In a nondescript brick building on the western edge of downtown Baltimore, the communications center that dispatches state police choppers to serious accidents in Maryland has the look and feel of a war room.
One monitor maps movements of a dozen state police helicopters every half-minute. Another shows whether local hospitals are at or near capacity - "red alert." Another beams video from cameras posted along major highways. A video feed also shows the helipad at the Maryland Shock Trauma Center, named for Dr. R Adams Cowley, the heart surgeon who 30 years ago created this emergency medical system as the first - and only - of its type.
"He had the vision and the political clout to pull it off," said Dr. Robert Bass, who oversees the system Cowley built. "We haven't seen the same nexus in other states."
The war room atmosphere may seem appropriate for another reason: A battle is looming for the future of the system.
Private helicopter services weren't an option when Cowley persuaded the Maryland State Police to run the emergency medical system, but now they are hovering over a piece of the business of trauma transport.
Two private companies already fly about 1,500 critically ill patients a year between hospitals in Maryland when they need specialized care at a particular facility. The companies want permission to back up the state police in responding to serious accidents on highways and elsewhere.
The two companies - MedStar Transport of Columbia and STAT MedEvac of Pittsburgh - already leave their Maryland bases to handle such emergencies in Virginia, the District of Columbia and Pennsylvania. They aren't allowed to do so within Maryland.
But the state police - though originally prodded into their medevac role by Cowley, some recall - are reluctant to give up their medical transport mission. A publicly run system is not swayed by profit considerations in delivering service, goes their argument.
"We have never sent a bill," Maj. James Hock, commander of the state police aviation division, said about the virtues of the current system. "And we have never made a decision based on cost."
Cost, however, is at the heart of the matter.
The $20 million spent on the system annually is funded largely by a $13.50 surcharge that Marylanders pay when they get their license plates renewed. All motorists in essence foot the bill for the trauma system, but no one gets charged if they require emergency air transport.
A private company, on the other hand, would bill patients or their insurance carriers several thousand dollars per flight. Supporters argue that introducing "privatization" - perhaps even eventually letting private carriers do all medevac work - would make the system more efficient and relieve a financial burden for the state.
"If the state did privatize, you'd have several companies step up to the table," said Ed Rupert, an executive whose air ambulance company, Air Methods Corp. of Englewood, Colo., does not operate in Maryland. "We would purchase the aircraft, lease the sites. You'd turn what is currently an expense to the taxpayer into a revenue producer."
The split has simmered for months behind the scenes. Both STAT MedEvac and MedStar say they aren't looking to put the state out of the medical transport business but want to offer a quicker alternative for a critically injured patient when the state fleet is busy.
"Our stance hasn't been that bold," said James Bothwell, chief operating officer of STAT. "We just want to get involved and see what happens."
But some in the private helicopter business acknowledge that successful backup duty would help them begin to mount a case that the state's three-decade monopoly shouldn't be seen as sacrosanct. A call for privatization could grow louder as the state begins to phase out its aging fleet in 2007 and buy new helicopters.
"We're staring down the barrel of a public expenditure that's approaching $100 million to replace these helicopters," said Bryson F. Popham, a Maryland lobbyist for CJ Systems Aviation Group of West Mifflin, Pa., which leases aircraft and provides pilots to the two private companies that serve the state. "That's when people will sit up and take notice."
Maryland's trauma system, and the medevac service to support it, were national pioneers. Cowley developed trauma medicine as a specialty after observing that, in severe injury cases, quick treatment was more vital than careful, deliberate diagnosis. He called the first 60 minutes after an injury "the golden hour."
"You don't need great science, or a great hospital or a great doctor. All you have to do is get the community organized into a system of care," he told The Sun in an interview in 1982.
He opened the country's first trauma center in 1969 at University Hospital, now University of Maryland Medical Center. He also obtained a federal grant for state police to get their first helicopter to do medical transport, following a model the U.S. military used in the Vietnam War.