Medical Helicopters Dr Hicham Al Mawla Medical Helicopters

Medical Helicopters Dr. Hicham Al Mawla

Medical Helicopters �What is the role of medical helicopters in the modern American EMS system?

Medical Helicopters �In many areas, the indication for summoning a medical helicopter is: The presence of a patient.

Medical Helicopters �Medical industries that have quickly gotten out of hand: � 1980 s: Boutique psychiatric and substance abuse facilities. � 1990 s: Home health care agencies. � 2000 s: Medical helicopters and motorized wheel chairs.

Medical Helicopters Number of Medical Helicopters by Year 1200 1000 800 600 400 200 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Medical Helicopters �There are more medical helicopters in Dallas/Fort Worth than all of Canada or Australia.

Medical Helicopters �Are patients needs or helicopter operator profits driving HEMS in the United States?

Medical Helicopters � In 2002, Medicare increased the rates for medical helicopter transport. � Price for airlift ranges from $5, 000 to $15, 000, 5 to 10 times that of a ground ambulance. � Helicopters in the US have doubled from a decade ago; and with more of them scrambling for business, specialists say that emergency personnel are feeling more pressure to use them. � In 2004, the number of flights paid for by Medicare alone was 58 percent higher than in 2001. � Spending by Medicare has more than doubled to $103 million over the same period.

Medical Helicopters �In FY 2001, the University of Michigan’s flight program “Survival Flight”: �$6, 000 operational Rosenberg BL, Butz DA, Comstock MC, Taheri. Aeromedical Service: How Does it Actually Contribute to the Mission? J Trauma, 2003; 54: 681 -688 costs �$62, 000 in inpatient revenues � 28% of ICU days �Helicopter patients were twice as likely to have commercial health insurance compared to regular patient profile.

Costs �Comparison of patients before and after helicopter placement. �Sussex = £ 55, 000 �Cornwall = £ 800, 000 �London = £ 1, 200, 000 �No improvements in response times. �Scene times longer. �Conclusion: �HEMS costly �Benefits small � Snooks HA, Nicholl JP, Brazier JE, Lees-Mlanga S. The Costs and Benefits of Helicopter Emeregency Services in England Wales. J Pub Health Med. 1996; 18: 67 -77

Costs �Prospective comparison of seriously-injured patients (survivors) transported by HEMS and GEMS. �“As there is no evidence of any improvement in outcomes overall for the extra cost, HEMS has not been found to be a cost-effective service. ” � Nicholl JP, Brazier JE, Snooks HA. The Cost and Effectiveness of the London Helicopter Emergency Services. J Health Serv Res Policy. 1996; 1: 232 -237

Interfacility � Retrospective review of 388 pedi patients. � 80 HEMS (16% mortality) � 288 GEMS (5% mortality) �Mean total transport time 170 minutes faster by HEMS. �No significant differences in LOS, ICU days. � No differences in outcomes (except mortality) which was due to increased severity of HEMS population. Quinn-Skillings GQ, Brozen R. Outcomes of Interhospital Transfers fo Critically-Ill Patients: A Comparison of Air and Ground Transport. Ann Emerg Med. 1999; 34: 597

Interfacility � Prospective study of: �Local HEMS: 1, 234 �Non-Local HEMS: 25 �GEMS: 153 � Deaths: �HEMS: 19% �GEMS: 15% � No differences found at 30 days for: �Disability �Health status �Health care utilization � Patients transported by HEMS did not have improved outcomes over GEMS. � These data argue against a large advantage of HEMS in interfacility transport. Arfken CL, Shapiro MJ, Bessey PQ, Littenberg B. Effectiveness of helicopter versus ground ambulance services for interfacility transport. J Trauma. 1998; 45: 785 -790

Interfacility � Comparison of interfacility � HEMS associated with patients with unstable angina or MI transported by GEMS because HEMS was unavailable due to weather. � Compared to HEMS transports. � No differences in deaths within 72 hours. more total deaths (9/48 v 1/48) � Interfacility transport of cardiac patients by air offers no outcome advantage. Stone CK, Hunt RC, Sousa JA. Interhospital transfer of cardiac arrest patients: does air transport make a difference? Air Med J. 2004; 13: 159 -162.

Interfacility � 145 patients transported � HEMS transport faster for from 20 hospitals to the University of Wisconsin hospital by HEMS. � Dispatch times: all patients. � For stable patients it may be reasonable to use GEMS. �GEMS: 5 6 �HEMS: 17 8 � Referral hospital times: �GEMS: 25 13 �HEMS: 31 11 � HEMS patients transport faster. Svenson JE, O’Connor JE, Lindsay. Is air transport faster? A comparison of air versus ground transport times for interfacility transfers in a regional referral system. Air Med J. 2006; 25: 170 -172

Interfacility � Retrospective cohort of 243 patients transported by GEMS and 139 patients by air in Ontario. � Time interval between decision to transfer and the actual time has longer for GEMS (41. 3 vs. 89. 7 minutes). � Travel time shorter by helicopter (58. 4 vs. 78. 9) � Distance of transport not an accurate indicator of transport time. Karanicolas PJ, Shatia P. Willamson J, et al. The fastest route between two points is not always a straight line: an analysis of air and land transfer of nonpenetrating trauma patients. J Trauma. 2006; 61: 396 -403.

Neonatal � 10 -year study of neonatal air transport in Norway. � 236 acute care transfers. � 13 LBW infants � 7 deaths (3. 2%) �Low mortality overall. Lang A, Brun H, Kaaresen PI, Klingenberg C. A population-based 10 -year study of neonatal air transports in North Norway. Acta Paediatr. 2007; 96: 955 -959

Pediatric Transports � 1991 -1992 Utah review: �“Air medical transport �HEMS = 561 is expensive and sometimes may be used unnecessarily. ” �FWEMS = 313 � Diller E, Vernon D, Dean JM, � 874 pedi patients �Charges (average): �GEMS = $526 �HEMS = $4, 879 �FWEMS = $4, 702 Suruda A. The Epidemiology of Pediatric Air Medical Transports in Utah. Prehosp Emerg Care. 1999; 3: 217 -227

Burns �Retrospective review of HEMS transports to burn center over 2 -year period. �GEMS transports used as control group. �Excluded: �Inhalation injury �Burns > 24 hours old �> 200 mils away �>30% BSA burn �Associated trauma

Burns �Evaluated and found no difference in: �TBSA burned �% of 3° burns �LOS �Vent days �Age �Transport mileage �Patients with < 30% TBSA and < 200 miles should be transported by GEMS. De. Wing MD, Curry T, Stephenson E, et al. Cost-effective use of helicopters for the transportation of patients with burn injuries. J Burn Care Rehabil. 2000; 21: 535 -540

Burns � 437 consecutive acute burn patients to western PA burn center: �GEMS = 339 �HEMS = 98 �< 25 miles = 18 �> 25 miles = 80 �Inhalation injury: �GEMS = 3% �HEMS = 28% �Reduce use of HEMS for burn patients. Slater H, O’Mara MS, Goldfarb IW. Helicopter transportation of burn patients. Burns 2002; 28: 70 -2

Obstetrics � 22 HEMS transports of �HEMS = $4, 613. 64 preterm labor patients. �No outcome difference found. �No deliveries in flight. $581. 12 �GEMS = $604. 02 $306. 02. Van Hook JW, Leicht TG, Van Hook CL, et al. Aeromedical transfer of preterm blabor patients. Tex Med. 1998; 94: 8890

Trauma � 1990 -2001 retrospective review of all patients brought to the Santa Clara Valley Trauma Center (CA) by HEMS. � 947 consecutive patients: � 911 blunt trauma � 36 penetrating trauma �Mean ISS = 8. 9 �Mortality = 15 (in ED)

Trauma � 312 (33. 5%) discharged � 84 (8. 9%) required early home from the ED. � 620 hospitalized: operation. �Only 17 (1. 8%) underwent surgery for life-threatening injuries. � 339 (54. 7%) had an ISS 9. � 148 had an ISS 16.

Trauma �HEMS faster than GEMS = 54. 7% �Only 22. 8% of the study population possible benefited from HEMS transport. �HEMS is used excessively for scene transport. New criteria should be developed. � Shatney CH, Homan J, Sherck J, Ho C. The Utility of Helicopter Transport of Trauma Patients from the Injury Scene in an Urban EMS Setting. J Trauma. 2002; 53: 817822

Trauma � 1987 -1993 review of all helicopter and ground transports from scene to trauma center. �North Carolina Trauma Registry � 1, 346 (7. 3%) transported by HEMS. �TS = 12 3. 6 �ISS = 17 11. 1 � 17, 344 (92. 7%) transported by ground. �TS = 14 3. 6 �ISS = 10. 8 8. 4

Trauma �Outcomes for HEMS �Only a very small subset transport not uniformly better for HEMS. of patients benefited from HEMS Transport. �Only TS between 5 -12 � Cunningham P, Rutledge R, Baker and ISS between 21 -30 achieved significance. CC, Clancy RV. A Comparison of the Association of Helicopter and Ground Ambulance Transport with the Outcome of Injury in Trauma Patients Transported from the Scene. J Trauma. 1997; 43: 940 -946

Trauma �Retrospective Boston �Crude Mortality: Med. Flight study (19951998): �Air = 9. 4% � Complicated study �OR 0. 76. statistically �a priori? �Ground = 3. 0% � Thomas SH, Harrison TH, Buras WR, et al. Helicopter transport and blunt trauma mortality: a multicenter trial. J Trauma. 2002; 52: 136 -145

Trauma VARIABLE OR SE WALD p Value 95% CI (OR) Air Transport 0. 756 0. 098 0. 031 0. 586 -0. 975 Increasing Age 2. 71 0. 259 <0. 001 2. 25 -3. 27 Scene Mission Type 1. 49 0. 160 <0. 001 1. 21 -1. 84 ALS EMS Baseline BLS EMS 0. 423 0. 060 <0. 001 0. 320 -6. 666 Missing EMS 0. 554 0. 129 0. 011 0. 351 -0. 784 ISS < 9 Baseline ISS 9 -15 4. 08 1. 02 <0. 001 2. 50 -6. 66 ISS 16 -24 19. 5 4. 88 <0. 001 12. 0 -31. 9 ISS > 24 163 37. 2 <0. 001 104 -255 Missing 22. 1 10. 0 <0. 001 9. 11 -53. 7 <0. 001

Trauma � Phoenix study (1983 - 1986): �ISS = 20 -29 (451) �ISS = 30 -39 (155) �Mean age = 30. 5 years �Male = 76% �GEMS = 259 � GCS Mean = 10. 4 � TS Mean = 12. 7 �HEMS = 347 � GCS Mean = 9. 6 � TS Mean = 12. 1 �Mortality: �HEMS = 18% �GEMS = 13%. � No survival advantage for the HEMS group in an urban setting with sophisticated EMS system. � Schiller WR, Knox R, Zinnecker H et al. Effect of helicopter transport of trauma victims on survival in an urban trauma center. J Trauma. 1988; 25: 1127 -1134

Trauma � 4 -year retrospective review of trauma scene flights. �Audit of scene flights provided half-way through. �Inappropriate flights decreased after audit. �Criteria for HEMS should be based upon physiologic criteria. � Norton R, Wortman E, Eastes L. et al. Appropriate Helicopter Transport of Urban Trauma Patients. J Trauma. 1996; 41: 886891

Trauma � Review of 122 consecutive victims of noncranial penetrating trauma in Houston: � Average RTS = 10. 6 � Died = 15. 8% � HEMS transport faster = 0% � 4. 9% of patients required intervention not available on ground EMS. � Only 3. 3% received such intervention. �Scene flights in Houston for noncranial penetrating trauma are not efficacious. � Cocanour CS, Fischer RP, Ursic CM. Are Scene Flights for Penetrating Trauma Justified? J Trauma. 1997; 43: 83 -88

Trauma � Retrospective review of New England flight service. � Results compared to nationalized database. � 13% reduction in mortality when compared to controls. � 35% reduction in mortality when TS between 4 and 13 �No differences at extremes of RTS. �Rapid utilization of HEMS can have a dramatic effect on patient outcomes. � Jacobs LM, Gabram SGA, Sztajnkrycer MD, Robinson KJ, Libby MCN. Helicopter Air Medical Transport: Ten-Year Outcomes for Trauma Patients in a New England Program. Connecticut Med. 1999; 63: 677 -682

Trauma �Retrospective review of 1, 877 HEMS and GEMS trauma patients transported from the scene. �Multiple parameters evaluated by logistic regression analysis: �CUPS �Patient age �ISS �RTS Significant Predictors of Not a Significant Predictor of Trauma Mortality �Total out-of-hospital time Lerner EB, Billittier AJ, Dorn JM, Wu YW. Is Total Out-of-Hospital Time a Significant Predictor of Trauma Patient Mortality? Acad Emerg Med. 2003; 10: 949 -954

Trauma � Comparison of prehospital scene times (PST) between GEMS and HEMS. � Patients: 1, 457 � GEMS: 1, 197 � HEMS: 260 � GEMS PST: 24. 6 minutes � HEMS PST: 35. 4 minutes � Logistic regression analysis and correction for ISS, RTS, age. �PST not associated with increased mortality. � Ringburg AN, Spanjersberg WR, Franema SP et al. Helicopter emergency medical service (HEMS): impact on scene times. J Trauma. 2007; 63: 258 -262

Penetrating Trauma � Danville, PA study 1990 - 1998. � 2, 048 penetrating trauma cases: � GEMS = 2, 914 � HEMS = 494 � Mean transport time: � GEMS = 30. 5 minutes � HEMS = 52. 7 minutes � Mean ISS: � GEMS = 9 � HEMS = 16. �Despite longer transport and higher ISS, controlling for injury severity found no difference in survival. � Dula DJ, Palys K, Leicht M Madtes K. Helicopter versus Ground Ambulance Transport of Patients with Penetrating Trauma. Ann Emerg Med. 2000; 38: S 16

Pediatric Trauma �All pediatric HEMS trauma transports for 3 year period. �Results: � 189 patients �Median age = 5 �RTS > 7 = 82% �ISS: � 0 -15 = 83% � 16 -60 = 15% �> 30 = 3% � 14% intubated � 18% admitted to PICU � 4% taken directly to the OR.

Pediatric Trauma � 33% discharged home and not admitted. �The majority of pediatric patients transported by helicopter sustained minor injuries. � Eckstein M, Jantos T, Kelly N, Cardillo A. Helicopter Transport of Pediatric Trauma Patients in an Urban Emergency Medical Services System: A Critical Analysis. J Trauma. 2002; 53: 340 -344

Pediatric Trauma �Retrospective analysis of pedi trauma patients transported by air to pedi trauma center from scene and compared to those from other hospitals. �Patients: �Scene = 379 �Death rate = 8. 7% �ICU hours = 149. 1 �Hospital = 842 �Death rate = 5. 5% �ICU hours = 118. 3

Pediatric Trauma �Retrospective analysis was not able to demonstrate any benefit from direct transport from the scene. �Hospital stabilization before air transport may improve survival. � Larson JT, Dietrich AM, Abdessalam SF, Werman H. Effective Use of an Air Ambulance for Pediatric Trauma. J Trauma. 2004; 56: 89 -93

Pediatric Trauma �Children’s National Medical Center Study: � 3, 861 children �Retrospective review �Patients: �HEMS = 1, 460 �Mean ISS = 9. 2 �Transport time = 45. 1 minutes �GEMS = 2, 896 �Mean ISS = 6. 7 �Transport time= 43. 2 minutes

Pediatric Trauma � 83% of children transported by air not critically-injured (85% overtriage). � Outcomes uniformly better for children criticallyinjured. � HEMS triage based upon GCS and pulse rate better and more accurate. � Moront ML, Gotschall CS, Eichelberger MR. Helicopter Transport of Injured Children: System Effectiveness and Triage Criteria. J Pedi Surg. 1996; 8: 11831188

Rural Trauma �Iowa Study of 918 rural trauma victims. �Classified as: �Essential = 14. 0% �Helpful = 12. 9% �Not a Factor = 56. 6% �Died = 16. 5% �Based on the data, it was impossible to determine prospectively which patients would benefit from HEMS. Urdanetta LF, Miller BK, Rigenburg BJ et al. Role of Emergency Helicopter Transport Service in Rural Trauma. Arch Surg. 1987; 122: 992 -996

Staffing �Louisville study: � 145 consecutive adult trauma flights with MD. � 114 without MD. �Z statistic and other parameters revealed mortality and care to be similar. � It appears that experienced nurses and paramedics , operating with wellestablished protocols, car provide aggressive care equal to that of a physician. Hamman BA, Cue JI, Miler FB et al. Helicopter Transport of Trauma Victims: Does a Physician Make a Difference? J Trauma. 1991; 31: 490494

Staffing �Australian study: � 67 patients in physician group � 140 in paramedic group �W statistic showed 8 - 19 extra survivors per 100, 000 in the physician group. �Physicians perform more procedures without increasing scene time which decreases mortality. Garner A, Rashford S, Lee A, Bartolacci R. Addition of Physicians to Paramedic Helicopter Services Decreases Blunt Trauma Mortality. Aust N Z J Surg. 1999; 69: 697 -701

Staffing �Comparison of nurse/nurse and nurse/paramedic crew performance based on patient severity. �Multiple parameters examined. �No objective differences in outcomes of patients when crew types were compared. Burney RE, Hubert PL, Maio R. Comparison of Aeromedical Crew Performance by Patient Severity and Outcome. Ann Emerg Med. 1992; 21: 375 -378

Staffing �Prospective 2 -year follow-up and repeat of previous study comparing nurse/nurse and nurse/paramedic crew performance based on patient severity. �No objective differences in outcomes of patients when crew types were compared. Burney RE, Hubert PL, Maio R. Variation in air medical outcomes by Crew Composition: a two-year follow -up. Ann Emerg Med. 1995; 25: 187192

Staffing � “Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medicallydesirable for one-half of flights. ” �Mortality in blunt trauma improved when physician part of the crew. Bartolacci RA, Munford BJ, Lee A, Mc. Gougall PA. Air medical scene response to blunt trauma: effect on early survival. MJA. 1998; 169: 612612

Usage � 162, 730 patients from �HEMS patients: PA Trauma Registry treated at 28 accredited trauma centers. �Younger �HEMS: 15, 938 �Likely to have systolic �GALS: 6, 473 �Interhospital and calls without ALS excluded. �Male �More seriously injured BP < 90 mm. Hg.

Usage � Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival. � Braithwaite CEM, Rosko M, Mc. Dowell R, Gallagher J, Proneca J, Spott MA. A Critical Analysis of On-Scene Helicopter Transport on Survival in a Statewide Trauma System. J Trauma. 1998; 45: 140144

Usage � Finnish Study. � 588 flights: � 40% aborted � Estimated that: � 3 patients (1. 5%) were saved. � 42 patients (20%) mostly with cardiovascular disease benefitted. � Remaining patients benefited from ALS care and not HEMS. �A minority of patients benefit fro HEMS. � Hurola J, Wangel M, Uusaro A, Rukonen E. Paramedic helicopter emergency service in rural Finland —do the benefits justify the cost. Acta Anaesthesiol Scand. 2002; 46: 779 -784

Usage �Retrospective review of HEMS transports in FDNY (1996 -1999). � 182 transports: �Scene-Hospital = 32 �NYC Hospital-NYC Hospital = 18 �Outside NYC Hospital – NYC Hospital = 122 �NYC Hospital – Outside NYC Hospital = 10 � FDNY infrequently uses HEMS. � Asaeda G, Cherson A, Giordano L, Kusick M. Utilization of Air Medical Transport in a Large Urban Environment: A Retrospective Analysis. Prehosp Emerg Care. 2001; 5: 36 -39

Usage � 1995 -2000 comparison of HEMS and GEMS transport in Philadelphia. � 29, 074 transports � ISS > 15 = 4, 640 � 5 -15 mile radius = 1, 245 � HEMS = 12. 24% � GEMS = 87. 66% � For patients 5 -15 miles from trauma center, HEMS transport takes longer. � HEMS outcomes worse. � Basile JF, Sorondo B. Comparison Between Helicopter EMS and Ground EMS Transport Time and Outcomes for Severely-Injured Patients within a 5 -15 Mile Radius from a Trauma Center. Prehosp Emerg Care. 2004; 8: 99

Usage �Retrospective study 7, 584 GEMS and 1, 075 HEMS transports. �Transport times: � GEMS provided shortest prehospital interval at distances < 10 miles. � Simultaneously dispatched HEMS provided shortest prehospital interval > 10 miles. � Non-simultaneously dispatched HEMS was faster if > 45 miles. � Diaz MA, Hendey GW, Bivins HG. When is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times. J Trauma. 2005; 58: 148 -153

Usage � Retrospective review of all patients transported 20032004. � HEMS transfer in the acute setting is of debated value. � Triage categories need to be � 156 trauma patients revised. �Average ISS = 12 (range 1 - � Melton JT, Jain S, Kendrick B, 46) �Discharged home = 45 (41%) � 24 to OR � 10 to ICU � 2 died Deo SD. Helicopter emergency ambulance service (HEAS) transfer: an analysis of trauma patient case-mix, injury severity and outcomes. Ann R Coll Surg Engl. 2007; 89: 513 -516

Medical Helicopters � Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF. Helicopter Scene Transport of Trauma Patients with Nonlife -Threatening Injuries: A Meta. Analysis. J Trauma. 2006; 60: 1254 -1266

Bledsoe, et al. �Considerations: �Severe injury: �ISS > 15 �TS < 12 �RTS ≤ 11 �Weighted RTS ≥ 4 �Triss Ps < 0. 90 �Non-life-threatening injuries: �Patients not in above criteria �Patients who refuse ED treatment �Patients discharged from ED �Patients not admitted to ICU

Results � 48 papers met initial inclusion criteria. � 26 papers rejected: �Failure to stratify scores. �Failure to differentiate scene flights. �Failure to differentiate trauma flights. � 22 papers accepted. �Span: 21 years �Cohort: 37, 350

Results �ISS ≤ 15: �N = 31, 244 �ISS ≤ 15 = 18, 629 �ISS ≤ 15 = 60. 0% [99% CI: 54. 5 to 64. 8] �TS ≥ 13: �N = 2, 110 �TS ≥ 13 = 1, 296 �TS ≥ 13 = 61. 4% [99% CI: 58. 5 to 80. 2]

Results �RTS > 11: �Insufficient data �TRISS Ps > 0. 90: �N = 6, 328 �TRISS Ps > 0. 90 = 4, 414 �TRISS Ps > 0. 90 = 69. 3% [99% CI: 58. 5 to 80. 2]

Results 70 68 66 64 N=37, 350 Percentage with minor injuries 62 60 58 56 ISS TS TRISS Source: Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MO. Helicopter scene transport of trauma patients: a meta-analysis. J Trauma. 2006: 60: 1254 -1266

Results �Patients discharged < 24 hours: �N = 1, 850 �Discharged < 24 hours = 446 �Discharged < 24 hours = 25. 8% [99% CI: -0. 90 to 52. 63]

Medical Helicopter Accidents �Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10 -Year Review. Journal of Trauma. 2004; 56: 1325 -1329

Medical Helicopter Accidents 25 21 19 19 20 15 15 12 10 5 16 15 9 8 3 4 11 10 4 2 0 19 93 19 96 19 99 20 02 20 05 1993 -2007 (Source: NTSB) Accidents

Medical Helicopter Accidents Source: NTSB

Medical Helicopter Accidents 1993 -2002 10 9 8 7 6 5 4 3 2 1 0 PM 10 M 8 P M 6 P M 4 P M 2 P PM 12 M A 10 M 8 A M 6 A M 4 A M 2 A 12 A M Accidents Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10 -Year Review. J Trauma. 2004; 56: 1225 -1229

Medical Helicopter Accidents by Cause 2% 11% Pilot Error 26% Mechanical Failure 61% Undetermined Other Source: NTSB & Bledsoe BE and Smith MG. Medical Helicopter Accidents in the United States: A 10 -Year Review. J Trauma. 2004; 56: 1225 -1229

Occupational Deaths per 100, 000 per Year All Workers 5 Farming 26 Mining 27 Air Medical Crew 74 US 1995 -2001 Source: Johns Hopkins University School of Public Health

Fatal Crashes per Million Flight Hours (2001) Source: AMPA, A Safety Review and Risk Assessment in Air Medical Transport (2002)

Medical Helicopter Accidents �Weather a factor in one- fourth of all crashes. o Source: AMPA. A Safety Review and Risk Assessment in Air Medical Transport, 2002

Pressure on Pilots �Undue pressure from: �Management �Dispatch �Flight Crews �Pressure to: �Speed response or lift-off times �Launch/continue in marginal weather �Fly when fatigued or ill EMS Line Pilot Survey, 2001

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