Modern Medical Transport: The Evolution of Air Care Services

Aero-medical evacuation evolved over 100 years from a somewhat ill-defined vision passionately held by a few, to a pervasive life-saving service widely supported in developed countries throughout military and civilian medical services. And in less developed nations, international aid agencies and foreign military institutions often respond to natural disasters with significant airborne medical and food/recovery services. In short, air ambulance services and aero-medical evacuation has moved from an emergency transport service to a flying critical care unit with a broad range of equipment and well-trained staff.

 

As described in “The Origin of Air Ambulance Services”, progress was hard fought and generally unsuccessful during the WW I-era. The period from 1918 to 1936 produced limited experimentation, but advocates continued their cause. Medical airlift of injured personnel back to Germany during the Spanish Civil War began in 1936.

 

Civilian air ambulance services expanded slowly. In remote wilderness areas in Norway and Sweden, bush pilots were pressed into service for air evacuation. In 1928 the first formal, full-time air ambulance service was established in the Australian outback, called the Royal Flying Doctor Service. Marie Marvingt set up the first civil air ambulance service for Africa in 1934, based in Morocco. The first civilian air ambulance service in North America was established by the Saskatchewan government in Canada. And the Los Angeles-based Schafer Ambulance Service expanded in 1947 to offer air response services. This was the first FFA certified air ambulance service in the United States.

 

New air services were beginning to spread but well-trained paramedics and the recognition of paramedicine were still decades away. If a doctor or nurse were not involved in the flight, the focus was only on transporting the patient to medical treatment. Even during the Korean War, the extensive use of the Bell 47 helicopter as depicted in the movie and television show M*A*S*H, provided a single seat for the pilot and two external stretchers for wounded.

 

The Vietnam War period saw tremendous strides by the US military in better integrating infantry corpsmen, helicopter evacuation, and basic airborne medical services, until patients could be delivered to field hospitals. Widely credited with increasing battlefield survivability, hard numbers are difficult to find. One estimate put the death-rate of WW II wounded evacuated by plane at 4.5 percent versus 2.5 percent using helicopters in Vietnam. And some US researchers suggested by 1969, with trained medical corpsmen, air ambulances provided better survival rates for wounded soldiers than traditional emergency response units did for injured motorists on California freeways.

 

Articles adapted from the US Army Medical Department Journal and made available on-line by The Free Library, provide extensive detail on the history and success of various air medical units before, during, and after this period. And their work continues with modern Blackhawk helicopters on today’s battle fronts.

 

Modern Aero-medical Services

 

The modern air ambulance is a helicopter, fixed-wing propeller or turbo-prop plane, or a variant of a corporate jet. Helicopters are used to access sites where fixed wing aircraft cannot land and generally take patients to the closest large hospital trauma center. Fixed-wing aircraft are limited to airport-to-airport transport, or in some cases a suitable highway near the emergency. The focus on longer distance services where the final leg to the treatment facility is handled by ground ambulance or helicopter. All are far better equipped than their predecessors of decades past.

 

Air ambulances are now generally loaded with the same medical equipment as a trauma center, like an EKG, cardiac monitors, cardiac pacemakers, CPR equipment, respirators, ventilators, and medications, as well as modifications to make it easier to load stretchers. According to Matt Clements, a flight paramedic based in London, Ontario, Canada – one of the larger services in North America -- his Sikorsky helicopter has most essential equipment but in a somewhat smaller size.

 

While loaded with life support equipment there are some understandable environmental conditions with which to cope. The limited space in the aircraft or helicopter can constrain the on-board crew’s efforts to fully examine a patient and administer some treatments. Noise in a helicopter complicates communication between crew members, with an injured patient, and makes chest auscultation – using a stethoscope to hear what is going on with the heart and breathing – more difficult. Perhaps a less anticipated complication, to an untrained person, is the impact of variable air pressure. If the air ambulance does not have a pressurized cabin, well-trained crew must carefully monitor the behavior of gases interacting with air pressure and changes in physiology.

 

Enhanced Standards for Medical Personnel

 

The emergence of associations and agencies such as the Air Medical Physician Association (AMPA) and the Commission on Accreditation of Medical Transport Systems (CAMTS) have tremendously enhanced our industries understanding of, and commitment to, best medical and business practices. These efforts have contributed a great deal to the safety of patients and the medical professionals who treat them.

 

Requirements for air ambulance pilots and onboard medical personnel do vary from state to state, but most meet or exceed those of the CAMTS.

 

Air ambulance pilots are required to have several thousand hours of flying experience including several hundred hours of night flying and their instrumentation ratings. Since fixed- wing aircraft generally transport patients for longer periods of time and over greater distances than helicopters, not only is a completely different kind of certification required, a higher level of training is often expected.

 

Doctors and nurses need specialized training, usually including five years of on-the-ground trauma center experience. Civilian flight nurse training can be highly variable, but certifications in basic and advanced life support, cardiac life support, and pediatric advanced life support are fundamental. The Neonatal Resuscitation Program, the Pre-Hospital Advanced Life Support Examination, a nationally recognized trauma course and the Certified Flight Registered Nurse Examination may be required in additional to substantial critical care experience.

 

Becoming a certified EMT (Emergency Medical Technician) qualified for air ambulance duty is not a short path. The US Bureau of Labor Statistics describes four levels of progressive training: EMT-Basic, a 1985 and 1999 specification for EMT-Intermediate, and a Paramedic certification. And then there are a handful of specialty certifications to help a candidate stand out from others competing for a job. The CAMTS’ 7th edition specification calls for medics to be trained in Advanced Life Support (ALS), Pediatric Advanced Life Support (PALS), and as a Critical Care Technician (CCT). EMT-Basic can require up to a year’s worth of on the job experience beyond initial training, and two levels of intermediate certification may require another 30 to 350 hours of training. At the Paramedic level, caregivers receive more training in anatomy, physiology, and advanced medical skills. The National Flight Paramedics Association (NFPA) estimated that roughly 1,200 flight paramedics were working in 277 flight medical programs in the Unites States in 2008.

 

The advanced training and advanced assessment skills usually give air paramedics more autonomy to make time-critical medical care decisions in route to treatment. Where patients are being airlifted between facilities, reading x-rays and interpreting lab results during the flight enable contingency planning, advanced planning for treatment on the ground, and consultation with supervising physicians.

 

Given the life-saving nature of the job for patients and potentially life-risking nature of the job for crews, air ambulance professionals must keep their skills up-to-date. Continuing coursework in occupational safety, sea rescue and boat-to-helicopter maneuvers are advised and may be mandated. Ongoing coursework and workshops in fatigue-related stress situations are recommended. Additionally, civil and military organizations periodically hold training exercises between ground-based first responders and air ambulance teams to ensure the safe and smooth handoff of injured personnel to aero-medical evacuation teams.