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Emergency Medical Services at the Crossroads
Air Ambulance Systems
Air medical operations have grown substantially since their inception in the 1970s. Today there are an estimated 650–700 medical helicopters operating in the United States (Gearhart et al., 1997; Helicopter Association International, 2005; Meier, 2005; Baker et al., 2006), up from approximately 230 in 1990 (Blumen and UCAN Safety Committee, 2002; Helicopter Association International, 2005). These helicopter operations are owned and managed by a variety of entities, including for-profit providers, nonprofit organizations such as local hospitals, government agencies such as the state police, and military air medical service providers. Many air medical providers were originally employed as hospital contractors but now work on an independent basis. Typically, the base helipads for these providers are located in airports, independent hangars and helipads, and designated areas of a hospital (Branas et al., 2005).
Air ambulance operations have served thousands of critically ill or injured persons over the past several decades (Blumen and UCAN Safety Committee, 2002). However, there has been growing concern about the safety of these operations. Approximately 200 people have lost their lives as a result of air medical crashes since 1972, and these deaths have been increasing as the industry continues to expand (Blumen and UCAN Safety Committee, 2002; Bledsoe, 2003; Baker et al., 2006). Crashes are often attributable to pilots flying in poor weather or at night. Li and colleagues (2001) found a four-fold risk of a fatal crash in flights that encountered reduced visibility. Baker and colleagues (2006) found that crashes in darkness represented 48 percent of all crashes and 68 percent of all fatal crashes. In addition, some companies are flying older, single-engine helicopters that lack the instruments needed to help pilots navigate safely (Meier, 2005). In 2004 and 2005 a total of 12 fatal air ambulance crashes occurred—the highest number of fatal crashes in two consecutive years experienced in the industry’s history (Isakov, 2006). Recent increases in Medicare payments have led to greater competition in the industry, which has added to concerns regarding safety (Meier, 2005).
Air medical services are believed to improve patient outcomes because of two primary factors: reduced transport time to definitive care and a higher skill mix applied during transport. However, presumed gains in transport time do not necessarily occur, given the time it takes the helicopter crew to launch, find a suitable landing position, and provide care at the scene. This is especially true when the distance to the scene is short. Questions have also been raised regarding the appropriateness of air ambulance deployments in specific patient care situations (Schiller et al., 1988; Moront et al., 1996; Cunningham et al., 1997; Arfken et al., 1998; Dula et al., 2000). A 2002 study found that helicopters were used excessively for patients who were not