Health and fitness of technical crew members

Fit to operate?

Dr Philip Lucas shares his personal thoughts on the health and fitness to fly of Technical Crew Members, based on his experience of working alongside Wiltshire Air Ambulance (WAA)

If you are a paramedic in the front seat of an air ambulance, are you fit and healthy enough to safely fulfil this role? What are the consequences of a sudden incapacitation while in the front seat at a critical stage of flight?

Risky business

HEMS operations are by their nature, hazardous from an aviation point of view. The flights are unscheduled, often carried out in restricted airspace with frequent landings in unprepared areas with the pressure of knowing that you are potentially delivering life-saving care to the scene. To add to the hazards, the recent development of night flights present the additional challenges of disorientation, low-light and easily concealed obstructions.

Such a flying regimen demands a high degree of flying skills and airmanship. A lot of air ambulances employ aircrew with experience in military flying operations, which have similar demands. However, these military operations are mainly conducted on platforms that have two pilots in the front seat. A lot of air ambulance operations have a pilot/paramedic combination as an alternative.

While paramedics are trained to a good standard of airmanship through their crew training courses, the health dimension also requires consideration

Air ambulances currently operate with either two pilots (mostly this is only during darkness) or a single pilot, teamed with a paramedic in the front seat operating as a technical crew member (TCM). The latter combination applies to the majority of UK air ambulances1. As defined by the European Aviation Safety Agency (EASA)2, the role of the paramedic is to assist the pilot ‘during HEMS operations which may require the operation of specialised on-board equipment’3. The TCM is providing a regulated, flight safety-critical role and therefore their actions should not be mitigated by their general health.

While paramedics are trained to a good standard of airmanship through their crew training courses, the health dimension also requires consideration. Helimed operations are inherently demanding and call on a high standard of medical fitness.

helicopter pilot medical conditions winch rescue

Current state

The current standard of health monitoring practice at air ambulance units is for crew members to verbally declare themselves ‘fit’ at the daily brief. While this is always needed to cover acute illness, self-declared fitness is not against an agreed standard and also puts the onus on individuals where there may be self-induced pressure to ensure that they are able to fly that day. It could be argued that if this is the only form of health monitoring for TCMs within a unit, then this would be insufficient to ensure an individual is fit to fly.

The UK Civil Aviation Authority (CAA) demands that airline cabin crew, who occupy no front-seat role, but nonetheless perform safety-related tasks, undergo medical assessments4. However, there are no

such CAA-led standards for HEMS crewmembers. Each air ambulance operator has to interpret itself what the medical standards should be for their HEMS crew. Wiltshire Air Ambulance has taken steps to meet this challenge and this may be a benchmark to consider as good practice.

The regulatory framework

EASA has published the requirements for operators with TCMs in HEMS and NVIS (night vision imaging system) operations. Regulation ORO.TC.105 sets down the conditions for assignment to duties where TCMs can only start duties if they ‘are physically and mentally fit to safely discharge assigned duties and responsibilities’. The guidance material for this EASA order is adopted by the British Helicopter Association (BHA) in its HEMS Guidelines, Number 11 as follows:

The technical crewmember in HEMS, HHO or NVIS operations should undergo an initial medical examination or assessment and, if applicable, a re-assessment before undertaking duties

Any medical assessment or reassessment should be carried out according to best aeromedical practice by a medical practitioner who has sufficiently detailed knowledge of the applicant’s medical history

The operator should maintain a record of medical fitness for each technical crew member.

Technical crew members should:

Be in good health
Be free from any physical or mental illness that might lead to incapacitation or inability to perform crew duties
Have normal cardiorespiratory function
Have normal central nervous system
Have adequate visual acuity 6/9 with or without glasses
Have adequate hearing, and
Have normal function of ear, nose and throat.

In Wiltshire

Within this framework, WAA has developed its own health monitoring for TCMs, and has set medical standards which are described below.

First, a medical passenger5 such as a doctor or non-TCM paramedic who works solely with the patient and not in the front seat, signs their own declaration of fitness every 90 days. These medical passengers are, as such, not crucial to flight safety and therefore not subject to health monitoring. Pilots are required to undertake annual medical assessments in accordance with their licensing requirements, and they are also not monitored. TCMs who operate in the front seat, next to the

pilot, are subject to the medical assessment. When paramedics join WAA as TCMs, they complete a detailed health form, adapted from the CAA

Light Aircraft Pilot Licence (LAPL) medical standard. GP clinical summaries are obtained. The flight medical doctor then undertakes an evaluation that includes a look at their medical history, basic

observations, ECG, eyesight, hearing and a clinical examination.

For medical standards, the BHA guidance is that an individual is assessed to the equivalent standard of a DVLA Group 2/Light-Aircraft Pilot’s License/Class 2 Private Pilot Medical. WAA sets the standard

as appropriate to the work the paramedic is carrying out in the aviation environment. For example, as all front seat paramedics employ NVIS, eyesight requirements are much more stringent, approaching military standards.

Once working on the unit, TCMs are encouraged to declare any problems to the flight medical doctor. Any condition is assessed in the context of their flying role. Confidentiality is paramount, of course, so any condition that affects flying is passed onto the management purely in the context of restrictions in practice. For example, ‘Unfit front seat one month, but fit to work as a medical passenger, medical assessment required before return to full duties’, or ‘Unfit flying two weeks, fit for base work’.

Health is monitored on a yearly basis, through either a self-declaration or further examination, depending on age or risk factors. A health certificate is then renewed for a further 12 months. If a paramedic has a clinical problem that can affect work, a letter can be written to a consultant or GP explaining the paramedic’s occupational role and how it is affected. This helps provide guidance for the clinician on how to test for, or manage, a condition. The flight medical doctor is also available

as a ‘reach-back’ to deal with any medical problems a paramedic may present with.

The way ahead

I would suggest that air ambulance units consider the following measures to ensure the occupational health of those paramedics who are working as front seat crew in a helicopter, in order to ensure aviation safety and meet the EASA TCM Medical Standards requirement:

Appointment of a Flight Medical Doctor

A flight medical doctor should be a primary care physician. They would ideally work in pre-Hospital Emergency Medicine (PHEM) themselves, to help understand the working environment.

They also need experience and/or a qualification in aviation medicine or occupational health. They should not be involved in base management or clinical governance as this would mean a conflict of interest in maintaining confidentiality and independence. Such a doctor can also look at occupational health patterns to identify where the working environment can be improved.

Provision of periodic medical assessments

The chance to talk in an informal, one-to-one environment about any work or health concerns is important for the wellbeing of the HEMS crew members. It is important to ensure that eyesight and hearing standards are also maintained, and crews have appropriate equipment for their protection, such as adequate hearing protection.

Ensuring speedy referrals

If a paramedic is off sick, it is important that secondary care services understand how to manage a condition in the context of the individual working in the aviation environment. A letter to their GP can provide information to add to this dimension. The Doctor can ensure any referrals are rapidly made to ambulance service occupational services such as physiotherapy or mental health with minimal delays.

With thanks to Richard Miller, Georgio Bendoni and Jill Crooks from Wiltshire Air Ambulance for their assistance in preparing this article.

Case Studies

Below are a couple of case studies which are theoretical, but illustrate the thinking behind aircraft medical standards and how guidance from other organisations can assist in balanced decision making and understanding of risk.

Case One

History: On yearly monitoring, a middle-aged paramedic with a family history of cardiovascular disease is found to have an incidental high blood pressure reading. The Flight Medical Doctor gave him an automatic cuff and sent him away to complete a week of home BP monitoring in accordance with National Institute of Clinical Excellence guidance. When these figures were returned, it was found that the readings were consistently high. A clinical examination revealed no cardiac abnormalities or retinal changes.

Guidance: There is CAA guidance for pilots with hypertension that dictates which anti-hypertensives are acceptable and which are not. A pilot can continue flying on these medications once shown to be stable with no side effects. Furthermore, cabin crew are also temporarily grounded until they are stable on antihypertensive medication. It could be considered reasonable that a paramedic in this case follows this guidance.

Decision: The paramedic is sent to his GP with a covering letter explaining the occupational background and which medications are acceptable. While he is stabilising on the medications at work, he is declared unfit to fly until it was determined there were no side effects. However, he is fit to carry out all other medical duties on base and on the response car, with a discussion about side effects he may experience. In future, at his annual medical, the medication is reviewed and a 12-lead ECG is taken.

Case Two

History: A paramedic has sustained a cycling injury resulting in an isolated fractured clavicle, for which conservative treatment was indicated. He is initially provided with Ibuprofen and co-codamol for analgesia and is fitted with a sling.

Decision: This injury will be incompatible with flying for the duration of time that the clavicle is healing. However, you would be looking to assess the paramedic once he has been discharged from the fracture clinic. Before returning to flying duties, you would complete a cockpit assessment. This would cover fitting and removing the helmet, strapping in, reaching everything in the cockpit and most importantly, effecting a rapid evacuation of the aircraft and moving quickly to safety. Given the need to carry heavy medical bags, often on the shoulder, an assessment of carrying representative loads would be also carried out. While there are ways to compensate for the injury while it is healing, care has to be taken that other compensatory muscle groups not being overstrained. The flight medical doctor can also ensure that a timely referral can be made to any available physiotherapy service. Codeine would not be compatible with flying duties, but simple analgesia is fine, as long as it is well tolerated. It is important that the TCMs do not self-medicate, in line with other aircrew.