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Home > Topics > Air Medical Transport
April 17, 2012

Study: Helicopter beats ambulance for trauma patients

Results show effectiveness of helicopter emergency medical services compared to its alternative, ground emergency medical services

The University of Maryland

BALTIMORE, Md. — If you are severely injured, a helicopter flight to a top-level trauma center will boost your chance of survival over ground transport. That’s the conclusion of a rigorous, national comparison of the effectiveness of helicopter versus ground emergency medical services, published in the April 18, 2012, issue of the Journal of the American Medical Association.

Survival after trauma has increased in recent years with improvements in emergency medical services coupled with the rapid transportation of trauma patients to centers capable of providing the most advanced care. What has not been clear until this study, is the effectiveness of helicopter emergency medical services (HEMS), a limited and expensive resource, compared to its alternative, ground emergency medical services (GEMS).

“We looked at the sickest patients with the most severe injuries and applied sophisticated statistical analyses to the largest aggregation of trauma data in the world,” says the study’s principal investigator, Samuel M. Galvagno Jr., D.O., Ph.D., assistant professor, Department of Anesthesiology, Divisions of Trauma Anesthesiology and Critical Care Medicine, University of Maryland School of Medicine. “We were careful at every step to balance all the potential other factors that could explain any benefit of the helicopter. After all that, the survival advantage of helicopters remained,” says Galvagno.

Dr. Galvagno is on the staff of the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, where many of the life-saving practices in modern trauma medicine were pioneered. The Shock Trauma Center was the first fully integrated trauma center in the world, and remains the epicenter for trauma research and training both nationally and internationally today.

“The use of helicopter emergency medical services in the United States has been a controversial subject over the last decade or so, centering on the costs and the potential for crashes, says Thomas M. Scalea, M.D., the Francis X. Kelly Professor of Trauma in the Department of Surgery; director of the Program in Trauma, University of Maryland School of Medicine; and physician-in-chief at the R Adams Cowley Shock Trauma Center. “Previous studies have found a survival benefit by using helicopters, but the studies were small and left some doubt. This study in JAMA is very robust,” says Dr. Scalea.

“Dr. Galvagno’s research demonstrates how statistics and technology can be used to help researchers mine huge databases for useful information to help determine best care for patients and appropriate utilization of limited health care funds,” says E. Albert Reece, M.D., Ph.D., M.B.A., vice president for medical affairs, University of Maryland; the John Z. and Akiko K. Bowers Distinguished Professor; and dean, University of Maryland School of Medicine. “Advances in the emerging science of comparative effectiveness, coupled with the expertise of physician researchers who have direct patient care experience, will deliver data that clinicians, policy-makers and ultimately the public can use to make informed decisions.”

For this study, Dr. Galvagno developed the most rigorous comparison of helicopter and ground transport to date. He and his team tracked patients meeting certain criteria who were listed in the 2007-2009 version of the American College of Surgeons (ACS) National Trauma Data Bank (NTDB). The NTDB contains more than 1.8 million patient records from more than 900 centers in the United States.

To meet the study’s criteria, patients had to be adults (over age 15) who sustained blunt or penetrating trauma with an injury severity score greater than 15 (critically injured). They had to be taken to either an ACS Level I or Level II trauma center in the United States (centers that meet certain high standards of care, with Level I the highest). The main outcome measure was survival to discharge from the hospital.

“Dr. Galvagno is an anesthesiologist whose specialties include intraoperative care of people who have suffered trauma and the care of critically ill patients. He not only treats patients but also has major research interests in the improvement of patient safety and care,” says Peter Rock, M.D., M.B.A., the Dr. Martin A. Helrich Professor and chair of the Department of Anesthesiology at the School of Medicine. “His experience as a former paramedic and now in the Air Force Reserve where he assists in the evacuation of wounded warriors has taught him that saving lives is a combination of quality care both in the field and on the way to a trauma center, coupled with rapid transport and expertise at the hospital. All of those factors come together in this study.”

A total of 223,475 adult patients met the criteria: ground transport accounted for 161,566, while 61,909 patients were flown in helicopters. Overall, 7,813 (12.6 percent) HEMS patients died compared to 17,775 (11 percent) transported by GEMS. This raw data shows a significant difference, but Dr. Galvagno says the odds for helicopter transport improved when statistical models were applied to the numbers to factor in so-called “confounding” factors that could lead to a misinterpretation of the data. These include injury severity, age, vital signs, type of injury, gender and trauma center. The researchers also developed statistical models to account for missing data in the NTDB, including travel time and distance to trauma centers, key bits of information that could impact survival.

Dr. Galvagno and his team conclude that the helicopter is associated with a 16 percent increased rate of survival for the 156,511 patients transported to Level I trauma centers. That percentage means 65 patients must be transported to save one life. The 64,964 patients who went by chopper to Level II trauma centers had a 15 percent survival advantage, meaning 69 must be transported to save one life.

Dr. Galvagno says the study raises many questions that need to be explored further. “The benefits of the helicopter, we believe, are related to multiple factors. Certainly time and crew expertise play a role. Beyond that, we’re not sure. More study is warranted,” says Dr. Galvagno.

Trauma is the leading cause of death and disability among young people around the world, according to the researchers. In the United States, more than 50 million people are injured each year, resulting in approximately 169,000 deaths annually and a lifetime cost of $406 billion.

The R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center is the nation's first coordinated trauma system and is dedicated to multidisciplinary research and treatment of critical injury and illness. Shock Trauma is where the “golden hour” concept in critical care medicine was born. The center currently treats more than 8,000 trauma and critical care patients each year and trains trauma providers from around the world including U.S. military medical professionals and international trauma teams.

This study was performed without any commercial funding or extramural sponsorship. Dr. Galvagno was funded, in part, by an institutional training grant when this study was initiated as part of his Ph.D. program at the Johns Hopkins Bloomberg School of Public Health.

Comments
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Josh Scott Josh Scott Wednesday, April 18, 2012 5:48:19 AM But the"golden hour" concept has been debunked. So what says the rest of their research shouldn't be suspect?
Jeffrey Bilyk Jeffrey Bilyk Wednesday, April 18, 2012 8:23:34 AM That's irrelevant of this study. It has nothing to do with the golden hour - only that the concept originated there years ago. All it's saying is arrival to an ACI/ACII center as quickly as possibly is beneficial. Has that golden hour concept been overtaught, overmarketed, and overused as a justification for endless expansion of the HEMS industry, sure it has. That being said, severely injured trauma patients should be delivered to a trauma team ASAP. I can assure you, that if you suffer a traumatic aortic disruption or epidural hematoma or femoral artery rupture as a result of slamming your car into a tree at 80mph, then time is NOT your friend.
Brianna Harris Brianna Harris Wednesday, April 18, 2012 8:41:06 AM I've never seen anyone write an essay as a fbook post before...
Bryon Umbenhower Bryon Umbenhower Wednesday, April 18, 2012 8:57:08 AM I have never seen a 1 paragraph essay...
Brent Jensen Brent Jensen Wednesday, April 18, 2012 10:14:24 AM They say they factoted in traval time.. What was it they factored. That ground may take longer... Did they look at ground reqest vs avaliblity of air transport.
Matthew Salvador Matthew Salvador Wednesday, April 18, 2012 10:22:40 AM PROPAGANDA!!!!
Joss G Po Joss G Po Wednesday, April 18, 2012 10:32:36 AM the rolling stones lied? I thought Time was on my side....
Jeffrey Bilyk Jeffrey Bilyk Wednesday, April 18, 2012 3:04:02 PM I was rebutting the post on the article Brianna Harris, you have to click the link to see it. This, yes, does make me look a tad crazy.
KevinAmy Johnson KevinAmy Johnson Wednesday, April 18, 2012 9:56:06 PM Maybe it's late and I just don't read good. Perhaps the research ends up helping us take better care of trauma patients. Golly gosh this doesn't strike me as a study that makes me drop my bagel. I think I need the cliff notes to find the aha moment the author seams to be trying to get at. Hope the researchers didn't spend too much money, to find out getting to a good hospital fast is good for sick people. Oh that's if helicopters. are faster than ford trucks...um yahhhh.
Roland O'Leary Roland O'Leary Wednesday, April 18, 2012 10:03:28 PM After 30 years in EMS/Fire working for numerous agencies, 15 plus as an ALS provider, I have found that speed is helpful once in a while. but skill and expertise in managing the patient trumps it most every time. I work for a ground transport service that transports from Level 4 and 5 facilities, at times 2 plus hours to Level 2 facilities and at other times up to 6 plus hours in bad weather with critical patients to Level 1 facilites. I do darn well in delivering my patients alive. Though if I had the knowledge (of which I am continually working to gather) and training of a Fight Medic or Nurse, I'm sure I could do better. When was the last time a Flight Medic had to deal with a critical patient for 6 plus hours without their nurse. Me... I'm on my own with an EMT driver, my patient at times on a vent, with a chest tube(s) and multiple meds on a pump, and I'm still getting the job done. And I do it most of the time without running code. I will wager I have lost fewer patients in my ambulance in my 20 plus years in ambulances, than most flight crews loose in a year. Let's compare apples to apples, not apples to oranges, (BLS vs Flight, and single ALS provider cars vs Flight crews (Nurse and Medic). You may find a different picture. That said... God knows, there are times I am glad the hospital called the helicopter. I have also been glad to see them on scenes. They do a excellent job. One that I have decided I am too old to do. I also like to be able to treat, and comfort my patients, as well as talk to them duing transport. Something that is often hard to do, if not impossible, in most choppers once airborne. Again, apples and oranges. Take care.... Stay Safe.....
Jeffrey Langlois Jeffrey Langlois Friday, April 20, 2012 4:12:48 PM Let me say, I do value the option of having our local medflight for certain events. However, I would love to see the geography of the areas surveyed, as well as the proximity of ems service areas to level 1 trauma centers. More often than not, we summon a helicopter per area protocol only to make the 12 minute transport ourselves, as the chopper is usually about 20-30 minutes out. (if it is flying that day). Obviously there are situations such as prolonged extractions etc., it just seems like our patients are usually better off time-wise if we just treat and transport ourselves. Pointing out that we have always been lucky/skilled enough to secure our airways and gain access etc., is this only a time issue, or is the study pushing the extended bag of tricks and advanced training of HEMS?
Andy Gomes Andy Gomes Friday, April 20, 2012 4:24:54 PM Well said Jeff
Jeffrey Langlois Jeffrey Langlois Friday, April 20, 2012 4:26:48 PM Thanks Andy, you guys are in the same boat I bet, just approaching RI from a different angle...
Ashley Agri Ashley Agri Friday, April 20, 2012 4:40:58 PM I like helicopters :) but not the 15,000$ bill afterwards!
Michael Stone Michael Stone Saturday, April 21, 2012 4:54:05 AM HEMS has its place in Rural areas. The medics need to be skilled enough and intelligent enough to take into account the factors of how long it will take for HEMS to make the scene, do their assessment, and fly to the destination vs how long it will take the ground crew to get to the same destination. In areas where you have first responders if they are trained to recognize potential flight situations and request HEMS before the medics arrive on scene it can dramatically decrease the response time of HEMS. We need to be thinking!
Steve Jacobi Steve Jacobi Saturday, April 21, 2012 1:17:07 PM Golden hour means they don't need to rush into the OR within the hour. It doesn't mean you stay in the field and play for an hour or transport to a facility that can do nothing definitive for the patient and does not have the appropriate meds or equipment to stabilize. It also doesn't mean you put a patient into an ambulance that lacks the properly trained personnel and all you can do a drive really, really fast. Debunking the Golden Hour does not mean you DO NOT treat. Whether the intervention is surgical or by pharmacology, some injuries just can not be ignored with broad over generalizing statements made in EMS by those who fail to see the bigger picture. The Golden hour can also apply to cardiac muscle and brain tissue. Are you also debunking that doing 12-lead ECGs in the field to determine the most appropriate facility for PCI? How about CVA recognition? Is that crap also that you need to get the patient to the hospital in a timely manner to receive appropriate treatment? But then I guess you know better than the AHA and any of the physicians who have spent years becoming educated and training to provide the best possible care for the best outcomes.
Steve Jacobi Steve Jacobi Saturday, April 21, 2012 1:20:17 PM Helicopter crews also provides a higher level of care during transport especially if there are experienced ICU/Trauma RNs on the team. They should have the meds, the equipment and the expertise to provide better stabilization than what a typcial ground crew can.
KevinAmy Johnson KevinAmy Johnson Monday, April 23, 2012 6:09:57 PM Read it again, along with some comments...nothing. I for the life of me don't experience a wow moment. Please somone essssplain this to me. Fast is good, and good hospital is good, is all I get. I thunk I knew that.
Brian Sch Brian Sch Wednesday, December 12, 2012 7:43:12 AM I suffered a ruptured aorta and colon in a car accident in Michigan. I was in the ER within 15 minutes of the accident. There's no doubt in my mind that U of M Survival Flight saved my life. Another ten minutes and I would have bled out. Circumstances were definately on my side but without it I wouldn't be here.

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