Fixed-Wing Air Ambulances (Airplanes)
Fixed-wing aircraft travel at greater speed, cover a greater service area, and offer several other advantages over the ground ambulance and the helicopter. The patient cabin often is larger than the cabin in helicopters.
Many airplanes can transport 2 patients and allow room for 2 or more transport team members or additional family members, although the transport of 2 critically ill patients may result in space limitations. Each patient may require individual transport teams, monitors, and other medical equipment. Weight restriction, weather, noise, vibration, and turbulence are less of a factor with fixed-wing travel than with helicopter travel. Airplanes have the ability to fly above or around inclement weather conditions on long-distance transports. The cost per mile for long-distance, fixed-wing transport is often less than for helicopter transport. As a general rule, for transports more than approximately 150 miles, programs should consider the use of an airplane or jet rather than a helicopter.Certain makes and models of airplanes have the capability to provide a pressurized cabin, which helps combat the effects of altitude on the physiologic functions and provides for a safer and more comfortable transport environment. Smaller fixed-wing aircraft typically are not pressurized and are limited to flying at lower altitudes. Pressurized aircraft, flying at actual altitudes of 30 000 to 40 000 feet usually can simulate a cabin altitude of 7000 to 8000 feet (or even lower, although this feature is not often used because of effects on efficiency and cost). When transporting patients with significant respiratory compromise and for whom altitude-related hypoxia is a concern, it may be beneficial to fly at lower altitudes, allowing cabin pressure to approach that of sea level.
The greatest limitation to the use of fixed-wing aircraft is the necessity to land at an airport, which may be distant from the referral and/or receiving facilities.
The length of the runway needed depends on the type of aircraft used. Generally speaking, jets require longer runways than propeller airplanes. Also, with fixed-wing transports, patients require multiple transfers—from facility to ambulance and ambulance to airplane. Stresses of flight, discussed in Chapter 11, are of significant relevance when flying at altitudes above 8000 feet and are especially important with pressurized aircraft that may fly at an altitude of 30 000 to 40 000 feet. Although a pressurized cabin is extremely beneficial, a loss of cabin pressure at altitude can be very hazardous.Although most ground ambulances and medical helicopters are dedicated and properly designed for patient transport, the same is not always true with airplanes. There is a potential that fixed-wing “ambulance” providers (or any type of ambulance provider) promote their patient transport capabilities in what could be considered a less than ideal medical transport environment. The patient litter, oxygen tanks, and medical equipment may not be secured properly. The medical gas and electrical systems may be inadequate for long transports. Before using any fixed-wing provider, carefully inspect the airplane and the medical configuration to be certain that the emphasis is on safety and appropriate medical capabilities and that appropriate FAA certifications have been received. Professional airmedical organizations, such as the Association of Air Medical Services and the Commission on Accreditation of Medical Transport Systems, also can provide service information.
Similar to helicopters, fixed-wing aircraft also have interval maintenance schedules set forth by the aircraft manufacturer and the FAA. A properly maintained aircraft is a safe aircraft; therefore, the preservation, inspection, overhaul and repair of the aircraft, including replacement of parts, ensure that the aircraft remains airworthy throughout its operational life. Although maintenance requirements vary for different types of airplanes, some inspection is required at least once every 12 calendar months, whereas inspection is required for others after each 100 hours of operation.
This depends on the kind of operation, climatic conditions, storage facilities, age, and construction of the aircraft. An airplane can also be inspected on the basis of calendar time, time in service, number of system operations, or any combination of these. An FAA-certificated airframe and power mechanic holding an Inspection Authorization, an FAA-certificated repair station that is appropriately rated, or the aircraft manufacturer must render inspection and repair services.The cost of operating fixed-wing aircraft can be substantially higher than that of operating a ground ambulance but often less than a helicopter program. Fixed-wing vendors may use their aircraft for nonmedical transports. This business venture defrays some operational costs (see “Vehicle Operations”) of the plane. On the other hand, aircraft availability may be limited when the plane is on a business flight and an urgent fixed-wing transport is pending. The transition of the interior of a plane to a medically configured format may also delay transport; thus, delivery of urgent medical care is compromised.
The purchase price of new fixed-wing aircraft may be prohibitive for a particular transport team or hospital system budget. Used fixed-wing aircraft prices are more reasonable. These prices can range from $3 million for a Beechcraft King Air turboprop (Raytheon, Kansas) to $12 million for a Learjet (Bombardier Aerospace USA, Canada, Ireland). General estimates of annual aviation expenses include pilot and copilot salaries (approximately $60 000 each), hangar fees ($24 000), insurance ($28 000), training ($20 000), and computerized maintenance ($10 000). Total direct operation costs can vary depending on the number of hours of flight annually. For example, a Lear 36 jet with 200 annual hours of flight time will have direct operating costs at approximately $200 000; at 400 annual hours, approximately $400 000; and at 600 annual hours, approximately $600 000. However, because of these operational constraints, the airplane is not practical for transports of less than 150 miles, unless traveling to an island or similarly isolated area.