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AVIORADAR - Croatian aviation website

Emergency medical transport - How much is a child's life worth?

Written by: Nenad Sredojević.

© Avioradar - Marko Kovačićek


First, we want to distance ourselves from any insinuations that we aim to criticize the work of emergency services, the Croatian Air Force, the 112 Center and medical staff. On the contrary, we greet them and thank them.

On Friday, February 5, 2021, a four year old boy who needed medical care at KBC Zagreb was urgently transported from Dubrovnik to Zagreb on Croatian Government's aircraft, Bombardier Challenger 604 reg. 9A-CRO. The little boy had a ruptured aneurysm which required urgent medical attention.

Such transport is common because Dubrovnik has only a general hospital that does not have the equipment or professional medical staff for certain procedures and services.

It sounds horrible that Dubrovnik does not have a child intensive unit, which was extremely important in the case of our boy, but this is not our topic here, so we will leave it to experts to comment.

Our domain is aviation.

Namely, the event on Friday made us think about the time of such an intervention and how big of a factor time is.

We talked about time as a factor with Goran Franić, Bacc.med. tech. He has been flying for the last three years as a medical technician in the FAI Aviation Group, which is one of the leading companies in the world. Fifteen years before that he spent in emergency medical care in Split-Dalmatia County and had 300 flights by HRZ helicopters. He was also a member of a pilot project of the Government of the Republic of Croatia when HEMS was flown by Italians. He colected a total of 2,000 hours of “Air Ambulance” missions, from simple to fully intensive care.

Goran emphasized that it is difficult to be precise without complete medical documentation, but the speed of reaction is certainly a factor.
"In general, with such patients, if you can't be fast, you do stabilization, then transportation, but the problem here is that this is a child who needs transport and Dubrovnik does not have a children's intensive care unit. All children who need intensive treatment are transported to Split and in severe cases to Zagreb." - Goran told us.

We talked about the aviation segment of this very common situation with Đani Bodlović, a Member of EASA ESPN-R (ex EHEST) European Safety Promotion Network Rotorcraft, who explained to us from the aviation aspect that neither the Croatian Government's plane nor the helicopters belonging to HRZ and MUP are adequate for medical transport, because they do not meet the basic safety requirements since medical transport it is not their purpose.

Ultimately, helicopters should not transport civilians at all, while the Government's plane is in a VIP configuration and is not intended to transport patients.

This was confirmed to us by Goran, who stated that the aircraft used are not equipped with medical equipment, nor are the medical staff flying on such flights educated for the job, which is not a negligible fact.

MUP helicopters do not have a long enough range, so they need to make a fuel stop en route, while on the other hand, the Government plane is a very slow option.

In addition, there is not a single heliport in Croatia that is in accordance with the regulations.

To show you the difference in reaction time to situations like with  our little patient, we made a calculation and timeline on two examples of the Friday case.

Example 1 (as happened on Friday):

14:11 - Center 112 Dubrovnik receives an request from OB Dubrovnik to transport a four-year-old child with a ruptured aneurysm, the request is then forwarded to the Directorate for the use of official aircraft
15:20 - 9A-CRO takes off from Pleso
16:05 - 9A-CRO lands in Dubrovnik / Čilipi
16:20 - takes off from Čilipi to Pleso
17:10 - lands on Pleso, the boy is transferred to an HMP vehicle and takes the road to KBC Zagreb.

We have no information when the boy was admitted to KBC Zagreb, but according to our information, the ambulance needs between 20 and 40 minutes from Pleso to KBC, so we will take the average for this analysis. Half an hour.

17:40 - the boy is in KBC Zagreb and finally receiving the proper care 

Total time: 3 hours and 29 minutes

It should be noted that the boy had to be transported from Dubrovnik General Hospital to Dubrovnik Airport, which also takes, depending on traffic, between 20 and 40 minutes.

This transport was carried out while the plane was on its way to Dubrovnik. This is very important because, as Goran Franić explains, this type of patient is extremely sensitive to all types of force on the body, which means that sudden action of G force can create a problem or even be fatal for the patient. According to Goran, road transport is the worst option for such a patient. However, he emphasizes that transport by plane, although faster, is still not a best option because the G forces are much higher than in transport by helicopter.

He explained to us that in decision making, those responsible are guided by the principle of lesser evil. So, one option is not to transport at all where the fatal outcome is almost certain, or to transport patient by plane, so the chances of a positive outcome increase.

But you are probably wondering why they didn't transport our boy by helicopter? 

Available helicopters would prolong the transport too much because there are no MUP or HRZ helicopters positioned in Dubrovnik. More importantly, a suitable helicopter for such a flight (MUP's EC135) does not have a range to make it without landing for fuel, which in that case should be in, for example, Zadar. In that case, it is no longer about precious minutes but hours.

Can it be better? Yes!

HEMS (Helicopter Emergency Medical Service), which, in addition to its core business, also performs medical transport like this, is a completely normal thing in developed countries of Europe and the world.

Croatia, except for one attempt with an Italian operator, does not have such a service.

For this story we will say that there is, as it should be, so let's look at another example in which our four-year-old boy would be transported by a helicopter AgustaWestland AW139, which is quite enough for HEMS on the Adriatic coast.

We will be optimistic and say that, for this story, the AW139 is stationed at the OB Dubrovnik heliport, which is in the immediate vicinity. We will also say that the crew is on duty 24/7 at the 112 Dubrovnik Center, which is just below the heliport.

Example 2 (Active specialized HEMS service according to regulations and safety conditions - AW139)

14:11 - received a call at the 112 Dubrovnik Center
14:30 - take-off from the OB Dubrovnik heliport (transport by ambulance is minimal)
16:00 - landing at the heliport of Dubrava Hospital
16:10 - the boy is in KBC Zagreb and his care is taken over by those who do it best (transport by ambulance is minimal)

The difference between these two examples is 1:30 hours , so instead of 3 and a half hours, we transported our little boy in 2 hours. We reduced the transport by ambulance from an hour to only 15 minutes. That may be life saver for some other child.

Yes, it happens that patients are not transported at all because it is estimated that they will certainly not survive the flight. Would they be transported in our second example? Some would. Lives would be saved.

Our little boy is in Zagreb, some improvement has been noticed, but he is far from being out of danger, and recovery is still not in sight. 

We want our little friend and his family to win this battle.

The Government of the Republic of Croatia, ie the Ministry of Health, is announcing an international tender for HEMS in a March. However, making Dubrovnik a base is still not planned, and all emergencies will be covered by the base in Split!

This makes our second example an unfulfilled dream. 

Answer to the question from the title: Obviously not much.