Setting up an Aeromedical Service in Maldives Background information

The Japanese based Insurance Company (JBI) has awarded us the contract to set up and operate an Air Ambulance service in the Maldive Islands in the Indian Ocean on their behalf. Before embarking on the various aspects of the setup, it would be ideal to have a brief overview of the service area.

Geographical location of Maldives on the global map

Satellite Image of Maldives (southern most island not in image)

Maldives1

is

Southern

Asia

country, formed by a group of atolls in the Indian O cean, south-southwest of India and west of Srilanka. There are approximately 1,190 coral islands grouped into 26 atolls (200 inhabited islands, plus 80 islands with tourist resorts); it is hence an archip elago with strategic location astride and along major sea lanes in Indian Ocean. The local languages are Dhivehi (official, dialect of Sinhala, script derived from Arabic) and English ( spoken by most government officials). Although the land area is only about 295 sq Kms, the islands are spread over an area of approximately 500 by 100 kms. Male is the capital city island, and is roughly central to all islands. The main airport is in Hulhule island, just east of Male. There is one other large airport at Gan, and several others around the island. Fishery and tourism are the main economy of the nation. The country legal system is based on the Islamic Religion with English common law inf luences, primarily in commercial matters.

Telephone mobile available atolls.

services networks across

and are the no

There

are

conflicts in the country.

There is a real risk of inundation of areas with sea water as the highest natural level above sea in Maldives is no more than 3 metres. There is also the risk of damage from Tsunamis in this region due to the low elevation of the islands. availability Fresh is a

water

concern.

Transportation is mainly
Map of Maldives

by boats and seaplanes, with some well

established seaplane operators in the island. The southern city of Thiruvanthanapuram in India and Colombo in Srilanka are about 800 kms from Male. The weather is tropical. The Male airport is served by many international airlines.

With this background information, the following issues will need to be looked into in order to set up the air ambulance services 2 for the JBI client

1. Funding 2. Regulations and Laws governing Air Ambulance Service in Maldives 3. Logistic considerations for setting up operations headquarters / office in Maldives: 4. Local logistical issues for patient transfers for the client in Maldives 5. Legal and Insurance Issues 6. Aircraft and other Transport Vehicle Issues 7. Equipment/ supplies / oxygen/ documentation papers 8. Organizational layout 9. Communication facilities

10. Policies and Protocols 11. Personnel 12. Interface Issues 13. Ethical and Cultural Considerations 14. Mission Acceptance 15. Safety of the Crew 16. Standards and Quality Monitoring 17. Marketing

The above issues are further elaborated below

1.

Funding The following are the subdivisions when looking into funding issues for the service Funding Model Finance Management - Fixed cost , running costs External / Third party financial agreements for outsourced services Reimbursement Issues Financial Risk Assessment

The operations of the Air Ambulance Service (AAS) for the JBI in the Maldives will be funded and financed by the JBI. Conventional air ambulance services are funded usually government or Charity/Not for profit organization in countries like Australia 3, but other models do exist in other countries 4. Here the insurance company has decided to contract its aeromedical service needs to our company that will cater to its needs. As the JBI has had to mount many aeromedical missions for tourists from the islands, they have awarded us the contract to set up and operate an Air Ambulance service in the Maldives Islands in the Indian Ocean on their behalf. The contract is for 18 months to establish the service.

At the beginning it would be important to detail the funding model that will be used for the services. The terms of the funding will need to be clear from the start. Since the JBI has dealt with other air ambulance companies / aeromedical services in the past, they would have data on the costs involved in the same, and have chosen to have their own unit that would be cost effective for them. It is important to be aware of other air ambulance services in the vicinity (and their pricing) that could be potential competitors to our service in future. All fixed, running and hidden costs will need to be calculated, and their financial responsibility will need to be clearly stated. The JBI has intended to lease a Eurocopter Squirrel based at Male International airport in the Maldives for tourist flights, and use it as required for patient transfers. There are no details available as to the land based or sea based transportation services for patients. A CASA-235 which operates flying cargo between Male and Colombo in Sri Lanka some 350 miles away, is also expected to be available although the call-

out delay will be 2-3 hours. Costing analysis for other areas of the service like administrative, personnel, equipment, and insurance will need to be done and funding approved.

Ideally, as the JBI have atleast 3 transfers a week, it would be appropriate to have a funding model wherein the fixed costs of setting up the unit and running costs are borne by them, and a fee for management of the same is paid to us. So in essence, a fee for set-up and management of the service will paid to our company, while the JBI bears the fixed and running costs of the unit. The benefit of this model will be gauged against using other services that are not dedicated to the company and the benefits of controlling the variables of the service.

In order to ensure smooth running on a 24/7 basis, there has to be a clear liaison between the finance management of the JBI and us, to ensure that funds are available as needed during the operations of the unit.

2.

Regulations and Laws governing Air Ambulance Service in Maldives:

Prior to starting an air ambulance service, it is important to know about the regulatory needs in the region of operations with regards to the following Aviation and Airport regulations - The regulations governing use and operation of aircrafts (helicopters, winged aircraft) for aeromedical purposes should be sought out and clarified with the local authorities. This will include regulations pertaining to the aeromedical equipment to be used on board. The aircraft companies from whom the aircraft are being leased as well as any other aircraft (e.g. international and local commercial airlines, local sea planes) will need to be contacted and their assistance solicited for the same. The Maldives Airport Company Ltd. 5 controls the airports in Maldives , and they should be contacted to assist with this issue when needed. Medical Regulations Each country has its own medical and nursing laws that govern the respective disciplines. In the case of employment of paramedics, each country has its regulations with regards to their scope of service. Since our air ambulance services will operate in Maldives and possibly in Sri Lanka, it would be necessary to be aware of medical regulations in these countries with regards to the medical workforce. Another important regulation is with the medical equipment, consumables and drugs. All policies and protocols must take this into account, especially with regards to travelling with narcotic medications.

Local Business regulations - It will be necessary to establish a business unit in Maldives in order to facilitate operations on the island. We will need to adhere to the local business regulations.. In collaboration with The JBI, this matter can be managed effectively. Most countries have legal personnel who can assist with the same. This will have financial implications that need to be discussed with the JBI and ideally stipulated in the contract.

Banking needs and regulations Appropriate banking accounts and regulations as per Maldives will need to be looked into to allow for regular running of the unit, as well as payment needs for other third party service providers.

Local Labour / employment regulations - As there will be staff employed on location, it will be necessary to know about the local labour / employment regulations. These would regulate office structure, work policies, employment contracts, remunerations, leave scheduling and planning, employment benefits etc. It will require recruitment of HR management personnel well versed with the local regulations. It also pertains to employment of expatriates on the service. It will be difficult to procure individuals with the specific experience and skill sets for the service from the local population, and recruitment of expatriates will need to be done within the labour law framework of Maldives.

3.

Logistic considerations for setting up operations headquarters / office in Maldives:

Location of the Head quarters(HQ) / office The base HQ/ office to run the operations will need to be on the main island of Male and a possible secondary office / storage space on Hulhule that houses the International Airport. Since the Hospital and other secondary services are easily available in Male, it might seem prudent to have the office located there to allow for better medical care of patients prior to their transfer to the airport. We would have the patients transferred from their respective locations in the island for stabilization at the main hospital in Male prior to organizing overseas evacuations. This will help ensure that there are no undue cancellations/delays of the aeromedical evacuation due to patient conditions or call out times for the aircraft. It will also allow for the service to have less equipment and allow for cases where in simultaneous calls need to be answered Regulations The office premises and infrastructure will have to comply with the local regulations regarding office structures. The physical base of operations should demonstrate an appropriate and safe work environment for all personnel with adequate lighting, ventilation, and storage of equipment for patient care 6. Communications The premises must have all the following communications link facilities Internet, Email, Land line telephone ,Fax and Mobile connections to allow effective communications. Paperwork and documents Aeromedical Services require precision documentation to be maintained. This will require sufficient forms available for such purposes. If pre-printed documentation forms are not made available, digital copies of the same (with facilities for ad-hoc printing at the office) will be needed.

4. Local logistical issues for patient transfers for the client in Maldives

In order to better understand the needs of the client (since the JBI has had multiple requests for aeromedical services in the past) it would be very useful to have this information in order to prioritise the expected needs of the patients based on Demography of patients Sex of patient, Age groups, Language preferences, Cultural and religious restrictions Type of medical conditions This will help decide the type of equipment, drugs and skills needed for doing medical evacuations out of Maldives. Areas to be transferred from Information on the locations of the patients in Maldives when the request for medical assistance was made will be useful to decide on making prior arrangements at common locations to facilitate the same. Accessibility from areas Maldives is relatively flat with tropical weather conditions. Since it is a large group of atolls distributed over a wide area, sea and air transport play a vital role in the daily life of the natives. There are few established seaplane companies in the region that do regular domestic transport between the atolls, as well as some aeromedical evacuation. The airport is 2 kms over water from the capital Male, hence can be accessed by both air and sea. As only one helicopter will be leased out by the JBI for the purpose of aeromedical service, it will be necessary to have links with the seaplane companies in Maldives (e.g. The Trans Maldivian Airways 7 and the Maldivian Air Taxi 8 ) as well as a boating company (for the Male to airport route) to ensure back up services, 24/7 access and cost effectiveness at all times.

Photo of Trans Maldivian Airways Plane

Photo of Maldivian Air Taxi Aircraft

Map showing distances from Male and Major resorts in the Northern sectors of Maldives

Above : Map showing distances from Male and Major resorts in the Southern sectors of Maldives Below: Male International Airport aerial photo

Medical facilities in Maldives There are multiple small clinics scattered over the islands of Maldives numbering nearly 232, and 2 larger hospitals in the main island of Male 9. Of the 2 large hospitals, The ADK hospital
10

is a private hospital while the Indira Gandhi Memorial hospital is a public hospital run by
11

the Male Health Services Corporation Ltd (MHSC)

( a government of Maldives undertaking). It is

important to know in detail the level of medical expertise in each of the hospitals and clinics as this will impact the decision making process for medical evacuations. It is also important to be kept up to date on any changes in the facilities, and establish links with the medical and administrative counterparts in these medical facilities. Ground ambulances can be out sourced from these medical service providers to complete the transport links for patients.

Above: Detail Map of Male island with location of ADK hospital Tertiary Medical facilities in Colombo JBI patients who cannot be treated for their medical conditions in Maldives will need aeromedical evacuations to centres in the vicinity that have the facility. The closest advanced medical centres to Maldives are in Colombo, Srilanka and in Thiruvanthanapuram (Kerala, India). Since the cargo plane available for such evacuations operates between Male and Colombo, the medical facilities of Colombo will have to be used. Links will need to be established with some of the private clinics in Colombo based on their expertise and approval from JBI. It is best to visit these locations to have a firsthand account of the facilities and logistics necessary to transport the patient from the airport to the selected clinic/ hospital. The medical, administrative and financial agreements with these medical centres will need to be formulated and agreed upon as part of the collaboration with the medical centres in Colombo. Travel document requirements to Colombo Based on the nationality of the patients (probably mostly Japanese), the travel documents required for aeromedical transfers of these patients to Colombo will have

to be secured prior to such evacuations. The Sri Lankan Embassy in Male, Maldives will need to be approached to help with necessary documentation needs as well as establish a link to ensure quick processing, and emergency processing during consular off-hours. Travel document needs for the medical staff providing the aeromedical transfers will also need to be ensured if they are to remain or disembark at Colombo. It will also be necessary to liaise with the Japanese Embassy in Srilanka to assist with the visa / travel documents for their nationals.

5.

Legal and Insurance Issues

Aircraft Insurance Since the aircrafts will be leased out or outsourced, the responsibility for their insurance will be with the third party providers of the aircrafts. A copy of the same or a letter from the service provider to that effect will be needed to maintain records with us. The insurance should cover their areas of work. Indemnity and Medical Personnel insurance Medical and Nursing Crew will need indemnity, death and disability insurance from work related accidents. The indemnity insurance cover must be valid over most countries including Japan, Maldives and Srilanka. Further insurance covers like Health Insurance may be needed based on prevailing labor laws or employment practices. If specialist individual medical / nursing personnel are to be used by us for on the service on a fee-for-service basis, they would need to take out their own indemnity cover and provide a copy of the same to the company. Company General Insurance The Company will need to take out separate insurance for indemnity, equipment and assets and any other insurance as stipulated by local business regulations. The company will be in a region that is at risk for Tsunamis, and will need to be covered for the same as well.

6.

Aircraft and other Transport Vehicle Issues Choice of Aircraft A Eurocopter Squirrel Helicopter based in Maldives that currently is used for tourists, will be leased by the JBI and used for air ambulance service as required. A CASA 235 cargo plane will be available from Colombo as per the JBI on an ad-hoc basis with a call out time of 2-3 hrs. Apart from these 2 air transport modes, there is also the prevalence of the de Havilland Twin Otter seaplane that is widely available from local Above: Eurocopter AS 350 Squirrel Helicopter photo tour operators in Maldives and could possibly be used in cases of emergencies or exigencies. Issues surrounding them will be -

Air worthiness of aircraft, availability In the urge to cut costs, many aircraft operators (and some aeromedical service providers) around the world have turned a blind eye to the safety measures
12

Although a relatively safe mode of travel, aircraft crashes have been on the rise due to increased traffic and financial stressors forcing some to cut corners. It is imperative for us to have regular CASA 235 Photo (interior picture below) assurances of air worthiness of the aircrafts from the service providers. Any incident related to safety should not be tolerated , and alternative service providers with proven safety track records will need to be identified in the event of safety failures by the currently contract aircraft providers. Pilot and aircrew credibility, availability It has to be ensured that the pilots and aircrew manning these aircraft are certified to do the same and have enough experience and credibility to manage aeromedical evacuations. Documentation of the same will be important. Although the prerogative of the aircraft provider, we should be able to have details on availability of the Pilots and air crew, especially for the helicopter. The decision to fly with only one pilot or a pilot and co-pilot will depend on local aviation regulations and experience levels of the pilots. Accessibility of the aircraft There are 2 international and 5 domestic airports at Maldives (Table A). The Helicopter service provider will have knowledge of the helipads available at the various locations in Maldives. The seaplanes would have access to most areas of the archipelago. For the purpose of simplicity, the airport at Hulhule could be exclusively used for the CASA 235 aeromedical evacuations. An Equipment base at Male and if possible a secondary base at HulHule would help with quickly making the aircraft ready for aeromedical evacuation.

Table A. List of Airports in Maldives 13

Island

Atoll

ICAO

IATA Airport name

Coordinates

International airports Gan Addu (Seenu) VRMG GAN Gan International Airport
004136S 0730920E0.69333S 73.15556E

Hulhul

North Mal (Kaafu)

VRMM MLE Ibrahim Nasir International 041130N 0733145E4.19167N Airport 73.52917E

Domestic airports Hanimaadhoo Haa Dhaalu VRMH HAQ Hanimaadhoo Airport

064439N 0731013E6.74417N 73.17028E 032815N 0725010E3.47083N 72.83611E 002917N 0725949E0.48806N 72.99694E 015133N 0733119E1.85917N 73.52194E 001833S 0732602E

Maamigili

Raa

VRMV VAM Maamigili Airport

Kaadedhdhoo Gaafu Dhaalu

VRMT KDM Kaadedhdhoo Airport

Kadhdhoo

Laamu

VRMK KDO Kadhdhoo Airport

Fuvahmulah

Gnaviyani

VRMR FVM Fuvahmulah Airport

Cost per sortie the cost for the mode of air transportation used will be have to be documented and audited in order to ensure cost effectiveness and quality control. Maintaining efficiency will be the key to a successful service provision and cost management. All flight details must be documented by the aircraft service provider and a copy provided to us. Aeromedical Service compatibility for aircraft Since the Helicopter is usually used for tourist purposes and will need to be available for aeromedical use when necessary, it needs to be quickly and effectively made compatible for use as an Air Ambulance Helicopter. It would hence have to be reconfigured so that it can quickly be fitted out to perform aeromedical evacuation. This will require compatible equipments like stretchers, medical equipment, consumables and drugs to be designed/contained to fit securely into the helicopter. They will also have to be stored securely in the vicinity of the helicopter base to perform the process quickly. The same applies for the CASA 235 plane that will have to be configured quickly to perform aeromedical transfers. This will add more lag time before the aircrafts are ready to perform aeromedical evacuations. The same concerns apply to other aircraft like the seaplanes that may be used for the same purpose. All this will have implications on type of equipment used, training needs and protocols for the air ambulance services.

Regulations with regards to on-board equipment All equipment used on board these aircrafts must comply with regulations governing the use of such equipment on board Other internal transportation modes There will be the need to use land based ambulances in Male and at the airport. There may be need to use boat services with other islands close to Male and the airport. Commercial airlines Commercial airlines scheduled to fly Male Colombo
14

can also be an alternative

solution for patient transfers to Colombo, provided the carriers permit. The various commercial airlines will need to be contacted to confirm if such aeromedical transfers are possible, along with the list of medical onboard equipment that they will allow. Airport and Male Base Since there is the need to outfit the aircraft when needed for aeromedical service, there will need to be an equipment base that is manned 24/7 to allow for equipment storage along with trained personnel who can carry out the operations. Flying conditions There must be clear documented communication between pilots, medical personnel, and communication specialists regarding the most current and forecasted weather is part of a formal briefing prior to every flight mission, along with documented evidence of all preflight checks done in compliance with safety regulations for the type of aircraft 6 . 7. Equipment/ supplies / oxygen/ documentation papers

Equipment and medical consumables/ supplies as well as medications (drugs, i.v solutions etc.) , oxygen, documentation papers necessary for aeromedical services based on previous needs will need to be shortlisted. They must be compatible and accepted for use in the various aircrafts that will be used for air ambulance services. Also to note that it is ideal that they can be serviced locally, and consumables / spares should be available locally. It is important to ensure a proper supply chain management of the medical itenary in the island. Once purchased, training needs for the medical crew with the equipment and consumables as well as protocols for their use will need to be established 8. Organizational layout

Prior to proceeding to recruitment of personnel, an organizational chart will need to be prepared to address the recruitment needs. The team will need to be headed by the Medical Director who answers to the Board of the JBI. The liaison officer between the JBI and air ambulance service will be provided for by the JBI. At this juncture it would be ideal to appoint personnel with wide experience in each of the respective field of air ambulance operations to guide the recruitment process and protocol/policy formulations. Key positions to be filled in each of the categories Operations and logistics Manager, Medical Control Physician, Clinical Care Nursing Supervisor. 9. Communication facilities

In order to carry out regular operations smoothly and effectively, having adequate communications facilities are a key component. Communication systems will need to be robust and effective over a wide range of mobility. A mix of Cellular Telephone services with roaming capability (Providers in Maldives - Dhirugga, Wataniya) , Satellite phones, Internet, e-mail, walkie talkies , fax and land lines will be needed to allow for

uninterrupted communication links. Cellular services will also be needed to Srilanka. All measures must be taken to ensure that communication costs are effectively managed.

10. Policies and Protocols Detailed protocols and policies will need to be designed for the following aspects of the air ambulance service Medical Aviation Communication Personnel

The policies and protocols must be detailed and non ambiguous. 11. Personnel Recruitment of personnel, both medical and non medical, to run the air ambulance service will need careful planning. It will need to be a mix of a small number of full-time staff as necessary, and a pool of temporary staff that can be called upon on an as-needed basis Non Medical Personnel These will have to be full time employed staff who man the administrative and office activities. They will be needed to receive calls, prioritize requirements, call out personnel, anticipate disruptions, supply essential logistics and information. They will have to be well versed with the running of an air ambulance service, with prior experience being preferred. There would have to be a mix of people who can communicate in both local languages as well as English, Sinhalese and Japanese languages. They will need to be individuals who are clam under pressure, innovative and capable of coping with deadlines, challenges and changing priorities. They will all need adequate indoctrination upon employment. Nursing Staff Recruitment of nursing staff for the air ambulance service would best be carried out by the Chief Medical Officer and Flight Nurse of the air ambulance service. As they patients are expected to be Japanese speaking, it is important that they are well versed with the Japanese language. It is also important that they have adequate communication skills in the languages spoken on Maldives and in Sri Lanka. Based on the needs of the service, there will be a mix of few fully employed staff and some on a temporary roster. The European nurses working in the local resort who also speak Japanese would be ideal candidates from whom to choose nursing staff for the air ambulance, both for permanent and temporary posts. These nurses will need to have adequate critical care nursing back ground, with certification in advanced cardiac and trauma life support
15

. The local hospitals will also be good head-

hunting grounds for qualified nursing personnel. The employed nursing staff will need to perform off-duty activities like ongoing education, care and replenishment of equipment materials, case file management, training temporary nursing work force when not flying. The following personal attributes will be needed in temporary (and also permanent) Nursing Staff 16

Availability at short notice Cool headed under unexpected stressful circumstances Working knowledge of a couple of languages (especially useful are Dhivehi, Singhalese and Japanese).

Personal fitness with weight in proportion to height. Possession of a full passport. Ability to improvise Ability to recognise their limitations Sense of humour Last probably most important is a love of flying

It will be important to ensure that the nursing staff are aware of the expected work load and conditions prior to recruitment, and are able to balance work/family life and organizational concerns, in order to prevent disappointments and high turnovers. They will need adequate indoctrination as well as conflict management skills to work in such environments 17. Flight Doctors There should be a mix of full time employed flight doctors and others who are listed to be called as per requirements. They will all need to be registered to practice in Maldives, with adequate working permits, visa / passports as needed. Local or expatriate doctors may be used. The following qualifications/ knowledge / work experience is highly desired Advanced Cardiac Life Support Advanced Trauma Life Support Neonatal Resuscitation Program Pediatric Advanced Life Support Patient care capabilities and limitations (i.e., assessment and invasive procedures during transport). Infection control Stress recognition and management. Altitude physiology/stressors of flight Ground ambulance rules /regulations Appropriate utilization of medical/ground interfacility services Emergency Medical Services. Hazardous materials recognition and response. Communication skills in English, Dhivehi, Singhalese and Japanese).

Local hospitals may be approached to provide doctors on temporary basis. All doctors will need proper indoctrination into the service, and clear employment policies issued. Flight Paramedics It is necessary to verify if paramedics are permitted to carry out aeromedical mission in supervised/ unsupervised manner, local medical laws with respect to scope of their services will govern their use and employment. Selection and Recruitment For all staff involved in field activities, selection and recruitment should take into considerations General fitness and medical screening. They will need to accept vaccinations that are needed in the emergency working environment as well as part of travel requirements. They will need to be energetic, problem solvers, inventive, calm under pressure. They will need to be flexible in their availability, any possible family issues will need to be cleared prior to recruitment. Specialist Personnel Some air ambulance transfers may require specialized assistance due to the clinical nature of the patient and the skill level of the air ambulance medical crew- e.g. critical care patients on ventilators. Unless a very common occurrence, specialist medical personnel will need to be used on occasions. They can be sourced from the liaison clinics/hospitals in Srilanka or Maldives. Specialty care personnel must have appropriate licensure requirements to practice their specialty in Maldives and Sri Lanka. They will have to be accompanied by one of the regular medical/nursing staff during a mission 6 .

They will need to be educated in in-flight treatment modalities, altitude physiology, general aircraft safety and emergency procedures. Similarly any specialized equipment needs can also be out sourced from these receiving medical centers as needed. Prior identification of such personnel and equipment will be needed. Training There should be a policy and documentation system to ensure that the medical and non medical personnel undergo adequate training and skills improvement in their respective job profiles Crew and Team Management The human resources of the air ambulance service will need to be managed in terms of their contracts, rostering, training, leave scheduling and other human resource needs. A part of the administrative wing of the air ambulance service must be designated to handle the same. Also there must be clear policies and protocols regarding the personnel needed in a team for the air ambulance mission, indicating team composition for simple cases to critical care cases. Rostering As part of the team management, regular rosters should be made to ensure that there are adequate personnel to manage the various aspects of operations of the air ambulance service at all times. Office staff will need to be on a 24/7 roster basis, with enough back-up in case of unexpected absences. For the medical / nursing/ paramedical staff a similar rostering will be needed. The hours of work and other labor regulations in Maldives will need to be adhered to. Scheduling and individual work schedules should demonstrate strategies to minimize duty-time fatigue, length of shift, number of shifts per week and day to night rotation 6 . Payment for overtime regulations will need to be addressed as well. 12. Interface Issues There will be multiple interfaces at which the air ambulance services will interact with other companies. There has to be clearly identified and employed personnel who will look into these interfaces. Expected interfaces are o o o o o o o o o o JBI Local hospital in Maldives Hospitals In Srilanka Helicopter service provider CASA 235 Plane service provider Airport authorities in Maldives and Sri Lanka Commercial airlines operators Local boat and seaplane operators Embassy Srilankan, Japanese Public safety agencies, including ground emergency service providers

Cordial relations with frequent visits will be needed at all these interfaces to ensure smooth transfers of patients. Issues regarding payments must be clearly agreed upon and documented between the us, the JBI and third party service providers 13. Ethical and Cultural Considerations It is important to respect the cultural views and expectations of people in Maldives as well as the Japanese patients. The culture is predominantly Islamic in Maldives, and due attention must be paid to working within

the cultural framework of the country. Transport requests are accepted from authorized personnel with sensitivity to cultural differences and without discrimination due to race, creed, sex, color, age, religion, national origin, ancestry, or handicap 6.

14. Mission Acceptance Policies The air ambulance service must be clear on its capability and service nature. It has to clear if there will be a need for secondary air ambulance services as well as primary rescue air ambulance services. Search and rescue operations should not ideally be part of the mission capability of the service. Protocols and policies must clearly state the kind of missions the service will undertake, and when additional help will be sought from local or external agencies 15. Safety of crew The health and safety of the crew and the team is an important aspect that has implications on policy/protocol formation and financing. Areas of concern include Hearing protection, Aircraft emergency equipment and training (e.g. HUET Training), manual handling, special clothing, biohazards / waste management, anxiety and post traumatic stress issues, quality policy, incident reporting, immunization (based on health needs in Maldives and Srilanka ) 16. Standards and Quality monitoring Once the unit is set up and running, it is imperative to maintain and monitor professional standards and quality. These will have to be audited, and such responsibilities will have to be clearly assigned to staff. The service may aim to apply for accreditation process like the CAMTS. The Safety Management system must include 6 Description of the scope of service A statement of policy commitment from the accountable executive. A non-punitive system for employees to report hazards and safety concerns. A system to track, trend and mitigate errors or hazards. A system to track and document incident root cause analysis. A Safety Manual. A system to audit and review organizational policy and procedures, ongoing safety training for all personnel (including managers), a system of pro-active and reactive procedures to insure compliance, etc. There is evidence of managements decisive response to non-compliance in adverse safety or risk situations. 17. Marketing As it is an air ambulance service set up for a single client, there may not be any immediate need for marketing, and the JBI will probably place this service description in their own marketing media. Still it would be important that due credit is given to the management and running of the unit by us, and that all necessary up-to-date contact information and details are available online or in the media kit for the service.

In conclusion, there will be many issues that will come up once the air ambulance service is set up and operational. There needs to be a constant vigilance and management of issues as they arise and mitigation of the same. Ensuring safe, timely and effective air ambulance operations will be vital to improving and maintaining patient and customer satisfaction, and company credibility.

*** References:
1. CIA World Fact Book Maldives. Available at https://www.cia.gov/library/publications/the-worldfactbook/geos/mv.html . Accessed on 28th July 2012 2. AVMX 722 Module 1: Establishing an Aeromedical Service. Department of Aeromedical Transport and Retrieval, University of Otago, New Zealand. 3. Colman B. Taylor et al. An investigation into the cost, coverage and activities of Helicopter Emergency Medical Services in the state of New South Wales, Australia. Injury 2011; 42(10) 1088-94 4. Micheal J. Greene . 2010 Critical Care Transport Workplace and Salary Survey. Air Medical Journal 2010; 29 (5) : 222-35 5. The Maldives Airport Company Ltd. website. [cited 2nd August 2012] http://www.macl.aero/new/ 6. Commission on accreditation of Medical Transport Systems. 7TH Edition 2006. [cited 3rd August 2012] Available at : http://www.nemspa.org/assets/documents/AccreditationStandards_7th_Edition_2006_1_.pdf 7. Trans Maldivian Airways website. [cited 3rd August 2012] Available at http://www.tma.com.mv/HTMLPages/index.htm 8. Maldivian Air Taxi website. [cited 3rd August 2012] Available at http://www.maldivianairtaxi.com/beta/gallery/ 9. Directory of Health Facilities Maldives. [Cited 3rd August 2012]. Available at http://www.health.gov.mv/PDF/health%20facilities.pdf 10. ADK hospital website. [cited 3rd August 2012]Available at http://www.adkhospital.mv/ 11. Male Helath Services Corporation ltd. website. [cited 5th August 2012]Available at http://mhsc.com.mv/en/ 12. Christine Negroni . Air Ambulance Crashes Prompt Examination of Troubled Industry. [cited 5th August 2012]. Available at http://www.thecrashdetectives.com/uploads/Air_Ambulance_Crashes_Prompt_Examination_of_Tro ubled_Industry.pdf 13. List of Airports in Maldives Wikipedia. [cited 5th August 2012]Available at http://en.wikipedia.org/wiki/List_of_airports_in_the_Maldives 14. Flight Schedules for Maldives. [cited 8th August 2012]Available from http://fis.com.mv/cgibin/webfids.pl 15. Donna Arvin Isfort. So you want to be a flight nurse. J Emerg Nurs 1999; 25 : 531-2. 16. Royal College of Nursing England Inflight Nursing Requirements. [cited 8th August 2012] Available at http://www.rcn.org.uk/development/communities/specialisms/in_flight/resources/flight_nursing/requ irements 17. Bee, R. (2012). Flight nursing: What is it and why are nurses leaving? University of California, Davis). ProQuest Dissertations and Theses. [cited 8th August 2012]Available from http://search.proquest.com/docview/1022975042?accountid=14700

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