“IFR” stands for “Instrument Flight Rules.” It refers to a set of rules governing the conduct of flight under weather conditions where navigation by Visual Flight Rules (VFR) is no longer reliable. The conditions for IFR flight and the flight rules themselves are contained in the FAA’s “Instrument Flying Handbook. (Advisory Circular 61-27C).”
The debate among users continues with this issue. Some pilots and passengers have always believed two is better than one. On certain levels this is still true today. Anyone flying 100 miles offshore, or over mountainous terrain at night feels better knowing that there are two engines working for him or her. However, with the advent of truly reliable turbine engines, the probability of and engine failure is greatly reduced making the single-engine helicopter a safe and economical choice. A great deal depends on the type of missions flown, and the space required to accomplish it. All medium and large capacity helicopters are multi-engine, needed for the power required to lift the payload.
The “Golden Hour” concept provides that along the route to the surgeon’s knife in that first hour, a patient should benefit from an organized EMS system which provides increasingly advanced care (e.g. BLS to ALS to the physician-level care provided by air medical crews). The complete EMS trauma subsystem must include: Rapid discovery of the injured patient and notification of EMS. Fast response of BLS EMS. Early activation by trained and authorized requesters. Timely availability of ALS resources. Rapid access to physician level intervention through HEMS response or the closest Emergency Department. Rapid transport to identified trauma centers. Inter-hospital transfer to needed specialty care by critical care ground ambulance helicopter or fixed wing air ambulance as needed. Excellent planning and coordination of EMS resources. Quality assessment of each component in the combined air and ground emergency response. A recent paper cites the Maryland system as having these components in place and organized well, and calls upon other systems to emulate it. It has been well demonstrated that organized trauma systems with trauma centers save lives.
In the early 1980’s, the first analytical attempts to determine the life-saving impact on mortality by HEMS response to injury scenes began to appear, largely demonstrating reductions in mortality compared with ground systems.18-20, 38 Since the ‘80’s, there have been many published medical studies which have attempted, through a variety of means, to assess HEMS’ impact on trauma mortality and morbidity for both scene and interfacility flights. Overall, these studies have demonstrated the power of HEMS to affect improvements in trauma-related mortality and morbidity.
As a part of an organized trauma system, HEMS cuts the injury-tooperating- room time significantly. Medical helicopters, dispatched simultaneously with ground EMS, can give over 54% of the US population access to a full-service trauma center within 60 minutes that they otherwise would not have.
Medical helicopters also discourage time-costly intermediate stops at small, non-trauma center hospitals. Such stops have been shown to be detrimental to trauma patients, even where HEMS is called from that hospital for the final leg of the trip.
In the future, improvements in cell phone technology and automatic crash notification (ACN) technology in cars may cut the time required to discover and report a crash injury to almost zero. Using “urgency” indicators generated by automatic crash notification data sent from crashed cars to dispatch centers, along with special medical protocols for assessing the probability of severe injury from the crash, will soon provide a rational and effective way for helicopters to be launched within minutes of an accident, no matter ho remote, thereby further improving the speed of EMS response to patients.
Examples of recent study findings demonstrate that: s Patients severely injured enough to require inter-facility transfer were four times more likely to die after the HEMS serving that area was discontinued. HEMS reduced injury mortality by 24% in a multi-center study with some 16,000 patients in Boston. Even injury patients in urban areas experienced a transport-time benefit by HEMS in 23% of the cases.
Traumatic brain injury (TBI) is frequently associated with events causing severe, multiple trauma in patients, and is the leading cause of death and disability in children and in adults in their most productive years. As with other major injury, treatment of traumatic brain injury is time-critical. Outside of urban areas, the reduced availability of the neurosurgical services required to treat traumatic brain injury has posed a challenge to EMS. Recent studies indicate that early advanced care by air medical crews and air transport to definitive care by a neurosurgeon can overcome this challenge, resulting in significant improvement to moderately and severely traumatic brain injured patients.
HEMS is generally effective in trauma care circumstances such as when: There is an extended period required to access or extricate a remote (e.g. injured hiker, snowmobiler, or boater) or trapped patient (e.g. in a crashed car) which depletes the time windo to get the patient to the trauma center by ground. Distance to the trauma center is greater than 20 to 25 miles. The patient needs medical care and stabilization at the ALS level, and there is no ALS-level ground ambulance service available within a reasonable time frame. Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center via ground ambulance within the ideal time frame for best clinical outcome. There are multiple patients who will overwhelm resources at the trauma center(s) reachable by ground within the time window. EMS systems require bringing a patient to the nearest hospital for initial evaluation and stabilization, rather than by-passing those facilities and going directly to a trauma center. This may add delay to definitive surgical care and necessitate HEMS transport to mitigate the impact of that delay. There is a mass casualty incident.
In rural and frontier areas, HEMS and fixed wing aircraft play a particularly important role. Where the nearest ground ambulance is further, by traveltime, from the scene of injury than the nearest HEMS, the air medical service may be the primary ambulance for critically ill and injured patients in that area. Where the nearest ALS-capable medical facility is further, by travel-time, from the scene of the injury than is a HEMS or a fixed wing provider, the air medical service may be the primary ALS provider for critically ill or injured patients in that area. Where blood supplies or availability of other medical supplies or equipment are limited or non-existent, jeopardizing the care of the patient, the air medical service can bring these resources to the hospital with the patient.
The air medical service can transport specialized medical staff (surgical, emergency medicine, respiratory therapy, pediatric, neonatal, obstetric, and specialized nursing staff) to assist with a local mass casualty event or to augment the rural/frontier hospital’s staff in stabilizing patients needing special care before transport.
A heart attack occurs when an artery in the heart is blocked by a clot, and the heart muscle supplied by that artery is therefore deprived of oxygen. This causes chest pain, and the muscle is in jeopardy of dying. Untreated, these blockages can permanently damage the heart causing death or an otherwise reduced quality of life.
As with critical injuries, there is a window of time (generally thought to be two hours from symptom onset) in which the heart may be effectively treated before it, and the patient, die or are disabled. At any time in this window, the compromised heart may stop or otherwise require emergency treatment to keep the patient alive. Out of hospital, HEMS ALS has proven effective in dealing with these emergencies. Ultimately, these patients need either special medications or surgical procedures at specialist cardiac intervention hospitals to break up the blood clot, allowing blood and the oxygen it brings to return to the affected heart muscle. Done within those two hours, the heart may be undamaged or damage may be limited, allowing the patient not only to live, but to recover a normal life.
Similar to trauma centers, cardiac intervention centers have been developed to provide the more effective of these increasinglycommon surgical treatments. The scarcity of cardiac intervention centers, particularly outside of urban areas, suggest a role, supported by studies to date, for HEMS in quickly transporting patients, even patients whose hearts have stopped and been restarted, from remote hospitals to these centers.
Trauma Transport Protocols (TTP) describe the procedures used by the emergency medical services prehospital provider for dispatch of vehicles, assessment of the extent and severity of injuries of trauma patients and determination of the destination (facility) to which trauma alert patients are transported. TTP’s are a legal document that should outline, as accurately as possible, the actual procedures followed by the emergency medical service provider, written within the context of section 395.4045, Florida Statutes and Chapter 64J-2, Florida Administrative Code.
When to Submit TTP’s:
- Applying for initial licensure as an EMS provider.
- A change in medical directors for the EMS provider.
- A change in ownership of the EMS provider.
- A change in hospital destination for the routine transport of trauma alert patients. Any change in EMS providers or health care facilities that will impact transportation requirements.
- When the department requests a revision.
The approval period for TTPs is the same as the EMS provider’s two-year licensure period, unless revisions are made to department approved TTPs during that period.
Who Does Not Submit TTPs:
- A service that provides only inter-facility services and does not respond to the scene of an injury to provide stabilization of injured patients in prehospital settings. The EMS provider needs to submit to the Bureau of EMS either a copy of the Certificate of Public Convenience and Need or a letter from the director or chief of the service stating that it is an inter-facility service only.
A Public Policy Paper by the MedEvac Foundation International.
Air Ambulance Medical Services Summary
The use of air medical services (AMS) has become an essential component of the health care system. Appropriately used air medical critical care transport saves lives and reduces the cost of health care. It does so by minimizing the time the critically injured and ill spend out of a hospital, by bringing more medical capabilities to the patient than are normally provided by ground emergency medical services, and by quickly getting the patient to the right specialty care.
Dedicated medical helicopters and fixed wing aircraft are mobile flying emergency intensive care units deployed at a moment’s notice to patients whose lives depend on rapid care and transport. While AMS may appear to be expensive on a single-case basis compared with ground ambulance service, examining the benefits behind the cost on an individual and a system-wide basis shows that it is cost-effective. The picture of a helicopter at the scene of a car crash evokes visions not only of the life-saving power of air medical services, but also of the risks of the environment into which they fly. Yet, air medical patient care and transportation actually promises less risk to the patient than does a patient’s hospital stay. “Time is human tissue” is a saying that means death and disability from severe injuries, heart attacks, strokes, medical and surgical complications, and other time-dependent conditions often can be avoided if the right care is provided quickly enough.
AMS is a means to bridge geography and time. As technology provides new, time-sensitive care, the need for AMS will increase. As the costs of the health care system continue to rise, and the availability of even routine health care in rural communities is put at risk, AMS will play an increasingly important role in the delivery of health care. In these days of increased concern about homeland security and emergency preparedness, air medical services provide a valuable medical resource that can transport patients and medical staff long distances, as well as carry medical equipment and medical supplies to the affected area(s). AMS is an integral component of disaster planning and management. The recent experience of hurricanes Ivan, Katrina, and Rita illustrate the essential role of AMS in evacuating critically ill and injured infants and adults from hospitals and nursing facilities as well as providing direct scene support to disaster management teams. Without a prompt and massive AMS response of both dedicated air medical helicopters and fixed wing aircraft to the Gulf Coast, thousands of additional lives would have been placed at risk or even lost. Integrated air medical resources are an essential component of contemporary EMS systems.
Today, financial pressures, insurance issues, changing federal regulations, and competition all are forcing changes, consolidation, and in many cases reduced services or closure of emergency departments, trauma centers, hospitals and specialty physicians. These factors have contributed to the increased use of AMS to move patients to specialty centers, particularly from outlying areas. As with EMS in general, there has been a general lack of overall system planning and design to guide the development and implementation of needed AMS. Mechanisms that might provide such guidance, such as state EMS or health regulations, certificate of need (CON) processes, and federal aviation and healthcare regulations sometimes conflict with one another, providing a jumble of uncoordinated hurdles to AMS providers.
The future of Air Ambulance Services
Maintaining access to care is an ever greater challenge for both healthcare providers and policy makers. Natural and man made disasters have highlighted the need for an effective, available air medical system. This was exemplified in the air medical response to victims of Hurricane Katrina in which thousands of lives were saved during both scene response and the evacuation of critically ill patients from hospitals. air ambulance service has been shown to be cost-effective when looking at total medical costs as well as lives saved.
Much like other effective healthcare interventions (such as trauma systems), technologies (such as CAT scans), and specialty surgeries (such as those for heart attacks patients), air ambulance service is expensive to maintain. It is essential that public policy and funding sustain air ambulance service as a critical part of the medical and emergency preparedness safety net in our communities. Maintaining the readiness to respond is as essential as the actual care delivered by air ambulance service.
According to the US Department of Health and Human Services, “It was estimated that in 2000 there were 605 million persons worldwide aged 60 years or older. This number is projected to increase to almost two billion by 2050.” The trend is particularly noticeable in the U.S., with a rapidly aging population, especially in rural areas. The emergency medical needs of this population are reflected in the growing rates of trauma, as well as the increased occurrence of time-critical conditions such as heart attack, stroke, and non-trauma surgical emergencies (e.g. abdominal aneurysms and stomach/intestinal bleeding).
Recent studies examining the response to elderly trauma patients have found that many of these patients do not currently reach trauma centers in a timely manner. As medical science creates new ways to intervene in medical emergencies with technology that must be utilized within a critical window of time, the need for air medical services to bring that technology to patients, or to bring patients to that technology, will increase.
Current financial pressures on the health care system will only increase. The mismatch between demand and resource availability is becoming more acute. These pressures will continue to erode the availability of hospital based delivery of specialty care and life-saving technologies, particularly in rural areas. The need for increased access to ever scarcer specialty care resources, and the increased need to make such care mobile will increase the need for air ambulance service.
The Flying Doctor Service in Australia is one successful model of providing both emergency and routine medical services by air to far-flung populations. The Association of Air Medical Services believes that it is essential to assure that every person has access to quality air medical and critical care transport when needed. It is imperative that policy and funding support the availability and sustainability of air ambulance service to every community.
Like heart attacks, some strokes are caused by interruption of blood predominately from a blood clot, only this time in the brain. As in heart attacks, there is a window of time (optimally within 90 minutes but generally no more than three hours) in which clotbusting treatment can result in patients suffering little to no long term damage and disability from these events. Therefore, patients transported to specialty centers for the clot-busting treatment of strokes can benefit from a well-coordinated ground and air system to accomplish early transfer.
From 1972 through September, 2002, when HEMS safety research by Dr. Ira Blumen of the University of Chicago Aeromedical Network (UCAN) was completed, HEMS had flown approximately three million hours, transporting some two and three-quarter million patients. In that time, there were 166 crashes involving HEMS, with 183 fatalities. The UCAN study found that while the number of crashes each year has fluctuated, the number per 100,000 patients flown had dropped from 17.36 in 1980 to 5.5 in 2001.
The risk to patients, estimated over the years of the study, is reported as a fatality rate of 0.76/100,000 patients. Subsequent admission to a hospital carries with it a greater risk of death from complications or errors: various recent estimates range from 1.2/100,000 patents to 292/100,000 patients.
Nonetheless, any form of medical transport incurs inherent risk and in the past few years there have been increased numbers of accidents associated with the increased number of helicopters and transports. In an editorial comment in the UCAN study, a past president of the National EMS Pilot Association emphasizes that the causes of crashes haven’t changed over the years. The top three causes are “risk taking, pre-flight planning, and in-flight decisionmaking,” reflecting the unique pressure placed on crews by the condition of the patient and by the feelings of obligation to fly.
The air ambulance service community has taken significant steps, particularly in the area of aircrew resource management (a proven airline industry safety tool) to improve its safety for patients. Some HEMS prograir ambulance service are replacing aircraft, hiring pilots to fly under Instrument Flight Rules (IFR), and employing new technologies such as night vision goggles (NVG’s) and terrain avoidance warning systems (TAWS), especially important when weather conditions abruptly change mid-mission.80 Transport medicine is among the most complex arenas of medicine, and is characterized by the need to provide immediate access to time-sensitive care for critically ill and injured patients at the same time that operations are conducted in hostile environmental conditions with limited planning time. As Justice Oliver Wendell Holmes once noted: “to be safe does not mean to be risk free.” Recognizing that risk cannot be completely eliminated, it is essential both for the public served, and the pilots, nurses, paramedics, physicians, and other health care providers who deliver care, that the practice environment be as safe as possible.
To that end, the Association of Air Medical Services has already initiated Vision Zero (http://aamsvisionzero.org/) and has joined the International Helicopter Safety Team (IHST, www.ihst.org), led by the American Helicopter Society (AHS), the Helicopter Association International (HAI), the Federal Aviation Administration (FAA), and Transport Canada to reduce helicopter accidents by 80% in the next ten years.
These initiatives seek more effective methods and approaches to avoiding errors in complex systems premised on the model that providers must work collaboratively, on a voluntary basis, with regulators to identify and accelerate the implementation of best practice standards. These efforts focus on developing and implementing strategies using cost benefit analysis and evidence based best practices related to safety in order to prioritize investment and financial plans to result in a goal of zero serious injuries or fatalities.
We estimate that there are nearly 400,000 rotor wing transports annually, with an additional 150,000 patient flown by fixed wing aircraft each year. (US only)
In 1926, the United States Army Air Corps used a converted DeHaviland aircraft to transport patients from Nicaragua to France Army Base in Panama, one hundred and fifty miles away. The first civilian air medical transport was completed in 1928 when a DeHaviland Fox Moth aircraft in the service of Australia’s Royal Flying Doctor Service took off on its first mission. The Royal Flying Doctor Service holds the distinction of being the first civilian air medical transport program.