Air-Medical Services: Then and Now

Air-medical services are an important component of healthcare systems. Access to critical care and specialty services for many people in the United States has dramatically improved with their availability. 

The transport of acutely injured and ill patients by air is an integral part of regionalized systems of healthcare. The use of air-medical services within trauma systems is further noted for its “well-trained crews and either fixed-wing aircraft or helicopters to rapidly manage and transport seriously ill patients from remote locations.”¹ 

A Brief History

Air transport of ill and injured patients started in 1784 with moving injured soldiers to a medical facility by hot-air balloon. In 1903 the Wright brothers’ development of the fixed-wing airplane opened the door for significant progress in air-medical transport and led to a Curtiss JN-4 biplane being converted into an air ambulance in 1918. 

The first U.S.-based, Federal Aviation Administration-certified air ambulance was established in Los Angeles in 1947. Civilian air ambulances were introduced in the 1970s and have since become a lucrative industry. The U.S. Air Force continued its rapid development of air-medical transport capabilities through creation of the critical care air transport team at Texas’ Lackland Air Force Base in 1994. 

Before 2002 hospitals owned and operated most air ambulances. Negotiations on rulemaking with health-industry stakeholders in 2002 led to Medicare officials creating a national fee schedule for air ambulances “based on a thorough investigation of the reasonable cost for emergency medical services.”² 

This increased the Medicare reimbursement rate for helicopter air ambulance transport, particularly raising the rate for rural transports. The rate increase enabled for-profit operators to greatly expand their presence in the air ambulance industry. Since the reimbursement increase for-profit operators have added hundreds of new air ambulance bases and vehicles nationwide. 

“In 2003 there were 545 helicopters flying out of 472 air bases in the United States,” according to one report. “By 2015 those numbers had nearly doubled, with 1,045 helicopters at 864 bases. Further, although air ambulance transports made up less than 1% of total ambulance claims in 2011, they represented 8% of the total Medicare spending on ambulance services because of their high price tag.”² 

Air ambulance services may be defined as: 

• Hospital-based, in which a hospital controls the business by providing medical services and staff while contracting pilots, mechanics, and aircraft; 
• Independent, in which operations are not controlled by a specific medical facility but by independent providers who directly employ the medical and flight crews; 
• Government-operated, in which a state or municipal government or military unit owns and operates the air ambulances. 

Helicopter EMS

Some air ambulance providers have helicopters and fixed-wing airplanes available, but most emergency medical transports use helicopters. Helicopters were first widely used for patient transport during the Korean War. Patients were secured to stretchers outside the helicopter, and no care was provided during transport.³ 

In a 2012 study, patients transported by helicopter showed a benefit in terms of “survival, time interval to reach the healthcare facility, time interval to definite treatment, better results, or a benefit in general.”⁴ The most important outcomes are “functional survival, pain relief, and earlier advanced life support (ALS) care as well as the benefits of HEMS in the rural setting, which is the provision of timely access to Level I or Level II trauma centers and in nontrauma interfacility transport of cardiac, stroke, and even sepsis patients.”

Moreover, regional healthcare and EMS systems benefit from HEMS “extending the advanced level of care throughout a region; providing a ‘backup’ for areas with limited ALS coverage; minimizing transport times; making available direct transport to specialized centers; and offering flexibility of transport.”⁴ 

Air-Medical Safety

Any form of medical transport incurs risk, and in recent years air-medical transport has seen numerous accidents. Risks can stem from issues within the competitive environment of the industry, including “helicopters flying in bad weather, stealing dispatch calls from other operators, and flying to accident scenes even when no one had called them,” according to testimony during 2009 hearings held by the National Transportation Safety Board.² 

Also, operators “would accept a second dispatch call before they had completed their first, leading to unnecessary delays in transporting patients; [and] created close ties with ground EMS services and hospitals, hiring staff members from the local ground ambulance company, with knowledge that paramedics would be more likely to call their friend when they needed an air ambulance.”²  Another issue raised in testimony to the NTSB involved “operators who often flew patients who could have been safely transported by ground, costing both patients and taxpayers thousands of dollars per trip.”² 

The safety of air-medical services is a continuous concern. In response the industry has emphasized attitudes toward safety, avoiding risky behavior, and scrutinizing accidents. The safe utilization of helicopter EMS is guided by rules developed to identify patients whose conditions and locations make them most likely to benefit from HEMS. 

As the guidelines for utilization of air-medical service address the issue of targeted time savings, the issue of safety is still a paramount concern. Researchers confirmed “from 1998 to 2012, for-profit air ambulance operators averaged 7–8 crashes per year, while not-for-profit or public operators averaged one crash every year or two.”² 

Recent accident data from the National Transportation Safety Board shows that “for-profit air ambulance companies continue to have more accidents than other providers.”² Between 2010 and 2016, flights operated by the four largest for-profit air ambulance companies—Air Methods, PHI Air Medical, Air Medical Group Holdings, and Metro Aviation—accounted for 68% of industry accidents.² 

The top three causes of crashes are “poor decision-making in accepting flights, preflight planning, and in-flight decision making.”⁵ These factors reflect the “pressure placed on crews by the condition of the patient, by the feelings of obligation to fly, and a pervasive ‘can do’ attitude.” 

Air-medical operators use safety management systems to assess flight risk without knowing the patient type or acuity; this prevents bias or emotional factors from pressuring a decision.³ The degree of patient care and safety in HEMS is influenced by the “competence, composition, and number of crew members.”⁶ 

Another area of safety concern for consumers is the qualifications of medical staff aboard the air ambulance. “Stress during flight, oxygen partial pressure reduction (hypoxia, reduction of barometric pressure, temperature reduction, moisture reduction), dehydration, noise, vibrations, acceleration forces, and fatigue are the necessary considerations in air transport for patients”;⁷ thus, the air-medical community has taken significant steps to further air-medical service safety for patients. These include:

• Improved air crew resource management with established criteria for helicopter pilot training, including training for how to handle unexpected weather conditions, poor visibility, and hazards unique to air ambulance operations;
• Introduction of new resources to aid pilot decision-making, such as better weather reporting, safety risk analysis tools, sharing turn-down decisions between competing programs, and educating emergency medical services about the dangers of helicopter shopping;  
• Improved operational control centers, some with “virtual copilots” who use technology to follow the mission and provide real-time decision-making information to pilots to reduce risk; 
• Introduction of more HEMS programs to replace aging aircraft, flying under instrument flight rules (IFR), and employing new technologies such as night-vision goggles and terrain avoidance warning systems; 
• Collaboration of air-medical operators with the National Transportation Safety Board; and 
• Developing new standards and safety management systems to support the industry’s Vision Zero safety goal.⁵ 

Conclusion

The ability of air-medical services to provide for many communities over wide geographic areas can reduce the need for additional ground ambulances. Air-medical services allow all patients at any location to benefit from these systems of care. 

The critical care delivered by air-medical transport service can reduce morbidity, improve overall healthcare system efficiency, and save lives. It helps prevent the likelihood of a critical patient suffering disability as a result of injury or illness by getting them quickly to definitive care.

The safety of air-medical services is enhanced with the training and competence of flight crews and leaders working with regulators to implement best-practice standards. However, the industry must continue to develop more effective methods and approaches to safety. Most important, it must continue to focus on developing and implementing strategies to achieve a goal of zero serious injuries or fatalities. 

References

1. Isakov A. Urgent air-medical transport: Right patient, place and time. CMAJ, 2009 Oct 27; 181(9): 569–70.

2.  Consumers Union. Up in the Air: Inadequate Regulation for Emergency Air Ambulance Transportation, https://advocacy.consumerreports.org/wp-content/uploads/2017/04/Up-In-The-Air-Inadequate-Regulation-for-Emergency-Air-Ambulance-Transportation.pdf.

3. Floccare DJ, Stuhlmiller DF, Braithwaite SA, et al. Appropriate and safe utilization of helicopter emergency medical services: A joint position statement with resource document. Prehosp Emerg Care, 2013 Oct–Dec; 17(4): 521–5. 

4. Thomas SH, Arthur AO. Helicopter EMS: Research Endpoints and Potential Benefits. Emerg Med Int, 2012; 2012: 698562. 

5. MedEvac Foundation International. Air Medical Services: Critical Component of Modern Healthcare Systems, https://aams.org/wp-content/uploads/2014/01/Public-Education-Paper.pdf.

6. Rasmussen K, Roislien J, Sollid SJM. Does medical staffing influence perceived safety? An international survey on medical crew models in helicopter emergency medical services. Air Med J, 2018 Jan–Feb; 37(1): 29–36.

7. George I, Stergiannis P. Risk factors in air transport for patients. Health Sci J, 2013 Jan; 7(1): 11.

Karen Beasley Grabenstein, MBA, MAEd, ACHE,  is a veteran paramedic, vice chair of the executive board of the Georgia Emergency Medical Services Association, and president of the group’s educators division. She is currently program director at Air Evac, Statesboro, Ga., and an adjunct professor at Columbia Southern University.