Case Histories.

1. A 22-year-old female was a passenger in an
automobile which was struck from the rear by @
large truck. She was diagnosed as having a dis-
location of two cervical vertebrae with incom-
plete flaccid paralysis of both arms and the right
side of the body. While in the hospital, she re-
gained partial function of the arms. She had
“received a collar” following reduction of disloca-
tion. Approximately five weeks later, while still
in the hospital, a cast was applied following a
second reduction. The elevation of the city of
hospitalization was 6,800 feet msl. One week
later, the patient was placed on a bed board,
taken by ambulance to the airport, and placed in
a reclining position in a twin-engine aircraft.
The flight elevation was 8,500 feet at first and
later rose to a maximum of 9,200 feet. The
patient was discussing the flight with the nurse
and crew, and was not observed initially to have
any difficulty in breathing. Later, however, the
attending nurse noticed the patient’s head droop.
The nurse administered oxygen, attempted to
cut off the cast, and requested the pilot to land
because she was having difficulty with the patient.
The nurse could detect no vital signs prior to the
landing; and after the landing, the patient was
pronounced dead. At autopsy, both lungs were
edematous and congested, and the right lower
lobe manifested pneumonia with coalescing
patches. The cause of death was reported to be
bronchial pneumonia, secondary to fractured
cervical vertebra. The hospital records revealed
a spike in temperature the day before departure
and a pulse rate of 120. The patient, on atropine
because of complaints of frequent swallowing of
saliva, had also received one and a half grains of
codeine before the flight. Prior to the accident,
she had been living at sea level. The air-taxi
operator was told that the patient was fine for the
flight and that there should be no problem with
the planned maximum flight altitude of 9,200
feet.

2. A twin-engine aircraft was used to transport
a middle-aged man who had been hospitalized
with a diagnosis of leaking aortic aneurysm. At
the request of the patient’s family, the man was
to be flown to a well-known medical center for
surgical correction. The patient’s doctor was
reluctant to release him but, at the insistence of
the family, a release was effected. The patient, in
a marginal medical condition, was transported to

the airport by ambulance. He was loaded on
board the aircraft with no attendant available
and with only one pilot on board. The flight
covered a distance of approximately 1,100 miles.
At the time of landing, the pilot first observed
that the patient seemed to be in shock. There
had been no effort made to detect pulse or respi-
ratory rate, or to observe the patient’s general
condition during the flight.

3. A twin-engine aircraft was used to transport
a patient, previously hospitalized in a southern
city for cardiovascular disease, to her home in the
northern United States. There were no inquiries
made by the patient’s physician regarding alti-
tude or the use of oxygen during flight. There
was no oxygen available, no medical attendant
on board, and only one pilot was present. When
the aircraft reached the city, the patient was
dead. The pilot stated that he was responsible to
provide transportation and was not responsible
for the patient’s care.

4. A child was admitted to a southeastern
hospital with second and third degree burns over
the trunk. Because of business and personal
pressures, the parents urged the physician to re-
lease the child for travel home. The physician
finally consented and left instructions with the
parents concerning necessary care, but no effort
was made to secure medical assistance in flight.
The child was placed on a single-engine aircraft
with no medical attendant present and, ap-
parently, with no space for the parents. The
copilot was given instructions from the parents
regarding medication and other instructions
which had been received from the physician,

5. An elderly patient was being transported
from a southeastern city to a northern city for
prolonged nursing-home care. At the time of
transfer, the patient was considered to be in
marginal condition following a CVA which re-
sulted in partial paralysis. The aircraft was
equipped with suction, oxygen, and a nurse
familiar with aeromedical evacuation problems.
The patient was sedated during the flight. A
physician was available at the point of dispatch
for consultation with the nurse via telephone each
time the aircraft stopped for refueling. The
eventual altitude flown was higher than that
planned and, during the flight, the patient became
cyanotic and showed evidence of respiratory
distress. Oxygen was employed and the nurse
requested that the pilot descend to a lower alti-



Ill. Need for Organization.

There is a clear need for unity among opera-
tors, such as can occur through a national organi-
zation. Such unity could not only elevate stand-
ards but could also do much to stimulate produc-
tion of appropriate equipment for the general
aviation air-ambulance operator. Costs could
possibly be pared by coordination of to-and-
from flights to reduce one-way revenue flights.
Since there will be unscheduled, overnight stops,
hospitalization when required could be facilitated
through interaction with members of an organi-
zation such as the Flying Physicians Association,
a presently constituted, aeromedically-oriented
association with members throughout the country.

A group of persons from government and in-
dustry with interests in air-ambulance service met
recently in Oklahoma City under the chairman-
ship of the senior author to initiate a national
air-ambulance organization. Their recommenda-
tions, which are listed below, give some indication
of the high standards that could be promoted
through such an organization.

1. There should be provisions for environ-
mental controls for adequate heating and cooling
of the area occupied by the patient.

2, There should be provisions for an AC power
source aboard aircraft so that necessary medical
devices can be utilized in flight.

8. There should be provision for emergency
airway management, laryngoscopy, suction equip-
ment, various size suction catheters, and a hand-
operated ventilator with associated airways.
There should be on-board provision for periph-
erally humidified oxygen with a flow meter for
the patient.

4. Drugs, instruments, trauma control equip-
ment (such as splints and bandages), and any
other indicated device or equipment should be
placed on board when appropriate to the illness
or the mission.

5. Litters should be so constructed that they
may be anchored to the aircraft with the patient
secured to the litter. They should be stressed to
the same “g” requirements as that of the aircraft.
The restraints securing the patient to the litter
should be such that they distribute their forces
uniformly and avoid pressure points. Further,
access to the aircraft should be through a door
constructed in such a way that it provides a
minimum of movement of the litter and the

patient while the latter is being placed in the
aircraft.

6. Communications should be provided between
pilot and attendant, and it is desirable to have
communications between the attendant and the
ground. The communications should allow the
attendant to remain in the immediate vicinity
of the patient.

7. Attendants should be on every ambulance
flight and they should be briefed medically on the
interhospital transfers. Further, it should be re-
quired that the attendant and the _pilot-in-
command have knowledge of basic resuscitative
techniques and basic aviation physiology.

8. Illumination in the aircraft should be avail-
able in the area of the litter. Portable lighting
facilities should also be available so that areas
around the patient can be highlighted.

Some topics not covered in this paper, but
which require consideration in air-ambulance op-
erations, include the following: transportation of
premature and other infants; transplant donor,
or organ, transportation and the effect of their
support devices on navigation equipment; im-
portance of noise protection for the patient; and
medicolegal responsibilities, such as insurance.

IV. Summary.

The Military Airlift Command has developed
an excellent international system with outstand-
ing features of safety and convenience. Al-
though some of these features are not applicable
to the general aviation air-ambulance network,
many MAC standards set goals for the general
aviation air-ambulance operator to strive toward.
A great deal could be accomplished by a national
organization of air-ambulance operators which
could set standards, encourage joint efforts to pro-
vide equipment modernization, and possibly re-
duce costs by coordination among members to de-
crease the number of one-way revenue flights.

At the present time, some states are consider-
ing laws pertaining to air-ambulance operations.
It is the opinion of the authors that if any na-
tional regulations governing patient transporta-
tion by air are written, many government agen-
cies including the FAA could be involved.
Recent changes in Federal Aviation Regulations,
Part 135, provide much higher operational stand-
ards for the air-taxi operation than previously
existed. These changes affect any air-ambulance


Taste 1.—Availability of Specified Medical Items and Services Reported in a Survey of 30 Secondary Air-Ambulance
Operations

Availability of Items and Services

Total Number Readily Can Not Inadequate or
of Respondents Available Obtain Available No Information
Obtained
Litters____-.------------- 30 22 0 5 3
(Patient must
furnish if
desired)
Litter Restraints. -....---- 30 14 7 7 2
(Use seat belts) (See text)
Medical Attendants_-.----- 30 6 5 15 4
(with aeromedi- (Patient must
cal experi- furnish if
ence) desired)
Oxygen_..---------------- 30 14 5 7 4
(Patient must
furnish if
desired)
Suction. 30 6 5 17 2
Aeromedical Consultatior 30 8 0 19 3

straps, and with greater distribution of pressure
by the use of wider securing devices.* The re-
port. notes that presently-used litters are too nar-
row for nearly five per cent, and too short for
over five per cent, of Air Force personnel.*
Since casts and other appliances may require ad-
ditional accommodation, the need for different or
larger litters becomes evident. One air-ambu-
lance firm which we contacted has constructed a
vest. with straps attached to assist in restraint
(we have a verbal report of an apparently
similar device being marketed by a West German
firm), but seven firms reported no litter restraint
at all. We assume that the negative answer was
in reference to litter restraints and that at least
seat, belts are available.

Attendants and Crew. The National Research
Council has urged that the 30,000 medical corps-
men (many with aeromedical experience) who
leave the service annually be appropriately
utilized Air Force reserve units have well-
trained, experienced personnel,? many of whom
might well prefer air-ambulance work to their
present occupation (which in most cases, in our
experience, is already medically related). How-
ever, only 20 per cent of the operations contacted
by us have technicians available with aero-
medical experience.

It is anticipated that the considerable recent
efforts directed toward the formation of a na-
tional registry of attendants for surface ambu-
lances * will eventually be extended to include
the aeromedical technician. Certainly much of
the training provided for surface emergency
medical technicians would be applicable to aero-
medical technicians, especially for primary air-
ambulance service. Altitude physiology would
have to be added since it is of particular im-
portance for secondary air-ambulance service.
The stabilized, low-risk patient can have con-
siderable discomfort or experience a life-threaten-
ing exposure if hypoxia or hypobaric problems
either are not prevented or are mismanaged.
Programs in physiological training are conducted
at the FAA’s Civil Aeromedical Institute (Okla-
homa City, Oklahoma) and at a number of USAF
bases. Although only 1,000 or so applicants per
year have previously taken advantage of this op-
portunity, over 8,000 general aviation pilots
applied in 1970,! as a result of increased aware-
ness of availability of the training.

Without assurance that air-ambulance workers
are well represented among participants in
physiological training programs, consideration
should be given to requiring them to take such
training. Since it should not be necessary for an



tude. The pilot at first refused, but following
persistent urging by the copilot and the nurse,
finally did descend to a lower altitude.

6. An air-evacuation flight, with a nurse at-
tendant on board, transported an elderly nursing-
home patient with cardiovascular disease from a
northern city to a southeastern city. During the
flight, the aircraft was vectored by ATC from
its proposed path of flight with some increase in
the enroute flight time. Also, the aircraft was
required to enter a holding pattern at several
points, resulting in an unplanned fuel stop.
While the aircraft was on the ground, there were
delays in obtaining fuel; the patient reported
being extremely uncomfortable due to the high
temperature at ground level. The pilot was ap-
parently either unaware of any method of ex-
pediting the flight, or could see no need to do so.
(During preparation of this paper, the FAA
announced that air-ambulance flights can now use
“LIFEGUARD” on the flight plan if the pilot
requests air-ambulance priority status;? such
flights have previously been given priority on re-
quest, but, until “LIFEGUARD,” there was no
standard procedure for requesting priority
handling.)

7. A single-engine aircraft was transporting an
automobile accident victim with serious injury
to a larger hospital in the state in which the
accident had occurred. The flight was during
hours of darkness. The patient apparently died
shortly after takeoff, and the aircraft was return-
ing to the originating airport. Probably due to
mismanagement of mixture control, the aircraft
lost power and made a crash Janding. The 30-
year-old female nurse accompanying the patient
was in a rear seat of the four-seat aircraft and
was not wearing a seat belt. The right front
seat had been removed to accommodate the canvas
stretcher which was neither secured nor re-
strained in any fashion, nor was the patient
secured to the litter. At impact, both litter and
patient were thrown out of the aircraft, the nurse
received a concussion requiring hospitalization,
and the 30-year-old male pilot experienced serious
injury including multiple fractures.

Scope of Services Currently Available.

To gain more information on the scope of
services available to the physician who might re-
quest air-ambulance service, 30 firms providing
such services were contacted. They were selected

in convenient cities from the yellow pages of the
telephone directory. The authors do not main-
tain that the sampling was complete for cities
surveyed (although completeness was attempted),
nor that the city selection was at random. The
approach was that of a physician requesting in-
formation on air-ambulance service with the fol-
lowing information needed :

1. Type and cost of aircraft.

2. Litters. (Do you furnish them or does the
patient?)

8, Availability of litter restraints. (How do
you fasten the patient in the aircraft?)

4. Availability of an attendant knowledgeable
in aeromedical evacuation.

5, Availability of oxygen.

6. Availability of suction.

7. Availability of a physician for consultation
regarding aeromedical problems, (Is it all right
for the patient to fly?)

Results of the contacts with air-ambulance op-
erators appear in Table 1. Not all questions were
answered since some operators declined to re-
spond to detailed questions unless service was
actually being requested.

Cost. Based on our survey, the cost of air-
ambulance transportation (a range from single-
engine fixed gear at 26 cents per mile to jet air-
craft at rates over $1.00 per mile) appears to be
comparable to that of surface ambulances. The
cost of surface transportation per mile is about
the same or higher than the cost quote for twin-
engine, propeller-driven aircraft. This finding
is consistent with conclusions made at a VA
hospital that it is both easier and more eco-
nomical to transport its patients by air Al-
though it has been suggested that pressurized air-
craft be required for air-ambulance flights, at
least for secondary service, this is not econom-
ically feasible (nor is the implied assumption
accurate that all pressure-change problems would
be eradicated).

Litters and Restraint. With the degrees of
freedom of movement which can occur in flight,
the problem of helicopter patients vibrating out
from under restraints is only one of many re-
straint problems encountered with patients in the
reclining position. A USAF report mentions the
problem of aggravation of wounds by litter straps
and suggests experimentation both with movable


equipped and staffed as a ground ambulance.
The air-ambulance operator frequently appears to
assume that no one would be referred for aero-
medical transportation who is not in adequate
condition to be so transported. ‘The operator also
assumes that the physician will prescribe any sup-
portive regimen required to provide safe trans-
poration, but many physicians are not aware of
of the special problems associated with flight and
may not give proper consideration to patient wel-
fare in the potentially hostile environment of re-
duced barometric pressure and reduced partial
pressure of oxygen.

Proper administrative involvement of physi-
cians would be expected to aid patient transfer
by the establishment of uniform documentation
of patient status including among others, diag-
nosis, condition, and type and time for admini-
stration of medication (preferably on a Green-
wich mean time basis). It would be of particular
advantage to have the necessary forms available
at all hospitals.

In fact, a specified procedure is necessary to
avoid the previously mentioned problems of un-
justified confidence or avoiding responsibility in
either the dispatching physician or the air-ambu-
lance operator. Only two of the firms which we
contacted mentioned that they require a written
release from a physician prior to accepting a
patient for transportation. It is the opinion of
many of the experienced personnel in the Mili-
tary Airlift Command that proper preparation
of patients and document, standardization would
be a significant aid to convenient and safe patient
transportation.

Additional Service Considerations.

In addition to the topics covered above, there
are other considerations which require attention
in air-ambulance service.

Choice of Patients. Patients with heart disease
should be excellent candidates for aeromedical
transportation providing supplementary oxygen
is available. However, a patient with pneumo-
thorax, post traumatic emphysema, intestinal ob-
struction, or penetrating eye injuries would, of
course, constitute a risk regardless of oxygen
administration if exposed to sufficiently decreased
barometric pressure. These and other conditions
require pressurized aircraft.

Pressurization. Although pressurization would
eliminate hypoxic and hypobaric difficulties, it

can also cause problems, as manifested by a case
in which an air ambulance retained sea level
pressurization until Janding at an airport of 3,000
feet elevation. The sudden pressure reduction
upon opening the door caused a bottle of intra-
venous fluids to surge out through the vent, and
probably forced fluid through the IV tube at an
increased rate. Moreover, sudden increases in
pressure, such as would occur in a rapid descent,
could cause increased rates of flow of blood from
plastic donor bags, with the associated hazards
of cardiovascular overload. Although the air
splint is desirable for aviation transportation
since it is lightweight, changes associated with
gas expansion at altitude could conceivably im-
pair a patient’s circulation by pressure from the
splint. One air splint now manufactured has a
safety valve. An attendant could restore vented
pressure either as the ambient pressure increased
at the end of a flight, or at the time of any re-
duction in altitude. Physiological indoctrination
would give pilots and technicians the back-
ground to handle or prevent such problems. Any
internally used balloon or pressure device would
be less easily managed.

Turbulence. Frequently flights remain below
5,000 feet over level terrain without encounter-
ing too much turbulence, but over hilly or moun-
tainous terrain, turbulence may be difficult to
avoid at even moderate altitudes. Besides the
discomfort. so generated, especially for a sick or
injured person, the possibility of air sickness is
always present, and thus every air-ambulance
operator should follow the practice of the
Military Airlift Command and refuse to carry
a patient with maxillofacial or dental surgery
which has necessitated wiring of the jaws. The
military will transport such patients only with
elastic tie bands or an emergency release mecha-
nism which can be activated by the patient or
attendant.

g Forces. Although short term forces of
turbulence or maneuvering will not usually con-
stitute a problem for the properly restrained
patients, the person with some form of traction
could be subject to marked changes in traction
forces, These changes in g forces are prevented
in USAF Military Airlift Command flights by
the use of spring tension devices in place of
weights. The concomitant reduction in weight
would be of particular benefit to general aviation.



TECHNICAL REPORT STANDARD TITLE PAGE

T. Report No. 2. Government Accession No. 3. Recipient's Catalog No.
FAA-AM-71-18
4. Title ond Subtitle 3, Report Date
April 1971
AEROMEDICAL TRANSPORTATION AND GENERAL AVIATION 6. Performing Organization Code
7. Authors) 3. Porforming Organization Report No,

Harry L. Gibbons, M.D.
Carl Fromhagen, M.D.

9. Performing Orgonization Name and Address 10, Work Unit No.
FAA Civil Aeromedical Institute
P. 0. Box 25082 Ti. Contract or Grant No.

Oklahoma City, Oklahoma 73125

13. Type of Report and Period Covered

12. Sponsoring Agency Name and Address

Office of Aviation Medicine OAM Report
Federal Aviation Administration
800 Independence Avenue, S. W. 14. Sponsoring Agency Code

Washington, D., C. 20590

15. Supplementary Notes

16, Abstroct

The advantages of aircraft in providing military medical evacuation are well
documented, Training and experience have resulted in a reliable and safe
military medical evacuation system. Many studies have been done or are in
process which pertain to civil emergency helicopter evacuation.

Fixed-wing secondary ambulance service is growing at a rapid rate without the
benefit of studies such as those pertaining to helicopter primary ambulance
service. Problems associated with this growth relate to equipment, crew
training, and knowledge of the physiology of flight. Legislative and/or
education efforts are needed to assure optimum general aviation patient

transportation.
17. Key Words 18, Distribution Statement
Air Ambulance, Ambulance Attendant, Availability is unlimited, Document may
Physiological Factors - Flight, be released to National Technical Informa-
Patient Evacuation tion Service, Springfield, Virginia 22151,
for sale to the public.
19. Security Classif. (of this ropert) 20, Security Classif. (of this page) Ti No. of Pages | 22. Price
Unclassified Unclassified 10 $3.00

Form DOT F 1700.7 (0-69)



”

©

10.

1.

12,

13.

14,

15.

16.

17.

18.

19.

. Allison Distributors:

REFERENCES

. Ahnefeld, F. W. and H. Boll: Der Hinsatz Von

Hubschraubern Bel Der Versorgung Bon Notfall-
patienten, WEHRMEDIZINISCHE MONATS-
SCHRIFT, 13 :329-334, 1969,

. Anonymous: Air Ambulance Flights Receive Priority

Status, FAA HORIZONS, December 22, 1969.

. Anonymous: Air Ambulances Demonstrate Versatil-

ity at Kennedy Symposium, STRIDES, 11:1 (No.
2), 1970.

| Anonymous: Ambulance Use Costs More Than Air,

FEDERAL TIMES, p. 9, October 1969.

Medie Air. (Advertisement),
BUSINESS AND COMMERCIAL AVIATION, p. 38,
November 1969.

. Baker, R. J.: (Quoted in) What Next in Trauma,

MEDICAL WORLD NEWS, p. 58, October 18, 1968.
Brenner, R.: Letter to the editor, GOVERNMENT
EXECUTIVE, p. 11, August 1969.

Anonymous: Civilian Injured Atrlifted in Test, U.S.
MEDICINE, p. 28, September 15, 1970.

Department of Transportation, Federal Aviation
Administration Regulation 91,32, Part 91, General
Operating and Flight Rules, June 17, 1970.

East, W.: PERSONAL COMMUNICATION, Feb-
ruary 10, 1969.
Funsch, H.: PERSONAL COMMUNICATION,
March 23, 1970.
Harris, D. A.: Human Factors Aspects of Aero-

medical Evacuation Litters. USAF Report SAM-
TR-69-59, Brooks AFB, Texas, 1969.

Harris, J.: PERSONAL COMMUNICATION, March
23, 1970.

Anonymous: Helicopter
NEWS, January 19, 1970.
Himmel, N. 8.: Business Flying: Interest in Air-
Ambulance Use Increases, AVIATION WEEK &
SPACE TECHNOLOGY, pp. 71-72, 77-78, March 24,
1969.

Anonymous: Hire Medical Corpsmen,
Council Urges, AID, 4:1 (No. 8), 1969.
Hoffman, D.: PERSONAL COMMUNICATION,
September 24, 1970.

Hudgens, R. P.: Air Ambulance... a growing
service. FLIGHT MAGAZINE, 56:36-88 (No. 7),
1967.

Kennedy, R. H.: Ambulance Personnel in Emergency
Care. In Kennedy, R. H. (Ed.): Emergency Care,
Philadelphia, W. B. Saunders, pp. 1-5, 1966.

Ambulance Cited, AMA

Research

37667

10

20. Lindsey, R.: Helicopter Takes on Role as Ambu-
lance, THE NEW YORK TIMES, p. 16, March 8,
1970.

. Major, R. H.: A History of Medicine, Vol. 2, Spring-
field, Illinois, C. C. Thomas, p. 647, 1954.

. Mateer, C, A.: Review of Proposal for Military
Support of Air Medical Evacuation Systems (AMES)
to Aid Highway Accident Victims, MEMORANDUM
REVIEW, 1969.

. Anonymous: Medical Unit Offers Air Ambulance
Plan, AVIATION WEEK & SPACE TECHNOLOGY,
p. 118, November 17, 1969.

. Packard, F. R.: History of Medicine in the United
States, Vol. 1, New York, Hafner, pp. 641-643, 1963.

5. Anonymous: Plans Advanced for Emergency Medical
Technician Registry, AID, 4:1, 6, 7 (No. 6), June
1969,

. Pope, J. C.: PERSONAL COMMUNICATION, Feb-
ruary 26, 1970.

27. Richardson, D. R.: Air Transport of the Injured.
In Kennedy, R. H. (Ed.): Emergency Care, Phila-
delphia, W. B. Saunders, pp. 103-106, 1966.

. Schmidt, Virginia and J. Schmidt: Injured Skiers
Get a Break, AOPA PILOT, 12:44-47, April 1969.

. Schultz, M. J.: Help is a Helicopter, TODAY'S
HEALTH, pp. 68-72, April 1969.

. Secretary of the Air Force: Aeromedical Bvacua-
tion. Background Information Report No. 68-3,
USAF Office of Information, Washington, D.C., 1968.

Spoor, D, H. and F. M. G. Holmstrom: Clinical
Suction Systems Requirements in Aeromedical Evac-
uation, USAF Report SAM-TR-68-52, Brooks AFB,
Texas, October 1969.

©
8

re
&

31.

Taft, D. A.: Casualty Evacuation and Treatment in
Viet Nam as Applied to Civilian Practice. Paper
presented to the Washington State Medical Center,
Seattle, Washington, September 17, 1969.

Turner, H. S, and H. V. Ellingson: Use of the Heli-
copter as an Emergency Vehicle in the Civilian
Environment: Results of a Survey-Questionnaire,
AEROSPACE MEDICINE, 41:135-138, 1970.

United States Air Force Regulations 164-1: World
Wide Aeromedical Evacuation, May 15, 1964.

33.

34,

35. Walton, L, B.: The Community Chopper, ROTOR-

WAYS, 1:2-5 (No. 4), undated.


operator, but at present there are no regulations
which mention the specialty of air-ambulance
operation.

Efforts are necessary (be they legislative and/
or educational) to bring the care of the patient
being transported by air to the same level pro-
vided by surface transportation in those states
and cities with regulations. The fact that a
patient is being transported does not alter his

patient status. This is best summed up in the
words of Brigadier General Harold F. Funsch, a
pioneer and a present leader in the movement to
provide modern, safe, and convenient patient
transportation: “Patients are not cargo, patients
are not passengers, patients are patients.” This
motto of the Military Airlift Command should
be the dictum -of all general aviation air-
ambulance operators.



indoctrinated technician to explain or to justify
to an uninformed pilot the need for flight-profile
changes, flight crews should also be required to
receive this training.

Aeromedical indoctrination of flight crews
would provide other benefits; although not di-
rectly related to flight safety, they would at least
tend to prevent crew distraction. Two recent
incidents demonstrate the value of knowledge of
the gas laws obtained through physiological
training. A commercial pilot was transporting
the remains of a traffic fatality. Near midnight,
as the unpressurized, super-charged, twin-engine
aircraft climbed through 14,000 feet, vocalization
sounds came from the body for a matter of sec-
onds. The lone pilot was shaken, but continued
the flight. The pilot’s greatest concern was that,
were he to discuss his experience, his FAA
medical certificate might be in danger due to
suspected psychiatric problems. Four months
later, while taking physiological training, a
presentation of Boyle’s Law brought him to the
realization that gas expansion in the lungs of the
cadaver had reached a point where the gas
escaped and vibrated the vocal cord.

In another case, a commercial pilot was level-
ing off at altitude when the cadaver he was trans-
porting seemed to emit a prolonged sigh. The
pilot had helped load the body on the plane and
was convinced that it contained no life, but he
experienced some consternation and could not
bring himself to tun around and look. He sub-
sequently became aware of what had probably
occurred during a discussion of aeromedical
principles and gas laws in a physiological train-
ing course.

Oxygen. Seven of the operators surveyed re-
ported no oxygen available; five others could
obtain it on request. However, a long-standing
NPRM applicable to general aviation recently
went into effect as a regulation which will re-
quire oxygen use for flights over 30 minutes above
12,500 feet and for all flights above 14,000 feet.?
As part of the intensive educational campaign by
the FAA to acquaint pilots with the need for an
oxygen source, pilots have been urged to use
aviators’ breathing oxygen with its very low
humidity to prevent freezing of the regulator.
Most physicians would anticipate that the oxygen
provided by an ambulance (surface or air) would
at least be medical oxygen, and preferably hu-
midified oxygen for some patients. Air ambu-

lance operators should, therefore, be aware both
of the need for humidification beyond the regula-
tor if the aircraft oxygen is used, and of the in-
creased likelihood of regulator freezing (due to
added cooling during expansion of oxygen to
greater-than-sea level volume) if medical oxygen
is used,

Some physicians feel strongly that low-level
flight in unpressurized aircraft will obviate the
tisk of depressurization one faces in high altitude
pressurized aircraft. A handbook from the
American College of Surgeons,’ in discussing
the air ambulance, makes no mention of hypoxic
problems, apparently assuming all flights are
either low level or pressurized.

Suction. Although suction equipment will cer-
tainly be needed on some air-ambulance flights
and should probably be a requirement for all sec-
ondary and primary air-ambulance aircraft, 17 of
the operators surveyed indicated that they had
no such equipment.

An Air Force study outlined the range of
pressures needed for various types of suction
(oral-nasopharyngeal versus closed cavity situa-
tions) and mentioned a need for at least 25 inches
Hg pressure for hospital use, and a minimum of
10 inches Hg for emergency field use. Follow-
ing the Air Force evaluation of three different
suction units, a general purpose respirator and a
chest suction unit were suggested.** None of the
general purpose aspirators now in use meet all of
the desired criteria noted above. The availability
of a 110-volt power source in air-ambulance air-
craft would permit presently available equipment
to meet the recommended requirements for tho-
racic suction. With an increase in air-ambulance
service, it is anticipated that equipment designed
specifically for general aviation aircraft use will
be available.

Aeromedical Consultation. The major de-
ficiency in the services offered by air ambulance
operators is the lack of contact: with a physician
knowledgeable in aeromedical evacuation (19 of
the firms reported none). The use of such a
physician would reduce all of the previously
mentioned problems. His absence is a manifesta-
tion of the unjustified confidence on the part of
the ambulance operator, or the customer, or the
patient’s physician, that the other party meets
certain standards. The physician and/or the
family assumes that an air ambulance is as well


Much has been written recently about the ad-
vantages of helicopter ambulance services, par-
ticularly on congested highways, on the ski slope,
and in other hard-to-reach areas.’ ® § 15 2028 29 95
Also, numerous studies are being conducted by
Federal agencies to evaluate various aspects of
helicopter evacuation.**

The federal studies mentioned above cover a
gamut of areas such as: comparison of small and
large helicopter effectiveness; validation of cost
effectiveness of utilizing helicopters for single
purpose missions; comparison of ground versus
air-ambulance effectiveness; effectiveness of com-
bined helicopter and ground ambulance service;
design and operation of a helicopter medical
evacuation system in a widely variable rural en-
vironment; development of data to validate new
training, equipment, and techniques for patient
handling; feasibility of employment of ex-
military corpsmen; and utilization of helicopters
to determine effects on reducing response time
and improving evacuation capability.”*

State air ambulance programs are in process in
California, Arizona, and Mississippi, and metro-
politan studies are being conducted in Detroit
and Minneapolis-St. Paul.?** One county in
Texas is currently using a joint military-civilian
helicopter service to evacuate automobile-accident
victims to San Antonio Hospitals; an experienced
corpsman accompanies the helicopters which are
on 24-hour alert.’ ”

Early in 1968, in Southgate, Michigan, the
nation’s first private helicopter ambulance service
was begun.’* Other private programs or studies
have been undertaken in Pennsylvania, North
Carolina, Maryland, Montana and other areas.’*
The Health Foundation of the District of Colum-
bia Medical Society has offered to provide match-
ing funds to provide helicopter ambulance serv-
The Missouri State Highway Patrol has
ordered a STOL fixed-wing aircraft for evacua-
tion of highway-accident victims.?°

ice.23

Although a recent paper opined that the cost
of helicopter equipment and crews may prevent
extensive civilian utilization,** there are other in-
dications that considerable growth in helicopter
ambulance use is expected. A recent advertise-
ment of an engine manufacturer stressed the ad-
vantages of helicopter ambulances.> There is also
a recent report that, in the Washington, D.C.

area, insurance companies have offered to provide
coverage for helicopter ambulance service through
regular health insurance programs.** This cover-
age would be based on $30 per helicopter pickup
plus $3 per operating minute. The authors as-
sume that this cost is based on the anticipated
reduction of mortality which has been predicted.*
Various publications have pointed out the avail-
ability of equipment and trained personnel (both
air crew and medical attendants) for civilian
programs should hostilities in the Far East
cease, e.g2° Surplus or obsolete military equip-
ment is presently being utilized in a program con-
ducted by a state National Guard and the state
university hospitals. In fact, there are some who
believe the only limiting factor to widespread
helicopter usage is the availability of heliports
since, unless the patient can be transported di-
rectly into the emergency room from the heli-
copter without use of an intervening ambulance,
advantages are significantly reduced.

Fived-Wing Ambulance Service. The use of
air-taxi transportation of patients has experienced
remarkable growth. There was a fivefold in-
crease in the number of trips and miles flown
from 1958 to 1966'* without the benefit of exten-
sive research such as is presently being performed
in helicopter evacuation.

The fixed-wing operation differs from the heli-
copter flight in that it usually involves trans-
portation of patients from one city to another
either for the convenience of the patient or the
family, or for prolonged intensive or special
medical treatment. This function is usually
designated as secondary ambulance service.
Whereas helicopter flights are usually of short
distance, the average fixed-wing flight for medical
transportation averages about 800 miles.*

II. Present Status.

There are many well-equipped air ambulances
with well-trained crews including aeromedical
technicians. Certainly most medical transporta-
tion flights are performed without difficulty, but
incidents have occurred which suggest that cer-
tain educational and legislative efforts should be
directed to air ambulance services both to remedy
the existing deficiencies and to prevent multipli-
cation of problems if continued growth in air
ambulance services occurs.


AEROMEDICAL TRANSPORTATION AND GENERAL AVIATION

I. History.

The herald of today’s helicopter and fixed-
wing ambulance was the “flying ambulance” or
“ambulance volante” introduced by Baron
Dominique Jean Larrey, a French Army Surgeon
serving under Napoleon.?? By comparison, the
“flying ambulances” of Larrey were heralds in
deed as well as in name since, prior to that time,
wounded were either carried to the rear by their
comrades or were left lying unattended where
they fell until the fighting ended. Larrey’s “fly-
ing ambulances” were small horse-drawn carts for
preliminary surgical treatment as well as trans-
portation of the wounded."

Some form of ambulance service existed as
early as the 11th Century; the British Ambulance
Association relates its founding to services pro-
vided in 1084 at the time of the crusades? In
spite of this early start and the marked progress
by Baron Larrey around 1800, there was, in gen-
eral, slow acceptance of the service. In 1862,
when ambulance companies were put into use in
the Army of the Potomac, the Surgeon General’s
recommendation that they be used in all armies
was disapproved by General Halleck on the
ground that they would be expensive, cumber-
some, and apt to lead to panic. However, some
progress was made during the Civil War and at
the Battle of Antietam, the wounded were col-
lected by ambulance, were placed under shelter,
and had treatment initiated within 24 hours.

The first hospital-associated ambulance service
was reportedly provided by Cincinnati General
Hospital prior to 1865.19 Motor-driven ambu-
lances first appeared in Chicago in 1899 and were
frequently used in World War I.° The evacua-
tion of patients by air first occurred during the
Russian siege of Paris in 1870 when 160 wounded
were successfully airlifted by balloon.*? Although
air evacuation was limited during World War I,
114 million patients were moved by air in World
War II. Helicopter ambulances first came into
use in 1950, during the Korean Conflict.?®

Helicopter Ambulance Service. Helicopter
evacuation and transportation services are
credited with contributing substantially to re-
duced mortality rates in the armed forces, The
mortality rate of those reaching a medical facility
was 8.1 per cent in World War I, 4.1 per cent
in World War II, and 2.5 per cent in the
Korean Conflict. It has remained at 2.5 per cent
in the Vietnam War.” There is a paradoxical
effect attributed to helicopter ambulance serv-
ice which results in the erroneous impression that
the mortality rate has not improved since the
Korean Conflict. Actually, the marked increase
in use of helicopter service has resulted in many
casualties reaching a medical facility who,

‘previously, would have died in the field. A

comparison of the number of deaths with the
number of wounded is a more meaningful indica-
tion of the success of evacuation and treatment.
In World War IT, 27 per cent of casualties were
either killed in action or died after admission to
a medical facility. In Korea, the rate was 22 per
cent; it has been reduced to 17 per cent in Viet-
nam.”

Based on such success in the military, the use
of helicopter ambulance service has been recom-
mended for civilian use both to diminish the
death rate among the approximately 10,000,000
disability-producing accidents per year in the
United States, and to facilitate treatment in the
innumerable acute illnesses requiring immediate
medical care. It has been estimated (by a
surgeon who was involved in military medical
care in Vietnam) that almost one-half of the
current highway toll could be saved if rapid
evacuation services ** were available. A similar
allegation appeared in Government Ewecutive,
stating that a soldier wounded in Vietnam has a
better chance of survival than a person receiving
the same degree of injury on the streets and high-
ways in most of the United States? The major
difference between the Vietnam battlefield and
United States highways is the rapid evacuation
of combat wounded by helicopter.