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Chest tube thoracostomy (CTT) is not frequently performed by non-physician-staffed air medical crews (AMC) due to concern regarding safety, efficiency and training requirements. This study compared two groups of patients requiring CTT, one group with insertion performed by an AMC and the other by a physician trauma service (TS) in the emergency department on patient arrival. The CTT of 172 patients managed at a Level I trauma center between October 1988 and September 1990 were reviewed. Seventy-two patients were managed by the AMC and received CTT in a prehospital setting; the air medical personnel placed the chest tube cleanly in all cases. Chest tubes placed by AMC were removed within 48 hours of transport to minimize infection risk. One hundred patients requiring CTT in the hospital setting were randomly selected from the trauma registry during a similar time span. The study compared the patients' Injury Severity Scores (ISS), and trauma scores, any placement complications and the overall mortality. While the AMC often treated patients with higher acuity, as reflected by ISS and trauma scores and overall higher mortality, the rate of complications between CTT performed by AMC and TS was similar. Appropriately trained AMC can safely perform CTT without putting patients at increased risk.