Cornwall Air Ambulance, the UK’s oldest dedicated helicopter emergency medical service (HEMS) provider, celebrated 35 years of operation in April 2022. The charity, which launched in 1987 as the ‘First Air Ambulance Service Trust’, initially operated on a shoestring budget with a small team of volunteer staff and an MMB Bo105 helicopter equipped with only minimal onboard equipment.
“Now, 35 years on,” explained Andrew ‘Alf’ Evans, CAA’s Head of Operations, “the crew are tasked to around 1,000 missions every year, with more than 31,000 under their belt since the service was first launched.” This includes 1,092 missions in 2021.
To support the immense demand for CAA’s services, the charity now flies 19 hours per day, all year round, and stations a dedicated full-time crew at its airbase – with CAA’s lifesaving missions and day-to-day operations, which cost around £5 million a year, being entirely funded through charitable donations.
“CAA is very well supported by the people of, and visitors to, Cornwall,” said Evans. “Around a third of funds come from gifts in wills; just under a quarter come from the CAA lottery, and donations and events are another significant source of income.”
In addition, CAA has received one-off grants in the past – however, funds are typically ‘ring-fenced for capital projects’ says Evans. Most recently, the charity was awarded funding from the UK Government’s Department for Health and Social Care for a planned expansion of its airbase, which is due to begin construction later this year. In addition, its paramedic team receives partial funding through the National Health Service (NHS).
An ‘emergency department in the sky’
Evans added that since its foundation, the charity has evolved ‘from an ambulance of the sky to a service closer to an emergency department for the sky’, equipped with sophisticated equipment and staffed by qualified Critical Care Paramedics – ‘the most highly qualified in the county’, said Evans. He explained that this gives CAA the ability to provide treatment and medical interventions that would otherwise only be received by patients once they had reached the hospital.
Despite the organization’s now comparatively venerable age, Evans says that the charity has no intention of slowing down but is instead ‘busy planning for the future.’
“Part of this has included welcoming two brand new Rapid Response Vehicles to the roster, with plans in motion to extend the current airbase,” he explained. Building work is reportedly now underway on the base expansion.
Another key development was the charity’s recent acquisition of a new AW169 helicopter, which entered into active service in April 2020 – just in time for the pandemic.
The aircraft, which was purchased following the success of CAA’s £2.5-million, two-year New Heli Appeal fundraising campaign, replaced a pair of leased MD 902 helicopters, and marks the first time that the charity has owned its own aircraft – a transition Evans described as a ‘big step for the charity’.
“It was a significant capital outlay, however it allows us to have much greater control over the aircraft,” he explained. “The crew ensured it was tailored to meet operational needs in Cornwall, and it has been kitted out to their exact requirements."
“The charity chose the AW169 as it is a very modern HEMS aircraft,” Evans continued, highlighting that the aircraft offers improvements to speed and range – enabling crews to carry out back-to-back missions across the county – and carry capacity – which has allowed crews to carry more medical equipment, including onboard blood transfusion equipment, introduced by CAA in early 2021.
“The bigger medical cabin allows for 360-degree access to a patient, which means two paramedics can work on a critically ill person at the same time. From a pilot’s perspective, it has great avionics such as a traffic collision avoidance system (TCAS), and is good for night flying with night vision imaging system (NVIS) goggles,” he added.
However, while the acquisition of the AW169 has given CAA a greater level of flexibility in how it operates, it also meant that the organization now has overall responsibility for the aircraft’s upkeep – a role that CAA contracted to Liskeard-based helicopter charter, management, and sales service provider Castle Air in November 2021.
In addition, to ensure that its crew were fully trained to operate the new aircraft, CAA also worked with manufacturer Leonardo, which provided simulation training to air ambulance pilots.
Managing Covid and other health challenges
With the onset of the coronavirus pandemic, CAA crew members were faced with the unusual task of training on a completely new aircraft while simultaneously introducing a raft of new standard operating procedures for treating patients.
“The helicopter was modified to have a double lined curtain between the cockpit and the medical cabin, and the ventilation systems were taped up to protect the pilot from contamination,” said Evans. “The medical crew [also] had to wear the highest level of personal protective equipment (PPE) to attend high-risk incidents, such as cardiac arrests.”
“Every patient was treated as a possible Covid risk,” Evans continued, “which meant the cabin inside the aircraft had to be sterilized, along with the kit, before the crew could attend another call. The charity received ultraviolet filter boxes to sterilize helmets and other equipment.”
The charity has evolved ‘from an ambulance of the sky to a service closer to an emergency department for the sky’
Standard PPE for CAA crews included Tyvek suits, a Level 3 face mask, a respirator, and double gloves. In addition, the team faced increased staff pressures ‘whenever someone in the team had to self isolate or had contracted the virus’.
Beyond responding to Covid-related cases, ‘some of the most common callouts for the crew are cardiac-related incidents’ – a side effect of Cornwall’s ‘significant elderly population’, Evans said. To tackle such incidents, CAA helicopters carry a Lund University Cardiopulmonary Assist System, or LUCAS device onboard its aircraft, which can be used for CPR interventions on cardiac arrest patients.
CAA crews also began carrying blood products onboard from the end of 2020, supported through a partnership with the Royal Cornwall Hospital Trust and Cornwall Blood Bikes. ‘In the first year, they administered 12 blood tranfusions at the scene of an incident’, said Evans.
A holiday hotspot – and a challenge landscape for HEMS operations
Operating air ambulance services in Cornwall poses an array of challenges – not least of which is the weather, brought on by the county’s maritime climate.
“The weather systems in Cornwall are unique, we can have all the four seasons in one day!” Evans says. “It is important that the pilots always keep track of weather, as the conditions can vary substantially from one part of the county to another.”
Conditions and wind directions can change rapidly, and Evans says that pilots need to have back-up plans in place to deal with this, including having backup hospitals to land at in the event of ‘short notice’ weather changes.
In addition, Cornwall’s extensive coastline – it is the only UK county bordered by sea on three sides – and CAA’s provision of services in the Isles of Scilly – an archipelago 45km off the Cornish coast – also poses significant challenges.
“Pilots must have a good knowledge of tide times and conditions at the start of each shift,” said Evans, adding that: “In readiness to fly over water, the helicopter has been fitted with in-built flotation rafts and the crew wear lifejackets on board. Along with this, the aircrew undergo Helicopter Underwater Escape Training (HUET) as part of their training to fly on board the aircraft.”
The helicopters have also been coated with ‘enhanced corrosion protection’ to safeguard them against the effects of saltwater spray.
When landing on a beach – a likely occurrence during the summer holiday season – CAA pilots will generally keep the rotors running, ‘to avoid breaking down below the high tide line’. In addition, ‘sand can play havoc with the engine’ – consequently the pilot will always aim to land between the high and low water mark where the sand is damp and ‘less likely to fly up into the engine’.
“When this happens,” Evans continued, “one paramedic acting as the technical crew member must stay with the pilot to ensure the public maintain a safe distance from the aircraft. Landing on beaches with lots of holidaymakers, tents and windbreaks can be provide a challenge when getting the aircraft close to a patient.”
Cornwall’s landscape also presents other challenges – its coastlines are defined by high cliffs and isolated coves, while its interior is dotted with remote rural settlements connected by narrow roads, with few medical facilities nearby. There is no motorway in the county, and the primary ‘A road’ network is prone to severe congestion, particularly during holiday periods.
Another key development was the charity’s recent acquisition of a new AW169 helicopter, which entered into active service in April 2020 – just in time for the pandemic
“Lots of people live a significant distance away from their nearest hospital,” explained Evans. “Furthermore, there is no major trauma centre in Cornwall – the nearest is Derriford Hospital in Plymouth, Devon.”
Beyond just causing congestion on roads, the regular influxes of holidaymakers also cause significant pressure on emergency services in the region – often meaning that crews will fly ‘back-to-back’ missions.
The population of Cornwall swells by as much as half a million over the summer period,” said Evans. “The team are tasked to a higher number of incidents in the peak summer months. Throughout the year they attend an average of three missions a day, but over the holiday season that figure is doubled. We also see an increase in coastal incidents as you would expect with more people enjoying the beach and sea in summer months.”
Working with the National Health Service (NHS) and other organizations
CAA operates in collaboration with the NHS’s South Western Ambulance Service Foundation Trust (SWASFT) – which coordinates emergency calls and responses from a central control room.
According to Evans: “Cornwall Air Ambulance is tasked to the most seriously sick and injured patients in the county. The HEMS desk call handlers at SWASFT coordinate all the assets in the South West. They will triage patients and deploy the most appropriate resource to them.”
He explained that depending on the nature of the incident, this could mean dispatching either a CAA aircraft, or a Coastguard helicopter, ‘as they have very different capabilities’.
SWASFT is currently in the process of transitioning its operations to the Emergency Services Network, a new system being implemented across England and Wales, which will allow all emergency services in the region to communicate on one network.
According to Evans, the intention is to ‘streamline the response to multi-agency incidents in future’. He added that Cornwall Air Ambulance will ‘follow [SWASFT’s] lead’ in transitioning to the new network.
In addition to SWASFT, Evans says that ‘the charity works closely with other air ambulance charities, particularly in the South West area. “This can be on deployment to major incidents, but also to discuss best practice and learnings across the sector,” he said. CAA also maintains a connection with Air Ambulances UK, an organization that works on behalf of air ambulance charities across the UK to advocate for support and funding for the sector.”
‘A vigorous recruitment process’
The NHS also serves as the primary source of CAA’s medical staff, who are also recruited through SWASFT – something Evans says ‘provides the whole medical team with close connections to the local hospitals, which support training days’.
Many of CAA’s medical recruits, Evans says, are ‘looking for career progression through the ambulance service’ – however, the process of being hired is challenging. “Roles within the air ambulance team are highly sought after, as vacancies do not come up often,” he said. “It is a vigorous recruitment process that involves two or three days of clinical scenarios, written exams, fitness tests, and formal interviews.”
CAA’s paramedics are trained to Masters’ degree level to become fully qualified Specialist Paramedics in Critical Care, said Evans. In addition: “Our doctors carry out in-house training such as the ability to administer blood transfusions and surgical skills. The medical team can [also] go into the hospital to work alongside physicians in the intensive care unit and emergency department to gain experience treating a wide range of patients,” he added.
Flight crew by contrast are typically recruited through a nationally advertised recruitment process – although Evans said that new roles ‘can attract international attention’.