# JAMA: Helicopters > Ground Based for Major Trauma



## EpiEMS (Apr 17, 2012)

Surprise, surprise, I suppose?

http://jama.ama-assn.org/content/307/15/1602.short

Measured by survival rates to discharge, helicopter-transported severely injured patients (ISS >15) to level I or level II facilities appeared to be more likely to survive than ground-transported patients. 

Cost-effectiveness, though, is another question.


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## johnrsemt (Apr 17, 2012)

Huh;  imagine that;  if you are flown which in most cases means you get to Level I or II much faster you have a better chance of surviving.   Miracles never cease.     Wait I thought that was the whole point behind flight services.

   Out here it may be 60-100 miles by ground on dirt/gravel roads;  then another 90 miles on paved roads.  If they are bad we fly them.    can save 2-4 hours in some cases.   Not to mention that sometimes the helicopter gets there before the ground units do


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## medicsb (Apr 17, 2012)

Not necessarily a surprise.  I think most people would say that medevacs could be beneficial if used properly.  This is supportive, but it is also pretty weak.  One thing, though, is that overall, there is some work needed to reduce inappropriate flights.   Almost half of the patients flown were discharged to home without any intervention.  I expect and accept over-triage to a certain extend, but I think that >40% to be at least double what I'd consider acceptable.


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## medicsb (Apr 17, 2012)

johnrsemt said:


> Huh;  imagine that;  if you are flown which in most cases means you get to Level I or II much faster you have a better chance of surviving.   Miracles never cease.     Wait I thought that was the whole point behind flight services.
> 
> Out here it may be 60-100 miles by ground on dirt/gravel roads;  then another 90 miles on paved roads.  If they are bad we fly them.    can save 2-4 hours in some cases.   Not to mention that sometimes the helicopter gets there before the ground units do




Those are exceptional circumstances and by no means the rule by which medevacs are generally used in the US.


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## medicdan (Apr 17, 2012)

I wrote a series of papers on this last year. There are a lot of issues and variables at play here... that all affect the data. I don't have institutional access to the article right now, but some thoughts:

-- There is a standing about two models of care: The Anglo-American model providing for para-professional (EMT/Paramedic) assessment and basic field treatment with rapid extrication to a hospital with a doctor, and the Franco-German model bringing the expertise to the patient (MD/RN on scene, allowing for scene assessment and treatment, delaying transport to a hospital. 

There is an argument that the real benefit from HEMS comes from bringing advanced personnel to the scene (APRNs, CCPs, etc), and that the actual rapid extrication (transport) matters less. Perhaps we should be delivering the advanced personnel and equipment via chopper and transporting by ground (with HEMS crew and equipment). I'm not sure I agree.

-- Depending on the region (and it's politics, among other things), HEMS providers have a strong incentive to be dispatched as often as possible (sometimes based on MOI only, for example in MVCs) and transport as often as possible (even if not medically necessary upon arrival). This doesn't support the rationalizations for HEMS, but certainly justifies the existence of the crew and expensive equipment, and the for-profit provider. 

-- As far as I know (and as of about a year ago), there were no scientifically founded studies of Cost-Effectiveness.

-- The advantages of HEMS stem for the rare MCIs and large-scale events. They allow patients to receive a high level of care, and depending on management, allow the first (and sickest)  patients at a scene to be transported first, and to a distant hospital, spreading the patient load and not overburdening the closest facilities. It's hard to quantify that in a single study. 

In a case in Israel in June 2005, HEMS proved it's value following a fairly rural train accident in Revadim, Israel. 289 passengers were injured, and a total of 35 trauma victims were transported by air. The length of time between the first helicopter landing and completion of the air evacuation was 83 minutes. Subsequent journal discussions and analyses hailed this disaster as impressive management of evacuation, particularly the fact patients were evacuated to four Level I trauma centers 40-80 km from the scene—decreasing local burden on adjacent hospitals. The HEMS evacuations that occurred, happened rapidly, HEMS crewmembers triaged alongside ground responders, and crew compositions were adapted to manage the incident appropriately. (citations available upon request). 

I have a lot of other sources and discussion points, but my internet is running out. I'll just clarify: I have not yet been proven of the benefits (or greater value) of much of HEMS. It remains the most expensive portion of prehospital care, and providers are more likely to die in the workplace in the country. Are these costs worth it, for a marginal improvement in patient outcomes?


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## silver (Apr 18, 2012)

emt.dan said:


> I wrote a series of papers on this last year. There are a lot of issues and variables at play here... that all affect the data. I don't have institutional access to the article right now, but some thoughts:
> 
> -- There is a standing about two models of care: The Anglo-American model providing for para-professional (EMT/Paramedic) assessment and basic field treatment with rapid extrication to a hospital with a doctor, and the Franco-German model bringing the expertise to the patient (MD/RN on scene, allowing for scene assessment and treatment, delaying transport to a hospital.
> 
> ...



I believe it said that the adjust rate of survival was increased by 1.5%. That doesn't really seem too worth it.


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## Farmer2DO (Apr 18, 2012)

johnrsemt said:


> Out here it may be 60-100 miles by ground on dirt/gravel roads;  then another 90 miles on paved roads.  If they are bad we fly them.    can save 2-4 hours in some cases.   Not to mention that sometimes the helicopter gets there before the ground units do



This is absolutely appropriate use of HEMS.  



medicsb said:


> Those are exceptional circumstances and by no means the rule by which medevacs are generally used in the US.



Agreed.  From my personal experience, HEMS is actually concentrated in areas that are population dense, rather than very rural areas (which are the ones that really need it).  I live in a rural area, but within 40 miles of 2 metropolitan centers that are approx 1 million people each, and I have 6 HEMS bases staffed 24/7 within 100 miles of my house.  Last week, they flew 2 patients from an MVA in my county.  The level I trauma center was 25 miles by ground, greater than 90% of it expressway.

There's a time and a place.  But I think it's an expensive, less safe transport model that is WAY overused.


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## KellyBracket (Apr 18, 2012)

When you look at the methods and results, you find (or rather don’t find) the one aspect that everyone thought would be the data point of most interest.

That is, prehospital transport tines.

The authors explain in the methods: “Total elapsed EMS times from dispatch to ED arrival were excluded as a variable because of a 57.8% prevalence of missing data.” They do use the 42% of records with EMS times recorded to do a limited analysis, which found that “results were not qualitatively different from our primary analyses.” They shy away from concluding anything, though, given that the data “cannot be assumed to be missing at random.”

Sooo, helicopters save lives, but we can’t say if it’s because of faster transport, or *in spite of slower transport* – we just don’t know.

In a way, it reminds me of a paper I reviewed that suggested that EMS placement of an IV saves lives, but they have no idea why or how.


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## socalmedic (Apr 18, 2012)

I cant speak to the efficacy or efficiency of medivac in most areas as my county  rarely flys anyone. when they do get flown it is via sheriff helo with one lone medic. however I can speak to the over triage note. I watched a video blog last week regarding just that, over triage to trauma centers, which the CDC suggests that 50% over triage is appropriate. if you are an AMR employee log onto Connect and search for "March Grand Rounds".


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## Martyn (Apr 19, 2012)

emt.dan said:


> -- As far as I know (and as of about a year ago), there were no scientifically founded studies of Cost-Effectiveness.


 
But can you actually put a cost effectiveness price on saving a life? Difficult.


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## johnrsemt (Apr 19, 2012)

Or can you put the cost of a life lost due to HEMS transporting non critical patients when a critical need for them comes up?

  When I was in Indiana we drove up on a wreck on the freeway (waved down by local FD); and stopped as the Helicopter landed. 
   We took a patient by ground; (wasn't boarded when we got there); we put them on LBB, and onto cot and into our truck as the HEMS crew was climbing into the ambulance with their patient.   We left before they did;  we drove 38 miles to the same Level I trauma center that they were flying their patient too.   We had patient on bed almost 25 minutes faster than they did.
   You can argue that they can do more on the scene than a ground ALS crew can do:  and you would be right;  but not if the patient didn't need it.

  Another time I was at a small hospital ED (using their facilities);  when I was done I overhead that they had a patient that needed to go to a bigger hospital.   I offered our services and was told by the doctor that they were going to fly him  he was too critical to be delayed in transporting him by ground.  20 mile transport.
    We stayed and waited and watched.  It took the helicopter 45 minutes to get to the hospital.  5 minutes for crew to come into the ED;  32 minutes in the ED  and the flight.    As we left I told the doctor that it was a good thing that they flew the patient;  because our 5-10 minutes on scene and 20 min transport would be harmful to the patient.    The doctor told me later that he never had counted the time of how long it takes.


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## EpiEMS (Apr 19, 2012)

Martyn said:


> But can you actually put a cost effectiveness price on saving a life? Difficult.



Unfortunately, there's no other way to apportion effectiveness. If we were to implement every life saving intervention, we'd be spending billions upon billions for negligible marginal improvements in lifespan.


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## Bullets (Apr 19, 2012)

Look at who is doing this study...a bunch of Docs from Baltimore Shock Trauma...So you think a bunch of docs at a trauma center in a HEMS heavy state like Maryland, who get most of their patients via HEMS is going to put out a study that basically invalidated their entire system? Doubt it


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## Jon (Apr 20, 2012)

silver said:


> I believe it said that the adjust rate of survival was increased by 1.5%. That doesn't really seem too worth it.





Martyn said:


> But can you actually put a cost effectiveness price on saving a life? Difficult.



True, it's hard to put a price tag on the patients life. Better question - how much increased risk of death to the EMS provider is a 1.5% increase in survival worth?


Out of 20 names being recognized this year as EMS LODD's, 4 are aviation-related. 1 was a ground MVC, and 1 was struck on a scene. For 2011's service, of the 43 recognized, there were 19 aviation-related LODD's, versus 2 struck on a scene, and 8 ground MVC's. In 2010, we recognized 26, 7 aeromedical, 5 MVC (including an ATV incident) and 1 struck (in station).

This has been a common trend. What percentage of EMS providers are flight? 1%? 5%? How come 20-40% of our LODD's are aviation-related? Is the risk worth it, especially at the frequency we use flight services?

2012 - http://www.nemsms.org/Press/2012PressRelease-Honorees.pdf
2011 - http://www.emsworld.com/news/10336202/national-ems-memorial-service-releases-names-of-2011-honorees
2010 - http://www.nemsms.org/2010.htm


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## wildmed (Apr 20, 2012)

Had an interesting discussion with our medical director about this paper on Wednesday. The statistical methods used to produce this paper have been massaged pretty throughly, and even with the many constraints on the sample used for this analysis the results are pretty underwhelming. Helicopter based EMS has a very important place in our system, however just like everything else in healthcare, financially driven operations have trashed it. 
Ironically, the places where HEMS could be of the most benefit, are by far the most dangerous places to fly a helicopter. There will always be risk involved in helicopter operations, but the question is where does the acceptable risk meet the actual benefit? I tend to interface with HEMS a lot in my various positions, 3 times in 72 hrs just last week, only 1 of those times did I really find it necessary( 250 mile IFT of critical Peds PT, we where on the receiving end). Even then, a fixed wing transport would have probably been more appropriate. 
The european model for HEMS is much more appropriate, bringing high level of care, to pts that need it the most, in the places that there really is no other option. The rescue culture in europe, unfortunately will probably never exist here in the US.
Ill have a lot of thoughts on HEMS, most of them I will keep to myself.


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## TheLocalMedic (Apr 21, 2012)

Bullets said:


> Look at who is doing this study...a bunch of Docs from Baltimore Shock Trauma...So you think a bunch of docs at a trauma center in a HEMS heavy state like Maryland, who get most of their patients via HEMS is going to put out a study that basically invalidated their entire system? Doubt it



Well played, sir.  I work in a rural area and have some misgivings about our local air ambulance.  I really don't see the benefit in flying patients out of county with the amount of time it takes to get the helicopter to scene, load the patient, and then fly them away.  Granted, the local hospitals aren't superb for trauma, and I will always fly burn patients and peds to the appropriate facilities, but I can say with certainty that it is significantly quicker to bring patients by ground most of the time.  There is something to be said for bringing more highly skilled responders to the patient, but there's really only so much that they can do given the fact that they are outside a hospital, isn't there?


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## Medic2409 (Apr 21, 2012)

A local, unnamed, service here requires that a helicopter be used if emergent ground transport is greater than 15 minutes.


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## medicsb (Apr 21, 2012)

Medic2409 said:


> A local, unnamed, service here requires that a helicopter be used if emergent ground transport is greater than 15 minutes.



I probably wouldn't name names either, but truth be told, services like that and the medical directors that support them should probably be outed in one way or another.  If logic won't work, than maybe public shaming would?


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## Farmer2DO (Apr 21, 2012)

medicsb said:


> I probably wouldn't name names either, but truth be told, services like that and the medical directors that support them should probably be outed in one way or another.  If logic won't work, than maybe public shaming would?



I agree.  As a general rule, that's ridiculous.


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## Medic2409 (Apr 22, 2012)

It would be nice if they could be publicly outed.  Unfortunately the board most likely won't let it happen.  Even if they are publicly outed, will the public care?

My understanding is that if I make a statement that I know to be true then legally it is not slander/libel.  

Perhaps a moderator will weigh in at this point.


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## usalsfyre (Apr 22, 2012)

When the unsaid motto of a combo service  is "he who owns the ground owns the sky"' there tends to be a conflict of interest...


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## silver (Apr 22, 2012)

Martyn said:


> But can you actually put a cost effectiveness price on saving a life? Difficult.



Yes and the world does whenever it doesn't suit their interests. Globally HIV/AIDS, cholera, and malaria are a prime example where no one really cares about saving lives.


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