Career Focus

Working in the air

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7168.2 (Published 07 November 1998) Cite this as: BMJ 1998;317:S2-7168

Jetting off to all parts of the globe still has a certain glamour - and getting paid to do so is sweeter still. Terry Martin outlines options for doctors in the world of civilian aviation

Chatting over a pint one day, a helicopter pilot told me that he'd had great difficulty choosing between a career in flying or in medicine, and I reflected on my own indecisions years before. Since then, I've met many aircrew who would have been equally happy in medicine, and even more doctors who have a passion for flying. If you're in the latter group it is possible to practise medicine and aviate at the same time, and be paid for it. Outside the military, there are four types of employment that bring the worlds of aviation and medicine together.

Commercial airlines - The responsibilities of doctors who work for airlines vary enormously. Some work almost exclusively with aircrew, offering preventive health services and medical examinations. Others effectively provide an occupational medicine service for engineering staff. Others advise the travelling public on their fitness to fly.

Civil Aviation Authority - The authority employs doctors who assess applicants for aircrew licenses. Like their airline counterparts, many doctors in the Civil Aviation Authority are qualified pilots, some flying part time as commercial aircrew in passenger aircraft.

Defence Evaluation and Research Agency (DERA) Centre for Human Sciences - Anyone interested in aeromedical research should consider working for the DERA. Opportunities exist for doctors to undertake research and for those seeking a career in either research or occupational medicine. Aviation medicine counts towards accreditation in occupational medicine. Project subjects include altitude physiology, thermal physiology, survival medicine, biodynamics, vestibular physiology, psychology, and neurophysiology.

Aeromedical transport - There has been an enormous growth in the air transfer of patients in recent years, and this may involve primary, secondary, or tertiary flights. Primary responses are those in which a helicopter serves as the means of transporting a patient to an emergency department. In secondary missions patients are transported from hospitals where some degree of stabilisation has been performed to a higher level medical facility. A tertiary flight is when a patient is transported for further specialist care or repatriation. Clearly, there are great differences between the operations of a helicopter air ambulance and a company which specialises only in repatriations. In Britain there is scope for doctors to work in all types of missions, but few are full time - most opt to maintain clinical proficiency in their chosen specialty and work in transport part time on an ad hoc basis. There are opportunities to fly with primary helicopters, such as the Helicopter Emergency Medical Service, and on international repatriations. For those who prefer a more adventurous existence yet with a predictable income, the Royal Auxiliary Air Force offers similar opportunities to the RAF without the need to commit to a six year commission.

Primary casualty evacuation

The United Kingdom is covered by a network of Search and Rescue helicopters, which are mainly crewed by well equipped paramedics, although doctors may be carried on some missions. These are inevitably doctors known to the Search and Rescue organisation, often trained and called out by the British Association of Immediate Care. They are usually general practitioners who volunteer their time and receive no fees. These doctors are also occasionally used on civilian helicopters, especially in sparsely populated areas, where helicopters are useful to cover large gaps in ambulance cover and great distances between hospitals. The only helicopter ambulances that routinely carry a doctor are those of the London Helicopter Emergency Medical Service. This service operates in an area which has a high density of trauma and where traffic congestion often impairs evacuation by road. Although there has been debate about the efficacy and costs of helicopter ambulances, it is generally agreed that trained doctors are valuable at the scene of an incident, especially when entrapment or logistic circumstances delay patient evacuation. At any one time there are four post-fellowship specialist registrars in the service, with each position usually limited to a six month contract. The initial month is spent on additional training in prehospital emergency care, on the helicopter itself, and working with the other emergency services.

International repatriation

While helicopter missions attract most publicity, most aeromedical operations involve fixed wing flights. Large, fast aircraft have brought cheap, affordable, and accessible travel to millions of people. The repatriation of those unfortunate enough to fall ill or become injured overseas is usually a matter for travel insurers, because few individuals can afford the expense of in-flight medical care during their return flight.

A seriously ill patient may require air ambulance facilities with a full aeromedical team and monitoring and therapeutic facilities; most cases are not so serious, although many still need an aeromedical escort.

The actual work of repatriation is contracted to medical assistance organisations by insurance companies. Doctors working for these organisations may act as coordinators (“on the desk”), may fly as aeromedical escorts, or both. The division of loyalties between insurers and patients can be a rather uneasy situation.

The desk doctor collates medical information from overseas, the medical regulations of airlines, and the guidelines and procedures of the organisation for which he or she works. Such doctors must have a good working knowledge of flight medicine and must be able to assess and decide on each patient's fitness to fly. Finally, they must coordinate arrangements for a safe and acceptable repatriation.

The duties of the in-flight medical team are not limited to the medical care of patients while airborne and the borders between medical and nursing care may become blurred. The optimal mix of skills of the in-flight team is controversial, and, although the in depth knowledge and advanced skills of the flight doctor may be essential, a paramedic or nurse has experience of patient care that is overlooked in traditional medical education.

A word of caution: aeromedical work is exciting, and there is a great temptation to accept assignments at short notice. Prospective part time flyers should ensure that they don't exceed agreed working hours. Bear in mind the need to be on peak performance throughout the entire mission, especially if the patient is actually being escorted on the return journey.

Medical directors of assistance companies should be trained in aviation medicine and be able to advise on problems specifically related to the flight environment. They must also be able to liaise with external expert specialists and authorise relevant operational decisions, such as flight timings. Medical directors have responsibility for the selection, assessment, training, and supervision of staff and for documentation, quality assurance, dealing with complaints, and the periodic review of medical protocols and guidelines. For these services, the remuneration is usually on a par with that of a consultant but is often supplemented by perks such as a company car, discounted holidays, and, of course, the pick of the best assignments.

Medicolegal liability

Medicolegal issues in aeromedical transport (such as jurisdiction, importation and exportation of drugs, international health regulations, and certification of births and deaths) are complex. When a fully qualified and registered British doctor escorts a patient of British nationality on board a British aircraft, belonging to a British airline, in British airspace, the responsibilities and obligations of that doctor are no different from those in normal everyday practice. The problems start when any of these variables are not British. Anyone considering aeromedical work must ensure that their insurance cover for malpractice is adequate. Practice in the United States is usually not covered, and it is essential to check that the medical assistance company has adequate independent cover for any doctors working in the United States or with US patients.

How to get started There are a number of different training pathways, depending on the type of work being contemplated. For those interested in research, King's College London offers a research based MSc in aviation medicine. Part of that course includes study for the diploma in aviation medicine (Royal College of Physicians). Doctors employed by DERA undertake training specific to their needs and to the requirements of their chosen research.

Doctors interested in working in the airline industry or Civil Aviation Authority should contact the organisation of their choice. The BMJ's classified section occasionally advertises these posts, but a prospective telephone call and follow up curriculum vitae will put you in a favourable position when a vacancy arises.

Anaesthetists, surgeons, and accident and emergency doctors who fancy the thrill of taking advanced emergency care to the streets of London should apply, in the first instance, to the director of accident and emergency care at the Royal London Hospital.

The Helicopter Emergency Medical Service advertises for trauma registrars periodically, but there is always a waiting list of enthusiasts. General practitioners who want to work in a helicopter service should have additional training in trauma, cardiac, and paediatric life support. Further training will be provided by the air ambulance or Search and Rescue unit after appointment.

One way into the arena of aeromedical transport is to attend the course “Clinical Considerations in Aeromedical Transport,” from which some of the medical assistance companies trawl for new talent each year. The high turnover of flight doctors means that these companies are happy to hear from prospective employees, and there is nothing to prevent doctors registering with more than one company. The six day course (held at the University of Surrey) addresses the special physical, physiological, and psychological stresses that are important in the flight environment. It describes the conditions that are suitable for air transport and how patients may be safely and efficiently carried, and provides the necessary background to enable sensible and safe decisions about fitness to fly.

Pros and cons of a career in air transport

Attractions

  • Variety of case mix - unless you are a specialist (such as a neonatologist doing baby transfers only), you will see all sorts of patients

  • Holistic approach - you are totally responsible for all the patient's needs during the transfer

  • Outside of normal experience - the flight environment poses particular challenges

  • Travel - anywhere in the world is possible

  • Money - pay rates differ between companies, but the remuneration is usually generous and includes time “resting” on the ground overseas as well as all travel expenses

  • Air miles - can be collected on many assignments

  • Duty free goods - must be purchased discretely, and not when accompanying the patient

Possible disadvantages

  • Fragile job security - full time workers may need to be self employed; part time work is not predictable

  • In flight patient care is unsupervised - you're on your own

  • Availability at short notice

  • Acting as interface between insurers and patients - seen to be “commercial”

  • Travelling can eventually become tiresome

  • Cost of malpractice insurance

Terry Martin, Senior House Officer, Anaesthetic Department, Princess Margaret Hospital, Swindon SN1 4JU

Useful addresses

  • Clinical Considerations in Aeromedical Transport course,

    University of Surrey

    Dr Terry Martin, Anaesthetic Department,

    Princess Margaret Hospital,

    Swindon SN1 4JU

    Tel: 01793 536231 (bleep 1379).

    Fax: 01793 480817.

    email: ccat_course{at}hotmail.com

  • DERA Centre for Human Sciences

    Dr Rollin Stott, principal medical officer,

    DERA Centre for Human Sciences,

    Building F138,

    Farnborough GU14 0LX

    Tel: 01252 394406.

    Fax: 01252 392097

  • Kings College London

    Professor John Ernsting, Human Physiology and Aerospace Medicine,

    School of Biomedical Science,

    Kings College London,

    London W8 7AH

    Tel: 0171 333 4176.

    Fax: 0171 333 4008.

    email: john_ernsting{at}kcl.ac.uk

  • Royal Aeronautical Society

    Aviation Medicine Group

    4 Hamilton Place,

    London W1V OBQ

    Tel: 0171 278 3686.

    Fax: 0171 499 6230

  • Royal Air Force Centre for Aviation Medicine

    Gp Capt Tony Batchelor,

    Royal Air Force Centre for Aviation Medicine,

    RAF Henlow,

    Bedfordshire SG16 6DN

  • Royal Auxiliary Air Force

    The Recruiting Officer,

    No 4626 (AE) Squadron,

    Royal Auxiliary Air Force,

    RAF Lyneham,

    Chippenham SN15 4PZ

    Tel: 01249 891257

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