Creating a Safe Haven

Building the ‘Perfect’ Medical Interior Rife With Challenges
Walter Heneghan
March 08, 2013
By Walter Heneghan
From Bell 206 Jet Rangers to the 21st century, next-generation AgustaWestland AW139, virtually every certified helicopter type in operation today has at one time or another served as an airborne ambulance. The Bell 47 immortalized in the series MASH had a stretcher strapped to the skid and military Bell 412s can be outfitted with a mass casualty configuration for up to six patients accompanied by two medical attendants.

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Ontario’s ORNGE came under scrutiny last year when its AW139 medical interior prevented paramedics from performing certain medical procedures. (Photo by Matt Nicholls)
 

Yet, the “perfect” medical interior retains a somewhat mystic status among Emergency Medical Services (EMS) programs, at times proving to be an elusive engineering feat and almost always a complicated dance between “form” and “function.”

 For more than 100 years, industrial designers and architects have used the mantra that “form follows function” as the guiding light for industrial design. A review of the guiding principles for some of Canada’s major airborne EMS programs delves into the successes and failures of program managers in their quest to be true to this advice.

Perhaps it would be instructive to consider form and function by looking into the history of this philosophy. The American architect Louis Sullivan is credited with coining the phrase in the late 19th century. Sullivan is widely considered to be America’s first truly modern architect by creating many original details and forms. The full quote informs the task at hand quite completely: “It is the pervading law of all things organic, and inorganic, of all things physical and metaphysical, of all things human and all things super-human, of all true manifestations of the head, of the heart, of the soul, that life is recognizable in its expression, that form ever follows function. This is the law.”

So, how closely has the air ambulance industry succeeded in the evolution of interior design? A close analysis of air medical transport conferences reveals that there are dozens of different EMS interiors. In fact, one could take a random sample of 20 different EMS companies and it’s highly probable that there will be 20 unique interiors. Some of the bigger completion centres for EMS aircraft include Swiss-based Aerolite, Washington state-based Lifeport, Air Methods in Colorado and Peterborough, Ont.-based Airtech.

Several considerations must be addressed when it comes to proper air medical design. When asked which is the most important, Preston Palmquist, account manager at Lifeport, a Sikorsky Aircraft EMS completion company, noted that the primary function of design is component based.
“Our core competencies are the medical deck (med-deck) plus ancillary systems,” Palmquist said at last fall’s Air Medical Transport Conference (AMTC) in Seattle. “Fixed-wing solutions are our bread and butter, such as King Airs and PC-12s. Many of these aircraft are multi-purpose, so the medical systems need to be modular and removable.”

11.1  
Designing the “perfect” medical interior is all about knowing the client and understanding the limitations of the aircraft – which is a fine balance. (Photo courtesy of Aerolite)
 
Lifeport Med decks are well-known around the world and can be removed to enable reconfiguration of aircraft for air ambulances or passengers. “Rotary-wing aircraft tend to be more dedicated to EMS,” Palmquist added. The biggest challenges for operators in EMS interior design, involved next gen aircraft – specifically, tougher FAR 29 certification requirements. “The challenge is to take what the industry wants from design to certification,” Palmquist said. “For instance, we had to go from a med-deck certified at 4 G to one certified for 16 G in order to meet the new airworthiness standards.”

Meeting such stringent requirements often adds cost and weight to new EMS interior systems – for example, add a stretcher system that requires self-contained wheels and the problems multiply. “We created a wheeled stretcher for use in the AW139, for example, but the FAR 29 requirements for G loading resulted in a stretcher that weighed 85 pounds. This was not a workable solution,” he said.

Calgary-based medical transport provider STARS knows all about the complexities of making interiors work out just right. After announcing in 2007 that it had purchased an AgustaWestland AW139 for its Edmonton base, the subsequent interior design proved to be too heavy and ultimately not certifiable – it was back to the drawing board.

“Our initial prototype wasn’t going to be successful due to weight and balance and dimensional considerations, so there was a change,” said Dr. Greg Powell, the former CEO of STARS. As a result, the interior design was scrapped and a different solution was created, ultimately delaying the introduction of the aircraft until late in 2012.

Designing the “perfect” medical interior is all about knowing the client and understanding the limitations of the aircraft – which is a fine balance, says European general manager Marcus Inabnit from Aerolite Max Bucher AG, a Swiss-based EMS completion specialist.  “We are not the owner of the interior,” he said. “Aerolite is the architect but the client owns the interior.” And there’s another key challenge in the process: translating the medical vision into a workable EMS interior. “Every customer has certain needs and requirements. We specialize in custom solutions; different medical programs have different medical needs.”

It’s a sound business model, yes, but the question remains: why are there no standard, commercial off-the-shelf OEM-supported medical interiors? Shouldn’t there be industry standards that dictate specific requirements? Aerolite’s American general manager Hans Brechner has the answer. “[It’s because] the doctors get involved, the medics get involved, the organization gets involved. A standard interior would never be sold, that’s the beauty of customization.”

Brechner admits customization adds complexity and subsequently price, and he echoed the sentiment expressed by Palmquist that new airworthiness standards present unique challenges. “We need to go in sequence,” he  said. “We need to develop the product, create a functional mock-up, go to EASA for an STC, then go into production. This is a long process, taking about a year from design to certification.”

In terms of standardization, adopting a consistent interior across the board is not necessarily realistic. “Even if the OEM offered a standard interior like Eurocopter does with the EC-135 and EC-145, this is just the starting point for specific customer modifications.”

Air Interiors In Focus
The precarious nature of medical interior design was front and centre in Ontario earlier this year, when the province’s medical transport provider, Ornge, was questioned about its custom designed, purpose built interior for its new Aerolight AW139 aircraft, which has since been redesigned (see sidebar).

AW139_4_SjCYe  
STARS' initial prototype for the AW139 wasn't going to work due to weight, balance and dimensional issues.
(Photo courtesy of STARS)


 
The company built exactly what Ornge wanted, “to the millimeter,” notes Brechner, but really had no opinion about the final design. The interiors have come under scrutiny by the provincial government in an investigation over their medical functionality. “Our task is to answer the question of whether or not we can get it certified for use in an aircraft,” Brechner said. “We are not medical people, just engineers. We built it to their specs.”

A functional, lightweight layout, simplicity, and redundancy are all key elements of an effective medical interior layout, say the experts – all designed to help the administration of medical care as quickly and efficiently as possible. Rob Blakely, Canadian Helicopters’ general manger and VP for EMS, says it’s all about ease of operation. Blakely has been involved in the HEMs world since 1977, first as a line pilot, then with increasing levels of responsibility. Blakely was a key influencer in the design of three different aircraft when Canadian held the Ontario EMS contract prior to its transfer to Ornge.

“The mission was critical to our thinking,” Blakely said. “For example, we have operations that have flown over 1,000 hours per year at a single, aircraft base, sometimes at distances over 250 nautical miles. Oxygen capacity was critical for us. With back-to-back missions and the aircraft not returning to its base for sometimes more than 12 hours, we needed lots of capacity.”

Blakely played a key role in the completion of the Sikorsky S-76, and says though it was utilitarian in design, it weighed less than 500 pounds and provided redundant electrical and oxygen systems. Functionality was critical to the solution.

“Our designs are very utilitarian in appearance, but are simple, durable, easy to maintain and very functional,” he said. “We have utilized both methods (an interior design/manufacturer provider and a local DAR). The local DAR resulted in a superior product which more closely met the requirements of the operation.”

James Mewitt, President of AIRTECH Canada, has been involved with EMS interior completions in the Canadian marketplace since 1984, and worked very closely with Canadian Helicopters and their interior design. “[The original CHL] interior was designed by CHL maintenance and design people, was over-engineered, and done the hard way,” according to Mewitt. “They put a lot of money into the design as they saw a potential resale market.”
Once AIRTECH had built several interiors, Mewitt explained, they discerned ways to improve the product, and the S76A interior that has become know as ‘the AIRTECH interior’, evolved accordingly. “Lots of operators get trapped by the brochure,” he added, “. . . without considering the real world effect of their decisions.”

Mewitt’s relationship with Canadian through the numerous evolutions was critical. He suggested that while an operator can manage the certification process of an interior that was originally certified through EASA or the FAA, “. . . being a Canadian facility and working with only one regulatory body is a real plus.” He said the best relationships are ones that are collaborative and where, “my company’s success mirrors the success of our clients.” The most important aspect of any interior project is identifying a champion. “Having a champion, an experience aviation person with his eye on the big picture is critical to the process.”

Bell-429-Interior  
Air Methods’ Frank Graham says when issues arise in the development of an interior, it’s often because a company is focusing on engineering the perfect solution, a solution that was achievable from an engineering perspective but did not necessarily meet the operational goals of the programs and their medical missions. (Photo courtesy of Air Methods)

 
Simplicity and functionality in design are sentiments reinforced by Frank Graham, a senior manager with Air Methods Corporation and EMS completion expert. Air Methods is the world’s largest air ambulance provider, operating more than 400 helicopters and fixed-wing aircraft worldwide and considered to be a leader in EMS completions. The company operates both dedicated and multi-function aircraft with many of the fixed-wing aircraft equipped with LifePort equipment.

Graham spent more than 17 years with Lifeport, before moving over to Air Methods after Sikorsky Aircraft purchased the interior provider, and says all the major interior designers are capable firms working to best meet the needs of their clients. Air Methods uses both Commercial Off the Shelf (COTS) products and designs from scratch. They are currently developing their own interiors to compete in the U.S. marketplace with Spectrum Aeromed and Aerolite. His mantra is simple: the aircraft must be functional above all else. “Form, fit and function. It is the engineer’s responsibility to understand what is the function of the interior,” he said.

Graham contends that when issues arise in the development of an interior, it’s often because a company is focusing on engineering the perfect solution, a solution that was achievable from an engineering perspective but did not necessarily meet the operational goals of the programs and their medical missions. Committees with varying perspectives on the design are important, he maintains, but there needs to be someone in charge, a traffic cop.

Dr. Powell concurs. “First and foremost, especially from the patient care aspect, you think about the mission,” he said. “Is it short or long range? Rescue and medical? Are you responding to trauma or inter hospital? Once you sort out the mission, only then can you proceed with the design build or interior purchase.”

Dr. Powell adds that it’s not always particularly easy to determine how the program will evolve. Even for experienced medical providers, the choices in medical design aren’t ever easy and wrong decisions can have devastating effects on the program’s mission.

Graham sums it up with one word: focus – focus on patient care, safety and providing the best product to save lives. “It is very rare for us to make a mistake that involves patient care,” he said. “We might miss the boat from a profit perspective, but the product will take care of the patient.”

Medical transport is indeed a delicate balance, one which Dr. Powell maintains must always stay focused on the patient first. “Medicine is a complex issue. We all seize the opportunity to be innovative especially when there is an opportunity to be creative,” he said. “Sometimes, from what I have seen, custom solutions come about because there is choice in the marketplace and the aircraft are customized simply because they can be.”

Looking ahead to the future, the next generation of avionics will offer challenges with programs that want real time data or video transmission to their home hospitals. Operators and engineers will be tasked with keeping the weight of these devices, and ultimately the entire EMS completion, as low as possible while addressing the next generation engineering concerns.

Whatever the solution, for operators to continue to succeed, they will need to be slaves to form, fit and function. It’s all about safety and creating that safe haven in a time of need – patients deserve as much.


Ornge introduces new AW139 interior
Ornge has redesigned the interior of its AW139 aircraft to offer patients improved safety – and work to stem the controversy created last year over its alleged inadequate design.

The new interiors will allow Ornge paramedics to perform CPR at any time during flight in a safe, secure environment.

Designed by Swiss-based Aerolite, the improvements are in response to paramedics’ concerns about their ability to perform certain medical procedures effectively in the AW139 interior.

“We transport the most critically-injured or ill patients, which means our paramedics must have an effective working environment,” said Ornge president and CEO Dr. Andrew McCallum. “The new interim interior solution will make it much easier for our paramedics to provide the care that patients need as we continue to improve patient safety.”

Transport Canada granted a temporary exemption Feb. 2 to use the existing interior with modifications for one year.

This addressed the most significant clinical concerns, since it allowed for life-saving CPR to be performed during all phases of flight if necessary for the patient.
 

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