Transcript Medical Helicopters - Dr. Bryan E. Bledsoe

Medical
Helicopters
Bryan Bledsoe, DO, FACEP
UNLV
Medical Helicopters
What is the role of
medical helicopters
in the modern
American EMS
system?
Medical Helicopters
In many areas, the
indication for
summoning a medical
helicopter is:
The presence of a
patient.
Medical Helicopters
Medical industries that have quickly
gotten out of hand:
1980s: Boutique psychiatric and
substance abuse facilities.
1990s: Home health care agencies.
2000s: Medical helicopters and motorized
wheel chairs.
Medical Helicopters
Number of Medical Helicopters by Year
1200
1000
800
600
400
200
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Medical Helicopters
There are more
medical helicopters
in Dallas/Fort Worth
than all of Canada
or Australia.
Medical Helicopters
Are patients needs
or helicopter
operator profits
driving HEMS in the
United States?
Medical Helicopters
In 2002, Medicare increased the rates for medical
helicopter transport.
Price for airlift ranges from $5,000 to $15,000, 5 to 10
times that of a ground ambulance.
Helicopters in the US have doubled from a decade
ago; and with more of them scrambling for business,
specialists say that emergency personnel are feeling
more pressure to use them.
In 2004, the number of flights paid for by Medicare
alone was 58 percent higher than in 2001.
Spending by Medicare has more than doubled to
$103 million over the same period.
Medical Helicopters
In FY 2001, the
University of
Michigan’s flight
program “Survival
Flight”:
Rosenberg BL, Butz DA, Comstock
MC, Taheri. Aeromedical Service:
How Does it Actually Contribute to
the Mission? J Trauma,
2003;54:681-688
$6,000,000
operational costs
$62,000,000 in
inpatient revenues
28% of ICU days
Helicopter patients
were twice as likely
to have commercial
health insurance
compared to regular
patient profile.
Costs
Comparison of
patients before
and after
helicopter
placement.
Sussex = £55,000
Cornwall = £800,000
London = £1,200,000
No improvements in
response times.
Scene times longer.
Conclusion:
HEMS costly
Benefits small
Snooks HA, Nicholl JP,
Brazier JE, Lees-Mlanga S.
The Costs and Benefits of
Helicopter Emeregency
Services in England and
Wales. J Pub Health Med.
1996;18:67-77
Costs
Prospective
comparison of
seriously-injured
patients
(survivors)
transported by
HEMS and GEMS.
“As there is no
evidence of any
improvement in
outcomes overall for
the extra cost,
HEMS has not been
found to be a costeffective service.”
Nicholl JP, Brazier JE, Snooks
HA. The Cost and Effectiveness
of the London Helicopter
Emergency Services. J Health
Serv Res Policy. 1996;1:232-237
Interfacility
Retrospective review of
388 pedi patients.
80 HEMS (16%
mortality)
288 GEMS (5%
mortality)
Mean total transport
time 170 minutes faster
by HEMS.
No significant
differences in LOS, ICU
days.
No differences in
outcomes (except
mortality) which was
due to increased
severity of HEMS
population.
Quinn-Skillings GQ, Brozen R.
Outcomes of Interhospital
Transfers fo Critically-Ill
Patients: A Comparison of Air
and Ground Transport. Ann
Emerg Med. 1999;34:597
Interfacility
Prospective study of:
Local HEMS: 1,234
Non-Local HEMS: 25
GEMS: 153
Deaths:
HEMS: 19%
GEMS: 15%
No differences found at
30 days for:
Disability
Health status
Health care utilization
Patients transported by
HEMS did not have
improved outcomes
over GEMS.
These data argue
against a large
advantage of HEMS in
interfacility transport.
Arfken CL, Shapiro MJ, Bessey
PQ, Littenberg B. Effectiveness
of helicopter versus ground
ambulance services for
interfacility transport. J Trauma.
1998;45:785-790
Interfacility
Comparison of
interfacility patients
with unstable angina or
MI transported by
GEMS because HEMS
was unavailable due to
weather.
Compared to HEMS
transports.
No differences in
deaths within 72 hours.
HEMS associated with
more total deaths (9/48
v 1/48)
Interfacility transport of
cardiac patients by air
offers no outcome
advantage.
Stone CK, Hunt RC, Sousa JA.
Interhospital transfer of cardiac
arrest patients: does air
transport make a difference?
Air Med J. 2004;13:159-162.
Interfacility
145 patients transported
from 20 hospitals to the
University of Wisconsin
hospital by HEMS.
Dispatch times:
GEMS: 56
HEMS: 178
Referral hospital times:
GEMS: 25 13
HEMS: 3111
HEMS patients transport
faster.
HEMS transport faster
for all patients.
For stable patients it
may be reasonable to
use GEMS.
Svenson JE, O’Connor JE,
Lindsay. Is air transport faster?
A comparison of air versus
ground transport times for
interfacility transfers in a
regional referral system. Air
Med J. 2006;25:170-172
Interfacility
Retrospective cohort of
243 patients transported
by GEMS and 139
patients by air in
Ontario.
Time interval between
decision to transfer and
the actual time has
longer for GEMS (41.3
vs. 89.7 minutes).
Travel time shorter by
helicopter (58.4 vs. 78.9)
Distance of transport
not an accurate
indicator of transport
time.
Karanicolas PJ, Shatia P.
Willamson J, et al. The fastest
route between two points is not
always a straight line: an
analysis of air and land transfer
of nonpenetrating trauma
patients. J Trauma.
2006;61:396-403.
Neonatal
10-year study of
neonatal air
transport in
Norway.
236 acute care
transfers.
13 LBW infants
7 deaths (3.2%)
Low mortality
overall.
Lang A, Brun H, Kaaresen PI,
Klingenberg C. A populationbased 10-year study of neonatal
air transports in North Norway.
Acta Paediatr. 2007;96:955-959
Pediatric Transports
1991-1992 Utah
review:
874 pedi patients
HEMS = 561
FWEMS = 313
Charges (average):
GEMS = $526
HEMS = $4,879
FWEMS = $4,702
“Air medical
transport is
expensive and
sometimes may be
used
unnecessarily.”
Diller E, Vernon D, Dean
JM, Suruda A. The
Epidemiology of Pediatric
Air Medical Transports in
Utah. Prehosp Emerg Care.
1999;3:217-227
Burns
Retrospective
review of HEMS
transports to
burn center over
2-year period.
GEMS transports
used as control
group.
Excluded:
Inhalation injury
Burns > 24 hours
old
> 200 mils away
>30% BSA burn
Associated
trauma
Burns
Evaluated and
found no
difference in:
TBSA burned
% of 3° burns
LOS
Vent days
Age
Transport mileage
Patients with <
30% TBSA and <
200 miles should
be transported by
GEMS.
DeWing MD, Curry T,
Stephenson E, et al. Costeffective use of helicopters for
the transportation of patients
with burn injuries. J Burn Care
Rehabil. 2000;21:535-540
Burns
437 consecutive
acute burn
patients to
western PA burn
center:
GEMS = 339
HEMS = 98
< 25 miles = 18
> 25 miles = 80
Inhalation injury:
GEMS = 3%
HEMS = 28%
Reduce use of
HEMS for burn
patients.
Slater H, O’Mara MS, Goldfarb
IW. Helicopter transportation of
burn patients. Burns
2002;28:70-2
Obstetrics
22 HEMS
transports of
preterm labor
patients.
No outcome
difference found.
No deliveries in
flight.
HEMS = $4,613.64
 $581.12
GEMS = $604.02 
$306.02.
Van Hook JW, Leicht TG, Van
Hook CL, et al. Aeromedical
transfer of preterm b\labor
patients. Tex Med.
1998;94:88-90
Trauma
1990-2001
retrospective
review of all
patients brought
to the Santa Clara
Valley Trauma
Center (CA) by
HEMS.
947 consecutive
patients:
911 blunt trauma
36 penetrating
trauma
Mean ISS = 8.9
Mortality = 15 (in
ED)
Trauma
312 (33.5%)
discharged home
from the ED.
620 hospitalized:
339 (54.7%) had
an ISS  9.
148 had an ISS 
16.
84 (8.9%) required
early operation.
Only 17 (1.8%)
underwent
surgery for lifethreatening
injuries.
Trauma
HEMS faster than
GEMS = 54.7%
Only 22.8% of the
study population
possible
benefited from
HEMS transport.
HEMS is used
excessively for
scene transport.
New criteria should
be developed.
Shatney CH, Homan J, Sherck
J, Ho C. The Utility of Helicopter
Transport of Trauma Patients
from the Injury Scene in an
Urban EMS Setting . J Trauma.
2002;53:817-822
Trauma
1987-1993 review
of all helicopter
and ground
transports from
scene to trauma
center.
North Carolina
Trauma Registry
1,346 (7.3%)
transported by
HEMS.
TS = 12  3.6
ISS = 17  11.1
17,344 (92.7%)
transported by
ground.
TS = 14  3.6
ISS = 10.8  8.4
Trauma
Outcomes for
HEMS transport
not uniformly
better for HEMS.
Only TS between
5-12 and ISS
between 21-30
achieved
significance.
Only a very small
subset of patients
benefited from
HEMS Transport.
Cunningham P, Rutledge R,
Baker CC, Clancy RV. A
Comparison of the Association
of Helicopter and Ground
Ambulance Transport with the
Outcome of Injury in Trauma
Patients Transported from the
Scene. J Trauma. 1997;43:940946
Trauma
Retrospective
Boston MedFlight
study (19951998):
Complicated
study statistically
a priori?
Crude Mortality:
Air = 9.4%
Ground = 3.0%
OR 0.76.
Thomas SH, Harrison TH, Buras
WR, et al. Helicopter transport
and blunt trauma mortality: a
multicenter trial. J Trauma.
2002;52:136-145
Trauma
VARIABLE
OR
SE
WALD p
Value
95% CI (OR)
Air Transport
0.756
0.098
0.031
0.586-0.975
Increasing Age
2.71
0.259
<0.001
2.25-3.27
Scene Mission Type
1.49
0.160
<0.001
1.21-1.84
ALS EMS
Baseline
BLS EMS
0.423
0.060
<0.001
0.320-6.666
Missing EMS
0.554
0.129
0.011
0.351-0.784
ISS < 9
Baseline
ISS 9-15
4.08
1.02
<0.001
2.50-6.66
ISS 16-24
19.5
4.88
<0.001
12.0-31.9
ISS > 24
163
37.2
<0.001
104-255
Missing
22.1
10.0
<0.001
9.11-53.7
<0.001
Trauma
Phoenix study (19831986):
ISS = 20-29 (451)
ISS = 30-39 (155)
Mean age = 30.5 years
Male = 76%
GEMS = 259
GCS Mean = 10.4
TS Mean = 12.7
HEMS = 347
GCS Mean = 9.6
TS Mean = 12.1
Mortality:
HEMS = 18%
GEMS = 13%.
No survival advantage
for the HEMS group in
an urban setting with
sophisticated EMS
system.
Schiller WR, Knox R, Zinnecker
H et al. Effect of helicopter
transport of trauma victims on
survival in an urban trauma
center. J Trauma. 1988;25:1127-
Trauma
4-year retrospective
review of trauma
scene flights.
Audit of scene
flights provided
half-way through.
Inappropriate flights
decreased after
audit.
Criteria for HEMS
should be based
upon physiologic
criteria.
Norton R, Wortman E, Eastes L.
et al. Appropriate Helicopter
Transport of Urban Trauma
Patients. J Trauma.
1996;41:886-891
Trauma
Review of 122
consecutive victims of
noncranial penetrating
trauma in Houston:
Average RTS = 10.6
Died = 15.8%
HEMS transport faster = 0%
4.9% of patients required
intervention not available on
ground EMS.
Only 3.3% received such
intervention.
Scene flights in
Houston for
noncranial
penetrating trauma
are not efficacious.
Cocanour CS, Fischer RP, Ursic
CM. Are Scene Flights for
Penetrating Trauma Justified? J
Trauma. 1997;43:83-88
Trauma
Retrospective review of
New England flight
service.
Results compared to
nationalized database.
13% reduction in
mortality when compared
to controls.
35% reduction in
mortality when TS
between 4 and 13
No differences at
extremes of RTS.
Rapid utilization of
HEMS can have a
dramatic effect on
patient outcomes.
Jacobs LM, Gabram SGA,
Sztajnkrycer MD, Robinson KJ,
Libby MCN. Helicopter Air
Medical Transport: Ten-Year
Outcomes for Trauma Patients
in a New England Program.
Connecticut Med. 1999;63:677682
Trauma
Retrospective review of 1,877 HEMS and
GEMS trauma patients transported from the
scene.
Multiple parameters evaluated by logistic
regression analysis:
CUPS
Patient age
ISS
RTS
Total out-of-hospital time
Lerner EB, Billittier AJ, Dorn JM,
Wu YW. Is Total Out-of-Hospital
Time a Significant Predictor of
Trauma Patient Mortality? Acad
Emerg Med. 2003;10:949-954
Trauma
Comparison of
prehospital scene times
(PST) between GEMS and
HEMS.
Patients: 1,457
GEMS: 1,197
HEMS: 260
GEMS PST: 24.6 minutes
HEMS PST: 35.4 minutes
Logistic regression
analysis and correction
for ISS, RTS, age.
PST not associated
with increased
mortality.
Ringburg AN, Spanjersberg WR,
Franema SP et al. Helicopter
emergency medical service
(HEMS): impact on scene times.
J Trauma. 2007;63:258-262
Penetrating Trauma
Danville, PA study
1990-1998.
2,048 penetrating
trauma cases:
GEMS = 2,914
HEMS = 494
Mean transport time:
GEMS = 30.5 minutes
HEMS = 52.7 minutes
Mean ISS:
GEMS = 9
HEMS = 16 .
Despite longer
transport and higher
ISS, controlling for
injury severity found
no difference in
survival.
Dula DJ, Palys K, Leicht M
Madtes K. Helicopter versus
Ground Ambulance Transport
of Patients with Penetrating
Trauma. Ann Emerg Med.
2000;38:S16
Pediatric Trauma
All pediatric
HEMS trauma
transports for 3
year period.
Results:
189 patients
Median age = 5
RTS > 7 = 82%
ISS:
0-15 = 83%
16-60 = 15%
> 30 = 3%
14% intubated
18% admitted to
PICU
4% taken directly
to the OR.
Pediatric Trauma
33% discharged
home and not
admitted.
The majority of
pediatric patients
transported by
helicopter
sustained minor
injuries.
Eckstein M, Jantos T, Kelly
N, Cardillo A. Helicopter
Transport of Pediatric
Trauma Patients in an Urban
Emergency Medical
Services System: A Critical
Analysis. J Trauma.
2002;53:340-344
Pediatric Trauma
Retrospective
analysis of pedi
trauma patients
transported by air
to pedi trauma
center from scene
and compared to
those from other
hospitals.
Patients:
Scene = 379
Death rate = 8.7%
ICU hours = 149.1
Hospital = 842
Death rate = 5.5%
ICU hours = 118.3
Pediatric Trauma
Retrospective
analysis was not
able to demonstrate
any benefit from
direct transport
from the scene.
Hospital
stabilization before
air transport may
improve survival.
Larson JT, Dietrich AM,
Abdessalam SF, Werman H.
Effective Use of an Air
Ambulance for Pediatric
Trauma. J Trauma. 2004;56:8993
Pediatric Trauma
Children’s
National Medical
Center Study:
3,861 children
Retrospective
review
Patients:
HEMS = 1,460
Mean ISS = 9.2
Transport time =
45.1 minutes
GEMS = 2,896
Mean ISS = 6.7
Transport time=
43.2 minutes
Pediatric Trauma
83% of children
transported by air not
critically-injured (85%
overtriage).
Outcomes uniformly
better for children
critically-injured.
HEMS triage based
upon GCS and pulse
rate better and more
accurate.
Moront ML, Gotschall CS,
Eichelberger MR. Helicopter
Transport of Injured Children:
System Effectiveness and
Triage Criteria. J Pedi Surg.
1996;8:1183-1188
Rural Trauma
Iowa Study of 918
rural trauma
victims.
Classified as:
Essential = 14.0%
Helpful = 12.9%
Not a Factor = 56.6%
Died = 16.5%
Based on the data, it
was impossible to
determine
prospectively which
patients would
benefit from HEMS.
Urdanetta LF, Miller BK,
Rigenburg BJ et al. Role of
Emergency Helicopter
Transport Service in Rural
Trauma. Arch Surg.
1987;122:992-996
Staffing
Louisville study:
145 consecutive
adult trauma
flights with MD.
114 without MD.
Z statistic and other
parameters revealed
mortality and care to
be similar.
It appears that
experienced nurses and
paramedics , operating
with well-established
protocols, car provide
aggressive care equal to
that of a physician.
Hamman BA, Cue JI, Miler FB et
al. Helicopter Transport of
Trauma Victims: Does a
Physician Make a Difference? J
Trauma. 1991;31:490-494
Staffing
Australian study:
67 patients in
physician group
140 in paramedic
group
W statistic showed
8-19 extra survivors
per 100,000 in the
physician group.
Physicians perform
more procedures
without increasing
scene time which
decreases mortality.
Garner A, Rashford S, Lee A,
Bartolacci R. Addition of
Physicians to Paramedic
Helicopter Services Decreases
Blunt Trauma Mortality. Aust N Z
J Surg. 1999;69:697-701
Staffing
Comparison of
nurse/nurse and
nurse/paramedic
crew performance
based on patient
severity.
Multiple parameters
examined.
No objective
differences in
outcomes of patients
when crew types
were compared.
Burney RE, Hubert PL, Maio R.
Comparison of Aeromedical
Crew Performance by Patient
Severity and Outcome. Ann
Emerg Med. 1992;21:375-378
Staffing
Prospective 2-year
follow-up and repeat
of previous study
comparing
nurse/nurse and
nurse/paramedic
crew performance
based on patient
severity.
No objective
differences in
outcomes of patients
when crew types
were compared.
Burney RE, Hubert PL, Maio R.
Variation in air medical outcomes
by Crew Composition: a two-year
follow-up. Ann Emerg Med.
1995;25:187-192
Staffing
“Based upon these
resuscitative efforts
and invasive
procedures, a physician
in attendance was
deemed medicallydesirable for one-half of
flights.”
Mortality in blunt
trauma improved
when physician part
of the crew.
Bartolacci RA, Munford BJ, Lee
A, McGougall PA. Air medical
scene response to blunt trauma:
effect on early survival. MJA.
1998;169:612-612
Usage
162,730 patients
from PA Trauma
Registry treated
at 28 accredited
trauma centers.
HEMS: 15,938
GALS: 6,473
Interhospital and
calls without ALS
excluded.
HEMS patients:
Younger
Male
More seriously
injured
Likely to have
systolic BP < 90
mmHg.
Usage
Logistic regression
analysis revealed that
when adjusting for
other risk factors,
transportation by
helicopter did not affect
the estimated odds of
survival.
Braithwaite CEM, Rosko M,
McDowell R, Gallagher J,
Proneca J, Spott MA. A Critical
Analysis of On-Scene
Helicopter Transport on
Survival in a Statewide Trauma
System. J Trauma.
1998;45:140-144
Usage
Finnish Study.
588 flights:
40% aborted
A minority of
patients benefit fro
HEMS.
Estimated that:
3 patients (1.5%) were
saved.
42 patients (20%) mostly
with cardiovascular
disease benefitted.
Remaining patients
benefited from ALS
care and not HEMS.
Hurola J, Wangel M, Uusaro A,
Rukonen E. Paramedic
helicopter emergency service in
rural Finland—do the benefits
justify the cost. Acta
Anaesthesiol Scand.
2002;46:779-784
Usage
Retrospective
review of HEMS
transports in FDNY
(1996-1999).
182 transports:
Scene-Hospital = 32
NYC Hospital-NYC
Hospital = 18
Outside NYC Hospital –
NYC Hospital = 122
NYC Hospital – Outside
NYC Hospital = 10
FDNY infrequently uses
HEMS.
Asaeda G, Cherson A,
Giordano L, Kusick M.
Utilization of Air Medical
Transport in a Large Urban
Environment: A
Retrospective Analysis.
Prehosp Emerg Care.
2001;5:36-39
Usage
1995-2000
comparison of
HEMS and GEMS
transport in
Philadelphia.
29,074 transports
ISS > 15 = 4,640
5-15 mile radius = 1,245
HEMS = 12.24%
GEMS = 87.66%
For patients 5-15 miles
from trauma center,
HEMS transport takes
longer.
HEMS outcomes worse.
Basile JF, Sorondo B.
Comparison Between
Helicopter EMS and Ground
EMS Transport Time and
Outcomes for SeverelyInjured Patients within a 515 Mile Radius from a
Trauma Center. Prehosp
Emerg Care. 2004;8:99
Usage
Retrospective study
7,584 GEMS and
1,075 HEMS
transports.
Transport times:
GEMS provided shortest
prehospital interval at
distances < 10 miles.
Simultaneously dispatched
HEMS provided shortest
prehospital interval > 10
miles.
Non-simultaneously
dispatched HEMS was faster
if > 45 miles.
Diaz MA, Hendey GW, Bivins
HG. When is the Helicopter
Faster? A Comparison of
Helicopter and Ground
Ambulance Transport
Times. J Trauma.
2005;58:148-153
Usage
Retrospective review of
all patients transported
2003-2004.
156 trauma patients
Average ISS = 12 (range
1-46)
Discharged home = 45
(41%)
24 to OR
10 to ICU
2 died
HEMS transfer in the
acute setting is of
debated value.
Triage categories need to
be revised.
Melton JT, Jain S, Kendrick
B, Deo SD. Helicopter
emergency ambulance
service (HEAS) transfer: an
analysis of trauma patient
case-mix, injury severity
and outcomes. Ann R Coll
Surg Engl. 2007;89:513-516
Medical Helicopters
Bledsoe BE, Wesley AK,
Eckstein M, Dunn TM,
O’Keefe MF. Helicopter
Scene Transport of Trauma
Patients with NonlifeThreatening Injuries: A MetaAnalysis. J Trauma.
2006;60:1254-1266
Bledsoe, et al.
Considerations:
Severe injury:
ISS > 15
TS < 12
RTS ≤ 11
Weighted RTS ≥ 4
Triss Ps < 0.90
Non-life-threatening injuries:
Patients not in above criteria
Patients who refuse ED treatment
Patients discharged from ED
Patients not admitted to ICU
Results
48 papers met initial inclusion criteria.
26 papers rejected:
Failure to stratify scores.
Failure to differentiate scene flights.
Failure to differentiate trauma flights.
22 papers accepted.
Span: 21 years
Cohort: 37,350
Results
ISS ≤ 15:
N = 31,244
ISS ≤ 15 = 18,629
ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8]
TS ≥ 13:
N = 2,110
TS ≥ 13 = 1,296
TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2]
Results
RTS > 11:
Insufficient data
TRISS Ps > 0.90:
N = 6,328
TRISS Ps > 0.90 = 4,414
TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to
80.2]
Results
70
68
66
64
N=37,350
Percentage
with minor
injuries
62
60
58
56
54
ISS
TS
TRISS
Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter
scene transport of trauma patients: a meta-analysis. J Trauma. 2006:60:1254-1266
Results
Patients discharged < 24 hours:
N = 1,850
Discharged < 24 hours = 446
Discharged < 24 hours = 25.8% [99% CI: 0.90 to 52.63]
Medical Helicopter
Accidents
Bledsoe BE, Smith
MG. Medical
Helicopter
Accidents in the
United States: A 10Year Review.
Journal of Trauma.
2004;56:1325-1329
Medical Helicopter Accidents
25
21
19 19
20
15
15
12
10
5
16
15
9
8
3 4
11
10
4
2
0
1993
1996
1999
2002
2005
1993-2007 (Source: NTSB)
Accidents
Medical Helicopter Accidents
18
16
14
12
10
Fatalities
Injuries
8
6
4
2
0
1993
1995
1997
1999
2001 2003
Source: NTSB
2005
2007
Medical Helicopter Accidents
1993-2002
10
9
8
7
6
5
4
3
2
1
0
Accidents
Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents
in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Medical Helicopter Accidents
Accidents by Cause
2%
11%
Pilot Error
Mechanical Failure
26%
61%
Undetermined
Other
Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents
in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Occupational Deaths per 100,000 per
Year
All Workers
5
Farming
26
Mining
27
Air Medical Crew
74
US 1995-2001
Source: Johns Hopkins University School of Public Health
Fatal Crashes per Million Flight
Hours (2001)
20
19
18
16
14
12
12
12
Airline
Commuter
10
Ground Ambulance
All Helicopters
8
6
6
Medical Helicopters
4
2
1
0
Source: AMPA, A Safety Review and Risk Assessment in
Air Medical Transport (2002)
Medical Helicopter
Accidents
Weather a factor in
one-fourth of all
crashes.
Source: AMPA.
A Safety Review
and Risk
Assessment in
Air Medical
Transport, 2002
Pressure on Pilots
Undue pressure from:
Management
Dispatch
Flight Crews
Pressure to:
Speed response or lift-off times
Launch/continue in marginal weather
Fly when fatigued or ill
EMS Line Pilot Survey, 2001
Summary
HEMS-related research scant and of
generally poor quality.
Papers showing benefit generally from
researchers and institutions with a
helicopter (a priori?).
Most negative literature from
researchers and institutions without a
helicopter.
Summary
In many articles there is a virtual
statistical “leap of faith” to justify
HEMS transports.
Concerns often expressed about
selection and publication bias (by both
sides).
Oftentimes there is an appeal to
emotion.
Summary
Argument often comes down to:
Speed
Better care
Traffic
Keeping local ambulances “available”
Oftentimes, factors not considered:
Costs
Risks
Comfort
Summary
Who benefits from HEMS?
Trauma patients with ISS > 30
Patients with time-sensitive surgical lesion
that cannot be managed at local hospital:
AAA
Epidural hematoma
Complex pelvic fractures
Significant chest trauma
Rescue situations where GEMS
ingress/egress impaired.
Summary
Who benefits from HEMS?
STEMI/ACS patients who need critical
intervention and HEMS will get them into
interventional lab in time and GEMS will
not.
Stroke care controversial (few stroke
patients are truly candidates for therapy).
Situations where road conditions would
prevent access to a facility for timesensitive care.
Summary
Who does benefit not from HEMS?
Most patients using current triage criteria.
Burn patients (unless > 30% TBSA and
GEMS cannot provide analgesia or airway
care).
Neonates (other than delivery of rapid
intervention team).
OB patients.
Summary
Who does not from HEMS?
Interfacility transfers unless patient has a
time-sensitive lesion/condition that would
not make a therapeutic window by GEMS
transport.
CPR cases (trauma or medical)
Most pediatric trauma (except those with a
high ISS or low or falling GCS).
Summary
Only a small number
of patients, when
objectively
evaluated, benefit
from HEMS
transport.
Physicians must
always weigh
benefits and risks
and costs.
Summary
Who is to blame for
the current mess?
Physicians
HEMS industry
Lack of state and
federal oversight of
HEMS.
Insurers.
Local EMS agencies
(cost shifting).