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Air ambulance services in the Arctic 1999-2009: a Norwegian study
© Norum and Elsbak; licensee Springer. 2011
- Received: 10 April 2010
- Accepted: 27 January 2011
- Published: 27 January 2011
Air ambulance services in the Arctic have to deal with remote locations, long distances, rough weather conditions and seasonable darkness. Despite these challenges, the people living in the area expect a high quality of specialist health care.
The objective of this study was to analyse the air ambulance operations performed in the Norwegian Arctic and study variations in diagnoses and flight patterns around the year.
A retrospective analysis. All air ambulance operations performed during the time 1999 - 2009 period were analysed. The subjects were patients transported and flights performed. The primary outcome measures were patients' diagnoses and task patterns around the year.
A total of 345 patients were transported and 321 flights performed. Coronary heart and vascular disease, bone fractures and infections were the most common diagnoses. Most patients (85%) had NACA score 3 or 4. Half of all fractures occurred in April and August. Most patients were males (66%), and one fourth was not Norwegian. The median flying time (one way) was 3 h 33 m. Ten percent of the flights were delayed, and only 14% were performed between midnight and 8.00 AM. The period April to August was the busiest one (58% of operations).
Norway has run a safe air ambulance service in the Arctic for the last 11 years. In the future more shipping and polar adventure operations may influence the need for air ambulances, especially during summer and autumn.
- Helicopter Emergency Medical Service
- Regional Health Authority
- Polar Night
- Flight Pattern
- Health Care Infrastructure
The Northern Norway Regional Health Authority (NNRHA) trust is responsible for the specialist health care service and all patient transportations in northern Norway. This includes the Norwegian Arctic areas (Svalbard, Bear Island, Hopen and Jan Mayen). Svalbard is a group of islands reaching up to the 80th degree northern latitude and covers an area of 61,020 km2. The land area constitutes 16% of Norway. The largest island is Spitsbergen, and its municipalities are Lonyearbyen, Barentsburg, Svea, Hornsund and Ny-Ålesund. The main airport is located at Longyearbyen, but there is also a minor one at Svea. The main industries on the island are coal mines, tourism, education, research and satellite services. According to data from Statistics Norway http://www.ssb.no, as of January 2009 there were a total of 2,570 inhabitants (2,085 Norwegians, 470 Russians and 10 Poles) on the island. There is a rich fishing area in the Svalbard zone, and fishermen from various nations such as Great Britain, Germany, Spain, Portugal, Russia, Iceland, the Faroe Islands and Norway fish in the area.
Whereas people living in the Arctic experience seasonable darkness and polar nights, the summer is light. For example, Longyearbyen experiences 4 months of seasonable darkness (no sun; 7 October - 8 March), including 2 months (14 November - 30 January) with complete darkness ("polar night"). "In compensation", there are 4 months of midnight sun during the summer (20 April - 23 August).
The Norwegian health care service in the region is provided by a small hospital unit in Longyearbyen. The unit is run by the University Hospital of North Norway (UNN) trust and is staffed with three medical doctors (one surgeon and two general practitioners). According to standard procedure, at least one doctor stays on the island at all times. Due to the limited staff, the hospital serves as a "preparedness hospital" taking care of primary health care, casualties and emergency care. Rough weather conditions, often presenting with strong winds, ice, cold temperatures and seasonable darkness, introduce challenges to health care in the Arctic. Long distances and almost no alternatives for landing make it necessary to be very cautious concerning safety before and during flights. Peoples' activities in the Arctic vary significantly around the year. The coal mines have reduced activity during the summer, fisheries experience limited access to the northern regions in winter because of enlarged polar ice coverage, cruise liners mainly operate in the area during summer, and polar adventure activities employing dog sleds or snowmobiles mainly take place during periods with daylight and snow (mainly spring and autumn). Based on this knowledge, we aimed to clarify the variations in patients' diagnoses and flights pattern around the year.
Flight data: Date and time of start and end of task, time spent, state of emergency (non-urgent, urgent, emergent) according to the Norwegian Index for Medical Emergency Assistance , destination (hospital) and any delay of more than 15 min.
Patient data: Sex, age, nationality, diagnosis (according to the international classification of diseases, ICD), oxygen support, intubation, analgesics given, degree of seriousness [National Advisory Committee on Aeronautics (NACA) scale; the scale is shown in Table 1], intravenous administrations and the use of vasopressor drugs.
The National Advisory Committee on Aeronautics (NACA) scale.
No injury or illness
Not acute life-threatening disease or injury
Acute intervention not necessary, further diagnostic studies needed
Severe, but not life-threatening disease or injury; acute intervention necessary
Development of vital (life-threatening) danger possible
Acute vital (life-threatening) danger
Acute cardiac or respiratory arrest
The Microsoft Office Excel 2007, Microsoft Corp., Redmond, WA, was employed for the calculations and database. Statistical Package for Social Science (SPSS) version 16.0, SPSS Inc., Chicago, IL, was employed for statistical analyses. Cases with an unknown value for a particular variable were excluded from analysis involving that variable. Statistical analyses were performed employing descriptive statistics and bivariate correlation analysis. All P-values are two tailed and considered statistically significant when P < 0.05.
No approval from the regional ethics committee was necessary as no individual patient identifiable data were accessed by the researchers.
Overview of air ambulance operations in the Norwegian Arctic during the time period 1999 - 2009.
Median age (yrs)
All (n = 345)
Sex not registered
Not Norwegian (total)
Heart and vascular disease
Heart and vascular disease together with bone fractures was the most frequent diagnosis. This has also been documented by other investigators [2, 3]. Gynaecologic and obstetric causes accounted for 10% of patients. This is because pregnant women are routinely evacuated to the mainland for childbirth. A similar situation has been described among Canadian Inuit residents in the Canadian Arctic . Researchers have commented that evacuation for childbirth has deleterious social and cultural effects . Canadians have therefore recently established community birthing centres in Nunavik and Nunavut. This is not a current policy for the Norwegian Arctic because of the limited number of women living in the region, risk factors and the capabilities (no permanent access to a surgeon) at the local hospital unit.
The high frequency of fractures in August has also been documented in a prior Norwegian study from the Norwegian Coast Guard . The authors argue that this situation is caused by the fact that workers and fishermen are less cautious when returning to work after their summer holiday.
In the future, stroke patients may become a growing group among the air ambulance patients because there will be more elderly people and new treatment guidelines. The role of air ambulance (helicopter) services in the transfer of stroke patients has been illustrated by Thomas and colleagues . Prior to thrombolytic therapy, a CT scan has to confirm the diagnosis. Because of the limited time window between symptom onset and initiation of therapy, an air ambulance service is important for the hasty transfer of patients to the mainland for CT scanning.
We have documented the logistics of the air ambulance service in the Norwegian Arctic and the variations around the year. Whereas the geography of northern Norway makes it necessary to include both airplanes and helicopters in the service, many countries employ helicopter emergency medical services (HEMS) alone [7, 8]. However, HEMS has limitations. In northern Norway rough weather conditions are a significant problem, especially during winter. A study from the region revealed an access rate of only 40% between November and March . Even in northern Norway, ground transportation may be a good alternative [10, 11]. However, because of the lack of roads and long distances, ground transportation is of limited value in the Arctic When appropriate, sea transport may be an alternative.
Despite the patients being airborne, there was a significant one-way flying time. Such a time span has also been shown employing heavy search and rescue helicopters in the Barents Sea . The complexity of running operations in remote and cold regions has been illustrated in Antarctica . In this report a ski-equipped airplane was employed, and a critically ill patient was transported 9 h north to New Zealand.
Daylight returns to Svalbard in early March, and in April people perform many outdoor activities. Dog sleds and especially snowmobiles are common means of transport. The sunlight reflected by the white cover of snow may cause "white out" and consequently an increased risk of accidents. Svalbard has the highest frequency of snowmobile accidents worldwide [14–16]. During a 3-year period (1997 - 2000), 107 snowmobile injuries were registered . Most injuries (79.4%) occurred in the time period between March and May. This is in accordance with the peak of fractures in April shown in our survey.
In the future, significant changes will occur in the Arctic. As the ice is melting because of worldwide climate changes, shipping may take advantage of new routes among Europe, Northern Russia, Asia and North America. Furthermore, polar adventure operations will become steadily more popular as the coast areas of northern Greenland and north of Svalbard will be available for longer periods. In such a setting, Svalbard may become an important base for air ambulance services in the Arctic.
Air ambulance service is costly and limited in terms of resources, especially in the Arctic . It should therefore be discussed whether passengers participating in polar adventure operations must have a declaration from their personal physician that they are fit for the journey. Such operations are very different from "tropical" cruise lines .
To achieve maximum value (health gain) for the money, an excellent fleet coordination system is mandatory. Furthermore, high-quality decision criteria for aeromedical evacuation are important [19–21]. This has been summarised with the words "right patient, place and time" . Another limitation has been the access to competent crew members . As long as the Norwegian government decides to keep and support the Norwegian municipalities on Svalbard, a basic health care infrastructure has to be funded. In light of the potential (shipping, fishery, oil/gas industry) development of the Arctic region, a parallel expansion of the health care infrastructure should be considered.
The NNRHA trust has been responsible for safe air ambulance operations in the Arctic, serving both Norwegians and others. The pressure on the limited resources is strongest in April, June, July and August. In the future, shipping and polar adventure operations will increase the need for health care services in the Arctic, especially during summer and autumn. This should be focussed on in future model-based analysis.
The author is a medical oncologist, professor at the Faculty of Medicine at the University of Tromsø and medical director at the North Norway Regional Health Authority.
The authors wish to thank the personnel at the library of the University of Tromsø for their support. Useful comments from colleagues at the NNRHA are also appreciated. The study was funded by the Northern Norway Regional Health Authority.
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