. Neonatal Retrieval

Neonatal retrievals involve heavy equipment, multiple personnel and precious cargo. It is not unusual that a mother is unable to accompany her child in flight – especially if she is obese. Even in comparison to helicopters such as the AW139, larger tiltrotor aircraft may more comfortably permit what is an important and compassionate measure.

9d. Major Trauma

The implications of tiltrotor technology for managing major trauma are significant. Existing operating procedures such as the Queensland Trauma Plan would experience significant reform in this context.

Currently, aeromedical teams (especially rotary wing) may work on a trauma patient on scene or in the back of an ambulance to achieve an optimal state for transfer (i.e. stabilization) before loading the patient in the aircraft. A rear-‐loading spacious tiltrotor, such as the V22 Osprey may enable this stabilization to occur within the aircraft. This practice could save time and improve survival.



9e. Critical Care Retrieval

Critically ill patients have low physiological reserves, a high likelihood for deterioration or change, are usually accompanied by lots of equipment and are demanding on retrieval staff. Caring for a critically ill patient within a confined space during the isolation of a flight between facilities is daunting and challenging. The ultimate outcome is measured by the patient’s recovery from illness/injury. Any measure that can be implemented to simplify and enhance clinical care of these vulnerable patients is well worthwhile.

Transferring patients between Intensive Care Units is a logistically challenging and life-‐threatening endeavor. Queenslanders still remember the floods of early 2013 whereby Bundaberg Hospital was evacuated. Disaster preparedness and tiltrotor technology is discussed further in section 12e.

The Australian Defence Force acts to support large-‐scale transfers of multiple critically ill persons over large distances. The Bali Bombings in 2002 are a good example of how the ADF utilized spacious heavy-‐lift aircraft to transfer multiple ICU patients simultaneously.

A large tiltrotor such as the V22 Osprey, could permit simultaneous transport of multiple critically ill patients necessary as part of routine aeromedical operations or disaster situations.

9f. Multiple Casualties

A service platform based upon large tiltrotors offers increased carrying capacity with less aircraft. This theoretically translates to better resilience in multi-‐casualty scenarios without disrupting systemic aeromedical functions. The benefit is multiplied beyond improved efficiency and patient care for the multiple casualties to include other patients/separate missions where there will be less service disruption.



9g. Organ Donation

The increased range and point-‐to-‐point transport efficiency offered by tiltrotors is nothing but good news for those awaiting access to donor organs. Tiltrotors if available should be applied for this purpose.



10. Technology Advances and Aeromedicine

Aeromedicine represents the coalface of integration between cutting-‐edge biomedical technology and state-‐of-‐the-‐art patient care.

Technology in aircraft needs to be:

• Compact • Lightweight • Battery operated (with good endurance) • Vibration and moisture resistant • Compatible with current practice • Ergonomic/useable The V22 Osprey has the ability to carry tactical vehicles

internally. Vehicle examples include:

• Boeing's Phantom Badger [21]

• General Dynamics Ordinance and Tactical Systems (GD OTS) Flyer Advanced Light Strike Vehicle (ALSV) [22]

The ability to carry a ground vehicle internally has potential

applications for remote primary response aeromedical missions. Historically, in areas where road ambulances cannot gain timely access to a patient, fixed wing retrieval operators may need to commandeer a private vehicle (such as a ute or a boat) for transport between the landing strip and the patient’s location. The nature of such missions usually means that such ground transport is “off road”.

Currently for remote locations (stations, areas isolated by flooding, areas inaccessible by aircraft etc.) this is the most feasible model of pre-‐hospital retrieval. The risks are obvious but unavoidable. For example, transporting an intubated patient on the tray of a ute is less than ideal. A purpose built off-‐road patient transport vehicle carried inside a tiltrotor could greatly complement vertical lift abilities and improve patient safety during hazardous rescues. Such a vehicle would also be useful if the tiltrotor was



unable to land on the grounds of a remote hospital and could be used to move the packaged patient to (and into) the aircraft safely.

Furthermore, as technology improves, compact and efficient amphibious vehicles are becoming available. Examples include:

• Argo ATV utilized by the SES for patient movement [23] • Quadski – a high speed ATV/jetski [24] The added benefit of using an amphibious vehicle is the ability

for water rescue or traversing water bodies.

Separately, consideration should be given to the emergence of Drone/Unmanned Aerial Vehicle (UAV) technology and how it could support aeromedical operations. The United States has developed a tiltrotor UAV -‐ the Bell Eagle Eye Tiltrotor [25] – which has potential application for Search and Rescue. UAVs may further support pre-‐hospital tiltrotor aeromedical rescue operations by assessing the scene for:

• Patient location(s) • Optimal landing sites prior aircraft arrival • Remote clinical co-‐ordination and scene planning of major incidents

• Disaster response planning • Security of personnel



10a. Anaesthetic Excellence

Retrieval Medicine personnel require exceptional anaesthetic skills as they inevitably need to manage difficult airways in relative clinical isolation. Safe airway management practice is important, especially where the clinician is striving to optimize the balance between treatment and transport. Along with the right skills, airway management can be significantly enhanced by equipment – where it can be the difference between life and death.

Equipment for Advanced Airway Management that could ideally be available as part of the interior of aircraft:

• Induction gasses • Endoscopes • Video laryngoscopes

10b. Ultrasound and other imaging

Portable imaging techniques such as Ultrasound have become standard place in the aeromedical setting.

10c. Telemedicine

Telemedicine is a contemporary technology that is revolutionizing rural healthcare delivery. One can foresee how this might be integrated into aeromedicine. The interior of the patient-‐care area might be fitted with cameras and microphones for remote viewing/recording of patient care. This will be suitable for:

• Liaising with staff at the scene prior arrival • Central clinical monitoring of patient care during transport • Communication with the receiving facility (high acuity patients)

Helmet-‐mounted cameras are already in use in aeromedicine and this technology serves to enhance service delivery.



10d. “Treat and Transport” – the deteriorating patient

As tiltrotor technology drives aeromedicine further clinicians will continue to push the limits of what’s possible in order to save lives. Tiltrotors will enable emergency personnel to access patients in record time and initiate transport sooner too. Conversely, larger distances will be covered and relative transport time of the unstable patient will increase. This means that it is inevitable that patients will deteriorate in-‐flight and one should be mindful of this when considering which model of tiltrotor is most suitable for aquisition. Realistically, the interior set up of a tiltrotor used for aeromedicine should comfortably accommodate the potential for in-‐flight resuscitation and the ergonomics associated with this.

10e. The retrieval team

As advances in critical care enable better quality and more intensive treatment at the roadside, there will proportionately be an increase in the number of staff required. This increased need for multiple team members in primary and complex cases justifies the need for tiltrotor aircraft that can carry multiple medical attendants per patient.

10f. Emergency/Last-‐resort Surgical Techniques

Emergency surgical techniques might become an option to clinicians mid-‐flight (in larger tiltrotors) as last-‐resort interventions. Beyond surgical airway and thoracostomy, this might include resuscitative thoracotomy, damage control laparotomy and caesarian section. Of course, the floor and exposed fittings would need to be suitable for body fluid exposure and other biohazard considerations. This idea should be further explored with the relevant experts in considering tiltrotors. Certainly tiltrotors could give emergency trauma teams increased mobility to access such patients that might



have previously perished without early damage-‐control surgical intervention.

10g. Accommodating future medical breakthrough

Medical minds have yet perceived all the medical possibilities of tomorrow. In establishing new aeromedical infrastructure this needs consideration. Reasonably, this involves acquiring aircraft that can incorporate more technology and hardware as it becomes available.

As initial care in rural facilities continues to improve with programs such as the Rural Generalist Pathway, retrieval aircraft need to offer more sophisticated care in order to fulfill the aeromedical principle of “maintain or increase the level of care in transfer”.



11. Attributes of the ideal aeromedical aircraft

Multiple options may be available for decision makers when it comes to an investment decision about tiltrotor technology, so it is useful to define the attributes aeromedicine could ideally hope for.

The perfect aeromedical aircraft:

-‐ Spacious interior suitable for medical purposes -‐ Large payload

o Can carry heavy equipment and personnel o Ideally large door/ramp access

-‐ High speed -‐ Long range -‐ Vertical lift -‐ Pressurized cabin -‐ Climate control -‐ Good lighting -‐ Minimum noise and vibration -‐ Stable/Minimal turbulence -‐ Minimum acceleration/deceleration forces -‐ Electricity/power to support multiple machines -‐ State of the art cockpit controls and software

o Search and rescue o Navigation/Weather systems o Communication o 24/7 operations (night vision etc.)

-‐ Cabin communication technology (phone, telehealth) -‐ Able to rescue via winch (stable hover) -‐ Able to transport multiple patients -‐ Able to house a vehicle if needed -‐ Cost efficient -‐ Safe -‐ Maintainable -‐ Small enough to land on hospital helipad



The V22 Osprey doesn’t appear to be pressurized, but it is

currently in operation and it is a large tiltrotor. Other tiltrotors will not be available until 2017. The V22 Osprey’s rear cargo door/ramp seems sensible in that it is suitable for “hot loading” a patient (while aircraft in operation), enables carriage of vehicles and large trolleys.

A cargo door enables the use of a dedicated stretcher/patient trolley for patient transfer into and out of the aircraft. A specially designed trolley might be utilized as a “patient care pod” incorporating all life support and patient monitoring equipment. The “pod” would be secured to the aircraft floor during flight and used to move the patient into and out of the aircraft, without needing to transfer the patient onto another trolley at the landing site or disconnect from the ventilator etc.

The AW609 is a newer generation machine, is pressurized and will be purely available to the civil aviation market.



12. Counting the Cost (investing in vertical lift capabilities)

Tiltrotor technology is promising to be more expensive than

fixed wing or rotary wing options. The investment needs to be clearly justified.

12a. Life is sacred and priceless

Life is sacred and priceless. In June 2014 Australia had spent more than $43 million on the search for MH370, and in the federal budget had also set aside nearly $90 million for 2015-‐2016. [26]

The late Fred Hollows famous quote, “an eye is an eye” in itself summises the approach healthcare professionals in Australia take when it comes to saving lives.

The Australian Defence Force takes the mortality of its personnel very seriously. Most rural doctors arguably feel the same pressure to offer our patients the best chance at life when it’s under threat.

Rural patients deserve the best Australia can offer. If a metropolitan resident suffered serious injury or illness in a rural area, their reasonable expectations of the health system should be met. It is clearly suboptimal if as a rural doctor one can’t offer reasonable access to equivocal emergency care.

To support rural health care (by optimizing quality of service) is to support the local economy and ensure public confidence.

The very existence and survival of sponsor-‐based rotary and fixed wing aeromedical services in Queensland is testimony to the adversity worth facing in bringing further improvement via the introduction of tiltrotors.

Investing in tiltrotor technology is clearly worthwhile to meet community expectations and preserve a hallmark of the Australian lifestyle – world class public safety.

A tiltrotor program would more suitably fit into a federal budget, and it may well be feasible as a relative expense in



comparison to other measures when it comes to harvesting political popularity and service delivery benefits.

12b. Sustainable aeromedicine – how can it be done?

One way or another, at the end of the day, it’s all about money. The long-‐term cost effectiveness of a tiltrotor program needs to

be defined.

As per the map in section 8, tiltrotors may promote the interstate networking of health service delivery, thereby improving efficiency of healthcare delivery on a national scale.

In considering the level of multi-‐tasking any Australian tiltrotor assets might be subject to, one needs to ponder the optimal model where aeromedical availability is off-‐set against a cost-‐benefit ratio. Is it better for patient care if less aircraft are more exclusive to aeromedicine? Or is it feasible to have more aircraft that are less exclusive to aeromedicine?

12c. Multi-‐tasking assets & potential non-‐aeromedical applications

Tiltrotors appear to be versatile to ANY task, in support of all government services. Potential non-‐military interested parties, for multitasking tiltrotor assets include (not exhaustive):

-‐ Ambulance & retrieval services -‐ Police services -‐ Fire and rescue (V22s capable of tanker function) -‐ VIP transport -‐ Intelligence -‐ Customs and border protection -‐ Federal police -‐ Mining

Potential military applications are discussed in section 5b.



12d. Future infrastructure considerations

Tiltrotors need inevitable inclusion in planning for healthcare delivery into the future and the utilisation of tiltrotor technology has implications for health infrastructure planning.

Planning for healthcare into the future will need to take into account:

• Increased regional and rural populations and their improved access to healthcare via the rural generalist program

• Rapid lateral spread of metropolis • Increased traffic and congestion on roads and at airports

Nationally, tiltrotors may enable further sub-‐specialisation of tertiary facilities due to increased capacity for transfer to such exclusive facilities. This model is more cost efficient, promotes research and is ultimately better patient care.

12e. Disaster preparedness – in the national interest

Just as for pre-‐hospital medicine, the focus for disaster response service delivery should be on preparedness (because workload is relatively unpredictable). To lag behind demand in a contemporary disaster setting represents epic Government and system failure.

It is worthwhile to highlight America’s successful utilisation of tiltrotors for humanitarian aid purposes –recently in the Phillipines as a result typhoon Haiyan in late 2013. The benefits realized were enormous. [27]

Reports on the success of tiltrotors in the Nepal 2015 Earthquake response are awaited.



13. Political Relevance – Rural Generalism

Rural and remote medicine is a key focus in the current state and federal political scene. This applies to medical workforce and infrastructure planning, in addition to addressing well-‐defined health inequalities and priority areas. Any measure to effectively improve healthcare for rural Australians is met with popularity. Affordability is an ever-‐present issue of unavoidable importance.

The Rural Generalist Program has been hugely successful in recent years in improving "healthcare in the bush". As Queensland’s own “home grown” project, the concept has been adopted at a federal level and is now being rolled out nationally. Introduction of the tiltrotor to Queensland Health’s rural arsenal would be a great innovation to be included in this movement.

The Australian Defence Force (ADF) is well aware of the V22 Osprey and its attributes. An article was published by a member of the ADF in the year 2000 highlighting the promise tiltrotors hold for aeromedical applications. [28]

In recent times the ADF has been clear about its intention to develop amphibious capabilities as a key future military strategy. For the US Military, the V22 Osprey is a cornerstone to enhanced amphibious capacity. It is therefore in the ADF’s interests to acquire tiltrotor aircraft. [29]

At a federal level, disaster management planning involves consideration of our regional interests in addition to internal preparedness. It is clear that as a self-‐deploying long-‐range vertical lift aircraft the V22 Osprey Tiltrotor is the perfect asset. At a state level, Government is focused on continued revitalization of frontline services for families via common-‐sense practical approaches. The Government desires that rural, regional and remote areas benefit from efficient and responsive aeromedical services. [3]

Just like the Rural Generalist Program, tiltrotors are a “game changer”.



14. Project Blueprint

The introduction of tiltrotor aircraft to Australia may provide

opportunity to centralize operational co-‐ordination of aeromedicine in Australia. Federal funding should be explored as a legitimate option given that tiltrotor technology is likely to be very expensive. Integration with existing government services (law enforcement, border protection, intelligence, military) should be considered as a means of justifying expense and enabling aeromedical access to a larger fleet of aircraft nationally.

Some progress:

• Mount Isa Centre for Rural and Remote Health (JCU -‐ Townsville) has shown interest to frame research around initial deployment of tiltrotor technology.

• Sydney HEMS is establishing a national retrieval database which will enable new research into retrieval medicine

• There has been promising integration of applied mathematics to emergency medicine which creates opportunity to use retrieval data for operational modelling research

PHASE STAGE MEANS VISIONARY Research/Information Acquisition Project/Working

Group Concept Development Promotion & Refinement

PIONEERING (testing the idea)

Planning & Preparation Funded Trial Implementation Evaluation

INTEGRATION INTO SYSTEM

Planning & Preparation Establishment of ongoing service provision

Implementation Refinement



15. References

1. Boeing 2014, Boeing: V-‐22 Osprey, Boeing, Chicago, Illinois, viewed May 2014, <http://www.boeing.com/boeing/rotorcraft/military/v22/index.page>.

2. AgustaWestland 2014, AW609, AgustaWestland, Italy/USA/UK, viewed May 2014, <http://www.agustawestland.com/product/aw609>.

3. Royal Flying Doctor Service 2014, Royal Flying Doctor Service, Sydney, New South Wales, viewed May 2014, <http://www.flyingdoctor.org.au>.

4. Queensland Government 2014, Department of Community Safety, Brisbane, Queensland, viewed May 2014, <http://www.emergency.qld.gov.au/emq/>.

5. Queensland Parliament 2014, Question on Notice, No.14, Asked on 11 February 2014, Queensland Parliament, Brisbane, Queensland, viewed May 2014, <http://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2014/14-‐2014.pdf>.

6. Queensland Government 2012, Summary Report: Review of Aeromedical Helicopter Services in Queensland, December 2012, Chief Health Officer Branch -‐ Department of Health, viewed May 2014, <www.southburnett.biz/pdfs/helicopterreview.pdf>.

7. Pilatus Aircraft Ltd 2014, PC-‐12 NG, Pilatus Aircraft Ltd, Stans, Switzerland, viewed May 2014, <www.pilatus-‐aircraft.com/#13>.

8. Beechcraft 2014, King Air B200, Beechcraft, Augsburg, Germany, viewed May 2014, <www.beechcraft.de/King-‐Air-‐B200.362+B6Jkw9MQ__.0.html>.

9. Legacy Aviation Group 2014, Product Analysis: Hawker 800XP Weight Statement, Legacy Aviation Group Inc, Houston, Texas/Los Angeles, California, viewed May 2014, <www.legacyaviationgroup.com/PDF/hawker_800xp_specs.pdf>.

10. Cessna Aircraft Company 2013, Cessna Caravan, Cessna Aircraft Company, California, USA, viewed May 2014, <www.cessna.com/en/caravan/cessna-‐caravan>.

11. AgustaWestland 2014, AW139, AgustaWestland, Italy/USA/UK, viewed May 2014, <http://www.agustawestland.com/product/aw139-‐0>.

12. Bell Helicopter Textron Inc 2014, The Bell 412, Bell Helicopter Textron Inc, Hurst, Texas, viewed May 2014, <www.bellhelicopter.com/en_US/Commercial/Bell412/1291148332166.html#/?tab=highlights-‐tab>.

13. North Queensland Helicopter Rescue Service (NQ Rescue) 2012014, Helicopter Information, North Queensland Helicopter Rescue Service (NQ Rescue), Mount Isa, Queensland, viewed May 2014, <www.nqrescue.com.au/heliinfo.html>.

14. Bell Boeing, viewed 7 July 2014, <http://www.iasa.com.au/folders/Publications/pdf_library/ospreypdfs/execv-‐22.pdf>.

15. Queensland Parliament 2013, Question on Notice, No.631, Asked on 10 September 2013, Queensland Parliament, Brisbane, Queensland, viewed May 2014,



<http://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2013/631-‐2013.pdf>.

16. Queensland Parliament 2014, Question on Notice, No.282, Asked on 2 April 2014, Queensland Parliament, Brisbane, Queensland, viewed May 2014, <http://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2014/282-‐2014.pdf>.

17. Queensland Parliament 2014, Question on Notice, No. 146, Asked on 6 March 2014,Queensland Parliament, Brisbane, Queensland, viewed July 2014, <http://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2014/146-‐2014.pdf>.

18. Queensland Parliament 2014, Question on Notice, No. 282, Asked on 2 April 2014,Queensland Parliament, Brisbane, Queensland, viewed July 2014, <http://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2014/282-‐2014.pdf> .

19. Queensland Government 2012, Summary Report: Review of Aeromedical Helicopter Services in Queensland, December 2012, Chief Health Officer Branch – Department of Health, viewed May 2014, <www.southburnett.biz/pdfs/helicopterreview.pdf>.

20. viewed 7 July 2014, <http://www.oecd.org/els/health-‐systems/Obesity-‐Update-‐2014.pdf>

21. viewed 7 July 2014, <http://www.janes.com/article/36534/boeing-‐s-‐phantom-‐badger-‐vehicle-‐cleared-‐for-‐v-‐22-‐carriage>

22. viewed 7 July 2014, <http://www.gd-‐ots.com/flyer.html> 23. viewed 7 July 2014, <http://www.argoatv.com.au/> 24. viewed 7 July 2014, <http://www.gibbssports.com/quadski-‐xl> 25. viewed 7 July 2014, <http://www.naval-‐

technology.com/projects/belleagleeyeuav/> 26. viewed 7 July 2014, <http://www.smh.com.au/federal-‐politics/political-‐

news/mh370-‐search-‐malaysia-‐and-‐australia-‐to-‐share-‐costs-‐20140609-‐zs2an.html>

27. viewed 7 July 2014, <http://www.nationaldefensemagazine.org/archive/2014/February/Pages/V-‐22Osprey,AmphibsProveValueDuringTyphoonHaiyanOperations.aspx>

28. Wilkins, Group Captain Peter S 2000, ‘The potential use of military tiltrotor aircraft for aeromedical evacuation, ADF Health, vol. 1, April 2000, viewed May 2014, <www.defence.gov.au/health/infocentre/journals/ADFHJ_apr00/ADFHealthApr00_1_2_58-‐63.pdf>.

29. Australian Government 2013, Defence White Paper 2013, Department of Defence, viewed May 2014, <www.defence.gov.au/WhitePaper2013/docs/WP_2013_web.pdf>.

tiltrotor may 2015

Documents

c aircraft

c neonatalretrieval

c telemedicine

b ultrasoundandotherimaging

c approximateareaofoperation

b obstetrictransfers

b militaryotherapplications

d majortrauma