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 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”: $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. Rosenberg BL, Butz DA, Comstock MC, Taheri. Aeromedical Service: How Does it Actually Contribute to the Mission? J Trauma, 2003;54:681-688
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 cost-effective 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: 56 HEMS: 178 Referral hospital times: GEMS: 25 13 HEMS: 3111 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 population-based 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. Cost-effective 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 blabor 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 life-threatening 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;43:940-946
Trauma Retrospective Boston MedFlight study (1995-1998): Complicated study statistically apriori? 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 Phoenix study (1983-1986): 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;25:1127-1134
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;63:677-682
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 Not a Significant Predictor of Trauma Mortality Significant Predictors of Trauma Mortality 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;56:89-93
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 medically-desirable 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 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. A minority of patients benefit fro 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 Severely-Injured Patients within a 5-15 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 Nonlife-Threatening Injuries: A Meta-Analysis. 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 N=37,350 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
Medical Helicopter Accidents Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. Journal of Trauma. 2004;56:1325-1329
Medical Helicopter Accidents 1993-2007 (Source: NTSB)
Medical Helicopter Accidents Source: NTSB
Medical Helicopter 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 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 US1995-2001 Source: Johns Hopkins University School of Public Health
Fatal Crashes per Million Flight Hours (2001) 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 time-sensitive 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).