Emergencias 2019;31:283-286

HISTORICAL NOTES Earliest air ambulance flights in : a forgotten part of the history of emergency medicine

El origen del aerotransporte sanitario en España. Una historia olvidada de la Medicina de Urgencias

Miguel Ángel González-Canomanuel

Introduction ammunition and medical supplies. These incipient sani- tary missions were carried out with great danger and By the end of May 1923, the first airplane for the meant on several occasions the demolition of the appa- transport of seriously injured people consigned for the ratus with the loss of the crews. Many of these pilots war in Morocco arrived at the Tablada aerodrome received the highest decoration of the aeronautics for (Seville). This news went completely unnoticed by the these missions2. media of the time, by health magazines and by almost Military bombers were also required for the move- all aeronautical magazines except the Revista Aérea ment of surgical teams to field hospitals. The first and (“Aerial Magazine”), published in between best-known case was the night of November 1, 1922 1923-1930 on a monthly basis and which was one of when Dr. Nogueras’ team in Melilla was asked to travel the pioneers specialized in this matter and precedent of to the Dar-Drius camp, where multiple people were in- the official Revista Aeronáutica (“Aeronautical jured from the last battles. This sanitary action was Magazine”). In addition to echoing the news, the ma- news in all the mass media of the time since, besides gazine left us a graphic document that attested to it. being the first one that was carried out in airplane, in it We can imagine that none of the people involved in participated a woman, the nurse Elvira López Maurín, the beginning of this new health-aeronautics area could who, without having obligation to go, lent herself vo- foresee the great development that would have in the luntarily. She was the first nurse to fly on an airplane in following years and the importance that currently enjo- a health mission in Spain (and possibly in the world). In ys this health transport. In this article we review the these times of the beginning of aviation, it was strictly most important historical facts of the first years of me- forbidden to mount women on military planes. This ac- dical air transport in Spain. tion was described as heroic by the media and was the first news and headlines about health aviation in Spain. Nurse Elvira López Maurín was rewarded and congratu- A difficult start in the Moroccan war lated by King Alfonso XIII, Queen Victoria Eugenia, the President of the Government, the Minister of War, the The first planes arrived in Spain in 1910. They ca- Royal Commissioner of the Spanish Red Cross (CRE) rried out the first demonstrations in Barcelona and and colleagues3. Madrid, with a large audience and mass media. Since On November 11, 1922, the ministerial order for that date, the development of aeronautics in Spain has the purchase of two medical transport planes was pu- been continuous. In 1913 the first squadron of opera- blished. The first sanitary airplane Breguet XIV Tbis Nº tional war planes was formed in Melilla, being one of 98 arrived at Tablada aerodrome (Seville) in May 1923. the first countries to use aviation in a military confron- Here he was received by the Duchess of Victoria (repre- tation. In command of one of these aircraft was the sentative of Queen Victoria Eugenia) and by the Royal medical captain Antonio Pérez Núñez who, in addition Commissioner of the CRE José de Hoyos y Vinent to being a military doctor, was a pioneer of Spanish (Figure 1). This plane joined the Nador aerodrome aviation and belonged to the first class of pilots1. After (Melilla) on 23 May 1923 and began sanitary flights in leaving his facet as an aviator, he was head of the first June. Later would arrive the second plane, designated health aviation service in Spain. with the numeral 99, to the aerodrome of Tetuan. The Years before the acquisition of aircrafts specifically latter was lost in an accident taking off from Oran designed for medical transport, the ones operating in (Algeria) in 1924. Morocco were required on many occasions to supply The first transfer of a wounded was that of the positions besieged by the enemy with food, water, Lieutenant Ordinales from Dar-Drius to Nador (Melilla)

Author affiliation::Servicio de Urgencias, Hospital Virgen de la Salud, Toledo, Spain. Contribution of the authors: The author has confirmed his authorship in the document of responsibilities of the author, agreement of publication and cession of rights to EMERGENCIAS. Corresponding author: Miguel Ángel González Canomanuel. Emergency Department. Virgen de la Salud Hospital. Av. de Barber, 30. 45071 Toledo, Spain. E-mail: [email protected] Article Information: Received: 10-7-2018. Accepted: 6-8-2018. Online: 1-7-2019. Editor in charge: Antoni Juan Pastor.

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Figure 1. The Breguet XIV T bis No. 99 was the first medical Figure 2. Lowering of a wounded at the breakwater of the transport aircraft in Spain. The image was taken at the end of base of Atalayón hydros, Mar Chica, Melilla (October 1925). May 1923 at the reception at the Tablada aerodrome by the Later they used the port of Melilla itself to save time in the Duchess of Victoria and the Royal Commissioner of the CRE transfer. In the nose of Junkers F13 the acronym CRE (Spanish (Spanish Red Cross) (right of the image). Image: Air Force Red Cross) can be seen. Image: Air Force Historical Archive. Historical Archive. on 8 June 1923 in a 30-minute flight. Normally this stretcher5. It operated from the Getafe aerodrome to journey was made in “artolas” (a device from which Melilla. The Sanitary was exposed in different fairs two patients hung on a stretcher carried by a donkey of national samples with other models of the Spanish or horse) or wagon, and took about two days. From aeronautical industry (we do not know if it was done this transfer until 1925, at least 28 more evacuations with commercial pretensions). were carried out with this single plane4. The Spanish civil aeronautics industry also took a The participation of the CRE in the beginning of sani- stand for health aviation. The company Construcciones tary aviation in Spain was decisive. The Duchess of Aeronáuticas Sociedad Anónima, in association with the Victoria was the architect of the organization of health French company Breguet, built a large sanitary airplane care and evacuation of wounded in those years of the in Getafe in 1928. The new Breguet 26 had the capaci- war in Morocco. She also took part in the first transfer of ty to transport four to six patients lying down. Two a surgical team by plane, as well as in the reception of prototypes were built of this model, one for civil use the first medical plane, using at different times the planes and the other for the CRE (Figure 3). The latter, which of the CRE for the supervision of the places of attention was photographed on multiple occasions, had the mis- of the wounded and the transport of medical material. fortune of crashing on one of its first flights6. In August 1925, the CRE acquired two Junkers F13 In 1929 there is the first news of the organization in aircrafts for a rapid medical evacuation of the seriously the civil field of several charter flights for the transport wounded of the Al Hoceima landing. These were cha- of surgical equipment to the . racterized by being able to operate in aerodromes as In May 1929, the First International Congress of well as in the sea by the easy installation of wheels or Sanitary Aviation was held in . The Spanish repre- floats (Figure 2). The planes were bought at the behest sentation falls on the medical lieutenant colonel D. of King Alfonso XIII, an aeronautical enthusiast, running Agustín van Baumberghen, the medical commander with his maintenance costs throughout the campaign. Antonio Pérez Núñez and the engineer Álvaro Elices These two planes, together with the Breguet, carried Gasset. The Spanish participation also includes the ae- out at least 36 transfers of patients from 1925 to 1927, rial exhibition of the gyroplane, invented by Juan de La the year in which the war ended4. Cierva, as an aircraft for medical transport. This takes These were the first air transports of sick people, in place at the Villacourby aerodrome on May 17, 1929, this case wounded, that took place in Spain. piloted by Mr. Massot7. From this moment on, rotary wing airplanes will be the most important aircraft in medical air transport in the world. The years after the war in Morocco In this first medical aviation congress it was decided that the second edition would take place in Madrid in The aerial medical evacuation structure that was 1933 to the detriment of the candidacy of the United made for the Moroccan war was dissolved with the sale States of America. In this decision the intercession of of medical aircrafts in 1927. King Alfonso XIII was important so that the Spanish In 1928 the Military Aeronautics transformed, in its merits were taken into account. This was the second Getafe workshops, an No. 40 plane into a sa- time that the King interceded for the development of nitary plane for the transport of a sick person on a health aviation in Spain.

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Figure 3. Breguet 26 photographed at Getafe airfield. In addi- Figure 4. The PA 19 gyroplane was the most advanced of its tion to wearing the emblem of the Red Cross, the rudder also time. In its sanitary version it could transport two patients features the coat of arms of the Military Health Service, the lying down with a healthcare professional and the pilot. This coat of arms of CASA (the aircraft manufacturer) and Elizalde version was the predecessor of the rotary wing devices for sa- (the Spanish engine manufacturer). Image: Air Force Historical nitary transport. Image: Bruce Chernov. Archive On June 5, 1933, the II International Congress of rentiating silhouette of the aircraft that distinguished it Sanitary Aviation, held at the Palacio de Exposiciones from other aircraft9. All these characteristics were more del Retiro in Madrid, was inaugurated by the President than fulfilled by the gyroplane. of the Government, Mr. Azaña. The congress was presi- The inventor had previously shown his interest in ded over by Dr. Cardenal, vice-rector of the Central the application of gyroplane for different tasks in the ci- University and professor of the Faculty of Medicine, and vil field: mail transport, surveillance, photography, ad- was attended by the most relevant figures from the ori- vertising and medical transport. Since the 1930s, the gins of this new sanitary-aeronautical speciality (Dr. gyroplane had been evaluated by armies and civil com- Chassaing, Mlle Malvrigt, I. Nemirousky, Dr. Tilmat). panies for the development of health missions. In Among the many speeches debated, the petition to au- August 1932, J. Paul Lukens participated with his PCA-2 thorise the gyroplane “La Cierva” for health air trans- gyroplane in the search for a rugged Lockheed in the port and the authorisation for women to be allowed to Harrisburg mountains. In the same year, James Faulkner, fly in health airplanes stood out8. with a gyroplane from the Autogiro Company of America, participated in the rescue of two fallen avia- tors in the Everglades, Miami. During the summer of The greatest Spanish contribution to 1932, in the second American armed action in international health aviation Nicaragua, one of the three experimental gyroplanes PCA-2/XOP-1, which was highlighted in the Marine The greatest contribution to aeronautics achieved Corps, carried out sanitary and reconnaissance evacua- by a Spaniard was the invention of the gyroplane by tions. In March 1934 a gyroplane, during meteorologi- Juan de la Cierva y Codorníu in 1920. The development cal tests, located a lost airplane, aiding the crew and of this new flying apparatus discovers a new way of un- transporting 174 kg of salvage material. In the Soviet derstanding flight and substantially expands its possibi- Union, N. I. Kamov developed a gyroplane in 1934 that lities. The improvement of his “Aerodynamic Theory of carried out rescue missions in the Arctic. In Spain, the rotary wings” and of his patents destined to the control gyroplane was used for the first time in health tasks in of the flight of these airships made possible the develo- the incidents in Asturias in 1934, where wounded peo- pment of the most known rotary wing aircraft at the ple were evacuated and medicines were transported. In present time that is the . The helicopter is the Sweden, AB Autogiro pilot Rolf von Bahr performed most used device for medical transport worldwide. taxi, rescue and ambulance flights at winter sports sta- The development of the gyroplane focused on offe- tions in 19357. ring greater safety in low speed flight, lower require- In 1933 the first large gyroplane with a PA-19 cabin ments for take-off and landing and increased comfort was built for the transport of four people (Figure 4). during flight. These characteristics were the ones sou- Due to its exceptional characteristics, a variant for me- ght by the incipient sanitary aviation to find the opti- dical transport was considered. The sanitary version mal aircraft for the transport of patients. At the I would have capacity for 2 patients lying on standard Congress of Sanitary Aviation in Paris (1929) these were stretchers, with a place for a doctor or healthcare pro- specified in four conditions: great flight safety, little fessional, in addition to the pilot. In terms of perfor- need for land to take off and land, comfort during the mance, it had a cruising speed of 180 km/h, a maxi- flight for the patient and others and, finally, the diffe- mum of 216 km/h, a landing speed of 0 km/h, a

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take-off distance without wind of 86 metres. It had a Hoceima. The organization of the II International side gate for access to the stretchers and was characte- Congress of Sanitary Aviation in Madrid meant a scien- rized by its great flight stability and resistance to turbu- tific support to the nascent aeronautical-sanitary specia- lence, great visibility for the pilot, its large glass surfa- lity in Spain. And finally, the invention by the Spanish ces and the possibility of downward vision. It had safety Juan de la Cierva y Codorníu, which revolutionised ae- glass surfaces, which prevented possible damage to the ronautics and the air transport of patients, which in occupants in the event of breakage. The interior was turn also revolutionised emergency medicine. The me- soundproofed and insulated from the outside with the dical helicopter is the direct descendant of the medical most advanced material. It also had continuous ventila- gyroplane. Today, rotary wing aircrafts continue to be tion of the interior of the cabin with fresh and hot air the basic pillar of medical transport, especially in places according to the needs, which allowed the windows to that are difficult to access by land. be kept closed, while the interior remained soundproo- fed and air-conditioned. Other noteworthy features Conflicting interests: The authors declare no conflicts of interest in re- were the large width of the landing gear, fitted with lation to this article. long-range shock absorbers, the anti-vibration engine Financing: The authors declare the non-existence of funding in relation to this article. anchorage system, a battery and electric starter system Ethical Responsibilities: All authors confirm in the author’s responsibili- that allowed it not to depend on aid for its ground ties document, publication agreement and assignment of rights to operation and a navigation light system for night EMERGENCIAS that confidentiality and respect for patients’ rights as flights10. well as international ethical considerations have been maintained. The transformation project was presented in 1933 Article not commissioned by the Editorial Board. and offered to the Spanish government in June of that Acknowledgements: To the Air Force Historical Archive of Villaviciosa year, coinciding with the II International Congress of de Odón and to the Documentation Centre of the Spanish Red Cross in Sanitary Aviation held in Madrid. The price of each air- Madrid for their collaboration and help. craft for the Spanish Military Aeronautics was 17,950 dollars. If these gyroplanes had been purchased, Spain could have been the first to use rotary wing aircraft References 7 specifically designed for medical transport . 1 García Dolz V. La escuadrilla de Zeluán. Aeroplano. 2005;23:4-10. The subsequent development by Igor Sikorski of the 2 Acedo Colunga F. El alma de la Aviación Española. Madrid: Espasa- first helicopter, thanks to the patents of Juan de la Calpe S. A.; 1928. 3 González Canomanuel MA, López Maurín E. La primera enfermera Cierva, opened up new possibilities for medical trans- militar de la aviación sanitaria española. La historia de un acto heroi- port that culminated in the well-known first rescue of a co olvidado. Sanidad Militar. 2017;73:68-74. wounded American army in the jungles of Borneo du- 4 González Canomanuel MA. Los primeros heridos y enfermos evacua- dos por vía aérea en España por la Aeronáutica Militar (1923-1927). ring the end of the Second World War in 1945. Sanidad Militar. 2018;7:191-7. To conclude, as a summary of what has been said, 5 Aviones militares españoles. Madrid: Instituto de Historia y Cultura we can affirm that health aviation in Spain began after Aérea; 1986. p. 59-60. 6 Martínez Cabeza JA. El Breguet XIX y los primeros años de CASA. the First World War during the last colonial war in Aeroplano. 2014;32:74-91. Morocco, highlighting at the dawn of its history the fli- 7 González Canomanuel MA. El desconocido autogiro ambulancia de ght of the surgical team of Dr. Nogueras and the heroic 1933, una innovación española predecesora en una década a la pri- mera utilización del helicóptero sanitario. Sanidad Militar. act of the nurse Elvira López Maurín at the end of 2015;71:125-31. 1922, which was the first appearance in the media of a 8 Libro de ponencias del II Congreso Internacional de Aviación health aviation activity. However, it was not until June Sanitaria. Madrid: Consorcio Editorial; 1933. 9 Libro del Premier Congrés Internacional de l’Aviation Sanitaire. 1923 that the history of air health transfers in Spain be- Paris,1929. gan, which continued during the disembarkation of Al 10 Noorduyn R. The Pitcairn PA-19 autogiro. Aero Digest.1933;22:48-51.

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