It was just after midnight on May 21, 1999, when three-day-old Joshua Conway stopped breathing—again. He'd been born one month early, and he had apnea: every time he fell asleep there was a chance he would stop breathing forever. For three days the doctors at Cullman Regional Medical Center, in Cullman, Alabama, had struggled to help him. But treating neonatal babies is tricky, requiring expensive equipment and specialists that even the best rural hospitals often lack. That night, Joshua's doctors knew they needed help. The baby's condition was critical. The closest children's hospital, however, was in Birmingham, 50 miles and a long hour's drive south. And time was of the essence.

Joshua's doctor put in a call to the Carraway Life Saver program, and moments later a Life Saver helicopter carrying a doctor, a flight nurse, and a fully equipped neonatal transport incubator landed at Cullman. The baby was in the hands of neonatal specialists in Birmingham in minutes.

Joshua was one of 172 critically ill or injured Appalachian children flown to critical-care facilities in Birmingham in 1999, thanks to the Life Saver program, a helicopter transport service run by the city's Carraway Methodist Medical Center. Although 21 of the 172 children died, 151 returned home. Had the children not been transported by helicopter, those numbers might well have been reversed.

"Getting a patient to the appropriate level of care as quickly as possible is the number-one thing," says Patrick Boyett, a Life Saver flight doctor. "Time is the most important factor, and that's the purpose for the helicopter. When it's needed, it's really needed. Many rural hospitals simply don't have trauma surgeons or neonatal surgeons, and the helicopter is the best means of getting a patient to critical care fast.

Delay Can Be Deadly

Indeed, Children's Hospital in Birmingham has the only pediatric level-one trauma-care center—the highest level—in Alabama, and Carraway Methodist Medical Center has one of only a few neonatal intensive-care units in the state. When a baby is born long before it's due, or a car wreck suddenly threatens a young life, Birmingham or Huntsville may be the only option, and driving 20 to 100 miles or more may be nothing short of deadly.

That was certainly the case when the car carrying Brian McClanahan, his cousin, and a friend slammed into a tree on March 5, 1999. It was evening and the three teenagers had just crested a hill on a winding country road 20 miles northeast of Birmingham. Suddenly, a car veered across the yellow line toward the car in which Brian was riding. Swerving to avoid the oncoming vehicle, the teenagers lost control of their car and hit the tree.

In the horrible silent moments after the crash, the driver squeezed out of the wreck and pulled his front seat passenger free. Miraculously, both had only minor injuries. But Brian was in trouble. In the impact of the crash, the 16-year-old's right femur snapped in half, the bone piercing his skin and an artery. He was pinned in the wreck and bleeding, with "possible closed head trauma and chest injury," according to medical reports, when emergency medical technicians (EMTs) arrived and called for a Life Saver helicopter.

The helicopter arrived quickly, but had to land in a field two miles away. An ambulance brought the Life Saver doctor to the wreck. For nearly an hour, EMTs wielding hydraulic metal cutters worked to free Brian. But the teenager had lost six units of blood and was near death. Afraid he might have to amputate Brian's leg, the Life Saver doctor finally managed to kick in the back seat, freeing the teenager. An ambulance rushed Brian to the helicopter, which flew him to Birmingham's Carraway Methodist in minutes.

"Your son is critical," the caller from the hospital told Sue McClanahan, Brian's mother, "and you'd better hurry." Her drive to Birmingham that night, she remembers, "seemed like an eternity. He was my youngest child, my baby." Four days later, on March 9, Brian was home with nothing more than a steel rod stabilizing his shattered femur. "When we got to the hospital that night," remembers Brian's mother, "they showed us the chopper. I like to believe that God's in control, but I have to say that chopper played a tremendous role in Brian's survival." Indeed, without the Life Saver trauma doctor at the scene and the quick helicopter transport, Brian in all likelihood would have died.

From Battlefields to Country Roads

Ironically, the techniques and technology that saved Brian McClanahan's life were developed for use in war. During the Korean War, the mobile army surgical hospital was developed. Helicopters were routinely used for the emergency medical evacuation of wounded soldiers from the field, often in difficult locations and under fire. Medical evacuation techniques were further refined during the Vietnam War. The helicopter's speed and ability to land just about anywhere, from country roads and fields to urban rooftops, could save lives anywhere, it was clear; and it wasn't much of a leap to realize its potential for civilian use. And, of course, the Vietnam War's end in the mid 1970s left a lot of highly skilled helicopter pilots and flight nurses looking for work.

Carraway's Life Saver program was typical of helicopter evacuation programs started by hospitals in the following decade. It began in 1981 with a single helicopter and a former helicopter gunship pilot, Vietnam veteran Brooks Wall, who also ran the program. Today, nearly 20 years and 28,000 patient flights later, Life Saver operates three Bell LongRanger helicopters. Each has nearly the treatment capabilities of an emergency room and is staffed by a pilot, a flight nurse, and a doctor. One helicopter is on standby 24 hours a day, and another 12 hours a day (the third is usually rotated for maintenance). The helicopters fly within a radius of 150 miles of Birmingham, an area that includes all 37 Appalachian Alabama counties.

Last year Life Saver helicopters flew 1,400 flights, or an average of nearly four every day. While most people's image of a rescue flight involves a helicopter landing on a highway or football field at an accident scene, only 30 percent of those 1,400 flights were so-called "scene" flights; the rest were inter-hospital transfers. Indeed, most critically injured or ill patients are immediately taken to the closest hospital, and their treating physicians decide whether a higher level of care is needed. To qualify for a helicopter flight, a patient must be deemed "critically" ill or injured, meaning that if they don't fly, they may not live.

"Flying a helicopter is too dangerous and too expensive to operate [as] a flying ambulance service," says Wall. Indeed, the cost is high. Operation expenses alone for each helicopter total $1,500 an hour. But Life Saver helicopters fly patients regardless of their ability to pay.

"On average it costs us about $4,000 per flight," says Warren Callaway, chief operating officer of Carraway Methodist Health Systems, "and we collect about $2,000. So we lose about $2,000 on every flight, and in the case of the neonates, they're largely uninsured—the last I looked we were collecting ten cents on the dollar. Our mission is to serve the community, but we can't if we don't get outside help."

A 1999 Appalachian Regional Commission grant that reimbursed the hospital for flights to uninsured patients in Alabama's Appalachian counties helped leverage other grants as well, says Callaway, including $100,000 from the United Way of Central Alabama. "I can't say it loudly enough. When you're talking about the Life Saver program, you're talking about people's lives."

That's something the doctors, flight nurses, and pilots are acutely conscious of, every day. "When I fly there's excitement, nervousness, apprehension, and adrenaline," says pilot Eddie Hardin. "Weather can close in, and if you're going to an accident scene you can have a lot of ground people talking to you and telling you to land in places where you can't see, and multiply that times ten at night. But the mission is rewarding. There's a sense that you're helping people in need, and in most cases the situation is literally lifesaving. Especially with the kids, it can really hit home. If it all goes right, you feel real good."

For young patients Joshua Conway and Brian McClanahan, everything did go right.

"When they took Joshua away it was really hard," says Bonnie Conway, the baby's mother. "But the hospital was great, and the doctor and nurse in the helicopter even checked on him a few days later." Six days after Joshua's midnight flight, he was able to return home. Multiple antibiotic treatments had stopped the infection that was contributing to his apnea. Now, a year later, Conway says her prematurely born baby is "huge and happy."

Brian McClanahan is also doing well. All he had was a badly broken leg, but pinned in the car on that March night, some 20 miles from a high-level trauma center, he nearly bled to death. He easily might have if he had had to endure a long ambulance ride. Today all that remains is a bad memory—his leg is healed and the metal rod has been removed. "Brian," says his mother, "can outrun me by a country mile."

Carl Hoffman is a freelance writer based in Washington, D.C.