1.1 History

Despite the challenges, France and the United Kingdom organized air ambulance services during the African and Middle Eastern Colonial Wars of the 1920s. For instance, during the suppression of the “Mad Mullah” in Somaliland in 1920, the British used an Airco DH.9A as an air ambulance. It carried a single stretcher behind the pilot under a fairing. The French evacuated over 7,000 casualties during this period. The concept continued to evolve, and an organized military air ambulance service transported wounded from the Spanish Civil War for treatment in Nazi Germany by 1936, a service that persisted through the Second World War.

The use of helicopters for medevac purposes saw its inception during World War II, with the evacuation of British combat casualties in Burma using a US Army Sikorsky R-4. Dedicated helicopter use by U.S. forces occurred in the Korean War, where they not only removed casualties from the battlefield but also transported critical patients to hospital ships after initial emergency treatment in field hospitals. This marked the beginning of the military’s extensive use of helicopters for casualty evacuation.

As aircraft capabilities advanced, so did the knowledge and expertise in the use of air ambulances. In Vietnam by 1969, specially trained medical corpsmen and helicopter air ambulances demonstrated better rates of survival for servicemen wounded in battle compared to motorists injured on California freeways. This milestone inspired the first experiments with civilian paramedics worldwide. More recently, during the Iraq War, UH-60 Black Hawk helicopters were utilized for air ambulance services, catering to both military personnel and civilians.

The application of military aircraft as battlefield ambulances continues to evolve globally, with a growing emphasis on fixed-wing aircraft for long-distance travel, including the repatriation of the wounded. Presently, a NATO working group is exploring the use of unpiloted aerial vehicles (UAVs) for casualty evacuation, showcasing ongoing advancements in the intersection of aviation and emergency medical services.

The inception of civilian air ambulances was likely incidental, emerging from the unique needs of remote and inaccessible regions, especially in northern Canada, Australia, and Scandinavian countries. In these areas, where settlements were cut off from road access for extended periods, if not year-round, the reliance on small aircraft and “bush” pilots became essential for transporting supplies, mail, and medical professionals. These bush pilots likely conducted the initial civilian air ambulance trips on an ad hoc basis, driven by the evident necessity for such services.

The early 1920s saw Sweden establishing a standing air ambulance system, followed by Siam (Thailand). In 1928, the first formal, full-time air ambulance service was founded in the Australian outback, evolving into the renowned Royal Flying Doctor Service, which remains operational today. Marie Marvingt established Africa’s first civil air ambulance service in Morocco in 1934, while the Highlands and Islands Medical Service introduced air ambulance services in 1936 to cater to remote areas of Highland Scotland.

While air ambulances quickly proved their worth in remote locations, their integration into developed areas progressed more gradually. After World War II, the Saskatchewan government in Canada established the first civilian air ambulance in North America, considering the vast distances and remote communities within the province. The Saskatchewan Air Ambulance service continues to operate to this day. In the U.S., J. Walter Schaefer founded the first air ambulance service in Los Angeles in 1947 as part of Schaefer Ambulance Service, becoming the first FAA-certified air ambulance service in the country.

During these early stages, paramedicine had not yet been established, and unless accompanied by a physician or nurse, air ambulances primarily focused on medical transportation. Much of the early use of aircraft as ambulances, particularly helicopters, involved the improvised use of military aircraft, a practice that gradually became more organized and persists globally today.

In the United States, approximately half a million air ambulance transports occur annually. Two significant research programs in the late 1960s, Project CARESOM in Mississippi and the Military Assistance to Safety and Traffic (MAST) system in San Antonio, assessed the impact of medical helicopters on mortality and morbidity in civilian settings. These programs, initially experimental, successfully highlighted the need for air medical services. Following their establishment, the challenge shifted towards operating these services cost-effectively. Many civilian governments began utilizing existing aircraft for other purposes to provide efficient air support to the evolving Emergency Medical Services. This adaptive approach has contributed to the widespread and critical role of air ambulances in modern healthcare systems.

Following the proven success of the concept, dedicated civilian air ambulance services began to emerge, marking a significant advancement in aeromedical care. On November 1, 1970, Christoph 1, the first permanent civil air ambulance helicopter, commenced operations at the Hospital of Harlaching in Munich, Germany. Christoph 1’s success prompted rapid expansion across Germany, with subsequent helicopters like Christoph 10 (1975), Christoph 20 (1981), and Christoph 51 (1989) entering service. As of 2007, around 80 helicopters named after Saint Christopher, such as Christoph Europa 5 and Christoph Brandenburg, serve various regions, including Denmark.

Austria adopted the German system in 1983 with Christophorus 1 entering service in Innsbruck. In 1975, Hans Burghart, one of the pioneers of civilian air rescue in Germany, presented the concept of “Rescue Helicopters in Primary and Secondary Missions” at an academic conference in the United States, impacting aviation training at Fort Rucker, Alabama.

The first civilian, hospital-based medical helicopter program in the United States commenced operations in 1972 with Flight For Life Colorado, featuring a single Alouette III helicopter based in Denver. In Ontario, Canada, the air ambulance program began in 1977, emphasizing a paramedic-based system of care, with physicians or nurses being relatively uncommon. Today, this system operates through a private contractor (ORNGE), with 33 aircraft stationed at 26 bases across the province, performing both interfacility transfers and on-scene responses.

Civilian air ambulance services have become commonplace globally, providing crucial support for ground-based EMS systems. In SFR Yugoslavia, the first air ambulance appeared in the 1980s, with much of the fleet repurposed from military service in response to increased car accidents on highways.

Air ambulance services worldwide vary in organization and funding models. Differentiation can be made based on military or civilian models, government-funded or fee-for-service operations, those donated by businesses, or those funded by public donations. The distinction between dedicated aircraft and those with multiple purposes and roles is also notable. Aircraft types, including rotary-wing, fixed-wing, or very large aircraft, contribute to the diversity of air ambulance services. Private aircraft charter companies often provide non-emergency air ambulance services on a fee-for-service basis in almost all jurisdictions. The evolution of these services highlights the critical role air ambulances play in providing emergency medical care and transportation.

Governments often play a significant role in providing air ambulance services, either directly or through contracted commercial service providers, such as aircraft charter companies. These services may focus on critical care patient transport, supporting ground-based EMS on scenes, or a combination of these roles. Governments typically establish guidelines to control operating costs and may specify operating procedures to limit potential liability. However, the day-to-day operations are usually managed by local experts, including physicians and aviation executives. Examples of this operating model include Ontario’s ORNGE program and the Polish Lotnicze Pogotowie Ratunkowe (LPR), which is a national system covering the entire country and funded by the government but operated independently.

In some regions, the air ambulance service is managed by a hospital or medical center, such as MetroHealth Medical Center in North East Ohio, which owns Metro Life Flight to transport patients to its level I trauma and burn unit. In the United Kingdom, the Scottish Ambulance Service operates helicopters and fixed-wing aircraft around the clock.

In cases where the presence of dedicated air ambulances is not practical due to cost considerations, aircraft may be operated by another government or quasi-government agency and made available to EMS for air ambulance service when needed. For example, in southern New South Wales, Australia, the helicopter responding as an air ambulance is operated by the local hydroelectric utility, with paramedics provided by the New South Wales Ambulance Service. In some instances, local EMS provides the flight paramedic to the aircraft operator as needed.

There are also cases where the air ambulance is run as a dual concern with another governmental body. For instance, the Wiltshire Air Ambulance in the UK was run as a joint Ambulance Service and police unit until 2014.

In other scenarios, paramedics may staff the aircraft full-time but have a dual function. In the Maryland State Police, for example, the flight paramedic is a serving State Trooper whose primary role is to act as the Observer Officer on a police helicopter when not responding to medical emergencies.

While many local jurisdictions do not charge for air ambulance services, the cost of providing such services is substantial. Therefore, many organizations, including government-run operations, may charge for their services. Fee-for-service operators, such as aircraft charter companies, hospitals, and private-for-profit EMS systems, are generally responsible for their own organization and may need to meet government licensing requirements. Rega in Switzerland is an example of a fee-for-service air ambulance provider. In the European Union, most air ambulance services operate on a fee-for-service basis, except for systems that rely on private subscription models. Overall, there is often a mix of operation types in different jurisdictions.