Helicopter rescue in the Lombardy: the essential characteristics of helicopters used in HEMS operations

Rescue and Helicopter Rescue in the Lombardy region: Dr. Angelo Giupponi talks to Emergency Live and explains the reasons for choosing the H145 Airbus and W139 helicopters

The Lombardy region has always been an excellence in the world of rescue and helicopter rescue.

Dr. Angelo Giupponi, director of the S.C. Elisoccorso, tells us how the rescue system has changed over the years, and what characteristics make a helicopter, in Lombardy, a suitable means of helicopter rescue.

Dr Giupponi, AREU Lombardy has always been an excellence of Italian rescue. It must be said, however, that most of the time the citizen only sees the ambulances whizzing by. Would you like to tell us, given your vast experience, what are the strengths of the 118 system to which you belong?

“The main advantage of Lombardy’s regional system with AREU (Agenzia Regionale Emergenza Urgenza), which is in charge of coordinating the entire rescue service, comes from the fact that it is a single decision-making body and that therefore the decisions and organisations identified by the management apply throughout the region.

Whereas until before the creation of the AREU there were 12 operating centres and 12 provincial 118 services on the regional territory, each of which could have its own rules, with the birth of the AREU a system has been created, i.e. a single system that decides and issues directives and documents valid for all the vehicles and personnel working for this structure.

Since the birth of the AREU, we have also introduced identical training courses for everyone (from the volunteer to the nurse to the doctor, who in almost all cases is an anaesthetist-resuscitator), recurrent checks with indentified standards, and the same operating methods.

Here, too, we have reduced the number of operations centres from 12 to 4, which have now become operations rooms; 112 has been set up with three regional centres that sort citizens’ calls by directing them to the body that is identified as the terminal of the citizen’s request.

Another important thing has been the introduction of nursing vehicles: the region of Lombardy has introduced not ambulances but machines that are called MSA1 (advanced rescue vehicle in which 1 indicates the presence of a single professional figure, namely the nurse).

These are nurses who, before carrying out this activity, must attend a course and obtain a licence.

Once they have obtained this qualification, they have the power, on 14 pathologies, to independently implement the decision-making algorithms.

They have the possibility to take a first step after which, they must contact the operating rooms where a doctor is always present (as mentioned, usually resuscitating anaesthetists) who then give the indication and therapeutic prescriptions and the nurse on site can continue with the therapy as prescribed by the doctor.

These 14 algorithms enable the nurse to start certain manoeuvres immediately and to use certain life-saving drugs.

This was the big step that meant that, in addition to the basic and MSA2 medical vehicles with the resuscitating anaesthetist and the nurse (which was the set-up that the Lombardy Region had before), these new advanced vehicles with professional nurses qualified in the care algorithms were introduced.

In addition to this, the five regional helicopters were added to supplement the road rescue.

They, too, used to move according to the indications of the hospital at which their respective bases were based, whereas now they are based on a regional system, and therefore the operational indications and everything that was said before about the vehicles also applies to the five helicopters.

Two years after the outbreak of the pandemic, Lombardy was the protagonist of the first case and therefore the forerunner of procedures and protocols: what has that experience left you, and how has it changed the way of providing rescue?

‘In the first two months of the first wave I was the director of the 118 emergency services in Bergamo.

I have extremely bad memories of that period, thousands and thousands of people died among my people, many more than the official statistics tell us.

But I also saw things I never expected to see. I have seen volunteers arriving from all over Italy to lend a hand, making themselves completely available, spending whole days working 24 hours a day.

I have seen rescue people never back down, even in those times when having a constant supply of PPE (personal protective equipment) was a very difficult thing to do and you had to make do somehow.

I have seen doctors and nurses no longer counting their hours and staying in the hospital, at the station and on the vehicles for times that would be unthinkable in ‘peacetime’.

I saw incredible support from the entire population. I saw people behaving like members of a community: everyone supported each other and gave each other a hand wherever possible and as far as they were able.

In the Bergamo area, AREU was able to provide us with 93 ambulances on a daily basis, considering that at the time the province of Bergamo worked with 20/25 ambulances as standard.

Ambulance meant personnel, all people who came from outside the province to whom we had to give sleep and food.

Some restaurants, even though they were closed and without our asking, prepared meals and brought them as a gift to the Bergamo AAT, in the same way hotels made rooms available, free of charge, for the rescuers who were there to help.

For two months, helping others had become the norm, regardless of the job one did and therefore of what one could provide.

The covid left a wealth of experience and knowledge at all levels.

It raised awareness that, very often, we do what we do too lightly and, then, this lightness could not exist: it raised the level of attention to one’s own safety when carrying out rescue work.

The thing that I and the Presidents of the rescue associations in Bergamo are most proud of is that in those two months when everything happened, very few rescue workers became ill, despite the fact that they were people who entered homes when little or nothing was known about Covid.

This means that they began to understand the importance of PPE and the need to use it well to safeguard their own and others’ health.

Keeping a rescue system in place while preventing our volunteers from falling ill: this is one of the greatest satisfactions that I and the three presidents of the provincial associations feel we have brought home.”

Moving on, however, to talk about helicopter rescue more specifically. What, if you had to explain it to an ordinary citizen, are the main functions performed by the helicopter in AREU Lombardy?

“The helicopter is one of the means available on the regional chessboard.

It is an ambulance, a medical vehicle that flies. The ability to fly means greater speed of movement in urban or road environments and the ability to reach inaccessible areas that would otherwise not be reached by road vehicles.

Helicopters in the Lombardy Region have the task of carrying out the same rescue activities that other advanced means of transport have, and therefore of making both primary interventions and, if necessary, secondary interventions.

The main thrust, in our area, has been to make the helicopter a vehicle used primarily for primary rescue operations.

In fact, in Lombardy, primary interventions now account for over 90% of the activity carried out on average by a helicopter: this percentage is only reduced for the helicopter operating from the Caiolo (SO) base.

This is because the Province of Sondrio is very extensive (in the north, longitudinally from east to west borders) and has a hospital network that does not have all the high specialities.

For this reason, it is necessary for citizens suffering from certain pathologies to be taken by helicopter to some of the other provinces where the supply of hospital specialities is much higher.

The number of interventions has almost doubled in the last few years: while in 2016/2017 there were around 3200 interventions per year, today there are almost 6000.

This is because the helicopter is now used to supplement roadside rescue and is sent at the same time as these in situations where it is presumed that, due to the pathology at hand, the hospital best suited to treat that problem is not the one close to the event but is located a significant distance away: in this case, the patient can reach the hospital in less time.

Moreover, during the Covid period, when the hospital network in Lombardy was collapsing, we started taking Covid patients by helicopter to hospitals all over Italy.

This was possible thanks to Como’s helicopter, which, by virtue of its internal structure, allowed the flight crew to be physically separated from the medical compartment, thus safeguarding the pilots.

In addition, by concentrating the activity on just 1 of the 5 regional helicopters, we were able to focus operational capacity and knowledge of transport issues (self-protection, how to use PPE, clinical management of patients, etc.) on a smaller number of medical personnel, thus achieving greater performance.

Speaking of rescue, what are the technical characteristics that make a specific helicopter model suitable for helicopter rescue?

“Regione Lombardia uses two helicopter models, which are the H145 produced by Airbus and the AW139 produced by Leonardo.

They are machines that do their job very well and, more or less, have similar characteristics.

Or rather, both models possess those qualities that enable them to carry out helicopter rescue work well.

First of all, from a technical point of view, the ability to operate from the plains to the mountains is fundamental in our region, as the entire fleet is deployed in any regional area.

In addition, the vehicles must be fast, powerful, and capable of reaching any area in a timely manner.

They must have a sanitary van that can accommodate the patient, the personnel, and also all the equipment needed to provide assistance.

They must be reliable and above all have no technical problems that often render it inoperative.

The helicopter must be ready: when needed, the pilot must be on board and I, as a doctor, must be certain that we will take off within a short time.

The helicopters must also have good manoeuvrability because we work on the plains but also in built-up areas and in valleys that are often very narrow, so the helicopter must be able to operate in restricted areas.

And then the choice we have made is to choose a vehicle that, if necessary, has greater flight autonomy.

This is because in the case of transporting patients outside the region, we must be able to make even very long journeys without intermediate stops for refuelling.

So the larger machine, the AW139, has a greater operating range than the other and is therefore used on these occasions.

The other one, the Airbus H145, is smaller and a bit more ductile, it also has a high power-to-weight ratio, and so the choice of positioning the smaller machine, for example, in the Sondrio province, which is enclosed between the Alpine arc and the Pre-Alps arc, makes mountain rescue work easier, just as positioning the same machine in densely populated areas makes it necessary to find less space for landings, facilitating rescue action.”

Your regional neighbours in Trentino-Alto Adige recently bought a pentapala H145 and I noticed a positive evaluation of it: would you like to explain why this technical aspect makes the performance of the machine better?

“I don’t know it directly from having worked on it, but only from having flown with it: the correct evaluation of a machine, regardless of the technical characteristics stated by the manufacturers, I believe can only be expressed after having used it in the area in which it operates.

Certainly that machine can be a further step forward compared to the machine we know well, the H145 D2, used in the Lombardy region.

It is potentially a lighter machine and therefore increases the power-to-weight ratio, which makes it even more efficient in rescue operations at height.

From a mechanical-constructive point of view, they have changed the main rotor block from a rigid rotor to a rotor with joints made of non-metallic material.

This absorbs vibrations: a detail that is particularly relevant for patients who, for example, have bone fractures (in which pain is exacerbated by friction) and for medical personnel who have to use electromedical equipment on board (the absence of vibrations leads to a more reliable result).

Finally, the helicopter’s light weight allows for a greater fuel capacity, thus increasing the vehicle’s flight autonomy: being able to carry out several consecutive operations without the need to waste time refuelling is no mean feat.

These are, broadly speaking, the big advantages of the D3 over the D2.”

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