Medical HelicoptersWhat is the role ofmedical helicoptersin the modernAmerican EMSsystem?
Medical HelicoptersIn many areas, theindication forsummoning a medicalhelicopter is:The presence of apatient.
Medical HelicoptersMedical industries that have quicklygotten out of hand:1980s: Boutique psychiatric andsubstance abuse facilities.1990s: Home health care agencies.2000s: Medical helicopters and motorizedwheel chairs.
Medical Helicopters0200400600800100012001998 1999 2000 2001 2002 2003 2004 2005 2006 2007Number of Medical Helicopters by Year
Medical HelicoptersThere are moremedical helicoptersin Dallas/Fort Worththan all of Canadaor Australia.
Medical HelicoptersAre patients needsor helicopteroperator profitsdriving HEMS in theUnited States?
Medical HelicoptersIn 2002, Medicare increased the rates for medicalhelicopter transport.Price for airlift ranges from $5,000 to $15,000, 5 to 10times that of a ground ambulance.Helicopters in the US have doubled from a decadeago; and with more of them scrambling forbusiness, specialists say that emergency personnelare feeling more pressure to use them.In 2004, the number of flights paid for by Medicarealone was 58 percent higher than in 2001.Spending by Medicare has more than doubled to$103 million over the same period.
Medical HelicoptersIn FY 2001, theUniversity ofMichigan’s flightprogram ―SurvivalFlight‖:$6,000,000operational costs$62,000,000 ininpatient revenues28% of ICU daysHelicopter patientswere twice as likelyto have commercialhealth insurancecompared to regularpatient profile.Rosenberg BL, Butz DA, ComstockMC, Taheri. Aeromedical Service:How Does it Actually Contribute tothe Mission? JTrauma, 2003;54:681-688
CostsComparison ofpatients beforeand afterhelicopterplacement.Sussex = £55,000Cornwall = £800,000London = £1,200,000No improvements inresponse times.Scene times longer.Conclusion:HEMS costlyBenefits smallSnooks HA, NichollJP, Brazier JE, Lees-MlangaS. The Costs and Benefits ofHelicopter EmeregencyServices in England andWales. J Pub Health Med.1996;18:67-77
CostsProspectivecomparison ofseriously-injuredpatients(survivors)transported byHEMS and GEMS.―As there is noevidence of anyimprovement inoutcomes overall forthe extracost, HEMS has notbeen found to be acost-effectiveservice.‖Nicholl JP, Brazier JE, SnooksHA. The Cost and Effectivenessof the London Helicopter
InterfacilityRetrospective review of388 pedi patients.80 HEMS (16%mortality)288 GEMS (5%mortality)Mean total transporttime 170 minutes fasterby HEMS.No significantdifferences in LOS, ICUdays.No differences inoutcomes (exceptmortality) which wasdue to increasedseverity of HEMSpopulation.Quinn-Skillings GQ, Brozen R.Outcomes of InterhospitalTransfers fo Critically-IllPatients: A Comparison of Airand Ground Transport. AnnEmerg Med. 1999;34:597
InterfacilityProspective study of:Local HEMS: 1,234Non-Local HEMS: 25GEMS: 153Deaths:HEMS: 19%GEMS: 15%No differences found at30 days for:DisabilityHealth statusHealth care utilizationPatients transported byHEMS did not haveimproved outcomesover GEMS.These data argueagainst a largeadvantage of HEMS ininterfacility transport.Arfken CL, Shapiro MJ, BesseyPQ, Littenberg B. Effectivenessof helicopter versus groundambulance services forinterfacility transport. J Trauma.1998;45:785-790
InterfacilityComparison ofinterfacility patientswith unstable angina orMI transported byGEMS because HEMSwas unavailable due toweather.Compared to HEMStransports.No differences indeaths within 72 hours.HEMS associated withmore total deaths (9/48v 1/48)Interfacility transport ofcardiac patients by airoffers no outcomeadvantage.Stone CK, Hunt RC, Sousa JA.Interhospital transfer of cardiacarrest patients: does airtransport make a difference?Air Med J. 2004;13:159-162.
Interfacility145 patients transportedfrom 20 hospitals to theUniversity of Wisconsinhospital by HEMS.Dispatch times:GEMS: 56HEMS: 178Referral hospital times:GEMS: 25 13HEMS: 3111HEMS patients transportfaster.HEMS transport fasterfor all patients.For stable patients itmay be reasonable touse GEMS.Svenson JE, O’ConnorJE, Lindsay. Is air transportfaster? A comparison of airversus ground transport timesfor interfacility transfers in aregional referral system. AirMed J. 2006;25:170-172
InterfacilityRetrospective cohort of243 patients transportedby GEMS and 139patients by air inOntario.Time interval betweendecision to transfer andthe actual time haslonger for GEMS (41.3vs. 89.7 minutes).Travel time shorter byhelicopter (58.4 vs. 78.9)Distance of transportnot an accurateindicator of transporttime.Karanicolas PJ, Shatia P.Willamson J, et al. The fastestroute between two points is notalways a straight line: ananalysis of air and land transferof nonpenetrating traumapatients. J Trauma.2006;61:396-403.
Neonatal10-year study ofneonatal airtransport inNorway.236 acute caretransfers.13 LBW infants7 deaths (3.2%)Low mortalityoverall.Lang A, Brun H, KaaresenPI, Klingenberg C. A population-based 10-year study of neonatalair transports in North Norway.Acta Paediatr. 2007;96:955-959
Pediatric Transports1991-1992 Utahreview:874 pedi patientsHEMS = 561FWEMS = 313Charges (average):GEMS = $526HEMS = $4,879FWEMS = $4,702―Air medicaltransport isexpensive andsometimes may beusedunnecessarily.‖Diller E, Vernon D, DeanJM, Suruda A. TheEpidemiology of PediatricAir Medical Transports inUtah. Prehosp Emerg Care.1999;3:217-227
BurnsRetrospectivereview of HEMStransports toburn center over2-year period.GEMS transportsused as controlgroup.Excluded:Inhalation injuryBurns > 24 hoursold> 200 mils away>30% BSA burnAssociatedtrauma
BurnsEvaluated andfound nodifference in:TBSA burned% of 3° burnsLOSVent daysAgeTransport mileagePatients with <30% TBSA and <200 miles shouldbe transported byGEMS.DeWing MD, CurryT, Stephenson E, et al. Cost-effective use of helicopters forthe transportation of patientswith burn injuries. J Burn CareRehabil. 2000;21:535-540
Burns437 consecutiveacute burnpatients towestern PA burncenter:GEMS = 339HEMS = 98< 25 miles = 18> 25 miles = 80Inhalation injury:GEMS = 3%HEMS = 28%Reduce use ofHEMS for burnpatients.Slater H, O’Mara MS, GoldfarbIW. Helicopter transportation ofburn patients. Burns2002;28:70-2
Trauma1990-2001retrospectivereview of allpatients broughtto the Santa ClaraValley TraumaCenter (CA) byHEMS.947 consecutivepatients:911 blunt trauma36 penetratingtraumaMean ISS = 8.9Mortality = 15 (inED)
Trauma312 (33.5%)discharged homefrom the ED.620 hospitalized:339 (54.7%) hadan ISS 9.148 had an ISS 16.84 (8.9%) requiredearly operation.Only 17 (1.8%)underwentsurgery for life-threateninginjuries.
TraumaHEMS faster thanGEMS = 54.7%Only 22.8% of thestudy populationpossiblebenefited fromHEMS transport.HEMS is usedexcessively forscene transport.New criteria shouldbe developed.Shatney CH, Homan J, SherckJ, Ho C. The Utility of HelicopterTransport of Trauma Patientsfrom the Injury Scene in anUrban EMS Setting . J Trauma.2002;53:817-822
TraumaOutcomes forHEMS transportnot uniformlybetter for HEMS.Only TS between5-12 and ISSbetween 21-30achievedsignificance.Only a very smallsubset of patientsbenefited fromHEMS Transport.Cunningham P, RutledgeR, Baker CC, Clancy RV. AComparison of the Associationof Helicopter and GroundAmbulance Transport with theOutcome of Injury in TraumaPatients Transported from theScene. J Trauma. 1997;43:940-946
TraumaVARIABLE OR SE WALD pValue95% CI (OR)Air Transport 0.756 0.098 0.031 0.586-0.975Increasing Age 2.71 0.259 <0.001 2.25-3.27Scene Mission Type 1.49 0.160 <0.001 1.21-1.84ALS EMS BaselineBLS EMS 0.423 0.060 <0.001 0.320-6.666Missing EMS 0.554 0.129 0.011 0.351-0.784ISS < 9 Baseline <0.001ISS 9-15 4.08 1.02 <0.001 2.50-6.66ISS 16-24 19.5 4.88 <0.001 12.0-31.9ISS > 24 163 37.2 <0.001 104-255Missing 22.1 10.0 <0.001 9.11-53.7
TraumaPhoenix study (1983-1986):ISS = 20-29 (451)ISS = 30-39 (155)Mean age = 30.5 yearsMale = 76%GEMS = 259GCS Mean = 10.4TS Mean = 12.7HEMS = 347GCS Mean = 9.6TS Mean = 12.1Mortality:HEMS = 18%GEMS = 13%.No survival advantagefor the HEMS group inan urban setting withsophisticated EMSsystem.Schiller WR, Knox R, ZinneckerH et al. Effect of helicoptertransport of trauma victims onsurvival in an urban traumacenter. J Trauma. 1988;25:1127-
Trauma4-year retrospectivereview of traumascene flights.Audit of sceneflights providedhalf-way through.Inappropriate flightsdecreased afteraudit.Criteria for HEMSshould be basedupon physiologiccriteria.Norton R, Wortman E, Eastes L.et al. Appropriate HelicopterTransport of Urban TraumaPatients. J Trauma.1996;41:886-891
TraumaReview of 122consecutive victims ofnoncranial penetratingtrauma in Houston:Average RTS = 10.6Died = 15.8%HEMS transport faster = 0%4.9% of patients requiredintervention not available onground EMS.Only 3.3% received suchintervention.Scene flights inHouston fornoncranialpenetrating traumaare not efficacious.Cocanour CS, Fischer RP, UrsicCM. Are Scene Flights forPenetrating Trauma Justified? JTrauma. 1997;43:83-88
TraumaRetrospective review ofNew England flightservice.Results compared tonationalized database.13% reduction inmortality when comparedto controls.35% reduction inmortality when TSbetween 4 and 13No differences atextremes of RTS.Rapid utilization ofHEMS can have adramatic effect onpatient outcomes.Jacobs LM, Gabram SGA,Sztajnkrycer MD, Robinson KJ,Libby MCN. Helicopter AirMedical Transport: Ten-YearOutcomes for Trauma Patientsin a New England Program.Connecticut Med. 1999;63:677-682
TraumaRetrospective review of 1,877 HEMS andGEMS trauma patients transported from thescene.Multiple parameters evaluated by logisticregression analysis:CUPSPatient ageISSRTSTotal out-of-hospital timeLerner EB, Billittier AJ, DornJM, Wu YW. Is Total Out-of-Hospital Time a SignificantPredictor of Trauma PatientMortality? Acad Emerg Med.2003;10:949-954
TraumaComparison ofprehospital scene times(PST) between GEMS andHEMS.Patients: 1,457GEMS: 1,197HEMS: 260GEMS PST: 24.6 minutesHEMS PST: 35.4 minutesLogistic regressionanalysis and correctionfor ISS, RTS, age.PST not associatedwith increasedmortality.Ringburg AN, SpanjersbergWR, Franema SP et al.Helicopter emergency medicalservice (HEMS): impact onscene times. J Trauma.2007;63:258-262
Penetrating TraumaDanville, PA study1990-1998.2,048 penetratingtrauma cases:GEMS = 2,914HEMS = 494Mean transport time:GEMS = 30.5 minutesHEMS = 52.7 minutesMean ISS:GEMS = 9HEMS = 16 .Despite longertransport and higherISS, controlling forinjury severity foundno difference insurvival.Dula DJ, Palys K, Leicht MMadtes K. Helicopter versusGround Ambulance Transportof Patients with PenetratingTrauma. Ann Emerg Med.2000;38:S16
Pediatric TraumaAll pediatricHEMS traumatransports for 3year period.Results:189 patientsMedian age = 5RTS > 7 = 82%ISS:0-15 = 83%16-60 = 15%> 30 = 3%14% intubated18% admitted toPICU4% taken directlyto the OR.
Pediatric Trauma33% dischargedhome and notadmitted.The majority ofpediatric patientstransported byhelicoptersustained minorinjuries.Eckstein M, Jantos T, KellyN, Cardillo A. HelicopterTransport of PediatricTrauma Patients in an UrbanEmergency MedicalServices System: A CriticalAnalysis. J Trauma.2002;53:340-344
Pediatric TraumaRetrospectiveanalysis of peditrauma patientstransported by airto pedi traumacenter from sceneand compared tothose from otherhospitals.Patients:Scene = 379Death rate = 8.7%ICU hours = 149.1Hospital = 842Death rate = 5.5%ICU hours = 118.3
Pediatric TraumaRetrospectiveanalysis was notable to demonstrateany benefit fromdirect transportfrom the scene.Hospitalstabilization beforeair transport mayimprove survival.Larson JT, DietrichAM, Abdessalam SF, Werman H.Effective Use of an AirAmbulance for PediatricTrauma. J Trauma. 2004;56:89-93
Pediatric TraumaChildren’sNational MedicalCenter Study:3,861 childrenRetrospectivereviewPatients:HEMS = 1,460Mean ISS = 9.2Transport time =45.1 minutesGEMS = 2,896Mean ISS = 6.7Transport time=43.2 minutes
Pediatric Trauma83% of childrentransported by air notcritically-injured (85%overtriage).Outcomes uniformlybetter for childrencritically-injured.HEMS triage basedupon GCS and pulserate better and moreaccurate.Moront ML, GotschallCS, Eichelberger MR. HelicopterTransport of Injured Children:System Effectiveness andTriage Criteria. J Pedi Surg.1996;8:1183-1188
Rural TraumaIowa Study of 918rural traumavictims.Classified as:Essential = 14.0%Helpful = 12.9%Not a Factor = 56.6%Died = 16.5%Based on the data, itwas impossible todetermineprospectively whichpatients wouldbenefit from HEMS.Urdanetta LF, MillerBK, Rigenburg BJ et al. Role ofEmergency HelicopterTransport Service in RuralTrauma. Arch Surg.1987;122:992-996
StaffingLouisville study:145 consecutiveadult traumaflights with MD.114 without MD.Z statistic and otherparameters revealedmortality and care tobe similar.It appears thatexperienced nurses andparamedics , operatingwith well-establishedprotocols, car provideaggressive care equal tothat of a physician.Hamman BA, Cue JI, Miler FB etal. Helicopter Transport ofTrauma Victims: Does aPhysician Make a Difference? JTrauma. 1991;31:490-494
StaffingAustralian study:67 patients inphysician group140 in paramedicgroupW statistic showed8-19 extra survivorsper 100,000 in thephysician group.Physicians performmore procedureswithout increasingscene time whichdecreases mortality.Garner A, Rashford S, LeeA, Bartolacci R. Addition ofPhysicians to ParamedicHelicopter Services DecreasesBlunt Trauma Mortality. Aust N ZJ Surg. 1999;69:697-701
StaffingComparison ofnurse/nurse andnurse/paramediccrew performancebased on patientseverity.Multiple parametersexamined.No objectivedifferences inoutcomes of patientswhen crew typeswere compared.Burney RE, Hubert PL, Maio R.Comparison of AeromedicalCrew Performance by PatientSeverity and Outcome. AnnEmerg Med. 1992;21:375-378
StaffingProspective 2-yearfollow-up and repeatof previous studycomparingnurse/nurse andnurse/paramediccrew performancebased on patientseverity.No objectivedifferences inoutcomes of patientswhen crew typeswere compared.Burney RE, Hubert PL, Maio R.Variation in air medical outcomesby Crew Composition: a two-yearfollow-up. Ann Emerg Med.1995;25:187-192
Staffing―Based upon theseresuscitative effortsand invasiveprocedures, a physicianin attendance wasdeemed medically-desirable for one-half offlights.‖Mortality in blunttrauma improvedwhen physician partof the crew.Bartolacci RA, Munford BJ, LeeA, McGougall PA. Air medicalscene response to blunt trauma:effect on early survival. MJA.1998;169:612-612
Usage162,730 patientsfrom PA TraumaRegistry treatedat 28 accreditedtrauma centers.HEMS: 15,938GALS: 6,473Interhospital andcalls without ALSexcluded.HEMS patients:YoungerMaleMore seriouslyinjuredLikely to havesystolic BP < 90mmHg.
UsageLogistic regressionanalysis revealed thatwhen adjusting forother risk factors,transportation byhelicopter did not affectthe estimated odds ofsurvival.Braithwaite CEM, RoskoM, McDowell R, GallagherJ, Proneca J, Spott MA. ACritical Analysis of On-SceneHelicopter Transport onSurvival in a Statewide TraumaSystem. J Trauma.1998;45:140-144
UsageFinnish Study.588 flights:40% abortedEstimated that:3 patients (1.5%) weresaved.42 patients (20%) mostlywith cardiovasculardisease benefitted.Remaining patientsbenefited from ALScare and not HEMS.A minority ofpatients benefit froHEMS.Hurola J, Wangel M, UusaroA, Rukonen E. Paramedichelicopter emergency service inrural Finland—do the benefitsjustify the cost. ActaAnaesthesiol Scand.2002;46:779-784
UsageRetrospectivereview of HEMStransports in FDNY(1996-1999).182 transports:Scene-Hospital = 32NYC Hospital-NYCHospital = 18Outside NYC Hospital –NYC Hospital = 122NYC Hospital – OutsideNYC Hospital = 10FDNY infrequently usesHEMS.Asaeda G, ChersonA, Giordano L, Kusick M.Utilization of Air MedicalTransport in a Large UrbanEnvironment: ARetrospective Analysis.Prehosp Emerg Care.2001;5:36-39
Usage1995-2000comparison ofHEMS and GEMStransport inPhiladelphia.29,074 transportsISS > 15 = 4,6405-15 mile radius = 1,245HEMS = 12.24%GEMS = 87.66%For patients 5-15 milesfrom traumacenter, HEMS transporttakes longer.HEMS outcomes worse.Basile JF, Sorondo B.Comparison BetweenHelicopter EMS and GroundEMS Transport Time andOutcomes for Severely-Injured Patients within a 5-15 Mile Radius from aTrauma Center. PrehospEmerg Care. 2004;8:99
UsageRetrospective study7,584 GEMS and1,075 HEMStransports.Transport times:GEMS provided shortestprehospital interval atdistances < 10 miles.Simultaneously dispatchedHEMS provided shortestprehospital interval > 10miles.Non-simultaneouslydispatched HEMS was fasterif > 45 miles.Diaz MA, Hendey GW, BivinsHG. When is the HelicopterFaster? A Comparison ofHelicopter and GroundAmbulance TransportTimes. J Trauma.2005;58:148-153
UsageRetrospective review ofall patients transported2003-2004.156 trauma patientsAverage ISS = 12 (range1-46)Discharged home = 45(41%)24 to OR10 to ICU2 diedHEMS transfer in theacute setting is ofdebated value.Triage categories need tobe revised.Melton JT, Jain S, KendrickB, Deo SD. Helicopteremergency ambulanceservice (HEAS) transfer: ananalysis of trauma patientcase-mix, injury severityand outcomes. Ann R CollSurg Engl. 2007;89:513-516
Medical HelicoptersBledsoe BE, WesleyAK, Eckstein M, DunnTM, O’Keefe MF. HelicopterScene Transport of TraumaPatients with Nonlife-Threatening Injuries: A Meta-Analysis. J Trauma.2006;60:1254-1266
Bledsoe, et al.Considerations:Severe injury:ISS > 15TS < 12RTS ≤ 11Weighted RTS ≥ 4Triss Ps < 0.90Non-life-threatening injuries:Patients not in above criteriaPatients who refuse ED treatmentPatients discharged from EDPatients not admitted to ICU
Results48 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 yearsCohort: 37,350
Results545658606264666870ISS TS TRISSPercentagewith minorinjuriesSource: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopterscene transport of trauma patients: a meta-analysis. J Trauma. 2006:60:1254-1266N=37,350
Medical Helicopter Accidents0123456789101993-2002AccidentsSource: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidentsin the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Medical Helicopter Accidents61%26%11%2%Accidents by CausePilot ErrorMechanical FailureUndeterminedOtherSource: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidentsin the United States: A 10-Year Review. J Trauma. 2004;56:1225-1229
Occupational Deaths per 100,000 perYearAll Workers 5Farming 26Mining 27Air Medical Crew 74US 1995-2001Source: Johns Hopkins University School of Public Health
Fatal Crashes per Million FlightHours (2001)1612 121902468101214161820AirlineCommuterGround AmbulanceAll HelicoptersMedical HelicoptersSource: AMPA, A Safety Review and Risk Assessment inAir Medical Transport (2002)
Medical HelicopterAccidentsWeather a factor inone-fourth of allcrashes.Source: AMPA.A Safety Reviewand RiskAssessment inAir MedicalTransport, 2002
Pressure on PilotsUndue pressure from:ManagementDispatchFlight CrewsPressure to:Speed response or lift-off timesLaunch/continue in marginal weatherFly when fatigued or illEMS Line Pilot Survey, 2001
SummaryHEMS-related research scant and ofgenerally poor quality.Papers showing benefit generally fromresearchers and institutions with ahelicopter (a priori?).Most negative literature fromresearchers and institutions without ahelicopter.
SummaryIn many articles there is a virtualstatistical ―leap of faith‖ to justifyHEMS transports.Concerns often expressed aboutselection and publication bias (by bothsides).Oftentimes there is an appeal toemotion.
SummaryArgument often comes down to:SpeedBetter careTrafficKeeping local ambulances ―available‖Oftentimes, factors not considered:CostsRisksComfort
SummaryWho benefits from HEMS?Trauma patients with ISS > 30Patients with time-sensitive surgical lesionthat cannot be managed at local hospital:AAAEpidural hematomaComplex pelvic fracturesSignificant chest traumaRescue situations where GEMSingress/egress impaired.
SummaryWho benefits from HEMS?STEMI/ACS patients who need criticalintervention and HEMS will get them intointerventional lab in time and GEMS willnot.Stroke care controversial (few strokepatients are truly candidates for therapy).Situations where road conditions wouldprevent access to a facility for time-sensitive care.
SummaryWho does benefit not from HEMS?Most patients using current triage criteria.Burn patients (unless > 30% TBSA andGEMS cannot provide analgesia or airwaycare).Neonates (other than delivery of rapidintervention team).OB patients.
SummaryWho does not from HEMS?Interfacility transfers unless patient has atime-sensitive lesion/condition that wouldnot make a therapeutic window by GEMStransport.CPR cases (trauma or medical)Most pediatric trauma (except those with ahigh ISS or low or falling GCS).
SummaryOnly a small numberof patients, whenobjectivelyevaluated, benefitfrom HEMStransport.Physicians mustalways weighbenefits and risksand costs.
SummaryWho is to blame forthe current mess?PhysiciansHEMS industryLack of state andfederal oversight ofHEMS.Insurers.Local EMS agencies(cost shifting).