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                    History of Air

                                        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

                                M     odern 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 medi-
                                cine would be incomplete and much less interesting without some un-
                                derstanding 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 1870. Balloons
                                were used to evacuate more than 160 soldiers from the besieged city.

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                                   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 pro-
                              cedure 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
                                   French senator, pilot, and medical doctor Emile Raymond sug-
                              gested aerial support for the military as early as 1912. 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 an-
                              other French doctor, M. Gautier, stated that surgery would be revolu-
                              tionized if aeroplanes could be used to evacuate the injured. Later in
                              1913, two of his French compatriots, M. Uzac and Charles Julliot, sug-
                              gested that air ambulance support during war be recognized and pro-
                              tected 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 1906.
                                   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 1939. Although sev-
                              eral 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 fab-
                              ric, allowing for flight in colder climates. Sikorsky continued to de-
                              velop 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.

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          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 poten-
                              tial 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 rotor-
                              wing 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 evacu-
                              ated 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 helicop-
                              ter 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

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                             FIGURE 3-2
                             A UH-1
                             Courtesy of Sheldon Cohen/Bell Helicopter

                                 hold patients inside, where medical personnel could begin treatment dur-
                                 ing 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 reduc-
                                 tion 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 ini-
                                 tiation 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 dis-
                                 cussions 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 1969. 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, Pro-
                                 ject CARESOM was deemed a success, and each of the three communities

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                              was given the chance to keep its helicopter in operation. Because of the
                              high operating costs, the cities of Tupelo and Greenwood chose to discon-
                              tinue their programs. In Hattiesburg an air ambulance district was formed
                              and the program continued, supported by tax money paid by the resi-
                              dents 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 emer-
                              gency 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 pa-
                              tients, 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 repre-
                              sent 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

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                                 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. Critical-
                                 care 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 medi-
                                 cine 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 sys-
                                 tems will advance, acting as backup for pilot decision-making and re-
                                 ducing 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

                             Figure 3-4
                             A tilt-rotor aircraft
                             Courtesy of Sheldon Cohen/
                             Bell Helicopter

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                                are frequent. However, manufacturers will first have to demonstrate a
                                record of safety and reliability at least equivalent to that of modern rotor-
                                wing 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, reimburse-
                                ment 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.

                                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 experi-
                                mentally in 1969 and has expanded in the decades since. The technol-
                                ogy continues to advance, even as the financial climate becomes more


           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

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           3. 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 220

           6. 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

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