For entrepreneurs, the maturing of a growing market they created comes as a mixed triumph. On the one hand come the recognition, fame and loads of money that flow from not only setting the pace but also defining the race. On the other, there’s the pressure that the inevitable competition brings as other smart people sharpen their pencils and try to top the original business concept with improvements.

To counter this, the successful entrepreneur looks for ways to expand the original market, a process that almost always redefines the concept behind the original business. The term for it in “business speak” is that worn cliché, the “paradigm shift.”

Ever since their introduction some 40 years ago, the cabins of business jets have undergone a transformation from being one of the least accessible places on earth to becoming just another marketplace. Most new jets emerge from the completion centers better equipped with modern telecommunications equipment than many offices. And in terms of medical emergencies, the same holds true. Where this trend is taking us is best illustrated by a look at how far we’ve come, when not only was there no “doctor in the house” but the nearest medical attention was precious long minutes or even hours away.

Back in the mid-1980s, one of RJR Nabisco’s business jets was en route from Miami to Teterboro in the wee hours of a Tuesday morning following an ABC Sports Monday Night Football broadcast. Among others on board the Falcon 50 was superstar sportscaster Frank Gifford. Midway through the flight, the captain stepped into the cabin to make sure his passengers had been well provided for.

Returning to the cockpit, the captain discovered his copilot slumped over the controls, apparently unconscious. Frantic, he shouted to his passengers for aid and within seconds they had moved the stricken copilot to a cleared portion of the aisle. Gifford, trained in CPR from his days as a football player, began that procedure. Meanwhile, the pilot requested an immediate landing and only minutes after the copilot’s condition was discovered, the Falcon 50’s wheels touched the tarmac at Raleigh-Durham International.

The man never regained consciousness and was pronounced dead on arrival at a local hospital. Stricken above one of America’s more densely populated regions, the hapless copilot, for the few crucial moments during which he needed quality medical care, might as well have been on the dark side of the moon.

MedAire: The Pace-Setting Pioneer

The best alternative emergency health-care professionals could provide in the mid-1980s revolved around a fairly limited selection of in-flight medical services in which a ground-base physician, informed of the patient’s condition by the flight crew’s observations, offered advice on the best interim care options until the aircraft could get on the ground for help. While perhaps not the first to offer this type of service, Phoenix-based MedAire has certainly become the largest and (perhaps this being the fate of a “paradigm setter”) most diversified company of its type.

MedAire’s bread and butter is its 24/7 MedLink Global Response service. Begun in 1986, its simplicity and effectiveness defined an industry. Through MedAire’s Global Response Center in Phoenix, flight crews get immediate access to the expertise of board-certified emergency physicians.

These physicians manage thousands of such calls every year and are trained and familiar with the unique constraints associated with the aircraft environment. In fact, one MedLink physician noted, “We won’t ask that a patient be laid down in the aisle of an aircraft type we know to be too short or too narrow. We’ve also got a complete medical profile of that passenger, provided they’re subscribed with us, so we start ahead of the game, knowing at least as much as that individual’s personal physician what can and cannot be safely done with them.”

The MedLink communications center is located inside the emergency medical complex of Good Samaritan Regional Medical Center in Phoenix, a Level I Trauma Center, giving MedLink physicians immediate access to specialists in nearly every field of medicine, including those in a poison control center. The communications center itself is equipped with the latest in computer and telecommunications technology. All systems are 100-percent secure, with complete redundancy in the event of a system failure.

In the event of a medical emergency, the MedLink physician contacted will recommend to the pilot whether a diversion or emergency landing should be considered. In such situations, MedLink uses its exclusive and proprietary medical resource database, which provides information on airports, medical facilities and emergency-response resources in more than 5,000 cities worldwide.

Whether a flight diverts or continues to its original destination, MedLink coordinates the emergency ground transportation, as well as the patient’s admission into the most appropriate medical facility. MedLink maintains continuous contact with the admitting medical facility, keeping the information pipeline open among patient, family and patient’s employer, as well as any other medical personnel, until the patient is officially discharged. And it does this worldwide.

First Aid Kits/Defibrillators/Remote Vital-signs Monitoring

No business jet operator would dream of going aloft without an extensive medical kit, something more than the basic “Bactine and Band-Aid” variety. The kits prepared by the leading in-flight health-care providers can all be customized to meet the requirements of specific passengers or expanded to meet the health demands of the less developed areas of the world. Of course, the more sophisticated the kits, the greater the need for in-depth training of cabin personnel, especially if the aircraft operated does not include a cabin attendant among its usual crew complement. Imagine the dilemma of that Nabisco Falcon 50 pilot had no one in the cabin stepped forward to try and resuscitate his unconscious copilot.

Sadly, that man could likely have been saved today. Becoming as ubiquitous in the cabin as packets of peanuts and a wet bar are automated external defibrillators (AEDs)– those lifesaving and essentially foolproof devices that can analyze a cardiac incident and within a few precious seconds apply an accurate jolt of electricity, enough to restore heart action. Almost every airline includes AEDs as part of its basic cabin safety package, a good idea that will take on the force of law next May 12 when regional and major carriers will have to equip all their scheduled Part 135 and 121 aircraft (with a capacity of at least 30 passengers) with AEDs.

Today’s AEDs are inexpensive, compact and (as noted) essentially foolproof, and they can be found nearly everywhere the public gathers. As the boomer generation goes gray, there is no excuse not to have one on your company’s aircraft. However, it should be remembered that defibrillators are classified by the Food and Drug Administration as class III medical devices, which means purchase must be authorized by a physician and AED use must be under the guidelines approved by medical direction and control. This is yet another reason to turn to a professional in-flight medical services company for help and advice.

Remote vital-signs monitoring brings digital data on the patient’s condition right to the attending physicians on the ground, essentially allowing those doctors a glimpse inside the patient, albeit at a distance. The more the ground-based doctors know, the better the overall odds of recovery. Essentially, smart heart-rate, blood-pressure and respiration monitors capable of transmitting their findings, remote vital-signs monitors are somewhat costly and require fairly sophisticated training of flight or cabin crew for effective operation. After all, the support from the doctors on the ground is only as good as the information they receive from the aircraft.

Among the better-known such systems is the Tempus 2000 from Remote Diagnostics Technologies of Basingstoke, England. In one compact box, roughly the size of a car battery, is a 12-lead electrocardiogram, blood pressure detector and leads for measuring pulse rate and temperature, as well as oxygen and carbon dioxide blood concentration. Jet Aviation and PrivatAir use the Tempus 2000, as does Virgin Atlantic and British Midlands airline.

A World of Differences

The services described above form the core of what’s traditionally come to be associated with in-flight medical services providers. As the big dog on the porch, MedAire has set the pace in the air-care business and offers all three. Being the leader has attracted competitors. It has also created wide pricing and service level differentials. For its part, MedAire does not release a rate schedule, maintaining its services are too tailor-made, too customer specific to quote out of hand.

Just as the business jet makers over the past two decades have built increasingly larger and longer-range jets, the air-care service providers have felt the competitive pinch to add more to their menu of available services. With both eyes focused on the increasing hazards executives face while traveling in a more dangerous post-9/11 world, MedAire started GlobaLifeline, a service package that includes options few businesspeople would have even remotely considered necessary a few years ago.

Among the services available via GlobaLifeline are evacuation and repatriation coverage, including procedures more reminiscent of a Tom Clancy novel than the everyday life of a business traveler. For example:

•    Inadequate facilities and a questionable blood supply in Ethiopia due to a high HIV-AIDS population made it necessary for MedAire to seek an upgraded facility for a critically ill client. The MedLink physician questioned the patient’s ability to tolerate the necessary five-hour flight to Johannesburg, due to severe hemorrhaging. Based upon medical capabilities and a shorter flight time, the patient was evacuated by air ambulance to Nairobi, Kenya, where he was later stabilized and released.

•    A MedAire client vacationing in Tahiti was in a scooter accident that resulted in severe rib fractures. MedLink was alerted that the client had been taken to a local public medical facility. Upon assessment, the MedLink physician determined that the local level of care was inadequate and made arrangements to transfer the patient to a private clinic. There, the availability of appropriate medical equipment was still questionable when it was discovered that the client had suffered a collapsed lung and risked a life-threatening arterial injury. A MedLink physician, armed with the proper medical supplies, was dispatched to Tahiti to stabilize and escort the patient back to the U.S. aboard a private, air-ambulance-configured jet.

MedAire’s growing commitment to its overseas travel markets was further evidenced earlier this year when it signed an agreement with the Ford Motor Co. and Ford Motor (China) Ltd., calling for construction, staffing and administration of a new 24-hour medical clinic for the use of Ford employees and their dependents. MedAire had long provided Ford with in-flight medical services, so they turned to a familiar source when in need of what amounts to a clinical facility in China.

The clinic will provide occupational health care, as well as primary and urgent health-care services for Ford’s expatriate employees and their families. The new clinic is located inside the Hilton Hotel in Chongqing (the city of 36 million straddles the Yangtze River and until recently was known as Chungking).

“Asia offers some good opportunities for us,” said company Med-Aire CEO Joan Garrett. “This kind of growth in that part of the world is part of our strategy of horizontal expansion.”

SARs Evacuation

Illustrating how far it has come from its early days of providing only in-flight air care, MedAire last May was instrumental in the evacuation of a potential victim of Severe Acute Respiratory Syndrome (SARS). Contacted by the Centers for Disease Control (CDC), Med-Aire’s Global Response Center coordinated the quick removal of a sick physician from his bed in Taipei, Taiwan, to a hospital in Georgia. “Any air-medical transport evacuation has its fair share of details,” admitted MedAire vice president
of global operations Robert Valente. “But the 18-hour flight time and the nature of the patient’s potential illness made this a particularly complex event.”

MedAire physician Dr. Ron Williams served as chief medical officer aboard the jet, later commenting, “SARS typically has a very rapid onset. Many times assistance companies can take a day or more to coordinate all aspects of arranging an air medical transport evacuation. But with SARS, time is absolutely of the essence.”

Number Two–Does It Try Harder?

But what about MedAire’s competitors? What do they offer and how do they stack up against the company that essentially established the industry?

Based in Olympia, Wash., AirCare International makes its niche in the business aviation industry in several ways. Of course, the company provides the basic core services (referring its client’s in-flight emergencies to its own stable of board-certified physicians at George Washington University Department of Emergency Medicine). However, AirCare’s Access program has added two features offering services until recently not usually associated with in-flight medical services, (Med-Aire now has a similar service package) but serving as a reminder of how the business has integrated itself horizontally as competition intensifies.

AirCare’s two new sister services are called AccessVIPdesk and AccessiJet.

AccessVIPdesk is a worldwide concierge service, performing almost every duty of that traditional hotel service provider. Forgotten birthday gifts or hard-to-find Broad- way tickets, AccessVIPdesk is one of the more esoteric services offered by an in-flight medical services provider.

AccessiJet is a new safety and security service available to AirCare’s Access subscribers. AccessiJet gives travelers the latest intelli- gence on their destinations, specific information on required immunizations, climate, security, local transport and more. The data is current and available 24/7.

More Than Just the Facts

But it isn’t for just these services that AirCare International is famous. For some 21 years, AirCare subsidiary’s FACTS Training International’s trademark white trailers– housing emergency procedures trainers derived from real fuselage sections–have crisscrossed the U.S., training thousands of crews in hands-on emergency procedures. Today, those trailers still make the rounds, configurable to simulate the interiors of many business jets.

Built to train crews as teams instead of individuals, the AirCare fleet of mobile simulators has trained more than 2,000 personnel, both cabin, cockpit and even frequent executive flyers.

Today, as administered by AirCare founder and president Dr. Doug Mykol, the company is a combination of AirCare International’s in-flight medical assistance and with the training expertise of Facts Training International, which AirCare International purchased on Feb. 1, 1998, merging the two companies to form the largest corporate aircrew emergency procedures training organization in the world. Like MedAire, the company has found the surest road to success lies in diversification into nearly every conceivable aspect of business travel. Another dimension was added to the AirCare family of companies in October 2001, when AirCare purchased Stark Survival, adding open-water and survival-training programs to the scope of the company’s capabilities.

AirCare’s Access prides itself on being more than just a link to a doctor. Of course there’s immediate emergency telemedical advice, assistance and referral, but the service can also locate legal aid or translation services and perform security or medical evacuations. Like MedLink, Access has branched out into serving the worldwide luxury yacht market.

So much of business jet operation seems to fall into the “if you have to ask, you can’t afford it” category, but in these financially querulous times, hard-nosed, basic questions about prices and value have to be asked and answered. The difficulty in a head-to-head examination is that what we’ll call the (for want of a better name) intensity of those services can vary widely. How many doctors on call at how many locations? Total size of staff and related overhead charges? Total depth of the package offered? It all adds up to be a long, strange trip to the bottom line, with an “apples and oranges” comparison almost inevitable.

In AirCare’s case the company’s prices vary with the aircraft operated. A proposed corporate enrollment for a flight department operating a Gulfstream GIV-SP, GIV, GV and Learjet 45 comes to $5,995 annually ($3,000 for the first aircraft; $1,000 for each additional comparably sized jet and $995 for the light jet). Also included is annual in-flight emergency medical/defibrillator training for up to 10 crewmembers. AirCare full medical assistance package, as well as AccessVIPdesk and AccessiJet concierge and security services.

ER-Link

Based in Germantown, Wis., ER-Link is the newest kid on the in-flight medical block, starting operations last year, after conducting four years of market and medical research. The concept behind ER-Link is the establishment of a datalink between onboard medical-monitoring equipment and an emergency medical team at the University of Texas. Via its proprietary “blue box,” ER-Link simultaneously sends vital life-sign infor- mation to its trauma doctor, the company doctor and a specialist in real time from aircraft, ship, ambulance or clinic. The blue-box concept is a collaborative effort among ER-Link, The University of Texas Medical Branch in Galveston, electrocardiogram maker Welch Allyn Protocol and Zoll Medical, which designs, manufactures and markets a line of cardiac resuscitation devices and accessories.

ER-Link itself is the creation of Lanna and Paul Egan, who began working on the system in 1998. Lanna is a registered nurse who still spends every other week working in an intensive-care unit at a local Level One Trauma Center in southeastern Wisconsin. For his part, Paul has owned and operated several businesses since 1969 while serving the local community as a volunteer fire chief.

The research work preceding the ER-Link looked at various ways to download patient vital-sign information to a doctor so he could suggest a plan of action based on the newest, most accurate information. Training of corporate executives to operate the system was suggested but later rejected. “We dropped that idea because an executive could go through an entire career with the company without ever having to use this system,” said Paul Egan. “The recurrent training needed would be a waste of such a person’s time. There were also retention considerations: just how much would they remember in a crisis? A study by Glendon and Kenon suggested memory retention of first-aid skills would not be enough to save a patient six months after completion of the course. It just wasn’t worth it.”

While ER-Link’s partnerships were being formed, Paul Egan started work on several different computer programs that would allow voice and vital-sign information to be transmitted over any standard digital or analog telephone at rates as low as 2,400 bps.

Like any startup business, ER-Link is offering low introductory rates, claiming worldwide service for just $750 per aircraft, a rate it maintains represents a “half off” annual introductory rate.

ER-Link is up and running, headquartered out of a new site in Germantown, Wis., with a secondary backup center located 20 miles away in Slinger, Wis. The backup center was established in another area to prevent a system crash in the event of a natural or man-made disaster.

As the sciences of both medicine and aeronautics progress, it’s hard to predict what sort of on-the-spot emergency treatment capabilities will emerge. The margin of safety enjoyed by today’s corporate traveler already exceeds expectations of four decades ago by at least an order of magnitude. If one thing is sure in scientific and medical progress, it is that the pace of advancement can always be expected to accelerate.