soldiers has been reduced to as little as 36 hours, with medical care provided throughout (Gawande, 2004).

Air ambulance operations for U.S. civilians have traditionally followed the military model of “trauma medevac,” which emphasizes speed—moving the patient away from the site of the injury and to definitive care. However, a growing trend in the air medical industry is to bring more of the assets of the trauma center directly to the patient (Judge, 2005). One of the long-recognized goals of EMS is to deliver patients to definitive care within the “golden hour” (Lerner and Moscati, 2001), and in most cases this remains a primary objective. Air ambulance providers play a key role, especially in rural areas, where trauma centers are typically farther away from the scene of an incident. Branas and colleagues (2005) estimated that medical helicopters provide access for 81.4 million Americans who otherwise would not be able to reach a trauma center within an hour.

The Atlas and Database of Air Medical Services (ADAMS)—developed by academic researchers and supported by the Federal Highway Administration and NHTSA—now provides a map of available air medical service areas across the United States. ADAMS indicates that air medical providers have a heavy presence in many urban and suburban areas of the country, but that coverage is sparse in many rural locales. While it is inherently difficult to provide timely care to these remote areas, they have a particular need for greater coverage by air ambulance providers. Data indicate that in 2001, about 39 percent of vehicle-miles traveled were on rural roads, but 61 percent of all crash fatalities occurred on these roads (Flanigan et al., 2005).

In addition to concerns about access, there are concerns regarding safety. As noted earlier, there has recently been an increase in the number of air ambulances involved in crashes and this has prompted greater scrutiny from the media and regulators. The Federal Aviation Administration (FAA) is responsible for certifying the safety of air ambulance programs operating in the United States. However, because of a decrease in the number of FAA inspectors, along with a rapid increase in the number of air medical providers, safety checks have not been sufficiently rigorous in recent years according to print media reports (Davis, 2005; Meier, 2005). This comes at a time when Medicare reimbursements for air medical transport have increased, and competition within the industry has grown substantially (Meier, 2005). In response to growing concerns regarding air ambulance safety, the FAA released guidelines in August 2005 instructing air ambulance firms to implement safety measures, such as using checklists to ensure that maintenance steps have been completed and improving decision making about whether to launch in unsafe weather conditions (Davis, 2005).

The Airline Deregulation Act of 1978 gave the FAA, rather than the states, regulatory authority over the operations of this industry. Court cases between states and the federal government involving air ambulance opera-



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