ARTICLE IN PRESS
Air Medical Journal ■■ (2017) ■■–■■
j o u r n a l h o m e p a g e : h t t p : / / w w w. a i r m e d i c a l j o u r n a l . c o m /
Helicopter Emergency Medical Services Literature 2014 to 2016:
Lessons and Perspectives, Part 2—Nontrauma Transports
and General Issues
Stephen H. Thomas, MD, MPH, Ira Blumen, MD
HEMS Safety
Health care interventions of nearly all
types, from antibiotics to hospitalization,
entail risk. That risk is usually carried by pa-
tients alone, but there are risk categories (eg,
care of violent patients or those with com-
municable disease) in which caregivers are
also at risk. Aviation safety is the first pri-
ority of HEMS; thus, it is the opening topic
in this part of the review.
Safety Remains the First Point in
Discussing HEMS
It is nearly universal in the air medical
transport literature in recent years for there
to be some comment about the risk of
HEMS. A typical study from the end of 2016
includes in its opening paragraph the fol-
lowing: “The human cost of HEMS is also
well-documented, with more than 200
deaths from 1980 to 2008. HEMS flight
crews have one of the most dangerous oc-
cupations in the USA, with more than 100
deaths per 100,000 employees (compared
to 21 deaths per 100,000 police officers).”1
It is not within this review’s scope to
delve into the long and critically impor-
tant history of aviation safety in HEMS.
Neither is it the editorial purpose to frame
the known risks of HEMS against those risks
associated with ground EMS (GEMS), risks
that are far less well characterized because
in part of the lack of reliable GEMS safety
data. These topics and other vital statistics
of HEMS safety are covered in detail in a
separate recently published textbook
chapter by 1 of the authors (I.B.).2
Overall Accident and Fatality Rates
On the overall safety front, important
contributions have been made in the anal-
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Air Medical Journal
yses of HEMS accidents in the United
Kingdom and the United States. A 2014
report 3 calculated that over a quarter
century of UK HEMS operations, the fatal ac-
cident rate was .04 per 10,000 missions
(with comparable rates from the United
States and worldwide ranging from .04 to
.23 per 10,000 missions).
In a 2016 study from the United States,
Boyd and Macchiarella4 reported a detailed
analysis of the country’s HEMS-related ac-
cidents from 1983 to 2014. Overall HEMS
accident rates declined by 71% over those
3 decades, whereas the fraction of fatal ac-
cidents (36%-50%) and injury profile were
unchanged over time.
Safety of Night HEMS Operations
The 2014 to 2016 HEMS safety studies
from continental Europe included a focus on
night flights, which have been traditional-
ly eschewed by the region’s HEMS operators
because of safety concerns. A Dutch study5
of 513 nighttime flights found 0 accidents;
the authors concluded that nighttime op-
erations should not be precluded by safety
considerations. German data reported in
2016 identified a similar (0) incidence of
nighttime crashes; the Germans made the
case that if aviation operations are prop-
erly planned and conducted, then nighttime
operations are safe.6
An Australian group assessing US data
also focused on night operations, taking the
course of assessing types of pilot experi-
ence. In a 2016 report that assessed 32
single-pilot nighttime fatal HEMS crashes
between 1995 and 2013, the Australians
found that pilot domain task experience (ie,
HEMS-specific total flight hours’ experi-
ence) was inversely correlated with the
likelihood of a fatal accident.7 In the Aus-
tralians’ analysis, the cutoffs for safety
margin increase occurred at 2-, 4-, and 10-
year experience levels.
Another assessment of US data (from
Pennsylvania) found that operations at night
(1900-0600) were associated with a higher
risk of fatal crash or injury. In fact, night op-
eration was the only parameter of the
studied operational variables (eg, weather,
impaired visibility, and aircraft model) found
to have a significant association with a fatal
crash or injury in this study.8
For-Profit HEMS Service Status and Safety
The US HEMS safety literature included
some different topics with particular rele-
vance to that country. Some of the more
prominent ongoing HEMS debate in the US
literature demonstrates unsettled safety
issues such as those relating to profit motive.
A thought-provoking report from a US
group9 found that human and pilot errors
were significantly more common with com-
mercial (for-profit) operations compared
with public sector (nonprofit) operators.
Subsequent controversy over the findings10
has highlighted the need for further inves-
tigation of the thesis that profit motive has
a positive, negative, or no association with
safety.
Multiple-Diagnosis HEMS Topics
This section covers HEMS studies from
2014 to 2016 that addressed topics that
cross diagnostic lines. The 2 general areas
of discussion are cost-benefit analysis and
airway management. Some further details
on related information regarding specific
patient groups are presented in subse-
quent sections addressing HEMS use for 2
 ARTICLE IN PRESS
2 S.H. Thomas, I. Blumen / Air Medical Journal ■■ (2017) ■■–■■
specific nontrauma patient populations:
STEMI and iCVA.
Patient Safety Issues in HEMS Transport
Aviation safety being covered previ-
ously, there is another set of safety concerns
related to HEMS transport. These concerns
deal with the HEMS environment (eg, ac-
celeration and altitude) and its potential for
ill effects on transported patients. This
section considers 2014 to 2016 publica-
tions in this arena.
In 2016, a University of Southern Cali-
fornia pediatric transport group assessed
acceleration forces in multiple axes during
various phases of GEMS, HEMS, and air-
plane transport. 11 The accelerations
measured for HEMS were no different than
those observed in the other 2 transport
modes.
One group of studies has continued to
visit the long-known 12,13 question of
altitude-related increases in endotracheal
tube (ETT) cuff pressures. The 2014 to 2016
literature reaffirms that barometric changes
associated with increased altitude have the-
oretical potential to increase cuff pressures
to potentially dangerous levels. These high
cuff pressures, potentially problematic for
any patient but usually emphasized with pe-
diatric cases (with smaller airways), have
not been reported to cause actual patient-
centered adverse outcomes.
Three 2016 studies, all from the United
States, reported opposite findings regard-
ing ETT cuff pressures. One team14 found
that properly inflated adult (7.5 mm) ETT
cuffs are not likely to be associated with
dangerous cuff pressure increases below
8,000 feet above sea level. However, another
group reported that potentially dangerous
cuff pressure elevations occurred to equal
degrees in all 3 of the tested ETT sizes (4.0,
6.0, and 8.0).15 A third group, testing 3 sizes
of ETTs (3.0, 4.0, and 6.0), also found po-
tentially dangerous cuff pressure elevations
at altitudes as low as 1,500 feet (with cuff
pressures regularly surpassing 30 cm H2O)
and 2,800 feet (with cuff pressures regu-
larly surpassing 50 cm H2O) above mean sea
level.16
Perhaps the best synthesis of real-world
relevance with regard to ETT cuff pres-
sures comes from Massachusetts. In 2016,
these investigators reported that the main
problem with regard to HEMS transport of
post-ETI patients was that the pretransport
cuff pressures were (on average) more than
double the recommended levels.17 Their rec-
ommendations to check ETT cuff pressures
before and during transport to maintain
optimal safety are consistent with the
general consensus of the studies mentioned
here.
Airway Management by HEMS Crews
Airway management and endotracheal
intubation (ETI) are among the most im-
portant of all out-of-hospital interventions.18
A detailed discussion of airway manage-
ment and its risks and benefits are outside
the scope of this review. However, given the
importance of the subject, some relevant
HEMS airway management studies from
2014 to present are noteworthy.
Although there are historic data showing
nonphysician HEMS crew ETI success rates
rivaling those achievable in the emergen-
cy department setting,19 the most recent
literature addressing HEMS ETI comes from
air medical crews including physicians. In
2015, a multinational study (from 5 Euro-
pean countries and Australia)20 showed
similarly impressive ETI results; HEMS phy-
sicians’ first-pass ETI success rate was 86%,
and the overall ETI success rate was 98.8%
with airways successfully established in
100% of patients.
Perhaps the most compelling evidence
of HEMS bringing additional airway exper-
tise to the patient comes from a 2015 Dutch
study from another physician-staffed air
medical crew.21 In an unusual design, the re-
searchers were able to assess HEMS versus
GEMS ETI attempts in the same patients;
GEMS crews were allowed to attempt ETI,
and then if they failed HEMS crews would
intervene. The same medications (admin-
istered within the same protocols) were
used throughout the airway management
attempts. The HEMS physicians’ first-
attempt ETI success rate of 84.5% was nearly
twice that of the GEMS paramedics’ first-
attempt success rate of 46.5%.
HEMS crews’ ETI success reports of
recent years include pediatric patients. In
2015, an Australian group reported 100% in-
tubation success rates by their paramedic-
staffed HEMS crew, for both adult and
pediatric patients.22 In a 2016 Swiss study
focusing solely on airway management in
425 children, Schmidt et al23 reported a 95%
first-pass ETI success rate, with a 98.6%
overall ETI success rate. Another 2016 study
from Switzerland24 reported on HEMS phy-
sician airway management in 1,047 cases;
they found a 96.4% rate of first-pass ETI
success with an overall ETI success rate of
99.5%, with no requirement for surgical
airways.
The airway success of HEMS crews is
well-documented and is not presented here
to imply that all HEMS crews have the
same success or that GEMS crews do not
have the capability to reach these levels of
ETI success. However, the rates of airway
management success in the HEMS litera-
ture are consistently high, and both airway
and ventilatory management (with resul-
tant impact on outcome) appear potentially
better for HEMS compared with GEMS
cases.25,26
Future directions for airway manage-
ment in HEMS will need to include skills
maintenance in an era of enlarging crews
with more limited ETI training and prac-
tice opportunities. Comparisons of HEMS
crew success rates with GEMS crew success
rates may help determine when HEMS
should be deployed. Furthermore, there
needs to be a follow-up investigation to
glean more information along the lines of
a 2015 report from a rural US state
(Mississippi)27 that HEMS is needed to bring
ETI skills for interfacility transports, partic-
ularly those from referring facilities staffed
by physicians lacking ETI experience.
HEMS Costs and Benefits
If there is no benefit to HEMS trans-
port, then the risk:benefit calculations
cannot be favorable. Additionally, there are
monetary cost issues. Despite classic
reports28 arguing that a region-based cost
of HEMS is no higher than the cost of re-
sponse time–equivalent GEMS critical care
coverage, HEMS’ concentration of resources
translates into widespread perception (even
among some HEMS advocates) 29 of air
medical transport as being a high-cost
option.
Recent years have seen consensus state-
ments from organizations such as the
National Association of EMS Physicians and
the American College of Emergency Physi-
cians reaffirming the position that
appropriately used HEMS improves patient
outcomes.30 However, with increasing pres-
sures on health care spending, risk:benefit
and cost:benefit calculations are of critical
importance.
In 2015, a Norwegian group,31 noting
their country’s oft-cited report32 of a HEMS
benefit-to-cost ratio of 5.87, published an
analysis promoting Norway’s success in op-
timizing HEMS access. The group reported
that Norway has achieved a national goal for
90% of the population to be reachable by
HEMS within 45 minutes.31
Scandinavians’ attention to costs and
benefits has included assessment of the
limits of transport distances (for interfacility
missions) for which HEMS maintains cost-
effectiveness over airplane transports. A
Swedish financial analysis reported in
2014 33 found that HEMS retained cost-
effectiveness over airplanes up to a range of
300 km (186 miles).
Another Swedish group reported on cost-
effectiveness for HEMS use in STEMI. Schoos
et al34 analyzed STEMI transports arising
from the islands comprising much of Swe-
den’s coastal population centers and
calculated that surface transport (by boat)
was simply not an option if percutaneous
 ARTICLE IN PRESS
S.H. Thomas, I. Blumen / Air Medical Journal ■■ (2017) ■■–■■
coronary intervention (PCI) were to be
achievable within any reasonable time
frame. The same year South Korean inves-
tigators reported similar findings.35
Although the nonmortality end points
are still underused in contemporary HEMS
studies, there are some relevant prelimi-
nary data from the past few years. In 2016,
a group from Copenhagen found that
physician-staffed HEMS deployment for
trauma was associated with decreased out-
of-work time (ie, improved functional
outcome).36 For nontrauma, the best avail-
able evidence is still tied to surrogate end
points. With stroke, for instance, 201437 and
201638 studies report the use of HEMS as a
time-saving device with linkage to func-
tional outcome improvements, but the
researchers’ conclusions are based on ex-
trapolation of time to intervention evidence
from the recent stroke literature.39,40
One of the barriers that must be over-
come by HEMS cost-benefit analysis is the
difficulty of assigning value levels to ad hoc
HEMS uses that may be critical for individ-
ual cases but that do not occur with
frequency sufficient for robust analysis. For
example, HEMS has been noted to be the
only mechanism for time-critical delivery
of life- or limb-saving therapy such as pro-
thrombin complex concentrate in Scotland41
or crotalid antivenom in the United States.42
In the latter case, the flexibility of HEMS was
noteworthy in that it allowed expedited
transport of antivenom to a patient at a rural
hospital for whom there was no capability
for timely air transport back to the tertia-
ry center (because of impending weather
deterioration).42
Difficulties with executing prehospital
randomized controlled trials (RCTs) combine
with lack of precise outcomes benefits data
to cloud HEMS cost-benefit calculations.
While ongoing work such as a 2015 U.K.
assessment43 of public’s willingness to pay
for various models of HEMS (public-sector
services were preferred) is useful, future
HEMS research must include refinement of
cost-benefit analyses.
HEMS for STEMI
The premise of HEMS use for STEMI is
that “time is myocardium.” HEMS use for
transporting cardiac patients is largely sup-
portable through the logic that getting
patients to PCI faster results in improved
outcome. This premise, solidly founded in
the cardiology literature for patients of a
variety of age groups and PCI times,44-47 is
primarily related to primary PCI, but there
is also evidence supporting time-saving
outcome benefits for postthrombolysis
angioplasty.48
The application of time savings as a sur-
rogate variable has 2 main foundations,
which have been described in detail
elsewhere.49 First, the movement of STEMI
patients with HEMS could allow patients to
arrive at PCI centers within the time
window of clear benefit from angioplasty.
Second, HEMS can potentially affect further
time savings even in patients who, if trans-
ported by GEMS, would have arrived within
the PCI window; this is important because
every 30 minutes of ischemia time increases
STEMI mortality by 8% to 10%,45 and time-
related mortality improvement is seen with
incremental savings of roughly 15 minutes.44
The evidence base supporting properly
deployed HEMS as a saver of time and
myocardium is rapidly growing. One rep-
resentative study from the Critical Care
Transport Collaborative Outcomes Research
Effort (CCT CORE) group was presented at
the 2014 American Heart Association Sci-
entific Assembly50; the work has since been
published.51 The authors, based in Qatar and
the United States, reported a 6-center trial
using previously validated methodology49
from a regional study using geographic in-
formation system (GIS) software to calculate
transport logistics. Using a combination of
GIS and actual primary PCI transport logis-
tics for HEMS (n = 257) and GEMS (n = 27)
transports of > 15 miles, the authors found
that HEMS case times usually fell within
predefined PCI target windows of 90
minutes (67.7% of cases) or 120 minutes
(91.1% of cases). Compared with the
GIS-calculated GEMS times, HEMS was es-
timated to accrue a median time saving of
32 minutes (interquartile range, 17-46). The
number needed to transport for HEMS to get
1 additional case to PCI within 90 minutes
was 3. In the varied contexts of this multi-
center study, the number of lives saved by
HEMS, solely through time savings, was cal-
culated as 1.34 per 100 HEMS PCI transports.
The CCT CORE cardiac study included
both scene and interfacility missions, but
most of the cases were secondary trans-
ports. Scene transports were the focus of a
2015 study from rural Belgium52 that as-
sessed the use of HEMS for the primary
response for 342 STEMI patients. Time gains
compared with GEMS were calculated using
GIS. The Belgians found that HEMS use re-
sulted in savings of 60 minutes (interquartile
range, 47-72 minutes) for STEMI patients
undergoing primary PCI. Similarly, posi-
tive time savings were found in a
preliminary report from North Carolina,
where HEMS use for scene cases always
saved at least 15 minutes.53
Cardiac flights from a Danish island-
dotted geography were reported in 2014.34
In a study reminiscent of some of the early
trauma literature, the authors of this review
of 101 STEMI cases concluded that HEMS
improved outcome based on the capabili-
3
ty of the aircraft to extend the reach of the
primary PCI. The patients in the study com-
prised a group for whom surface transport
was simply not an option. For these 101
STEMI individuals who received timely PCI
solely because of the presence of HEMS, the
likely benefit from HEMS seems clear.
HEMS for iCVA
The case for HEMS use for iCVA is similar
to that for its use in STEMI; time savings
translate into reduced cell death and im-
proved outcome. One recent report of over
25,000 HEMS-transported stroke cases
found that HEMS allowed patients to reach
tertiary care within 2 hours in a very high
percentage of the time (96% of cases), which
would not have been achievable by GEMS.54
Air medical transport can enable
neurointervention (eg, thrombolytic
therapy) for patients who would not oth-
erwise be eligible, and HEMS can also speed
time-critical therapy even for patients who,
if transported by GEMS, would have reached
stroke centers within the therapeutic
window.40,55 The neurology literature, in-
cluding major studies in JAMA, has
established that savings of every 15 minutes
within the “lysis window” (up to 270
minutes) reduces iCVA mortality by 4% and
has commensurately salutary effects on the
functional outcome.39,40
Some of the 2014 to 2016 HEMS stroke
studies have followed the pathways set by
the STEMI studies using GIS. These are ex-
ampled by a CCT CORE multicenter study
presented at the 2016 European Stroke As-
sociation meeting.38 The authors from Qatar
and the United States found that when
stroke patients’ transport distances (from
scenes or referring hospitals) exceeded 15
miles, HEMS saved the a priori–defined clin-
ically relevant time minimum of 15 minutes
in every single case (the median time
savings was calculated at 48 minutes).38
Although it appears that HEMS can save
time (and improve outcome) in iCVA, a 2014
study from Denmark 56 showed HEMS
should not be assumed to be a time-saving
transport mode. Their study identified that
system delays associated with secondary
HEMS transport translated into faster times
to thrombolytic therapy when GEMS was
primarily dispatched. The Danish group
made a clear case that although HEMS may
be useful in some time-critical cases, there
is a caveat that HEMS must be quickly dis-
patched and transports must be expedited
in order for speed benefit to occur.56
A 2016 report of a year’s experience in
Georgia found that scene activation of HEMS
transport for severe hemiparesis or hemiple-
gia (representing severe iCVA) was
associated with a high rate of timely throm-
bolytic therapy and other neurointervention
 ARTICLE IN PRESS
4 S.H. Thomas, I. Blumen / Air Medical Journal ■■ (2017) ■■–■■
that could never have been achieved with
GEMS transport. In 60% of the cases trans-
ported, the diagnosis was iCVA (in these
patients who were transported based on
symptoms and physical findings alone);
time-critical intervention was provided for
47% of the 45 cases.57
The Georgia findings were replicated in
an Ohio report58 covering a longer time
period (2011-2015) and more patients (n =
136 iCVA scene flights). The Ohio group
found that prehospital triage was accept-
ably accurate and that 28% of the scene-
transported HEMS-suspected iCVA cases
received thrombolytic therapy with an ad-
ditional 10% undergoing other time-critical
neurointerventional procedures.
A third US study also assessed HEMS
transports for suspected iCVA and focused
on the frequency with which “stroke
mimics” were transported in an overall pop-
ulation of 3,376 cases transported from
2007 to 2013. The authors, who were from
the University of Pittsburgh, found that
stroke mimics (eg, hemiplegic migraine) ac-
counted for 32% of scene HEMS missions for
presumed iCVA and mimics comprised 16%
of interfacility HEMS missions for sus-
pected iCVA.59
One of the most interesting 2014 to 2016
iCVA studies involving HEMS addressed
hemorrhagic transformation risk in a
murine model. A group from Iowa60 admin-
istered tissue plasminogen activator (tPA)
in a murine in vivo model and assessed
reperfusion and hemorrhagic transforma-
tion risks associated with helicopter flight
compared with tPA-treated control mice
who were not flown. The authors found no
adverse effect associated with tPA treat-
ment for these mice exposed to the aviation
transport setting; neither infarction volumes
nor hemorrhagic transformation rates were
problematic.
With questions about tPA safety seem-
ingly resolved, the final iCVA HEMS study
to be addressed provides an update on the
role of air transport in assuring stroke center
access in the United States. The 2014 study
from the University of Cincinnati,37 reaf-
firming the system-based importance of
iCVA tPA treatment, reported that HEMS in-
creases the proportion of the US population
with timely (< 60 minutes) access to lysis-
capable stroke centers from 81% to 97%.
HEMS increased the proportion of US citi-
zens with timely access to endovascular-
capable iCVA centers from 56% to 85%.
HEMS for Sepsis
The increased attention to rapid inter-
vention (in the emergency department) for
sepsis has translated into interest in assess-
ing whether HEMS can improve outcome in
these cases. Unfortunately, the question has
been difficult to answer because of the lack
of randomization capability combined with
the natural tendency toward higher acuity
in HEMS cases. A 2016 study from the Mayo
Clinic61 that addressed the subject was not
able to control for the fact that, compared
with GEMS sepsis transports, HEMS cases
had far higher illness severity. The Mayo
group found that HEMS was associated with
a faster transport time and that HEMS trans-
port allowed for equal outcomes regardless
of transport distance. However, HEMS cases
had significantly higher mortality than
GEMS cases. This finding demonstrates the
ongoing difficulties in assessing any
outcome of HEMS on patients in whom
there is no clear acuity adjustment capa-
bility to account for the fact that sicker
patients are more likely to go by HEMS than
GEMS.
Conclusion and Areas for Further
Investigation
Many questions remain unanswered
about HEMS. However, there is a body of ev-
idence addressing HEMS’ potential impacts,
which are often paid insufficient attention
in the HEMS debate. Available informa-
tion ranges from cost-benefit studies to
analysis of surrogate timing end points and
even safety studies of tPA-treated mice.
There is no doubt that the expansion of the
HEMS literature in the nontrauma realm will
continue, and the proper and judicious role
of air medical transport for these indica-
tions will become better defined.
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Stephen H. Thomas, MD, MPH, is a professor and chair-
man in the department of emergency medicine at Hamad
General Hospital and Weill Cornell Medical College in
Qatar in Doha, Qatar, and a senior lecturer of emergen-
cy and resuscitation medicine at the Queen Mary College,
University of London, and can be reached at
SThomasMD@gmail.com. Ira Blumen, MD, is a profes-
sor in the department of medicine, section of emergency
medicine at the University of Chicago in Chicago, IL, and
a medical director at the University of Chicago Aero-
medical Network.