POSITION PAPER

Position Paper on the

Appropriate Use of Emergency
Air Medical Services
by the Association of Air Medical Services
Hospitals must document effective use of their resources
every three years for the Joint Commission on Accredita-
tion of Healthcare Organizations (JCAHO) through a utili-
zation review program. Air medical services remain a large
expense for healthcare institutions, so the board of direc-
tors of the Association of Air Medical Services (AAMS)
directed the Medical Advisory Committee to develop a
document on the appropriate utilization of air medical ser-
vices. The purpose of the paper was to suggest broad
guidelines for the use of air medical services and to thereby
sent out by regional representatives, and a large response
resulted. Many revisions were made before the Medical
Advisory Committee met to decide the details of the final
draft.
When completed in May 1990, the document was sent
out to all program directors and medical directors for their
approval. The response was overwhelmingly positive. In
July 1990, the AAMS Board of Directors gave its unanimous
approval for the document published here.
- Alexander Jablonowski, MD
-

help ensure the proper allocation of available resources. Lifeline

This project generated substantial interest among St. Anthony Medical Center
program directors and medical directors. Early drafts were Rockford, IL

I. Introduction It is not the intent of AAMS to 5. To promote the concept that

A. Background
Air medical services have become
an important adjunct to emergency pa-
tient care in both scene responses and
interhospital transports. Literature de-
scribes improvement in air medical pa-
tient o u t c o m e , v e r i f y i n g its
importance.l'2'3 The Association of Air
Medical Services (AAMS) is dedicated
to the safe and proper use of air medi-
cal transport. The standards of AAMS
strive for excellence in patient care. 4
Because air medical transport is be-
coming integrated into the EMS sys-
tem, this association feels that it
should offer guidelines for its proper
use.
The goal of AAMS in creating this
document is to publish broad bound-
aries of use. Within these boundaries
individual air medical services can es-
tablish guidelines suited to their type
of service.
dictate standards of medical practice.
B. Purpose
1. To establish broad guidelines for
the appropriate use of air medical ser-
vices.
2. To enhance the quality of patient
care by advocating the proper use of
air medical services. This includes
consideration of medical direction of
the air medical service.
3. To promote the concept that ad-
junctive use of air medical services can
reduce morbidity and mortality by de-
creasing transport time.
4. To promote the concept that
matching the high-risk and critical
patient's needs with the proper facility
allows access to specialized care that
can reduce morbidity and mortality.
This may include the transportation of
specialized care teams and/or equip-
ment to the patient.
timely transport to the appropriate
hospital can reduce disability and total
health care costs.
6. To publish descripters of specific
illnesses, injuries, and conditions that
identify high-risk and critical patients.
These descripters can be used to iden-
tify patients transported from scenes
and interfacility transfers.
II. General Concepts of
Air Medical Utilization
AAMS believes that air medical
transport should be used when its in-
herent advantages over land-based
transport enhance patient care. This
may include interfacility transports or
scene responses.
Aircraft are useful in transporting
essential drugs, equipment and highly
trained personnel to a patient. Organ
transplant teams and donor organs can
be promptly transported.

The Journal of Air Medical Transport ° September 1990 29

POSITION PAPER
AAMS believes that the transporta-
tion of patients should include consid-
eration of."
• Perceived medical benefits to
patients which include the
following:
• timeliness and urgency of
transport
• appropriate receiving facility
• specialized medical crew
expertise available during
transport
• The safety of the transport
environment;
• The cost of the transport.
tk Time
Emergency patient care is a contin-
uum of discovery and treatment that
includes the elements of:
• dysfunction recognition
(anatomical and/or
physiological);
• assessment;
• diagnosis;
• supportive interventions;
all culminating in definitive medical
and/or surgical therapy.
The continuum of critical and high-
risk patients is usually time-depen-
dent. The more time that elapses after
the event, the less the chance of recov-
ery and survival; i.e., the "Golden
Hour" of trauma. 5
Non-trauma patients also must be
treated within their disease specific
"Golden Hour. ''3'6'7 Examples include
the following conditions: cardiac pa-
tients who require thrombolysis; pa-
tients with dissecting aneurysms who
require immediate surgery; neonates
who require access to special care
units to survive; hemorrhaging pa-
tients who require aggressive resus-
citation and restoration of blood
volume, and others.
Time affects survival. Inefficient
transport times expose patients to an
environment where the ability to re-
spond to life-threatening complica-
tions is seriously hampered.
When air medical services can
significantly reduce the time to deliver
critical or high-risk patients to defini-
tive care, they should be employed.
30
Examples may include, but are not lim- sidered include, but are not limited to,
ited to: trauma victims; high-risk moth- the following:
ers; neonates; cardiovascular patients, • anatomical and physiological
and hemorrhagic states. identifiers
• mechanisms of injury identifiers
B. Patient Transport Decisions • situational identifiers
Medical direction is preeminent in
defining which patients will benefit E. Medical Direction
from air medical transport. This may Medical direction of air medical pro-
be accomplished on-line or through grams should be appropriate to the
protocols and standing orders. It is es- type of patient and situation. This may
sential that patients transferred be- be accomplished on-line or through
t w e e n m e d i c a l facilities have protocols and standing orders.
physician-to-physician communication
to ensure continuity of care and also to III. Criteria for Emergency Air
establish parameters of care during Medical Transport Utilization
transport. This section lists the general cri-
teria and patient identifiers that may be
C. Appropriate Facility used to customize service-specific air
Within geographic limitations, medical guidelines. They are not in-
patients should be referred to an ap- tended to be all-inclusive nor rigidly
propriate facility. Considerations for applied in place of medical judgment.
choosing a facility may include, but are These criteria concern patients who
not limited to, the following: are at hospital facilities or non-hospital
• a hospital or facility that matches locations where appropriate or urgent
the needs of the patient based medical treatment is not available. In
upon the physician's knowledge the case of interfacility transfers, such
of the capabilities of equally transfers may require clearance f~om
"equipped" hospitals; the offline medical direction with con-
• a hospital or facility where the current input from the transferring
patient has previously undergone and receiving physicians. Scene re-
specialized treatment and where sponses may be governed by the pro-
the patient's medical records are t o c o l s and s t a n d i n g o r d e r s . All
located and are likely to transport decisions will be made in the
significantly influence care; best interest of the patient.
• a hospital or facility where the In the case of trauma patients where
attending physician practices, speed is important, air medical trans-
ensuring appropriate continuity port should be used if it decreases the
of care; amount of time required to deliver the
• a hospital or facility with a critically injured patient to a trauma
specialized level of care not center or appropriate facility. If the in-
available in the referring jury is such that it is not time depen-
institution. dent and a delay will not increase
morbidity or mortality, other modes of
D. Patient Selection Criteria transportation may be considered.
Even though they are necessary to In the case of the critical patient, air
guide first responders, rigid adher- medical services may provide ad-
ence to descripters identifying appro- vanced life support treatment during
priate air medical patients should not transport which may not otherwise be
replace decisions based on sound available.
medical j u d g m e n t . T i m e l y EMS
response demands a degree of overtri- tk General Criteria
age. It is intended to protect the patient 1. The patient requires critical care
and must be accepted as a part of air life support (monitoring, personnel,
medical service. Examples to be con- medications, or specific equipment)
The Journal of Air Medical Transport ° September 1990
POSITION PAPER
during transport that is not available
from the local ground ambulance ser-
vice.
2. The patient's clinical condition
requires that the time spent out of the
hospital environment (in transport
mode) be as short as possible.
3. The potential for delays which
may be associated with ground trans-
port, including road obstacles and traf-
fic, is likely to worsen the patient's
clinical status.
4. The patient is located in an area
which is inaccessible to r e g u l a r
ground traffic.
5. The patient requires specific or
timely treatment, not available at the
referring hospital or facility.
6. The patient's clinical condition
requires that care be given by physi-
cian(s) at the receiving hospital who
are intimately familiar with the
patient's history, including previously
begun chemotherapy regimens and
extensive prior invasive procedures.
7. The use of a local ground trans-
port team would leave the local area
without adequate EMS coverage.
B. Trauma Patients
1. Lengthy extrication of the patient
from the accident site and the severity
of the patient's injury requires delivery
of a critical care team to the accident
site.
2. One or more of the following
mechanisms of injury with a motor ve-
hicle accident is present:
• there had been structural
intrusion into the patient's space
in the vehicle;
• the patient was ejected from
the vehicle;
• another person in the same
vehicle died;
• the patient was a pedestrian
struck by a vehicle traveling
more than 20 mph;
• the patient was not wearing a
seat belt in a car which
overturned;
• the patient was thrown from a
motorcycle traveling more than
20 mph;
32
• the front bumper of the vehicle
was displaced to the rear by
more than 30 inches, or the front
axle was displaced to the rear.
3. The patient fell from a height of
greater than 20 feet.
4. The patient experienced a pene-
trating injury anywhere on the body
between the mid-thigh and the head.
5. The patient experienced an am-
putation or near-amputation and re-
quired timely evaluation for possible
reimplantation.
6. The patient experienced a scalp-
ing or degloving injury.
7. The patient experienced a severe
hemorrhage.
Included are those patients with a
systolic blood pressure of less than 90
mmhg after initial volume resuscita-
tion and those requiring ongoing
blood transfusions to maintain a stable
blood pressure.
8. The patient experienced burns of
the skin greater than 15% of the body
surface, or major burns of the face,
hands, feet or perineum, or associated
with an airway or inhalation injury.
9. The patient experienced, or had
great potential to experience, injury to
the spinal cord, spinal column, or neu-
rologic deficit.
10. The patient suffered injuries to
the face or neck which might result in
an unstable or potentially unstable air-
way and might require invasive proce-
d u r e s (such as e n d o t r a c h e a l or
nasotracheal intubafion, tracheotomy,
or cricothyroidotomy) to stabilize the
airway.
11. The patient had a score from an
objective ranking system for trauma
(such as the Champion Trauma Score,
Revised Trauma Score, CRAMS, Glas-
gow Coma Scale, etc.) at the scene of
the a c c i d e n t or at the referring
hospital's e m e r g e n c y department
which indicated a severe injury.
12. The patient is a child less than
five years of age with multiple trau-
matic injuries.
13. The patient is greater than 55
years of age and has multiple traumatic
injuries, whether with or without pre-
existent illness, such as diabetes mel-
The Journal of Air Medical Transport • September 1990
litus, coronary artery disease, chronic
obstructive lung disease, or chronic
renal failure.
14. The patient is an adult with a
respiratory rate of less than 10 or
greater than 30 breaths per minute, or
a heart rate of less than 60 or greater
than 120 beats per minute. 8
C. Adult Medical/Surgical Patients
1. The patient experienced a respi-
ratory or cardiac arrest within the past
12 hours or is experiencing acute re-
spiratory failure not responsive to ini-
tial therapy.
2. The patient requires continuous
intravenous vasoactive medications or
mechanical ventricular assist to main-
tain a stable cardiac output.
3. The patient requires continuous,
intravenous anti-dysrhythmia medica-
tions or a cardiac pacemaker to main-
tain a stable cardiac rhythm.
4. The patient requires mechanical
ventilator support or is at risk of having
an unstable airway.
5. The patient experiences an acute
deterioration in mental status.
6. The patient requires immediate
invasive therapy for hypothermia.
7. The patient has an indwelling pul-
monary artery catheter, intra-aortic
balloon pump, arterial line or in-
tracranial pressure monitor.
8. The patient has a respiratory rate
of less than 10 or greater than 30, or a
heart rate of less than 50 or greater
than 150, or a systolic blood pressure
of less than 90 mmhg or greater than
200 mmHg.
9. The patient has evidence of signif-
icant acidosis (such as arterial pH<7.2)
not responsive to initial therapy.
10. The patient requires immediate
transport in a critical care environment
to a medical center that can perform
organ transplantation or procurement.
11. The patient is experiencing an
acute myocardial infarction, a dissect-
ing or leaking aneurysm, or an acute
cerebrovascular accident in evolution
and requires therapy or diagnostic pro-
cedures not available at the referring
institution.

12. The patient is experiencing
seizures which cannot be controlled at
the referring institution.
13. The patient is pregnant with a
high-risk obstetrical condition (includ-
ing placenta previa, abruptio placenta,
eclampsia, pre-eclampsia, or prema-
ture labor with or without rupture of
the membranes) and requires urgent
transport to a pefinatal center.
D. Pediatric Patients
1. The patient is experiencing or has
a high risk of developing cardiac dys-
rhythmias or cardiac pump failure that
requires interventions not available at
the referring hospital.
2. The patient is experiencing or has
a high risk of developing acute respira-
tory failure or respiratory arrest and is
not responsive to initial therapy.
3. The patient requires invasive
airway procedures (including endotra-
cheal or nasotracheal intubation, tra-
cheotomy, or cricothyroidotomy) and
assisted ventilations.
4. The patient is experiencing any of
the following unstable vital signs:
• respiratory rate < than 10 or
> 60 breaths per minute;
• systofic blood wessure <
60 mmHg in a neonate;
• systolic blood pressure < 65 mm-
Hg in an infant < 2 years of age;
• systolic blood pressure < 70 ram-
Hg in a child 2-5 years old
or systolic blood pressure <
80 mmhg in a child 6-12 years.
5. The patient is experiencing any of
the following clinical conditions:
• near-drowning with signs of
hypoxia or altered mental status
• status epilepticus
• acute bacterial meningitis
• acute renal failure
• unstable toxicologic syndrome
• Reye's syndrome
• hypothermia
• multiple trauma
IV. Position Summary
A. Proper Use of Service
Air medical services can signifi-
cantly reduce the time to deliver criti-
cal or high-risk patients to definitive
The Journal of Air Medical Transport • September 1990
care and may provide a higher level of
care than is otherwise available.
B. Appropriate Facility
A facility's appropriateness is not
based solely on geographic proximity.
C. Patient Qualifications
Descripters may assist in the deci-
sion for determining appropriateness
of air medical patients but should not
replace decisions based on medical
judgment.
D. Medical Direction
Medical direction is preeminent in
defining which patients will benefit
from air medical transport.
Acknowledgements
The authors would like to thank Dr.
Henry Bock, who put together the ini-
tial draft of this paper; the contributors
who shared input during the interme-
diate drafts; and the Medical Advisory
Committee members--Drs. Nicholas
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POSITION PAPER
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ford, Richard Slevinski and Wendy
Witt--who shaped the final draft.
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COPYRIGHT1989G.R.L.
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