Emergency Medical Services at Airports in India : Dr. P.K.Verma

A large number of people travel by air globally on international as well as domestic airlines. In India, there has been a phenomenal increase in air travel and it has been predicted that this number will increase manifolds in the coming years. A large chunk of this population of air travelers consists of older persons and those with sickness. Under the physiological stress of flight, even a healthy person is vulnerable to sickness. The stress of flight includes the Pre-flight stress of reaching on time and catching the flight, long queues, carrying the baggage, walking long distances, missing the initial or connecting flight etc. The In-flight stress may be caused by the artificial environment created due to cabin pressurization, turbulence, cramped and uncomfortable seating for a long duration.

To cater to various needs of air travelers, huge infrastructure is required. As per available data (Airport Authority of India), there are more than 125 functional airports in India, including 18 International Airports, 07 Customs Airports, 78 Domestic Airports and 28 Civil Enclaves at Military Airfields

The Airports not only include various building complexes but also a large number of government and private agencies, business establishments and employees such as vendors, administrative and technical staff, ground staff and security staff etc. Visitors in significant numbers are invariably present at the airport to receive or send-off their near and dear ones. In a large International Airport, the airport community comprises of more than 30,000 to 40,000 employees of various categories and at any given time more than 10 to 15,000 employees are always present at the Airport building complex and surrounding areas.

Airport building complex is a hub of various activities. Apart from civil, electrical and mechanical activities happening at any time of the day or night, there is constant human activity. Huge quantities of fuel and other hazardous material are almost always present at the airport. It is a place where accidents can happen and people may fall sick¹, ².

With so much of population present, it is natural to encounter sickness, accidents or death at the airport. The IATA Medical Manual, April 2016³ recommends that the airport operator has direct responsibility to ensure that emergency services are provided at the airport. Airports Council International in its “Policies and Recommended Practices Handbook 2009, SEVENTH edition|Emergency medical services at airports recommends that emergency medical services should be provided for passengers and other persons and arrangements should be made for supportive medical facilities, locally and regionally.

1. BASIC PRINCIPLES OF EMERGENCY MEDICAL SERVICES

The basic aim of emergency medical service has been universally described as:

• to Preserve Life,


• to Prevent Further Injury, and


• to Promote Recovery.

There are six stages of pre-hospital care which are indicated by the six arms of the ‘Star of Life”, a symbol devised by the American Medical Association⁵.

• Early detection– members of the public, or another agency, find the incident and understand the problem


• Early reporting– the first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted


• Early response– the first professional (EMS) rescuers are dispatched and arrive on the scene as quickly as possible, enabling care to begin


• On-scene/ field care– the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.


• Care in transit-– the emergency medical service load the patient into suitable transport and continue to provide appropriate medical care throughout the journey


• Transfer to definitive care– the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, into the care of physicians

1. SCOPE OF EMERGENCY MEDICAL SERVICES AT THE AIRPORT

International Civil Aviation Organization (ICAO), created in 1944 under the auspices of United Nations sets standards for safe, secure and efficient civil aviation which are binding to all 191 member nations throughout the world, CivilAviation Regulation Part XI, DGCA, Government of India On Aerodrome Emergency Services, Facilities and Equipment⁶. The ICAO Airport Services Manual, Doc 9137-AN /898, Part 7-Airport Emergency Planning, Appendix 3/Airport Medical Services, page 59-60,¹and ICAO Annex 14, Aerodrome Standards, Aerodrome Design And Operations-Chapter 9, Emergency And Other Services⁷recommends the provision of Airport Medical Care Facility.

Medical Facility Disaster Management First Responder-Initial response by the

At the airport at the airport medical team present at the airport

Isolation of Crew Collection of their

24X7 Emergency Medical Services sample of blood, Urine& gastric contents

Attending the emergency call immediately Coordination of clinical activities at the

disaster site & documentation-Triage,

Initial stabilization/first aid to patient treatment &Transportation of Casualties

Shifting the patient to nearby hospital Handling of Dead

Internal Shifting of stretcher cases

Coordination with Police and other

Concerned agencies

VIP Movement-Escort Duty

Preparedness for Disaster & Maintenance

Participation in various drills & exercises of Disaster Management Stores

The Emergency Medical Services at the airport should be able to provide primary treatment for basic ailments and accidents before the patient is shifted to a nearby hospital for definitive treatment in case required. However, it should be able to deal with any type of medical emergency and should be equipped like an ICU with staff trained to deal with any medical emergency. Further, this facility is integrated with Airport Emergency Plan. The staff of the airport emergency Medical Services is the first responder and forms the nucleus of medical service planning to deal with any airport emergency.

1. PECULIARITIES OF PROVISION OF MEDICAL FACILITIES AT THE AIRPORT

• Entry Permit- No person can work at the airport without valid Airport Entry Permit (AEP), issued by the Bureau of Civil Aviation Security. All doctors, nurses, ambulance drivers and other staff members must have the Airport Entry Permit to work inside the airport. In addition, the ambulance drivers must have Airport Driving Permits (ADP) to drive the ambulances inside the airport. Every ambulance must have Airport Vehicle Permit (AVP) to function inside the airport.


• Familiarity with Terminal Building & Topography of Airport - No person can work inside the airport efficiently unless he/she is familiar with the layout of the terminal building, location of various buildings in the airport complex and grid map of the airside.

1. Majority of the times the treatment is provided at the call site, i.e. where the patient is located inside the airport. This may be anywhere in the airport building complex, beyond security hold area or even inside the aircraft. The team of doctor & nurse with the emergency medical kit and other necessary medical equipment has to reach the patient within a stipulated time period⁸.


2. If the patient requires stabilization, he/she is brought to the Medical Centre at the terminal building and after initial treatment/stabilization shifted to the nearest/appropriate hospital for further management.

• Detection and Reporting of Patient-TheAirline Staff/Airport staff informs the terminal operations about the patient and requirement of emergency medical staff. The terminal operations, in turn, inform the emergency medical centre about the medical emergency and location of patient. In case of medical emergency inside the aircraft, the aircrew first informs the ATC. The ATC informs the AOCC (Airside Operation Command & Control) which informs the terminal operation/emergency medical centre about the medical emergency and location of patient.


• Sometimes patients immigration has to be cleared and his/her luggage has to be retrieved if already loaded,by the airport operator or the concerned airlines before shifting him/her to hospital.


• Information to next of kin-If the patient is alone and/or unconscious, effort must be made by the airport operator or the concerned airlines to contact his/her relation/friend before shifting him/her to the hospital. In case of foreign national, the concerned embassy should be approached.


• If the patient is alone and unconscious, the airport operator or the concerned airlines is required to send a staff to accompany the patient to the hospital.


• Multi-agency Involvement-The airport is a secure area and movements are restricted. Even those persons with AEP (Airport Entry Permit), including the medical team, have to undergo security check while entering the SHA (Security Hold Area) and their equipment has to undergo X-Ray scanning. After reaching the call site, the medical team will require identification & isolation of patient and wheel chair/stretcher trolley to shift the patient to the medical centre/ambulance. All these activities require involvement and coordination of security, airlines, airport and emergency medical staff.


• Who is responsible for patient-Once the passenger has entered the airport premises, he/she is the responsibility of the airport operator. However, once the passenger has checked-in and before he/she checks-out, he/she is the responsibility of the concerned airlines. Thus, it is confusing as to which agency has overall responsibility of patient to support the emergency medical team.

The Medical team can only provide medical services. However, for such mandatory requirements as provision of wheel chair/stretcher trolley, shifting the patient, coordination with security & immigration, retrieval of luggage of passenger if already loaded, contact with relations/embassy (foreign passenger), accompanying the patient to hospital in case of lone patient etc., the medical team depends on the Airport Operator and or concerned Airlines for such support.

The airport operator is responsible to provide 24x7 appropriate Emergency Medical Services/first aid to the airport users-passengers and should support the medical team as and when required and coordinate with various agencies involved.

• Limited Resources. The medical facility at the airport is a stand-alone facility with limited staff. Invariably the present day airports are huge and very busy. There are instances of medical teams receiving multiple calls simultaneously. Under such circumstances, the available staff has to be used judiciously.


• Medico legal formalities. All injuries and deaths at the airport should be treated as medico-legal and promptly reported to the Local Police.The Medicolegal formalities should be done to avoid any legal complication later on.


• Ambulance Shifting of Stretcher Cases – Internal Shifting. Inside the airport, only those ambulances can operate which have a valid permit (AVP-Airport Vehicle Permit) driven by the driver who has ADP (Airport Driving Permit). When a patient arrives from any hospital in its ambulance to board an aircraft, the patient is shifted to airport ambulance to reach up to the aircraft. Similarly, when a patient arrives in an aircraft for treatment at any hospital in the city, he is put in the airport ambulance to be taken out of airport where he can be shifted in concerned hospital's ambulance. Only airport ambulances can do internal shifting unless the patient is so serious that double shifting should be avoided and outside ambulance is allowed after required formalities.

Dr.P.K.Verma is MBA, M.D. in Aviation Medicine with vast experience in the field of Aviation Medicine.He has worked as Consultant - Aviation Medicine and Administration, Medanta - The Medicity & Chief Administrator-Airport project, Indraprastha Apollo Hospital, New Delhi.