Improving Helicopter EMS activation through a recommendation of joint standardization

 White Paper


The helicopter emergency medical community


JD Graziano

Boston University School Medical School

Health Care and Emergency Management Program

*Article published with full permission of author


Disasters represent a large challenge to helicopter emergency medical services and transport teams, including the sudden and often unplanned operations of working with other transport teams that do not routinely work together. Cataclysmic events are often a result of series of events different from the routine responses that lead to a changing environment and situation. Managing disaster scenarios requires Incident commanders being adaptive in the heat of a chaotic and often emotionally charged situation. By their nature, disasters are unpredictable and unexpected. A clear and concise set of national standards involving policies and procedures for helicopter transport needs to be developed. Responding to a disaster is an aspect of response for emergency services, both air and ground transport teams maybe asked to participate in an operation that must be addressed and carefully planed for before the disaster strikes.

Helicopters have become an indispensable aid for dealing with disasters. Specialty transport teams come into their own when they are put into operation during the initial stages after the disaster has taken place. People who have fallen victim to a catastrophe or are endangered by a disaster cannot afford to wait until a “clearer picture” of the damage from a emergency has been established, a set of standard operating procedures must be in place for quicker helicopter activation. In fact, the helicopter can contribute towards establishing this picture, and as a result should be considered immediately when a major occurrence has taken place. It is advisable that an authorized (i.e. Accreditation for Air Medical transport) body prepares the procedures for rescue operations of this kind in advance. The final decision for the need of air assets should be delegated, if possible to those at the scene of the disaster. Otherwise considerable time might be wasted which could lead to very serious consequences. The following white paper will review the importance of planning and activation of HEMS in a disaster, while demonstrating that at this point the best way to improve HEMS activation in disasters is by using a single set of standards to be used at both a international and national level.


Having a strong communication system between the ground emergency medical services/Incident Command/HEMS using a preplanned algorithm is invaluable. The standardization of activation criteria is a tool that can make or break the success of making the right decision to activate HEMS assets. A study conducted in 2004 in the United Kingdom from the journal of Emergency Medicine. reports on the idea behind a set algorithm and provides insight to a set of standards used of helicopter activation:

“A simple algorithm has been produced to assist front line ground ambulance personnel, air ambulance crews, and immediate care doctors attending trauma patients in selecting the most appropriate mode of transport from the incident scene to hospital”(Black et al, 2004).

The decision to use a helicopter is not straightforward, and a number of important geographical, physiological, and pathological factors need to be considered. The transfer of a seriously injured patient by helicopter may be hazardous and transportation by road may often be a safer option. A transport algorithm is a useful guide to those who may be faced with making finely balanced decisions that may have an important impact on patient outcome:

“Decisions regarding the appropriate mode of transport to hospital for trauma patients are potentially complex and should be determined by the environment and circumstances of injury, the clinical state of the patient, the incident location’s accessibility, the clinical resources at the scene, and the proximity and resources of adjacent hospitals” (Black et al, 2004).

Knowledge of the available resources and the estimated transport must always be taken into consideration. Response teams requesting medevac need to have knowledge of local district and regional hospitals, and the location of their helipads or nearest landing sites to make the best-informed decision for the patient. “A detailed estimate of total transport time from scene to hospital is required to ascertain whether road or air ambulance transfer will offer the fastest mode of transport to hospital. When a helicopter is requested by a ground crew already on scene helicopter mobilization and flight times may delay transfer times further”(Nicholl, 1997). Disaster bring chaotic moments in asset management, there is nothing more important than quickly gathering and distributing accurate information. Activating an established algorithmic plan is the only way to us HEMS in timely manner.

The algorithm for recommendation has been designed by Black et al. 2004 in the conducted UK study to be widely applicable by using simple physiological values that can easily be determined by any ambulance crew, air ambulance paramedics, and immediate care doctors. A structured approach to HEMS activation will aid in a complex transport decision making for injured patients at the scene of a disaster. The algorithm is designed to identify patients with adverse clinical signs and injury patterns that predispose to decompensation and secondary injury during transport. “Critical care interventions are performed to reduce the risk of life threatening secondary injury from hypoxia, hypercarbia, and hypotension occurring during transport. It may not be possible to readily identify and effectively manage deterioration in flight” (Lockery et al, 1999).

Using this complete algorithm in disaster response can help in preserving quick and effective decision making that could make the difference in appropriate asset management or over triage and poor asset use. The key factors for determining the most suitable mode of transport are (Black et al, 2004):

  • Access to a suitable helicopter/road vehicle
  • Environmental conditions
  • Contraindications to helicopter transport
  • Patient’s physiological status
  • Presence of specific injury patterns
  • Accessibility to the incident location by road and air
  • The availability of resources to deliver prehospital critical care interventions, principally rapid sequence induction and tracheal intubation at the scene
  • Total transfer time from scene by road to hospital compared with helicopter (including packaging and loading, flight and transfer time from helipad to the hospital’s emergency department)

The Problem

EMS and HEMS agencies have responded to both large and small disasters, simple and multifaceted. All disaster plans should keep these in mind and use them as a guide to aid in building a better plan of operational use of HEMS. Identifying the problems that continually develop during disasters operations allowing emergency response personnel to create and integrate standard operating guidelines for HEMS into their response protocols.


The following algorithm has been designed to be widely applicable by using simple physiological values that can easily be determined by ambulance crews, air ambulance paramedics, and doctors. The protocol is to guide potentially complex transport decision making for injured patients at scene. It is also designed to identify patients with adverse clinical signs and injury patterns that predispose to decompensation and secondary injury during transport.

Absolute contraindications to helicopter transport:

  • Hazardous environmental conditions Pilot makes decisions, not a medical team decision. Examples (visibility, low clouds, high winds)
  • Aggressive/uncooperative patients Crew/aircraft have potential to become compromised.
  • Patients chemical agents of any kind can compromise safety of crew or pilots.

Hostile environment:

  • Evacuation of patients from a unsecure military or armed conflict should be done as quickly and safely as possible by ground/air. Safety of crew and aircraft should always come before clinical interventions.
  • Reduced level of consciousness: using GCS or AVPU scores as criteria for patient transportation.
  • Airway obstructions: Continual audible breathing, after suctioning and basic airway adjuncts (Nasal airway) have been used.
  • Respiratory compromise/distress: Respiratory rates < 10 or >30, or unresolved cyanosis or arterial oxygen saturation < 90% after using high flow oxygen.
  • Shock: Impalpable radial pulse, or hypotensive, capillary refill >2 seconds, or unable to obtain a pulse oximeter reading.
  • Significant head or facial trauma injury: Clinical evaluation of facial injuries, complications of bleeding, focal neurological signs or seizures

Prehospital critical care:

These skills should be available and defined as: Rapid Sequence induction (RSI) and tracheal intubation; mechanical ventilation, lung decompression/pleural decompression procedures, hemorrhage control; long bong and pelvic fracture stabilization, emergency IV pain control and anesthesia for limps and amputations.

Transport time:

Time for ground transport of patient from scene to definitive care. Time should be compared to time for helicopter arrival, movement of the patient from scene to helicopter or helicopter landing zone. That includes but not limited to packaging and loading patient into helicopter. Teams must evaluate transfer times; hospital helipads to emergency department, i.e. not only ‘flying time’. Anything that could be >30 min by ground is likely to benefit from air transport.

Hospital Selection:

Patients should always be, if possible transported to definitive care based on the patients injuries/illness and needs. (for example, if patient is having an MI-cathertization lab is needed).


Decisions regarding the appropriate mode of transport to hospital for trauma patients are potentially complex and should be determined by the use of a standardization of protocol involving; the environment and circumstances of injury, the clinical state of the patient, the incident location’s accessibility, the clinical resources at the scene, and the proximity and resources of adjacent hospitals. Critically injured patients, who potentially have the most to gain by rapid transport to definitive care, may not be well served by air transfer where the risk of sustaining secondary injury is increased. Currently some emergency service infrastructure of air ambulances around the world may or may not always have the crews to provide the necessary critical care clinical interventions to ensure the safe transport of severely injured patients. Many other aero medical services in other European countries, Australasia,and North America do provide crews with the necessary critical care skills (Malacrida, 1980). The transport algorithm will be a useful guide to those who may be faced with making transport decisions that may have an important impact on patient outcomes in a disaster scenario.



Canadian Journal of Surgery. (2014, February 4). Helicopters save lives: Helicopter transport increases trauma survival over ground ambulance, study shows. ScienceDaily. Retrieved March 20, 2014 from

Eckstein M, Jantos T, Kelly N, et al. (2002) Helicopter transport of pediatric trauma patients in an urban emergency medical services system: A critical analysis. J Trauma 5, 340-344.

Moront ML, Gotschall CS, Eichelberger MR(1996). Helicopter transport of injured children: System effectiveness and triage criteria. J Pediatr Surg 31(8),1183-1186.

M. Kit Delgado, Kristan L. Staudenmayer, N. Ewen Wang, David A. Spain, Sharada Weir, Douglas K. Owens, Jeremy D. Goldhaber-Fiebert. Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States. Annals of Emergency Medicine, 2013; DOI: 10.1016/j.annemergmed.2013.02.025

Shatney CH, Homan SJ, Shrek JP, Ho CC (2002). The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma 53,817-822.

Stanford University Medical Center. (2013, April 25). Cost-effectiveness of helicopter transport of trauma victims examined. ScienceDaily. Retrieved March 24, 2014 from

Study:Helicopter beats ambulance for trauma patients. (2012, April). EMS1 2(9), 4-5.

Thomas SH, Cheema F, Wedel SK, Thomson D.(2002) Trauma helicopter emergency medical services transport: annotated review of selected outcomes-related literature.  Prehosp Emerg Care. 6(3),359-371


Author: J.D. Graziano, BA, NRP, FP-C:  JD is a graduate student at Boston University School of Medicine. JD is a US trained Paramedic, Critical Care Paramedic and certified Flight Paramedic in the Midwestern United States.  JD is active in the world of Free Open Access Medical Education and is an advocate for continuation of EMS education and Critical Care Medicine provided by Paramedics. This article submission was published with full permission from the author by Distance CME.