The paper work requirements are listed on the application for AIR ambulance licensure, “Air Ambulance Service Provider Licensure Application”, DOH Form 1575. Click on the application and the application checklist to review most requirements. Other requirements will be found in Section 401, Florida Statutes, & Chapter 64J-1, Florida Administrative Code. The following is a partial list of the major requirement: Certificate of Public Convenience and Necessity (COPCN) from the county commission in the county you wish to operate your prehospital service, a medical director (licensed Florida physician) with a Department of Justice-Drug Enforcement Administration (DEA) registration (prehospital only), aircraft vehicle liability insurance, trauma transport protocols and an approved radio communication system. Approval of a radio communication system is completed by Department of Management Services-Information Technology Program. Contact DMS for more information on EMS radio communication systems.
Every person, firm, corporation, association or governmental entity owning or acting as an agent for the owner of any business or service which furnishes, orperates, conducts, maintains, advertises, engages in, proposes to engage in or professes to engage in the business or service of providing prehospital or interfacility advanced life support services or basic life support transportation service must be licensed as a basic or advanced life support ambulance service, before offering such service to the public.
Reference Section 401.25, Florida Statutes & Section 64J-1.002, & 64J-1.003, Florida Administrative Code.
An ambulance driver must meet the following requirements:
- Is at least 18 years of age;
- certifies under oath that he or she is not addicted to alcohol or any controlled substance, and is free from any physical or mental defect or disease that might impair their ability to drive an ambulance;
- Upon initial designation as a driver, has not within the past 3 years, been convicted of reckless driving or driving under the influence of alcohol or controlled substance and has not had a driver’s license suspended under the point system provided for in Chapter 322, Florida Statutes;
- successfully completed a 16 hour course of instruction on driving an authorized emergency vehicle, which includes, at a minimum, classroom and behind the wheel training. Section 64J-1.013, Florida Administrative Code for details on the 16 hour course content;
- possess a valid American Red Cross or National Safety Council first aid course or its equivalent; and
- possess a valid American Red Cross or American Heart Association cardiopulmonary resuscitation card.
There is no standard aircraft utilized in medEvac operations. Airplanes (fixed-wing aircraft) vary in size from single-engine turboprops such as the Pilatius PC-12 to twin-engine aircraft like the Cessna Citation, Beech B-200, and Lear 35. Most are either turboprop or jet aircraft which lends to faster, more versatile performance. In helicopter operations, again, no one make or model is the standard. Helicopters are chosen for a myriad of reasons such as payload capability, range, economy of operation, and geographic location. The most common helicopters found in medEvac use are the Bell 206/407, and Eurocopter AS-350 for single-engine aircraft. For multi-engine the medium sized Bell 222/230, Eurocopter BO-105, BK-117, and Agusta A-109 are widely used. The largest multi-engine helicopters in service with medEvac services across the nation are the Sikorsky S-76, Bell 412, and the Eurocopter AS-365. All aircraft used in medEvac operations have proven themselves with thousands of safe transports.
Chapter 401, Florida Statutes and Chapter 64J-1, Florida Administrative Code, are the law and rules, respectively, that governs Florida Emergency Medical Services.
Chapter 401, Florida Statutes
Section 64J-1, Florida Administrative Code
BLS vehicles are required to have at a minimum an emergency medical technician (EMT) attending the patient and a driver meeting the requirements in Section 401.281, Florida Statutes.
ALS vehicles are required to have at a minimum a paramedic attending the patient and an EMT.
Aircraft-Prehospital air ambulances are required to have a minimum of one paramedic.
Interfacility air ambulance staffing is based on the patient’s condition as determined by the medical director.
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.
Yes, when it is necessary for a permitted vehicle/aircraft to be out of service for routine maintenance or repairs, a substitute vehicle/aircraft meeting the same transport capabilities and equipment specifications as the out of service vehicle/aircraft may be used for a period of time not to exceed 30 days. An unpermitted vehicle/aircraft cannot be placed into service, nor can a BLS vehicle be used at the ALS level unless it is replacing a vehicle that has been temporarily taken out of service for maintenance. When such a substitution is made, the following information shall be maintained by the licensee and shall be accessible to the department:
- identification of permitted vehicle/aircraft taken out of service;
- identification of substitute vehicle/aircraft; and,
- the date on which the substitute vehicle/aircraft was placed into service, the date on which it was removed from service and the date the permitted vehicle/aircraft was returned to service.
The Effects of Altitude
Even in pressurized aircraft, the air medical environment presents unique stresses on our patients. These stresses include immobility, noise, motion, vibration, hypoxemia, decreased humidity, gravity, and decreased barometric pressure with subsequent air expansion. To assure that our patients are transported as safely and comfortably as possible, the following protocols apply:
1. Head and Neck
- Balloons: All balloons (e.g. nasal balloons for posterior nasal bleed) shall be filled with water whenever possible.
- Trapped air: Medical aircraft pressure may need to be adjusted for patient comfort due to the expansion of trapped air in sinuses, dental cavities, or middle ear blockage. Patients with intracranial or intracerebral air will need to be flown at or near a sea-level equivalent pressure. Patients prone to middle ear block will be offered chewing gum and/or afrin nasal spray if clinically appropriate.
- Eye injuries: Air ambulance cabin pressure may need to be adjusted for patients with eye injuries. In addition, these patients and patients with recent eye surgeries shall have their heads elevated and immobilized during flight. Supplemental oxygen will be used for all patients with recent eye injury or eye surgery due to the high oxygen requirements of the retina.
- Neurology insults: All patients with head injuries, brain injuries or cranial surgery shall be loaded with their feet to the rear of the medical aircraft. The patient’s head will be elevated to 30 degrees. Oxygen saturation will be maintained at or above 95%. Foley catheters will be inserted. Patients with a Glasgow Coma Scale (GCS) score of 9 or less shall be intubated unless their baseline GCS is normally 9 or less, or unless they have a valid current DNR requesting no intubation. NG tubes will be inserted unless the patient has a crib form plate or basilar skull fracture.
- Eye humidification: Comatose patients shall be given artificial tears every hour during a medical flight unless eyelids are taped closed. Patients and passengers with contact lenses shall be offered moisturizing eye drops at frequent intervals.
- Seizures: All patients with a history of seizures or a high potential for seizures shall be evaluated for anticonvulsant medication and/or sedation.
- Trauma patients: If the patient complains of c-spine, examine x-ray. If x-ray is not available, apply neck brace prior to transport.
- Wired jaws: An antiemetic shall be given prior to transport via air ambulance. Wire cutters shall be available in the event of emesis.
- Trapped air: Patients with decompression sickness or those who are at risk of decompression sickness shall be flown at a sea-level equivalent altitude for pressurization purposes.
- Hydration: Fluids shall be encouraged (clinical condition permitting) or IVs administered or adjusted to compensate for low humidity environment. Patients shall receive frequent mouth care with lemon glycerin swabs or fluids.
- Recent MI or unstable angina: Those patients shall be flown in accordance with U.S. Air Ambulance’s unstable angina/recent MI protocol.
- Shock: All patients in shock of any kind shall have an NG tube inserted.
- CHF: All patients in CHF shall have oxygen saturation at or above 95%. They shall be placed with their feet to the rear of the medical aircraft and transported in a sitting or semi-fowler’s position.
- Trapped air: Patients with a pneumothorax shall have this air vented via closed chest tube or needle decompression. If venting is not possible, air ambulance cabin altitude will be adjusted to accommodate this.
- Air filled devices: Airway cuffs shall be filled with water to prevent excessive tracheal pressure.
- Suctioning: Patients with artificial airways shall be suctioned prior to the medical air flight, then at each refueling stop. Frequent suctioning may be required depending on the patient’s clinical condition.
- Pulmonary secretions: Thick and difficult pulmonary secretion may be worsened by the low humidity. Mucous plugs may form. Patients with this problem will be offered humidified air via mask or Guifesen preparations to act as expectorant/mucolytic.
- Oxygen: Oxygen will be available on all medical flights. All air ambulances should prepare for at least 2 lpm. Any patient with a known disease or condition that lessens tissue oxygenation, (e.g. CHF, anemia, COPD, narcotics) or whose condition might be aggravated by hypoxia shall be placed on oxygen during flight with oxygen saturation at or above 90% at all times. (Exceptions to this are addressed elsewhere in this protocol). Patients already on 100% oxygen prior to flight will need to be flown at lower altitudes to maintain adequate oxygenation.
- Special precautions for chronically hypoxic COPD patients: Patients with severe COPD whose oxygen saturations normally run less than 90% should be given only enough oxygen to maintain their “normal” oxygen saturation. Attempting to go higher will only lead to further carbon dioxide retention and possible respiratory arrest or cardiac arrest.
- Severely obese patients: To reduce the risk of barobariatrauma, the patient will be placed on 100% oxygen for 15 minutes prior to the medical air transport. Oxygen saturation will then be maintained at or above 95% throughout the flight with supplemental oxygen.
- Appropriate oxygen supplies: For patients known to require oxygen, the Medical Coordinator will calculate the amount of oxygen needed to meet the patient’s needs for the duration of the air ambulance trip, bedside-to-bedside. Due to potential unforeseen delays in patient transport, a minimum of 150% of the calculated need will be loaded with the patient.
- Air filled devices: All balloons shall be filled with water, when possible. If not possible, the pressure must be monitored closely. (e.g. Sengstaken-Blakemore tubes for bleeding esophageal varices.)
- Trapped air: NG tubes, orogastric tubes and colostomy bags shall be vented during flight, not clamped.
- Patients with non-vented intestinal or peritoneal air (e.g. bowel obstruction or recent surgery) may need medical aircraft cabin pressure adjusted to avoid complications of air expansion.
- Air sickness: Patients who are prone to or who develop air sickness shall be offered an antiemetic. This can be done by mouth, injection (IM or IV), suppository (e.g. phenergan) or patch such as trans-derm Scop.
- Air filled devices: Balloons such as Foley catheters shall be filled with water when possible.
- Voiding: Patients shall be encouraged to void prior to their air ambulance flight as well as during fueling stops. For patients who cannot void easily, Foley catheters will be considered on all flights that are expected to be six hours or longer.
- Patient shall be turned and repositioned at least every two hours whenever possible. For flights over 4 hours, the stretcher should be padded to reduce tissue breakdown.