Guest Editorial Thomas Judge, CCT-P

HEMS: Luxury or Necessity?

Editor’s Note: Air Medical Journal is participating in the Global Theme Issue on Poverty and Human Development, a
project of The Council of Science Editors. Journals throughout the world are simultaneously publishing papers on this
topic of worldwide interest to raise awareness, generate interest, and stimulate research into poverty and human devel-
opment. This is an international collaboration with hundreds of journals from developed and developing countries.
Please go to http://www.councilscienceeditors.org/globalthemeissue.cfm for more information.

The editors thank Thomas Judge for contributing this guest editorial on the poorer populations served by medical trans-
port programs throughout the world.

Knowing is not enough; we must apply.

Willing is not enough; we must do.—Goethe
Epigraph for the 2007 Institute of Medicine report, “EMS at the Crossroads”

Although HEMS has long referenced helicopter emer-
gency medical services, a more accurate descriptor of the
shorthand might be “high acuity emergency medical trans-
portation systems” incorporating rotor, fixed, and ground
vehicles and the supporting technology and infrastructure
to sustain their availability and operations. Modern HEMS
(acronym spelling aside) is an essential element in the com-
plex mosaic of immediate emergency care, serving as inte-
grator and the glue between disparate entities of the health
care system. Worldwide, critically ill and injured patients
rely on HEMS minute to minute to both provide uniquely
capable vehicles and, more importantly, decrease the time to
specialist care. Well-rehearsed choreography of these dis-
tinct but related constituent components results in lives
saved and access to care otherwise unavailable because of
location or the absence of locally available specialist care
needed to stabilize and transport a vulnerable patient.
We know that overcoming this combination of factors—
managing the geography of time—is as challenging as man-
aging the most insidious of disease process. Grievously ill
and injured patients in rural areas have much higher death
rates from the same disease or injury than their urban coun-
terparts. As an example, data from the National Highway
Traffic Safety Administration indicates that there are 35%
more vehicle crashes, substantially increased rates of injury,
and 49% more deaths in rural areas than urban from similar
events.1 Delays in notification, delays in emergency
response, and time to specialist care are all factors in this
dilemma. The Institute of Medicine’s recent study2 of the US
emergency care system notes the “speed and quality of EMS
[emergency medical services] services are critical factors in
a patient’s ultimate outcome,” with “decisions made and
actions taken” determining the life and death outcomes.
Well-developed comprehensive emergency care and medical
transport systems help shift the balance of the playing field
for those with geographic barriers to access, extending the
hope of care.
Although most of the interest and commentary on access
has to do with geographic barriers to care, emergency care
systems have a much more substantial safety net role in
ensuring access to care. In addition to managing geography,
(H)EMS in every society of the world is responsible for
ensuring care to all in need, regardless of insurance coverage
or financial ability to reimburse the cost of care. Poor, work-
ing poor, immigrant populations not covered by social bene-
fit systems, and those covered with minimal benefit coverage
such as Medicaid or Medicare in the United States rely on
the emergency care system for immediate care. Prehospital
and hospital emergency care in every health care system in
the world is universal care. It is the safety net.
Modern emergency care in both the prehospital and hos-
pital settings has become the default for all societal problems
large or small, and, more importantly, EMS is increasingly
the universal health care access point in any country for the

256 Air Medical Journal 26:6

poor, working poor, immigrants, for all needing care on
nights and weekends, as well as the default for overworked
primary care physicians faced with an emergency patient
arriving or calling during already fully scheduled office
hours. In many systems these patients are uncovered; those
without any resources to compensate the cost of care.
Minimally reimbursed/underinsured patients reach 50% to
60% or greater of all patient care delivery.
Perhaps the single most visible evidence of this safety net
is the HEMS response to the devastation of Katrina in New
Orleans and the Gulf Coast. Although much of the media
focus was on the public response—largely military in rescue
and transport—multiple civil medical transport providers
responded, immediately and without plans for compensa-
tion, driven by the need for care and the call for help.
By Thursday afternoon, 48 hours after the storm’s pas-
sage, local EMS and air medical agencies began the med-
ical evacuation process. By Thursday night, 31 separate
provider agencies from 14 states had positioned 50 med-
ical helicopters, 13 fixed-wing aircraft, and numerous
ground critical care ambulances staffed by critical care
physicians, nurses, and paramedics in the affected areas.
An additional 27 medical helicopters and 4 fixed-wing
aircraft within 2 to 3 hours’ flight time had been placed
on standby at request of adjoining state governors’
offices, FEMA, or hospitals requesting additional
resources. A number of air medical providers also sent
senior management teams to oversee their efforts with
additional communications and support equipment.
Most of the providers double-staffed to allow extended,
round-the-clock operations. Virtually this entire fleet
was assembled at the request of hospitals or local EMS
agencies tasked with evacuating hospitals. Much of the
cost of this response has never been reimbursed.3
This example is HEMS at its best, and although dramatic,
this response is played out on a daily basis in every imagi-
nable location. For the public, the potential patient, the
promise and delivery of services are profound.
In 1998, a consensus conference was held in Cape Town,
South Africa, representing EMS systems from 40 developed
and developing countries across five continents. The atten-
dees noted in a statement of principles that “in any health-
related emergency, access to an EMS system is the
inalienable right of every citizen.” Although conference par-
ticipants represented a spectrum of care systems—from early
development systems relying on family-responsible trans-
port with or sometimes without vehicle access to distant
clinics to the most evolved systems in North America and
Europe—the philosophy of an effective emergency care sys-
tem was seen by all as a desirable underlying societal pillar.
The conference papers stated, “An effective response must
include the primary assessment and treatment of any illness
or injury arising from that (unplanned) event and continu-
ing care during transport to the place of definitive medical
treatment where that is necessary. Within available resources
an EMS system must ensure that patients receive appropriate
care which optimizes their chances of survival, recovery, and
return to normal social and economic activity.”4
November-December 2007
Although the organization, funding, resource availability,
capability, reliability, and complexity of emergency care sys-
tems vary widely across and within continents, and are con-
textually dependent on underlying societal belief structures
and resources, the conceptual base of immediate lifesaving
care for injury or illness is considered in most countries an
evolving expectation of the populace.
This expectation has led worldwide to increased demand
for services. All societies are facing rapidly increased
demand and costs for every sector of health care. The bal-
ance of need, demand, and cost is in constant tension.
Matching the public’s need and demand for comprehensive
emergency care systems with the organization and funding
necessary to deliver reliable quality care remains complex
and under strain. The preamble to a 1996 white paper
developed by the National Highway Traffic Safety
Administration, The EMS Agenda for the Future, noted the
emergency care system of the future “will be developed
from redistribution of existing health care resources and
will be integrated with other health care providers and pub-
lic health and safety agencies. It will improve community
health and result in more appropriate use of acute health
care resources. EMS will remain the public’s emergency
medical safety net.”5
Two immediate points from the EMS Agenda and the
Cape Town papers must be recognized as constants in an
increasingly difficult balance. The last sentence in the pre-
amble properly describes EMS as the public’s safety net, but
the issue of resources to fund the need, while never having
been properly funded, is increasingly a system at risk.
The demand for emergency care, increasingly mis-
matched with the reality of available resources, is a rapid
and increasing challenge and one that will only become
more complex. Demand is multifactorial, with underlying
population and demographic/economic changes (increased
numbers, elderly, immigration, and refugee population
movement); changes to health care infrastructure, including
reduced numbers of clinicians relative to population,
decreasing numbers of specialists, and decreasing facilities
in rural areas; rapidly changing diagnostic and treatment
technology, including mobile and communications tech-
nologies, all combining to drive growth.
Coupled with an increased, media-driven public expecta-
tion of care via new therapies for cardiac disease, stroke, or
injuries, there has been a relentless year-on-year growth of
access into the emergency care system in virtually every
country of the world. Constantly evolving disease processes
that range from rapidly increasing vehicle trauma rates in
the developing world to dramatically increased risks of
rapid high-contagion illness as a result of air travel are
emerging demand drivers.
Why is this important in the context of medical trans-
port, a relatively small subset of the emergency care system?
Medical transportation has long been conceptualized as the
“glue” of trauma systems. New changes in cardiac and
stroke care will extend this phenomenon. Numbers from
both rural and urban systems show 3% to 7% year-on-year
growth in EMS calls and transports.6-10 Whereas the num-
257
bers for all of emergency care highlight continued relentless
growth, the numbers for high-acuity transport are even
more startling. Data from the state EMS offices in New
Hampshire and Maine highlight an 8% to 12% annual
increase in emergency interhospital transfers. A similar rate
was observed by STARS in Calgary, Canada.
However, this underlying growth rate does not take into
account a number of profound influences that will shape
demand in the future, including the demographic of the
aging baby boomers, decreased rural health care infrastruc-
ture, increased specialization of services into centers (burn,
cardiac, pediatric, etc.), decreased emergency departments,
changes in medical diagnostics and treatments, technology,
aviation, and transportation technical advances, the advent
of automatic crash notification technology, and improved
aircraft, which combined are estimated to double the under-
lying demand for medical transportation.
What do these trends—demand mismatched with
resources—portend for the future of medical transport? The
confluence of a growing mismatch between resources and
demand coupled with rapidly increasing costs (fuel, aircraft,
personnel, technology, and regulatory requirements) has
the potential to overwhelm the safety net. A recent
Government Accountability Office report “found that the
majority of ambulance providers’ costs were related to
readiness—the availability of ambulance and crew for
immediate emergency response—and were fixed costs.”11
Medical transportation providers have extremely high fixed
costs relative to production as a result of the costs of air-
craft, technology, and staffing across low volume. This
results in a superficially expensive unit cost per service
compared with other health care interventions. Although it
is easy to characterize high unit cost per service as cost pro-
hibitive, the reality is that evolved medical transport sys-
tems are a bargain for quality and access from a health care
policy standpoint and compare extremely favorably in
reducing preventable mortality and morbidity12 and in per
life-year saved with other health care interventions.13
There is a public and policy assumption that the system
will respond when called, regardless of adequately address-
ing resource needs. Ten years after the Agenda, the idealized
redistribution and widespread integration has yet to take
place. A study of the EMS system in Maine described the
system as “paper-thin,” noting “in its efforts to deliver services
in the face of clearly insufficient revenues, the EMS system
regulatory, coordinating, and provider efforts are at risk”
and that in “trying to do more with less, the system now is
in the unenviable position of having to do less with less at a
time when its role as the health care safety net is growing.”14
The need for the safety net remains. Couple this with
another finding from the Cape Town paper noting that,
regardless of the underlying method of financing health
care in any given country, “(t)here are unprecedented eco-
nomic constraints driving an agenda for change in both the
developing and developed world. World economic competi-
tion is imposing indirect constraints on all public expendi-
ture, including that on health care, and in most countries,
the search for improved value for money is not a luxury but
258
a necessity.” The demand for health care is limitless; the
resources to provide it are not.
The challenge to medical transport providers is keeping
the promise of access to care for all in need—this inalien-
able right—within a health care system in financial crisis.
The vision of a redistribution of resources from the greater
health care system into EMS has not materialized; in fact,
quite the opposite has occurred, with health care policy in
all systems seeking to reduce or fix costs against demand.
Health care policy in virtually all settings does not recog-
nize or reimburse the costs of readiness to respond. The
system we all rely on is stretched ever thinner. Yet all
HEMS—ground, fixed wing, and rotorcraft-based crews—
continue to respond, each and every minute, worldwide to
the next call for assistance. As the Institute of Medicine epi-
graph notes, willing is not enough; we must do.
References
1. Department of Transportation. Contrasting Rural and Urban Fatal Crashes 1194-
2003, DOT HS 809 896, Technical Report, NHTSA, December 2005.
2. Institute of Medicine: Committee on the Future of Emergency Care in the United
States Health System. Emergency Medical Services: At the Crossroads. ISBN 0-309-
66216-8. Washington, DC: National Academies Press; 2007.
3. US House of Representatives, Select Bipartisan Subcommittee to Investigate the
Preparation For and Response to Hurricane Katrina. A Failure of Initiative. Final report
and testimony by Association of Air Medical Services to the committee. February
2006.
4. Turner J, Judge T, Ward ME, Johns BM, Wilby J, Roberts G, et al. A new worldwide sys-
tems model for emergency services: statement from the Cape Town EMS Summit,
South Africa, January 1998. Prehosp Immediate Care 2000;4:180-183.
5. Delbridge TR, Bailey B, Chew JL, Conn AK, Krakeel JJ, Manz D, et al. EMS agenda for the
future: where we are… where we want to be. Prehosp Emerg Care 1998;2:1-12.
6. Pencheon D. On demand. Cambridge, UK: Cambridge University Press; 1997.
7. Emergency Health Care in Scotland Health Policy and Public Health Directorate. The
Scottish Office; 1994.
8. Kirby N. Up top, down under: meeting health care needs in the bushæthe challenges
and the opportunities. An Aussie yarn. First International Community Paramedicine
Symposium/Rural Healthcare Delivery, Dalhousie University, Halifax, Nova Scotia,
Canada, July 2005.
9. Medical Care Research Unit. The Future of Ambulance Services in the United
Kingdom 2000-2010. University of Sheffield: Ambulance Services Association; 2002.
10. Maine EMS/Maine Health Information Center Data Unit.
11. Government Accountability Office. Ambulance providers: costs and expected
Medicare margins vary greatly. GAO Report 07-383. Washington, DC: GAO; 2007.
12. Powell DG, Hutton K, King JK, Mark L, McLellan HM, McNab J, et al. The impact of a
helicopter emergency medical services program on morbidity and mortality. Air Med
J 1997;16:48-50.
13. Teng TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC, et al. Five hundred
life-saving interventions and their cost effectiveness. Risk Anal 1995;15:369-390.
14. An assessment of the Maine EMS system: report to the legislature. EMSSTAR Group,
September 2004.
Thomas Judge, CCT-P, is the executive director of LifeFlight of
Maine in Bangor/Lewiston, Maine, and the immediate past president
of the Association of Air Medical Services.
1067-991X/$30.00
Copyright 2007 Air Medical Journal Associates
doi:10.1016/j.amj.2007.09.001
Air Medical Journal 26:6