The role of helicopters in trauma management must be considered in the context of the provision of sophisticated, high-quality trauma care. The present review examines the evolution of systems of trauma care, the value of advanced life support (ALS), and the role of the Helicopter Emergency Medical Service (HEMS) in improving outcomes. Comparison is made of outcomes of patients managed by HEMS and road ambulances, and important aspects of HEMS including staffing and safety are discussed. There is a role for HEMS as part of a modern trauma system, in particular in bringing ALS skills and access to expert medical care to the rural accident scene or hospital at distances of up to 160 km. It is of greatest value when it is integrated into a well-organized ambulance service and emergency system with good triage and close medical supervision.