Medical Helicopters
Dr.Hicham Al Mawla
Medical Helicopters1Medical HelicoptersWhat is the role of
medical helicopters in the modern American EMS system?
2Medical HelicoptersIn many areas, the indication for summoning
a medical helicopter is:The presence of a patient.
3Medical HelicoptersMedical 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.4Medical Helicopters5Medical
HelicoptersThere are more medical helicopters in Dallas/Fort Worth
than all of Canada or Australia.
6Medical HelicoptersAre patients needs or helicopter operator
profits driving HEMS in the United States?
7Medical HelicoptersIn 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. 8Medical Helicopters
In FY 2001, the University of Michigans flight program Survival
Flight:$6,000,000 operational costs$62,000,000 in inpatient
revenues28% of ICU daysHelicopter 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
9CostsComparison of patients before and after helicopter
placement.Sussex = 55,000Cornwall = 800,000London = 1,200,000
No improvements in response times.Scene times
longer.Conclusion:HEMS costlyBenefits smallSnooks 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 10CostsProspective 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 11InterfacilityRetrospective 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;34:59712InterfacilityProspective study of:Local HEMS:
1,234Non-Local HEMS: 25GEMS: 153Deaths:HEMS: 19%GEMS: 15%No
differences found at 30 days for:DisabilityHealth statusHealth 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;45:785-79013InterfacilityComparison 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;13:159-162.14Interfacility145 patients transported from 20
hospitals to the University of Wisconsin hospital by HEMS.Dispatch
times:GEMS: 56HEMS: 178Referral hospital times:GEMS: 25 13HEMS:
3111HEMS patients transport faster.
HEMS transport faster for all patients.For stable patients it
may be reasonable to use GEMS.
Svenson JE, OConnor 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;25:170-17215InterfacilityRetrospective 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;61:396-403.16Neonatal10-year study of neonatal air transport
in Norway.236 acute care transfers.13 LBW infants7 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 17Pediatric Transports1991-1992 Utah
review:874 pedi patientsHEMS = 561FWEMS = 313Charges (average):GEMS
= $526HEMS = $4,879FWEMS = $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;3:217-22718BurnsRetrospective review of HEMS transports to
burn center over 2-year period.GEMS transports used as control
group.Excluded:Inhalation injuryBurns > 24 hours old> 200
mils away>30% BSA burnAssociated trauma19BurnsEvaluated and
found no difference in:TBSA burned% of 3 burnsLOSVent
daysAgeTransport 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;21:535-54020Burns437 consecutive acute burn patients to
western PA burn center:GEMS = 339HEMS = 98< 25 miles = 18> 25
miles = 80Inhalation injury:GEMS = 3%HEMS = 28%Reduce use of HEMS
for burn patients.Slater H, OMara MS, Goldfarb IW. Helicopter
transportation of burn patients. Burns 2002;28:70-221Obstetrics22
HEMS transports of preterm labor patients.No outcome difference
found.No deliveries in flight.HEMS = $4,613.64 $581.12GEMS =
$604.02 $306.02.Van Hook JW, Leicht TG, Van Hook CL, et al.
Aeromedical transfer of preterm b\labor patients. Tex Med.
1998;94:88-9022Trauma1990-2001 retrospective review of all patients
brought to the Santa Clara Valley Trauma Center (CA) by HEMS.
947 consecutive patients:911 blunt trauma36 penetrating
traumaMean ISS = 8.9Mortality = 15 (in ED)
23Trauma312 (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.24TraumaHEMS 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
25Trauma1987-1993 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 3.6ISS = 17 11.117,344
(92.7%) transported by ground.TS = 14 3.6ISS = 10.8 8.4
26TraumaOutcomes 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
27TraumaRetrospective Boston MedFlight study (1995-1998):
Complicated study statisticallya 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;52:136-14528TraumaVARIABLEORSEWALD p Value95%
CI (OR)Air Transport0.7560.0980.0310.586-0.975Increasing
Age2.710.259 11:Insufficient data TRISS Ps > 0.90:N = 6,328TRISS
Ps > 0.90 = 4,414TRISS Ps > 0.90 = 69.3% [99% CI: 58.5 to
80.2] 60ResultsSource: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM,
OKeefe MO. Helicopter scene transport of trauma patients: a
meta-analysis. J Trauma. 2006:60:1254-1266N=37,35061ResultsPatients
discharged < 24 hours:N = 1,850Discharged < 24 hours =
446Discharged < 24 hours = 25.8% [99% CI: -0.90 to 52.63]
62Medical Helicopter Accidents
Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United
States: A 10-Year Review. Journal of Trauma.
2004;56:1325-132963Medical Helicopter Accidents
1993-2007 (Source: NTSB)64Medical Helicopter Accidents
Source: NTSB65Medical Helicopter AccidentsSource: NTSB &
Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United
States: A 10-Year Review. J Trauma. 2004;56:1225-1229 66Medical
Helicopter AccidentsSource: NTSB & Bledsoe BE and Smith MG.
Medical Helicopter Accidents in the United States: A 10-Year
Review. J Trauma. 2004;56:1225-122967Occupational Deaths per
100,000 per YearAll Workers5Farming26Mining27Air Medical Crew74US
1995-2001Source: Johns Hopkins University School of Public
Health68Fatal Crashes per Million Flight Hours (2001)Source: AMPA,
A Safety Review and Risk Assessment in Air Medical Transport (2002)
69Medical Helicopter AccidentsWeather a factor in one-fourth of all
crashes.Source: AMPA. A Safety Review and Risk Assessment in Air
Medical Transport, 2002
70Pressure on PilotsUndue pressure from:ManagementDispatchFlight
CrewsPressure to:Speed response or lift-off timesLaunch/continue in
marginal weatherFly when fatigued or illEMS Line Pilot Survey,
200171
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