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HEMS: Luxury or necessity?
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 development. 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 transport 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 emergency medical services, a more accurate descriptor of the shorthand might be “high acuity emergency medical transportation 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 complex mosaic of immediate emergency care, serving as integrator 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 distinct 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 managing 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 counterparts. 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 256
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, working poor, immigrant populations not covered by social benefit 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 hospital 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 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 compensation, driven by the need for care and the call for help. By Thursday afternoon, 48 hours after the storm’s passage, local EMS and air medical agencies began the medical evacuation process. By Thursday night, 31 separate provider agencies from 14 states had positioned 50 medical 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 imaginable 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 attendees noted in a statement of principles that “in any healthrelated emergency, access to an EMS system is the inalienable right of every citizen.” Although conference participants represented a spectrum of care systems—from early development systems relying on family-responsible transport 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 system 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 continuing 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 systems vary widely across and within continents, and are contextually 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 balance 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 public 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 preamble 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 mismatched 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 technologies, all combining to drive growth. Coupled with an increased, media-driven public expectation 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 transport, 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 num257
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 infrastructure, 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 underlying 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 aircraft, 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 prohibitive, the reality is that evolved medical transport systems 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 addressing 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 economic constraints driving an agenda for change in both the developing and developed world. World economic competition is imposing indirect constraints on all public expenditure, 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 inalienable 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 recognize 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 epigraph notes, willing is not enough; we must do.
References 1. Department of Transportation. Contrasting Rural and Urban Fatal Crashes 11942003, 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 0-30966216-8. 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 systems 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
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 development. 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 transport 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 emergency medical services, a more accurate descriptor of the shorthand might be “high acuity emergency medical transportation 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 complex mosaic of immediate emergency care, serving as integrator 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 distinct 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 managing 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 counterparts. 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 256
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, working poor, immigrant populations not covered by social benefit 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 hospital 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 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 compensation, driven by the need for care and the call for help. By Thursday afternoon, 48 hours after the storm’s passage, local EMS and air medical agencies began the medical evacuation process. By Thursday night, 31 separate provider agencies from 14 states had positioned 50 medical 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 imaginable 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 attendees noted in a statement of principles that “in any healthrelated emergency, access to an EMS system is the inalienable right of every citizen.” Although conference participants represented a spectrum of care systems—from early development systems relying on family-responsible transport 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 system 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 continuing 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 systems vary widely across and within continents, and are contextually 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 balance 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 public 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 preamble 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 mismatched 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 technologies, all combining to drive growth. Coupled with an increased, media-driven public expectation 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 transport, 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 num257
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 infrastructure, 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 underlying 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 aircraft, 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 prohibitive, the reality is that evolved medical transport systems 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 addressing 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 economic constraints driving an agenda for change in both the developing and developed world. World economic competition is imposing indirect constraints on all public expenditure, 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 inalienable 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 recognize 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 epigraph notes, willing is not enough; we must do.
References 1. Department of Transportation. Contrasting Rural and Urban Fatal Crashes 11942003, 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 0-30966216-8. 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 systems 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