Helicopter EMS: Part 1: A Brief History

When it comes to the development of helicopter EMS (a.k.a. HEMS), many of the foundations were built during military operations.

"The first rotor-wing transports from a 'primary scene' took place during World War II," says Dawn Mancuso, executive director and CEO of the Association of Air Medical Services (AAMS). "Helicopters were also used regularly as an evacuation resource during the Korean Conflict in the 1950s, when unnavigable roads and indirect routes to medical care proved too difficult during wartime operations. However, the Viet Nam war was considered the pivotal moment in air-medical transport because it was at that time that in-flight medical treatments were also instituted."

"The impact of military HEMS was unmistakable," adds Matt Zuccaro, president of Helicopter Association International (HAI). "The vastly improved survivability of injured soldiers transported by helicopter to Vietnam field hospitals was dramatic, compared to previous wars. So it only made sense to consider extending this kind of service to the civilian sphere."

In 1969, the U.S. Department of Transportation provided one-year grants to purchase and operate three civilian helicopter ambulances in Mississippi. Under the name Project CARESOM, the helicopters were shared out between the cities of Greenwood, Hattiesberg and Tupelo. When project CARESOM wrapped up a year later, Hattiesberg elected to take over the 'Rescue 7' service. The other two sites declined, due to cost concerns. Now operated by the Southeast Mississippi Air Ambulance District (SEMAAD), Rescue 7 is still in operation and funded by local taxpayers.

Soon after the launch of Project CARESOM, "the first rotor-wing civilian community-based air-medical transport system arose in Maryland in 1970 through the State of Maryland Police Aviation Division," Mancuso says. "Among the first hospital-based rotor-wing air-medical transport operations was St. Anthony's Hospital in Denver, CO." From this point, other U.S. hospitals began to establish their own HEMS units, both to serve as air ambulances and to transfer patients between hospitals.

Today, there are three basic models of HEMS in the United States. The oldest is the so-called ‘traditional model,' where hospitals contract to a third-party operator to provide aircraft and pilots, while providing medical personnel and management themselves. Typically, these are nonprofit units.

Next is the community-based model, where the helicopters, personnel and basing are managed by a company separate from a local hospital/healthcare provider. Developed during the 1970s and 1980s, community-based HEMS can either be profit-based or nonprofit. In the case of profit-based, many HEMS services are managed akin to private ambulance companies, where the HEMS provider bears all of the costs and is paid by insurance firms, Medicaid or private individuals.

"Many hospitals got out of HEMS when they couldn't see any way either to make a profit or just break even," says Dr. Ira Blumen, a founding member of the Air Medical Physicians Association (AMPA). "Privately-run companies came in to fill this gap, using smaller helicopters and finding ways to expand their coverage into new markets."

The third model of HEMS is the 'government-operated' version, where governments take direct responsibility for providing HEMS in specific regions. This is the least common of U.S. HEMS models. Most services are provided by traditional or community-based carriers or 'hybrid' organizations that combine qualities of both.

Whatever the model, the evacuation-oriented nature of early HEMS units has given way to 'Flying ERs,' where onboard medical personnel have both the knowledge and equipment to perform complicated procedures.

"In the 20 years that I've been a HEMS physician, I've seen a real enhancement in HEMS care," says Dr. David Thomson. "What remains to be figured out, however, is the actual appropriateness of HEMS versus non-HEMS transport. There are times when patients go by air where ground ambulance would be a cheaper yet just as good alternative. Conversely, there are times when time-sensitive patients are sent out on the road when they could be moved faster by air."

This is just one of the issues facing today's HEMS community. Safety is an even bigger concern: When a HEMS unit crashes, the resulting media spotlight raises serious doubts on the part of HEMS professionals and the public. In some instances, it is clear that HEMS aircraft have crashed by attempting to fly missions beyond their capabilities, i.e., flying through a snowstorm at night without proper instrument flying equipment. At other times, crashes have occurred despite the aircraft and pilots doing everything properly--because accidents happen even in the best of circumstances.

The debate over HEMS safety--including disagreement as to whether such a debate is even justified in the first place--will be covered in part two of this three-part series. In part three, we will look at some of the technological, training and regulatory changes that are aimed at making HEMS safer for personnel and patients and whether these efforts can ever be enough.

James Careless is a freelance writer with extensive experience covering computer technologies.