Mario Pierobon reports on air medical provision on the strategically located island nation
Malta is a small archipelago located in the heart of the Mediterranean Sea. It lies in a strategic position between Europe and Africa – and not far from the Middle East. The country became a member of the European Union in 2004 and has managed to attract significant foreign investment that has permitted stable and solid economic growth over the last decade.
Whilst the country has traditionally been an important seaport along Mediterranean routes, its aviation industry has flourished in recent years. The Maltese aircraft registry counts in excess of 200 aircraft registered in Malta, with some 40 air operator certificates (AOC) held by aircraft operators having their principal place of business in Malta. In addition, four major MROs (maintenance, repair and overhaul providers) have set up shop in Malta handling heavy maintenance on anything from business jets to wide-body commercial jets, including A380 spraying.
In the context of an expanding aviation industry, the air rescue business is also playing a role – albeit a niche one given the small size of the country. This is in addition to the Maltese military, which is heavily involved in search and rescue operations in Malta’s vast sea territory in the Mediterranean.
The country offers comprehensive health services to its residents. However, due to its size, certain specialities are not available locally and agreements are in place with the British Government to treat certain medical cases, which are relatively rare and therefore not as cost-efficient to treat directly in Malta. This agreement has historical origins, due to Malta having been part of the British Empire until 1964. The medical system of Malta is modelled on that of the UK and the majority of medical doctors practising in Malta undergo medical studies in the UK. For these reasons, Maltese residents can benefit from treatment in the UK; the majority of them are cancer patients who fly to the UK for treatment or babies born with complications.
The transfer of patients to UK hospitals is often assigned to Air Malta, which it effects on its own scheduled flights. The state-owned national airline works in conjunction with the national health service of Malta to provide air services to carry patients to the UK either as stretcher or incubator cases. “In 2016, Air Malta handled 21 stretcher cases and 15 incubator cases, an average of approximately one case every 10 days,” says Stephen Gauci, head of corporate communications at Air Malta.
Air Malta is a small regional carrier with eight Airbus A320 aircraft in operation and it has no dedicated aircraft for patient transfer. Patients are instead placed on scheduled commercial passenger flights. “The airline has developed a system to dock incubators onboard the aircraft and connect to purpose-built and certified equipment that is installed onboard prior to the flight requiring the removal of three rows of seats on Air Malta’s A320/A319 aircraft. The airline is one of a very few that offer this service and the incubator docking system holds a unique airworthiness approval. Stretchers are also carried onboard, but do not require the removal of seats, but instead the seat backs are collapsed. Air Malta ordered its aircraft new from the factory with stretchers in mind, and the aft toilet compartment collapses to allow the stretcher to turn comfortably in and out of the aft door,” says Stephen Gauci. “The way it works is that the medical facility contacts Air Malta the day before the patient needs to be transferred to the UK. In case the requirement is to transfer a neonatal patient, during the night technicians at Air Malta reconfigure the aircraft that it is known will fly to the UK – normally London Heathrow – by removing three rows of seats at the rear of the cabin so that the incubator can fit. Once the aircraft flies back to Malta, then it is brought back to the standard configuration.”
In addition, Air Malta regularly transports live human organs for transplant patients waiting either locally or somewhere in Europe. The carrier also transports daily doses of radioactive material used in PET (positron emission tomography) scanning equipment; Air Malta’s daily flights are instrumental to keeping all the local hospitals’ equipment functioning properly.
Over the centuries, since the times of the Phoenicians, different powers have wanted to occupy Malta for strategic trading and military reasons. Nowadays, Malta is an independent country and attracts investors from all over the world wanting to base their businesses in this strategic location, and this includes investors in the air ambulance business. One such investor that has started an air ambulance operation in Malta is ER24 of South Africa. ER24 is a wholly owned subsidiary of private healthcare group MediClinic. Rescue Wings Malta was recently setup by ER24 and flies for insurance companies and their designated patient assistance firms that have a client base in the Mediterranean region and in North Africa. “They rely on our services that are well known as we fly with the livery of ER24. Because we are part of ER24, the clients of Rescue Wings Malta can fly anywhere in the world with basically no restriction. The set-up of the Maltese operation is part of ER24’s strategy in expanding its network. Rescue Wings Malta has in its fleet a King Air B200GT, which has a little bit more speed and range than the normal King Air 200. It is ideal for Malta,” says Andrew Lee, international business executive at ER24, who is based in Malta.
“We are in the business of transporting patients, ranging from stable cases all the way up to patients on full life support, many of which need care that the places they are currently at cannot provide. Patients are usually stabilised before being transported by air ambulance, transport of unstable patients is also possible but less common; it is contemplated only if treatment in the receiving facility is lifesaving, unavailable locally and transportation is achievable within an appropriate time window. This justifies the use and increased risks involved when transporting unstable patients by air. Apart from the pilots, the air ambulance crew normally consists of one doctor and one nurse,” says Chris Gauci, chief medical officer at Rescue Wings Malta. “We also fly patients that may, for various reasons, want to spend the recovery or rehabilitation period associated with their hospitalisation event in another facility, for example someone who is operated for a fracture and wants to continue the medical care in his/her home country. We provide patient repatriation for these patients. Our main clients at the moment are mainly from countries in the North African Mediterranean basin and usually flown to hospital facilities in Europe. The services described are normally covered by insurance or governments, depending on the particular arrangements.”
Lee believes that Malta is a good place to operate an air ambulance. “Our experience is that we became very successful in a short period of time. In the supply of emergency air ambulance services for the international travel insurance industry, we have partnered with Aspen Medical, a global medical company that operates clinics in several parts of the world and has opened a clinic in nearby Libya,” he says.
Near the Libyan capital city of Tripoli, an ‘oil and gas town’ is being unveiled. Palm City is a compound for workers of oil and gas companies, it counts 16 to 20,000 residents and offers high-quality residential facilities. Palm City has its own runway and is where the Aspen Medical clinic is located. “In my experience, Libya is a very good market, but it is also very volatile: there are times when you can fly in and help, some other times it is just too dangerous,” says Lee. “In order to reach Palm City, we have to fly to Tripoli first, clear customs there and then fly to Palm City. We are the official partners of Aspen Medical for medical evacuations. We bring back to Malta patients that need treatment which cannot be provided locally in Palm City. Once patients are in Malta, they will be accommodated in one of the local medical facilities, either St James’ Hospital, which is private, or, if necessary, the Mater Dei State Hospital, which is one of the best state hospitals in Europe. Normally patients from Libya are attended in Malta, but we have the capability to go into Europe as well, because we have other aircraft in the ER24 group that can come in: a King Air 350 and a Hawker 900XP.”
While Rescue Wings Malta operates internationally from its Maltese base, Malta also hosts an air ambulance provider that operates domestically. The VGH Air Ambulance is tasked with the transportation of stabilised patients between the islands of Gozo and Malta. Vitals Global Healthcare (VGH) runs the Gozo General Hospital, located in Gozo, the second largest island of the Maltese archipelago, and provides a rotary-wing air ambulance service in partnership with helicopter operator Gulf Med Aviation Services. The VGH Air Ambulance currently utilises a Bell 412 SPIFR helicopter operated in the SPVFR role day and night.
“Although the distance between the two receiving hospitals is approximately 24 nm, the time taken to transport a patient by road is significant due to the small water sound between the two islands requiring a ferry crossing. Typically, a road transfer could take in excess of three hours, whereas instead the transfer by the air ambulance helicopter reduces this to an average of 25 minutes, door to door,” says Chris Keating, flight operations and crew training manager at Gulf Med Aviation Services. “The helicopter operates as an air ambulance and does not yet fulfil a primary response role such as in the case of HEMS. It is equipped and capable of supporting sedated and ventilated patients, trauma cases and neonatal infants.”
The island of Gozo is inhabited by an ageing population, and during the summer months the population can almost double with tourists. “This presents a wide range of patient types ranging from cardiac or respiratory failures in the ageing population to life threatening trauma associated with recreational injuries amongst the local and tourist population. Medical staff from the Gozo General Hospital are utilised to support the patient in flight. The staffs have received intensive air ambulance training and can be dispatched as required to meet the needs of the individual patients being transported,” says Keating.
As a small nation, Malta has a small internal air rescue market. The country, however, is business friendly, strategically located and offers opportunities for international expansion that investors in the air ambulance business are capitalising on.