Air Ambulances

Air medical services is a comprehensive term covering the use of air transportation, aeroplane or helicopter, to move patients to and from healthcare facilities and accident scenes. Personnel provide comprehensive prehospital and emergency and critical care to all types of patients during aeromedical evacuation or rescue operations aboard helicopter and propeller aircraft or jet aircraft.

The use of air transport to provide medical evacuation on the battlefield dates to World War I, but its role was expanded dramatically during the Korean and Vietnam wars. Later on, aircraft began to be used for the civilian emergency medical services. Helicopters can bring specialist care to the scene and transport patients to specialist hospitals, especially for major trauma cases. Fixed-wing aircraft are used for long-distance transport.

In some remote areas, air medical services deliver non-emergency healthcare such as general practitioner appointments. An example of this is the Royal Flying Doctor Service of Australia an
Human care
which also provide emergency care.

Advantages

Air medical services can travel faster and operate in a wider coverage area than a land ambulance. This makes them particularly useful in sparsely-populated rural areas.

Air medical services have a particular advantage for major trauma injuries. The controversial theory of the golden hour suggests that major trauma patients should be transported as quickly as possible to a specialist trauma center. Therefore, medical responders in a helicopter can provide both a higher level of care at the scene of a trauma and faster transport to a trauma center. They can also provide critical care when transporting patients from community hospitals to trauma centers.

Indications for air transport

Effective use of helicopter services for trauma depends on the ground responder's ability to determine whether the patient's condition warrants air medical transport. Protocols and training must be developed to ensure appropriate triage criteria are applied. Excessively stringent criteria can prevent rapid care and transport of trauma victims; relaxed criteria can result in the patient being unnecessarily exposed to the potential dangers of dangerous weather conditions or other aviation-related risks.

Crew and patient safety is the single most important factor to be considered when deciding whether to transport a patient by helicopter. Weather, air traffic patterns, and distances (such as from the trauma scene to closest level 1 trauma centre) must also be considered. Another reason for cancelling a flight is based on the comfort of the flight crew with the flight. The general rule of safety is upon the crew, when there is one pilot and two medical crew is:

Some have questioned the safety of air medical services. While the number of crashes may be increasing, the number of programs and use of services has also increased. Factors associated with fatal crashes of medical transport helicopters include flying at night and during bad weather, and postcrash fires.

Air ambulance

An air ambulance is a specially outfitted helicopter or fixed-wing aircraft that transports injured or sick people in a medical emergency or over distances or terrain impractical for a conventional ground ambulance. Fixed-wing aircraft are also more often used to move patients over long distances and for repatriation from foreign countries. These and related operations are called ''aeromedical''. In some circumstances, the same aircraft may be used to search for missing or wanted people.

Like ground ambulances, air ambulances are equipped with medical equipment vital to monitoring and treating injured or ill patients. Common equipment for air ambulances includes medications, ventilators, ECGs and monitoring units, CPR equipment, and stretchers. A medically staffed and equipped air ambulance provides medical care in flight—while a non-medically equipped and staffed aircraft simply transports patients without care in flight. Military organizations and NATO refer to the former as '' medical evacuation (MEDEVAC)'' and to the latter as '' casualty evacuation (CASEVAC)''.

Air Traffic Control (ATC) grants special treatment to air ambulance operations, much like a ground ambulance using lights and a siren, only when they are actively operating with a patient. When this happens, air ambulance aircraft take the call sign MEDEVAC (formerly LIFEGUARD) and receive priority handling in the air and on the ground.

History

Military

As with many Emergency Medical Service (EMS) innovations, treating patients in flight originated in the military. The concept of using aircraft as ambulances is almost as old as powered flight itself. Although balloons were not used to evacuate wounded soldiers at the Siege of Paris in 1870, air evacuation was experimented with during the First World War.

The first recorded British ambulance flight took place in 1917 in Ottoman Empire when a soldier in the Camel Corps who had been shot in the ankle was flown to hospital in a de Havilland DH9 in 45 minutes
First Recorded Aeromedical Evacuation in the British Army
The same journey by land would have taken some 3 days to complete. In the 1920s several services, both official and unofficial, started up in various parts of the world. Aircraft were still primitive at the time, with limited capabilities, and the effort received mixed reviews.

Exploration of the idea continued, however, and France and the United Kingdom used fully organized air ambulance services during the African and Middle Eastern Colonial Wars of the 1920s. In 1920, the British, while suppressing the " Mad Mullah" in Somaliland, used an Airco DH.9A fitted out as an air ambulance. It carried a single stretcher under a fairing behind the pilot. The French evacuated over 7,000 casualties during that period. By 1936, an organized military air ambulance service evacuated wounded from the Spanish Civil War for medical treatment in Nazi Germany; this service continued during the Second World War.

The first use of medevac with helicopters was the evacuation of three British pilot combat casualties by a US Army Sikorsky R-4 in Burma during WW2, and the first dedicated use of helicopters by U.S. forces occurred during the Korean War, between 1950 and 1953. The French used light helicopters in the First Indochina War. While popularly depicted as simply removing casualties from the battlefield (which they did), helicopters in the Korean War also moved critical patients to hospital ships after initial emergency treatment in field hospitals.

Knowledge and expertise of use of air ambulances evolved parallel to the aircraft themselves. By 1969, in Vietnam, the use of specially trained medical corpsmen and helicopter air ambulances led U.S. researchers to determine that servicemen wounded in battle had better rates of survival than motorists injured on California freeways. This inspired the first experiments with the use of civilian paramedics in the world. The US military recently employed UH-60 Black Hawk helicopters to provide air ambulance service during the Iraq War to military personnel and civilians. The use of military aircraft as battlefield ambulances continues to grow and develop today in a variety of countries, as does the use of fixed-wing aircraft for long-distance travel, including repatriation of the wounded. Currently, a NATO working group is investigating unpiloted aerial vehicles (UAVs) for casualty evacuation.

Civilian

The first civilian uses of aircraft as ambulances were probably incidental. In northern Canada, Australia, and in Scandinavian countries, remote, sparsely populated settlements are often inaccessible by road for months at a time, or even year-round. In some places in Scandinavia, particularly in Norway, the primary means of transportation between communities is by boat. Early in aviation history, many of these communities began to rely on civilian "bush" pilots, who fly small aircraft and transport supplies, mail, and visiting doctors or nurses. Bush pilots probably performed the first civilian air ambulance trips, albeit on an ad hoc basis—but clearly, a need for these services existed. In the early 1920s, Sweden established a standing air ambulance system, as did Siam (Thailand). In 1928 the first formal, full-time air ambulance service was established in the Australian outback. This organization became the Royal Flying Doctor Service and still operates. In 1934, Marie Marvingt established Africa's first civil air ambulance service, in Morocco. In 1936, air ambulance services were established as part of the Highlands and Islands Medical Service to serve more remote areas of Highland Scotland. Air ambulances quickly established their usefulness in remote locations, but their role in developed areas developed more slowly. After World War II, the Saskatchewan government in Regina, Saskatchewan, Canada, established the first civilian air ambulance in North America. The Saskatchewan government had to consider remote communities and great distances in providing health care to its citizens. The Saskatchewan Air Ambulance service continues to be active as of 2022.
J. Walter Schaefer founded the first air ambulance service in the U.S, in 1947, in Los Angeles. The Schaefer Air Service operated as part of Schaefer Ambulance Service. Schaefer Air Service was also the first FAA-certified air ambulance service in the United States. When the Saskatchewan and Schaefer services began, paramedicine was still decades away, and unless a physician or nurse accompanied the patient, air ambulances primarily provided medical transportation. A great deal of the early use of aircraft as ambulances in civilian life, particularly helicopters, involved the improvised use of aircraft that belonged to the military. Eventually, this became more organized. This occurred not only in the United States, but also in other countries, and persists today. Today in the U.S., helicopters and airplanes carry out approximately a half-million transports per year.

Two research programs were implemented in the U.S. to assess the impact of medical helicopters on mortality and morbidity in the civilian arena. Project CARESOM was established in Mississippi in 1969. Three helicopters were purchased through a federal grant and located strategically in the north, central, and southern areas of the state. Upon termination of the grant, the program was considered a success and each of the three communities were given the opportunity to continue the helicopter operation. Only the one located in Hattiesburg, Mississippi did so, and it was therefore established as the first civilian air medical program in the United States. The second program, the Military Assistance to Safety and Traffic (MAST) system, was established in Fort Sam Houston in San Antonio in 1969. This was an experiment by the Department of Transportation to study the feasibility of using military helicopters to augment existing civilian emergency medical services. These programs were highly successful at establishing the need for such services. The remaining challenge was in how such services could be operated most cost-effectively. In many cases, as agencies, branches, and departments of the civilian governments began to operate aircraft for other purposes, these aircraft were frequently pressed into service to provide cost-effective air support to the evolving Emergency Medical Services.

As the concept was proven, dedicated civilian air ambulances began to appear. On November 1, 1970, the first permanent civil air ambulance helicopter, ''Christoph 1'', entered service at the Hospital of Harlaching, Munich, Germany. The apparent success of ''Christoph 1'' led to a quick expansion of the concept across Germany, with ''Christoph 10'' entering service in 1975, ''Christoph 20'' in 1981, and ''Christoph 51'' in 1989. As of 2007, there are about 80 helicopters named after Saint Christopher, like ''Christoph Europa 5'' (also serving Denmark), ''Christoph Brandenburg'' or ''Christoph Murnau am Staffelsee''. Austria adopted the German system in 1983 when ''Christophorus 1'' entered service at Innsbruck. Also in the year 1975 Hans Burghart, one of the inventor of the civilian air rescue in Germany, presented at one Academic conference in the US the concept "Rescue Helicopters in Primary and Secondary Missions" which had impact for the aviation training at Fort Rucker, Alabama.

The first civilian, hospital-based medical helicopter program in the United States began operation in 1972. Flight For Life Colorado began with a single Alouette III helicopter, based at St. Anthony Central Hospital in Denver, Colorado. In Ontario, Canada, the air ambulance program began in 1977, and featured a paramedic-based system of care, with the presence of physicians or nurses being relatively unusual. The system, operated by the Ontario Ministry of Health, began with a single rotor-wing aircraft based in Toronto. An important difference in the Ontario program involved the emphasis of service. "On scene" calls were taken, although less commonly, and a great deal of the initial emphasis of the program was on the interfacility transfer of critical care patients. Operating today through a private contractor (ORNGE), the system operates 33 aircraft stationed at 26 bases across the province, performing both interfacility transfers and on-scene responses in support of ground-based EMS. Today, across the world, the presence of civilian air ambulances has become commonplace and is seen as a much-needed support for ground-based EMS systems. In other countries of Europe, like SFR Yugoslavia, first air ambulance appeared in the 1980s. The most of the fleet was previously used in military service. With the increased number of car accidents in 1979 on highways, the Yugoslavian government made a decision to buy new or redistribution of use of old helicopters.

Organization

Air ambulance service, sometimes called Aeromedical Evacuation or simply Medevac, is provided by a variety of different sources in different places in the world. There are a number of reasonable methods of differentiating types of air ambulance services. These include military/civilian models and services that are government-funded, fee-for-service, donated by a business enterprise, or funded by public donations. It may also be reasonable to differentiate between dedicated aircraft and those with multiple purposes and roles. Finally, it is reasonable to differentiate by the type of aircraft used, including rotary-wing, fixed-wing, or very large aircraft. The military role in civilian air ambulance operations is described in the History section. Each of the remaining models is explored separately. This information applies to air ambulance systems performing emergency service. In almost all jurisdictions, private aircraft charter companies provide non-emergency air ambulance service on a fee-for-service basis.

Government operated

In some cases, governments provide air ambulance services, either directly or via a negotiated contract with a commercial service provider, such as an aircraft charter company. Such services may focus on critical care patient transport, support ground-based EMS on scenes, or may perform a combination of these roles. In almost all cases, the government provides guidelines to hospitals and EMS systems to control operating costs—and may specify operating procedures in some level of detail to limit potential liability. However, the government almost always takes a 'hands-off' approach to the actual running of the system, relying instead on local managers with subject matter (physicians and aviation executives) expertise. Ontario's ORNGE program and the Polish Lotnicze Pogotowie Ratunkowe (LPR) are examples of this type of operating system."History."
''ornge.ca.'' Retrieved: December 4, 2010. The Polish LPR is a national system covering the entire country and funded by the government through the Ministry of Health but run independently, there is no independent HEMS operator in Poland. In North East Ohio, including Cleveland, the Cuyahoga County-owned MetroHealth Medical Center uses its Metro Life Flight to transport patients to Metro's level I trauma and burn unit. There are 5 helicopters for North East Ohio and, in addition, Metro Life Flight has one fixed-wing aircraft.

In the United Kingdom, the Scottish Ambulance Service operates two helicopters and two fixed-wing aircraft twenty-four hours per day.

Multiple purpose

In some jurisdictions, cost is a major consideration, and the presence of dedicated air ambulances is simply not practical. In these cases, the aircraft may be operated by another government or quasi-government agency and made available to EMS for air ambulance service when required. In southern New South Wales, Australia, the helicopter that responds as an air ambulance is actually operated by the local hydroelectric utility, with the New South Wales Ambulance Service providing paramedics, as required. In some cases, local EMS provides the flight paramedic to the aircraft operator as-needed. In the case of the Los Angeles County Fire Department, the helicopters are brush fire choppers also configured as air ambulances with a paramedic provided from whichever fire department rescue unit has responded.

Sometimes the air ambulance may be run as a dual concern with another governmental body - for example, the Wiltshire Air Ambulance was run as a joint Ambulance Service and police unit until 2014.

In other cases, the paramedic staffs the aircraft full-time, but has a dual function. In the case of the Maryland State Police, for example, the flight paramedic is a serving State Trooper whose job is to act as the Observer Officer on a police helicopter when not required for medical emergencies.

Fee-for-service

In many cases, local jurisdictions do not charge for air ambulance service, particularly for emergency calls. However, the cost of providing air ambulance services is considerable and many, including government-run operations, charge for service. Organizations such as service aircraft charter companies, hospitals, and some private-for-profit EMS systems generally charge for service. Within the European Union, almost all air ambulance service is on a fee-for-service basis, except for systems that operate by private subscription. Many jurisdictions have a mix of operation types. Fee-for-service operators are generally responsible for their own organization but may have to meet government licensing requirements. Rega

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