A call comes in to operations: a young American woman vacationing on a dive boat in the Caribbean is suffering from serious burns after a fire broke out on board the vessel. Her passport and all documents were lost in the accident, and she needs to be repatriated to the U.S. for medical attention–fast.

The job of getting her home has fallen to the medical staff and flight crew of a Learjet 35 working for Fort Lauderdale, Fla.-based Aero Jet International. Stuart Hayman, president, said organizing the actual flight is the easy part; the hard part is coordinating the logistics associated with this complicated international transfer to the U.S. since the person to be transferred has no proof of citizenship.

Working with individual U.S. Customs and Immigration inspectors, the operations staff navigates the bureaucracy and obtains a verbal declaration of citizenship for the woman, allowing the flight crew and onboard medical staff to bring her home without much delay.

Being able to execute a patient transfer in a timely fashion is what separates international air ambulance providers from most other business jet operators. And as more foreign citizens seek sophisticated western health care and the mobile, affluent populations of North America and Europe age, demand is growing for the expertise that international air ambulance providers offer.

Unlike medevac flying, where the priority is to get a critically injured patient to a hospital–any hospital–quickly, long-range air ambulance patient transfer is primarily about transporting stabilized, non-emergency patients from bedside to bedside. Most often, this is required when a person becomes gravely ill or is seriously injured while overseas and needs access to North American or European medical attention, but the nature of the injuries is such that flying them on a commercial flight is not practical.

The bulk of such air ambulance work comes from insurance companies repatriating tourists. With a large number of vacationers and retired “snowbirds” from Canada and the northern U.S. vacationing in Mexico, the Caribbean, Central America and the southern U.S., there is a steady demand for patient transfers during the winter months, or what one Canadian flight nurse refers to as “hip, stroke and heart season.”

However, insurance companies are not the only ones that request patient transfer charters. Quite often, wealthy private citizens and foreign nationals seeking high-end U.S.-style health care are willing to pay the price to have a business jet take them to internationally recognized health facilities, such as the renowned Mayo Clinic centers in Minnesota, Arizona and Florida.

And while government contracts and charters make up a small percentage of international patient transfer work, many companies occasionally receive calls to retrieve injured soldiers, government personnel or private citizens after acts of terrorism or humanitarian disasters.

Logistical Challenges

Regardless of who is chartering a flight, every air ambulance operator’s priority is a fast response time (industry standard is two hours from the call to wheels up) to receive the patient anywhere in the world and quickly transfer him or her to the destination of choice without undue hardship. Making this happen regularly without incident means managing the myriad logistics associated with such missions, many of which appear or evolve during the course of a charter.

The key to success, say most operators, is effective coordination, preparation and planning among flight crews, medical staff and operations employees. Most companies have comprehensive checklists of items to cover before they give a quote to a potential client.

Jeff McIntosh, president of Winnipeg-based Canadian Global Air Ambulance (CGAA), said preparing for the unexpected and managing it when it happens is crucial to effective international air ambulance operations. “Every trip is different; sometimes the shortest can be the hardest.”

To illustrate his point, he related several stories in which flights arrived at foreign destinations and patients wanted to bring along excessive luggage or even pets. In the case of one long-distance charter, the patient’s family, including a two-year-old child, was to travel on board. Not surprisingly, the flight nurses were somewhat dismayed by the prospect of contending with a toddler within the confines of a Learjet 35 on a 12-hour flight.

Issues requiring consideration on every patient transfer include an assortment of “known knowns,” such as monitoring duty days, pre-positioning crews worldwide as required, obtaining foreign visas for medical staff and aircrew, landing rights, overflight permits (particularly over Cuba) and the pre-screening of patients with U.S. Customs and Immigration officials and the Department of Homeland Security.

In addition, the operators must also contend with “known unknowns,” such as international weather systems, unconventional airport operating hours, specific insurance requirements and the specific operating restrictions individual nations impose. For example, while most countries require liability insurance of approximately $25 million for air ambulance charter flights, Germany requires companies to obtain one-time $60 million insurance coverage before they can fly in or out of the country. And in Brazil aviation authorities require international charters to be flown by a crew of two captains.

Then there are the medical logistics to address. Aeromedical staff must arrange ground transportation and ensure that they have all necessary equipment. They must also obtain patient assessments before pickup. Sometimes–depending on the motives or capabilities of foreign medical facilities–these assessments are not accurate, with patients being in worse condition than originally reported.

Aeromedical Flight Crews

Having sharp staff prepare, plan and monitor the status of any charter is an important element on every flight, but the front line of any air ambulance company will always be the aircrew and medical staff on board each flight. Being able to adapt to unpredictable developments on the scene goes with the territory. “The challenges are there every day,” said McIntosh. “So you need the right people to come to solutions and decisions quickly.”

The pilots making the decisions have to be enthusiastic, committed individuals prepared to make the necessary short-term sacrifices inherent in the job. Companies depend a great deal on pilots’ ability to think and act for themselves.

Aero Jet’s Hayman said, “No matter how much planning we’ve done there are always changes, so we have to count on our crews on the ground to be able to make decisions.” He added that character goes a long way, too, noting, “We have some great staff who are willing to go into sometimes tough and tragic situations.”

For the most part, air ambulance pilots are relatively young first officers and captains at the early to intermediate stages of their flying careers. While requirements vary, most captains have around 5,000 hours total time, while first officers often enter the business with around 1,500 hours. Some pilots make careers of air ambulance flying, but most use it as a stepping-stone to build international jet experience toward the next phase of their careers.

Hayman conceded that air ambulance flying can be physiologically taxing, noting that crews are “operating in challenging and difficult locations…and the work can be exhausting; they are putting in long days, sometimes up to 10 hours of flying in a 14-hour duty day, often at night.” Nevertheless, what keeps many of them going, he said, is the reward of retrieving sick and injured people from dire circumstances. “What we do for a living is great. We’re bringing people home.”

Medical Training

Working just as hard as the pilots under similar circumstances are the aeromedical staff attending to the patients. In most cases, air ambulance flight nurses and doctors are highly qualified and experienced staff with considerable emergency, ICU and critical care experience. Beyond their medical duties, though, medical staff are also involved with the logistics of patient transfer flights, including coordinating requirements with insurance companies or arranging for a suitable receiving location upon arrival.

Lisa Moreljo, CGAA’s manager of medical operations, said one of the biggest challenges for Canadian air ambulance operators is finding available hospital beds for patients when they return. “We won’t pick up a patient unless we can find a bed at home,” she says. “Finding beds is a priority…it often takes a lot of sweet talking and swaying.”

Of course, combining the complex and demanding professions of medicine and aviation inside a cylindrical tube at FL350 is not without challenges. To improve crew coordination, most air ambulance companies equip their aircraft with standard medical equipment and require all medical personnel–contract or full-time–to undergo standardized aeromedical training in addition to company indoctrination.

“Taking care of people on the ground and taking care of people in the air are two different things,” says Moreljo. “You can’t just throw medical staff and equipment into an airplane and expect things to work normally. If a patient goes ‘south’ you need to have people who can work in that small environment and deal with the emergency.”

Location, Location, Location

Having a strategic geographic base of operations is essential to the success of any air ambulance company. Primarily serving the Caribbean and Central America, Aero Jet International headquarters its operations in Fort Lauderdale and has a secondary base of operations in San Juan, Puerto Rico.

Likewise, CGAA situated its headquarters in Winnipeg, the geographic center of North America, while maintaining two other bases of operations–one in Vancouver, serving the West Coast and Asia and the other in Toronto, serving the East Coast and Europe.

The downside to this, said McIntosh, is being “small and spread out. It requires a phenomenal amount of communication between bases and crews.” He said that good communication procedures between bases and crews and satellite communications go a long way toward removing impediments and shortening the distances involved.

The country in which an air ambulance jet is registered is also an important consideration when it comes to international patient transfer, particularly when the aircraft is operating in politically unstable parts of the world. Don Jones, president of Denver-based Air Ambulance Specialists, said, “It’s tough going into war zones with a U.S. registration. We don’t go to war zones because our insurance won’t cover it.” Indeed, many U.S. aeromedical operators say even if they could get insurance there is too much hassle and risk involved in trying to operate an American-registered jet in the world’s many hot spots.

As a result, Canadian air ambulance operators and aircraft registered in other “nice” (or at least neutral) countries tend to fare somewhat better in getting charter work to trouble spots due to a certain degree of political expediency. Consequently, it is sometimes convenient for American or significant European governments and insurance companies to charter operators such as CGAA or Skyservice to undertake charters on their behalf.

Mike Vallee, manager of Skyservice’s air ambulance operations, said, “Some of the places we go, such as the various republics of the former Soviet Union, are not what you might call ‘vacation’ destinations.” With such charters, he said, the company makes security arrangements as required. “We contract security from a supplier…who can give us everything from an up-to-the-minute intelligence briefing to armed perimeters around an aircraft.”

Vallee says that while the bulk of Skyservice’s air ambulance charters involve bringing home injured or sick tourists, a certain amount of work still comes in the wake of international terrorism and humanitarian disasters. Indeed, the company was involved in transferring patients from London after the terrorist attacks on the transit system this summer, and Vallee said the company often sees an increase in requests for price quotes after catastrophes.

As a result, Kelly Bartley, manager of customer service and solutions at CGAA, says the televisions–tuned to CNN, Fox and other international news agencies–are always on in operations. “Following an international incident we contact various embassies and consulates to make them aware of our services,” she said. “We’ve got to watch out for world events…We have to be watching what’s going on with  typhoon in Manila, a bomb in Iraq or an earthquake in Turkey.”

Altruism aside, at the end of the day air ambulance is still a business, and a tough one. “No matter how good your operations are you still have to watch the financial end, make smart decisions and market effectively,” said Don Jones. “International air ambulance is a small, highly competitive business…with considerable costs involved. A lot of companies think it’s easier than it is. It’s not [easy]–a lot fail.”

While there are many commonalities among aeromedical companies, each one seems to have its own business philosophy, structure and ideas about how to get the job done.

For example, some companies, such as Air Ambulance Specialists, employ and maintain all their own medical staff and equipment but often supplement their own aircrew and aircraft, as required, from a network of outside vendors who regularly operate with them.

Conversely, other companies, such as Skyservice Air Ambulance, instead opt to own and operate their own aircraft and flight crews, while relying mostly on contract medical staff. Vallee said, “Contracting medical staff allows us to lower our overhead. It gives us the best mix of medical expertise and cost effectiveness.”

Then there are those air ambulance providers, such as International Aero Jet and CGAA, that employ all their own aircraft and flight crews and maintain a full-time dedicated medical staff all under one roof. McIntosh said CGAA’s decision to hire a large staff of experienced and highly qualified medical personnel was a conscious business choice.

“The high overhead is what the ownership has chosen to do,” he said, adding that because it has its own dedicated staff the company has been “put on a preferred provider list with many customers.” Even so, he admits, keeping so many employees on the payroll and operating four Learjet 35s specifically dedicated to air ambulance ops from three different bases can be costly. “The key to having 60 people on staff with four airplanes is to keep them in the air. Currently, each of our aircraft flies approximately 1,200 hours per year.”

Customer Service

Customer service–to both the patient and the insurance company chartering the flight–is the other half of the business equation, said McIntosh. However, keeping the needs of the insurance company front and center at all times requires something of a paradigm shift for many new medical staff who are trained throughout their careers to treat the patient as the sole customer.

Moreljo said, “From a medical side, staff still regard the patient as the customer but from a practical business side they must also consider the needs of the insurance company. You have to strike a balance.”

One thing all insurance companies seem to appreciate is that companies such as CGAA strive to ensure no airplane goes anywhere empty. The company stays in regular contact with a variety of insurance companies looking to pair up trips whenever there is an empty leg. McIntosh said that by working closely with insurance companies, developing a sound reputation for high-end service, and being honest about the capabilities and limitations of what the company can and cannot do pays dividends. “We are developing partnerships with our top customers,” he said. “We share information with them about our challenges and in return we get intelligence about their needs.”

And it appears those “needs” are only going to increase. The aging populations of North America and Europe are fueling demand for international air ambulance patient transfers. Specifically, the baby boomers are beginning to reach the age of retirement and this relatively affluent segment of Western society is traveling more than ever.

“I think there’s a lot of room for a high-end international air ambulance operator,” said McIntosh. “The front end of the ‘boomers’ will be retiring in 2008. With their higher levels of disposable income they’ll be traveling more often, so for the next 15 to 20 years there is going to be  phenomenal amount of business for premium aeromedical services.”