I love helicopters. Riding in them is both unique and
exhilarating. I have spent many hours in a helicopter providing
emergency medical care in between police chases and other city
activities. Many have called air medical helicopters nothing more than
"flying billboards" for the hospitals that operate them. In this day of
dwindling healthcare dollars, we must ask ourselves some hard
questions: Do helicopters really make a difference in EMS? Do they
provide a significant benefit for the patient? Are the risks worth any
real benefit? Why do we not see a proliferation of helicopter
operations in other countries like we are seeing in the U.S.?
Unfortunately, any discussion of air medical helicopter efficacy often
results in an emotional response by many. I have heard flight nurses
say, "I know what I do makes a difference." Flight paramedics will
often relay a story about a particular patient they feel benefited from
helicopter transport. But, do helicopters really make a difference in
patient care and the subsequent quality of the patient's life? To
answer this, let's look at what the scientific literature says.
The use of civilian helicopters for
transport of ill and injured patients has become an integral part of
modern emergency care. Helicopter transport of emergency patients in
the United States evolved from experience gained in the Korean and
Vietnam Wars, when injured soldiers were transported from conflict
areas to military medical facilities for definitive care.1
The use of helicopters in the civilian sector began in the late 1960s,
when helicopters were used in dual-purpose law-enforcement or military
operations, but had a limited commitment to emergency medical response.2,3 Civilian helicopters dedicated exclusively to patient care and transport were first introduced in the U.S. in 1972.1,4
Over the last two decades, there has been a significant proliferation
of helicopter operations in the U.S., most of which are hospital-based
and many of which have more than one aircraft.5
The impetus for the development and
proliferation of civilian helicopter ambulances was based on the
concept of the "golden hour." First described by R Adams Cowley, the
"golden hour" is the period immediately following injury when
resuscitation and definitive care improve outcome.6,7
Although outcome is better the sooner definitive care is provided, the
actual concept of the so-called "golden hour" has been called into
The Scientific Evidence
Initial studies published in the
1980s were supportive of air medical transport of emergency patients.11,12
However, more detailed recent studies have shown that this may no
longer be the case. Several recent studies have shown that use of
helicopters for trauma patients actually benefits only a small number
of patients. Furthermore, these studies indicate that many EMS
providers summon medical helicopters when the patient's condition may
not warrant their use.
Researchers studied helicopter
usage in the Silicon Valley region of California. In a retrospective
review of 947 consecutive trauma patients transported to their trauma
center, they found that only 22.8% of study patients possibly benefited
from helicopter transport. They further found that 33.5% of patients
transported by helicopter were discharged from the emergency department
and not admitted to the hospital.13
In the Los Angeles area, researchers retrospectively evaluated
helicopter transport of 189 pediatric trauma patients and found that
85% of patients were considered to have minor injuries. Of the patients
transported by helicopter in their study, 33% were discharged home from
the emergency department and not admitted to the hospital.14
In another pediatric trauma study, researchers in Washington, DC, found
that approximately 85% of air transports in their study group of 3,861
injured children were considered over-triaged.15 A Boston
study of 1,523 patients transported by helicopter found that 24% of
patients transported from an accident scene were deemed inappropriate.16
Similar findings were reported from an Australian study. In northern
coastal New South Wales, researchers reviewed 184 medical records of
patients transported from an accident scene to a hospital. An expert
panel reviewed all helicopter patient retrievals. They found that only
17.3% of patients benefited from helicopter transport, while 1.7% of
patients were felt to have been potentially harmed. Seven percent of
patients were discharged from the emergency department and not admitted
to the hospital, while 36% were discharged from the hospital within 48
hours.17 In a Hong Kong study, 34.1% of patients transferred
by helicopter from a scene were discharged from the emergency
department and not admitted to the hospital.18 In a Norwegian study, researchers found that only 11% of the 370 patients transported by helicopter benefited.19
British researchers found no evidence of any improvement in patient
outcomes for patients transported by the London Helicopter EMS.20
When the University of Texas Medical Branch at Galveston discontinued
its hospital-based air medical helicopter, they found that there was no
decrease in transport time or increase in mortality for trauma patients
at their facility.21
In a five-year study of
blunt-trauma patients transported either by helicopter or ground
ambulance, researchers in Phoenix, AZ, found no survival advantage for
patients transported by helicopter in an urban setting with a
sophisticated prehospital care system.22
In a North Carolina study, researchers found that only a very small
subset of patients transported by helicopter appeared to have any
chance of improved survival based on their helicopter transport.23
In a detailed study of 162,730 patients treated at 28 accredited trauma
centers in Pennsylvania from 1987--1995, researchers found that
transportation by helicopter did not affect the estimated odds of
A Houston, TX, study found that patients with
penetrating trauma do not benefit from helicopter transport and scene
flights are not medically efficacious.25
In an eight-year
Pennsylvania study of 3,048 penetrating-trauma victims, researchers
found that patients transported by helicopter had longer transport
times and no significant difference in mortality compared with those
transported by ground.26 Likewise, transport of patients with severe head injuries and burns do not appear to benefit from helicopter transport.27,28
When interfacility helicopter
transport of patients was studied, the results were also interesting.
In a study of 1,234 patients transported between facilities by
helicopter, researchers found that those patients did not have improved
outcomes compared with those transported by ground.29 Clearly, additional studies are needed.
A factor often overlooked is
helicopter safety. There has been a steady increase in the number of
helicopter accidents. In fact, over the last 10 years in the U.S.,
there have been 83 helicopter accidents resulting in 70 deaths and 62
injuries. Furthermore, 52% of accidents in this 10-year period occurred
during the last three years of the study (2000--2002). The helicopter
most frequently involved was the single-engine Bell 206 Long Ranger,
followed by the twin-engine Eurocopter BK-117. Primary cause of
accidents in the study period was pilot error.30,31
Again, we have embarked on an EMS
adventure that has conflicting scientific evidence. But, medicine
evolves and prehospital medicine similarly evolves. When the original
studies were published regarding the effectiveness of helicopters, EMS
was in an earlier developmental stage. At that time, helicopters could
offer added patient care skills and interventions not available on
ground ambulances. Now, with prehospital care being considerably more
sophisticated, helicopters offer little more than increased speed. And,
in the overall scheme of things, speed makes a difference for only a
limited number of patients. The proliferation of helicopter operations
in this country over the last decade cannot be supported with science.
Helicopters cost between $1,500,000--$5,700,000 to purchase and up to
$1,000,000 a year per aircraft to operate. Thus, a significant amount
of financial resources are going into a transport modality that
actually benefits few patients. These large sums of money would buy
many AEDs and ground ambulances that would stand to benefit more of our
citizenry. With a dwindling healthcare dollar, we will soon have to
make some tough decisions.
There certainly is a role for
helicopters in EMS, but we have them in the wrong places. The majority
of the fleet is parked atop hospitals in urban centers where ground
transport takes only minutes. They need to be positioned where they
will benefit the people who need them the most--those who live in rural
settings. That is, they need to be closest to the hospitals and trauma
scenes where they can potentially make a difference. The literature
certainly supports the role of helicopter transport of critical
patients in the rural setting.32
Thus, there should be a strategically placed network of helicopters
that serves rural hospitals and providers. However, as long as
hospitals operate helicopters as "flying billboards," this will
probably never happen. Perhaps the solution is to follow the German and
Australian models and move EMS helicopters from hospitals to state-wide
EMS-type governing boards based on need.33 This would certainly promote fairness for all state residents, but I'm afraid that emotion may prevail.
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24. Brathwaite CEM, Rosko M, McDowell R, et al. A critical analysis of
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Bryan Bledsoe, DO,
FACEP, EMT-P, is an emergency physician, author and former paramedic
whose writings include: Paramedic Care: Principles and Practice and
Paramedic Emergency Care.