MADISON, Wis. -- The dramatic buzz and whir of a helicopter lowering to the scene of an accident is an emblem of modern emergency medicine.
So strongly does UW Health identify with the image that marketers chose a scene of a patient being transported from a helicopter for the cover of its latest annual report.
But do helicopter emergency medical services mean better outcomes for patients?
It depends on the condition of the patient, the distance to be traveled, and such logistics of transport as traffic or terrain, say experts. But it is hard to predict which patients will do better if moved by air, they say.
That makes it critical to review helicopter use after the fact, experts say, and the recent tragic deaths of three Med Flight workers have focused public and media attention on the issue.
On May 10, Dr. Darren Bean, nurse Mark Coyne and pilot Steve Lipperer transported an 86-year-old woman who was suffering from bleeding in the brain from a Prairie du Chien hospital to Gunderson Lutheran hospital in La Crosse. Gunderson Lutheran's own Med Link helicopter would have done the job, but it had been dispatched to a fatal car accident, so Med Flight from Madison responded instead, the Associated Press reported.
On the way home, Bean, Coyne and Lipperer's Eurocopter EC-135 crashed into a wooded hillside shortly after leaving La Crosse. The National Transportation Safety Board has not yet released the cause of the crash.
At Gunderson Lutheran, the 86-year-old woman also died.
There has been no public discussion suggesting that the woman should not have been flown the 60 miles to La Crosse, but the question of whether air transport improves patient outcomes is the focus of much medical research, many professional conferences and even the law in some states.
"Appropriate use of the helicopter is the hottest issue in the business," said Dr. Stephen Thomas, director of undergraduate emergency medicine education at Massachusetts General Hospital in Boston and a nationally known researcher on air medical transport.
Scientific research on the effect of air transport on patient outcome is all over the board.
A 2002 study at Stanford University School of Medicine and Santa Clara Valley Medical Center found that helicopters were used excessively to transport trauma patients in that northern California region.
A review of many studies, published in 2002 by Ohio State University College of Medicine, cites some showing that air transport resulted in significant reductions in the number of predicted deaths, but notes others did not demonstrate a significant impact on mortality. Still other studies, the researchers wrote, found that air transport has the greatest benefit for trauma patients with injuries neither too slight nor too severe.
Mike Slack, an Austin, Texas, attorney involved in medical air transport litigation and an outspoken critic of the industry, said transporters routinely fly when driving would have been just as fast, or faster.
Aircraft flying the relatively short distances of medical transport in urban areas go through the time -- and hazards -- of takeoffs and landings that nearby ground transport could accomplish more quickly, Slack said.
Studies in urban areas show that only in a small percentage of cases does air transport significantly improve patient outcomes, he said.
"Ground ambulances are swarming along all the time," Slack said in an interview. Without the weight limitations of a helicopter, ground ambulances can carry more equipment and personnel, and so can provide patients better care, he said.
What is missing from most medical air transport systems, said Slack, is triage, a process for determining proper medical response according to the condition of the patient.
"Many crashes involving air ambulances occur during medically unnecessary transports," Slack wrote in a position paper published in a trial lawyers newsletter. "This is typically due to the absence of qualified medical screeners who determine whether the dispatch requests are medically warranted before turning the 'go/no-go' decision over to the pilot."
Asked if Med Flight employs a standard protocol for deciding when a helicopter is needed, UW officials said no, but they also said it isn't necessary because of the way they operate.
UW Med Flight medical director Dr. Bruce Lindsay declined to be interviewed for this article, but UW Health spokesman Aaron Conklin wrote in an e-mail that Med Flight "is unusual in that it is one of a handful of programs in the United States in which a flight physician accompanies every flight. This provides a higher level of care than is possible in the great majority of flights done by other air medical services. Protocols are more useful for centers that transport patients without a flight physician on board."
Who makes the decision about which patients are suitable for air transport?
"When Med Flight is requested to go to the scene of an accident, assuming weather permits, Med Flight goes," Conklin wrote in the e-mail, the only mode through which the health care agency would respond to questions about the efficacy of air medical transport. "The flight physician and/or program medical director is in contact with emergency personnel at the site of the accident."
Conklin also said UW specialists conduct regular outreach efforts with emergency responders, some of whom may have limited medical training, to teach them when to call for a helicopter.
It can be a tricky decision.
Claire Rayford, professional relations marketing manager for Milwaukee-based Flight for Life, said assessing the need for air transport involves sizing up several things at the accident scene. Not only the wounded's physical condition but also the mechanism of injury -- how badly crumpled a vehicle was, whether the injured was ejected -- is important in assessing the likelihood of survival.
Some conditions are more treatable than others. Rayford and other professionals said victims whose trauma has caused a cardiac arrest, for example, are usually poor candidates for air transport.
"There are volumes of research that say those patients don't survive," said Rayford, who began her career as an emergency room nurse.
Henry Butts, chief of the Watertown Fire Department, said his workers have been adequately trained, by both Med Flight and Flight for Life, to decide when to call for a helicopter. All of them have the authority to do so.
"If they think they need it, we'll get it," said Butts, whose service area does not have a trauma center that can handle severely injured patients.
"The benefits of getting a patient to the appropriate medical facility as fast as possible outweigh other considerations other than safety."
Butts added that his department does not get follow-up communication from the flight programs on whether helicopter transport was needed, but sometimes does get information on patient outcome. "They've never asked why we called," he said.
Conklin said that in cases where a patient is transferred from one medical facility to another -- as in the doomed May 10 flight -- referring and receiving physicians confer on which patients warrant being flown.
"In certain cases, the decision may be reviewed by the flight physician prior to flight," Conklin said.
Thomas said his experience in the Boston area is that physicians at community hospitals resist allowing a patient for whom they sought air transport to another hospital to be switched to ground transport "They see this -- perhaps correctly, perhaps incorrectly -- as advocating for their patients," Thomas said. "We don't argue with the person standing there with the patient."
Dr. Ira Blumen, medical and program director of the University of Chicago Aeromedical Network, says the use of helicopters in transporting patients is bound to continue to grow.
Trauma centers are being consolidated in some areas of the country, meaning longer transport distances for those patients. In addition, helicopters are being used more often for stroke and cardiac patients, allowing for strategic placement of centers focusing on treatment of those conditions.
Geography makes a difference, too. The need for medical transport helicopters is different in south central Wisconsin, with a limited number of trauma centers, than in highly urban Chicago with eight or nine such centers, Blumen said.
"It doesn't take the place of ground transport, but air transport will remain an important adjunct to health care in the U.S.," he said.
Measuring the success of air transport and creating standards for it is still a work in progress, though.
The Commission on Accreditation of Medical Transport Systems, the national accrediting agency, calls for the establishment of triage guidelines to determine appropriate transport and for review of air transport use in systems where the triage is not conducted.
Slightly less than half of all the country's air ambulance programs are accredited by the commission (Flight for Life is one), and UW Med Flight began the year-long accreditation process in February, spokesman Conklin said.
Med Flight staff does not specially review appropriateness of aircraft use case-by-case, but looks at use in monthly blocks, he said. "Our critical care staff routinely review patient outcomes and quality. We've been satisfied that our use was appropriate."
Several states have enacted regulations of air medical transport services. New Jersey, for example, sets guidelines, focusing on ground travel time to a trauma center, helicopters' arrival time and whether multiple patients are involved, to help emergency medical services personnel decide when to call in a helicopter.
But Thomas of Massachusetts General said identifying those patients "most likely to benefit from helicopter transport is an evolving science," and that whether air transport was helpful is most often a judgment that can be made only after the patient is treated.
If 100 cases of helicopter transport are reviewed, Thomas said, maybe 50 did not have their lives saved by use of the helicopter. "Unfortunately, we don't know which half that is until later."