EMS: Courage and Compassion in Action: Angels in the Sky

By Shawn Godfrey08:30AM / Monday, October 15, 2007Print Story | Email Story

Shawn Godfrey

"Every time I hear a helicopter, I look to see whether it is an air ambulance, and if it is I think 'Thank God!' My wife is alive today due to the availability and timely response of [an air ambulance]." These are the words from a man whose wife was critically injured in an automobile crash last year, and because of rapid response and efficient treatment by emergency medical personnel and timely air transportation to a trauma center, the victim has fully recovered from her injuries and is since doing well. Helicopters, jets and cargo planes are a few of the types of aircraft that are often used as air ambulances. They are primarily utilized for emergency medical assistance in circumstances where a traditional ground ambulance cannot easily or rapidly reach the incident or for people living in remote locations or areas of difficult access where suitable medical facilities are not available. Air ambulances are also used for people who cannot travel long distances because of age, limited mobility or certain illnesses. Helicopters, for example, which are best suited for emergency scenarios, are an excellent way to quickly transport victims to specialty hospitals, like pediatric and burn centers that may be too far from an incident for a ground ambulance to travel. Helicopters also enable the distribution of the severely injured to trauma centers, therefore, helping to avoid overwhelming the hospitals closer to the scene. Alternatively, a Learjet may be used for patients simply requiring relocation ("bed to bed" transport) from one facility to another or the delivery of medical teams and life-saving donor organs to patients hundreds or thousands of miles away. Because of its extended fuel tank, the Learjet is frequently used for international travel. However, just because these jets have the capacity to travel internationally, there are regulations they must abide by to do so. The Federal Aviation Administration currently mandates that all planes traveling overseas must be equipped with special rafts and navigation equipment. Of all of the private aircrafts available, however, the Learjet is generally the least expensive for long distance travels. Air or Ground Criteria Making an informed decision in essential. When someone is seriously injured, emergency medical service personnel need to decide whether transportation by ambulance or air ambulance will get the patient to a trauma center quicker. There are several components to consider when making this decision: * ground travel time to the nearest trauma center (e.g., distance, traffic congestion) * the air ambulance's estimated time of arrival (ETA), the transfer time, and flight time to the trauma center * whether multiple patients are involved Guidelines Let's discuss each of these considerations separately. Generally, the factors which should be taken into account are: * Ground transport should be used for patients who are not physically entrapped and who are within approximately 20 minutes ground travel time from a trauma center. * Entrapped patients are an exception to the 20-minute rule, if the air ambulance can reach the scene while the patient is being rescued or extricated. * The air ambulance should generally be called to a scene that is more than 30 minutes by ground from a trauma center. * Air ambulance use when ground travel time is between 20 and 30 minutes is a gray area. There you need to consider factors such as the air ambulance's estimated time of arrival, in-flight time, extrication time, etc. * Keep in mind that, while a helicopter is fast once in flight, landing-zone positioning and loading the patient can easily add 5 to 10 minutes, or more, to the at scene time. * Consider requesting an air ambulance for incidents involving more than three critical patients. Additional manpower, communication with medical control, and transport options can be obtained by using the air medical system. To further my point, use of an air ambulance helicopter to transport a patient from one hospital to another hospital within the city may result in only minimal time-saving and, in some cases, it may prolong the transport time. This decision may also unnecessarily generate a considerable increase in health-care costs for the patient. On the other hand, poor ground accessibility or unsafe roads can make air travel advantageous. Again, making an informed decision is essential. In-Flight Care and Equipment The medical care required during flight is significantly different from care in a hospital or during ground transportation by ambulances. Hypoxia (reduced oxygen supply to the body) is always a consideration, with the addition of noise, vibration, limited physical space and motion of the aircraft. Special concerns exist for medical containers, such as glass bottles, or anything that may be pressurized and can, therefore, rupture in flight. Like in ground ambulances, both the air ambulance passengers and medical crew must be restrained to avoid injury. Certain medical treatment cannot be provided in flight, including dialysis and cardiac balloon support. Infusion devices should be automated or pump-driven and designed not to be dependent upon gravitational flows. Electrical equipment for aircraft should be battery driven and self-sustained, as most helicopters and fixed-wing aircraft are not equipped with standard 110-volt/60-cycle electrical outlets. Medical equipment is usually customized for each particular kind of mission. Like ground ambulance teams, air ambulance crews maintain a complete inventory of equipment and supplies to successfully manage critically-injured or ill patients. Standard equipment found in many air ambulances may include advanced airway and breathing devices, oxygen, advanced cardiac medications, defibrillators, CPR equipment and specially-approved stretchers. The most critical device, which should be included on all flights, is a pulse/oxygen monitor. This enables the medical team to continually monitor a patient's oxygen level and heart rate, therefore reducing the risk for hypoxia or cardiac abnormalities. Typical medical devices, such as a stethoscope, function very poorly in the aircraft environment because of background noise and vibration. Doppler devices, used in-hospital for augmented listening, and automated blood pressure monitors are far superior but still have technical limitations, even under the most benign circumstances. Other special monitors for fetal, cardiac or vascular status can be added to a flight as required. According to the FAA, the advantage of air ambulance transportation is that the cabin pressures may be controlled and limited much more closely than on a commercial aircraft, which will typically operate at the equivalent of 7,000-8,000 feet (barometric pressure of ~550 mmHg), although limiting the cabin altitude to 1,000 or 2,000 feet, or even to the altitude of the departure airport can seriously limit the range of most air ambulances with pressurized cabins, sometimes reducing the operating range by 50 percent, because the aircraft can no longer climb to its fuel efficient cruise altitude. Certain conditions, such as transporting decompression sickness patients to centers for hyperbaric treatment mandate cabin pressure limits. Depending on the equipment, crew composition, condition of the patient, and other in-flight considerations, there is sometimes room for one or more passengers to accompany the patient; however, since space in most air ambulances is usually limited, friends and family often must follow the air ambulance by other means. Accreditation and Training The primary accrediting body for air ambulance is the Commission on Accreditation of Medical Transportation Systems, which has recommended guidelines for basic life support, advanced life support and special in-flight medical care needs. Recommendations for appropriate training of medical personnel assigned to the aircraft are also available. This includes not only the understanding of the aircraft environment and the special physiologic conditions but also operating procedures for the aircraft and safe on-loading and off-loading of patients and emergency procedures. Emergency medical personnel must be trained, certified and/or licensed in accordance with their local governmental agencies. The certification or licensure levels of an air ambulance crew differ depending on state, country, or service provided and by class of the air ambulance. In most systems, in-flight personnel may consist of one or more members, such as an emergency medical technician or paramedic, a flight nurse (usually a nurse with intensive and/or critical care experience), a respiratory therapist, or in some cases, a physician. Obviously, the pilot is a given. Special Considerations Special considerations must be made for the decision to use air ambulance services. The first consideration is whether the flight is safe or not. If weather conditions or the condition of the aircraft itself is unsafe, then ground transportation should be used. Also, because the conditions of air ambulance flights offer more challenging circumstances than regular non-emergency flight services, the final decision for executing an aircraft to fly should be the pilot's Ã¯Â¿Â½ not the doctor or any other medical personnel. Failure to assign the full responsibility and authority to the pilot resulted in a series of aircraft accidents in the late 1980s, when doctors overrode pilots and ordered them to fly into dangerous weather conditions or take off in an unsafe aircraft. These accidents were the impetus behind the creation of the Association of Air Medical Services. In addition, logistical concerns are critical, particularly for helicopters, which require specialized landing zones that are appropriately lit and free of obstacles and must have controlled access so that spectators do not wander toward a helicopter positioned on the ground. There have been cases where individuals have walked through the tail rotor, with fatal outcome. A second consideration is experience and equipment of the transport. Air ambulances and helicopters are limited in what equipment they can carry, but almost uniformly the equipment is enhanced and the personnel are more experienced than ground units. This is because of the costs of operation and higher pay for flight personnel, resulting in additional incentives for state-of-the-art training and equipment. The most important question is whether the patient is so sick that ground or air transport is not appropriate. Certainly, any patient who is unstable or whose medical condition represents a threat to the health and safety of others should not travel by commercial aviation. Cost Cost and competition among air ambulance services is a double-edged sword, sometimes providing economic savings but in other cases resulting in unsafe cost-cutting maneuvers. Many insurance plans cover air ambulance services; however, it is important to check your individual plan to see that there is an air ambulance benefit and what the qualification criteria is. Like ground ambulance services, most insurance plans require that medical necessity is required. In other words, a physician must certify that the transportation by an air ambulance service is warranted and that transportation by any other means may endanger or ultimately exacerbate the patient. Most plans require that the transport is for a life threatening emergency or that the destination is the closest appropriate facility. In addition, be sure to check if there is a maximum benefit and what the benefit level is (for example, an 80 percent benefit level means the family must pay 20 percent of the charges). History of the Air Ambulance Ã‚Â· 1914-1918 - Early air ambulances were first tested by various military organizations Ã‚Â· 1928 - The first air ambulance service was established in the Australian outback. This organization became the Royal Flying Doctor Service. Ã‚Â· 1934 - The first civil air ambulance service in Africa was established in Morocco by Marie Marvingt. Ã‚Â· 1936 - A military air ambulance service evacuated wounded from the Spanish Civil War for treatment in Nazi Germany. Ã‚Â· 1946 - The first civilian air ambulance in North America was established by the Saskatchewan government in Regina, Canada - this service is still in operation in 2007. Ã‚Â· 1947 - Schaefer Air Service, the first air ambulance service in the United States, was founded by J. Walter Schaefer of Schaefer Ambulance Service in Los Angeles, California. Schaefer Air Service was also the first FAA-certified air ambulance service in the U.S. Ã‚Â· 1977 - Flight for Life Colorado began in 1972 with a single Alouette III helicopter, based at St. Anthony Central Hospital in Denver. It was the first civilian, hospital-based medical helicopter program in the U.S. Ã‚Â· 2007 Ã¯Â¿Â½ According to Commission of Accreditation of Medical Transport Systems, there are now more than 160 air ambulance/medical helicopter services in the country. Sources: The Federal Aviation Administration, www.faa.gov The Association of Air Medical Services, www.aams.org New Jersey Office of Emergency Medical Services, www. http://www.state.nj.us/health/ems/

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I had a friend who was involved in a very serious motorcycle accident on route 2. He required air transport because of his injuries and the distance from the hospital. The helicopter landed at the top of petersburg pass and he was transported to it by ambulance. The medics were great!! They really are angels in the sky!! ;)
from: wendy	on: 10-15-2007 12:00AM I Agree (0) - I Disagree (0)

We often fly patients out for extensive injuries. In some cases, I think the hard part IS determining which mode of travel is faster. It can be a tough call for us.
from: Jorge (EMT)	on: 10-15-2007 12:00AM I Agree (0) - I Disagree (0)

Shawn, As always good article. I liked the part about the history of it. Keep up the good work
from: Midnight Medicine	on: 10-16-2007 12:00AM I Agree (0) - I Disagree (0)

Loved the column. It is amazing to see how far emergency crews/technology has come.
from: MAR	on: 10-17-2007 12:00AM I Agree (0) - I Disagree (0)

Good background article, especially as it puts a focus on accreditation standards and also on the clinical input required for transport go/no go decision-making by any mode(without detracting from the pilot having ultimate fly or not fly decision). Don't know why it specifically identifies the Lear jet as an air ambulance as there are many more appropriate fixed-wing aircraft than this one despite its sexy name.
from: Ian	on: 10-17-2007 12:00AM I Agree (0) - I Disagree (0)

I liked the story. Thanks.
from: Stephan	on: 10-18-2007 12:00AM I Agree (0) - I Disagree (0)

Just a couple thoughts...You mentioned that helicopters are "best suited for emergency scenarios". While many of the transport missions of rotorwing flight involve emergency transport from an accident scene to a trauma center, there are a significant number of missions (program dependent) which are interhospital intensive care transports. Most if not all helicopters in use are equipped for intensive care transport and not just load and go situations. You mentioned that the "use of an air ambulance helicopter to transport a patient from one hospital to another hospital within the city may result in only minimal time-saving and, in some cases, it may prolong the transport time." Indeed this can in fact be the case however one must take into account that though overall the transport time may in fact be longer, the patient is being managed by a team more familiar with intensive care aspect of the transport and the length of the transport is secondary to the stability of the patient during the transport. Lastly you stated that "Certain medical treatment cannot be provided in flight, including dialysis and cardiac balloon support." This is not true. Many programs throughout the country provide Intra-Aortic Balloon Pump support and transport these devices daily. The Auto-Cat by the Arrow Corp. is specifically made for transport and is one of a number of cardiac balloon pumps utilized for transport on helicopters and fixed-wings. Other programs transport abiomed devices, left ventricular assist devices and ECMO devices. I will agree that there is no place in air medical transport for renal dialysis as this is a long term treatment and has little value in the acute setting. Thanks for the article and your insight.
from: Chris	on: 10-24-2007 12:00AM I Agree (0) - I Disagree (0)

Friends of Great Barrington Libraries Holiday Book Sale

12:15PM / Wednesday, December 17, 2025

GREAT BARRINGTON, Mass. — The Friends of Great Barrington Libraries invite the community to shop their annual Holiday Good-as-New Book Sale, happening now through the end of the year at the Mason Library, 231 Main Street.

With hundreds of curated gently used books to choose from—fiction, nonfiction, children's favorites, gift-quality selections, cookbooks, and more—it's the perfect local stop for holiday gifting.

This year's sale is an addition to the Southern Berkshire Chamber of Commerce's Holiday Stroll on this Saturday, Dec. 13, 3–8 PM. Visitors can swing by the Mason Library for early parking, browse the sale until 3:00 PM, then meet Pete the Cat on the front lawn before heading downtown for the Stroll's shopping, music, and festive eats.

Can't make the Holiday Stroll? The book sale is open during regular Mason Library hours throughout December.

Proceeds support free library programming and events for all ages.

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