air medical services air medical services air medical services are the use of aircraft, including both fixed-wing aircraft and helicopters to provide various kinds of medical care, especially prehospital, emergency and critical care to patients during aeromedical evacuation and rescue operations. a sécurité civile ec145 helicopter conducts rescues operations for the french minister of the interior sequence image of mountain take-off by an agusta a109 sp grand "da vinci" helicopter from rega air rescue service history during world war i, air transport was used to provide medical evacuation – either from frontline areas or the battlefield itself. in 1928, in australia, john flynn founded the flying doctor service (later the royal flying doctor service), to provide a wide range of medical services to civilians in remote areas; these included from routine consultations with travelling general practitioners, to air ambulance evacuations and other emergency medical services. fixed wing military air ambulances came into regular use during world war ii. helicopters became more commonly used for such purposes during the korean and vietnam wars. later, helicopters were introduced to civilian health care, especially for shorter distances, in and around large cities: transporting paramedics or specialist doctors as needed and transporting patients to hospitals, especially for major trauma cases. fixed-wing aircraft remained in use for long-distance medical transport. advantages air medical services can travel faster and operate in a wider coverage area than a land ambulance. this makes them particularly useful in sparsely-populated rural areas. air medical services have a particular advantage for major trauma injuries. the controversial theory of the golden hour suggests that major trauma patients should be transported as quickly as possible to a specialist trauma center. therefore, medical responders in a helicopter can provide both a higher level of care at the scene of a trauma and faster transport to a trauma center. they can also provide critical care when transporting patients from community hospitals to trauma centers. indications for air transport a eurocopter ec 145 of switzerland's rega air rescue service effective use of helicopter services for trauma depends on the ground responder's ability to determine whether the patient's condition warrants air medical transport. protocols and training must be developed to ensure appropriate triage criteria are applied. excessively stringent criteria can prevent rapid care and transport of trauma victims; relaxed criteria can result in the patient being unnecessarily exposed to the potential dangers of dangerous weather conditions or other aviation-related risks. crew and patient safety is the single most important factor to be considered when deciding whether to transport a patient by helicopter. weather, air traffic patterns, and distances (such as from the trauma scene to closest level 1 trauma centre) must also be considered. another reason for cancelling a flight is based on the comfort of the flight crew with the flight. the general rule of safety is upon the crew, when there is one pilot and two medical crew is: "3 to go, 1 to say 'no'". if one flight member is not comfortable with the flight for whatever reason, the flight is cancelled. some have questioned the safety of air medical services. while the number of crashes may be increasing, the number of programs and use of services has also increased. factors associated with fatal crashes of medical transport helicopters include flying at night and during bad weather, and postcrash fires. air ambulances often employ high-visibility colour schemes, like ontario's distinctive ornge helicopters. air ambulance an air ambulance is a specially outfitted helicopter or fixed-wing aircraft that transports injured or sick people in a medical emergency or over distances or terrain impractical for a conventional ground ambulance. fixed-wing aircraft are also more often used to move patients over long distances and for repatriation from foreign countries. these and related operations are called aeromedical. in some circumstances, the same aircraft may be used to search for missing or wanted people. like ground ambulances, air ambulances are equipped with medical equipment vital to monitoring and treating injured or ill patients. common equipment for air ambulances includes medications, ventilators, ecgs and monitoring units, cpr equipment, and stretchers. a medically staffed and equipped air ambulance provides medical care in flight—while a non-medically equipped and staffed aircraft simply transports patients without care in flight. military organizations and nato refer to the former as medical evacuation (medevac) and to the latter as casualty evacuation (casevac). air traffic control (atc) grants special treatment to air ambulance operations, much like a ground ambulance using lights and a siren, only when they are actively operating with a patient. when this happens, air ambulance aircraft take the call sign medevac (formerly lifeguard) and receive priority handling in the air and on the ground. military the bell h-13 became the first dedicated medevac aircraft during the korean war as with many emergency medical service (ems) innovations, treating patients in flight originated in the military. the concept of using aircraft as ambulances is almost as old as powered flight itself. although balloons were not used to evacuate wounded soldiers at the siege of paris in 1870, air evacuation was experimented with during the first world war. the first recorded british ambulance flight took place in 1917 in ottoman empire when a soldier in the camel corps who had been shot in the ankle was flown to hospital in a de havilland dh9 in 45 minutes. first recorded aeromedical evacuation in the british army the same journey by land would have taken some 3 days to complete. in the 1920s several services, both official and unofficial, started up in various parts of the world. aircraft were still primitive at the time, with limited capabilities, and the effort received mixed reviews. exploration of the idea continued, however, and france and the united kingdom used fully organized air ambulance services during the african and middle eastern colonial wars of the 1920s. in 1920, the british, while suppressing the "mad mullah" in somaliland, used an airco dh.9a fitted out as an air ambulance. it carried a single stretcher under a fairing behind the pilot. the french evacuated over 7,000 casualties during that period. by 1936, an organized military air ambulance service evacuated wounded from the spanish civil war for medical treatment in nazi germany; this service continued during the second world war. the first use of medevac with helicopters was the evacuation of three british pilot combat casualties by a us army sikorsky r-4 in burma during ww2, and the first dedicated use of helicopters by u.s. forces occurred during the korean war, between 1950 and 1953. the french used light helicopters in the first indochina war. while popularly depicted as simply removing casualties from the battlefield (which they did), helicopters in the korean war also moved critical patients to hospital ships after initial emergency treatment in field hospitals. knowledge and expertise of use of air ambulances evolved parallel to the aircraft themselves. by 1969, in vietnam, the use of specially trained medical corpsmen and helicopter air ambulances led u.s. researchers to determine that servicemen wounded in battle had better rates of survival than motorists injured on california freeways. this inspired the first experiments with the use of civilian paramedics in the world. the us military recently employed uh-60 black hawk helicopters to provide air ambulance service during the iraq war to military personnel and civilians. the use of military aircraft as battlefield ambulances continues to grow and develop today in a variety of countries, as does the use of fixed-wing aircraft for long-distance travel, including repatriation of the wounded. currently, a nato working group is investigating unpiloted aerial vehicles (uavs) for casualty evacuation. civilian a bell 412, departs mojave, california the first civilian uses of aircraft as ambulances were probably incidental. in northern canada, australia, and in scandinavian countries, remote, sparsely populated settlements are often inaccessible by road for months at a time, or even year-round. in some places in scandinavia, particularly in norway, the primary means of transportation between communities is by boat. early in aviation history, many of these communities began to rely on civilian "bush" pilots, who fly small aircraft and transport supplies, mail, and visiting doctors or nurses. bush pilots probably performed the first civilian air ambulance trips, albeit on an ad hoc basis—but clearly, a need for these services existed. in the early 1920s, sweden established a standing air ambulance system, as did siam (thailand). in 1928 the first formal, full-time air ambulance service was established in the australian outback. this organization became the royal flying doctor service and still operates. in 1934, marie marvingt established africa's first civil air ambulance service, in morocco. in 1936, air ambulance services were established as part of the highlands and islands medical service to serve more remote areas of highland scotland. air ambulances quickly established their usefulness in remote locations, but their role in developed areas developed more slowly. after world war ii, the saskatchewan government in regina, saskatchewan, canada, established the first civilian air ambulance in north america. the saskatchewan government had to consider remote communities and great distances in providing health care to its citizens. the saskatchewan air ambulance service continues to be active as of 2023. j. walter schaefer founded the first air ambulance service in the u.s, in 1947, in los angeles. the schaefer air service operated as part of schaefer ambulance service. schaefer air service was also the first faa-certified air ambulance service in the united states. when the saskatchewan and schaefer services began, paramedicine was still decades away, and unless a physician or nurse accompanied the patient, air ambulances primarily provided medical transportation. a great deal of the early use of aircraft as ambulances in civilian life, particularly helicopters, involved the improvised use of aircraft that belonged to the military. eventually, this became more organized. this occurred not only in the united states, but also in other countries, and persists today. today in the u.s., helicopters and airplanes carry out approximately a half-million transports per year. two research programs were implemented in the u.s. 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 located strategically in the north, central, and southern areas of the state. upon termination of the grant, the program was considered a success and each of the three communities were given the opportunity to continue the helicopter operation. only the one located in hattiesburg, mississippi did so, and it was therefore established as the first civilian air medical program in the united states. the second program, the military assistance to safety and traffic (mast) system, was established in fort sam houston in san antonio in 1969. this was an experiment by the department of transportation to study the feasibility of using military helicopters to augment existing civilian emergency medical services. these programs were highly successful at establishing the need for such services. the remaining challenge was in how such services could be operated most cost-effectively. in many cases, as agencies, branches, and departments of the civilian governments began to operate aircraft for other purposes, these aircraft were frequently pressed into service to provide cost-effective air support to the evolving emergency medical services. an ems bell 427 covering south bohemian, czech republic as the concept was proven, dedicated civilian air ambulances began to appear. on november 1, 1970, the first permanent civil air ambulance helicopter, christoph 1, entered service at the hospital of harlaching, munich, germany. the apparent success of christoph 1 led to a quick expansion of the concept across germany, with christoph 10 entering service in 1975, christoph 20 in 1981, and christoph 51 in 1989. as of 2007, there are about 80 helicopters named after saint christopher, like christoph europa 5 (also serving denmark), christoph brandenburg or christoph murnau am staffelsee. austria adopted the german system in 1983 when christophorus 1 entered service at innsbruck. also in the year 1975 hans burghart, one of the inventor of the civilian air rescue in germany, presented at one academic conference in the us the concept "rescue helicopters in primary and secondary missions" which had impact for the aviation training at fort rucker, alabama. the first civilian, hospital-based medical helicopter program in the united states began operation in 1972. flight for life colorado began with