Medical Helicopters

1. Medical Helicopters Bryan Bledsoe, DO, FACEP UNLV

2. Medical Helicopters • What is the role of medical helicopters in the modern American EMS system?

3. Medical Helicopters • In many areas, the indication for summoning a medical helicopter is: The presence of a patient.

4. 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.

5. Medical Helicopters

6. Medical Helicopters • There are more medical helicopters in Dallas/Fort Worth than all of Canada or Australia.

7. Medical Helicopters • Are patients needs or helicopter operator profits driving HEMS in the United States?

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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.

25. 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

26. 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

27. 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

28. 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

29. Trauma

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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.

50. 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