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Air Ambulance Industry – The Latest Happenings

There was a lot happening in the air ambulance industry in the past few days. From near-fatal accidents to celebrations, there was news that kept people on their toes. Here is a quick recap of some of the most noteworthy occurrences that took place recently.

Bowen Island Air Ambulance Crash

Last Friday was witness to some grueling moments as an air ambulance crashed in Bowel Island. The helicopter had crashed into the trees. Search and rescue teams were immediately dispatched to the site after receiving the information. A ground ambulance was also called to the spot. Details of the crash are just coming in, and it is not yet clear where the air ambulance was headed. Fortunately, no one was hurt in the crash. The crew consisted of two pilots, and the air ambulance was not carrying any patient at the time.

Laser Lights Haunt Air Ambulance Services Again

The laser flashing incident occurred on February 28th. The time was around 9:30 in the night. The air ambulance was in the Roath Recreation Ground in the United Kingdom. The mission had to be aborted due to this attack as the pilot suffered temporary blurring of vision and intense headaches. The police have again appealed to the general public to refrain from such unruly behavior. The offense can lead up to 5 years of imprisonment.

Air Ambulance Service Turns 20

Wales Air Ambulance service recently celebrated its 20th anniversary. The date was the first of this month. The charitable organization that has a humble beginning started its service with just one helicopter two decades ago, reflected the founder during the occasion. Today, the service operates four air ambulance helicopters with coverage across the United Kingdom. The charity has undertaken over 38,000 missions during its operation. The organization has now set up a fundraising effort and aptly named it My20.

What You Need to Know about IS-BAO Accreditation for Air Ambulance Specialists

When it comes to accreditations for an air ambulance company, CAMTS certification is one of the most popularly known. Big names in the industry have started to pile on their accreditation records with the IS-BAO certification. While this certification was already introduced in 2003, only several air ambulance specialists have successfully been accredited. Let’s take a look at some important information about the IS-BAO certification.

More about IS-BAO Accreditation

IS-BAO stands for International Standard for Business Aircraft Operations. It was developed by the International Business Aviation Council (IBAC) along with its member associations. As the name suggests, the certification proves that a certain service follows the recommended code of best practices for flight departments over the world. It was designed to ensure that these flight service companies maintain a high level of safety and professionalism.

The IS-BAO accreditation is recognized by the Federal Aviation Administration (FAA) in the U.S. and the Canadian Civil Aviation Authority (CAA) as meeting the ICAO standard. Additionally, it is also recognized as an industry standard for business aircraft operations by the European Committee for Standardization (CEN).

In 2012, the IS-BAO was amended so that it will facilitate the implementation by helicopter operators. It was a result of a joint effort made by the IBAC with helicopter associations like HAI, EHA, and BHA.

Benefits for Air Ambulance Specialists

The IS-BAO program can be beneficial to air ambulance specialists and the aviation community itself in a number of ways. Here are a few of those benefits:

  • The implementation of predictive and proactive methods enhance operational safety
  • The implementation of safety practices across teams promotes and improves safety culture
  • An integrated Safety Management System (SMS) helps in improving efficiency and effectiveness
  • Increased appreciation of aircraft operations at the executive level

Enhanced ability to carry out safety performance measurement

Ultimate Air Ambulance Guide: Everything you Need to Know!

1. Understanding Bed to Bed Air Ambulance Services

The goal of bed to bed air ambulance service is to maintain the continuity of care. Here the air ambulance specialists would meet the patient in the hospital, transport him/her to the airport in an ambulance and be with the patient until the patient safely reaches the receiving medical facility. This type of air medical transport ensures that the patient is in qualified hands throughout the journey and serves as a reassurance to both the patients and their loved ones. The team even keeps the receiving hospital informed about the medical status of the patient so that necessary measures are already in place.

2. Getting Your Doubts about Medical Flight Services Clarified Firsthand

Most air ambulance companies would have a flight coordinator assigned to you. One of the responsibilities of this individual would be to give you a complete picture about the service being provided from start to end. The person would be qualified enough to answer any queries that you may have and would also accommodate any special needs that you specify. He would ultimately come to you with a written proposal ensuring that you incur minimum costs.

3. Keeping the Cost of a Medical Flight Low

There is no doubt that medical flights are usually expensive; however, taking certain precautions can bring this cost down to a great extent. One of the important factors that decide the cost is the proximity of the treating facility to the aircraft. Lesser distance translates into lesser costs. Another factor is the urgency of transfer. If you can manage to give a few days’ notice in advance, the air ambulance service provider would be able to give you a connecting flight which can bring the costs down significantly.

4. Payment Checks Before Availing Air Ambulance Services

If you are dealing with a reputed medical air transportation service provider, you will always get a written proposal beforehand. You need to exercise caution to verify that all the costs are included in this proposal. You can ask your flight coordinator and confirm this. Ask straight up whether any “hidden costs” are involved. You might be expected to pay before you avail the services regardless of it being domestic or international air ambulance service. If you have any particular preference when it comes to payment modes such as payment through credit cards, debit cards, checks, etc., make them known.

5. Using a Broker to Avail Air Ambulance Services

Using a broker is not a bad thing. However, there are certain precautions that you must take. Since the broker does not actually own the air ambulances, he might not be in the know of everything about the service. Also, since he might be brokering for different air ambulance service providers, there might be a bit of inconsistency in services. Also, you might need to pay a bit extra as the broker would obviously charge a commission for his or her efforts. While paying a commission should be okay, you should insist that all the necessary information be provided to you to avoid any nasty surprises at the last minute. The best thing however is to take a bit of time and look for the best air ambulance service provider yourself and arrange an air ambulance. Moreover, there are several US air ambulance services available today and finding the right one for you will not be all that tough.

6. Insurance Coverage of Air Ambulance Costs

Several insurance plans cover air ambulance services but not all. It is therefore imperative that you check with your insurance provider beforehand. The insurance companies usually lay down certain criteria which are to be met by the patient for the coverage. The foremost of this would be the certification of the physician that the patient has a “medical necessity” for air ambulance and that any other means of travel could adversely impact the health of the patient. The insurance may have a clause which specifies that the patient has to be transported to the nearest medical facility. You also need to check the maximum benefit that the insurance would provide, as you might have to personally fund the remaining amount.

7. Understanding “Medical Necessity” for Air Ambulance Transport Coverage

In order to prevent misuse of air ambulance services that can cause a financial burden, insurance companies have clearly defined what constitutes a medical necessity. In fact, the American Medical Association has laid down a “Model Managed Care Contract” for this very purpose. It says that a qualified medical doctor can – for the purposes of diagnosing, preventing, or treating a disease, illness, or any symptoms – suggest air ambulances provided, the need is:

  • In agreement with the widely accepted medical care standards
  • Medically viable in terms of extent, frequency, site and duration
  • Not merely for monetary benefit of purchasers or health plan, or only for convenience of the doctor, medical care provider or patient.

8. Medicare and Air Ambulance Costs

Most air ambulance service providers will offer billing Medicare directly. However, the cost coverage would be limited to what Medicare actually agrees to reimburse, and you might have to pay the rest out of pocket. Also, there are specific situations in which Medicare covers the cost of medical air services.

9. Help with Ascertaining Insurance Coverage of Medical Flight Services

Most air medical transport service providers will assist you in knowing the coverage you can expect from your insurance provider. In fact, a good organization would have reimbursements specialists at their end. They would not only help you get the pre-authorization but also go a step ahead and take the responsibility of submitting letters of medical necessity, claims forms, and other such relevant documents.

10. Cost of Air Ambulance Services in the Absence of Insurance

Fortunately, the United States has some of the best medical care facilities in the world. So, in most instances the medical travel is within the country. A typical US air ambulance service can cost you just under $10,000. However, this is just an average estimate and the price can vary depending on the distance that the critically ill patient has to travel. Again, factors like pre-scheduling the flight can play a major factor in bringing down the expenses. Also, eliminating a medical flight broker can save you some money. The cost of international air ambulances services can be significantly higher.

11. Alternatives that Can Save Money as Opposed to Air Ambulances

While an

air ambulance service

is the easiest way to organize things, it is not always the cheapest. Some companies also offer you more cost-effective alternatives such as:

  • Boarding the patient on a commercial airliner with qualified medical staff and equipment
  • Utilizing commercial airline stretcher service where the last few seats are removed in order to accommodate the patient and the medical equipment
  • If the time involved in arranging the air ambulance flights is too long, you can choose ground travel with enough number of drivers to cover the distance along with the right medical personnel and equipment.

12. Understanding Air Ambulance Cards

Air ambulance cards are best described as membership programs that enable medical air transport domestically and internationally with just a single phone call. These can be ideal for people who frequently travel beyond their borders into countries where there are communication barriers and inadequate medical facilities. The carriers of air ambulance cards can rest assured that in case of any health eventuality, they can safely board air ambulance flights and return to their home country for quality treatment. The air ambulance card providers usually have worldwide air ambulance networks that enable them to provide a facility like this to their clients.

13. The Need for Air Ambulance Cards

Air ambulance cards act as an additional layer of protection beyond travel health insurances. While the best that travel health insurance can do is provide you with very limited medical evacuation coverage, air ambulance cards give you the complete solution. Most importantly, these cards bring with them the peace of mind that you are safe all the time. However, it must be noted that these cards are not intended to be a replacement for travel health insurance.

14. Check Whether Travel Health Insurance is as Good as Air Ambulance Card

Your credit card or travel health insurance might offer you evacuation through air ambulances to the nearest hospital in the country you are travelling or the nearest hospital in your home country. Air ambulance cards, however, go a step further. These cards will allow you to be air lifted to the hospital of your choice. Most importantly, you will not have to go through the approval and evaluation process which is a must with most medical insurances. You are also freed from the tedious claims process. Although the treating physician is consulted by the air ambulance card to verify the health criteria for transport, the ultimate decision of availing the air ambulance service is taken by the member.

15. Understanding the Cost Advantage of Air Ambulance Cards

While domestic air ambulance transport can cost anywhere between $5,000 to $10,000, international air ambulance services can be quite expensive going up to a $100,000. Moreover, you would have little time to arrange the money as the entire cost would have to be borne upfront. In stark contrast, when you have an air ambulance card, all you pay is a membership fee. You can also include your family in the membership depending on the plan that you choose.

16. Checks to Ensure Quality Care when Choosing an Air Ambulance Service

With the health of your loved one at stake and considerable cost involvement, it is natural for you to wonder whether you are in good hands. Therefore, before zeroing down on a particular air ambulance service, check whether:

  • The medical air transportation service is licensed by Federal Aviation Administration or FAA
  • The air ambulance service company has a medical director
  • The medical air transport company has malpractice and liability insurance
  • You are dealing with a broker or a company, which offers an air ambulance service that has a wide enough network
  • The medical flights are licensed in the state as air ambulance
  • There are enough qualified and trained air ambulance specialists in the medical flight
  • The air medical transport company provides bed to bed service

These simple questions to your flight coordinator will afford you peace of mind and ensure safety of the patient.

17. Ensuring that the Aircraft is Safe for Medical Air Transport

There are two aspects to reliable air ambulance companies. The first is qualified staff and the second is the safety of the aircraft itself. Ensuring that the air ambulance service that you choose is FAA licensed is the first step. The regulations laid down by the FAA ensure that the operation and maintenance of the aircraft are of a certain standard. It also ensures that you have a well-trained pilot at your service. In addition to this, you might want to inquire about the kind of annual training the pilot is given. You would also want to look at their safety track record.

18. Evaluating the Quality of Medical Care on the Air Ambulance

Check whether the air ambulance companies that you choose give a full disclosure about their staff and their experience. You do not want less experienced, minimum wage employees working multiple shifts taking care of you. Ensure that you have registered nurses and critical care flight paramedics on-board. Never shy away from asking your flight coordinator such questions.

19. Check Number of Personnel that Accompany the Patient on the Medical Flight

A standard team usually consists of at least two medical professionals one of whom is a nurse and the other a medical doctor. This can increase depending on the medical needs of the patient and the presence of paramedics might also be warranted.

20. Medications and Equipment On-board the Medical Flight

Medical emergencies have a way of making their way to patients without warning. Ask your flight coordinator whether basic equipment such as defibrillators, stretchers, heart monitors, ventilators, oxygen cylinders, equipment for resuscitation, and intravenous drug administration equipment would be readily available in the air ambulance. The medical flight also needs to carry the essential drugs that are vital for the health of the patient.

21. Health Precautions When Traveling Abroad

While air ambulance services would be available to you through most parts of the world, there are certain precautions that you need to take so that you have immediate quality medical care at hand. Looking at your insurance coverage must be your top priority. Your domestic insurance will not cover your expenses in case you are injured or ill overseas. You might also want a list of nearest hospitals that are easily accessible to medical flights.

22. Insurance Coverage When Travelling Overseas

The social security Medicare does not cover your health eventualities overseas. Not just that your private insurance provider too might not cover you internationally. Hospitals in many countries demand that you pay the treatment costs upfront. So, the first step would be to evaluate your insurance coverage and check how well you are covered when you are travelling abroad. Depending on the coverage, you can then seek additional insurance. Remember, the air ambulance services will carry you back to your home country, but until then, you may need to fend for yourself.

23. Travel Insurance and Travel Medical Insurance

You invest a certain amount when you travel abroad such as expenses for travel, stay, etc. These expenses are covered by your travel insurance depending on the coverage limit. Travel medical insurance on the other hand insures you against illnesses and injuries when you travel overseas. Most countries demand that tourists have both travel insurance as well as travel medical insurance. A good idea would be to check whether your travel medical insurance covers air ambulance services so that you are assured of quality medical care in your own country in case the need arises.

24. Check Whether the Air Ambulance Service has Centralized Flight Operations

Having centralized flight operations has several advantages. The main one being that the scheduling automatically becomes more efficient. This efficiency translates into quicker transit and lower costs. Such air ambulance companies would be able to check the status of air ambulance worldwide and set you up with one that suits your location and medical necessities best.

25. Assistance You Can Expect from the US Government if Disabled Abroad

If locating appropriate medical services is an issue, the US Consulate would help you with that. It would also assist you with quick transfer of funds if the need arises. However, the responsibility to pay your expenses incurred on medical care and transfer such as air ambulance transport would entirely rest on your shoulders. The US Embassy website too has a lot of useful information to safeguard your health when travelling abroad.

26. Flying with a Medical Escort Service instead of Air Ambulance

While you might need to travel utilizing an aircraft for medical necessities, an air ambulance service as such may not be warranted. In a situation like this, you can save money and time by utilizing the service of a commercial medical escort. This specialist would be able to provide you services like sedation, oxygen, cardiac monitoring, pain management, and would take care of the patient’s other essential medical needs. The medical escort would accompany the patient throughout the journey until he or she safely reaches the desired destination. To qualify for a service like this, your doctor will have to approve that you would be able to sit for the duration of the flight without adverse health repercussions. Most companies that offer air ambulance services also offer medical escort services.

27. Understanding Critical Care Air Ambulance Services

There are times when a patient needs facilities that are as good as an intensive care unit when travelling through air ambulances. This is where critical care air ambulance services come into picture. This service virtually can transform an aircraft into a flying intensive care unit with equipment like intra-aortic balloon pumps, newborn incubators, saturation monitors and other high-technology medical equipment. The flight would also have onboard air ambulance specialists who are well-versed with tackling any eventualities that the patient’s medical condition can cause. The care coordination in such instances has to be very precise as there is little room for delay or error.

28. Understanding Medical Repatriation with International Air Ambulance Services

Returning to the home country or medical repatriation is often a complex procedure. You need experienced personnel who can arrange the repatriation on time so that the health of the patient remains unaffected. At times, this can mean going through complex procedures. Having an in-depth understanding of international rules and regulations is a must. An international air ambulance service that employs bilingual individuals helps in such situations. The repatriation may demand that the service provider is well versed with procedures such as preparing citizenship papers, coordinating with foreign consulates, and taking care of clearances and customs issues.

29. Organ Procurement through Medical Air Services

Organ recipients usually have to wait for months or years together on the waiting list to receive an organ donation such as kidneys, liver, or eyes. The transit time from the donor’s location to the recipient’s location is always critical to keep the organ viable. Then, there are issues such as maintenance of the organ in the right medical environment. Air ambulance services play a major part in this live-saving effort which is extremely time sensitive. Communication, coordination, ground staff and equipment play a huge role in such situations.

30. The Affiliations that Matter when Choosing Air Ambulance Services

The fact that the air ambulance service is affiliated with either all or several of the organizations listed below ensures that the patient is in safe hands. These affiliations demand that the air ambulance services maintain certain standards in order to be accredited. The major ones are:

Things to Know Before Availing Air Ambulance Service

From carrying the elderly who find it tough to get through the security precautions of commercial flights to carrying critical patients, an air ambulance can cater to a whole range of medical transportation needs. Air ambulances are always well-equipped with medical facilities and have experts onboard such that ferrying patients is as safe as it gets. However, knowing certain things beforehand can make this medical travel more comfortable.

Who is Best Suited for Air Ambulance Service?

Air ambulances are best suited for patients who need to travel a distance that is in excess of around 250 miles. The air ambulance route becomes almost the safest way to travel when the patient is suffering from severe burns, spinal cord injury, or needs ongoing treatment for ailments such as cancer.

Air Ambulance Service Beyond National Borders

Most air ambulance service providers can carry their patients not just across national borders but also across continents. However, owing to several procedural demands such as acquisition of visa, landing arrangements and permits, it is wise to book the flights well in advance. In general, when there is a medical emergency, the arrangements can be made within as little as 2 hours depending on the destination.

Accompanying the Patient in Air Ambulances

The number of people who can travel along with the patient entirely depends on the size of the flight and the service chosen. Usually, a minimum of 1 to 2 people can accompany the patient as preference has to be given to qualified staff to care for the patient.

Planning Your Luggage Before Boarding

Naturally, preference is given to the medical equipment and the comfort of the patient. This means that there is just a little space in the air ambulance for personal luggage. It is a good idea to get most of the personal luggage transported through a commercial flight. A bit of planning and carrying only the essential items is the best way to go about your luggage.

You Do not Have to Worry about Logistics

When you avail the air ambulance service, the provider will ensure that there is perfect coordination during boarding and disembarking from the aircraft such that qualified staff is available at all times. All that a loved one has to do is be with the patient and follow the guidelines provided.

REVA Air Ambulance Receives Prestigious Award from City of Fort Lauderdale Florida

REVA Air Ambulance has announce that they were awarded Fort Lauderdale’s Achievements in Community Excellence (ACE) award, for superior efforts to Fort Lauderdale  Executive Airport.

air-ambulance-award-aceREVA is known for operating the nation’s largest fleet air ambulances.  The award proves REVA’s continued work to surpass Fort Lauderdale’s Noise Abatement Program.

Mayor Seiler congratulated REVA CEO Stuart Hayman for “striving to help make Fort Lauderdale Executive Airport a better neighbor to the surrounding community, and for outstanding contributions in the areas of economic development and community outreach.”

Having successfully completed over 20 thousand medical flights, REVA offers  air ambulance medical transportation worldwide.


REVA Air Ambulance and Medical Flights Company Accredited by NAAMTA

REVA Air Ambulance and Medical Flights Company Accredited by NAAMTA. Following a comprehensive audit of its medical techniques and facilities, REVA air ambulance company is now a NAAMTA Alliance member.  announces pleased to announce that following a comprehensive audit of its medical techniques and facilities, the National Accreditation Alliance of Medical Transport Applications has awarded REVA with NAAMTA’s full medical transport accreditation.  REVA, which is the result of the merger of FAA Air Carrier Certificate holder Aero Jet International, Inc., and Air Ambulance Professionals, operates domestic and international medical flight services. REVA’s first Air Ambulance company headquarters is still located in Florida, but now also has bases in Arizona and Puerto Rico.


NAAMTA accreditation confirms REVA’s best-practices standards, its culture of safety and continuing education, and its commitment to the well-being of both its clients and its flight teams, said REVA CEO Stuart Hayman on Monday at the joint conference announcing the achievement.

“Earning NAAMTA accreditation has been a top priority since the first day of our merger 18 months ago with Aero Jet International, Inc., and Air Ambulance Professionals. Since then, every staff member, every medical associate and every management, training, and safety action at REVA has been aimed at ensuring that we meet or exceed NAAMTA’s high standards,”  said REVA Program Director Lesa Armstrong, R.N.


Armstrong explained that by applying the Alliance’s best-practices standards and implementation protocols to all aspects of air-ambulance transportation, REVA integrates medical, technical, and management standards. “In simple terms, we now practice a unified standard, across the board.  This reflects the highest and best quality measures in each of the fields that make up air-ambulance services,” she said.

“Whether we’re looking at medical practices or financial management, whether we’re examining aircraft maintenance or continuing education, NAAMTA holds members to the highest and best reference against which our clients, patients, medical personnel, and flight crews can our measure performance,” CEO Hayman said. “It’s an accreditation that our clients can trust.”

In welcoming REVA to the prestigious roster of NAAMTA-accredited medical transportation firms, NAAMTA Executive Director Roylen Griffin said his auditors found overwhelming evidence of REVA’s commitment to quality management and safety practices at every level of its organization.

NAAMTA accreditation is built on providing standards that focus on quality patient care and the safe transport of everyone involved.  NAAMTA’s Alliance brings each member organization to the vanguard of continuous improvement for medical transport. The Alliance’s site audit found the Core Values at REVA to be the driving force of every employee interviewed. “We are very impressed,” Griffin said.  “The accreditation process demonstrates REVA’s dedication to the individual patient before, during, and after transport.”

“Accreditation is continuous dynamic,” Griffin added. “NAAMTA advocates a continual self-auditing and monitoring. REVA’s participation in the auditing process, from start to completion, demonstrates its commitment to our high standards, which clients, technical staffs, and medical professionals recognize.”

NAAMTA accreditation places REVA in a select body of medical transportation providers.  “Each provider, individually and as a group under the NAAMTA umbrella, demonstrates a corporate value system in which quality standards are not just enforced, but are continually monitored, developed and defined as medical transportation systems and expectations advance alongside the progress of medicine, patient care, and allied technologies,” Griffin said.

Accreditation by NAAMTA is awarded for three years, during which time members are encouraged to participate in on-going professional, technical and medical development, both on-line and in the seminars and workshops offered by NAAMTA.


NAAMTA is based in American Fork, Utah. It is the medical transportation field’s leading auditing agency for overseeing unified performance quality standards for medical personnel, flight personnel, equipment, management, and financial performance by its members. Its auditing standards are certified by the International Standardization Organization (ISO) and endorsed by multiple specialty fields within the medical transportation industry.

REVA Air Ambulance is the result of the merger of Aero Jet International, Inc., and Air Ambulance Professionals. Aero Jet International, Inc., the Air Carrier Certificate holder, operates all flights and has been delivering quality transportation for more two decades from bases in Fort Lauderdale, Florida, San Juan, Puerto Rico, and Phoenix, Arizona.  Medical staff, pilots, mechanics, maintenance and support personnel are fully licensed, certified, and trained, meeting and exceeding industry standards and quality expectations. Aircraft are fully FAA certified. The fleet is accredited by the European Aeromedical Institute (EURAMI), a quality compliance designation; the Canadian Transportation Agency International License; U.S. Treasury Cuban operation authorization; all required State of Florida and State of Arizona emergency medical air ambulance services and emergency medical service licenses; and others, including operating certificates and permits for Bermuda and sites within the European Union.



Air Ambulance Cost and Cost – Effectiveness

Maintaining the resources necessary to respond with an air ambulance to an emergency is a complex and costly undertaking, much like that of fire departments and hospital emergency departments. The high fixed costs of maintaining a response infrastructure are necessary in order to be ready to serve.

This is especially problematic in maintaining rural emergency care services. Recent studies from the Capitol Area Health Roundtable and the Government Accountability Office (GAO) have highlighted that current reimbursement does not adequately support the cost of maintaining services.

Helicopters and fixed wing aircraft cost millions of dollars to purchase or lease, operate, house and maintain.  Highly trained crews available on a 24-hour/7 days per week basis, and the infrastructure which governs, trains, funds, supports, and links them and their service to the EMS system, are also expensive.

As few systems are publicly funded, maintaining the availability of this essential resource inevitably translates into a single patient mission charge that seems expensive in comparison with a lower-priced ground ambulance for the same mission. It has proven a mistake, however, to make such an isolated comparison and to equate the lower charge with cost-effectiveness and the higher charge with costprohibitiveness. In the managed care push of the mid-1990’s, air ambulance service was interpreted by some in this way, as an expensive system contributing to the high cost of health care.  They postulated that the industry would shrink and require redesign.  That did not happen and, as the value of air ambulance service is increasingly demonstrated, reimbursement for air medical services has actually improved and services have expanded in response to other changes in the healthcare system.

At least one carefully constructed economic model comparing helicopter versus ground EMS has been crafted.  It demonstrates that on a system level (that is, funding a system of air ambulances versus a system of ground ambulances covering the same large geographic area and volume of calls), the cost per patient transported would be $4,475 for the ground system and $2,811 for the air system (1991 dollars). A cost-effectiveness study of helicopter EMS for trauma patients by Gearhart and colleagues concluded that such service is, indeed, cost-effective.  In looking at the cost per year of life saved by 500 emergency medical interventions, another researcher found the average to be $19,000 (e.g. clot-busting medication treatment for heart attack is $32,678; kidney dialysis is $40,000). That study estimated paramedic ground EMS to cost $8,886 per year of life saved while the Gearhart paper establishes a comparable figure for medical helicopter use of $2,454.

As increasingly difficult decisions about apportioning health care dollars in our aging society are faced, air ambulance service should not only be considered cost-effective in its current roles, but may increasingly serve medically isolated populations in new ways.

History of Air Medical and Air Ambulance Services in the United States

In 1926, the United States Army Air Corps used a converted airplane to transport patients from Nicaragua to an Army hospital in Panama, 150 miles away. The routine interhospital military use of airplanes1 dates to World War II, as does the first air evacuation of U.S. soldiers from the site of injury, which occurred in what was then Burma.

The routine medical evacuation mission of helicopters, however, evolved unintentionally during the Korean conflict in the 1950’s. Because roadways in the fighting front of Korea were often rough and indirect, they could not be relied upon for the rapid and gentle evacuation of troops to the field surgical units. Instead, helicopters on other missions would be rerouted to pick up the critically wounded and fly them quickly and smoothly, often in time to benefit from life- or limb-saving surgical care.

The Army, seeing this advantage over ground transportation, rapidly began testing dedicated medical helicopters. During the course of the war, over 22,000 troops were evacuated by helicopter. It is felt that rapid, smooth field evacuation and the specialized skills offered by surgeons seeing hundreds of patients earlier at the field hospitals contributed to a reduced mortality rate for wounded, hospitalized soldiers, compared with previous wars.

The Viet Nam conflict brought further sophistication to the same general concept: fast and smooth air evacuation of the critically injured to field surgery for stabilization. The aircraft changed, as did medical capabilities. Field emergency care and rapid evacuation for over 800,000 troops reduced the war-long mortality even further.

A theme from WWI through Viet Nam began to repeat: stabilize the critically wounded soldier in the field, provide advanced care enroute, and get the patient to a trauma-qualified surgeon in less than an hour, and the extent and impact of injury, including the likelihood of death, can be reduced.

In 1966, the landmark National Academy of Science white paper Accidental Death and Disability: The Neglected Disease of Modern Society underscored the profound impact of death and disability caused by injury, particularly car crashes. It also detailed a lack of coordinated response to injury, including the observation that “Helicopter ambulances have not been adapted to civilian peacetime needs.”

The National Academy of Science white paper contributed substantially to the development of the modern EMS system and its trauma care subsystem. Its impact was compounded by the influence of returning military units, and military medical helicopter pilots discharged to law enforcement and other public safety flying roles. These led to the dual-purpose adaptation of military and public safety helicopters to the evacuation of injured civilians, such as the Military Assistance to Safety & Traffic (MAST) program, established in 1970, and the Maryland State Police aviation program which in March, 1970, became “the first civilian agency to transport a critically injured trauma patient by helicopter.”

The first civilian hospital-based medical helicopter service was established in 1972 at St. Anthony’s Hospital in Denver, Colorado. By 1980, some 32 helicopter emergency medical services (HEMS) programs with 39 helicopters were flying more than 17,000 patients a year. By 1990, this grew to 174 services with 231 helicopters flying nearly 160,000 patients. Ten years later, 231 helicopter services with 400 aircraft were flying over 203,000 patients each year.10 By 2005, 272 services operating 753 rotor-wing (helicopter) and 150 dedicated fixed wing aircraft were in operation.  There are now approximately a half-million helicopter and fixed wing transports each year.

Historically, the typical helicopter EMS service has been operated by or affiliated with a hospital with one or two aircraft. In the past decade, many of these services have become independent, community-based resources with hospital affiliations. The rapid growth of AMS, particularly in the late 1980’s and again in the last 5 years, can be attributed to changes in the overall health care system. The need to quickly bring critically injured patients to surgical care brought AMS (mainly medical helicopters) into existence. In more recent years, the closure of rural hospitals because of reimbursement and other financial pressures, or their conversion to Critical Access Hospitals (CAH’s) with reduced services and fewer specialist physicians, has created large geographical gaps in the availability of specialized surgical resources. Unfortunately, these rural areas are also the location of the most serious car crashes and are where 60% of fatal crashes in the U.S. occur, a rate nearly double that of similar accidents in suburban or urban areas.

The use of aircraft with skilled medical crews helps to close these gaps and improves access to specialist care. As more time-dependent medical treatments (e.g. “clot-busting” drugs, angioplasty, or surgery for heart attacks or strokes) have been shown to improve patient outcomes, the absence of specialty care and physicians in these same areas continues to contribute to the increased use of aircraft to get patients rapidly to these life saving treatments at specialty hospitals.

Research in the early 1970’s reinforced the notion held by wartime physicians that, for the critically injured patient, surgical intervention in the first hour after injury was crucial. The notion of this “Golden Hour” has survived, with minor variation, to the present day. With this influence, the Accidental Death and Disability…white paper, and the fresh experience of military medical helicopter success in this arena, it is understandable that civilian HEMS adopted trauma as its predominant mission in its early years.

Medical Flight Industry Overview by AAMS

It is estimated that there are around 400,000 helicopter EMS missions flown each year. There are an additional 100,000 – 150,000 fixed wing medical flights each year. In 2002, there were roughly 400 dedicated EMS helicopters. At the close of 2008, there are a little more than 800 flying EMS missions. Valid reasons exist for the growth in air medicine that are specifically linked to the changes in the overall healthcare system. The top three include:

1. An aging demographic.
According to the US Department of Health and Human Services, “It was estimated that in 2000 there were 605 million persons worldwide aged 60 years or older. This number is projected to increase to almost 2 billion by 2050.” This trend is particularly noticeable in the US, with a rapidly increasing aging population, especially in rural areas. The medical needs of this population demographic are reflected in the growing rates of trauma, as well as the increased occurrence of time-dependent diseases such as heart attack, stroke, and non-trauma surgical emergencies such as gastro-intestinal bleeds.

2. Closure of emergency departments and hospitals, as well as local, community-based ambulance services.
According to the American Hospital Association, emergency departments in community hospitals have declined from just over 5000 in 1992 to approximately 4600 in 2002, a trend that is expected to continue. As a result, air medicine is becoming the health care safety net and access point for many rural individuals and communities.

3. Changes in the delivery and availability of rural healthcare.

Rural hospitals have been undergoing a rapid change in mission and structure during the last 50 years. In an effort to help maintain a sufficient number of hospitals, the Centers for Medicare & Medicaid Services has developed the Critical Access Hospital program which pays full cost for Medicare beneficiaries. This has come in exchange for structural changes in the hospital, which include reducing beds to 25 or fewer and shortening average length of stay to less than 96 hours. The expected result is to keep hospitals open, which is a tremendous benefit to rural communities. However, it also leads to a concurrent need to transfer complex patients to distant trauma and tertiary care centers, requiring a rapid and even more sophisticated medical transport system.

Higher Level of Care

Helicopter emergency medical services (HEMS) are integral to the US healthcare system for several reasons:

The crews aboard air ambulances provide more than the advanced-life-support-level medical skills and equipment found on ground ambulances. In addition, they bring the additional skills, equipment and supplies of a tertiary hospital, including more advanced drugs, and more sophisticated critical care medical skills whenever they respond to a community hospital, to the scene of an injury or accident, or to a pre-planned rendezvous point with a ground ambulance (a common practice for fixed wing, or airplane, air ambulances). This higher level of care is especially important in rural areas, which may have few advanced-life-support ground ambulances to call upon. The current configuration for the medical crew on board advanced-medical-support units is most typically a specially trained critical care nurse and paramedic. Other specialist caregivers or physicians may be added to the team as needed. This configuration effectively initiates tertiary hospital care directly at the patient’s bedside, whether at the
scene of an emergency or at a community hospital. Almost exclusively, the AMS team handles the most critically ill and injured patients. The benefits of air transport have been demonstrated to outweigh any stressors that flying might add, even for the sickest trauma and, notably, heart attack patients.

Speed, Access and Better Patient Outcomes

Helicopter air ambulances are used to transport patients from the emergency scene to a hospital, and for shorter flights between smaller hospitals and trauma centers or specialty hospitals (burn or cardiac centers, for instance). Fixed wing air ambulances (airplanes) are used for transporting patients on longer inter-hospital flights.

Air medical transport is beneficial not only because it provides a higher level of medical care to the patient en-route, but also because it provides speedier response and travel times. When treating the critically ill or injured, it is always important to minimize the time spent delivering a patient to a physician’s direct care. Helicopters fly point-to-point, minimizing the distance traveled and avoiding the traffic delays experienced by ground ambulances.

Patients isolated from ground EMS or trauma centers by distance, lack of ambulancepassable roads or by terrain features such as mountains, canyons, forests, and bodies of water, benefit greatly from air medical service. Helicopter EMS is also a timesaving way to avoid urban and suburban traffic congestion.

Patient Conditions and Transport Selection

Following are the top three patient conditions most often associated with Helicopter Emergency Medical Services (HEMS):

• Cardiac Care/Myocardial Infarction: Several studies suggest that the scarcity of cardiac intervention centers have resulted in a greater need for HEMS in quickly transporting cardiac and cardiac-arrest patients, particularly outside of urban areas.
• Cerebrovascular Accidents/Strokes: As with heart attacks, only a short window of time exists in which anti-thrombotic treatment can result in patients suffering little to no long-term damage and disability. That treatment window is optimally within 90 minutes but generally no more than three hours. Therefore, patients transported to specialty centers for the treatment of strokes can benefit from a well-coordinated ground and air system to accomplish early transfer.
• Critical Trauma: Scene responses (i.e. motor vehicle crashes, stabbings, shootings, etc.) constitute 33% of HEMS missions. Medical studies have revealed correlations between HEMS transports and improvements in traumarelated
mortality and morbidity. As a part of an organized trauma system, HEMS reduces the injury-to-operating-room time significantly. HEMS discourages time-costly intermediate stops at small non-trauma center facilities. Such stops have been shown to be detrimental to trauma patients.
• Other conditions that may warrant air medical transport include:
o High Risk Obstetrics/Neonatal Care: When a pregnant woman or fetus experiences complications, these can be life-threatening for both mother and child.
o Complex Pediatrics: Children are very resilient patients who often do not show signs of a severe illness or injury until they are close to death, at which point they suddenly deteriorate. When this occurs, they require
access to neonatal and pediatric intensive care units, which are becoming increasingly limited.
o Complex Surgical and Medical Conditions: Air medical service is indicated for a number of other time-critical patient conditions. Examples of these include aortic aneurysms, poisoning or overdose, organ transplantation (movement of patients and organs), and respiratory complications requiring ventilator support. In addition, HEMS is often required when emergency kidney-dialysis is needed or when carbon monoxide poisoning or diving-related incidents have occurred.

Focus on Safety

Safety is the highest priority for air medical crews. After all, these are the people at work aboard the aircraft. However, providing these lifesaving services is not without risk. AAMS works closely with the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB), and Congress to manage that risk for the sake of the crews and patients.

In recent years, special focus has been placed on advances in safety management systems, aviation technologies, and crew training. Numerous aviation technologies have been refined and incorporated into many air medical programs’ operations. Among these technologies are night vision goggles (NVSs) and enhanced vision systems, radar
altimeters, GPS navigation, satellite tracking, and, more recently, helicopter terrain alert warning systems (HTAWS). Survivability gear, which includes such products as fire retardant flight suits, helmets, eye protection, and satellite phones, also has become the standard for most air medical programs across the country.

In addition, enhanced crew and safety management systems have become a part of the everyday operation of air medical systems. Often referred to as Air Medical Resource Management (AMRM), such systems greatly improve both safety and efficacy on air medical missions by enhancing the ability of aviation personnel, flight crew, ground based communication staff, and management to interact proactively on a mission-tomission basis.

Safety management systems further help companies track incidents, identify issues, and solve problems before they happen or become system-wide mistakes that lead to tragedy. Some of the most important advances have been made in risk-management models. These simple management tools help pilots, crews, and managers determine
what environmental conditions are acceptable and greatly enhance the management of risk across air medical systems both large and small. While numerous advances and improvements have been made in air medical services
safety, more remains to be done, particularly with regard to the nation’s existing aviation infrastructure.
Currently, low-altitude aviation vehicles – including helicopters that perform such off-airport operations as air-medical, law-enforcement, firesuppression, and search-and-rescue missions – do not have access to certain
components of the aviation infrastructure, which was built specifically for scheduled, commercial airlines.

Air Ambulance and Medical Flights – The Trauma System

The “Golden Hour” concept provides that along the route to the surgeon’s knife in that first hour, a patient should benefit from an organized EMS system which provides increasingly advanced care (e.g. BLS to ALS to the physician-level care provided by air medical crews). The complete EMS trauma subsystem must include: Rapid discovery of the injured patient and notification of EMS. Fast response of BLS EMS. Early activation by trained and authorized requesters. Timely availability of ALS resources. Rapid access to physician level intervention through HEMS response or the closest Emergency Department. Rapid transport to identified trauma centers. Inter-hospital transfer to needed specialty care by critical care ground ambulance helicopter or fixed wing air ambulance as needed. Excellent planning and coordination of EMS resources. Quality assessment of each component in the combined air and ground emergency response. A recent paper cites the Maryland system as having these components in place and organized well, and calls upon other systems to emulate it. It has been well demonstrated that organized trauma systems with trauma centers save lives.

In the early 1980’s, the first analytical attempts to determine the life-saving impact on mortality by HEMS response to injury scenes began to appear, largely demonstrating reductions in mortality compared with ground systems.18-20, 38 Since the ‘80’s, there have been many published medical studies which have attempted, through a variety of means, to assess HEMS’ impact on trauma mortality and morbidity for both scene and interfacility flights. Overall, these studies have demonstrated the power of HEMS to affect improvements in trauma-related mortality and morbidity.

As a part of an organized trauma system, HEMS cuts the injury-tooperating- room time significantly. Medical helicopters, dispatched simultaneously with ground EMS, can give over 54% of the US population access to a full-service trauma center within 60 minutes that they otherwise would not have.

Medical helicopters also discourage time-costly intermediate stops at small, non-trauma center hospitals. Such stops have been shown to be detrimental to trauma patients, even where HEMS is called from that hospital for the final leg of the trip.

In the future, improvements in cell phone technology and automatic crash notification (ACN) technology in cars may cut the time required to discover and report a crash injury to almost zero. Using “urgency” indicators generated by automatic crash notification data sent from crashed cars to dispatch centers, along with special medical protocols for assessing the probability of severe injury from the crash, will soon provide a rational and effective way for helicopters to be launched within minutes of an accident, no matter ho remote, thereby further improving the speed of EMS response to patients.

Examples of recent study findings demonstrate that: s Patients severely injured enough to require inter-facility transfer were four times more likely to die after the HEMS serving that area was discontinued. HEMS reduced injury mortality by 24% in a multi-center study with some 16,000 patients in Boston. Even injury patients in urban areas experienced a transport-time benefit by HEMS in 23% of the cases.

Traumatic brain injury (TBI) is frequently associated with events causing severe, multiple trauma in patients, and is the leading cause of death and disability in children and in adults in their most productive years. As with other major injury, treatment of traumatic brain injury is time-critical. Outside of urban areas, the reduced availability of the neurosurgical services required to treat traumatic brain injury has posed a challenge to EMS. Recent studies indicate that early advanced care by air medical crews and air transport to definitive care by a neurosurgeon can overcome this challenge, resulting in significant improvement to moderately and severely traumatic brain injured patients.

HEMS is generally effective in trauma care circumstances such as when: There is an extended period required to access or extricate a remote (e.g. injured hiker, snowmobiler, or boater) or trapped patient (e.g. in a crashed car) which depletes the time windo to get the patient to the trauma center by ground. Distance to the trauma center is greater than 20 to 25 miles. The patient needs medical care and stabilization at the ALS level, and there is no ALS-level ground ambulance service available within a reasonable time frame. Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center via ground ambulance within the ideal time frame for best clinical outcome. There are multiple patients who will overwhelm resources at the trauma center(s) reachable by ground within the time window. EMS systems require bringing a patient to the nearest hospital for initial evaluation and stabilization, rather than by-passing those facilities and going directly to a trauma center. This may add delay to definitive surgical care and necessitate HEMS transport to mitigate the impact of that delay. There is a mass casualty incident.

In rural and frontier areas, HEMS and fixed wing aircraft play a particularly important role.  Where the nearest ground ambulance is further, by traveltime, from the scene of injury than the nearest HEMS, the air medical service may be the primary ambulance for critically ill and injured patients in that area. Where the nearest ALS-capable medical facility is further, by travel-time, from the scene of the injury than is a HEMS or a fixed wing provider, the air medical service may be the primary ALS provider for critically ill or injured patients in that area. Where blood supplies or availability of other medical supplies or equipment are limited or non-existent, jeopardizing the care of the patient, the air medical service can bring these resources to the hospital with the patient.

The air medical service can transport specialized medical staff (surgical, emergency medicine, respiratory therapy, pediatric, neonatal, obstetric, and specialized nursing staff) to assist with a local mass casualty event or to augment the rural/frontier hospital’s staff in stabilizing patients needing special care before transport.