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A History of Medical Evacuations by Air

By Chris Demarest

The first recorded medical evacuation by air occurred during World War I, when a wounded Serbian soldier was loaded into a French biplane and flown from the battlefield. At the time, however, the idea of routine evacuation didn't seem to have much of a future. Most biplanes were small and cramped. Getting into the open cockpits required climbing on top of the plane and dropping down into the seat—hardly an easy feat for wounded patients.

Another deterrent lay in the political mentality of the time—the idea that sacrifices were to be expected in wartime. The loss of lives, even a great number of lives, was considered a cost of conducting war. Twenty-five years later, during World War II, this mindset still held sway even among some top American generals. Many felt that there was no need to divert aircraft from their intended missions as troop transports, fighters, and bombers.

Mounting casualties soon helped change their minds. The Army Air Corps began using C-47 Skytrain cargo planes to ferry the wounded from field hospitals to distant, larger hospitals. Still, air evacuation remained a secondary mission for Skytrains, even as the program resulted in the evacuation of more than 10,000 casualties from Burma, Gaudalcanal, and New Guinea by January 1942.

The next phase in the development of medevac capabilities was training medical personnel to accompany the wounded. In February 1943, the Army Nurse Corps graduated the first class of flight nurses in Bowman, Ky. The four-week course covered aeromedical physiology, loading procedures, and survival skills, all of which remain part of current medevac curricula.

At the peak of the program during the Second World War, nearly 100,000 casualties were transported each month. General Dwight Eisenhower praised the success of the air medevac program, saying that it contributed to an enormous drop in war-related fatalities.

The period after the war brought many changes to the U.S. military. The Air Corps became the U.S. Air Force, and it continued to develop air evacuation programs. But it was not until the early 1950s, with the onset of the Korean War, that the military took a more aggressive approach to creating large-scale air medevac capabilities. The rough, mountainous terrain and poor roads of the Korean countryside often made removal of casualties by land impossible. Air transport was the logical solution, and, given the landscape, helicopters seemed the obvious choice of carrier.

In 1945, Igor Sikorsky, a pioneer in the field of rotary-wing aircraft, had designed a small, lightweight helicopter capable of carrying four passengers. This model, the H-5, saw little action during World War II but was used more widely during the Korean War. In June 1950, the H-5 proved its worth in a rescue of downed United Nations pilots behind enemy lines and soon became part of an official medevac unit.

Back in the U.S., Bell Aircraft Corporation had been developing a new, even lighter helicopter. In November 1950, four H-13 Sioux helicopters were shipped to Korea with the 2nd Helicopter Detachment. By the end of the next month, 5,000 casualties had already been transported by the Sioux aircraft.

With its unique fishbowl-like cockpit, the H-13 Sioux became an icon in later years thanks to its exposure in the television show M*A*S*H. Its value lay in its speed, which reduced the time lost between injuries and treatment at the forward medical facilities. But it was limited by its size and, more importantly, had no room for a medical "aidman," as medevac paramedics were called, to treat patients en route from the battlefield to the hospital.

After the Korean War, the Army Medical Department collaborated with Bell to design an aircraft that would allow for patient support en route. In 1962, this effort produced the H-1 Iroquois, later referred to as the "Huey." These new helicopters had an engine four times more powerful than the Sioux, and were two feet longer, with room for stretchers and medical personnel. Now critical care could continue seamlessly from the field to the hospital.

The Army's 57th Medical Company put the Huey to the test when the aircraft were shipped to South Vietnam in 1963. Conditions for the flight crew were tough. About one third of the unit's pilots and 297 crewmembers were killed in Vietnam and some 200 helicopters were lost, but between 1963 and 1973, Hueys logged almost half a million medevac missions and evacuated more than 900,000 casualties.

After returning stateside in 1973, the 57th deployed to Fort Campbell, Ky., and became one of the first participants in the Military Assistance to Safety and Traffic (MAST) program, which provided air ambulance services to the civilian population in Virginia and the Carolinas.

Over the past few decades, private companies and hospitals have sought to take advantage of what had been learned in military situations, and apply that knowledge to serving the civilian population. In 1972, officials in Denver were working on a bid to host the 1976 Olympic games. Realizing that many of the venues would be in remote locations, Saint Anthony's hospital developed a helicopter service. The Olympics ended up in Austria, but, under the name "Flight for Life," the hospital began medevac operations in 1972. Within eight years, the country had 25 similar civilian programs.

As early as 1984, officials at Dartmouth-Hitchcock discussed establishing an air ambulance service for northern New England, where the rugged terrain and dispersed population could make such a program a valuable resource. It took another ten years, but at 7:00 a.m. on July 1, 1994, the Dartmouth-Hitchcock Air Response Team (DHART) went into service. Norman Yanofsky, M.D., head of the emergency department, recalled DHART's inaugural day in the Summer 2007 issue of Dartmouth Medicine:

I'll never forget the first day the helicopter was in service. We had no idea what would happen. I thought that it might be as much as two weeks before anybody called us. . . . Within 15 minutes we got called down to Springfield, Vt. It was a scene call—an unconscious person who had been in an automobile accident. I think we got seven calls the first day. . . . In fact, one of our crew members got so tired and dehydrated—because it was a very hot July day—that they had to give her IV fluids just to keep her going.

DHART began with one helicopter, an Agusta 109 CMAX, and four pilots, all of whom were contracted through a helicopter-charter company based in Louisiana. The hospital staffed the medical side of the program with six nurses and six paramedics. It was a bare-bones operation in many ways, but it was up and running.

For the first five years, DHART made do without an onsite hangar. In the winter, space was rented at nearly Lebanon Airport to provide protection from the snow and freezing temperatures. The medical crews worked out of a nearby office complex, but the space had its limitations. "It was the size of my office here," DHART Operations Manager John Hinds says, pointing around a small room in the current DHART hangar. "It was tiny." In 1999, DHART moved to its permanent home, a large steel hangar located on the northeast side of the Medical Center.

There have been changes to the aircraft as well. In 1998, an American Eurocopter EC-135 replaced the Agusta 109 CMAX. Hinds, one of the original paramedics, describes the Agusta as "a Ferrari. It could go fast, but lacked carrying capacity or range." Considering the need to cover great distances in a region known for its scattered communities, range is particularly important. In 2001, another EC-135 was added to DHART.

This newer helicopter has been designated DHART 1, and it has had more air time than the other aircraft, DHART 2. Both helicopters have GPS units and satellite tracking, but DHART 1 also has the added safety feature of a proximity warning system that alerts it to any aircraft approaching its airspace.

Also in 2001, DHART incorporated ground units into its transportation arsenal—two critical-care ambulances called mobile intensive care units, or MICUs (pronounced "MICK-yous"). The MICUs provide transportation when time is not a critical factor or when severe weather grounds the helicopters. Once DHART began providing ground as well as air transport, its name was changed to Dartmouth-Hitchcock Advanced Response Team, allowing the program to keep the same acronym and call sign.

Today it takes a staff of about 50 to keep DHART flying around the clock, including five administrators, seven communications specialists, eleven paramedics, eleven nurses, six ambulance drivers, two mechanics, and seven pilots. Much has changed at DHART over the years, but the goal—reaching patients and getting them to a hospital as quickly as possible—remains the same.

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