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The advantages of EMS helicopters are greatly exaggerated...May 1 2005 at 3:20 PM
Johnny Bob (Login jbob)
from IP address 126.96.36.199
Because online articles often disappear, the very important text of these articles is copied below...
EMS Mythology: Part 6
By Bryan E. Bledsoe, DO, FACEP, EMT-P
EMS Myth #6
Air medical helicopters save lives and are cost-effective
I love helicopters. Riding in them is both unique and exhilarating. I have spent many hours in a helicopter providing emergency medical care in between police chases and other city activities. Many have called air medical helicopters nothing more than "flying billboards" for the hospitals that operate them. In this day of dwindling healthcare dollars, we must ask ourselves some hard questions: Do helicopters really make a difference in EMS? Do they provide a significant benefit for the patient? Are the risks worth any real benefit? Why do we not see a proliferation of helicopter operations in other countries like we are seeing in the U.S.? Unfortunately, any discussion of air medical helicopter efficacy often results in an emotional response by many. I have heard flight nurses say, "I know what I do makes a difference." Flight paramedics will often relay a story about a particular patient they feel benefited from helicopter transport. But, do helicopters really make a difference in patient care and the subsequent quality of the patient's life? To answer this, let's look at what the scientific literature says.
The use of civilian helicopters for transport of ill and injured patients has become an integral part of modern emergency care. Helicopter transport of emergency patients in the United States evolved from experience gained in the Korean and Vietnam Wars, when injured soldiers were transported from conflict areas to military medical facilities for definitive care.1 The use of helicopters in the civilian sector began in the late 1960s, when helicopters were used in dual-purpose law-enforcement or military operations, but had a limited commitment to emergency medical response.2,3 Civilian helicopters dedicated exclusively to patient care and transport were first introduced in the U.S. in 1972.1,4 Over the last two decades, there has been a significant proliferation of helicopter operations in the U.S., most of which are hospital-based and many of which have more than one aircraft.5
The impetus for the development and proliferation of civilian helicopter ambulances was based on the concept of the "golden hour." First described by R Adams Cowley, the "golden hour" is the period immediately following injury when resuscitation and definitive care improve outcome.6,7 Al-though outcome is better the sooner definitive care is provided, the actual concept of the so-called "golden hour" has been called into question.8,9,10
The Scientific Evidence
Initial studies published in the 1980s were supportive of air medical transport of emergency patients.11,12 However, more detailed recent studies have shown that this may no longer be the case. Several recent studies have shown that use of helicopters for trauma patients actually benefits only a small number of patients. Furthermore, these studies indicate that many EMS providers summon medical helicopters when the patient's condition may not warrant their use.
Researchers studied helicopter usage in the Silicon Valley region of California. In a retrospective review of 947 consecutive trauma patients transported to their trauma center, they found that only 22.8% of study patients possibly benefited from helicopter transport. They further found that 33.5% of patients transported by helicopter were discharged from the emergency department and not admitted to the hospital.13 In the Los Angeles area, researchers retrospectively evaluated helicopter transport of 189 pediatric trauma patients and found that 85% of patients were considered to have minor injuries. Of the patients transported by helicopter in their study, 33% were discharged home from the emergency department and not admitted to the hospital.14 In another pediatric trauma study, researchers in Washington, DC, found that approximately 85% of air transports in their study group of 3,861 injured children were considered over-triaged.15 A Boston study of 1,523 patients transported by helicopter found that 24% of patients transported from an accident scene were deemed inappropriate.16 Similar findings were reported from an Australian study. In northern coastal New South Wales, researchers reviewed 184 medical records of patients transported from an accident scene to a hospital. An expert panel reviewed all helicopter patient retrievals. They found that only 17.3% of patients benefited from helicopter transport, while 1.7% of patients were felt to have been potentially harmed. Seven percent of patients were discharged from the emergency department and not admitted to the hospital, while 36% were discharged from the hospital within 48 hours.17 In a Hong Kong study, 34.1% of patients transferred by helicopter from a scene were discharged from the emergency department and not admitted to the hospital.18 In a Norwegian study, researchers found that only 11% of the 370 patients transported by helicopter benefited.19 British researchers found no evidence of any improvement in patient outcomes for patients transported by the London Helicopter EMS.20 When the University of Texas Medical Branch at Galveston discontinued its hospital-based air medical helicopter, they found that there was no decrease in transport time or increase in mortality for trauma patients at their facility.21
In a five-year study of blunt-trauma patients transported either by helicopter or ground ambulance, researchers in Phoenix, AZ, found no survival advantage for patients transported by helicopter in an urban setting with a sophisticated prehospital care system.22 In a North Carolina study, researchers found that only a very small subset of patients transported by helicopter appeared to have any chance of improved survival based on their helicopter transport.23 In a detailed study of 162,730 patients treated at 28 accredited trauma centers in Pennsylvania from 19871995, researchers found that transportation by helicopter did not affect the estimated odds of survival.24 A Houston, TX, study found that patients with penetrating trauma do not benefit from helicopter transport and scene flights are not medically efficacious.25 In an eight-year Pennsylvania study of 3,048 penetrating-trauma victims, researchers found that patients transported by helicopter had longer transport times and no significant difference in mortality compared with those transported by ground.26 Likewise, transport of patients with severe head injuries and burns do not appear to benefit from helicopter transport.27,28
When interfacility helicopter transport of patients was studied, the results were also interesting. In a study of 1,234 patients transported between facilities by helicopter, researchers found that those patients did not have improved outcomes compared with those transported by ground.29 Clearly, additional studies are needed.
A factor often overlooked is helicopter safety. There has been a steady increase in the number of helicopter accidents. In fact, over the last 10 years in the U.S., there have been 83 helicopter accidents resulting in 70 deaths and 62 injuries. Furthermore, 52% of accidents in this 10-year period occurred during the last three years of the study (20002002). The helicopter most frequently involved was the single-engine Bell 206 Long Ranger, followed by the twin-engine Eurocopter BK-117. Primary cause of accidents in the study period was pilot error.30,31
Again, we have embarked on an EMS adventure that has conflicting scientific evidence. But, medicine evolves and prehospital medicine similarly evolves. When the original studies were published regarding the effectiveness of helicopters, EMS was in an earlier developmental stage. At that time, helicopters could offer added patient care skills and interventions not available on ground ambulances. Now, with prehospital care being considerably more sophisticated, helicopters offer little more than increased speed. And, in the overall scheme of things, speed makes a difference for only a limited number of patients. The proliferation of helicopter operations in this country over the last decade cannot be supported with science. Helicopters cost between $1,500,000$5,700,000 to purchase and up to $1,000,000 a year per aircraft to operate. Thus, a significant amount of financial resources are going into a transport modality that actually benefits few patients. These large sums of money would buy many AEDs and ground ambulances that would stand to benefit more of our citizenry. With a dwindling healthcare dollar, we will soon have to make some tough decisions.
There certainly is a role for helicopters in EMS, but we have them in the wrong places. The majority of the fleet is parked atop hospitals in urban centers where ground transport takes only minutes. They need to be positioned where they will benefit the people who need them the mostthose who live in rural settings. That is, they need to be closest to the hospitals and trauma scenes where they can potentially make a difference. The literature certainly supports the role of helicopter transport of critical patients in the rural setting.32 Thus, there should be a strategically placed network of helicopters that serves rural hospitals and providers. However, as long as hospitals operate helicopters as "flying billboards," this will probably never happen. Perhaps the solution is to follow the German and Australian models and move EMS helicopters from hospitals to state-wide EMS-type governing boards based on need.33 This would certainly promote fairness for all state residents, but I'm afraid that emotion may prevail.
1. Meir DR, Samper ER. Evolution of civil aeromedical helicopter aviation. South Med J 82:885891, 1989.
2. Military Assistance to Safety and Traffic (MAST). Report of test program by the Interagency Study Group. DHEW publication No. HSM-72-7000. Washington, DC.
3. Proctor HJ, Acai SA, Jr. Assets and liabilities of helicopter evacuation in support of emergency medical services. NC Med J 37:2528, 1976.
4. Baxt WG, Moody P, et al. The impact of rotorcraft aeromedical emergency care service on mortality. JAMA 249:30473051, 1983.
5. Collett H. Air medical helicopter transport. Hosp Aviat 7(7):57, 1998.
6. Boyd DR, Cowley RA. Comprehensive regional trauma/emergency medical services (EMS) delivery systems: The United States experience. World J Surg 7:149157, 1983.
7. Cowley RA. Trauma center: A new concept for the delivery of critical care. J Med Soc NJ 74:979987, 1977.
8. Lerner EB, Moscati RM. The golden hour: Scientific fact or medical "urban legend"? Acad Emerg Med 8(7):758760, 2001.
9. McNicholl BP. The golden hour and prehospital trauma care. Injury 25:251254, 1994.
10. Bledsoe BE. The Golden Hour: Fact or Fiction? Emerg Med Serv 31(6):105, 2002.
11. Baxt WG, Moody P. The impact of rotorcraft aeromedical emergency care service on trauma mortality. JAMA 249(22):30473051, 1983.
12. Baxt WG, Moody P, Cleveland HC, et al. Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: A multicenter study. Ann Emerg Med 14:859864, 1985.
13. Shatney CH, Homan SJ, Shrek JP, Ho CC. The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma 53:817822, 2002.
14. Eckstein M, Jantos T, Kelly N, et al. Helicopter transport of pediatric trauma patients in an urban emergency medical services system: A critical analysis. J Trauma 5:340344, 2002.
15. Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of injured children: System effectiveness and triage criteria. J Pediatr Surg 31(8);11831186, 1996.
16. Reenstra WR, Tracy J, Hirsch E, Millham F. Evaluation of the "appropriateness" of triage requests for air transport to Level I trauma centers directly from the scene versus a community hospital. Ann Emerg Med 34(4):S73, 1999.
17. Wills VL, Eno L, Walker C, Gani JS. Use of an ambulance-based helicopter retrieval service. Aust N Z J Surg 70(7):506510, 2000.
18. Wong TW, Lau CC. Profile and outcomes of patients transported to an accident and emergency department by helicopter: Prospective case series. Hong Kong Med J 6(3):249253, 2000.
19 Hotvedt R, Kristiansen IS, Forde OH, et al. Which groups of patients benefit from helicopter evacuation? Lancet 347:13621366, 1996.
20. Brazier J, Nicholl J, Snooks H. The cost and effectiveness of the London Helicopter Emergency Medical Service. J Health Serv Res Policy 1(4):232237, 1996.
21. Chappell VL, Mileski WJ, Wolf SE, Gore DC. Impact of discontinuing a hospital-based air ambulance service on trauma patient outcomes. J Trauma 2(3):486491, 2002.
22. Schiller WR, Knox R, Zinnecker H, et al. Effect of helicopter transport of trauma victims on survival in an urban trauma center. J Trauma 28(8):L11271134, 1988.
23. Cunningham P, Rutledge R, Baker CC, Clancy TV. 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 43(6):940946, 1997.
24. Brathwaite CEM, Rosko M, McDowell R, et al. A critical analysis of on-scene helicopter transport on survival in a statewide trauma system. J Trauma 45(1):140144, 1998.
25. Cocanour CS, Fischer RP, Ursic CM. Are scene flights for penetrating trauma justified? J Trauma 43(1):8386, 1997.
26. Dula DJ, Palys K, Leicht M, Madtes K. Helicopter versus ambulance transport of patients with penetrating trauma. Ann Emerg Med 36(4):S76, 2000.
27. DiBartolomeo S, Sanson G, Nardi G, et al. Effects of 2 patterns of prehospital care on the outcome of patients with severe head injury. Arch Surg 136(11):12931300, 2001.
28. Slater H, O'Mara MS, Goldfarb IW. Helicopter transportation of burn patients. Burns 28(1):7072, 2002.
29. Arfken CL, Shapiri MJ, Bessey PQ, Littenberg B. Effectiveness of helicopter versus ground ambulance services for interfacility transport. J Trauma 45(4):785790, 1998.
30. Bledsoe BE. Air medical helicopter accidents in the United States: A five-year review. Prehosp Emerg Care 7(1):9498, 2003.
31. Bledsoe BE. Air Medical Helicopter Accidents in the United States (in press).
32. Urdaneta LF, Miller BK, Ringenberg BJ, et al. Role of the emergency helicopter transport service in rural trauma. Arch Surg 122:992996, 1987.
33. Weil TP. Health care reform and air medical transport services. J Emerg Med. 13(3):8187.
Bryan Bledsoe, DO, FACEP, EMT-P, is an emergency physician, author and former paramedic whose writings include: Paramedic Care: Principles and Practice and Paramedic Emergency Care.
Safety record of air ambulance industry under scrutiny
Friday, March 04, 2005
By Kevin Helliker, The Wall Street Journal
For weeks now, federal regulators have been investigating the safety record of the air-ambulance industry, which has experienced four deadly crashes this year.
But an increasing body of evidence suggests there is a larger question to be asked about emergency-medical air transports: Do they benefit most patients?
The conventional wisdom is that air ambulances save the lives of patients who are too critically ill to withstand a slower ride in a ground ambulance. Yet some observers of the industry say medical air transports actually save very few lives -- while costing as much as 10 times more than ground ambulances. A number of published studies including research at Stanford University and the University of Texas, show that the flights often transport minimally injured patients when ground transport frequently could get them to a hospital faster, and with less risk to others.
"In 20 years of experience in urban critical-care helicopter transport, I can count on the fingers of one hand the number of times I thought flying a patient to the hospital made a significant difference in outcome compared to lights and siren," says David Crippen, an associate professor of critical care and emergency medicine at University of Pittsburgh Medical Center.
Inspired by images of helicopters evacuating wounded soldiers in Vietnam, the air-ambulance industry took root in the 1970s and has grown steadily ever since. The industry fleet has nearly doubled since 1997, and patient transports are rising an estimated 5 percent a year, according to Tom Judge, president of the Association of Air Medical Services, a trade group.
The current probe of this year's fatal crashes, begun in January, comes as the industry has drawn increasing scrutiny over not just safety, but also efficacy and possible overuse. Also in January, the journal Prehospital Emergency Care published an abstract reporting that a study of 37,500 helicopter-transported patients determined that two of three had only minor injuries. One of four had injuries too minor to require hospital admission. "The evidence says too many patients are being flown, and yet they keep flying more," says Bryan Bledsoe, a physician who co-authored the Prehospital Emergency Care abstract.
Among other recent research critical of air-transport use, Stanford University trauma surgeon Clayton Shatney conducted a study of 947 patients flown to Santa Clara Valley Medical Center and concluded that helicopter service potentially saved the lives of only nine of them -- while potentially serving as detriment to five who could have arrived faster by ground. Travel by helicopter often is slower in urban situations, in part because of a lack of places to land. "In multicasualty situations, it has not been uncommon that ground ambulances arrive before an airship with patients from the same event," says the Stanford study, published in 2002 in the Journal of Trauma, Injury, Infection and Critical Care.
To be sure, there are situations where there is little debate that medical air transport has clear benefits, such as in rural areas where patients must travel long distances quickly. Some smaller hospitals that fly patients to bigger facilities say they must err on the side of caution with a patient they aren't equipped to handle themselves. And there is research that shows a value for patients. A 2002 study, conducted by an air medical service in Boston compared patients flown with patients driven and showed a 24 percent survival benefit among the most seriously injured who were flown. "That's an enormous benefit," says Mr. Judge of the Association of Air Medical Services.
The cost of air ambulances varies -- generally from $5,000 to $10,000 a trip, and sometimes as much as $25,000, according to industry experts. That is typically five to 10 times as much as ground ambulance. But ground transportation also can be not just less expensive, but faster: A 1995 study of air transport of potential organ donors in Houston, conducted by trauma surgeon Christine Cocanour, found that 27 of 28 would have arrived faster by ground ambulance.
Air-transport industry leaders, including Stephen Thomas, a physician and associate medical director of Boston MedFlight, an emergency medical air-transport service, attribute the high rate of minimally injured patients to the difficulty of conducting accurate injury assessments at the scene of accidents -- especially considering that such calls often are made not by physicians but by paramedics and even police.
But the majority of air transports occur not from accident scenes but from hospitals, according to the Association of Air Medical Services and others. Frequently, doctors at a smaller hospital assess and stabilize patients before dispatching them to larger medical centers.
Insurance companies -- which often must pay for the costly transport -- say they are reluctant to second-guess the decisions of these doctors, who may view air transport as the least-risky choice for both the patient's health and the hospital's liability.
Consider the decision on Jan. 11 to fly Ryan Memering out of Memorial Hospital of Carbon County in Rawlins, Wyo. Mr. Memering had two fractured vertebrae and a deep gash inside his mouth from a car accident. Doctors at Carbon County made the decision to fly him to a larger trauma center in Casper, 120 miles away.
Hospital officials in Rawlins say that ordering the air transport was a clear-cut decision: Though the 45-bed rural hospital has a small intensive-care unit, it lacks full-time specialists for higher-level acute or trauma care. "Any time you have something out of their scope of practice, that's a liability for anyone. Do you want to take that risk?" asks Candace Hofmann, the hospital's ambulance director.
The plane dispatched to retrieve Mr. Memering attempted to land in the dark at Rawlins Municipal Airport. It crashed three miles away, killing three of four crew members on board. Not until the next day did Mr. Memering get flown to the Casper hospital, where doctors performed no surgery and released him in four days. "The staff there said Rawlins had panicked basically," says Serena Memering, the patient's wife. Her husband, she says, "feels guilty that three people died because of this. In my opinion, it was a waste of lives."
The Rawlins crash represented the third fatal accident of an air ambulance during the first two weeks of 2005, prompting federal regulators to open a probe.
Safety experts say the industry's crash record is less a threat to patients than to crew members, who if they worked 20 hours a week for 20 years would face a 40 percent chance of being involved in a fatal crash, according to Johns Hopkins University epidemiologist Susan Baker, a professor in the Johns Hopkins Bloomberg School of Public Health who has studied the industry. Possible outcomes of the federal probe include a requirement that pilots wear night-vision goggles. The four fatal crashes so far this year of air ambulances have killed six crew members and one patient.
Patients can end up paying for helicopter transport that wasn't medically necessary. After 9-year-old Tyler Herman fell and broke his jaw in the wilds of Arizona, doctors at a community hospital decided the boy should fly to Phoenix to undergo plastic surgery for a gash on his face. During the flight he was well enough to sit up and remark on the scenery. Upon arriving in Phoenix, he waited nearly 20 hours to undergo surgery. "We could have driven him there in four hours," says Sharon Herman, the boy's mother. Her insurance didn't cover air transport, leaving the Hermans with a bill for $25,000.
On its own, the air ambulance doesn't appear to be a huge money maker. Earnings at the industry's largest player, Air Methods Corp., climbed to $5.1 million from $3.4 million during the five years ended in 2003. But a 2003 Journal of Trauma study conducted by the University of Michigan Health System, which runs a flight service, found that flown-in patients had better insurance and generated significant "downstream revenue" because the patients developed a relationship with the hospital and often returned years later.
(Amy Schatz contributed to this article.)
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