In my opinion, this topic is similar to so many in Emergency Medicine in that it is extremely difficult to study. It is not a like studying a certain type of cancer, where we can do a double blind, placebo controlled trial and come up with a relatively indisputable answer. Most Emergencies dont easily lend themselves to easy research. When all is said and done, people tend to form an opinion and the only thing that can make them stop expressing that opinion is their own death.
The best argument that I have heard is that with a helicopter crew, you can recruit, heavily train, and devote a lot of resources to a few dozen individuals. This results in paramedics that are highly trained, and much more able to handle severely sick individuals. The flight paramedics where I work put in chest tubes, run drips, and are experts in RSI. The helicopter gives them a much greater mobility and improves the patient care over a huge geographic area. The amount of resources that you would have to devote to the entire ground EMS system to achieve the same paramedic expertise would be astronomical.
There are a plethora of articles on Pubmed regarding cost and impact on mortality and morbidity. I included a few of the articles with their conclusions. In my opinion, most inter-city transfers and MVA scenes dont need helicopter. However, it is a resource that we all have. The more we use them, the more expertise we create, and the more useful they are. The less we use them, the less patient care they experience and the quality of care will decrease.
Can J Surg. 2007 Apr;50(2):129-33. Air versus ground transport of major trauma patients to a tertiary trauma centre: a province-wide comparison using TRISS analysis.
CONCLUSION: The transport of trauma patients with an ISS = 12 by a provincially dedicated rotor wing air medical service was associated with statistically significantly better outcomes than those transported by standard ground ambulance. This is the first large Canadian study to specifically compare the outcome of patients transported by ground with those transported by air.
J Trauma. 1997 Dec;43(6):940-6.
A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene.
CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.
Prehosp Disaster Med. 1999 Jul-Sep;14(3):159-64. Differences in mortality rates among trauma patients transported by helicopter and ambulance in Maryland.
CONCLUSION: The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.
J Emerg Med. 2000 Apr;18(3):349-54. Scene disposition and mode of transport following rural trauma: a prospective cohort study comparing patient costs.
The prehospital transport costs were significantly more for patients transported to a rural hospital first. The costs incurred at the trauma center were highest for those patients transported directly from the scene. Many severely injured patients were initially transported to a rural hospital rather than directly to the trauma center. At both the scene and rural hospital, consistent use of triage criteria appeared to be lacking in determining the severity of injury, appropriate destination, and mode of transport for trauma patients. Since no significant difference in prehospital helicopter and ground transport costs was demonstrated, the decision on mode of transport should be in the best interest of patient care.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
CONCLUSIONS: The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.
BMJ. 1995 Jul 22;311(6999):217-22. Effects of London helicopter emergency medical service on survival after trauma.
CONCLUSION--Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.
J Trauma. 2007 Aug;63(2):258-62.Helicopter emergency medical services (HEMS): impact on on-scene times.
CONCLUSIONS: Combined EMS/HEMS assistance at an injury scene is associated with longer OST. When corrected for severity of injury and patient characteristics, no influence of longer OST on mortality could be demonstrated.
Unfallchirurg. 2007 Apr;110(4):334-40. [The influence of transportation mode on mortality in polytraumatized patients. An analysis based on the German Trauma Registry]
CONCLUSIONS: Only minor differences in age and ISS were found between the groups. The time between the accident and arrival of the physician was longer in the HEMS group. The HEMS group also remained on the scene for longer, but had a higher rate of intervention. According to our analysis of the German Trauma Registry, patients with multiple injuries benefit from HEMS transportation.
J Trauma. 1997 Jul;43(1):83-6; discussion 86-8. Are scene flights for penetrating trauma justified?
CONCLUSIONS: Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. This conclusion rests on the findings that arrival at a trauma center was not hastened by scene flights and that only 4.9% of patients required prehospital care by the medical flight crew beyond the capabilities of the first-responding EMS personnel (2.5 and 6.7% for ALS and BLS responders, respectively). Based on this experience, we believe that in metropolitan areas, scene flights for victims of noncranial penetrating injuries should be restricted to critically injured patients likely to require prehospital care by the medical flight crew that is beyond the capabilities of the first responders or when the scene flight is likely to significantly hasten the arrival of the injured patient to an appropriate trauma center.
