Over centuries of medical care, those in the know at any given time felt confident that what they were doing to help people was, in fact, helpful. Many a doctor has laid hands on a child in her sick bed, administered a medicine, and reassured worried parents that all would be well. We modern-day doctors are no exception in believing that the treatments we give are the correct approach.

In looking back, we know that many treatments used in the past were not helpful, and some were actually harmful. Arsenic and bloodletting come to mind immediately.

A critical question to ask today is, “What treatments commonly used today will be thought of as useless or harmful by future generations of doctors?” Dextromethorphan? Thrombolytics for stroke? NSAIDs in the elderly? Coumadin? Botox?

What about the use of medical helicopters?

The use and number of medical helicopters has grown rapidly over the past two decades. According to the Adams Atlas & Database of Air Medical Services, there are now 840 rotary wing aircraft in operation. According to the Association of Air Medical Services, these services make more than 500,000 flights per year.

Enormous sums have been spent on helicopters, fuel, maintenance, pilots, nurses, paramedics, and training. With all this money being spent, it must be clear that helicopters are really good things to have—and they most certainly are directly responsible for saving the lives of hundreds of thousands of people per year. Or maybe not.

Helicopters are credited with saving many lives in war. Wounded are evacuated quickly to field hospitals where critical treatment is given. The logical conclusion was to apply this to civilian medical care. Is this logical?

In war, roads are bad and people shoot at you on the way to the hospital. This is not the case in America. In war, most injuries are blast or penetrating. Here at home, most of the trauma that comes by air is blunt. These differences may prove to be quite important.

One study shows that when an air medical service was discontinued, there was no change in trauma mortality or transport times (J. Trauma 2002;52:486-91). This is very interesting, but it may not apply universally. In the West, where transport times are long, helicopters may make a difference. In Maryland, where they have a statewide trauma system that flows to shock trauma in Baltimore, helicopters probably do make a difference.

Let’s assume, for argument’s sake, that helicopters indeed are helpful and make a difference in mortality. How many lives would you sacrifice in the process?

Let’s start with 35. That’s the number of people who died in medical helicopter crashes from December 2007 to November 2008. More were injured.

Is it okay to kill a few in an effort to save an unproven number of others? This seems like a discussion that should go on at the Pentagon, but we actually make these choices every day in medicine. We use drugs and treatments that we know carry significant risk, but choose to use them because of a favorable risk–benefit analysis. Some risk does exist, and a rare patient will die or suffer from a known adverse effect of our treatment.

The difference here is that not only are we putting patients at risk, we are putting their caregivers at risk as well. How many of you would give thrombolytics for stroke if, in giving it, YOU were subjected to a small but real chance of cerebral hemorrhage?

This brings us back to the question of whether helicopters are worth the risk to all involved. There will not be a universal answer, so it should be examined on a regional basis. In an era of soaring deficits and looming Medicare insolvency, we will be forced to do not only a risk–benefit analysis but a cost–benefit analysis as well.

I’ll admit that I’ve never flown on a helicopter. I had the chance to do this as a resident but declined. This decision was shaped by my experience as a medical student. When I was rotating on the infectious disease service at St. Vincent’s Hospital, Life Flight encountered unexpected fog on a fateful December evening and entered the woods of southern Michigan. The pilot and the emergency medicine resident, Dr. Jean Hollister, perished. The flight nurse survived with terrible injuries.

Every time I accept a transfer by air, I wonder if the risk taken by the crew is warranted for the particular problem of the patient. Should their lives be risked to fly a drunken person with minor injuries from one of the Lake Erie islands? (Yes, this happens.) Should their lives be risked to fly someone with ventricular arrhythmias that have been brought under control by medication?

Some will brand me a heretic for raising this question. Those that shout the loudest should probably be the first to put aside their parochial interests and consider the possibility that nothing would change if their helicopter was grounded.

It would be easy enough to prospectively look at every transfer by air, determine how much time was saved over ground transportation, and decide if any lifesaving measures took place during the time saved that wouldn’t have been equally successful if provided after that time.

This exercise will either affirm the usefulness of any given flight service—or cause some to pause and consider if resources might be better directed to another endeavor. This will determine who is flying for patient benefit and who is flying for hospital benefit.

And who among us is willing to risk their life for a hospital?

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo Medical Center. Your feedback is welcomed at David.Baehren@utoledo.edu.