The transport of a critically ill patient by ambulance or aircraft introduces the additional problems of acceleration, altitude, vibration, and thermal insult, which may worsen physiological instability and must be managed within a restricted space with limited lighting and equipment. The quality of the personnel transporting the patient is paramount for successful outcome. The qualifications of the transporting team should be at least equal to those of the personnel who would normally look after the patient within the hospital.

The minimal guidelines for aeromedical personnel in the United Kingdom specify that accompanying physicians should be from the specialty relevant to the patient's disease (A.n..o.n.y.m.o.u.s,,,1.9.91.). More recent recommendations for the transfer of head injury patients state that accompanying physicians should have at least 2 years experience in this specialty (Neuroanaesthe,s,ia.,,,Society 1.996). In some situations a nurse may be replaced by a technician or a paramedic to provide optimal support.

In the United States, most aeromedical and almost all ground ambulance personnel are non-physicians (nurses, paramedics, or emergency medical technicians). Unlike much of Europe, the United Kingdom, and Russia, in North America training and resources are such that physicians generally do not attend scene responses and rarely participate in interhospital transports. The replacement of various team members by other physicians, nurses, paramedics, or emergency medical technicians depends on the particular circumstances. In most cases, the placement of two physicians as part of a transport team duplicates resources and is not economically feasible. In addition, in the United States most aeromedical and group transport systems are privately owned and operated rather than government run; however, there are federal and state regulations which govern the operation of these services.

Flight programs are variable with respect to the types of mission that they undertake. The medical director must have an in-depth knowledge of the diagnosis and treatment of the types of patients being transported with protocols available to provide uniformity of care. Successful operation of an aeromedical transport program requires smooth integration of existing prehospital emergency medical service systems with referring hospitals. Thus a knowledge of prehospital care, the operation of emergency medical service systems, and regional referral patterns is required. The medical director should be licensed to practice medicine in the region in which the aeromedical transport service is based, should be able to recognize and stabilize critical patients with a wide range of medical and surgical conditions, and should have a knowledge of the emergency medical service and the extensive hospital referral systems including dispatch, communications, law, and regulations. The medical director should actively participate in the early prehospital management of the acutely ill or injured patient, should have management experience including quality assurance, and should have expertise in teaching medical and paramedical personnel ( Tho,m§s,,,,§,Dd C„anu.b.b,a 1994; M.ayiieId,,,,§nd,,,,,Lin,dsiLom 1996).

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