Medical monitors may also be affected by the aircraft's electronic equipment; therefore, the medical monitors should be checked for accuracy by medical personnel before use with a patient.
Additional Equipment/Other. The following additional items of equipment are recomended for EMS operations:
(1) Radios Capable of Air-to-Ground Communications.
To ensure a safe and satisfactory completion of transportation and to coordinate with ground transportation service when necessary for the patient.
(2) Medical Oxygen System. A medical oxygen system including bottles, lines, gauges, regulators, and other system components which has been installed by approved data on an aircraft becomes an "appliance." If a single servicing port is installed in accordance with AC 27-1, as revised, Certification of Normal Category Rotorcraft, or AC 29-2A, as revised, Certification of Transport Category Rotorcraft, the system may be serviced by any person trained by the certificate holder. An oxygen bottle installed in a rack in the cabin area having its own regulator, hose, and mask feeding directly to the patient may e removed and serviced by any person trained by the certificate holder. If servicing is accomplished by removing and replacing bottles or by disconnecting lines, regardless of the type fitting, it must be accomplished by an appropriately certified mechanic or repairman.
NOTE: Information concerning equipment installation in the referenced advisory circulars are applicable to airplanes and helicopters.
Supplemental Lighting Systems. Some aircraft may require additional interior lighting since standard aircraft lighting may not be sufficient for adequate patient care. An emergency lighting system with a self-contained battery pack may be incorporated to allow for continued patient care and for emergency egress from the aircraft in the event of a primary electrical failure. A means to shield the cockpit from light in the patient area should be provided for night operations.
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(4) EMS Electrical Power. All wiring, electrical components, and installation procedures must conform to the requirements of FAR Parts 23 or 25. An electrical load analysis must be performed to preclude an overload on the aircraft generating system. The system should be designed to give the pilot a fast means of shedding electrical load in an emergency situation.
(5) Motor-driven Vacuum/Air Pumps. Motors and/or Any motor-driven device should be installed in a way to preclude pumps must be installed in accordance with FAR Parts 23 or 25. in materiale contact with any flammable fluid, gas, or foreign materials that may cause heat buildup and possibly fire. Aircraft should be flight-tested with electrical motors running to check for RFI/EMI.
Incubators. Incubators, balloon pumps, or other large carry-on medical equipment must be restrained in an appropriate manner to the following ultimate load factors:
(1) 3.0G upward, 6.6G downward; and (i1) 9.0G forward, 1.5G sideward.
NOTE: If pull test data are not provided by the equipment manufacturer to verify that specific equipment can withstand the above loads, the certificate holder must demonstrate the above loads on each specific piece of equipment, or use an approved restraining device. Aircraft cargo straps or safety belts provide a satisfactory restraint in many'instances. Also, mechanical (metallic) fasteners may be used for attachment.
NOTE: The incubator lid latches should withstand appropriate loads (approximately 15 pounds and any significant lid load).
The operator should ensure the unit has minimum movement when secured if straps or belts are used. If the incubator includes features requiring electrical power, operation should be evaluated to assure there is nc interference with the instruments and equipment that are required by the FAA airworthiness certificate for safe operation of the aircraft.
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The operator should provide padding for the infant for forward and downward loads and movement. Mattresses and all padding used should be constructed in accordance for Aircraft Seat Cushions, dated September 17, 1986.
Stretchers (Litters) . Stretchers must be in compliance with FAR Section 23.785 with restraint devices meeting FAR Section 23.561. Restraining devices, including shoulder harnesses, must be available to ensure patient safety.
(8) Child Restraint. Infant seats provided must meet DOT/FAA restraint and securing criteria.
(9) Intercom System (ICS). An ICS should be provided for flight crewmembers and medical personnel to communicate with each other during flight. This is particularly important if the cabin noise level is above 72db and for those instances in which the cabin medical personnel need to talk immediately with the flightcrew regarding a patient's medical condition.
NOTE: If a master minimum equipment list has been approved that includes the above equipment, the installed items listed in (1) through (9) above in this paragraph should be included in the minimum equipment list.
Additional Equipment Installation. Many times in an airplane, equipment is installed for the purpose of patient care only. This equipment should be installed, using approved data, in racks that meet the g-loading requirements of an emergency landing. The racks should be removed and replaced by a certified FAA mechanic, but the medical equipment in the racks used for patient care should be installed so that it may be removed readily to accompany the patient. Instructions for removal and replacement should be contained in the operator's manual required by FAR Part 135.
(1) The certificate holder must ensure that the installation of all additional equipment is compatible with the aircraft systems. FAR Section 135.91(a) (1) (iv) requires that all installed equipment, including portable devices, be appropriately secured. The structure supporting the equipment must be designed chap Par 1 5
AC 135- 15 11/19/90 to restrain all loads (up to the ultimate inertia specified in the emergency provisions/emergency landing conditions) required by FAR Parts 23 and 25. Equipment installed aboard the aircraft should meet the static and dynamic loads specified in AC 27-1 and AC 29-2, as revised.
(2) The installation of additional equipment by a STC or field approval. Normally the STC should provide instructions and operational supplements, weight and balance data, and instructions for continued airworthiness.
(3) Each installation must be evaluated at the time of its approval. This is to determine if a mechanic is required to perform installation or if other personnel can be trained for removal and replacement of these items. Frequent removal and replacement may constitute maintenance and would require a certificated mechanic.
If an installation does not require tools and can be performed in accordance with approved data and procedures in the operator's manual, any person trained by the certificate holder may be authorized to install the equipment.
2. RECORDS.
a. Maintenance Records. Each certificate holder must comply with the maintenance recording requirements of FAR section 135.439. When aircraft are sold, the certificate holder must comply with FAR Section 135.441, Transfer of Maintenance Records.
b. Flight Records. Records required by FAR Section 135.63 must be kept at the certificate holder's principal business office, or at other operational locations approved by the Administrator. The following records should also be maintained at operational bases located at other than the principal business office:
(1) Flight crewmember's flight time and rest records.
The flight time and rest records must contain information to show compliance with the flight, duty, and rest requirements of FAR Part 135, Subpart F.
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A copy of the most recent competency and or proficiency flight check. For each pilot assigned to that particular location, a copy of the current flight/proficiency check should be available.
(3) Current airworthiness documentation. For the pilot to determine the acceptability of the aircraft before each flight, airworthiness documentation must be available.
(4) Flight manifest records. For each multiengine aircraft, flight manifest records must be maintained for a minimum of 30 days.
3 . OPERATIONS SPECIFICATIONS.
Additional Requirements. FAR Part 135 certificate holders may use EMS procedures authorized with the appropriate operations specifications. The operations specifications may contain conditional authorizations that apply to individual operators. The approving authority for the operations specifications will be either the POI, PMI, or PAI of the FAA CHDO having jurisdiction over the certificate holder. The operations specifications include the following items:
(1) Location of all bases of operation where EMS activities will be performed.
(2) Exemptions, as appropriate.
(3) Deviations, as appropriate.
(4) Special authorizations.
Maintenance Operations Specifications. Operations specifications indicated in AC 120-49 are the same as those needed for EMS operations. However, in addition the following are items that should be considered:
(1) Special/medical and navigation/communication equipment, if appropriate to the operations being conducted.
(2) If the aircraft is being maintained under an Approved Aircraft Inspection Program, operations specifications must include the make, model, and registration number of the aircraft on that program.
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c. Weight and Balance. A weight and balance program allowing the use of estimated weight for medical passengers will be authorized on operations specifications. The actual weight of medical personnel and flightcrew should be used for piston powered aircraft and aircraft of nine or less passengers. This program should be addressed in the operator's manual.
FACILITIES. The facilities include the business office the manual as required by FAR Section 135.21, as well as the of operations.
a. Maintenance. Maintenance facilities should be large enough to accommodate the largest aircraft used by the certificate holder, adequately lighted, and properly equipped for required maintenance. Additional specialized equipment may be required for the EMS equipment installed in the aircraft.
contract maintenance will be performed in accordance with the procedures outlined in the operator's manual.
Operations. The operations facilities should have an area for flight planning, scheduling, flight following, training and recordkeeping. Classrooms and/or training devices should be available to flightcrews for recurrent training.
NOTE: An aircraft shall be available in accordance with FAR Section 135.97 to enable each pilot to maintain and demonstrate ability to conduct all operations for which the pilot is authorized.
5. MANUAL. Each certificate holder conducting EMS operations should prepare a manual. Appropriate portions of the manual should be available in each aircraft and at each flight operations location. The following items are suggested for inclusion in the operator's manual as well as items identified in FAR Section 135.23:
a. Names of the EMS/A management personnel that have authority to act for the certificate holder.
b. Copy of the front page of the certificate holder's operations specifications.
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c. Accident and incident notification procedures to include the local FAA, National Transportation Safety Board, and FAA CHDO telephone numbers.
d. Special actions or procedures that may be required during EMS flights.
medical personnel and flightcrew. Responsibilities and required coordination between
f. Special ground handling requirements.
g. Use of "Lifeguard" call sign during air ambulance/EMS flights.
h. Refueling procedures for normal and emergency situations.
NOTE: Items listed in 5 a through h do not preclude a certificate holder from including other items in the operator's manual required by FAR Part 135.
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CHAPTER 2. TRAINING GENERAL. This chapter outlines recommended training for all EMS personnel including flight crewmembers and medical personnel.
a. Flight Crewmember. Because of the circumstances in which EMS work is accomplished, aircraft may be frequently assigned to fly in less than ideal weather conditions; i.e., night, low ceiling and/or low visibility, and into remote areas.
(1) Pilots should undergo regular recurrent training to ensure they will be familiar with all instrument flight procedures authorized on the operator's operations specifications. Since medical flights may use airports with no air traffic control (ATC) assistance, no-radar environment and limited facilities, pilots must be proficient in nonprecision approach procedures.
(2) A training program should be prepared that will address the possibility of a forced landing in a remote area.
The program will address procedures relevant to the evacuation of a patient under extreme conditions related to a forced or precautionary landing.
Training should also address procedures to be followed in the event of a fire or smoke in the cabin either while airborne or on the ground. Particular attention should be paid to the needs of the patient during and after evacuation.
b. Medical Personnel. Medical personnel assigned duty during flight should be instructed in the use of aviation terminology. Medical personnel should use aviation terminology a of instructions iron ex to avoid confusion or misunderstandings of instructions from the flightcrew during the EMS mission.
(1) Medical personnel should also be trained to properly use, remove, and replace medical equipment installed on the aircraft.
(2) Medical personnel should be trained in physiological aspects of flight prior to being assigned duty during flight.
(3) Medical personnel should also be trained in aircraft evacuation and patient loading and unloading.
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NOTE: The training program should consider the particular aircraft being used, and its safety features. A practice evacuation using emergency exits should be accomplished.
Ground crew and other ground personnel (i.e., nurses, paramedics, etc). EMS/A operations require stringent safety precautions around the aircraft especially during loading and unloading. The FAA recommends that each certificate holder develop a training program that encompasses, in addition to their normal training program, at least the following:
(1) Loading and unloading the aircraft.
(2) Use of visual cues for positioning and parking the aircraft (i.e., standard hand signals, communications, etc.).
Medical personnel should be familiar with procedures to direct ambulances and ground equipment to the aircraft.
A program coordinated with local authorities
(e.g., fire and police departments) to deal with aircraft fuel spillage/leaks, aircraft fires, and other situations requiring emergency responses.
(4) Safe handling of oxygen equipment by all involved personnel. All personnel authorized to refill oxygen should be trained in the use of the recommended cascade system. If liquid oxygen (LOX) is to be used, the specific nature of LOX should be addressed.
NOTE: The FAA recommends that this program involve a licensed airframe and power plant mechanic to teach the correct procedures for handling oxygen equipment.
Maintenance Personnel. In addition to meeting the Flight Crewmembers, maintenance personnel should be trained by the manufacturers of the aircraft modification equipment, or in other maintenance training programs approved by the Administrator.
(1) Inspection of installation, as well as removal and reinstallation of special medical equipment, should be a part of this training.
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Supplemental Training. Training on servicing and maintenance of medical oxygen systems, along with characteristics of medical oxygen versus aviator-breathing oxygen, should be included in the training program.
NOTE: Recurrent training is recommended for all maintenance personnel.
Cockpit Resource Management (CRM). The FAA recommends that, when feasible, EMS/A flights be conducted under instrument flight rules (IFR) with two pilots. The FAA also recommends that a training program be established for CRM and use of checklists.
should be trained in "challenge and response" methods of checklist use. First officers should be trained to assist the pilot as directed. Cockpit procedures should be developed that one pilot is designated to fly the aircraft while the second pilot tends to the emergency.
Judgment and Decisions. The decisionmaking process should have input from all elements involved in an EMS operation.
Aeromedical directors, aircraft operators, the flightcrew, medical personnel, and ground crew contribute to this process.
The degree of input from each element depends upon the type and complexity of every mission.
Management personnel, including the aeromedical director, should be familiar with appropriate FAR and FAA guidelines related to safe operations. Management personnel should participate in the certificate holder's training program to gain knowledge concerning EMS/A operations.
(2) An essential element in flight operations is the timely decision to conduct a particular flight (or continue a flight as planned). To reach a decision, each participant in the decisionmaking process must be familiar with aircraft operations pertaining to the mission being planned.
(3) All personnel assigned to EMS should be trained in the operational aspects of each type of aircraft used. Training should include, but is not limited to, the range of each aircraft concerning the number of crewmembers and passengers carried, equipment installed, including carry-on equipment, weather capabilities, safety around aircraft, and safety in airport areas.
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(4) The certificate holder should be thoroughly familiar with the operational characteristics of each aircraft, and the qualifications of each flight crewmember.
Pilot judgment may be defined as: The mental process by which the pilot recognizes, analyzes, and evaluates information regarding himself/herself, the aircraft, and the external environment. Good pilot judgment can be developed as part of a flightcrew training program. Pamphlet DOT/FAA/PM-86/42, Aeronautical Decision Making for Commercial Pilots, is recommended to improve aeronautical decisionmaking.
The pamphlet covers the concepts of judgment and decisionmaking and is designed to be reviewed under the supervision of a flight instructor.
Decisions concerning flight operations should be made by the pilot in command (PIC) or management personnel qualified in accordance with FAR Section 135.39.
does not include medical personnel such as the aeromedical director or chief nurse of an EMS operation.
A final decision to conduct a flight, or to continue a flight as planned, should be made by the PIC based on his/her judgment. The decision should not be based solely upon the condition of the patient.
(8) The final step is the decision to conduct the flight in a safe and timely manner.
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