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In 1997, the Massachusetts Department of Public Health (MDPH) established a process to centralize air medical transport information. This database is one of the first statewide, population-based sources for civilian rotary-wing air medical transports (U.S. Coast Guard, police, and military missions are not included). The purpose of this database is to facilitate MDPH review of air medical transport service utilization, with input from a multidisciplinary committee. This article discusses the challenges in producing uniform data from multiple service submissions and presents aggregate "baseline" utilization information for 1996. These data served as a starting point for later studies using data linkage. This indexed article is the first to report statewide, population-based data for all types of air medical helicopter transports. The only other indexed "statewide air medical transport" paper focused on scene transports to trauma centers in Pennsylvania. A previous article by the authors in the July-September 2000 Air Medical Journal provided an overview of air medical transports for fatal motor vehicle crashes for 1 region of the state.

In a retrospective study of mission data of ADAC Air Rescue of the years 2000 and 2001 the quality of preclinical care of 1,946 patients with severe head injuries and 1,878 polytraumatized patients was examined. The actual preclinical care of these patients was compared with a catalogue of eleven thesis-like recommendations. These recommendations were previously derived from corresponding publications of national and international specialist companies and were introduced in a binding manner by the senior doctors of the participating air rescue centres. The results of the study show that 73.3% of the severe head injuries were preclinically intubated and 94.4% were supplied with oxygen, 82.2% were analgosedated. 94.8% could be delivered to the hospital of destination. 65.9% had a systolic blood pressure of >120 mmHg upon admission to the hospital. 71.4% of severe head injury victims were equipped with a cervical support, 23.3% had the blood pressure documented. 47.3% reached the hospital of destination in less than 60 minutes. Among polytraumatic patients the intubation was performed in 75.7%, the supply with oxygen in 90.7%, 88.6% of the patients were analgosedated. 78.7% of patients suffering from concomitant head injuries were provided with a cervical support and only 22.8% had a blood sugar measurement documented. A concomitant severe thorax trauma was treated by a thorax drainage in 59.2%. 35.6% of the polytraumata reached the hospital of destination in less than 60 minutes. The work describes the preclinical patient care of severe head injuries and polytraumata, pointing out deficits and presenting optimization possibilities, particularly in the area of training. Furthermore, the work shows the concept of the medical quality management in an air rescue enterprise. The total evaluation of all air rescue centres participating in data collection forms the basis of an external quality comparison. The data evaluation of a single station makes regional strengths and weaknesses visible, deficits can be proven and proposals for optimization be developed. The presentation of the time history of data yields continuous standard information on the state of the patient care at the relevant air rescue location and enables the analysis of improvement concepts based on the updated data.

Introduction: Unintended misplacement or removal of the endotracheal tube (ETT) complicates the care of up to 18% of intubated patients. This project analyzed the incidence of such complications in patients transported by a flight program., Methods: 9-month analysis of all intubated patients transported by the flight team., Results: 340/926 patients transported were intubated. One extubation was unplanned and no patients were delivered to the receiving hospital with an esophageal or endobronchial ETT placement. After initial examination, 19/241 ETTs placed before flight team arrival were repositioned. Rates of misplacement on arrival at the receiving hospital and of unplanned extubation were significantly lower than those reported in the EMS or critical care literature., Conclusion: Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients.

Objective: To determine the frequency and consequences of vehicular crashes among dedicated pediatric and neonatal transport teams., Methods: A three-page questionnaire was sent to the transport teams of National Association of Children's Hospitals and Related Institutions (NACHRI) member hospitals. The survey instrument consisted of three sections. The first section requested demographic information about the team and asked the team to report any vehicular collisions or incidents in the previous five years. The second section was directed at teams that did not report collisions or incidents and asked the team to identify potential reasons for their safety record. The third section was directed to those teams reporting collisions or incidents and asked about the causes and consequences of these events., Results: Ninety of 153 (59%) surveys were returned. Thirty-eight of the 90 teams (42%) reported at least one collision in the previous five years. A total of 66 collisions were reported (nine aircraft crashes and 57 ambulance collisions). The number of collisions was not related to the total number of transports performed by the team. Most teams attributed the collisions to errors on the part of a team member or to the actions of a third party. Collisions resulted in eight deaths, ten cases of moderate to severe injury, and 28 minor injuries to patients, health care workers, and/or the ambulance crew. All deaths resulted from aircraft crashes. Additionally, there were operational impacts upon the teams. These included missed workdays and disability on the part of team members and changes in team practices. Collision-free teams attributed their safety record to specific policies of the team and/or the vehicle owner or vendor and to luck., Conclusions: Collisions/crashes among pediatric transport teams are unusual. However, they have resulted in deaths, injuries, and disability. Collisions/crashes appear to be caused by the actions of a team member and/or those of third parties. Specific safety policies on the part of the team and/or vehicle owner or provider may prevent or decrease collisions/crashes.

Background: Helicopter transport of pediatric trauma patients in an urban Emergency Medical Services system remains controversial., Methods: A retrospective review of pediatric patients transported by helicopter to a pediatric trauma center in Los Angeles, California, was conducted over a 3-year period. Pediatric patients (age < 15 years) are transported by helicopter if ground transport to a pediatric trauma center would exceed 20 minutes. Emergency Medical Services reports and hospital records were reviewed for key prehospital and outcome indicators., Results: One hundred eighty-nine patients met the study inclusion criteria. The median age was 5 years (range, 0-14 years). The most common mechanisms of injury were falls and automobile versus pedestrian crashes. Eighty-two percent of patients had a Revised Trauma Score > 7. Of the 175 (93%) patients whose hospital records were available, 24 (14%) were intubated in the emergency department, 32 (18%) were admitted to the intensive care unit, and 7 (4%) were taken directly to the operating room. Injury Severity Scores (ISSs) were as follows: ISS 0 to 15, 146 (83%); ISS 16 to 30, 26 (15%); and ISS > 30, 3 (2%). Fifty-seven (33%) patients were discharged home from the emergency department., Conclusion: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.

Background: A national air ambulance service, including helicopters and airplanes, was implemented in Norway in 1988. The main intention was to offer advanced medical services when needed. All helicopters are manned by anesthesiologists. Catchment areas for the 11 helicopters span from cities to scarcely populated areas, particularly in the north. Our aim was to assess what proportion of ambulance missions carried out by the rescue helicopter in Bodø, northern Norway, delivered advanced medical treatment needing the skills of an anesthesiologist., Methods: Flight and ambulance records (n = 2078) from 1988 and 1990-98 (10 years) were analyzed retrospectively. Inter-hospital transfers (n = 147) and search- and rescue missions (n = 332) were not included. According to the level of medical treatment given missions were categorized into three groups (A, B and C). Treatment in groups A and B would not require an anesthesiologist., Results: Two thousand and seventy-eight ambulance missions carried 2166 patients (114 per 100 000 per year). Median take-off and on-scene times were 29 and 55 min, respectively. Seven hundred and fifty-five patients (35%) suffered from cardiovascular disease, 495 (23%) were injured and 250 (12%) were parturients. One hundred and seven patients (5.0%) received advanced prehospital emergency treatment requiring an anesthesiologist. Forty-five of the 107 patients survived to discharge from hospital, amongst whom 28 had received intravenous nitroglycerin for angina or suspected myocardial infarction., Conclusion: In our rural area, with a widely scattered population, 95% of patients received medical treatment not requiring an anesthesiologist. A selective use of the anesthesiologist seems indicated.

Background: The benefit of the Helicopter Emergency Medical Service (HEMS) is not well documented. The aim of our study was to investigate the potential health benefits of HEMS, and their relation to cost of the service in a rural area in Finland. We also evaluated whether the patient benefit is due to early Advanced Life Support (ALS) procedures performed on-scene, or due to rapid transport of patients to definitive care., Methods: We reviewed all helicopter missions during 1 year (1999). Based on given prehospital care, we divided these missions into various categories. At the time of discharge, in-hospital records were reviewed for patients who received prehospital ALS care in order to estimate the potential benefit of HEMS., Results: There were 588 missions. In 40% (n = 233/588), the mission was aborted. ALS care was given on-scene to 206 patients. It was estimated that in this group lives of three patients (1.5%) were saved, and 42 (20%) patients, mostly with cardiovascular disease, otherwise benefited from the service. The majority (84%) of the patients benefited from on-scene ALS procedures only. The cost for beneficial mission was euro 28 444., Conclusion: A minority of all patients did benefit from HEMS. Benefit was related to early ALS care and the cost per beneficial mission was 28 444.

Introduction: The purpose of this study is to descriptively review the air medical transport of geriatric patients within the provincial air medical program of Nova Scotia., Methods: This study was based on a retrospective review of charts from March 14, 1996, to February 24, 1998, and included patients 65 years or older transported by air ambulance. All trauma and nontrauma missions were included in the program's adult services component (more than 15 years old). The total population served is approximately 1 million., Results: Fifty-nine geriatric patients were transported from a total of 175 adult missions during the study period, representing 33.7% of the adult services total. Nontrauma missions numbered 48 (81.3%), with the remainder (11, 18.6%) being trauma. Overall mortality in our study cohort was 32.2%., Conclusion: Air medical transport usually is associated with trauma transport of the younger patient. This program review demonstrates that one-third of adult air medical transports in this province are for patients older than 65 who are critically ill, though often with nontrauma conditions, and are associated with a high mortality rate. Air medical transport programs should have strategies, education, and protocols that reflect the unique pathophysiology of the elderly.

Objective: Conflicting reports exist regarding the appropriate utilization of helicopter transport for victims of trauma. It has been suggested that adult patients are more severely injured compared with pediatric patients when transported by helicopter. The purpose of this study was to determine whether injury severity and survival probability in pediatric trauma patients were similar to those for adults when helicopter transport was utilized at a suburban trauma center., Methods: The authors conducted a retrospective review of all trauma patients transported by helicopter from the accident scene. Patients were identified from the Christiana Care Health System trauma registry from January 1995 to November 1999. Pediatric patients were defined as those aged 15 years and younger. Data collected were utilized to determine injury severity score (ISS), revised trauma score (RTS), and survival probability., Results: Nine hundred sixty-nine patients were transported; 143 were pediatric. There was no statistical difference noted in ISS (14.21 adult, 12.76 pediatric; p = 0.1506) and RTS (7.23 adult, 7.31 pediatric; p = 0.1832). Mean length of stay was less for the pediatric group (7.5 days adult, 5.2 days pediatric; p = 0.008). Survival probabilities were likewise similar for the two groups, yet the difference met statistical significance (0.92 adult, 0.95 pediatric; p = 0.03)., Conclusion: Pediatric patients transported from the accident scene by helicopter have similar ISSs and RTSs compared with adults. These data suggest that prehospital selection criteria for the two groups are similar.

Objective: To evaluate the accessibility and distribution of the Norwegian National Air Emergency Service in the 10-year period from 1988 to 1998., Material and Methods: The primary material was annual standardized activity data that included all helicopter missions. A multivariate model of determinants for use of the helicopter service was computed by linear regression. Accessibility was measured as the percentage of the population reached in different flying times, and we evaluated the service using a simulation of alternative locations for the helicopter bases., Results: The helicopter service (HEMS) has short access times, with a mean reaction time of 8 minutes and a mean response time of 26 minutes for acute missions. Nearly all patients (98%) are reached within 1 hour. A simulation that tested alternative locations of the helicopter bases compared with current locations showed no increase in accessibility. The use of the service shows large regional differences. Multivariate analyses showed that the distances of the patients from the nearest helicopter base and the nearest hospital are significant determinants for the use of HEMS., Conclusion: Establishment of a national service has given the Norwegian population better access to highly qualified prehospital emergency services. Furthermore, the HEMS has a compensating effect in adjusting for differences in traveling distances to a hospital. Safety, cost-containment, and gatekeeper functions remain challenges.

Purpose: To review and characterize 4 years of experience with suggested nontraumatic aortic emergencies (dissections/ruptures) transported by a new, provincially dedicated rotor-wing air medical program, Methods: Retrospective 4-year review of air medical program's mission records and review of related hospital records. Patients listed as suspected aortic emergencies (nontraumatic) in the air medical records were included. Mission records were reviewed for EMS diagnosis, blood pressures before and after transport, transport times, and mortality. Hospital records were reviewed for diagnosis, interventions/treatment, and mortality. Blood pressures below 80 mmHg systolic were considered hemodynamically unstable., Results: A cohort of 34 patients were identified, of whom 31 (91%) arrived at the hospital alive. Twenty-five patients (74%) arrived hemodynamically stable, with a mean out-of-hospital time of 60 minutes, and nine patients (26%) were hemodynamically unstable (mean out-of-hospital time was 54 minutes). No significant difference arose in times between these two groups (P = 0.16). Overall mortality was 53% (18). Differences in transport time between survivors and deaths was not statistically significant (P = 0.93). The diagnoses on admission to hospital: 14 (41%) were RAAA, five (15%) AAA no rupture, eight (24%) aortic dissections, and four (12%) had no aortic pathology. Seventeen patients (50%) received emergent surgical intervention. The EMS diagnosis was correct in 76% of cases., Conclusion: Our program transported 34 suspected aortic emergencies of which 17 were immediate surgical candidates on arrival. Aortic emergencies are not infrequent within our program. Specific policies and procedures based on continuing quality review should be in place to optimize the transport and care of these patients.

Analysis of 437 consecutive acute burn patients transported to our burn center revealed 339 transported by ground and 98 by helicopter. There were 18 air transport patients from within a 25-mile-radius, and 80 flown further than 25 miles. Mean age was the same in all groups (P>0.05). Percent total body surface area (TBSA) burned was 8.26% in ground transport patients, significantly less than the 20.35% (within 25 miles) and 21.40% (greater than 25 miles) seen in helicopter transports (P<0.0001). Three percent of ground transport patients and 28% of helicopter patients had inhalation injury (P<0.0001). There was no difference in incidence of inhalation injury among helicopter groups (28 vs. 29%, P=0.8). In patients with coexistent inhalation injury, the mean TBSA burned was significantly larger when compared with the TBSA of burns without inhalation injury (P<0.001). Air transported groups contained patients whose status was not critical based upon lack of inhalation injury and small burn size, and who could have been transported by ground. Non clinical factors such as insurance status, desire to keep ground ambulances in their community, and competing helicopter services reluctant to refuse to transport a patient appears to be factors in choosing air ambulance transportation. Regional single helicopter services and regional cooperative ground ambulance services should reduce use of helicopter transport of burn patients when it is not clinically indicated.

Background: An increase in fatal accidents in helicopter ambulance missions in Norway has put focus on the guidelines for use., Methods: Ambulance records from the physician-staffed SeaKing rescue helicopter in Bodø, Northern Norway, from 1988 to 1998 were analysed retrospectively., Results: 2,498 ambulance missions carried 2,590 patients. Median time to lift-off was 29 minutes, and one-way median flying time was 26 minutes. Four local communities with a total of 12,000 residents (6.3% of the population served by the helicopter) ordered 70% of the missions. 35% of the patients suffered from cardiovascular disease, 12% were in labour, 3.2% were seriously traumatized, while 20% had minor injuries. A total of 107 patients (4%) received advanced pre-hospital emergency treatment. Thirty-eight (1.5%) were intubated and received cardiopulmonary resuscitation, of whom two survived to discharge. Over a period of 11 years, 53 patients were intubated by the anaesthesiologist. Oxygen or intravenous lines as the only treatment effort were given to 72%., Interpretation: It takes about an hour to reach remote locations by rescue helicopter. A substantial amount of the transports could have been carried out by ground ambulance without loss of health benefit. We question the need for an on-board anaesthesiologist.

Background: The study objectives were to assess the ship physician's diagnostic accuracy in making the decision to air evacuate critically ill patients from cruise ships, to determine the outcome of these patients, and the overall benefit of air evacuation., Methods: From October 1999 to May 2000, we performed a prospective study of critically ill patients coming from cruise ships in the Caribbean and transported to our institution by air ambulance. Demographics, initial diagnosis, and treatment on board were collected by the triage officer at the time of the cruise physician's first call. In route complications and flight team composition were obtained from the air ambulance monitoring log. Patients were followed-up in the hospital for complications, outcome, and final diagnosis., Results: A consecutive series of 104 patients were considered for analysis. There were 65 men and 39 women (mean age: 68.7 years). Cruise physician's diagnosis was correct in more than 90% of the cases. Internal medicine and surgical conditions represented 80.8% and 19.2% of the cases respectively, falling mainly into three categories: cardiac (34.6%), neurological (20.2%), and digestive (14%). Two cardiac arrests and 1 ventricular fibrillation were successfully resuscitated and 5 of 15 myocardial infarctions received thrombolytic therapy on board. Air transfers were warranted in 96.1% of the cases and physician presence in the flight was considered appropriate in 97.6%. In route complications and mortality rate were 5.8% and 2.9% respectively, related to serious cardiac events. Among the 98 hospitalized patients, 10 patients developed new complications and 5 died. The overall mortality rate was 7.7%., Conclusion: The cruise industry appears off to a good start in the medical treatment of passengers needing air evacuation to a land based medical facility. There is room for improvement and adoption of American College of Emergency Physicians (ACEP) and International Council of Cruise Lines (ICCL) Health Care Guidelines are meaningful first steps. Analysis of Caribbean medical facilities and implementation of active telemedicine conferencing represent alternatives to air evacuation that need to be studied.

Anaesthetists are often employed as medical escorts for patients undergoing international transfer by air ambulance. There is little published data on the types of patients being transferred and on the incidence of adverse events. We performed a retrospective review of the documentation of all air ambulance transfers performed by a single company over a 2-year period followed by a prospective assessment of all high-risk patients transferred over a 1-year period. Of 483 transfers identified, 47% were defined as high-risk and 20% were of patients receiving mechanical ventilation. In the prospective group, 28% of patients required pretransfer optimisation, 7% required a major therapeutic intervention during transfer and there was a major adverse event in 12% of transfers. There were two deaths during transport. These data support the recommendation that escorting personnel should be from an appropriate speciality, have reasonable seniority and be adequately trained and supervised.

Objective: To determine the incidence of physiologic deterioration in critically ill and injured pediatric patients during interhospital transport with air and ground ambulance, Design: Prospective, descriptive study, Setting: All children were treated in regional hospitals and then transported to a pediatric tertiary care center., Patients: Children (n = 100) with a median age of 1.4 years (range 1 week to 18 years), Main Results: Three sets of physiologic scores were calculated: at the time of referral, on departure from the referring hospital, and arrival at the tertiary care center. The incidence of significant physiologic deterioration based on the calculated physiologic scores was 5.6% (n = 4) during ground and 3.4% (n = 1) during air ambulance transports. Critical events occurred in 15% of ground and 31% of air ambulance transports., Conclusion: No difference existed in the incidence of adverse events or physiologic deterioration when air ambulance transports were compared with ground ambulance transports for critically ill children by our team. The physiologic scoring system we chose is simple and easy to use for quality assurance.

No studies had been conducted about Spanish HEMS programs, so we conducted a nationwide survey by phone from January to June 1999. We identified 18 HEMS programs in 13 regions, which transported 4870 patients in 1998. The primary/interhospital missions ratio was 51.25/48.75. In 78% of responding programs, the medical crew was a physician and a nurse. Only 33% of HEMS had standard medical equipment; most lacked noninvasive blood pressure monitors, and one-third of the medical personal were correctly protected with flight helmets and flight suits. It is necessary to study the cost-effectiveness of the Spanish model of HEMS.

Introduction: On-site times for helicopter EMS (HEMS) providers are hypothesized to increase when procedures indicated by national standards of care and local HEMS are not consistently completed by ground EMS (GEMS) or ED providers before HEMS arrival in trauma cases., Methods: In this prospective study, we divided all trauma missions (120) flown by a university-based HEMS during a 3-month period into interfacility missions (between hospitals, ground providers are ED personnel) and scene missions (between scenes and hospitals, ground providers are GEMS). HEMS completed forms identifying which procedures were completed and omitted by GEMS or ED providers. We collected relevant times from county dispatchers and HEMS flight control., Results: Ground providers frequently did not complete indicated basic and advanced procedures. A relationship existed between scene GEMS omissions and HEMS on-site times. If no procedures were omitted, average HEMS time on-site was 13 minutes, increasing to 17 minutes for one procedure omitted and 20 minutes for two or more. No relationship was found on interfacility missions between ED provider omissions and HEMS on-site times. However, any existing effect may have been eclipsed by external factors significantly extending HEMS on-site times (mean 43 minutes). An average of 93 minutes elapsed between the request for HEMS transport and patient arrival at the transferring hospital., Conclusion: GEMS frequently omit indicated procedures. For scene missions, reducing the number of indicated procedures omitted by scene GEMS providers could reduce on-site HEMS times. For interfacility missions, further study is indicated to determine what occurs before HEMS is contacted and while HEMS is on-site.

Introduction: In Sweden, several ambulance helicopter programs have been used during the past 3 decades. This article describes one of these programs., Setting: The catchment area of the helicopter system under study was a typical rural setting with a population density of less than 5 people per square kilometer., Methods: We describe in detail, with special reference to medical aspects, the activities of an helicopter ambulance program in 1997., Results: A total of 288 missions, including 328 patients (204 men), were analyzed. Trauma cases (29%) and patients with cardiovascular (24%) and neurologic problems (13%) dominated the missions. One-sixth of the cases occurred at night. The median response time was 12 minutes, and the median on-scene time was 28 minutes. The medical interventions performed included intubations; central venous catheter, arterial needle, and duodenal tube insertions; and medication administered intravenously, orally, and intrabronchially., Conclusion: We detected a higher rate of trauma cases than in previously published investigations, probably related to the outdoor activities of the area. We believe that the rapid institution of thrombolytic treatment in suspected acute myocardial infarction and a more rapid and flexible transport of trauma cases in a rural area are important. We estimate that, in most cases, the helicopter service could provide a quicker transport than a ground ambulance; however, for short distance transports, ground ambulance is faster than helicopter ambulance.

Objective: To investigate the incidence of hypotension associated with the use of midazolam for prehospital rapid-sequence intubation (RSI)., Methods: A retrospective review was performed using charts from the two aeromedical agencies servicing the authors' region. The RSI protocols used by crews from the northern (north) and the southern (south) parts of the region were identical, with the exception of midazolam dosing. The north crews used 0.1 mg/kg for all patients, while the south crews used 0.1 mg/kg up to a maximum of 5 mg. All patients receiving midazolam for prehospital RSI were pooled, with multiple linear regression used to investigate the relationship between midazolam dose and both hypotension and a decrease in systolic blood pressure (SBP) following RSI. Patients weighing >50 kg and patients with traumatic brain injury (TBI) were evaluated separately to determine differences between north and south with regard to midazolam dosing and incidence of hypotension. Multivariate logistical regression was used to test for these differences and for potential confounders such as age, initial SBP, and Glasgow Coma Scale score (GCS)., Results: A total of 219 patients were identified from the north (n = 75) and the south (n = 144). Multiple linear regression revealed a statistically significant relationship between midazolam dose and both hypotension and an SBP decrease following RSI. There was no difference between north and south with regard to age, sex, incidence of TBI, initial SBP, or GCS. In patients >50 kg, those from the north received higher doses of midazolam and had a higher incidence of hypotension than those from the south. This relationship was also present in 184 patients with TBI., Conclusion: The use of midazolam with prehospital RSI is associated with a dose-related incidence of hypotension.

Background: Search and rescue helicopters from the Royal Norwegian Air Force conduct ambulance and search and rescue missions in the Barents Sea. The team on board includes an anaesthesiologist and a paramedic. Operations in this area are challenging due to long distances, severe weather conditions and winter darkness., Material and Methods: 147 ambulance and 29 search and rescue missions in the Barents Sea during 1994-99 were studied retrospectively with special emphasis on operative conditions and medical results., Results and Interpretation: 35% of the missions were carried out in darkness. Median time from alarm to first patient contact was 3.3 hours and median duration of the missions was 7.3 hours. 48% of the missions involved ships of foreign nationality. About half of the patients had acute illness, dominated by gastrointestinal and heart diseases. Most of the injuries resulted from on-board accidents; open or closed fractures, amputations, and soft tissue damage. 90% of the patients were hospitalised; 7.5% would probably not have survived without early medical treatment and rapid transportation to hospital.

Introduction: Air medical transport of high-risk obstetric (HROB) patients can be accomplished and advantageous for neonate survival and maternal morbidity. A survey of U.S. helicopter air medical programs was conducted to determine the frequency and current practices of HROB transport., Methods: Each program was contacted by telephone, and air medical personnel were asked to answer 12 questions based on personal experience and statistics compiled by their programs., Results: Of the 203 programs surveyed, 133 (66%) provided responses. The mean number of HROB transports was 45.6 per year (4.6% of the mean 995 total transports). Although 83% of the responding programs used the standard flight crew during the HROB transport, only 52% required crew members to maintain neonatal resuscitation certification. Only 56% of the aircraft allow pelvic access in the normal patient configuration. While only 22% of programs have specific HROB launch (dispatch) protocols, 50% reported having obstetricians involved in dispatching flights, and 84% carry tocolytic agents in their drug kit. The greatest concerns included in-flight delivery (60%), inadequate fetal monitoring (6%), and inexperience (5%)., Conclusion: While HROBs account for 5% of air medical flights, many programs appear to be poorly prepared for these patients.

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.

This study was performed to evaluate the performance of military rotary air medical transport in the El Paso, Texas, region with regard to mortality. A retrospective review of transport and inpatient medical records was undertaken. All trauma patients air transported from January 1, 1996, to February 28, 1998, were included. Patients for whom records were unavailable were excluded. Mean time intervals for prehospital and interhospital transport were calculated. Injury severity and survival data were calculated using Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score (TRISS) methodology. Two hundred sixty-seven patients were eligible for analysis (83% of the total). TRISS analysis predicted 241 survivors; the actual number of survivors was 241 (mean = 0.98, z = 0.03) despite the fact that 6 individuals died who were predicted to live and 3 individuals lived who were predicted to die. We conclude that the actual mortality rate of those patients transported by military aeromedical lift equaled that predicted by TRISS methodology.

Objectives: To study the profile of airlifted patients and their outcomes after arrival at the hospital, and to evaluate the appropriateness of their prehospital care and the decision to use aeromedical evacuation., Design: Prospective case series., Setting: Accident and emergency department of a public hospital, Hong Kong., Patients: All patients transported to the department by a helicopter of the Government Flying Service from June 1998 through November 1998., Main Outcome Measures: Demographic data, sources and locations of referral, clinical features, triage category, interventions used, and outcome., Results: A total of 186 patients were transferred by helicopter during the 6-month study period. The 101 patients who had been transferred from a rural hospital or clinic were older (mean age, 50 years versus 35 years), comprised more females (55% versus 26%), had a higher overall mortality rate (19.8% versus 3.6%), and had a higher hospital admission rate (91.1% versus 37.6%) than the 85 patients who had been airlifted from the scene of an emergency. Neurological disorders were the most common presentation among interfacility transfers (21.8%). Among the 85 scene transfers, limb injuries (32.1%) and heat illnesses (24.4%) were the most common reasons for helicopter transport. Most interfacility transfers were appropriate, but 34.1% of patients who had been transferred from the scene of the emergency were later discharged and 21.1% refused consultation., Conclusions: Scene and interfacility transfers by helicopter have different patient profiles, and a substantial proportion of scene transfers may be inappropriate. Guidelines such as field triage and helicopter dispatch criteria need to be established.

Aims: To describe our experience in transit care of the critically ill in Northland and to highlight the multidisciplinary co-operation which renders this an efficient model of transit care in suburban and rural areas., Methods: Since its inception in 1988, Northland's wholly community owned rescue helicopter has played an integral part in transit Intensive Care in Northland. This aids in transportation of medical and nursing intensive care staff to outlying primary hospitals for patient stabilisation, subsequent transfer of the patient to the intensive care unit (ICU) in Whangarei and, occasionally, for transfer to specialised critical care services in Auckland., Results: As of August 1999, over 3,900 helicopter missions have been accomplished. A doctor, vetting each request for Medevac, minimises over-triage, thus ensuring adequate levels of transit care and effective utilisation of expensive resources. More than 90% of non-obstetric adult patients were ventilated and the number of Medevac missions increased over the years. The Accident Compensation Corporation (ACC) funds 40% of all flights, another 40% of flights are funded by Northland Health and the Order of St John funds the remainder., Conclusions: With a widespread geography, efficient transit care of the critically ill is imperative to quality hospital care and ensures equity of access to the rural populace. The Whangarei system of transit intensive care is an ideal template for suburban and rural areas.

Background: John Hunter Hospital is the major trauma centre for a region covering more than 25,000 square kilometres. The helicopter primary retrieval service for trauma is paramedic staffed and protocol driven. The aim of the present study was to assess the overtriage rate created by such protocols, and to assess the benefit to patient outcomes that may be attributable to the service., Methods: The John Hunter Hospital trauma database was used to identify all cases arriving by helicopter in 1996, as well as their demographic details, injury severity score, details of the accident and outcome. An expert panel reviewed the medical records for the 184 primary retrievals. Using a consensus model, estimates of time delay or saving were calculated and likelihood of benefit, no benefit or harm was assessed., Results: A total of 3087 trauma patients were assessed at John Hunter Hospital in 1996, of which 8% arrived by helicopter. Of the primary retrievals, 67.6% had an injury severity score of 9 or less, with only 17.9% having a score of 16 or greater. Twelve patients were discharged from Emergency and 36% were discharged within 48 h. The overall mortality was 5.0%. Twenty-five per cent of patients were retrieved within 35 km of John Hunter Hospital with minimal attributable benefit. Overall 1.7% of patients were felt to have been potentially harmed, 17.3% to have benefited and 81.0% to have had no attributable benefit related to the helicopter use., Conclusions: Although the majority of retrievals are for minor injuries, the service provides benefit for the region. There is potential for harm, however, where base hospitals are overflown in situations where patients have airway compromise, and where patient transfer is delayed due to helicopter activation. Primary helicopter tasking to trauma cases within 35 km of the major trauma centre is seldom beneficial.

This article presents study results from an assessment of the performance of the air medical (and advanced life support) components of the EMS system in response to fatal motor vehicle crashes. Results are presented for one of Massachusetts' five EMS regions, including the finding that air medical transports are involved in 20% of the fatal crashes for the region and transport 11% of the involved individuals. Although the study focused on air medical utilization, it also identified issues related to the future implementation of motor vehicle automatic crash notification (ACN) and telematics that could relay crash severity data from onboard computers (e.g., event data recorders) to auto manufacturers' help centers or state emergency call centers. This technology will place new demands on state EMS systems. To meet the challenges posed by these technological changes, states will need to assess the type and number of EMS services required to respond to ACN motor vehicle crashes and develop methods to determine what level of service to deploy based on the information relayed from the vehicles. An initial step in this evaluation process is to determine the current use of EMS resources to place planned system changes and demand into context.

Objectives: To analyze a high-volume military air ambulance unit and review the U.S. Army air medical transport system and Military Assistance to Safety and Traffic (MAST) program., Methods: The setting was a remote medical system with numerous ground emergency medical services. All patients transported between January 1, 1996, and February 28, 1998, were included. Patients who were dead on scene or for whom records were unavailable were excluded. A retrospective review of transport and available inpatient records was conducted., Results: Five hundred seventeen patients were transported during the study period; 461 patients met inclusion criteria (89%). Of these, 70% were classified as trauma; 30% possessed medical or other surgical diagnoses. Prehospital responses numbered 71.6%, while 28.4% were interhospital transfers. Missions averaged 23.4 minutes per flight, with no major aircraft mishaps. Prehospital utilization review showed appropriate use; 35% of interhospital trauma and 11% of interhospital nontrauma missions were staffed inadequately by these criteria. Time intervals, procedures, and program impact are discussed., Conclusion: This and similar units participating in the MAST program provide effective air transport in settings underserved by civilian programs. Quality and wartime readiness could be improved by centralized medical direction, treatment and transfer protocols, and enhanced training of medics. Further investigations of the clinical impact of advanced training and a two-medic aircrew model are warranted.

Introduction: Transporting intubated patients is common among ground and air crews, and providing adequate oxygenation/ventilation through transport ventilators (TV) or manual ventilation (MV) is clinically challenging. However, very little data chronicle service or practice patterns of oxygenation/ventilation within the industry., Methods: During February 1998, a national sample of 250 air transport agencies was surveyed regarding activities and services surrounding this population of transported patients. One-hundred-ninety-three surveys (77%) were returned., Results: Approximately 40% of responding agencies use rotor-wing transportation only. Various combinations of rotor-, fixed-wing, and critical care ground transport were reported among the sample. Crew configuration consisted primarily of RN/EMT-P (75%). For pre-hospital intubated patients, MV alone (37.3%), TV alone (10.9%), or a combination of MV and TV (43.5%) was used, depending on transport circumstances. Programs not involved in pre-hospital transports accounted for 8.3% of returned surveys. Interfacility transports used MV (6.8%), TV (39.4%), and a combination (53.4%). One respondent did not answer the question, accounting for 0.4% of the returned surveys. More than 75% of programs monitored oxygenation/ventilation during transport. Usually some combination of pulse oximetry and CO2 monitoring was used. More than half (59%) of reporting agencies transport more than 80 intubated adults each year., Conclusion: Considerable variation exists in practices involving the transport of intubated patients.

The county of Jämtland is a sparsely populated area in which an ambulance-helicopter has been in use since the middle of the 1970's. A prospective study was undertaken during a six month period with the aim of evaluating the benefits of the helicopter as compared with the use of road-ambulance transport alone. Total number of patients involved was n = 249. Both flight nurses and receiving doctors found that in most cases, patients transported by helicopter manned with a flight nurse were given higher quality care. A follow-up study by specialists from the receiving departments confirmed that for 3% (n = 8), transport by ambulance-helicopter resulted in "probably better prognosis", and that for 2% (n = 6) the result was "lifesaving".

Disability and handicap outcome measures are fundamental components of trauma system evaluation. These outcomes are described for survivors of major trauma, attended by the HEMS, London system. Together with measures of injury severity, three functional instruments (Functional Independence Measure (FIM), Glasgow Outcome Scale (GOS) and return to pre-injury work status (RTW)) were used to measure outcome in 201 trauma patients. By 12 months post injury 84.1% of cases were independent in Motor FIM, 88.1% in Cognitive FIM, 79.1% had good outcomes in GOS (grades 4 and 5) and 69.2% had returned to work. The functional measures showed a statistically significant relationship with minor and major and trauma (ISS < 16 and > or = 16): FIM (motor p < 0.002; cognitive p < 0.0003), GOS (p < 0.002) and RTW (p < 0.002). Division according to severity of principal injury confirmed the greatest disability and handicap resulted from the severest injuries (AIS 4-5): 68.9% achieved independence in Motor FIM, 73% in Cognitive FIM and only 40% returned to work. When grouped according to body region of principal injury, neurological injury, particularly severe injury (AIS 4-5) to head and spinal cord regions showed the poorest outcomes. FIM, GOS and RTW are recommended as standard indicators of disability and handicap for trauma registries and outcome studies.

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.

Introduction: Caring for an infectious patient in the air medical environment presents a special challenge to all air crew members (ACMs) involved. The purpose of this study was to survey the infectious disease control practices of air medical programs (AMPs) that are members of the Association of Air Medical Services., Methods: A structured telephone survey was designed to gather data. Using one interviewer (an undergraduate student) with no knowledge of the study's goal minimized experimental bias. AMPs from 151 geographically selected areas were called between June and August 1996. Only the programs' chief flight nurses (CFNs) were targeted as respondents., Results: The response rate was 91% (138 of 151). Although no program refused to participate, 13 CFNs were unavailable to be interviewed. Mission profile was 32% scene and 68% interhospital with an annual average of 950 patient transports per program. Transport type was 61% rotor-wing aircraft, 17% fixed-wing, and 22% both. Flight physicals for ACMs were required by 57% of the AMPs. Pre-employment screenings for rubella, tuberculosis (TB), and varicella were noted. Interestingly, 17% of the AMPs reported pre-employment HIV testing. Immunization was mandated by 57% of AMPs, including hepatitis B virus, measles, rubella, and tetanus. Nine percent of the respondents refused to accept a transport with specific contagious conditions, primarily TB. A formal decontamination policy was in effect at 88% of the AMPs, and OSHA-approved filter masks were available at 70%. Pathogen exposure reporting was required by 97%., Conclusion: A current, comprehensive infection control program, continuing education, and 100% compliance with standard precautions will help reduce the possibility of accidental exposures. These strategies to reduce transmission also can be extended during training sessions to the prehospital and hospital personnel with whom the air medical program serves.

Background and Purpose: Rapid transport of patients to specialized centers is widely used in the management of myocardial infarction, trauma, and more recently, acute stroke. We evaluated the role of helicopter transportation as it relates to the availability of acute stroke therapies and patients' perceptions of care., Methods: We reviewed records of all patients transferred to a university hospital within 24 hours of stroke onset from January 1996 to December 1997. Data were collected on demographics, neurological deficit, treatment, and outcome. In addition, a questionnaire was sent to all patients with items about perceived reasons for helicopter transfer, expected and actual treatment, outcome, and overall impression., Results: Helicopter transfer was used for 73 stroke patients. Before transfer, 8 patients (11%) received tissue plasminogen activator (tPA). On arrival, no patient received tPA, 38 patients (52%) were enrolled in acute stroke studies, and 35 patients (48%) received no specific medication. All but 2 patients were managed in a specialized stroke unit. Of the 35 patients who received no specific therapy, 24 (69%) were ineligible for treatment or study enrollment owing to 1 or more exclusion criteria, but rarely (3%) because of time. Of the 45 respondents to the survey, most (84%) were transferred at the suggestion of the physician at the originating hospital because of a possible treatment that was unavailable there. Most patients (93%) believed that there was a benefit from emergent helicopter transfer to a stroke center, although 40% of respondents received no specific therapy., Conclusion: Interhospital transfer by air may benefit a substantial number of acute stroke patients by offering potential therapies and intensive management not available elsewhere.

Introduction: Historically our program has used the practice of hot-loading at scenes as a time-saving measure. This practice potentially exposes patients and health care personnel to a variety of risks. Currently no data exist supporting the use of hot-loading as a time-saving technique. We prospectively studied load times and scene times for both hot- and cold-loading methods., Methods: Hot- or cold-loading methods were randomized according to odd or even days of the month for scene runs. Both loading times and total scene times were recorded. An ANOVA was used to compare the times, taking into consideration the aircraft in use (BO 105 or BK 117)., Results: A total of 104 flights were entered into the study. For loading time, hot-loading showed a statistically significant difference (F [1,100] = 112.84, P = 0.000). Means for hot- and cold-loading times are 3.071 and 5.033 minutes, respectively. The interaction effect of aircraft and loading method also was significant (F [1,100] = 4.637, P = 0.034). The BO 105 (on high skids) was slower to hot-load. In contrast, the BK 117 (additional pretakeoff system checks) was slower to cold-load. The type of aircraft alone showed no effect on loading time. Total scene times were evaluated using the same procedures. A statistically significant difference also was found for the effect of hot-loading on total scene time (F [1,100] = 11.391, P = 0.001). Means for hot and cold total scene times are 10.54 and 13.615 minutes, respectively., Conclusion: Hot-loading does decrease our program's overall scene times. The clinical significance of this procedure was not evaluated.

Objective: To analyze flight crew airway management in four different settings (in flight, at trauma scenes, in ambulance, and in referring hospitals) and in two different aircraft used by the same helicopter EMS (HEMS) service. The null hypothesis was that there was no association between practice setting, or aircraft, and airway practices or success rate., Methods: This retrospective study analyzed all patients in whom advanced airway management was attempted by the HEMS service during the study period October 1991 through October 1997. Data used were from flight records of Boston MedFlight Critical Care Transport Service, which uses a nurse/paramedic crew and had a paralytic-assisted intubation protocol in place. Data were analyzed with chi-square and Fisher's exact testing, risk ratio analysis, and logistic regression., Results: Advanced airway management was attempted in 722 patients, with an airway placed in 705 (97.8%). Intubation success was unrelated to site of airway management (p = 0.14), but patients were more likely to have intubation attempted prior to flight (as opposed to in flight) if the crew were in the AS365N2 Dauphin as compared with the BK-117 (p<0.0001). In addition, patients were 0.77 times as likely (95% confidence interval, 0.68-0.88) to receive paralytic-facilitated intubation if airway management occurred in the hospital setting as compared with other sites., Conclusions: While HEMS crew airway management success rates are equally high in all practice settings, airway management decision making and practice appear to be significantly influenced by practice setting and aircraft type. These data support contentions that nonphysician HEMS crews can effectively manage airways in a variety of circumstances.

Introduction: Hot-loading is a common practice among rotor-wing air medical programs that respond to scene calls. Drawbacks include noise, flying debris, and risk of serious injury. The purpose of this study was to identify the frequency, ground time, and short-term outcomes of hot-loaded patients flown by the STAR Flight program., Methods: A 1-year retrospective records review identified all hot-loaded patients. Results were analyzed by call nature, number of patients, and type of aircraft., Results: In 1996 STAR Flight transported 1184 individuals from the scene of illness or injury; 269 (23%) were hot-loaded. Overall, hot-load ground times averaged 7.0 minutes. The shortest mean time, 6.6 minutes, was for single trauma patients. Medicine patients averaged 7.3 minutes, and multipatient transports required 10.3 minutes. Mean scene times for those flown in the Bell 412 and 206 were 6.9 and 7.4 minutes, respectively. Thirty percent of hot-loaded patients were considered critical., Conclusion: Hot-loading rarely was accomplished in less than the helicopter shutdown/startup time. Multipatient hot-loads always exceeded shutdown/restart intervals. Medicine and Bell 206 transports required the longest mean ground times. Most of STAR Flight's hot-loaded patients were not critically ill or injured.

Introduction: Helicopter transport of the combative patient is a major safety hazard facing air medical teams. Although physical restraints alone are helpful, the addition of chemical restraint (CR) often is necessary to control these patients while in flight., Methods: A survey was conducted to determine the current practices of using nonparalyzing CR in air medical transport programs nationwide. The survey consisted of 24 questions on the use of CR during transport. Each U.S. program belonging to the Association of Air Medical Services was contacted by telephone, and a flight nurse or paramedic provided answers based on personal experience and statistics compiled by his or her individual program., Results: Of the 100 programs responding, benzodiazepines were used most commonly to control agitation with 51% using micazolam. Patients with a head injury required CR more frequently than any other condition (73%). Crews flying larger aircraft reported less need for CR. A physician order was required by only 30% of the programs, but delays infrequently endangered the patient (2%). Only 7% of the responding programs had a patient whose condition deteriorated because of CR., Conclusion: CR is necessary in air medical transport. Most programs use short-acting benzodiazepines. Crews in smaller aircraft use CR more frequently, and head injury is the most common condition requiring such restraint.

Objective: To describe the air-transported patients treated at Primary Children's Medical Center (PCMC), the sole pediatric tertiary care center in Utah and a referral center in the intermountain region. This study describes the patients who utilized the air medical transport system, the medical services provided in the prehospital setting, and the corresponding charges for transport and treatment., Methods: Participants were air-transported patients aged 17 years and less who were treated at PCMC during the calendar years 1991-1992. The study population excluded patients who were transported to other medical facilities, and newborns. Data were abstracted retrospectively from the patients' medical and transport records. Data collected included demographic information, patient diagnoses, and treatments performed during transport. Financial data were supplied by the hospital., Results: During the study period, 874 pediatric patients met the participant criteria. Helicopter and fixed-wing transports comprised 561 and 313, respectively, from nine states in the mountain and western regions. The majority (313, 56%) of the patients transported by helicopter were trauma patients, while the majority (195, 62%) of fixed-wing transports were for illness-related conditions. Scene transports accounted for 120 (21%) of helicopter transports. Children with special health care needs accounted for 171 (20%) of all transports., Conclusions: Injury severity scores indicate that, overall, air-transported patients were more severely injured than comparable ground-transported patients. However, it is apparent that some patients who were air-transported could have been transported by ground ambulance without detriment. medical services.