Air ambulance

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Air ambulance

A Eurocopter EC 145 of Switzerland's Rega air rescue

service.
An air ambulance helicopter landing in a car park

An air ambulance is an aircraft used for emergency medical assistance in situations where either
a traditional ambulance cannot reach the scene easily or quickly enough, or the patient needs to
be transported over a distance or terrain that makes air transportation the most practical transport.
These and related operatations are referred to as Aeromedical. Air ambulance crews are supplied
with equipment that enables them to provide medical treatment to a critically injured or ill
patient. Common equipment for air ambulances includes ventilators, medication, an ECG and
monitoring unit, CPR equipment, and stretchers.

Contents
[hide]

• 1 History
o 1.1 Military
 o 1.2 Civilian
• 2 Organization
o 2.1 Government operated
o 2.2 Multiple purpose
o 2.3 Fee-for-service
o 2.4 Donated by business
o 2.5 Public donations
o 2.6 Operating model
o 2.7 "Heavy-lift"
• 3 Standards
o 3.1 Aircraft and flight crews
o 3.2 Medical staffing
o 3.3 Medical control
o 3.4 Equipment and interiors
o 3.5 Challenges
o 3.6 Cost-effectiveness
• 4 See also
• 5 References

• 6 External links

[edit] History
[edit] Military

As with many innovations in Emergency Medical Service (EMS), the concept of transporting the
injured by aircraft has its origins in the military, and the concept of using aircraft as ambulances
is almost as old as powered flight itself. Air medical transport likely first occurred in 1870 during
the Siege of Paris when 160 wounded French soldiers were transported by hot-air balloon to
France.[1] During the First World War air ambulances were tested by various military
organizations. Aircraft were still primitive at the time, with limited capabilities, and the effort
received mixed reviews. The exploration of the idea continued, however, and by 1936, an
organized military air ambulance service was evacuating wounded from the Spanish Civil War
for medical treatment in Nazi Germany. The first dedicated use of helicopters by U.S. forces
occurred during the Korean War, during the period from 1950-1953. While popularly depicted as
simply removing casualties from the battlefield (which they did), helicopters also expanded their
services to moving critical patients to more advanced hospital ships once initial emergency
treatment in field hospitals had occurred. Knowledge and expertise of use of aircraft as
ambulances continued to evolve along with the aircraft themselves, and by 1969, in Vietnam, the
use of specially trained medical corpsmen and helicopters as ambulances led U.S. researchers to
conclude that servicemen wounded in battle had better rates of survival than motorists injured on
California freeways. This conclusion inspired the first experiments with the use of civilian
paramedics in the world.[2] The US military has recently employed UH-60 Black Hawk
helicopters to provide air ambulance service during the Iraq War to both civilians and military
personnel.[3] 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.

Early Air Ambulance Efforts

Light helicopters like this Bell

Older version of a Danish air H-19 moves wounded to more
47 Sioux removed the wounded
ambulance advanced care offshore (Korea)
from the battlefield (Korea)

[edit] Civilian

The first civilian uses of aircraft as ambulances were probably incidental. In northern Canada,
Australia, and in the Scandinavian countries, remote, sparsely populated settlements were often
inaccessible by road for months at a time, or even year round. In some cases in Scandinavia,
particularly in Norway, the primary means of transportation between communities was by boat.
Early on in aviation history, many of these communities began to receive service from civilian
"bush" pilots, flying small aircraft and transporting supplies, mail, and visiting doctors or nurses
to the isolated communities. Bush pilots probably performed the first civilian air ambulance
trips, albeit on an ad hoc basis, but clearly, a need for such services existed. In 1928 the first
formal, full-time air ambulance service was established in the Australian outback. This
organization became the Royal Flying Doctor Service[4] and continues operating to the present. In
1934, the first civil air ambulance service in Africa was established in Morocco by Marie
Marvingt.[5]

Australia's Royal Flying Doctor Service

King Air 200 Ambulance King Air Pilatus PC 12/45

Air ambulances were useful in remote areas, but their usefulness in the developed world was still
uncertain. Following the end of the Second World War, the first civilian air ambulance in North
America was established by the Saskatchewan government in Regina, Saskatchewan, Canada,
which had both remote communities and great distances to consider in the provision of health
care to its citizens.[6] The Saskatchewan air ambulance service continues to be active as of 2009.

Back in the United States, 1947 saw the creation of the Schaefer Air Service, the country's first
air ambulance service. This service was founded by J. Walter Schaefer, of Schaefer Ambulance
Service in Los Angeles, California.[7] Schaefer Air Service was also the first FAA-certified air
ambulance service in the United States. It should be noted that at the time of the creation of the
Schaefer and Saskatchewan services, paramedicine was still decades away, and unless the patient
was accompanied by a physician or nurse, they operated primarily as medical transportation
services. A great deal of the early use of aircraft as ambulances in civilian life, particularly
helicopters, involved the improvised use of aircraft belonging to branches of the military.
Eventually this would become more organized. This mode of usage occurred not only in the
United States, but also in other countries, and persists to this day.

Military Aircraft Supporting Civilian Air Ambulance

Israeli Military Helicopter as Air

Swedish Search and Rescue Dutch Search and Rescue
Ambulance

Two 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.[8] Upon termination of the grant, the program was
considered a success and each of the three communities was given the opportunity to continue
the helicopter operation. Only the one located in Hattiesburg 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.
 Government Agency Aircraft Performing Double Duty

German 'Christoph' Air

Hong Kong Government Flying Ambulance of the Federal
Service Italian Government Helicopter
Ministry of the Interior

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.[9] 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. Austria adopted the German system in 1983 when Christophorus 1 entered
service at Innsbruck. The first civilian, hospital-based medical helicopter program in the United
States began operation in 1972.[10] 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. Ornge
operates the largest and most sophisticated program of aero-medical transport in North America.
[citation needed]
Over 17,000 admissions are dispatched annually, making Ornge North America's
largest operator in the field of transport medicine. 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.

Modern Civilian Air Ambulances

 Devon Air West Palm Beach, Florida
German Air Rescue - DRF
Ambulance Trust

Swedish King Air

[edit] 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 will be explored separately. It should also be noted that 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.

[edit] Government operated

Scottish Ambulance Service - The UK's only Government funded air ambulance service.

Ornge air ambulance service in Ontario, Canada.

In some cases, air ambulance services will be provided by government, either directly or by
means of a negotiated contract with a commercial service provider, such as an aircraft charter
company. Such services may focus on the transfer of critical care patients, may support ground-
based EMS on scenes, or may perform a combination of these roles. In almost all cases, the
government will provide guidelines for use to both hospitals and EMS systems, in order to keep
operating costs under control, and may specify operating procedures in some level of detail in
order to limit potential liability, but 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 LPR are examples of
this type of operating system.[11]. 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 airplane.[12]

In the United Kingdom, the Scottish Ambulance Service operates two helicopters and two fixed-
wing aircraft twenty-four hours per day. These represent the UK's only government-funded air
ambulance service.

[edit] Multiple purpose

Snowy Hydro SouthCare Bell 412 helicopter in Australia

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 Queensland, Australia, the helicopter that responds as an air ambulance is actually
operated by the local hydroelectric utility, with the Queensland Ambulance Service or New
South Wales Ambulance Service providing paramedics, as required. In some cases, the flight
paramedic will be provided to the aircraft operator by local EMS on an as-needed basis. In other
cases, the paramedic will staff the aircraft full-time, but will have 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.[13]

[edit] Fee-for-service

Switzerland REGA Fee-for-service

In many cases, local jurisdictions do not charge for air ambulance service, particularly for
emergency calls. This is not, however, universally true. The cost of providing air ambulance
services is considerable, and many such services, including government-run ones, charge for
service. There are certain groups which, in particular, charge for service. These tend to be
privately-owned companies, such as aircraft charter companies, hospitals, and some private-for-
profit EMS systems. Within the European Union, almost all air ambulance service is on a fee-
for-service basis, except for those systems which 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 of
Switzerland is an example of such a service.[14]

[edit] Donated by business

German Auto Club

In some cases, a local business or even a multi-national company may choose to fund local air
ambulance service as a goodwill or public relations gesture. Examples of this are common in the
European Union, where in London the Virgin Corporation funds the Helicopter Emergency
Medical Service, and in Germany and The Netherlands a large number of the 'Christoph' air
ambulance operations are actually funded by ADAC, Germany's largest automobile club.[15] In
Australia and New Zealand, many air ambulance helicopter operations are sponsored by the
Westpac Bank. In these cases, the operation may vary, but is the result of a carefully negotiated
agreement between government, EMS, hospitals, and the donor. In most cases, while the sponsor
receives advertising exposure in exchange for funding, they take a 'hands off' approach to daily
operations, relying instead on subject matter specialists.

Public donations supported

[edit] Public donations

In some cases, air ambulance services may be provided by means of voluntary charitable
fundraising, as opposed to government funding, or they may receive limited government subsidy
to supplement local donations. Some countries, such as the U.K., use a mix of such systems. In
Scotland, the parliament has voted to fund air ambulance service directly, through the Scottish
Ambulance Service. In England and Wales, however, the service is funded on a charitable basis
via a number of local charities for each region covered.[16]

[edit] Operating model

The operating model for the EMS system is often a valid way of differentiating air ambulances.
The Anglo-American model tends to be paramedic-led,[17] with occasional in-field involvement
by physicians and nurses. In these cases, the emphasis is on the transport of the patient to
definitive care, usually a hospital. While supportive and life-saving care may occur, the aircraft
exists primarily as a means of transportation for the patient. Many hospital-based systems in the
U.S. are examples of this model. In the Franco-German model,[18] the response is physician-led,
with a doctor attending on almost every call. The emphasis here is to bring definitive care rapidly
to the patient, wherever they are. This may involve considerable 'on-scene' times, as physicians
attempt complex interventions which would, in the other model, not be attempted until the
patient reached the hospital. In these cases, the helicopter is a means of delivery of the physician
and support staff (paramedic or nurse) to the scene. Further transport is generally accomplished
using a ground ambulance, and air transport occurs only in the most dire of circumstances. The
French SAMU system is an example of this model. The lines of distinction can be somewhat
blurred between these models, as systems which use the Anglo-American model for ground
ambulances may instead use the Franco-German approach to air ambulance service. The Dutch
system is an example of this, as is the HEMS program in London, England.

Operating Models
 Dutch Crossover model
Franco-German model Anglo-American model

[edit] "Heavy-lift"

Recently retired USAF C-9 Nightingale air ambulance.

A final area of distinction which requires mention is the operation of truly large aircraft,
generally fixed-wing in nature, as air ambulances. The infrequency of demand for such a service
in the civilian sphere means that the majority of such operations are confined to the military,
which requires them in support of overseas combat operations. Military organizations with a
capability of this type of specialized operation include the United States Air Force,[19] the
German Luftwaffe, and the British Royal Air Force. Each operates aircraft staffed by physicians,
nurses, and corpsmen/technicians, and each has the capability of providing long distance
transport, along with all required medical support, to dozens of injured persons simultaneously.
One exception to the 'military-only' rule is the German automobile club, ADAC, which operates
a large air ambulance aircraft specifically for the repatriation of individuals who subscribe to
their own or affiliated travel insurance and protection plans.

Heavy lift capability

German Luftwaffe A310 German Auto Club Dornier 328 USAF C-17 Globemaster
[edit] Standards
[edit] Aircraft and flight crews

HAL Dhruv air ambulance in Bangalore, India.

In most jurisdictions, air ambulance pilots must have a great deal of experience in piloting their
aircraft because the conditions of air ambulance flights are often more challenging than regular
non-emergency flight services. After a spike in air ambulance crashes in the United States in the
1990s, the U.S. government and the Commission on Air Medical Transportation Systems
(CAMTS) stepped up the accreditation and air ambulance flight requirements, ensuring that all
pilots, personnel, and aircraft meet much higher standards than previously required.[20] The
resulting CAMTS accreditation, which applies only in the United States, includes the
requirement for an air ambulance company to own and operate its own aircraft. Some air
ambulance companies, realizing it is virtually impossible to have the correct medicalized aircraft
for every mission, instead charter aircraft based on the mission-specific requirements.

While in principle CAMTS accreditation is voluntary, a number of government jurisdictions

require companies providing medical transportation services to have CAMTS accreditation in
order to be licensed to operate. This is an increasing trend as state health services agencies
address the issues surrounding the safety of emergency medical services flights.[21] Some
examples are the states of Colorado,[22] New Jersey,[23] New Mexico,[24] Utah,[25] and Washington.
[26]
According to the rationale used to justify the state of Washington's adoption of the
accreditation requirements, requiring accreditation of air ambulance services provides assurance
that the service meets national public safety standards. The accreditation is done by professionals
who are qualified to determine air ambulance safety. In addition, compliance with accreditation
standards is checked on a continual basis by the accrediting organization. Accreditation
standards are periodically revised to reflect the dynamic, changing environment of medical
transport, with considerable input from all disciplines of the medical profession.

Other U.S. states require either CAMTS accreditation or a demonstrated equivalent, such as
Rhode Island,[27] and Texas, which has adopted CAMTS' Accreditation Standards (Sixth Edition,
October 2004) as its own. In Texas, an operator not wishing to become CAMTS accredited must
submit to an equivalent survey by state auditors who are CAMTS-trained.[28][29] Virginia and
Oklahoma have also adopted CAMTS accreditation standards as their state licensing standards.
[21]
While the original intent of CAMTS was to provide an American standard, air ambulance
services in a number of other countries, including three in Canada and one in South Africa, have
voluntarily submitted themselves to CAMTS accreditation.
Japanese Physician Delivery Helicopter

[edit] Medical staffing

The makeup of the medical crew staffing an air ambulance varies depending on country, area,
service provider, and type of air ambulance. In services operating under the Anglo-American
model of service delivery, the helicopter is most likely to be used to transport patients, and the
crew may consist of Emergency Medical Technicians, Paramedics, flight nurses, a Respiratory
Therapist, or in some cases, a physician. Services with a primary focus on critical care transport
are more likely to be staffed by physicians and nurses. In the Franco-German model, the aircraft
is much more likely to be used as a method of delivering high-level support to ground-based
EMS. In these cases, the crew generally consists of a physician, often a surgeon, anesthetist,
trauma specialist or similar specialty, accompanied by a specially-trained advance care
paramedic or nurse. In these cases, the object is the rapid delivery of definitive care, occasionally
even performing emergency surgical procedures in the field, with the eventual transport of the
patient being accomplished by ground ambulance, not the helicopter.

[edit] Medical control

The consultant led Emergency Medical Retrieval Service in Scotland.

The nature of the air operation will frequently determine the type of medical control required. In
most cases, the available skill set for an air ambulance staffer is considerably greater than that of
a typical paramedic. As a result, those operating in this environment will often be permitted by
medical control to exercise more latitude in medical decision-making. Assessment skills tend to
be considerably higher, and, particularly on interfacility transfers, permit the inclusion of such
factors as the reading of x-rays and the interpretation of lab results. This allows for advance
planning, consultation with supervising physicians, and the issuing of contingency orders in case
they are required during the flight. Some systems operate almost entirely off-line, using
protocols for almost all procedures and only resorting to on-line medical control when protocols
have been exhausted. Some air ambulance operations have full-time, on-site medical directors
with pertinent backgrounds (e.g., emergency medicine); others have medical directors who are
only available by pager.[30] For those systems operating on the Franco-German model, the
physician is almost always physically present, and medical control is not an issue.

[edit] Equipment and interiors

Most aircraft used as air ambulances, with the exception of charter aircraft and some military
aircraft, are equipped for advanced life support and have interiors that reflect this. The challenges
in most air ambulance operations, particularly those involving helicopters, are the high ambient
noise levels and limited amounts of working space, both of which create significant issues for the
provision of ongoing care. While equipment tends to be high-level and very conveniently
grouped, it may not be possible perform some assessment procedures, such as chest auscultation,
while in flight. In some types of aircraft, the aircraft's design means that the entire patient will
not be physically accessible in flight. Additional issues occur with respect to pressurization of
the aircraft. Not all aircraft used as air ambulances in all jurisdictions have pressurized cabins,
and those which do typically tend to be pressurized to only 10,000 feet above sea level. These
pressure changes require advanced knowledge by flight staff with respect to the specifics of
aviation medicine, including changes in physiology and the behaviour of gases.

Equipment and interiors

Typical helicopter interior Typical helicopter interior Fixed-wing interior

[edit] Challenges

Beginning in the 1990s, the number of air ambulance crashes in the United States, mostly
involving helicopters, began to climb. By 2005, this number had reached a record high. Crash
rates from 2000–2005 more than doubled the previous five year's rates.[31] To some extent, these
numbers had been deemed acceptable, as it was understood that the very nature of air ambulance
operations meant that, because a life was at stake, air ambulances would often operate on the
very edge of their safety envelopes, going on missions in conditions where no other civilian pilot
would fly. As one side result, it should be noted that of all EMS personnel who lose their lives in
the line of duty in the United States, nearly fifty percent do so on air ambulance crashes. In 2006,
the United States National Transportation Safety Board (NTSB) concluded that many air
ambulances crashes were avoidable[32], eventually leading to the improvement of government
standards and CAMTS accreditation.[33]

[edit] Cost-effectiveness

Whilst some air ambulances do have effective methods of funding, in the UK, they remain
almost entirely charity funded, as improved cost-benefit ratios are generally achieved with land
based attendance and transfers. Health outcomes, for example from London's Helicopter
Emergency Medical Service, remain largely the same for both air and ground based services.[34]