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ANNAPOLIS — New regulations to determine whether an injured patient is airlifted to a trauma center went into effect Thursday, less than two weeks after a state police medevac helicopter crashed in a Prince George's County park, killing four of the five people on board.

On-scene paramedics are now required to consult with an emergency room physician in cases when the injuries are not obviously grave before a helicopter is dispatched. Previously, that decision was made on the scene without a doctor's input.

"A helicopter under no circumstances is mandated," said Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems. "In order to be utilized, a helicopter has to save time and be of clinical benefit."

Emergency medical technicians perform a four-step triage assessment on the scene to make an initial determination of whether to seek air transport. A patient is to receive ground transport when the nearest trauma center is less than 30 minutes away, except in extreme cases.

If there are major physiological failures or anatomical injuries, no physician discussion is required. But if the injury is not obvious, such as internal bleeding, or the patient fits certain criteria — examples include those who are younger than age 5 or older than 55, on dialysis, or more than 20 weeks pregnant — emergency technicians must consult with a trauma room physician to determine proper protocol.

The modified guideline is "a good intermediate approach," to making the state's emergency response system safer and more effective, Bass said. It will also ease the stress on emergency providers who previously made the decision of whether to call for medevac service.

"It enables a pause and a discussion and we think that can be helpful, both for those providers who are anxious about sending patients [by air] and those providers who could benefit from taking a little time" to discuss the situation with a physician," Bass said.

The state medevac system had been under scrutiny for being overused and having poor management practices even before the fatal Sept. 28 crash. But making drastic changes to a 12-helicopter fleet that is regarded as one of the nation's best would be misguided and could put more lives at risk, Bass said.

"We expect that we're going to come through this and be a better system," he said. "We're trying to look at these issues and work in a sure-footed manner to move the system ahead and not take any drastic measures."

All but two medevac helicopters remained grounded as of Wednesday, State Police spokesman Greg Shipley said.

Troopers 1 and 7 operating out of Baltimore city and St. Mary's County, respectively, were in use. A U.S. Park Police helicopter stationed in Frederick is providing support in the western regions of the state. Officials hope to get the rest of the fleet back in service as soon as possible, but have set no specific timetable, Shipley said.