Medical Helicopters


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Medical Helicopters

  1. 1. Medical Helicopters<br />Bryan Bledsoe, DO, FACEP<br />UNLV<br />
  2. 2. Medical Helicopters<br />What is the role of medical helicopters in the modern American EMS system?<br />
  3. 3. Medical Helicopters<br />In many areas, the indication for summoning a medical helicopter is:<br />The presence of a patient.<br />
  4. 4. Medical Helicopters<br />Medical industries that have quickly gotten out of hand:<br />1980s: Boutique psychiatric and substance abuse facilities.<br />1990s: Home health care agencies.<br />2000s: Medical helicopters and motorized wheel chairs.<br />
  5. 5. Medical Helicopters<br />
  6. 6. Medical Helicopters<br />There are more medical helicopters in Dallas/Fort Worth than all of Canada or Australia.<br />
  7. 7. Medical Helicopters<br />Are patients needs or helicopter operator profits driving HEMS in the United States?<br />
  8. 8. Medical Helicopters<br />In 2002, Medicare increased the rates for medical helicopter transport.<br />Price for airlift ranges from $5,000 to $15,000, 5 to 10 times that of a ground ambulance. <br />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. <br />In 2004, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. <br />Spending by Medicare has more than doubled to $103 million over the same period. <br />
  9. 9. Medical Helicopters<br />In FY 2001, the University of Michigan’s flight program “Survival Flight”:<br />$6,000,000 operational costs<br />$62,000,000 in inpatient revenues<br />28% of ICU days<br />Helicopter patients were twice as likely to have commercial health insurance compared to regular patient profile. <br />Rosenberg BL, Butz DA, Comstock MC, Taheri. Aeromedical Service: How Does it Actually Contribute to the Mission? J Trauma, 2003;54:681-688<br />
  10. 10. Costs<br />Comparison of patients before and after helicopter placement.<br />Sussex = £55,000<br />Cornwall = £800,000<br />London = £1,200,000<br />No improvements in response times.<br />Scene times longer.<br />Conclusion:<br />HEMS costly<br />Benefits small<br />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 <br />
  11. 11. Costs<br />Prospective comparison of seriously-injured patients (survivors) transported by HEMS and GEMS.<br />“As there is no evidence of any improvement in outcomes overall for the extra cost, HEMS has not been found to be a cost-effective service.”<br />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 <br />
  12. 12. Interfacility<br />Retrospective review of 388 pedi patients.<br />80 HEMS (16% mortality)<br />288 GEMS (5% mortality)<br />Mean total transport time 170 minutes faster by HEMS. <br />No significant differences in LOS, ICU days.<br />No differences in outcomes (except mortality) which was due to increased severity of HEMS population.<br />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<br />
  13. 13. Interfacility<br />Prospective study of:<br />Local HEMS: 1,234<br />Non-Local HEMS: 25<br />GEMS: 153<br />Deaths:<br />HEMS: 19%<br />GEMS: 15%<br />No differences found at 30 days for:<br />Disability<br />Health status<br />Health care utilization<br />Patients transported by HEMS did not have improved outcomes over GEMS.<br />These data argue against a large advantage of HEMS in interfacility transport.<br />Arfken CL, Shapiro MJ, Bessey PQ, Littenberg B. Effectiveness of helicopter versus ground ambulance services for interfacility transport. J Trauma. 1998;45:785-790<br />
  14. 14. Interfacility<br />Comparison of interfacility patients with unstable angina or MI transported by GEMS because HEMS was unavailable due to weather.<br />Compared to HEMS transports.<br />No differences in deaths within 72 hours.<br />HEMS associated with more total deaths (9/48 v 1/48)<br />Interfacility transport of cardiac patients by air offers no outcome advantage. <br />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.<br />
  15. 15. Interfacility<br />145 patients transported from 20 hospitals to the University of Wisconsin hospital by HEMS.<br />Dispatch times:<br />GEMS: 56<br />HEMS: 178<br />Referral hospital times:<br />GEMS: 25 13<br />HEMS: 3111<br />HEMS patients transport faster.<br />HEMS transport faster for all patients.<br />For stable patients it may be reasonable to use GEMS.<br />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<br />
  16. 16. Interfacility<br />Retrospective cohort of 243 patients transported by GEMS and 139 patients by air in Ontario.<br />Time interval between decision to transfer and the actual time has longer for GEMS (41.3 vs. 89.7 minutes).<br />Travel time shorter by helicopter (58.4 vs. 78.9)<br />Distance of transport not an accurate indicator of transport time.<br />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.<br />
  17. 17. Neonatal<br />10-year study of neonatal air transport in Norway.<br />236 acute care transfers.<br />13 LBW infants<br />7 deaths (3.2%)<br />Low mortality overall.<br />Lang A, Brun H, Kaaresen PI, Klingenberg C. A population-based 10-year study of neonatal air transports in North Norway.<br /> Acta Paediatr. 2007;96:955-959 <br />
  18. 18. Pediatric Transports<br />1991-1992 Utah review:<br />874 pedi patients<br />HEMS = 561<br />FWEMS = 313<br />Charges (average):<br />GEMS = $526<br />HEMS = $4,879<br />FWEMS = $4,702 <br />“Air medical transport is expensive and sometimes may be used unnecessarily.”<br />Diller E, Vernon D, Dean JM, Suruda A. The Epidemiology of Pediatric Air Medical Transports in Utah. Prehosp Emerg Care. 1999;3:217-227<br />
  19. 19. Burns<br />Retrospective review of HEMS transports to burn center over 2-year period.<br />GEMS transports used as control group.<br />Excluded:<br />Inhalation injury<br />Burns > 24 hours old<br />> 200 mils away<br />>30% BSA burn<br />Associated trauma<br />
  20. 20. Burns<br />Evaluated and found no difference in:<br />TBSA burned<br />% of 3° burns<br />LOS<br />Vent days<br />Age<br />Transport mileage<br />Patients with < 30% TBSA and < 200 miles should be transported by GEMS.<br />DeWing MD, Curry T, Stephenson E, et al. Cost-effective use of helicopters for the transportation of patients with burn injuries. J Burn Care Rehabil. 2000;21:535-540<br />
  21. 21. Burns<br />437 consecutive acute burn patients to western PA burn center:<br />GEMS = 339<br />HEMS = 98<br />< 25 miles = 18<br />> 25 miles = 80<br />Inhalation injury:<br />GEMS = 3%<br />HEMS = 28%<br />Reduce use of HEMS for burn patients.<br />Slater H, O’Mara MS, Goldfarb IW. Helicopter transportation of burn patients. Burns 2002;28:70-2<br />
  22. 22. Obstetrics<br />22 HEMS transports of preterm labor patients.<br />No outcome difference found.<br />No deliveries in flight.<br />HEMS = $4,613.64  $581.12<br />GEMS = $604.02  $306.02.<br />Van Hook JW, Leicht TG, Van Hook CL, et al. Aeromedical transfer of preterm blabor patients. Tex Med. 1998;94:88-90<br />
  23. 23. Trauma<br />1990-2001 retrospective review of all patients brought to the Santa Clara Valley Trauma Center (CA) by HEMS.<br />947 consecutive patients:<br />911 blunt trauma<br />36 penetrating trauma<br />Mean ISS = 8.9<br />Mortality = 15 (in ED)<br />
  24. 24. Trauma<br />312 (33.5%) discharged home from the ED.<br />620 hospitalized:<br />339 (54.7%) had an ISS  9.<br />148 had an ISS  16.<br />84 (8.9%) required early operation.<br />Only 17 (1.8%) underwent surgery for life-threatening injuries.<br />
  25. 25. Trauma<br />HEMS faster than GEMS = 54.7%<br />Only 22.8% of the study population possible benefited from HEMS transport.<br />HEMS is used excessively for scene transport. New criteria should be developed.<br />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<br />
  26. 26. Trauma<br />1987-1993 review of all helicopter and ground transports from scene to trauma center.<br />North Carolina Trauma Registry<br />1,346 (7.3%) transported by HEMS.<br />TS = 12  3.6<br />ISS = 17  11.1<br />17,344 (92.7%) transported by ground.<br />TS = 14  3.6<br />ISS = 10.8  8.4<br />
  27. 27. Trauma<br />Outcomes for HEMS transport not uniformly better for HEMS.<br />Only TS between 5-12 and ISS between 21-30 achieved significance.<br />Only a very small subset of patients benefited from HEMS Transport.<br />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;43:940-946 <br />
  28. 28. Trauma<br />Retrospective Boston MedFlight study (1995-1998):<br /> Complicated study statistically<br />apriori?<br />Crude Mortality:<br />Air = 9.4%<br />Ground = 3.0%<br />OR 0.76.<br />Thomas SH, Harrison TH, Buras WR, et al. Helicopter transport and blunt trauma mortality: a multicenter trial. J Trauma. 2002;52:136-145<br />
  29. 29. Trauma<br />
  30. 30. Trauma<br />Phoenix study (1983-1986):<br />ISS = 20-29 (451)<br />ISS = 30-39 (155) <br />Mean age = 30.5 years<br />Male = 76%<br />GEMS = 259<br />GCS Mean = 10.4<br />TS Mean = 12.7<br />HEMS = 347<br />GCS Mean = 9.6<br />TS Mean = 12.1<br />Mortality:<br />HEMS = 18%<br />GEMS = 13%.<br />No survival advantage for the HEMS group in an urban setting with sophisticated EMS system.<br />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;25:1127-1134 <br />
  31. 31. Trauma<br />4-year retrospective review of trauma scene flights.<br />Audit of scene flights provided half-way through.<br />Inappropriate flights decreased after audit. <br />Criteria for HEMS should be based upon physiologic criteria.<br />Norton R, Wortman E, Eastes L. et al. Appropriate Helicopter Transport of Urban Trauma Patients. J Trauma. 1996;41:886-891 <br />
  32. 32. Trauma<br />Review of 122 consecutive victims of noncranial penetrating trauma in Houston:<br />Average RTS = 10.6<br />Died = 15.8%<br />HEMS transport faster = 0%<br />4.9% of patients required intervention not available on ground EMS.<br />Only 3.3% received such intervention.<br />Scene flights in Houston for noncranial penetrating trauma are not efficacious.<br />Cocanour CS, Fischer RP, Ursic CM. Are Scene Flights for Penetrating Trauma Justified? J Trauma. 1997;43:83-88 <br />
  33. 33. Trauma<br />Retrospective review of New England flight service.<br />Results compared to nationalized database.<br />13% reduction in mortality when compared to controls.<br />35% reduction in mortality when TS between 4 and 13<br />No differences at extremes of RTS. <br />Rapid utilization of HEMS can have a dramatic effect on patient outcomes.<br />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;63:677-682<br />
  34. 34. Trauma<br />Retrospective review of 1,877 HEMS and GEMS trauma patients transported from the scene.<br />Multiple parameters evaluated by logistic regression analysis:<br />CUPS<br />Patient age<br />ISS<br />RTS<br />Total out-of-hospital time<br />Not a Significant Predictor of Trauma Mortality <br />Significant Predictors of Trauma Mortality<br />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<br />
  35. 35. Trauma<br />Comparison of prehospital scene times (PST) between GEMS and HEMS.<br />Patients: 1,457<br />GEMS: 1,197<br />HEMS: 260<br />GEMS PST: 24.6 minutes<br />HEMS PST: 35.4 minutes<br />Logistic regression analysis and correction for ISS, RTS, age.<br />PST not associated with increased mortality.<br />Ringburg AN, Spanjersberg WR, Franema SP et al. Helicopter emergency medical service (HEMS): impact on scene times. J Trauma. 2007;63:258-262<br />
  36. 36. Penetrating Trauma<br />Danville, PA study 1990-1998.<br />2,048 penetrating trauma cases:<br />GEMS = 2,914<br />HEMS = 494<br />Mean transport time:<br />GEMS = 30.5 minutes<br />HEMS = 52.7 minutes<br />Mean ISS:<br />GEMS = 9<br />HEMS = 16 . <br />Despite longer transport and higher ISS, controlling for injury severity found no difference in survival.<br />Dula DJ, Palys K, Leicht M Madtes K. Helicopter versus Ground Ambulance Transport of Patients with Penetrating Trauma. Ann Emerg Med. 2000;38:S16<br />
  37. 37. Pediatric Trauma<br />All pediatric HEMS trauma transports for 3 year period.<br />Results:<br />189 patients<br />Median age = 5<br />RTS > 7 = 82%<br />ISS:<br />0-15 = 83%<br />16-60 = 15%<br />> 30 = 3%<br />14% intubated<br />18% admitted to PICU<br />4% taken directly to the OR.<br />
  38. 38. Pediatric Trauma<br />33% discharged home and not admitted.<br />The majority of pediatric patients transported by helicopter sustained minor injuries.<br />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<br />
  39. 39. Pediatric Trauma<br />Retrospective analysis of pedi trauma patients transported by air to pedi trauma center from scene and compared to those from other hospitals.<br />Patients:<br />Scene = 379<br />Death rate = 8.7%<br />ICU hours = 149.1 <br />Hospital = 842<br />Death rate = 5.5%<br />ICU hours = 118.3<br />
  40. 40. Pediatric Trauma<br />Retrospective analysis was not able to demonstrate any benefit from direct transport from the scene.<br />Hospital stabilization before air transport may improve survival.<br />Larson JT, Dietrich AM, Abdessalam SF, Werman H. Effective Use of an Air Ambulance for Pediatric Trauma. J Trauma. 2004;56:89-93<br />
  41. 41. Pediatric Trauma<br />Children’s National Medical Center Study:<br />3,861 children<br />Retrospective review<br />Patients:<br />HEMS = 1,460<br />Mean ISS = 9.2<br />Transport time = 45.1 minutes<br />GEMS = 2,896<br />Mean ISS = 6.7<br />Transport time= 43.2 minutes<br />
  42. 42. Pediatric Trauma<br />83% of children transported by air not critically-injured (85% overtriage).<br />Outcomes uniformly better for children critically-injured.<br />HEMS triage based upon GCS and pulse rate better and more accurate.<br />Moront ML, Gotschall CS, Eichelberger MR. Helicopter Transport of Injured Children: System Effectiveness and Triage Criteria. J Pedi Surg. 1996;8:1183-1188<br />
  43. 43. Rural Trauma<br />Iowa Study of 918 rural trauma victims.<br />Classified as:<br />Essential = 14.0%<br />Helpful = 12.9%<br />Not a Factor = 56.6%<br />Died = 16.5%<br />Based on the data, it was impossible to determine prospectively which patients would benefit from HEMS.<br />Urdanetta LF, Miller BK, Rigenburg BJ et al. Role of Emergency Helicopter Transport Service in Rural Trauma. Arch Surg. 1987;122:992-996<br />
  44. 44. Staffing<br />Louisville study:<br />145 consecutive adult trauma flights with MD.<br />114 without MD.<br />Z statistic and other parameters revealed mortality and care to be similar.<br />It appears that experienced nurses and paramedics , operating with well-established protocols, car provide aggressive care equal to that of a physician.<br />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<br />
  45. 45. Staffing<br />Australian study:<br />67 patients in physician group<br />140 in paramedic group<br />W statistic showed 8-19 extra survivors per 100,000 in the physician group.<br />Physicians perform more procedures without increasing scene time which decreases mortality.<br />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 <br />
  46. 46. Staffing<br />Comparison of nurse/nurse and nurse/paramedic crew performance based on patient severity.<br />Multiple parameters examined.<br />No objective differences in outcomes of patients when crew types were compared.<br />Burney RE, Hubert PL, Maio R. Comparison of Aeromedical Crew Performance by Patient Severity and Outcome. Ann Emerg Med. 1992;21:375-378 <br />
  47. 47. Staffing<br />Prospective 2-year follow-up and repeat of previous study comparing nurse/nurse and nurse/paramedic crew performance based on patient severity.<br />No objective differences in outcomes of patients when crew types were compared.<br />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 <br />
  48. 48. Staffing<br />“Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medically-desirable for one-half of flights.”<br />Mortality in blunt trauma improved when physician part of the crew.<br />Bartolacci RA, Munford BJ, Lee A, McGougall PA. Air medical scene response to blunt trauma: effect on early survival. MJA. 1998;169:612-612<br />
  49. 49. Usage<br />162,730 patients from PA Trauma Registry treated at 28 accredited trauma centers.<br />HEMS: 15,938<br />GALS: 6,473<br />Interhospital and calls without ALS excluded. <br />HEMS patients:<br />Younger<br />Male<br />More seriously injured<br />Likely to have systolic BP < 90 mmHg.<br />
  50. 50. Usage<br />Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival.<br />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<br />
  51. 51. Usage<br />Finnish Study.<br />588 flights:<br />40% aborted<br />Estimated that:<br />3 patients (1.5%) were saved.<br />42 patients (20%) mostly with cardiovascular disease benefitted.<br />Remaining patients benefited from ALS care and not HEMS.<br />A minority of patients benefit fro HEMS.<br />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<br />
  52. 52. Usage<br />Retrospective review of HEMS transports in FDNY (1996-1999).<br />182 transports:<br />Scene-Hospital = 32<br />NYC Hospital-NYC Hospital = 18<br />Outside NYC Hospital – NYC Hospital = 122<br />NYC Hospital – Outside NYC Hospital = 10<br />FDNY infrequently uses HEMS.<br />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<br />
  53. 53. Usage<br />1995-2000 comparison of HEMS and GEMS transport in Philadelphia.<br />29,074 transports<br />ISS > 15 = 4,640<br />5-15 mile radius = 1,245<br />HEMS = 12.24%<br />GEMS = 87.66%<br />For patients 5-15 miles from trauma center, HEMS transport takes longer.<br />HEMS outcomes worse.<br />Basile JF, Sorondo B. Comparison Between Helicopter EMS and Ground EMS Transport Time and Outcomes for Severely-Injured Patients within a 5-15 Mile Radius from a Trauma Center. Prehosp Emerg Care. 2004;8:99<br />
  54. 54. Usage<br />Retrospective study 7,584 GEMS and 1,075 HEMS transports.<br />Transport times:<br />GEMS provided shortest prehospital interval at distances < 10 miles.<br />Simultaneously dispatched HEMS provided shortest prehospital interval > 10 miles.<br />Non-simultaneously dispatched HEMS was faster if > 45 miles.<br />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<br />
  55. 55. Usage<br />Retrospective review of all patients transported 2003-2004.<br />156 trauma patients<br />Average ISS = 12 (range 1-46)<br />Discharged home = 45 (41%)<br />24 to OR<br />10 to ICU<br />2 died<br />HEMS transfer in the acute setting is of debated value.<br />Triage categories need to be revised.<br />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<br />
  56. 56. Medical Helicopters<br />Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF. Helicopter Scene Transport of Trauma Patients with Nonlife-Threatening Injuries: A Meta-Analysis. J Trauma. 2006;60:1254-1266<br />
  57. 57. Bledsoe, et al. <br />Considerations:<br />Severe injury: <br />ISS > 15<br />TS < 12<br />RTS ≤ 11<br />Weighted RTS ≥ 4<br />Triss Ps < 0.90<br />Non-life-threatening injuries:<br />Patients not in above criteria<br />Patients who refuse ED treatment<br />Patients discharged from ED<br />Patients not admitted to ICU<br />
  58. 58. Results<br />48 papers met initial inclusion criteria.<br />26 papers rejected:<br />Failure to stratify scores.<br />Failure to differentiate scene flights.<br />Failure to differentiate trauma flights.<br />22 papers accepted.<br />Span: 21 years<br />Cohort: 37,350<br />
  59. 59. Results<br />ISS ≤ 15:<br />N = 31,244<br />ISS ≤ 15 = 18,629<br />ISS ≤ 15 = 60.0% [99% CI: 54.5 to 64.8] <br />TS ≥ 13:<br />N = 2,110<br />TS ≥ 13 = 1,296<br />TS ≥ 13 = 61.4% [99% CI: 58.5 to 80.2] <br />
  60. 60. Results<br />RTS > 11:<br />Insufficient data <br />TRISS Ps > 0.90:<br />N = 6,328<br />TRISS Ps > 0.90 = 4,414<br />TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to 80.2] <br />
  61. 61. Results<br />N=37,350<br />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<br />
  62. 62. Results<br />Patients discharged < 24 hours:<br />N = 1,850<br />Discharged < 24 hours = 446<br />Discharged < 24 hours = 25.8% [99% CI: -0.90 to 52.63] <br />
  63. 63. Medical Helicopter Accidents<br />Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. Journal of Trauma. 2004;56:1325-1329<br />
  64. 64. Medical Helicopter Accidents<br />1993-2007 (Source: NTSB)<br />
  65. 65. Medical Helicopter Accidents<br />Source: NTSB<br />
  66. 66. Medical Helicopter Accidents<br />Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents <br />in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229<br />
  67. 67. Medical Helicopter Accidents<br />Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents <br />in the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229<br />
  68. 68. Occupational Deaths per 100,000 per Year<br />US1995-2001<br />Source: Johns Hopkins University School of Public Health<br />
  69. 69. Fatal Crashes per Million Flight Hours (2001)<br />Source: AMPA, A Safety Review and Risk Assessment in <br />Air Medical Transport (2002) <br />
  70. 70. Medical Helicopter Accidents<br />Weather a factor in one-fourth of all crashes.<br />Source: AMPA.A Safety Review and Risk Assessment in Air Medical Transport, 2002<br />
  71. 71. Pressure on Pilots<br />Undue pressure from:<br />Management<br />Dispatch<br />Flight Crews<br />Pressure to:<br />Speed response or lift-off times<br />Launch/continue in marginal weather<br />Fly when fatigued or ill<br />EMS Line Pilot Survey, 2001<br />
  72. 72.
  73. 73. Summary<br />HEMS-related research scant and of generally poor quality.<br />Papers showing benefit generally from researchers and institutions with a helicopter (a priori?).<br />Most negative literature from researchers and institutions without a helicopter.<br />
  74. 74. Summary<br />In many articles there is a virtual statistical “leap of faith” to justify HEMS transports.<br />Concerns often expressed about selection and publication bias (by both sides).<br />Oftentimes there is an appeal to emotion. <br />
  75. 75. Summary<br />Argument often comes down to:<br />Speed<br />Better care<br />Traffic<br />Keeping local ambulances “available” <br />Oftentimes, factors not considered:<br />Costs<br />Risks<br />Comfort <br />
  76. 76. Summary<br />Who benefits from HEMS?<br />Trauma patients with ISS > 30<br />Patients with time-sensitive surgical lesion that cannot be managed at local hospital:<br />AAA<br />Epidural hematoma <br />Complex pelvic fractures<br />Significant chest trauma<br />Rescue situations where GEMS ingress/egress impaired.<br />
  77. 77. Summary<br />Who benefits from HEMS?<br />STEMI/ACS patients who need critical intervention and HEMS will get them into interventional lab in time and GEMS will not.<br />Stroke care controversial (few stroke patients are truly candidates for therapy).<br />Situations where road conditions would prevent access to a facility for time-sensitive care.<br />
  78. 78. Summary<br />Who does benefit not from HEMS?<br />Most patients using current triage criteria.<br />Burn patients (unless > 30% TBSA and GEMS cannot provide analgesia or airway care).<br />Neonates (other than delivery of rapid intervention team).<br />OB patients.<br />
  79. 79. Summary<br />Who does not from HEMS?<br />Interfacility transfers unless patient has a time-sensitive lesion/condition that would not make a therapeutic window by GEMS transport.<br />CPR cases (trauma or medical)<br />Most pediatric trauma (except those with a high ISS or low or falling GCS).<br />
  80. 80. Summary<br />Only a small number of patients, when objectively evaluated, benefit from HEMS transport.<br />Physicians must always weigh benefits and risks and costs.<br />
  81. 81. Summary<br />Who is to blame for the current mess?<br />Physicians<br />HEMS industry<br />Lack of state and federal oversight of HEMS.<br />Insurers.<br />Local EMS agencies (cost shifting).<br />