An Overview
of the Development
of Helicopter Emergency
Medical Services in Japan
Just a decade has passed since Doctor-Heli was born in
Japan. In August 1999, the Doctor-Heli Investigation
Committee started with the support of the secretariat function
from the Internal Affairs Office of the Japanese Cabinet. In
October of that same year, a trial operation of helicopter
emergency medical services (HEMS) was started at two hospi-
tals, Okayama and Kanagawa Prefectures, respectively. This
was done in parallel to the government movement, the results
of which are given in Table 1.
In June 2000, the Doctor-Heli Investigation Committee con-
cluded its work, and, in April 2001, the first Doctor-Heli oper-
ation officially started from the two trial operations. A fully
dedicated and medically equipped helicopter now stands by at
an emergency medical care center on a daily basis.
Calls for an ambulance are routed through the national
emergency phone number 119 (911 equivalent), and a local
fire department requests the emergency center to dispatch
the helicopter, which is staffed with a flight physician and
flight nurse and lifts off within 2 to 5 minutes for an acci-
dent site. The primary mission of the helicopter is rapid
transportation of a physician and a nurse to an accident site
288
Wataru Nishikawa and Yutaka Yamano
to provide immediate, lifesaving medical treatment and
decision-making, with transportation of a patient consid-
ered the secondary mission. Patients are treated and medical
decisions are made by the flight physician as to the best
method of transportation required by the patient. Ground
ambulances transport some patients.
A decade has passed since the first HEMS bases started serv-
ices, and significant growth has occurred in these 10 years. The
term Doctor-Heli comes up quite commonly in the general pub-
lic, and it has become the theme of TV dramas in Japan. After 10
years of promoting the services, the public is finally recognizing
the contribution of HEMS, but this was a slow process. At the
time the Doctor-Heli program started, the Ministry of Health,
Labor, and Welfare announced its unofficial plan for 30 HEMS
bases nationwide. However, in March 2006, 5 years after the ini-
tial start of the program, only 10 programs, or one third of the
target, had been implemented (Figure).
The delay was caused by several factors, but the largest
was financial. Raising the funds for the operational cost of
an emergency helicopter program was very difficult because
of the initial method of sharing costs. The Ministry set the
Air Medical Journal 29:6
Table 1. Results from Trial Operation of Doctor-Heli from October 1999 to September 2000
Death Severe* Normal Moderate Minor Total
Number of patients transported by air|| 70 53 203 113 27 466
Number of patients not transported by air 116 112 98 113 27 466

NOTE. Functional status, resources, and advantages over ground established by consensus emergency physician panel led by Dr.
Kunihiro Mashiko.
Air transports were done with a flight physician and a flight nurse; ground transports were done with a paramedic.
Japanese paramedics operate at the US equivalent of an EMT.
This research was not published but was used as evidence to support expansion of the Doctor-Heli program.
*Deterioration of movement function remains and requires nursing.
No trouble remains, and patients completely returned to normal life.
No danger to life and no handicap remains, but hospital treatment required.
Ambulatory treatment will be enough for complete recovery.
||Number of patients to whom Doctor-Heli responded in the period from October 1999 to September 2000.
Presumptive number of patients and their conditions if they had been transported by an ambulance other than Doctor-Heli.

operational cost of a Doctor-Heli base at 180 million yen
(US $2 million), with central and local governments (prefec-
tures) sharing the cost 50:50. This cost-sharing rule created
challenges for taxpayers, because prefectures were unable to
bear the cost and thus were unable to implement a local
HEMS operation.
Studies support the advantages of operating a medical
helicopter to decrease mortality, decrease the recovery
period, and reduce costs for hospital expenses and medical
expenses when immediate medical care is provided to a
Prefecture basing strategy and coverage for Japan during HEM-
Net growth.
patient at the site of accident, thus reducing the burden on
health insurance. Unfortunately, decision-makers at the
Ministry of Health, Labor, and Welfare did not initially
embrace this concept and were not supportive of an
expanding Doctor-Heli program.
Lack of Public and Political Awareness Slows
Growth
Another cause for the delay in the spread of the Doctor-Heli
program was a lack of social awareness. In fact, the general
population for many years did not know about the program.
Those who were involved in the trial operation of Doctor-Heli
noted the dramatic 40% reduction in mortality, as well as a
twofold increase in patients returning to normal activities of
daily living, especially in comparison with similar cases trans-
ported by ground ambulance, as noted in Table 1. However,
these data did not translate into a language that the public
could grasp in terms of a value proposition. Consequently,
there was no incentive to motivate the general population to
pressure the local and central government for the widespread
implementation of the Doctor-Heli system.
In recent years Japan has seen an increasing number of crit-
ically ill or injured patients who require transfer from one
hospital to another to optimize medical care in a setting of
increasing population, congested ground transportation, and
decreasing medical resources. A recent example was a case in
which a hospital in the Tokyo Metropolitan area refused to
accept a high-risk premature delivery, necessitating an
extended ground transport to another facility and ultimately
resulting in maternal death. This case demonstrated that the
transportation of critical patients is not unique to the remote
areas of Japan, as many believed. Now, major local govern-
ment officials, prefectural assembly members, and commu-
nity leaders have begun to show their support for the
Doctor-Heli system.

November-December 2010 289

 The superiority of advanced medical care and timesaving
capability of HEMS is much more cost effective than con-
structing a special expressway for ambulances to bypass the
constant traffic congestion, which is being considered by
some in Japan.
Legislation and Fundamental Policy
On June 27, 2007, the National Legislature enacted the
Special Measures Law That Promotes Securement of
Emergency Medical Service Using a Medically Dedicated
Helicopter, the Doctor-Heli Special Law. The objective of
the law is to find ways to reduce local government costs for
helicopter operation by using funds from health insurance
and workers accident compensation insurance. The overall
objective was to finance the HEMS system within 3 years. Just
1 year later, on June 27, 2008, the Cabinet adopted the
Fundamental Policy for Economy and Financial Reform that
further boosted the overall EMS infrastructure. It also stresses
the Doctor-Heli program as required to provide the highest
quality emergency medical care for Japan.
In yet another sign of government support, the Ministry of
Health, Labor, and Welfare earmarked funds from the fiscal
2009 budget for the operational costs of 24 additional
290
Doctor-Heli programs. To date there are 18 Doctor-Heli pro-
grams (see map), with another six slated for implementation
by March 2010.
In an effort to mitigate political agendas preventing the
continued growth of the Doctor-Heli system, a bipartisan
coalition of 139 National Legislative members was forged on
November 20, 2008. At the first coalition meeting, the fol-
lowing two resolutions were adopted:
1. Secure necessary funding to deploy the Doctor-Heli
System in each prefecture
2. Enhance central government tax revenues for local
governments to ease the financial burden required for
the introduction of the Doctor-Heli System in each
prefecture
With the adoption of both resolutions, a higher burden of
financial responsibility falls on the central government, lessening
the impact to the often financially challenged local governments.
Lifesaving Efficiency and Reducing Time to
Medical Treatment
Fourteen Doctor-Heli programs based at various hospitals
carried out 5,253 missions in fiscal 2007, a period from April
1, 2007, to March 31, 2008. The 11 programs, which had
Air Medical Journal 29:6
been in service for 1 full year, completed 5,194 missions;
thus, the average number of missions performed was 472 per
program per year.
A total of 4,901 patients were treated by the flight physi-
cians and subsequently transported by the Doctor-Heli sys-
tem. Based on past scientific studies, an estimated 10%, or
500 patients, would have died without this aid. Moreover, the
number of patients who were estimated to have improved
recovery and resumed their place in society should have
increased 1.5 to 2.0 times, compared with the results with
ground ambulances, as shown in Table 1.
The Doctor-Heli program kept progressing, and the num-
ber of programs increased to 18 by the end of fiscal 2008,
from April 1, 2008, to March 31, 2009. The program was
used 5,635 times, and 5,182 patients were treated in the full
fiscal year.
The current number of the programs is 21, as of March
2010. Five more programs are expected to start services in fis-
cal 2010, six more in fiscal 2011, and five more in fiscal
2012. The total number of Doctor-Heli programs should
reach 40 in fiscal 2013.
Optimal Distribution of Doctor-Heli Bases
Discussion regarding what the optimal number of med-
ically equipped helicopters is for Japan is ongoing. In the
HEMS model in Germany, a target to reach a patient in 15
minutes 90% of the time was established. This, projected to
population and geography, results in an average range for the
helicopter to be 50 km or roughly 15 minutes of flight time.
For Japan to meet a similar objective would require approxi-
mately 50 dedicated helicopters stationed throughout the
country. Japan is currently slated for 24 helicopters by the
March 2010, approximately half of the required number.
Of course, time required is variable, depending on the sit-
uation, and therefore 90% is the target used to keep arrival
at the site within 15 minutes. Actual results achieved by
Doctor-Heli in the areas served in 2005 were that medical
treatment was started within 15 minutes for 84% of the mis-
sions. Germany, having 94% country area compared with
Japan, has approximately 80 HEMS programs, as well as an
integrated ground ambulance system, to accomplish the 15-
minute target.
A study completed by the Japanese Ministry of Internal
Affairs and Communication for Fire and Disaster
Management Agency in 2007, Required Time from When
the Ambulance Is Called to the Time the Patient Is
Transported to Hospital, showed the Toyama Prefecture has
the fastest transport time of 25.4 minutes, with the national
average being 33.4 minutes. The slowest is Metropolitan
Tokyo, with a time to patient transport of 47.2 minutes.
Switzerland is another country that, despite its mountain-
ous terrain within the Alps, has an established system in
which an EMS helicopter with a doctor on board gets on-site
within 15 minutes. The Swiss network consists of 13 HEMS
bases, servicing a population density equivalent to 120 bases
November-December 2010
in Japan. These helicopters with doctors on board are avail-
able 24 hours per day.
To determine the optimal number of Doctor-Heli programs,
one must consider the mountainous terrain and remote
islands. If one compares Japan with the Swiss model, an argu-
ment can be made to place as many as 120 helicopters across
the country. That being said, whatever number is decided on,
the extensive training of flight physicians, flight nurses, and
pilots and the creation of government policy, including budg-
etary resources, must be established. With a shortage of emer-
gency-trained physicians, this task is daunting.
Filling the Gaps of a Challenged Care System
Not only is the distribution of HEMS in Japan behind other
countries, but also the EMS system of Japan is in danger of
breaking down. The emergency medical system has been col-
lapsing, with a chain of trends that includes a decreasing
number of physicians and the closure of emergency depart-
ments and hospitals. Fundamental measures are necessary to
reverse this situation and return it to an acceptable situation.
Doctor-Heli has played an important role as a stopgap
measure to slow this deterioration. Not all of the EMS prob-
lems can be resolved by the Doctor-Heli program, but it is
being used as a means to supplement the current situation
while promoting fundamental improvement of the medical
system.
Conclusion
Ten years have passed since the birth of the Doctor-Heli
program. Social awareness of its contribution to medical
emergencies has gradually improved, with more focused
efforts necessary. Legislative support has grown, and funding
has stabilized. Initial growth has been slow, but expansion
seems to be gaining momentum. The challenge of covering
Japan with adequate HEMS resources is the next challenge as
the program evolves in a difficult and deteriorating healthcare
system.
Wataru Nishikawa and Yutaka Yamano are directors in the
Helicopter Emergency Medical Network (HEM-Net) in Japan.
1067-991X/$36.00
Copyright 2010 Air Medical Journal Associates
doi:10.1016/j.amj.2010.05.009
291