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Introduction: Aeromedical evacuations from the past few decades have yielded massive amounts of data that may inform the Military Health System (MHS) on patient needs, specifically for understanding the inpatient and outpatient needs of evacuees. In this study, we evaluate inpatient and outpatient trends based on aeromedical evacuation data from recent conflicts. We anticipate that evacuations requiring MHS inpatient beds are primarily trauma-related and necessitate an increased need for inpatient trauma care., Materials and Methods: We conducted a descriptive analysis of aeromedical evacuations using the U.S. Transportation Command Regulating and Command & Control Evacuation System database. We queried the database for aeromedical evacuations originating from the U.S. EUCOM and ending in the CONUS, from January 1, 2008 to June 4, 2020. With the resultant data, evacuee demographics were characterized by gender, age, active duty (AD) versus non-AD, and branch of service. Following this, the proportion of battle injury to disease and non-battle injury was categorized by both patient age ranges and year. Additionally, evacuations were stratified by their ICD codes, as well as the primary specialty responsible for care. Lastly, evacuations were categorized by inpatient and outpatient care status., Results: The final dataset yielded 32,485 unique patients. The majority of evacuees were male (86.9%) with a mean age of 29.0 ± 9.6 years. Evacuees were primarily AD Military (96.7%), with the majority of those personnel being in the Army (70.2%). The total number of evacuations steadily increased from 2008 (n = 3,703) until a peak in 2010 (n = 4,929), which was also the peak year for battle injury (n = 1,472). Battle injury was also most prevalent in the 21 to 24 age group (24.7%) and declined in older age groups. Regarding diagnoses, the leading categories were injury/poisoning (33.1%), psychiatric (28.1%), and musculoskeletal (12.1%). As for specialty care of evacuees, psychiatry received the largest share of total evacuations (28.1%), followed by orthopedic surgery (22.7%) and general surgery (8.6%). Looking at proportions of inpatient and outpatient care, the majority of evacuees required outpatient care (65.6%) with a sizable minority requiring inpatient care (34.4%). Inpatient evacuations peaked in 2010 (n = 2,013), accounting for 40.8% of all evacuations that year. Orthopedic surgery had the largest share of inpatient evacuations (27.3%), followed by psychiatry (21.5%) and general surgery (18.2%). As for outpatient care, the specialties with the largest proportion of outpatient evacuations were psychiatry (33.6%), orthopedic surgery (20.3%), and neurology (9.8%)., Conclusions: The results of this study reveal what the MHS can expect in future conflicts. Most evacuations are for psychiatric-/injury-/musculoskeletal-related diagnoses, typically requiring care by psychiatrists, orthopedic surgeons, or general surgeons. Outpatient care is important, though it is critical to bolster inpatient care requirements as future conflicts may bring extensive numbers of inpatient casualties. The MHS should program and plan resources accordingly, planning for the care of surgical/injured and psychiatric patients., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Purpose: This study aimed to understand current prehospital trauma air-ambulance policies and triage guidelines across Canada. The research question centered on understanding the guidelines used by provinces and territories and identifying potential regional variations in air-ambulance triage., Methods: We conducted a cross-sectional survey from November 2022 to May 2023, involving trauma leaders from Canada's 13 provinces and territories. Participants were identified via the Trauma Association of Canada and professional networks. The survey, developed with expert input and pilot tested for clarity, focused on prehospital trauma-triage guidelines, level of adoption of Center for Disease Control and Prevention (CDC) triage guidelines, and auto-launch air-ambulance policies. Data were collected using an 18-item electronic survey. Potential response bias was considered, and confidentiality was maintained. A cross-sectional qualitative analysis was used to evaluate the guidelines' adoption and variations, with responses compared across regions., Results: The analysis revealed a nationwide adoption (11 of 11 respondents) of the CDC guidelines, indicating a standardized approach to patient transportation. Notably, many provinces and territories (5 of 11) endorse auto-launch protocols for air ambulances in specific scenarios. These policies offer advantages in geographically vast regions weighed against the cost of over-triage and inefficient resource allocation. Each province and territory tailors its approach based on factors such as geographic areas served, and available resources., Conclusion: This study provides a snapshot of the current state of prehospital trauma-triage guidelines in Canada. With some differences in nomenclature, Canadian provinces and territories widely apply the CDC guidelines to serve their populations. There is some regional variation on how transport is initiated within their borders. The findings underscore the delicate balance required for optimizing air-ambulance policies, considering factors such as timely access, resource allocation, and the local application of guidelines., Competing Interests: Declarations Conflict of interest There are no conflicts of interest to declare., (© 2024. The Author(s), under exclusive licence to the Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Helicopter emergency medical services (HEMS) have become widespread around the world. However, previous studies of the influence of HEMS on mortality were limited to adult patients only and showed inconsistent and heterogeneous results. This study aimed to examine the association between HEMS and mortality among pediatric emergencies compared to ground emergency medical service (GEMS)., Methods: We searched relevant databases (MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials) and included articles in any language. The most recent search was on January 4th, 2024. We included prospective observational cohort studies or clinical trials that compared HEMS with GEMS in pediatric patients. We excluded any study that did not compare two or more groups of participants. Two pairs of researchers blindly screened studies and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. We conducted this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were extracted by four independent reviewers. We calculated the odds ratio using the random-effects model. The primary outcome was mortality., Results: Our search strategy yielded 1454 results. Of these, seven observational studies met our eligibility criteria; no RCT met the criteria. All studies targeted trauma patients only. HEMS was associated with lower mortality (Odds ratio 0.66, 95 % CI 0.59 to 0.74). Inconsistency between trials was determined to be low due to low heterogeneity (I 2  = 0 %). In a subgroup analysis conducted with and without physicians on the HEMS staff, we found no significant differences (I 2  = 0 %, p = 0.71)., Conclusion: Our systematic review and meta-analysis, which was limited to trauma pediatric trauma patients, revealed that HEMS deployment correlated with decreased mortality. Further research is necessary to more effectively measure the potential influence and applicability of HEMS for pediatric emergencies., Competing Interests: Declaration of competing interest Yusuke Tsutsumi reports financial support was provided by Japan Society for the Promotion of Science. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Young Australians living in rural and remote locations have poorer mental health outcomes and higher rates of self-harm and suicide than their major city counterparts. Significant service gaps and barriers exist in accessing general and youth-specific mental health services. With a lack of access, comes delays in treatment and associated poorer outcomes. This paper describes the characteristics of young people requiring an aeromedical retrieval (AR) for acute inpatient psychiatric care., Study Design and Methods: A retrospective secondary analysis was conducted of Royal Flying Doctor Service ARs for a six-year period from 2016 to 2021. Data were summarised by demographic, geographic, and diagnostic factors., Results: The total sample size was 1534 (60% male, 40% female; and 31% aged 12-17 years, 69% aged 18-24 years), with 668 (43.5%) affected by schizophrenia and related disorders. Port Augusta, 300 km north of Adelaide, had the highest proportion of aeromedical retrievals (4.4%). The Women's and Children's Hospital in Adelaide received the highest proportion of retrievals (25.6%). Statistically significant gender and age differences were identified as were specific high-usage geographical locations across several Australian states., Conclusions: AR is essential for young people in accessing specialist acute health services. Developmentally appropriate, responsive, youth mental health services are mostly located in large, already well-resourced major cities. Our study provides valuable information to assist governments, communities, and services to enhance the resources available for young people who live rurally., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Helicopter emergency services (HEMS) are widely used to bring medical assistance to individuals that cannot be reached by other means or individuals that have time-critical medical conditions, such as chest pain, stroke or severe trauma. It is a very expensive resource whose use and importance depends on local conditions. The aim of this study was to describe flight and patient characteristics in all HEMS flights done in Iceland, a geographically isolated, mountainous and sparsely populated country, over a 5-year course., Methods: This retrospective study included all individuals requiring HEMS transportation in Iceland during 2018-2022. The electronic database of the Icelandic Coast Guard was used to identify the individuals and register flight data. Electronic databases from Landspitali and Akureyri hospitals were used to collect clinical variables. Descriptive statistics was applied., Results: The average number of HEMS transports was 3.5/10,000 inhabitants and the median [IQR] activation time and flight times were 30 min [20-42] and 40 min [26-62] respectively. The vast majority of patients were transported to Landspitali Hospital in Reykjavik. More than half of the transports were due to trauma, the most common medical transports were due to chest pain or cardiac arrests. Advanced medical therapy was provided for 66 (10%) of individuals during primary transports, 157 (24%) of individuals were admitted to intensive care, 188 (28%) needed surgery and 53 (7.9%) needed a coronary angiography., Conclusion: In Iceland, the number of transports is lower but activation and flight times for HEMS flights are considerably longer than in other Nordic countries, likely due to geographical features and the structure of the service including utilizing helicopters both for HEMS and search and rescue operations. The transport times for some time-sensitive conditions are not within standards set by international studies and guidelines., (© 2024 Acta Anaesthesiologica Scandinavica Foundation.)

Background and Importance: Following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), a low body temperature on arrival at the hospital and on admission to the ICU is reportedly associated with increased mortality. Whether this association exists in the prehospital setting, however, is unknown., Objective: The objective of this study was to investigate whether the initial, prehospital core temperature measured post-ROSC is independently associated with survival to hospital discharge in adult patients following OHCA., Design, Setting and Participants: This retrospective observational study was conducted at East Anglian Air Ambulance, a physician-paramedic staffed Helicopter Emergency Medical Service in the East of England, UK. Adult OHCA patients attended by East Anglian Air Ambulance from 1 February 2015 to 30 June 2023, who had post-ROSC oesophageal temperature measurements were included., Outcome Measure and Analysis: The primary outcome measure was survival to hospital discharge. Core temperature was defined as the first oesophageal temperature recorded following ROSC. Multivariable logistic regression evaluated the adjusted association between core temperature and survival to hospital discharge., Main Results: Resuscitation was attempted in 3990 OHCA patients during the study period, of which 552 patients were included in the final analysis. The mean age was 61 years, and 402 (72.8%) patients were male. Among them, 194 (35.1%) survived to hospital discharge. The mean core temperature was lower in nonsurvivors compared with those who survived hospital discharge; 34.6 and 35.2 °C, respectively (mean difference, -0.66; 95% CI, -0.87 to -0.44; P  < 0.001). The adjusted odds ratio for survival was 1.41 (95% CI, 1.09-1.83; P  = 0.01) for every 1.0 °C increase in core temperature between 32.5 and 36.9 °C., Conclusion: In adult patients with ROSC following OHCA, early prehospital core temperature is independently associated with survival to hospital discharge., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To survey the current structure, capability and operational scope of pre-hospital and retrieval aeromedical teams across Australia., Methods: The medical directors of all Australian civilian adult aeromedical retrieval organisations with pre-hospital teams and/or doctors for inter-hospital critical care patient transport were contacted in a survey to qualitatively assess capacity and team structure., Results: All 17 organisations contacted completed the survey. While there is diversity in team structure with the pairing of doctors, paramedics and nurses, capacity for patient care is generally homogenous. A doctor/paramedic model is the more common team structure for rotary-wing missions, and doctor/nurse for fixed-wing. Differences are mostly due to state government controlled aspects of their health services. An advanced degree of intensive patient care occurs outside of the hospital. Land and sea rescue is an important aspect of Australian aeromedical work., Conclusion: Aeromedicine in Australia has many consistent elements, but variable contexts have resulted in a diversity of operational models., (© 2024 Australasian College for Emergency Medicine.)

Objective: To define the utility of the Triage Revised Trauma Score (TRTS), GCS/Age/arterial Pressure (GAP) score, and shock index (SI) in predicting the need for in-flight blood product administration in civilian trauma patients transported by an aeromedical platform., Methods: A retrospective chart review of 3582 aeromedical trauma cases was conducted. An initial TRTS, GAP score and SI were calculated for each patient, and the administration of in-flight blood products was also recorded. Receiver operating characteristic (ROC) curves were used to quantify the predictive discrimination of the TRTS, GAP score and SI on the need for in-flight blood product administration., Results: The SI showed a superior predictive value compared to the TRTS and GAP score. The SI showed an area under the curve on the ROC curve of 0.85 in both primary and inter-hospital transfer cases, indicating reasonable predictive value., Conclusion: The SI demonstrates favourable test characteristics for predicting the need for in-flight blood product administration. Prospective validation of these results is warranted., (© 2024 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

Background and Importance: Traumatic cardiac arrest is associated with poor prognosis, and timely evidence-based treatment is paramount for increasing survival rates. Physician-staffed helicopter emergency medical service use in major trauma has demonstrated improved outcomes. However, the sparsity of data highlights the necessity for a comprehensive understanding of the epidemiology of traumatic cardiac arrest., Objectives: The primary objective of the present study was to evaluate survival and return of spontaneous circulation (ROSC) and to investigate the characteristics of patients with traumatic cardiac arrest assessed by the Danish HEMS., Design: This was a population-based cohort study based on data from the Danish helicopter emergency medical service database., Settings and Participants: The study included all patients assessed by the Danish helicopter emergency medical services between 2016 and 2021., Outcome Measures and Analysis: Data were analysed using descriptive statistics, non-parametric testing and logistic regression analyses. Descriptive analysis of prehospital interventions included cardiopulmonary resuscitation, defibrillation, airway management, administration of blood products, and thoracic decompression. The primary outcome was 30-day survival, and the key secondary outcome was prehospital ROSC., Main Results: A total of 223 patients with TCA were included. The median age was 54 years (IQR 34-68), and the majority were males. Overall, 23% of patients achieved prehospital ROSC, and the 30-day survival rate was 4%. Factors associated with an increased likelihood of ROSC were an initial shockable cardiac rhythm, odds ratio (OR) of 3.78 (95% CI 1.33-11.00) and endotracheal intubation, OR 7.10 (95% CI 2.55-22.85)., Conclusion: This study highlights the low survival rates observed among patients with traumatic cardiac arrest assessed by helicopter emergency medical services. The findings support the positive impact of an initial shockable cardiac rhythm and endotracheal intubation in improving the likelihood of ROSC. The study contributes to the limited literature on traumatic cardiac arrests assessed by physician-staffed helicopter emergency services. Finally, the findings emphasise the need for further research to understand and improve outcomes in this subgroup of cardiac arrest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Trauma patients treated by the Helicopter Emergency Medical Services (HEMS) can be transported to the hospital either by helicopter or by ambulance, in both cases accompanied by the HEMS physician. The objectives of this study are first to compile an overview of patients treated and transported by the HEMS team with either the helicopter (patients transported by helicopter, PTH) or with the ambulance (patients transported by ambulance, PTA). In addition, to evaluate whether the existing information systems obtain relevant data for researching the decision-making process. The second objective is to identify potentially influencing factors that could be significant for further research., Methods: All patients in the period from 1 January 2011 until 31 December 2020, treated by HEMS and subsequently transported to hospitals were included in the study. To avoid overrepresentation of the PTA group, a random sample was taken, creating two groups in a 1:2 ratio (PTH n = 724, PTA n = 1448). Differences in patient and treatment characteristics between PTH and PTA were compared using t-tests, Mann-Whitney U tests, and chi-square tests., Results: PTH accounted for 12.2% of all transports. Approximately two-third of the patients were male and the mean age was around 40 years. PTH had lower iEMV (initial Eye opening, best Motor response, best Verbal response) and iRTS (initial Revised Trauma Score) scores, were more frequently transported to a level 1 trauma centre, underwent more prehospital treatments and were roughly twice as far from their hospital of arrival compared to PTA., Conclusion: The current dataset is, after some modifications, suitable to provide a comprehensive overview of patients treated by HEMS in the Netherlands. A predictive model could be developed using this dataset, which should include factors such as the patient's location, age, distance to the hospital, physician on duty, mechanism of injury and overall injury severity., (© 2024. The Author(s).)

The coronavirus disease 2019 pandemic has profoundly affected the Lombardy healthcare system. Although air transport of critical patients played a crucial role, there are still gaps in understanding how the pandemic impacted helicopter emergency medical services (HEMS). A retrospective observational analysis was performed using data from the regional emergency-urgency online portal. The investigation focused on patients airlifted by helicopter to the Lombardy emergency departments from January 1, 2019, to December 31, 2021. A total of 12,953 admissions to the emergency departments have been recorded (5,733 in 2019, 3,550 in 2020, and 3,670 in 2021). The monthly average of events changed significantly over the 3 years (2019 [477.7], 2020 [295.8], and 2021 [305.8]) (P < .001). Additionally, there was a notable increase in the percentage of severe cases with red triage codes in 2020 (28.9%) and 2021 (33.5%) compared with 2019 (19.9%). Moreover, the number of hospitalized patients increased in 2020 (39.9%) and 2021 (37.2%) compared with 2019 (27.7%). The HEMS documented a noteworthy decrease in mission numbers and an increase in patient clinical severity during the pandemic. Consequently, the HEMS might be allocated for specific roles in national pandemic plans during the alert phase activation, such as secondary transport between hospital facilities., Competing Interests: Declaration of competing interest The author(s) have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2024 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this scoping review was to identify and characterize helicopter emergency medical services (HEMS) outcomes literature from 2023, with the goal of describing updates to the Critical Care Transport Collaborative Outcomes Research Effort HEMS Outcomes Assessment Research Database (HOARD)., Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, a multireviewer approach was used to source and review articles published or in preprint databases from 2023. The articles included assessed a patient-centered outcome for HEMS versus a non-HEMS control group. Article characteristics included the journal impact factor (JIF), diagnostic group (trauma or nontrauma), and geographic origin. Categoric analyses comparing 2023 studies with HOARD studies from the previous decade (2013-2022) were executed with the Fisher exact test; nonnormal JIF data were described using median and interquartile range and analyzed (vs 2013-2022) with rank sum testing., Results: Of the initial records (N = 4,486), 4,410 were screened out, leaving 76 for full-text review. Of these, 58 were discarded, and 18 were classified as eligible for addition to HOARD. Most studies (14/18, 78%) focused on trauma, and an equally high proportion (14/18, 78%) came from North America. The median JIF was 2.4 (interquartile range, 1.2-3.6). Compared with HOARD studies from the previous decade, 2023 studies were similar with respect to diagnostic focus (P = .779), geographic origin (P = .171), and JIF (P = .531)., Conclusion: This scoping review provides information on 18 HEMS outcomes studies new to the evidence base in 2023., Competing Interests: Declaration of Competing Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: Anaphylaxis can lead to a life-threatening situation. Therefore, rapid diagnosis and emergency treatment is indicated. Immediate treatment with intramuscular adrenaline (or intravascularly with sufficient medical expertise) in anaphylaxis with cardiovascular and/or respiratory symptoms is recommended by various guidelines. Previous studies have shown that anaphylaxis is often not treated according to guidelines and that adrenaline in particular is rarely administered., Objective: The aim of the study was to investigate the data on emergency treatment and outcomes of patients with anaphylaxis by the air rescue and ground-based emergency services Dresden. Moreover, the results of the air- and ground-based services were compared. The focus was on administration of adrenaline and outcomes., Materials and Methods: Data from the ground-based emergency service Dresden (from 2012 to 2016) and the air rescue service Dresden (from 2008 to 2015) related to anaphylactic reactions were analyzed retrospectively. The severity of the anaphylaxis, the emergency medication administered, further monitoring, and outcomes were analyzed., Results: Data from 152 adults/29 children were analyzed for air rescue and 1131 adults/223 children for the ground-based emergency service. Adults with grade II-IV anaphylaxis received adrenaline in 19% (air rescue) and 7% (ground rescue) of cases. Children with grade II-IV anaphylaxis received adrenaline in 7% (air rescue) and 8% (ground rescue) of cases. Immediate drug therapy led to an improvement in general condition in 96-98% (air rescue) and 72-77% (ground-based emergency service) of cases. A significant correlation was found between the administration of adrenaline and the improvement in outcome in the ground-based emergency cohort., Conclusion: Guideline-compliant first-line therapy with adrenaline was not performed in the majority of the cases analyzed in this study. The significant effect of adrenaline on outcome demonstrated in this study emphases the need to improve the emergency treatment of anaphylactic reactions., (© 2024. The Author(s).)

Introduction: Rural emergency prehospital care in British Columbia is conducted primarily by the British Columbia Ambulance Services or ground search and rescue volunteers. Since 2014, the volunteer Air Rescue One (AR1) program has provided helicopter emergency winch rescue services to rural British Columbia. The aim of this research was to describe the activity of the AR1 program and to make recommendations to improve future operations., Methods: Data were collected retrospectively from September 2014 to May 2021, and parameters of emergency callout statistics from the organization's standard operating guidelines, rescue reports, and interviews were summarized and reviewed., Results: Of 152 missions within the study period, 105 were medically related rescues involving trauma or cardiac events. Snowmobiling, mountain biking, and hiking were the most common activities requiring rescue. The 38 medical callouts that were not completed by AR1 were reviewed for contributing factors. Response time varied due to the vast service area, but median time from request to takeoff was 55 min (interquartile range 47-69 min), and median on-scene time was 21 min (interquartile range 11-33 min)., Conclusions: AR1 provides advanced medical care into British Columbia's remote and difficult-to-access areas, minimizing delays in treatment and risk to patients and responders. Callout procedures should be streamlined enabling efficient AR1 activation. Collection of medical and flight information should be improved with standardized documentation, aiding in internal education and future research into the program's impact on emergency prehospital care. Future directions for improvement of care include the possibility of introducing portable ultrasound technology.

Background: Helicopter Emergency Medical Services (HEMS) in the United Kingdom (UK) are provided in a mixed funding model, with the majority of services funded by charities alongside a small number of government-funded operations. More socially-deprived communities are known to have greater need for critical care, such as that provided by HEMS in the UK. Equity of access is an important pillar of medical care, describing how resource should be allocated on the basis of need; a concept that is particularly relevant to resource-intensive services such as HEMS. However, the Inverse Care Law describes the tendency of healthcare provision to vary inversely with population need, where healthcare resource does not meet the expected needs in areas of higher deprivation. It is not known to what extent the Inverse Care Law applies to HEMS in the UK., Methods: Modelled service areas were created with each small unit geography locus in the UK assigned to its closest HEMS operational base. The total population, median decile on index of multiple deprivation, and geographic area for each modelled service area was determined from the most recently available national statistics. Linear regression was used to determine the association between social deprivation, geographic area, and total population served for each modelled service area., Results: The provision of HEMS in the UK varied inversely to expected population need; with HEMS operations in more affluent areas serving smaller populations. The model estimated that population decreases by 18% (95% confidence interval 1-32%) for each more affluent point in median decile of index of multiple deprivation. There was no significant association between geographic area and total population served., Conclusion: The provision of HEMS in the UK is consistent with the Inverse Care Law. HEMS operations in more deprived areas serve larger populations, thus providing a healthcare resource inversely proportional with the expected needs of these communities. Funding structures may explain this variation as charities are more highly concentrated in more affluent areas., (© 2024. The Author(s).)

Introduction: The primary objective of this study was to evaluate the association between the U.S. Air Force Critical Care Air Transport (CCAT) provider operational experience with compliance for lung protective ventilation (LPV) volumes recommended by Acute Respiratory Distress Syndrome Clinical Network guidelines., Materials and Methods: We performed a retrospective cohort study of CCAT providers transporting combat casualties requiring mechanical ventilation from the Middle East to Germany from 2007 to 2012. We reviewed CCAT medical records from 2007 to 2012 for the total number of patient transports by CCAT physicians and respiratory care practitioners (RCPs). Center for Sustainment of Trauma and Readiness Skills Cincinnati process improvement questionnaire data described provider demographics and clinical backgrounds. We linked these data to patient demographics and in-flight ventilation management from a prior CCAT cohort study. Patient inclusion criteria included transport by CCAT from the Middle East to Germany for traumatic injury requiring mechanical ventilation between 2007 and 2012. We excluded patients with no documented height or tidal volume. LPV compliance was defined as tidal volumes ≤8 mL/kg of predicted body weight during en route critical care transport. We performed a logistic regression analysis. This study was reviewed and approved by the 59th Medical Wing institutional review board (IRB)., Results: We analyzed 491 patient transports conducted by 71 (RCPs and 84 physicians. Patients had a median age of 25 years (IQR 22-30), 98% were male, median injury severity score was 24 (IQR 17-34), and median preflight PaO2/FiO2 was 285 (IQR 220-365). Median experience was 26 missions (IQR 13-40) for RCPs and 23 missions (IQR 12-38) for physicians. All in-flight tidal volumes were LPV compliant in 58.3% of missions. Unadjusted analysis showed higher LPV compliance for RCPs with in-garrison critical care experience. Multivariate models did not find an association between missions flown and LPV compliance but did demonstrate a positive association with physician specialty of medical intensivist (OR 3.0, 95% CI 1.6-5.7) and a negative association with flights in 2008 (OR 0.4, 95% CI 0.2-0.7) for LPV compliance., Conclusion: No association was found between number of missions flown by CCAT providers and lung protective tidal volume compliance. Linkage of multiple data sources enabled investigation of clinical and operational currency associations with a care quality metric compliance in the combat en route care environment. Future studies should evaluate the impact of ongoing CCAT training and quality improvement interventions on LPV compliance., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Current standards for hemoglobin monitoring during air transports of U.S. combat wounded are invasive and intermittent. Fielded pulse co-oximeters can noninvasively measure total hemoglobin, but this parameter is not currently utilized. The primary objective of this study was to assess the percentage of vital sign measurements with successful capture of total noninvasive hemoglobin measurement using spectrophotometry-based technology for Hb (SpHb) measurements in healthy participants during training flights. Secondary objectives were to assess the feasibility of a novel electronic data capture mechanism from usual patient movement items and perform a pilot analysis of SpHb changes in healthy participants during transitions from ground to air transport., Methods: We conducted a feasibility study enrolling healthy participants who had hemodynamic monitoring during usual U.S. Air Force Critical Care Air Transport (CCAT) flight training exercises from 2022 to 2023. Usual CCAT monitoring equipment and currently used Masimo Rainbow® pulse co-oximeters had the capability to measure SpHb. After each training exercise, the study team wirelessly downloaded case files from patient monitors utilizing the Battlefield Assisted Trauma Distributed Observation Kit (BATDOKTM) Case Downloader application. We then calculated point and precision estimates for the percentage of time for successful SpHb capture during the exercise and compared this to pulse oximetry (SpO2) capture. An a priori precision analysis for percentage of flight-time with successful SpHb data capture and descriptive statistics were performed. This study received Exempt Determination by the 59th Medical Wing IRB., Results: We analyzed 26 records with mean monitoring durations of 94.5 [59.3-119.9] minutes during ground phases and 78.0 [59.9-106.5] minutes during flight phases. SpHb measures were successfully captured for 97.7% (n = 4,620) of possible ground measurements and 97.2% (n = 3,973) of possible in-flight measurements compared to 99.5% ground and 98.2% in-flight capture for SpO2. Mean intervals of missing SpHb data were 2 ± 5 minutes on the ground and 4 ± 6 minutes in-flight. Mean SpHb increased by 0.93 ± 0.96 g/dL during the ground phase, but had minimal changes during ascent, cruising altitude or descent. The BATDOKTM Case downloader completed transfer for all files., Conclusion: Masimo Rainbow® SpHb pulse co-oximeters reliably captured continuous, noninvasive hemoglobin measurements using usual CCAT patient movement items in healthy participants during both ground and flight training. The BATDOKTM Case Downloader successfully imported case files from CCAT patient monitors. Mean SpHb measures had a small increase during the ground phase of monitoring followed by minimal changes when transitioning to flight altitude., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: Ruptured abdominal aortic aneurysms (rAAAs) are highly morbid emergencies. Not all hospitals are equipped to repair them, and an air ambulance network may aid in regionalising specialty care to quaternary referral centres. The association between travel distance by air ambulance and rAAA mortality in patients transferred as an emergency for repair was examined., Methods: A retrospective review of institutional data. Adults with rAAA (2002 - 2019) transferred from an outside hospital (OSH) to a single quaternary referral centre for repair via air ambulance were identified. Patients who arrived via ground transport or post-repair at an OSH for continued critical care were excluded. Patients were divided into near and far groups based on the 75th percentile of the straight line travel distance (> 72 miles) between hospitals. The primary outcome was 30 day mortality. Multivariable logistic regression was used to assess the association between distance and mortality after adjusting for age, sex, ethnicity, cardiovascular comorbidities, and repair type., Results: A total of 290 patients with rAAA were transported a median distance of 40.4 miles (interquartile range 25.5, 72.7) with 215 (74.1%) near and 75 (25.9%) far patients. Both the near and far groups had similar ages, sex, and ethnicity. There was no difference in pre-operative loss of consciousness, intubation, or cardiac arrest between groups. Endovascular aneurysm repair utilisation and intra-operative aortic occlusion balloon use were also similar. Neither the observed (26.8% vs. 23.9%, p = .61) nor the adjusted odds ratio (0.70, 95% confidence interval 0.36 - 1.39, p = .32) 30 day mortality rate differed significantly between the near and far groups., Conclusion: Increasing distance travelled during transfer by air ambulance was not associated with worse outcomes in patients with rAAA. The findings support the regionalisation of rAAA repair to large quaternary centres via an integrated and robust air ambulance network., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Rapid global population growth and urbanization have heightened the demand for emergency medical rescue, with helicopter medical rescue emerging as an effective solution. The advent of 5G communication technology, characterized by large bandwidth, low latency, and high reliability, offers substantial promise in enhancing the efficiency and quality of helicopter rescue operations. However, the full integration of 5G technology into helicopter emergency medical services is still in its nascent stages and requires further development. In this viewpoint, we present our experience from the Shenzhen University General Hospital of the application of 5G low-altitude network communication technology, body area network disease sensing technology, and 5G air-ground collaborative rapid diagnosis and treatment technology in aeromedical rescue. We consider that the 5G air-to-ground collaborative rapid diagnosis and treatment technology enables high-quality remote consultation, enhancing emergency medical rescue and providing strong support for future rescue operations., (©Wei Han Sr, Yuanting Li 2nd, Changgen Chen 3rd, Danni Huang, Junchao Wang, Xiang Li, Zhongliang Ji, Qin Li, Zhuang Li. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 01.08.2024.)

Introduction: An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS)., Materials and Methods: This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed., Results: A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1)., Conclusion: The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high., Competing Interests: Declaration of competing interest The authors declare no competing interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Inappropriate fluid management during patient transport may lead to casualty morbidity. Percent systolic pressure variation (%SPV) is one of several technologies that perform a dynamic assessment of fluid responsiveness (FT-DYN). Trained anesthesia providers can visually estimate and use %SPV to limit the incidence of erroneous volume management decisions to 1-4%. However, the accuracy of visually estimated %SPV by other specialties is unknown. The aim of this article is to determine the accuracy of estimated %SPV and the incidence of erroneous volume management decisions for Critical Care Air Transport (CCAT) team members before and after training to visually estimate and utilize %SPV., Material and Methods: In one sitting, CCAT team providers received didactics defining %SPV and indicators of fluid responsiveness and treatment with %SPV ≤7 and ≥14.5 defining a fluid nonresponsive and responsive patient, respectively; they were then shown ten 45-second training arterial waveforms on a simulated Propaq M portable monitor's screen. Study subjects were asked to visually estimate %SPV for each arterial waveform and queried whether they would treat with a fluid bolus. After each training simulation, they were told the true %SPV. Seven days post-training, the subjects were shown a different set of ten 45-second testing simulations and asked to estimate %SPV and choose to treat, or not. Nonparametric limits of agreement for differences between true and estimated %SPV were analyzed using Bland-Altman graphs. In addition, three errors were defined: (1) %SPV visual estimate errors that would label a volume responsive patient as nonresponsive, or vice versa; (2) incorrect treatment decisions based on estimated %SPV (algorithm application errors); and (3) incorrect treatment decisions based on true %SPV (clinically significant treatment errors). For the training and testing simulations, these error rates were compared between, and within, provider groups., Results: Sixty-one physicians (MDs), 64 registered nurses (RNs), and 53 respiratory technicians (RTs) participated in the study. For testing simulations, the incidence and 95% CI for %SPV estimate errors with sufficient magnitude to result in a treatment error were 1.4% (0.5%, 3.2%), 1.6% (0.6%, 3.4%), and 4.1% (2.2%, 6.9%) for MDs, RNs, and RTs, respectively. However, clinically significant treatment errors were statistically more common for all provider types, occurring at a rate of 7%, 10%, and 23% (all P < .05). Finally, students did not show clinically relevant reductions in their errors between training and testing simulations., Conclusions: Although most practitioners correctly visually estimated %SPV and all students completed the training in interpreting and applying %SPV, all groups persisted in making clinically significant treatment errors with moderate to high frequency. This suggests that the treatment errors were more often driven by misapplying FT-DYN algorithms rather than by inaccurate visual estimation of %SPV. Furthermore, these errors were not responsive to training, suggesting that a decision-making cognitive aid may improve CCAT teams' ability to apply FT-DYN technologies., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The War in Afghanistan ended in August 2021. Evacuation from the country was a large effort during the last days of the conflict. During evacuation efforts at Kabul Hamid Karzai International Airport, a suicide bombing occurred necessitating emergent medical care for many injured troops and civilians. The U.S. Air Force Critical Care Air Transport Teams (CCATTs) played a role in the medical care provided during the operations in Afghanistan. We report on in-flight events and interventions that took place during the final days of the Afghanistan withdrawal., Materials and Methods: We performed a retrospective chart review of patients requiring aeromedical evacuation from the Afghanistan theater of operations by CCATT from July 1 to August 30, 2021. From the CCATT patient care record, data abstractors collected patient characteristics, flight information, vital signs, laboratory values, in-flight interventions, and in-flight events in a study-specific electronic database. We performed descriptive analyses of patient characteristics and in-flight interventions. This study was approved by the San Antonio Institutional Review Board., Results: Nine patients were included in this analysis. Seven out of nine patients were foreign nationals; the remaining two were U.S. Marines. Five patients suffered penetrating injuries from gunshot wounds and four suffered blast injuries. Six received intravenous narcotic analgesia. Four received intravenous sedatives, and four received antibiotics in flight. Two patients required chest tube management. One patient received blood. Three patients were in acute respiratory distress., Conclusions: Severe injuries were sustained during the withdrawal efforts at the end of the War in Afghanistan. Critical Care Air Transport Teams played a role in the care and evacuation of patients out of theater during this unique and unprecedented time. Even given the limitations associated with retrospective studies and a small sample size, information reported in this study can help inform future decisions, and aid in preparatory efforts for future operations, that may require medical care by CCATT., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF)., Materials and Methods: We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF)., Results: We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%])., Conclusions: Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: The objective of this study was to use the National Emergency Medical Services Information System (NEMSIS) dataset to generate national air medical transport statistics., Methods: Retrospective review of the 2021 NEMSIS dataset to identify all air medical transfers, both fixed- and rotor-wing. Transfers where then subcategorized into interfacility and scene responses. Frequencies for each category were generated and reported., Results: A total of 317,267 air medical transfers were completed in 2021. These included 19,421 (6 %) with missing incident location code data. Of the 297,706 transfers with valid location codes, 208,689 (70%) were interfacility transfers, and 89,016 (30%) were scene responses., Conclusion: These preliminary results are consistent with other national estimates and achieve representation of all states and territories. Future work will include longitudinal analysis of NEMSIS datasets and direct survey of transport programs to establish long-term reliability., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has proven to be a significant hardship for the entire world. Health care systems and their workers have been stretched to their limits. Research regarding whether this increased strain has affected patient safety has not been sufficient, especially in emergency medical services. The aim of this study was to determine if there has been an increased rate of adverse events in ground and helicopter emergency medical services since the onset of the COVID-19 pandemic., Methods: A 2-year retrospective review was performed at a Midwest regional critical care transport service. The rate of adverse events for 1-year periods before and after March 13, 2020, was the primary outcome. All adverse events that generated a quality improvement incident report form (QIRF) were included, except those generated for non-clinical-related incidents. Additionally, a smaller time frame between May 1st and August 31st of both years was included containing all flagged adverse events from peer reviewers; not all of these generated a QIRF., Results: In the time period between March 13, 2019, and March 12, 2020, 5 of 3,154 (0.16%) calls generated a QIRF versus 21 of 3,185 (0.66%) calls between March 13, 2020, and March 12, 2021. There was a significant relationship showing an adverse event was more likely to happen after the onset of COVID-19 compared with before (χ 2 1 [N = 6,339] = 8.643, P ≤ .001). Additionally, from May 1st to August 31st, the total adverse event rates were 16.86% (143/848 calls) and 24.46% (387/1,582 calls) for 2019 and 2020, respectively. Similarly, statistical significance existed for adverse events occurring after onset of the pandemic versus before (χ 2 1 [N = 2,430] = 18.253, P ≤ .001)., Conclusion: A higher rate of adverse events for the year after the onset of COVID-19 existed. Additional studies looking at the causes of adverse events and patient outcomes should be undertaken to further understand this increase., Competing Interests: Declaration of Competing Interest The author(s) have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to conduct a detailed geospatial analysis of mobile phone signal coverage in the northwest macro-region of Paraná State, Brazil, seeking to identify areas where limitations in coverage may be related to lengthy travel times of the helicopter emergency medical service (HEMS) for the assistance of victims of road traffic injuries (RTIs)., Methods: An observational study was conducted to examine mobile phone signal coverage and HEMS travel times from 2017 to 2021. HEMS travel times were categorized into four groups: T1 (0-15 min), T2 (16-30 min), T3 (31-45 min), and T4 (over 45 min). Empirical Bayesian Kriging was used to map areas with low mobile signal coverage. The Kruskal-Wallis test and Dwass-Steel-Critchlow-Fligner comparative analyses were performed to explore how mobile signal coverage relates to HEMS travel times to RTI locations., Results: There were 470 occurrences of RTIs attended by HEMS, of which 108 (23%) resulted in on-site fatalities. Among these deaths, 47 (26.85%) occurred in areas with low mobile phone signal coverage ("shadow areas"). Low mobile phone signal coverage identified at 175 (37.24%) RTIs locations, was unevenly distributed across the macro-region. The lowest medians of mobile signal quality were predominantly found in areas with HEMS travel times exceeding 30 min, corresponding to signal strength values of -98.44 (T3) and -100.75 (T4) dBm. This scenario represents a challenge for effective communication to activate HEMS. In the multiple comparison analysis among travel time groups, significant differences were observed between T1 and T2 ( p  < 0.001), T1 and T3 ( p  < 0.001), T1 and T4 ( p  < 0.001), and T2 and T3 ( p  < 0.001), indicating a potential association between lower mobile phone signal coverage and longer HEMS travel times., Conclusion: It can be concluded that poor mobile phone signals in remote areas can hinder HEMS activation, potentially delaying the start of treatment for RTIs. Identification of the shadow areas can help communication and health managers in designing and implementing the necessary changes to improve mobile phone signal coverage and consequently reduce delays in the initial response to RTIs.

Objectives: Helicopter emergency services (HEMS) serve a crucial role in the triage and transport of critically ill patients. Rapid transport to definitive care has become the goal of all prehospital EMS as shorter scene intervals have been associated with decreased mortality. Over the past several years, we have seen a rise in physicians trained in emergency medicine and EMS responding in the prehospital setting in our HEMS region. Our goal is to determine if the presence of EMS physicians on scene calls with HEMS delays time to hospital for patients., Methods: This retrospective chart review collected on-scene time data from January 2016 to November 2020. Data were collected from our regional HEMS provider database via EMSCharts. We compared the HEMS scene intervals between calls which were serviced by HEMS crews alone, versus those where EMS physicians were present. The Wilcoxon rank-sum test was used to compare these two distributions, and a p-value <0.05 was used to determine statistical significance., Results: We analyzed 1106 scene calls, four of which were excluded as they should have been designated as inter-facility transfers. Our analysis included 1079 scene calls with HEMS crews alone, and 23 scene calls with EMS physicians, with median HEMS scene intervals of 18 min and 19 min, respectively. A Wilcoxon rank-sum test comparing both distributions had a p-value of 0.30 (z= -1.04)., Conclusion: There was no significant difference between HEMS scene intervals at calls serviced by HEMS crews alone versus those where EMS physicians were present. EMS physician presence was not associated with prolonged HEMS scene intervals.

BACKGROUND Even in the normal course of pregnancy, alarming symptoms and obstetric complications can occur, necessitating appropriate care. Medical rescue and Helicopter Emergency Medical Services (HEMS) teams are responsible for responding to emergencies and performing medical emergency procedures on scene and during patient transport to hospital. The purpose of our study was to present the characteristics of HEMS and Emergency Medical Service (EMS) interventions concerning pregnant women in Poland. MATERIAL AND METHODS The study involved a retrospective analysis of missions by HEMS and EMS crews of the Polish Medical Air Rescue concerning pregnant women in Poland. The analysis included all HEMS and EMS flights to cases of accidents and other emergencies and air transport missions where medical assistance had been provided to pregnant women between January 2011 and December 2020. RESULTS Polish Medical Air Rescue teams were most commonly dispatched to urban areas (79.46%) and for inter-hospital transport (75.85%). The mean patient age was 29.72 years, and the most common diagnosis, in accordance with the International Statistical Classification of Diseases and Related Health Problems (ICD-10), was premature labor (24.38%). CONCLUSIONS Pregnant patients aged 30 and older and those receiving HEMS and EMS assistance in urban areas were found to have a higher odds ratio for premature labor. A correlation was identified between the diagnosis associated with the Polish Medical Air Rescue intervention and the pregnant woman's age and location of call.

Introduction: There is significant interest in the mental health impact of the COVID-19 pandemic. Helicopter Emergency Medical Services (HEMS) attend the most seriously unwell and injured patients in the community; their data therefore present an early opportunity to examine self-harm trends. The primary aim was to compare the incidence of deliberate self-harm incident (DSH-I) encounters by HEMS before and during the first wave of COVID-19., Methods: Data were obtained from all three East of England HEMS: total number of activations and stand-downs, number of DSH-I activations and stand-downs, self-harm mechanism and number of 'severe' DSH-I patient encounters, in two 61-day periods: 1 March to 30 April in 2019 (control) and 2020 (COVID-19). Severe DSH-I was defined as cardiac arrest and/or died prehospital. Proportions were compared with a Fisher's exact test., Results: There were a total of 1725 HEMS activations: n=981 (control) and n=744 (COVID-19), a decrease of 24.2% during COVID-19. DSH-I patient encounters increased by 65.4%: n=26 (control) and n=43 (COVID-19). The proportion of encounters that were DSH-I and severe DSH-I both significantly increased during COVID-19: p=0.002 and p=0.001, respectively. The absolute number of hangings and falls from height both approximately tripled during COVID-19, whereas the number of other mechanisms remained almost constant., Conclusion: Despite a reduction in overall HEMS patient encounters, there were significant increases in both the proportion of DSH-Is and their severity attended by HEMS during the first wave of the COVID-19 pandemic in the East of England., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Helicopter emergency medical services (HEMSs) are used with increasing frequency for the transportation of injured patients from the scene and from treatment facilities to higher levels of care. Improved outcomes have been difficult to establish, and reports of overutilization and financial harm have been published. Our study was performed to evaluate statewide utilization for interfacility transfers (IFTs)., Methods: Data from the North Carolina state trauma registry from 2013 to 2017 were evaluated and ground, and helicopter IFTs were compared., Results: Overall interfacility use of HEMSs peaked at 7,861 patient transports in 2016, and the percent of all IFTs fell from 17% to 13.3% over the study period. Helicopter emergency medical services patients were more likely to be male (69.8%) and younger (48.0 vs. 56.2 years), and have higher Injury Severity Scores (14.6 vs. 9.0) and higher mortality (10.5% vs. 2.8%) than ground emergency medical services (GEMSs) patients. When adjusted for age, sex, Injury Severity Score, and transport distance, HEMSs survival was significantly higher (odds ratio, 0.353; 95% CI, 0.308-0.404; p < 0.0001). Normal prehospital vital signs (VSs) and Glasgow Coma Scale score motor component (GCS-M) were associated with low mortality rates in both groups. Abnormal prehospital VSs and GCS-M were associated with an 11.8% mortality rate in HEMSs patients and 3.1% in GEMSs patients. Normal referring facility VSs and GCS-M did not confer similar protection with a mortality rate of 10.0% in HEMSs patients and 2.8% in GEMSs. Changes in prehospital to referring facility VSs did not demonstrate a low mortality group. Abbreviated Injury Scale and changes in VSs did not identify HEMSs transport benefit groups., Conclusion: The proportion of HEMSs transfers fell over the study period and, while associated with a 10.5% mortality rate, had an outcome benefit compared with GEMSs. These patients could not be sorted into risk categories for transportation choice based on VSs or GCS-M derangement or by changes thereof, and opportunities for system improvement were not identified., Level of Evidence: Prognostic/epidemiological study, level III; Care Management, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion., Methods: We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score., Results: A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001)., Conclusion: Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent., Level of Evidence: Therapeutic/care management, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions., Methods: We designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) between January 1, 2010, and December 31, 2019., Results: During the study period, 9,963 (88.7 %) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3 %) at night. Of the victims with time-critical injuries (NACA ≥ 4), 21.1 % (n = 400) reached the hospital within 60 min during the day, and 9.1 % (n = 18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥ 4 were independently and highly significantly associated with longer mission times (p < 0.001). The greatest proportion of patients who needed hoist or HEC operations in the course of the HEMS mission during the daytime sustained moderate injuries (NACA 3, n = 3,731, 37.5 %) while practicing recreational activities (n = 5,492, 55.1 %). In daytime HHO missions, the most common medical interventions performed were insertion of a peripheral intravenous access (n = 3,857, 38.7 %) and administration of analgesia (n = 3,121, 31.3 %)., Conclusions: Nearly 20 % of patients who needed to be evacuated by a hoist were severely injured, and complex and lifesaving medical interventions were necessary before the HHO procedure. Therefore, only adequately trained and experienced medical crew members should accompany HHO missions., (© 2021. The Author(s).)

Abstract: Previous comparison studies regarding 2 types of transportation, helicopter (HEMS) versus ground emergency medical services (GEMS), have shown underlying heterogeneity as these options have completely different routes and consequent times with reference to one patient. To compare the 2 types of transportation on a case-by-case basis, we analyzed the retrospectively reviewed HEMS and predicted GEMS data using an open-source navigation software.Patients transferred by military HEMS from 2016 to 2019 were retrospectively enrolled. The HEMS records on the time of notification, injury point and destination address, and time required were reviewed. The GEMS data on distance and the predicted time required were acquired using open-source social navigation systems. Comparison analyses between the two types of transportation were conducted. Furthermore, linear logistic regression analyses were performed on the distance and time of the two options.A total of 183 patients were enrolled. There was no statistical difference (P = .3021) in the distance between the 2 types of transportation, and the HEMS time was significantly shorter than that of GEMS (61.31 vs 116.92 minutes, P < .001). The simple linear curves for HEMS and GEMS were separately secured, and two graphs presented the statistical significance (P) as well as reasonable goodness-of-fit (R2). In general, the HEMS graph demonstrates a more gradual slope and narrow distribution compared to that of GEMS.Ideally, HEMS is identified as a better transportation modality because it has a shorter transportation time (56 minutes saved) and a low possibility of potential time delays (larger R2). With a strict patient selection, HEMS can rescue injured or emergent patients who are "out of the golden hour.", Competing Interests: Conflict of interest statement: The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. No financial support has been received in association with this submission., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Despite evidence of benefit after injury, helicopter emergency medical services (HEMS) overtriage remains high. Scene and transfer overtriage are distinct processes. Our objectives were to identify geographic variation in overtriage and patient-level predictors, and determine if overtriage impacts population-level outcomes., Methods: Patients 16 years or older undergoing scene or interfacility HEMS in the Pennsylvania Trauma Outcomes Study were included. Overtriage was defined as discharge within 24 hours of arrival. Patients were mapped to zip code, and rates of overtriage were calculated. Hot spot analysis identified regions of high and low overtriage. Mixed-effects logistic regression determined patient predictors of overtriage. High and low overtriage regions were compared for population-level injury fatality rates. Analyses were performed for scene and transfer patients separately., Results: A total of 85,572 patients were included (37.4% transfers). Overtriage was 5.5% among scene and 11.8% among transfer HEMS (p < 0.01). Hot spot analysis demonstrated geographic variation in high and low overtriage for scene and transfer patients. For scene patients, overtriage was associated with distance (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06 per 10 miles; p = 0.04), neck injury (OR, 1.27; 95% CI, 1.01-1.60; p = 0.04), and single-system injury (OR, 1.37; 95% CI, 1.15-1.64; p < 0.01). For transfer patients, overtriage was associated with rurality (OR, 1.64; 95% CI, 1.22-2.21; p < 0.01), facial injury (OR, 1.22; 95% CI, 1.03-1.44; p = 0.02), and single-system injury (OR, 1.35; 95% CI, 1.18-2.19; p < 0.01). For scene patients, high overtriage was associated with higher injury fatality rate (coefficient, 1.72; 95% CI, 1.68-1.76; p < 0.01); low overtriage was associated with lower injury fatality rate (coefficient, -0.73; 95% CI, -0.78 to -0.68; p < 0.01). For transfer patients, high overtriage was not associated with injury fatality rate (p = 0.53); low overtriage was associated with lower injury fatality rate (coefficient, -2.87; 95% CI, -4.59 to -1.16; p < 0.01)., Conclusion: Geographic overtriage rates vary significantly for scene and transfer HEMS, and are associated with population-level outcomes. These findings can help guide targeted performance improvement initiatives to reduce HEMS overtriage., Level of Evidence: Therapeutic, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: As part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020., Method: This was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation., Results: The median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces., Conclusion: The intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately., (Copyright © 2021 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Virtually every country in the world has been affected by coronavirus disease 2019 (COVID-19). Nepal is a landlocked country located in Southern Asia. Nepal's population has suffered greatly due to a shortage of critical care facilities, resources, and trained personnel. For appropriate care, patients need access to hospitals mostly in the centrally located capital city of Kathmandu. Unfortunately, Nepal's resources and personnel dedicated to transferring COVID-19 patients are scarce. Road and traffic infrastructure problems and mountainous terrain prevent ground ambulances from performing effectively. This, in addition to Nepal lacking national standards for prehospital care, create great challenges for transferring patients via ground emergency medical services. The concept of helicopter emergency medical services (HEMS) began in 2013 in Nepal. Presently, 3 hospitals, Nepal Mediciti Hospital, Hospital for Advanced Medicine and Surgery (HAMS), and Grande International Hospital, coordinate with private helicopter companies to run proper HEMS. One entity, Simrik Air, has dedicated 2 Airbus H125/AS350 helicopters for the sole purpose of transferring COVID-19 patients. HEMS effectiveness is expanding in Nepal, but much remains to be accomplished., (Copyright © 2021 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Purpose: The SARS-CoV-2 virus has disrupted global and local medical supply chains. To combat the spread of the virus and prevent an uncontrolled outbreak with limited resources, national lockdown protocols have taken effect in the Netherlands since March 13 th , 2020. The aim of this study was to describe the incidence, type and characteristics of HEMS and HEMS-ambulance 'Lifeliner 1' dispatches during the initial phase of the COVID-19 pandemic compared to the same period one year prior., Methods: A retrospective review of all HEMS and HEMS-ambulance 'Lifeliner 1' dispatches was performed from the start of Dutch nationwide lockdown orders from March 13th until May 13th, 2020 and the corresponding period one year prior. Dispatch-, operational-, patient-, injury-, and on-site treatment characteristics were extracted for analysis. In addition, the rate of COVID-19 positively tested HEMS personnel and the time physicians were unable to take call was described., Results: During the initial phase of the COVID-19 pandemic, the HEMS and HEMS-ambulance was requested in 528 cases. One year prior, a total of 620 requests were received. The HEMS (helicopter and ambulance) was cancelled after deployment in 56.4% of the COVID-19 cohort and 50.7% of the historical cohort (P = 0.05). Incident location type did not differ between the two cohorts, specifically, there was no significant difference in the number of injuries that occurred at home in pandemic versus non-pandemic circumstances. Besides a decrease in the number of falls, the distribution of mechanisms of injury remained similar during the COVID-19 study period. There was no difference in self-inflicted injuries observed. Prehospital interventions remained similar during the COVID-19 pandemic compared to one year prior. Specifically, prehospital intubation did not differ between the two cohorts. The rate of COVID-19 positively tested HEMS personnel was 23.1%. Physicians who tested positive were unable to take call for a mean of 25 days (range 8-53)., Conclusion: A decrease in the number of deployments and increase in the number of cancelled missions was observed during the COVID-19 study period. No major differences in operational- and injury characteristics were found for HEMS and HEMS-ambulance dispatches between the initial phase of the COVID-19 pandemic in the Netherlands and the same period one year prior. These findings highlight the importance of continued operability of the HEMS, even during pandemic circumstances., Level of Evidence: III, retrospective comparative study.

Introduction: Measuring the performance of air ambulance services are complex and dynamic due to the variability and interconnectedness of emergency systems. The aim of this study is to review the range and nature of air ambulance outcome measures published in peer review articles and construct a quality framework based on the results. A scoping review of the literature was conducted to identify outcome measures that evaluate the quality of air ambulance services. Combined frameworks from the Institutes of Medicine (IOM) and Dr. Avedia Donabedian were used to create a dashboard structure for a framework of air ambulance outcome measures., Methods: A literature search strategy was undertaken, following PRISMA-ScR guidelines and included eight databases over the period 2001-2019. Qualitative content analysis was conducted in 4-phases: 1) table summary of selected article outcome measures, 2) content analysis themes, codes of outcome measures and independent variables 3) narrative description of main themes 4) visual dashboard diagram of service priorities and quality strategies, based on the findings., Results: Thirty-four articles were screened by full text and eighteen met the selection criteria. Twenty codes emerged and were grouped to form eight consistent outcome themes; asset/ team type, access to definitive interventions, prehospital factors, mortality, morbidity, responsiveness of service, accessibility of service and patient disposition., Conclusions: A quality framework consisting of eight outcome measures was created, it also identified seven gaps which ordinarily require performance evaluation; patient comfort and satisfaction reporting, cultural awareness training, safety alarms in place to identify volume stress, optimal coordination of resources, cost of service analysis, comprehensive patient journey time and an adaptive referral system analysis. The measures in the framework provide a broad perspective of air ambulance performance we believe will help decision-making and planning to improve patients experience and outcomes., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Objective: Limited information exists regarding the response of helicopter emergency medical services (HEMS) programs to patients with known or suspected coronavirus disease 2019 (COVID-19). The purpose of this study was to determine changes in flight operations during the early stages of the pandemic., Methods: A survey of the American College of Emergency Physicians Air Medical Section was conducted between May 13, 2020, and August 1, 2020. COVID-19 prevalence was defined as high versus low based on cases > 2,500 or ≤ 2,500., Results: Of the 48 respondents, the majority (89.6%) reported that their patient guidelines had changed because of COVID-19; 89.6% of programs reported transporting COVID-19-positive patients, whereas 91.5% reported transporting persons under investigation. The majority of respondents reported additional training in COVID-19 airway management (79.2%) and personal protective equipment use (93.6%). Permitted aerosol-generating procedures included bilevel positive airway pressure (40.4%) and high-flow nasal oxygen (66.0%). No difference in guideline changes, positive COVID-19/persons under investigation transport restrictions, or permitted aerosol-generating procedures were noted between high- and low-prevalence settings., Conclusion: COVID-19 has resulted in changes to HEMS guidelines regardless of local disease prevalence. The pandemic has persisted sufficiently long that data regarding the effectiveness of guideline changes should be analyzed. In the absence of definitive data, national best practices should be developed to guide COVID-19 HEMS transport., (Copyright © 2021 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: In early 2020, the coronavirus disease 2019 (COVID-19) pandemic outbreak has posed the risk of critical care resources overload in every affected country. Collective interhospital transport of critically ill COVID-19 patients as a way to mitigate the localised pressure from overloaded intensive care units at a national or international level has not been reported yet. The aim of this study was to provide descriptive data about the first six collective aeromedical evacuation (MEDEVAC) of COVID-19 patients performed within Europe., Methods: This retrospective study included all adult patients transported by the first six collective MEDEVAC missions for COVID-19 patients performed within Europe on the 18 th , 21 st , 24 th , 27 th , 31 st of March and the 3 rd of April 2020., Results: Thirty-six patients with acute respiratory distress syndrome (ARDS) were transported aboard six MEDEVAC missions. The median duration of mechanical ventilation in ICU before transportation was 4 days (3-5.25). The median PaO 2 /FiO 2 ratio obtained before, during the flight and at day 1 after the transport was 180 mmHg (156-202,5), 143 mmHg (118,75-184,75) and 174 mmHg (129,5-205,5), respectively, with no significant difference. The median norepinephrine infusion rate observed before, during the flight and at day 1 after the transport was 0,08 µg/kg -1 . min -1 (0,00-0,20), 0,08 (0,00-0,25), and 0,07 (0,03-0,18), respectively, with no significant difference. No life-threatening event was reported., Conclusion: Collective aero-MEDEVAC of COVID-19 critically ill patients could provide a reliable solution to help control the burden of the disease at a national or international level., (Copyright © 2020. Published by Elsevier Masson SAS.)

Background: Helicopter transport (HT) is an efficient, but costly, means for injured patients to receive life-saving, definitive trauma care. Identifying the characteristics of inappropriate HT presents an opportunity to improve the utilization of this finite medical resource., Methods: Trauma registry records of all HT for a 3-year period (2016-2018) to an urban Level I trauma center were reviewed. HT was defined as inappropriate for patients who were discharged home from the emergency department or had a hospital length of stay <1 day, and who were discharged alive. Chi-square analysis and Student's t -test were used for univariate analysis. Predictors with a P value of less than .15 were subject to binary logistic regression analysis. A P value ≤.05 was considered significant., Results: There were 713 patients who received HT during the study period. One-hundred and forty-eight (20.8%) patients met the criteria as an inappropriate HT. In univariate analysis, Glasgow Coma Scale >8, Shock Index <0.9, and fall mechanism were found to be significantly associated with inappropriate HT. Age >55 was found to be associated with an appropriate HT. The average Injury Severity Score of the inappropriate HT group was 3.86 (±3.85) compared with 16.80 (±11.23) ( P = .0001, Student's t -test)., Discussion: Our findings suggest that there are evidence-based predictors of patients receiving inappropriate HT. Triage of HT using these predictors has the potential to decrease unnecessary deployments and reduce health care costs.

Background: Aeromedical retrieval is an essential component of contemporary emergency care systems. However, in many locations, ground emergency medical services are dispatched to the scene of an incident first to assess the patient and then call for a helicopter if needed. The time to definitive care therefore includes the helicopter's flight to the scene, flight to the trauma center, and nonflying time. Mission ground time (MGT) includes the time required to get the helicopter airborne, as well as time spent at the scene, packaging and loading the casualty into the aircraft. Estimates of MGT typically vary from 10 to 30 min. The impact of MGT duration on population coverage-the number of residents that could be taken to a trauma center within a set time-is not known. The aim of this study was to compare population coverage for different durations of MGT in a single state., Methods: Coverage was calculated using elliptical coverage areas ("isochrones") based on the location of helicopter bases and Level I and Level II trauma centers. The calculations were performed using Microsoft Excel, assuming a cruising speed of 133 knots (246 km/h), and mapped using arcGIS. The access time threshold was set at 60 min, and we evaluated MGTs of 10, 15, 20, 25, and 30 min., Results: MGT has a marked impact on population coverage. The effect is, furthermore, not linear. When considering the state's three Level I trauma centers, decreasing MGT from 30 to 10 min increased population coverage from 61.2% to 84.2%. When also considering Level II centers, decreasing MGT from 30 min to 10 min increased coverage by 20%., Conclusions: Elliptical isochrones, with allowance for MGT, provide realistic estimates of population coverage. MGT significantly impacts the proportion of the population that can be taken to a Level I and/or Level II Trauma Center within a set time. The impact is not linear, reflecting the uneven distribution of the population. Consideration should be given to minimizing MGT to preserve the benefits of aeromedical retrieval., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center., Methods: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter., Results: A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD ± 27.9) and would take an estimated 71.5 min (±28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD ± 30.9) with an estimated 66.1 min (SD ± 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively)., Conclusions: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This report documents the numbers of air evacuations for diagnoses of coronavirus disease 2019 (COVID-19) among U.S. active duty service members (ADSMs) from locations in U.S. Central Command (CENTCOM) and U.S. European Command (EUCOM) areas of responsibility. Counted were COVID-19 evacuations both within and out of each of the theaters from 11 March through 30 September 2020. Of the 186 evacuations originating in CENTCOM, 185 resulted in the patients arriving at Landstuhl in EUCOM and 1 was within theater. A total of 169 of the CENTCOM evacuations took place in June through August 2020 and only 1 occurred in September. Of the 39 air evacuations originating in EUCOM, 38 were intra-theater transfers and 1 was to a CONUS facility. Most (n=32) of the EUCOM evacuations occurred in September. Evacuees were most often members of the Army (71%), enlisted personnel (63%), males (91%), and aged 30 years or older (58%). Among a random sample of 56 evacuees, 20% were asymptomatic. Among those with symptoms, the most common were cough, fatigue, congestion, headache, and sore throat.

Background: Organizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district., Methods: All primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable., Results: We included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 and p = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km, p < 0.001)., Conclusion: After relocating nine local OOH services into one large inter-municipal OOH district, we found no increase in requests for HEMS.

Background: Helicopter Emergency Medical Service (HEMS) conducts the evaluation of a patient's condition using NACA score before transporting the patient to hospital. The conditions inside the rescue helicopter limit or even make it impossible to conduct some medical procedures. An appropriate classification of the patient may lead to a lower possibility of occurrence of adverse events during the flight. The aim of the research was to evaluate the correlation of NACA score with the cardiac arrhythmia that may be life threatening., Methods: A retrospective observational study included a group of 47,131 patients, who were transported by HEMS services between 2012 and 2017. The research was conducted using the analysis of variance ANOVA running a post hoc test. In order to calculate the correlation of variables, Kruskal-Wallis and r-Pearson tests were carried out, interpreting the results according to J. Gilville's scale. The significance level was set at α = 0,05., Results: The average number of points using NACA score for the studied group was 4,06 (SD ± 1,38). Twelve heart rhythms were selected while evaluating correlations using NACA score. There was a significant relation between the ECG variable and NACA score (p = 0,003). There was a very strong correlation between NACA score and the following: VF/pVT (r-Pearson = 0,856; p = 0,006), PEA (r-Pearson = 0,810; p = 0,015) and Asystole (r-Pearson = 0,728; p = 0,026)., Conclusions: NACA score allows to predict the risk of occurrence of ventricular arrhythmia of the myocardium as well as cardiac arrest. The possibility of occurrence of a life-threatening rhythm is significantly higher in patients classified as NACA IV or higher., Competing Interests: Declaration of competing interest None., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

The aims of this article are to comment on pre-coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries., (Copyright © 2020.)

Background: Prehospital plasma improves survival for severely injured trauma patients transported by air ambulance. We sought to characterize the unexpected survivors, patients who survived despite having high predicted mortality after traumatic injury., Methods: The Prehospital Air Medical Plasma trial randomized severely injured patients (n = 501) to receive either standard care (crystalloid) or two units of prehospital plasma followed by standard care fluid resuscitation. We built a generalized linear model to estimate patient mortality. Area under the receiver operating characteristic curve was used to evaluate model performance. We defined unexpected survivors as patients who had a predicted mortality greater than 50% and survived to 30 days. We characterized patient demographics, clinical features, and outcomes of the unexpected survivors. Observed to expected (O/E) ratios and Z-statistics were calculated using model-estimated mortality for each cohort., Results: Our model predicted mortality better than Injury Severity Score or Revised Trauma Score parameters and identified 36 unexpected survivors. Compared with expected survivors, unexpected survivors were younger (33 years [24, 52 years] vs. 47 years [32, 59 years], p = 0.013), were more severely injured (Injury Severity Score 34 [22, 50] vs. 18 [10, 27], p < 0.001), had worse organ dysfunction and hospital resource outcomes (multiple organ failure, intensive care unit, hospital length of stay, and ventilator days), and were more likely to receive prehospital plasma (67 vs. 46%, p = 0.031). Nonsurvivors with high predicted mortality were more likely to receive standard care resuscitation (p < 0.001). Unexpected survivors who received prehospital plasma had a lower observed to expected mortality than those that received standard care resuscitation (O/E 0.56 [0.33-0.84] vs. 1.0 [0.73-1.32]). The number of prehospital plasma survivors (24) exceeded the number of predicted survivors (n = 10) estimated by our model (p < 0.001)., Conclusion: Prehospital plasma is associated with an increase in the number of unexpected survivors following severe traumatic injury. Prehospital interventions may improve the probability of survival for injured patients with high predicted mortality based on early injury characteristics, vital signs, and resuscitation measures., Level of Evidence: Therapeutic Level III.

Historically, if US soldiers at Camp Fuji become severely ill or suffer trauma, they are transported by the ground ambulance, as the doctor-led air ambulance in eastern Shizuoka has never been permitted to land at Camp Fuji. However, it is widely recognised that severely ill or traumatised patients require time-dependent medical management. It was therefore agreed to undertake a joint exercise between the US medical assets of Camp Fuji and the doctor helicopters in eastern Shizuoka prefecture in evacuating a simulated severely ill or traumatised US soldier. The aim of this article is to describe the background and rationale between this collaboration between the civilian Japanese air ambulance and the US medical assets in Camp Fuji., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)