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Tue Apr 20 21:29:37 BST 2004

--- DocRickFry at aol.com wrote:
> Note of course not a whit of data above to support views--just
> harangue and personal attack--this denigrating of SCIENCE and DATA 
> is always a tipoff that we are not dealing with any degree of 
> evidence based thinking or logic--but just someone's unsupportable 
> bias that they themselves cannot support, and cannot admit so--
> easier to attack the messenger, and quite unprofessional and 
> childish
> ERF

ARF !!! ERF !
You are so funny !
Do you happen to live 
... in a location that does not recognise trauma surgeons ? ))))

... or I am one lousy communicator

I was merely indulging myself in geography, history, loose links and
statement of facts

Geography: is Quebec (Sorry can only talk of what I know)

History: is no Heli Medevac here (Just a 10 million $ Challenger)

Loose links: Survival rate with Medics (OPALS being probably the most
definitive prehosp study out their; found some marginal benefits with
Medics (hint: not in Trauma, not in Cardiac arrests) 

Statement of fact: The Quebec Association of Emergency Physicians
(AMUQ) after scientific* review as found to clear benefit to
Heli-Medevac and that any decision to set-up one would imply a need
and a will to con$ider non-medical arguments to support such a choice
(Suprising in the face of absence of CCT or 24/24 TCP)
*That's for the science jib

As for my unstated personal opinion
Wich seems to be of concern to you ???)))))
Certainely not much to me

I happen to think that Medic are very useful and do save lives
As supported by scientific evidence
Albeit, we are not talking of bucket loads of class "A" saves
And I think Medics reduce morbidity and angst out there
I also contend that they introduce effectiveness and flexibility in
health care allowing adjustements and improvements (thrombolytics,
hospital bypasses... to apropriate level of care centers

I also think that Heli-Medevacs has not clearly shown to dramaticaly
save lives(Science)in the context of costs (Money and lives)
But having the ressources, the beliefs and dedication
I find it totaly commendable to offer this valuable service
All efforts are, and should be made to refine dispatches and Medevac
practices.

Charles Brault EMT-P

A few docs :
J Trauma 2002 Jan;52(1):136-145	
Helicopter Transport and Blunt Trauma Mortality: 
A Multicenter Trial.

Thomas SH, Harrison TH, Buras WR, Ahmed W, Cheema F, Wedel SK.

Boston MedFlight Critical Care Transport Service (S.H.T., T.H.H.,
S.K.W.), Department of Emergency Services, Massachusetts General
Hospital (S.A.T., W.A., F.C.), Division of Emergency Medicine,
Harvard Medical School (S.H.T.), Department of Surgery, Boston
Medical Center and Boston University School of Medicine (S.K.W.,
W.R.B.), Boston, Massachusetts.

BACKGROUND: Despite many studies addressing potential impact of
helicopter transport on trauma mortality, debate as to the efficacy
of air transport continues. 
METHODS: This retrospective study combined trauma registry data from
five urban Level I adult and pediatric centers. Logistic regression
assessed effect of helicopter transport on mortality while adjusting
for age, sex, transport year, receiving hospital, prehospital level
of care (Advanced Life Support vs. Basic Life Support), ISS, and
mission type (scene vs. interfacility). 
RESULTS: The study database comprised 16,699 patients. Crude
mortality for Air (9.4%) was 3.4 times (95% CI, 2.9-4.0, p < 0.001)
that of Ground (3.0%) patients. In adjusted analysis, helicopter
transport was found to be associated with a significant mortality
reduction (odds ratio, 0.76; 95% CI, 0.59-0.98; p = 0.031). 
CONCLUSION: The results of this study are consistent with an
association between helicopter transport mode and increased survival
in blunt trauma patients.

Arch Surg 2001 Nov;136(11):1293-300	
Effects of 2 patterns of prehospital care on the outcome of patients
with severe head injury.

Di Bartolomeo S, Sanson G, Nardi G, Scian F, Michelutto V, Lattuada
L.

Friuli Venezia Giulia Regional Helicopter Medical Service, Udine,
Italy. elifvg at libero.it

HYPOTHESIS: A pattern of prehospital care combining advanced life
support, physician staffing, and helicopter transport improves the
outcome of patients with severe brain injuries, compared with
combined expanded basic life support, nurse staffing, and ground
transport. DESIGN: Inception cohort from the data set of a
population-based, prospective study on major trauma. 
SETTING: Prehospital and hospital trauma systems of an Italian
region. 

PATIENTS: All patients with major trauma (Injury Severity Score,
>or=16) and severe head injury (Abbreviated Injury Scale score for
the head, >or=4) rescued alive from March 1, 1998, to February 28,
1999, who received either form of care. Patients with self-inflicted
injuries were excluded. The 184 patients who met the entry criteria
were divided equally between care groups. INTERVENTIONS: None. 

MAIN OUTCOME MEASURES: Mortality at 30 days and Glasgow Outcome Scale
score of survivors. RESULTS: After verifying the comparability of the
cohorts, no survival or disability benefit could be demonstrated (95%
confidence interval [CI] of the odds ratio for mortality
[helicopter/ambulance] [95% CI 1], 0.72 to 2.67; 95% CI of the
difference in Glasgow Outcome Scale score medians between helicopter
and ambulance groups [95% CI 2], 0.0 to 0.0). Similar results were
derived from analyses restricted to the subgroups identified by low
(<or=90 mm Hg) roadside systolic blood pressure (95% CI 1, 0.58 to
7.17; 95% CI 2, -1 to 2) and by need for urgent neurosurgical
intervention (95% CI 1, 0.16 to 2.60; 95% CI 2, 0 to 2). Exclusion
from the ambulance group of victims rescued in urban areas did not
change the results (95% CI 1, 0.80 to 3.24; 95% CI 2, 0.0 to 0.0).
Stratification by age, Injury Severity Score, and Glasgow Coma Scale
score demonstrated a small survival benefit (95% CI 1, 1.12 to 2.12)
in the ambulance subgroup with Glasgow Coma Scale score from 10 to
12. Multiple logistic regression analysis confirmed that the group
did not affect mortality. 

CONCLUSION: This study was conceived to emphasize the supposed
advantages of the combined helicopter, physician, and advanced
life-support rescue. No increased benefit compared with the simpler
rescue group could be demonstrated.

Air Med J 2001 Nov-Dec;20(6):33-6	 

Comparison of air and ground transport of cardiac patients.

Berns KS, Hankins DG, Zietlow SP.

Saint Mary's Hospital, Mayo Clinic, Mayo Medical Transport Service,
Rochester, Minn 55902, USA.

PURPOSE: To investigate the outcome of cardiac patients transported
by helicopter versus ground ambulance SETTING: A hospital-based
helicopter program in southeastern Minnesota METHODS: Retrospective
chart review assessing an 18-month period (January 1998 to June
1999). Charts were reviewed for type of cardiac diagnosis, level of
pain, treatments en route, time to intervention, and length of stay
(LOS). Two-hundred-sixty-six cardiac patients came by helicopter. Of
the 86 turndowns, 50 came by ground ambulance; 28 records were
recovered in this group. These patients composed the comparison
ground group. 

RESULTS: Prehospital time was less for patients transported by air
than ground transports (P <.001). The amount of time from the call
for transport until arrival at our hospital was less for helicopter
transports (P =.002). Air transports had more patients with reduced
chest pain on arrival. Difference in CCU LOS was not significant (P
=.94). Air patients spent an average of 2 fewer days in the hospital
than did ground patients (P =.036). 

DISCUSSION: Helicopter transport benefits the cardiac patient with
decreased chest pain as a result of more treatments en route;
decreased time from the call until arrival, resulting in decreased
time to intervention; and shorter prehospital time and hospital
stays. 
CONCLUSION: All of these improved variables relate to salvaged
cardiac muscle.

J Trauma 2002 Nov;53(5):817-22	
The utility of helicopter transport of trauma patients from the
injury scene in an urban trauma system.

Shatney CH, Homan SJ, Sherck JP, Ho CC.

Department of Surgery, Stanford University School of Medicine and
Santa Clara Valley Medical Center, San Jose, California 95128, USA.

BACKGROUND: Continuing controversy surrounding the value of scene
helicopter evacuation of urban trauma victims led to the present
study. METHODS: A retrospective review was performed of all patients
brought to our trauma center from the injury scene by helicopter from
1990 to 2001. 
RESULTS: The study included 947 consecutive patients, 911 with blunt
trauma and 36 with penetrating injuries. The mean Injury Severity
Score (ISS) was 8.9. Fifteen patients died in the emergency
department, 312 patients (33.5%) were discharged home from the
emergency department (mean ISS, 2.7), and 620 patients were
hospitalized (mean ISS, 11.4). Three hundred thirty-nine of the
hospitalized patients (54.7%) had an ISS < or = 9; 148 patients had
an ISS > or = 16. Eighty-four patients (8.9%) required early
operation, mostly for open extremity fractures; only 17 patients
(1.8%) underwent surgery for immediately life-threatening injuries.
For 54.7% of the patients, the helicopter was judged to be clearly
faster than would have been possible by ground transport. In 140
additional patients (14.8%) with prolonged scene time, the helicopter
was probably faster than ground ambulance. Considering faster
transport time and either the need for early operation or
hospitalization with an ISS > or = 9 as advantageous, a maximum of
22.8% of the study population possibly benefited from helicopter
transport.
CONCLUSION: The helicopter is used excessively for scene transport of
trauma victims in our metropolitan trauma system. New criteria should
be developed for helicopter deployment in the urban trauma
environment.

S Afr Med J 2002 Oct;92(10):807-11	 

The effect of air medical transport on survival after trauma in
Johannesburg, South Africa.

Buntman AJ, Yeomans KA.

Wits Business School, University of the Witwatersrand, Johannesburg.

OBJECTIVES: To assess the difference in survival of trauma patients
transported to a trauma unit via either road or air in Johannesburg,
South Africa. DESIGN: Prospective database analysis. SETTING:
Multicentre study utilising two trauma units. SUBJECTS: The study
evaluated 428 subjects admitted to the two sites. OUTCOME MEASURES:
Actual survival rates in each group (road and air) were compared with
the predicted survival rates. 
RESULTS: In the road group, 38.96 people were predicted to die and 51
actually died, therefore 23.61% (or 12.04 people) died
'unnecessarily', i.e. they died after having been predicted to live.
In the helicopter group, 38.15 people were predicted to die and 39
actually died, therefore 0.85 (39-38.15) people were not expected to
die. The 0.85 people represent 2.18% (0.85/39) of the total number of
dead in the helicopter group who died 'unnecessarily'. Therefore one
could argue that introduction of helicopter transport reduces the
number of dead by 21.43% (23.61-2.18).
CONCLUSIONS: Patients with a certain injury severity are more likely
to survive if transported by air to a trauma unit.

Conn Med 1999 Nov;63(11):677-82	

Helicopter air medical transport: ten-year outcomes for trauma
patients in a New England program.

Jacobs LM, Gabram SG, Sztajnkrycer MD, Robinson KJ, Libby MC.

Department of Traumatology and Emergency Medicine, University of
Connecticut School of Medicine, Farmington, USA.

BACKGROUND: Twenty-five years have passed since the introduction of
the first civilian hospital-based air medical helicopter service.
This study reviews the impact of a single air medical service during
a decade of service on the survival of severely injured trauma
patients. 
METHODS: A retrospective database analysis was performed to determine
program demographics and obtain outcome data. The outcomes of trauma
patients were compared to mortality derived from a national database
utilizing physiologic indices of severity. 
RESULTS: Outcome analysis demonstrated an overall 13% reduction in
mortality for air transported patients when compared to controls.
Stratification based upon Trauma Score demonstrated a 35% reduction
in mortality for victims transported directly from the scene with
scene scores between four and 13, and essentially no difference in
outcome for patients at Trauma Score extremes. 
CONCLUSIONS: Rapid utilization of helicopter air medical transport
can have a dramatic impact upon patient outcome, especially within a
select group of scene transported trauma patients with Trauma Scores
ranging from four to 13.

Acad Emerg Med. 2002 Jul;9(7):694-8. 	
Injury mortality following the loss of air medical support for rural
interhospital transport.

Mann NC, Pinkney KA, Price DD, Rowland D, Arthur M, Hedges JR,
Mullins RJ.

Intermountain Injury Control Research Center, University of Utah,
School of Medicine, Salt Lake City, UT 84108, USA.
clay.mann at hsc.utah.edu

OBJECTIVES: This study evaluated variation in mortality among
interfacility transfers three years before and after discontinuation
of a rotor-wing transport service. 
METHODS: A retrospective cohort assessment was conducted among
severely injured patients transferred from four rural hospitals to a
single tertiary center in regions with continued versus discontinued
rotor-wing service. Thirty-day mortality following discharge from the
receiving tertiary facility served as the primary outcome measure. 
RESULTS: Discontinuation of rotor-wing transport decreased
interfacility transfers and increased transfer time. Transferred
patients were four times more likely to die after (compared with
before) rotor-wing service was discontinued (p = 0.05). No difference
was noted in the region with continued rotor-wing service [odds ratio
(OR) = 0.53, p = 0.47]. 
CONCLUSIONS: Injury mortality increased with loss of air transport
for interfacility transfer in a rural area.

Anaesthesiol Reanim 2001;26(4):102-4	 

Using helicopters for secondary transfer--does the patient benefit?

Brampton WJ.

Department of Anaesthetics, Cheltenham General Hospital.
william.brampton at egnhst.org.uk

In common with many expensive, high-technology devices, helicopters
have been introduced into medical practice without the systematic
assessment of benefit (if any). The civilian use of helicopters has
evolved from a military role in evacuating casualties and is now
increasingly directed towards secondary transfer of patients between
hospitals as well as primary retrieval from the community. Whilst
cost restraints have delayed the development of such services in the
UK they have become increasingly available in the last decade.
Helicopters are fast, once airborne, have a high profile and generate
considerable enthusiasm, but they carry the disadvantages of
increased response time, increased time at scene, space restriction,
noise, lower safety margins, weather and daylight dependence, and
high cost. When considering secondary transfer, it is highly unlikely
that the advantage of speed in the air outweighs these disadvantages.
Although studies are limited, none has shown any advantage for
helicopter against road transport in either primary or secondary
transport. The money required to run a helicopter service would be
far better spent on establishing properly-equipped and trained
road-based retrieval teams who can stabilise the patient on site and
then continue treatment in transit, particularly as it has actually
been shown that this approach can be used to transfer critically-ill
patients without significant deterioration.

J Burn Care Rehabil 2000 Nov-Dec;21(6):535-40	 

Cost-effective use of helicopters for the transportation of patients
with burn injuries.

De Wing MD, Curry T, Stephenson E, Palmieri T, Greenhalgh DG.

Shriners Hospital for Children, Northern California, Sacramento
95817, USA.

We performed a retrospective review to analyze the use of helicopters
for the transportation of patients with burn injuries to determine
whether a more cost-effective approach could be developed without
impairing the quality or delivery of health care. Charts were
reviewed for all patients with burn injuries who were transported by
helicopter to our hospitals during a 2-year period. Patients with
inhalation injuries, with burn injuries received more than 24 hours
before admission or more than 200 miles from our burn center, with
more than 30% total body surface area (TBSA) burned, or with
associated trauma injuries were excluded. Control patients with burn
injuries who were transported by ambulance were identified and
matched to the patients with burn injuries transported by helicopter
for the percentage of TBSA burned, the percentage of third-degree
burns, transport mileage, and age. The outcome was evaluated by
comparison of length of stay, days on ventilator, and mortality rate.
Comparisons were performed with Student t test. The transportation
charge was determined for the patients transported by helicopter who
we believed were eligible for transport by ambulance. Forty-seven of
85 patients transported by helicopter matched the inclusion criteria
and had survived. There was no statistically significant difference
between the percentage of TBSA burned, the percentage of third-degree
burns, length of stay, days on ventilator, age, or transport mileage.
There was, however, a significant difference in the time from the
injury to admission to the hospital, as well as in the charge for
transportation. Patients who had less than 30% TBSA thermal cutaneous
injuries without evidence of inhalation injury, and who are less than
200 miles from a burn center may be safely transported by ambulance.
Ambulance transportation may take additional time; however, stricter
protocols for helicopter transportation of patients with burn
injuries will result in potentially substantial savings without
affecting outcomes for patients.

Prehosp Emerg Care 2001 Jan-Mar;5(1):36-9	
Utilization of air medical transport in a large urban environment: a
retrospective analysis.

Asaeda G, Cherson A, Giordano L, Kusick M.

Fire Department of the City of New York, Office of Medical Affairs,
Emergency Medical Services Command, Brooklyn, New York 11201, USA.

OBJECTIVE: To determine the utility of air medical transport in a
large urban environment. METHODS: The authors conducted a
retrospective analysis of all air medical transports of patients in
the Fire Department of the City of New York EMS (emergency medical
services) Command for the period of January 1, 1996, to December 31,
1999. These data were evaluated for frequency of air medical
transport, patient condition at time of flight, and necessity of air
evacuation. RESULTS: During the study period, some form of air
medical transport was used 182 times. Of this number, 32 were for
transports of patients from a scene of an incident to a hospital
within New York City; 18 for interfacility transport of patients from
a hospital facility within New York City to another facility within
New York City; 122 for interfacility transfers of patients from
medical facilities outside of the New York City area to a facility in
New York City; and ten for transport of patients from New York City
medical facilities to facilities out of the area. 
CONCLUSION: The Fire Department of the City of New York EMS Command
utilizes air medical evacuation for patient transports very
infrequently. The parameters of New York City's large urban
environment may not be conducive to air medical transport. These data
seem to be consistent with experiences of other large urban cities.

Unfallchirurg 2000 Feb;103(2):137-43	

[Effect of logistic and medical emergency resources on fatal outcome
of severe trauma]

[Article in German]

Biewener A, Holch M, Muller U, Veitinger A, Erfurt C, Zwipp H.

Klinik und Poliklinik fur Unfall- und Wiederherstellungschirurgie,
Universitatsklinikum Carl Gustav Carus, TU Dresden.

122 cases of patients who died in sequel of an accident (recruitment
period 1993/94, mean ISS 40 +/- 19) in reach of air rescue base
Dresden, Germany, were examined. Data were assessed from autopsy
protocol and the protocol of the physician who treated on scene. We
analyzed the time course of the emergency, the scheduled emergency
medical service and the quality of prehospital diagnosis and therapy
by the emergency team. The mean response time was 8.1 +/- 5.9 min,
the mean distance between EMS bases und incident location 5.9 +/- 5.7
km. In 94.4% of all cases a mobile intensive care unit--with an
emergency physician as crew member--was on scene, in 5.6% a paramedic
car. Air rescue by helicopter, including an emergency physician, was
performed only in 8.7% of all cases although a helicopter was
available in 54% of all accidents. Mechanisms of injury were traffic
accident (71.4%), fall (14.3), 5.9% accident on building site, shot
and stab injuries (5.9%) and burns (1.7%). 82 patients reached the
emergency room alive (67.2% mean ISS 37 +/- 18). Only 26% of all
patients were transported directly to a level I trauma center. Mean
survival time of all 122 patients was 146 +/- 30.4 h. Severe head
injury described by autopsy protocol was diagnosed on scene in 82%.
Preclinical treatment was:intubation and ventilation (63%), O2
insufflation (17.4%), no specific treatment (19.6%). Severe thoracic
trauma was diagnosed in 54%. Preclinical treatment was:intubation and
ventilation (64.8%), O2 application (18.8%), no specific treatment
(16.2%). Severe thoracic trauma with hemato-pneumothorax (n = 26) was
recognized by the emergency physician in 65.6%, specific therapy
(application of chest drain) was performed in 7.1%. Preclinical
diagnosis rates concerning abdominal trauma were 29% and 27.8% in
case of unstable pelvis fracture. Hemorrhagic shock related to these
injuries was found in 44.2%, mean resuscitation volume applicated in
these cases was 960 +/- 610 ml. Typical faults in diagnosis and
treatment were underestimating of severe trunk trauma and
non-consistent use of invasive treatment procedures. Primary
transport of the severely injured patient to a level I trauma center
by helicopter was performed only rarely.

Prehospital Disaster Med 1999 Jul-Sep;14(3):159-64	 

Differences in mortality rates among trauma patients transported by
helicopter and ambulance in Maryland.

Kerr WA, Kerns TJ, Bissell RA.

Maryland State Police Aviation Division, Baltimore 21220, USA.
wkerr1 at gl.umbc.edu

INTRODUCTION: A comprehensive state-wide emergency medical services
and helicopter transport system has been developed in the State of
Maryland on the principle that early definitive care improves patient
outcomes. The purpose of this study was to determine if empirical
data exist to support the theory that air medical transportation
services provided by the Maryland State Police (MSP) Aviation
Division contribute to an improved trauma patient survival rate in
Maryland. 
METHODS: A retrospective study was conducted on the records of all
patients transported by helicopter or ground ambulance and admitted
to the R Adams Cowley Shock Trauma Center (STC) of the University of
Maryland Medical System. Data were obtained from the Maryland
Institute of Emergency Medical Services Systems (MIEMSS) Shock Trauma
Clinical Registry for the period January 1988 through July 1995,
covering 23,002 patients. Patients included those transported
directly from the scene of injury to the STC as well as those from
interfacility transfers. All patients were stratified by injury
severity and compared by outcome (mortality) using Mantel-Haenszel
statistics. 
RESULTS: During the study period, 11,379 patients were transported by
ground and 11,623 were transported by MSP helicopter. The mean Injury
Severity Score (ISS) for patients transported by ground was 12.7 (SD
= 12.52) and the mean ISS for patients transported by air was 14.6
(SD = 13.42), p < 0.001. Among patients classified as having a high
index of injury severity, the mortality rate was lower among those
transported by MSP helicopter than among those transported by
ambulance. The mortality rate was significantly lower for air
transported patient with an ISS higher than 31. 
CONCLUSION: The State of Maryland has demonstrated a commitment to
its citizenry and invested heavily in its public safety air medical
service. This study suggests the rapid air transport of victims of
traumatic events by specialized personnel in Maryland has a positive
effect on the outcome of severely injured patients. Further research
is necessary to clarify the causal relationships in order to more
fully elucidate the value of this resource.

Conn Med 1999 Nov;63(11):677-82	
Helicopter air medical transport: ten-year outcomes for trauma
patients in a New England program.

Jacobs LM, Gabram SG, Sztajnkrycer MD, Robinson KJ, Libby MC.

Department of Traumatology and Emergency Medicine, University of
Connecticut School of Medicine, Farmington, USA.

BACKGROUND: Twenty-five years have passed since the introduction of
the first civilian hospital-based air medical helicopter service.
This study reviews the impact of a single air medical service during
a decade of service on the survival of severely injured trauma
patients. 
METHODS: A retrospective database analysis was performed to determine
program demographics and obtain outcome data. The outcomes of trauma
patients were compared to mortality derived from a national database
utilizing physiologic indices of severity. 
RESULTS: Outcome analysis demonstrated an overall 13% reduction in
mortality for air transported patients when compared to controls.
Stratification based upon Trauma Score demonstrated a 35% reduction
in mortality for victims transported directly from the scene with
scene scores between four and 13, and essentially no difference in
outcome for patients at Trauma Score extremes. 
CONCLUSIONS: Rapid utilization of helicopter air medical transport
can have a dramatic impact upon patient outcome, especially within a
select group of scene transported trauma patients with Trauma Scores
ranging from four to 13.

Medevac safety
NTSB Report

Title: Commercial Emergency Medical Service Helicopter Operations.
NTSB Report Number: SS--88-01, adopted on 1/28/88
NTIS Report Number: PB88-917001

HB-AKK

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