History of Air. Medicine. Introduction Modern air medicine is a relatively recent phenomenon dating back

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1 DESCMC03_ QXD 08/06/ :18 PM Page 25 History of Air Medicine CHAPTER 3 Objectives Upon completing this chapter, the reader should have a better understanding of the following topics: The origins of air medicine Early development of the helicopter The role of the helicopter in the Korean and Vietnam Wars Early civilian uses of medical helicopters The future of air medicine Introduction Modern air medicine is a relatively recent phenomenon dating back only some 35 years. However, like most modern technologies, its roots may be traced back considerably farther. A discussion of air medicine would be incomplete and much less interesting without some understanding of its origins and evolution. This chapter will explore the ancestry of modern air medicine. The Origins of Air Medical Transport The first written record of the term air ambulance is in Jules Verne s Robur le Conquérant (1866), which describes the rescue of shipwrecked sailors by an airship (balloon) named the Albatross. The first documented use of an air ambulance occurred during the Siege of Paris in Balloons were used to evacuate more than 160 soldiers from the besieged city. 25

2 DESCMC03_ QXD 8/04/05 7:53 PM Page 26 During the 1890s, M. de Mooy, chief of the Dutch Medical Service, suggested a system for evacuating the injured using litters suspended from balloons. Although government officials ultimately ruled this procedure too risky, de Mooy constructed several emergency balloons that were used quite successfully on the Amiens battlefront. In 1903 the possibility of using combustion-driven vehicles to transport casualties from the battlefield was first raised. The idea was met with cynicism. One critic was heard to say, Nothing has been found to equal the force of the horse for economy and safety. Patients, being probably in a nervous condition, will be alarmed at the idea of being taken off in a motor car. A similar statement was made when the French government was asked in 1917 to use biplanes as air ambulances. Are there not enough dead in France today without killing the wounded in airplanes? French senator, pilot, and medical doctor Emile Raymond suggested aerial support for the military as early as In September of that year Raymond flew over a battlefield in a Bieroit airplane, reporting the location of injured soldiers for stretcher parties. In October 1913 another French doctor, M. Gautier, stated that surgery would be revolutionized if aeroplanes could be used to evacuate the injured. Later in 1913, two of his French compatriots, M. Uzac and Charles Julliot, suggested that air ambulance support during war be recognized and protected by the Geneva Convention. In 1923, during an International Red Cross meeting about the effectiveness of air ambulances, a supplement was written for inclusion in the Geneva Convention of The first recorded attempt at designing an air ambulance in the United States occurred in 1909 in Pensacola, Florida. Representatives of the U.S. Army Medical Corps and Coast Artillery Corps engineered an airplane with provisions for a stretcher patient. The pilot would be a physician who would both fly the airplane and provide medical care. Unfortunately the aircraft crashed on the first test flight. In 1931 Igor Sikorsky patented a design with a single large main rotor and a small antitorque tail rotor. In 1938 United Aircraft agreed to fund the development of the aircraft. The final product was an open-cockpit helicopter with a 65-horsepower engine that turned a three-blade main rotor. The VS-300 first flew in Although several models of the aircraft crashed, a determined Sikorsky continued to make modifications on the VS-300 and was ultimately successful in designing a practical rotor-wing aircraft. The S-47 was the prototype for the first helicopter produced in quantity for the U.S. Armed Forces. In World War II, the cabin of the S-47 was covered with fabric, allowing for flight in colder climates. Sikorsky continued to develop larger and more powerful helicopters. The S-51 and S-55 were first used for search and rescue and medical evacuation during the Korean War. 26 Chapter 3

3 DESCMC03_ QXD 8/04/05 7:53 PM Page 27 The Modern Era If we had to trace the advent of modern air medicine to one point in time, it would have to be the beginning of the Korean conflict, when the potential of the helicopter as a medical tool was first fully appreciated. On August 4, 1950, just one month after the start of the Korean War, the first rotorwing medical evacuation was performed with a bubble-fronted Bell 47 (as seen in the TV series M*A*S*H). The wounded were transported on basket stretchers attached to the top of the landing gear on the outside of the small helicopter (Figure 3-1). They were covered with blankets in a nearly futile effort to maintain body heat and prevent wound contamination. It is estimated that more than 20,000 injured soldiers were evacuated by helicopter. The World War II casualty/death rate of 4.5 deaths per 100 casualties dropped to 2.5 per 100 casualties during the Korean War. While there were some technological advances in medicine during that period, the improvement is largely attributed to use of the helicopter to evacuate patients to definitive care more quickly. The external litter, however, did not allow for medical care during transport. The next major advance in AM transport occurred during the Vietnam War, where the Bell UH-1 helicopter was placed into operation (Figure 3-2). Affectionately known as the Huey, this aircraft was large enough to FIGURE 3-1 A Bell 47 Courtesy of Sheldon Cohen/Bell Helicopter History of Air Medicine 27

4 DESCMC03_ QXD 8/04/05 7:53 PM Page 28 FIGURE 3-2 A UH-1 Courtesy of Sheldon Cohen/Bell Helicopter hold patients inside, where medical personnel could begin treatment during the flight to a field hospital. The mass deployment of these aircraft as medivac units reduced the average delay until treatment to one hour. The ability to carry patients inside the aircraft was a key element in the reduction of mortality and morbidity. Military medics performed procedures previously done only by physicians: they started central lines, inserted chest tubes, and sutured bleeding wounds. This care, coupled with the initiation of specialty hospitals for the treatment of different types of injuries, resulted in a reduction in the mortality rate to 1 death per 100 casualties. The success of the medivac helicopter in the military generated discussions about its potential in the civilian environment. The first known civilian application of a medical helicopter was in 1958 in Etna, California. Bill Mathews, a businessman, started a helicopter service to ferry patients for Dr. Granville Ashcraft, the town s only physician. The town druggist also used the helicopter to deliver drugs during emergencies. Two programs were implemented in the United States to assess the impact of medical helicopters on mortality and morbidity in the civilian arena. Project CARESOM was established in Mississippi in Three helicopters were purchased through a federal grant and based in three small cities (Tupelo, Greenwood, and Hattiesburg). Operating expenses were paid from the grant for one year. Upon termination of the grant, Project CARESOM was deemed a success, and each of the three communities 28 Chapter 3

5 DESCMC03_ QXD 8/04/05 7:53 PM Page 29 was given the chance to keep its helicopter in operation. Because of the high operating costs, the cities of Tupelo and Greenwood chose to discontinue their programs. In Hattiesburg an air ambulance district was formed and the program continued, supported by tax money paid by the residents of the seven participating counties. That program, named Rescue 7, has operated continuously ever since. At roughly the same time the Military Assistance to Safety and Traffic (MAST) system was begun at Fort Sam Houston in San Antonio, Texas. MAST was started as an experiment by the Department of Transportation to study the feasibility of using military helicopters to augment existing emergency medical services. In its first 10 years of operation, MAST expanded nationally and transported more than 16,000 patients. Also, in 1969 the state of Maryland received a grant to purchase Bell Jet Ranger helicopters and started one of the nation s first medivac programs. The four helicopters, manned by paramedics, were strategically based throughout the state for quick response to emergency situations. When they were not carrying patients, the helicopters were used for law enforcement and traffic control. Today there are over 220 rotor-wing flight programs operating in the United States, mostly hospital based. These modern aircraft represent a huge advance in technology over those used during the Korean War. Current models are larger, safer, quieter, and faster and incorporate modern medical technology (Figure 3-3). Many are configured as flying FIGURE 3-3 Modern RW air ambulance (Koala) Courtesy of American Eurocopter History of Air Medicine 29

6 DESCMC03_ QXD 8/04/05 7:53 PM Page 30 critical-care units with all the necessary medical paraphernalia. Today s typical air medical program offers a turbine-powered aircraft with a cabin large enough to accommodate a patient and a medical team. The patient can be given advanced care before and during transport. Criticalcare patients have access to ventilators, cardiac monitors, and a host of other equipment and supplies that were not available in hospitals even a decade ago. A Look to the Future Although no one knows for certain what the future holds, in air medicine a few things seem relatively certain. Turbine engines will continue to evolve, providing more power from lighter packages. These advances will allow for increased payload and additional range. Reliability will continue to improve, leading to even safer machines. Pilot support systems will advance, acting as backup for pilot decision-making and reducing the likelihood of accidents caused by pilot error. Flight following technology will continue to advance. The use of satellite tracking and communications systems will likely increase. Tilt-rotor aircraft are currently in the test stage of development (Figure 3-4). As these machines gain acceptance in the aviation industry, they will almost certainly be adopted for air medical use and will offer significant benefits to air medical programs. A single craft that is capable of vertical takeoff and landing and has a cruise speed of 275 knots will become increasingly attractive to hospitals operating both rotor-wing and fixed-wing aircraft, especially in areas where long-distance flights 30 Chapter 3 Figure 3-4 A tilt-rotor aircraft Courtesy of Sheldon Cohen/ Bell Helicopter

7 DESCMC03_ QXD 8/04/05 7:53 PM Page 31 are frequent. However, manufacturers will first have to demonstrate a record of safety and reliability at least equivalent to that of modern rotorwing ships. The high price of tilt-rotor aircraft will also have to come down before they can be used by the medical community. Health care reimbursement has been decreasing for the last decade. Some experts feel this will be a permanent condition of the health care system. Others believe that the current environment is so financially hostile that long-term survival is not possible and that major changes will have to take place in order for services to be continued. Yet others feel the pendulum will begin moving in the other direction, reimbursement dollars will flow more freely again, and air medicine may be able to attract some of them. We will continue to see the formation of more partnerships and consortia as health care dollars become increasingly scarce. This arrangement will allow new, more cost-effective programs to be created and operated. It will also give struggling stand-alone programs a chance at survival. But future belt-tightening is inevitable. There will likely be a return to publicly funded emergency medical services, including air medical programs. Thinning profit margins are forcing many for-profit services to reconsider their operations. Summary Air medicine has an exciting history, extending from the first attempts in the early twentieth century to the independent civilian system that we know today. Modern air medicine came of age during the Korean and Vietnam wars. Civilian use of medical helicopters began experimentally in 1969 and has expanded in the decades since. The technology continues to advance, even as the financial climate becomes more constrained. REVIEW QUESTIONS 1. The first functional helicopter was invented by: a. Alexander Graham Bell c. Leonardo Aerospatiale b. Igor Sikorsky d. John P. Vertol 2. The first widespread use of the rotor-wing air ambulance was during: a. World War I c. The Korean Conflict b. World War II d. The Vietnam War History of Air Medicine 31

8 DESCMC03_ QXD 8/04/05 7:53 PM Page This aircraft was widely used as an air ambulance during the Vietnam War: a. Bell 47 c. Bell 206-L4 b. Sikorsky S-76 d. Bell UH-1 4. A government-funded program begun in Mississippi in 1969 to evaluate the practicality of rotor-wing air ambulance use in the civilian environment was called: a. Project CARESOM c. MED Flight b. MAST d. Stat Medivac 5. There are currently rotor-wing air medical programs operating in the United States alone: a. 75 c. 175 b. 125 d. More than The tilt-rotor aircraft offers technological advancement over traditional air medical craft. Some advantages include that they are: a. Capable of service as both a fixed-wing and rotor-wing aircraft b. Capable of attaining speeds much greater than a typical rotor-wing aircraft c. Cheaper to operate than conventional rotor-wing aircraft d. a and b 32 Chapter 3