Helicopters were first used to transport wounded soldiers during World War II. They were used more extensively during the Korean and Vietnam wars. Civilian helicopter emergency medical services (HEMS) began at St. Anthony Hospital in Denver, CO, in 1972.
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Helicopter emergency medical service: the past and the pre-sent.
Today, many countries in the world are using helicopters for medical evacuation.
Prehospital care in Nepal is in its infancy. Only a few ambulances offer advanced care for Nepal's population of more than 28 million. HEMS teams are offered from 3 hospitals: Grande, Nepal Mediciti, and HAMS. All are located in the capital of Kathmandu.
The first Nepali prehospital care conference was held in July 2018. The main focus of the conference was to enhance the system at a national level.
There is a dire need for prehospital care in Nepal, and a great deal remains to be completed for the system to be efficient.
From November 2017 through August 20, 2021, a total of 936 patients were received at Nepal Mediciti Hospital. Five hundred eighty-five (62.50%) patients were evacuated with a physician onboard, whereas 351 (37.50%) patients were transported without the support of a medical crew. During the same period, 3,900 patients were delivered to Nepal Mediciti Hospital by ground emergency medical services (EMS). These numbers demonstrate a substantial need for prehospital care.
Patients Transferred via HEMS in Nepal
There are 2 methods of carrying patients by helicopter in Nepal. One is with the support of medics onboard, and the next is without any trained medical crew in flight. A transfer begins when a sending physician or caretaker requests a patient be taken to a higher level of care. When the information is received, the prehospital care on-duty physician tries to obtain the current status of the patient while prehospital care staff members gather the information about the earliest possible helicopter to fly.
The prehospital care department assists in dispatching the helicopter. The helicopter departs from the airport to rendezvous with the medical team that is based at the hospital. The air travel time is less than 5 minutes to each of the 3 HEMS hospitals. In the meantime, the medical team responds to the helipad. It takes approximately 10 minutes to reconfigure the helicopter into a flying intensive care unit (ICU). The prehospital care physician and a paramedic or nurse will deliver care to the patient.
The second method occurs when the helicopter lands directly at the referring facility's nearby airport, helipad, near the patient's home, or a scene. No trained personnel are collected en route. There are no medical personnel or equipment onboard throughout the flight. The patient will only receive care once he or she arrives at the receiving hospital's helipad.
In Nepal, medical evacuation from a scene is not popular. Most patients outside of the capital are initially taken to a local hospital. When it is determined that the patient will need multispecialty highly advanced care, HEMS is called for transfer. The majority of cases that have been evacuated by a medical team are from hospitals located in the periphery of the country.
This was a retrospective study of 425 patients previously admitted to Nepal Mediciti Hospital from November 1, 2017, to December 15, 2019. SPSS Version 20 (IBM Corp, Armonk, NY) was used for the statistical analysis.
Most patients rescued with support were from the Narayani zone (110 nautical miles round trip from Kathmandu). The patients without medical support were mostly from the Gandaki zone (164 nautical miles round trip).
The majority of patients were between the ages of 18 and 45 years; 93 (38.27%) were rescued with team support and 90 patients (49.45%) without. One hundred seventeen patients (48.15%) received respiratory support from a mechanical ventilator out of the 243 transferred with the medical support team. Seventy (28.81%) of those patients had suffered traumatic injuries. Sixty-seven (36.81%) of 182 patients with no medical support were trauma related. Of the patients with no support, 8 (4.4%) patients were intubated. They received bag-valve-mask support from an accompanying person without proper training, such as a family member or caregiver.
One hundred eighty (74.07%) patients with medical support went to the ICU. Forty-two (23.07%) patients who did not receive care en route went to the ICU. These numbers suggest that more of the medically supported patients were critically ill at the time of transport. Ninety-one patients (50.55%) transferred with support stayed in the ICU for 1 to 5 days compared with 38 (90.48%) for those transferred without medical support.
Seventy-six (32%) patients rescued with a medical team onboard had a total hospital stay of 1 to 5 days, whereas 78 (42.8%) patients who were transferred without support stayed 1 to 5 days. Three (1.23%) patients brought in by the team had hospital stays more than 180 days. None of the patients stayed more than 180 days who were without care en route.
Ten (4.1%) from the supported group and 10 (5.49%) from the unsupported group went directly to surgery. Sixty-nine (28.4%) patients brought by the team died, whereas 6 (3.3%) of the unsupported patients died during the course of treatment in the hospital. The patients brought under the care of the team were in critical condition at the time of assessment. Those patients brought without support were considered to be in moderate or less critical condition at the time of dispatch.
In the Narayani zone, there are several medical centers including 2 medical colleges. These medical centers receive patients from surrounding areas. Once it is determined that multispecialty advanced care is required, a helicopter with medical support is requested. Because of the medical centers receiving patients first, the sending physicians are aware of the need for physician-staffed HEMS.
The Gandaki zone is located in the hills of Nepal. Several helicopters are stationed at the Pokhara airport nearby. Because of this close proximity and the helicopter's availability all of the time, family members or caregivers immediately request a helicopter to take the patient to Kathmandu for treatment. The patients may or may not be assessed by a local physician or at a medical clinic. An ambulance or private vehicle brings the patient to the airport or a nearby helipad. The patient is loaded with a caregiver and delivered straight to Kathmandu. This is the main reason that many are transferred without care from this area.
Many helicopter companies are advising people to request the medical team also. Because there is an extra cost for a medical team, many families refuse medical support and only want the helicopter for transfer.
Almost half of the patients rescued by the team were supported by a mechanical ventilator. A lack of knowledge that the medical teams exist could be a reason the intubated patients were transferred with only a caregiver bag and valve mask. Training is ongoing to spread awareness about the medical team and the need for support if the patient is intubated or critically ill.
Many of the trauma cases were flown directly to Mediciti in Kathmandu. The trauma patients who were flown from outlying facilities were transferred because of a lack of advanced surgical and critical care hospitals in the periphery of the country. In their study, Melton et al
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Helicopter emergency ambulance service (HEAS) transfer: an analysis of trauma patient case-mix, injury severity and outcome.
suggested that 41% of their patients were discharged from the casualty. Our study has suggested that nearly three quarters of the cases rescued by the team compared with one quarter of the self-landed patients went directly to the ICU via the emergency room. This shows that more often HEMS is dispatched when patients are considered critical. However, in both systems, more than 90% of patients’ total ICU stay is 1 to 5 days.
In our study, a total hospital stay greater than 180 days rarely occurred. Three patients transferred with a team and no patients transferred without a team stayed more than 180 days. All 3 were central nervous system–related trauma requiring long-term hospital care.
Higher mortality rates were seen in those brought by the medical team, which suggested that medical rescue was called in either extreme conditions or too late. A delayed response could be from a lack of information, no helicopters available, or weather delays.
A study by Dardis et al
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cost-benefit evaluation of helicopter transfers to the Beaumont neurosurgical unit.
revealed that the use of HEMS appeared to save about 1 to 3 hours compared with ground EMS, and the ground EMS system is as effective as HEMS. In Nepal, HEMS is also becoming more popular. The benefits of rapid transportation and the availability of medical support onboard are becoming more well-known. A study conducted by Rasmussen et al
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Does medical staffing influence perceived safety? An international survey on medical crew models in helicopter emergency medical services.
suggested that medics onboard, especially a physician and an assistant, have more patient safety in HEMS.
Because of undeveloped roads and traffic infrastructure problems, as well the unavailability of advanced medical care throughout Nepal, HEMS has been proven to be beneficial. The costs associated with HEMS could be burdensome for most patients. However, this study would also be beneficial to develop national standards and guidelines for prehospital care and EMS/HEMS.
Published online: October 21, 2021
The authors thank Mr. Narendra Timilsina and Mr. Manish Dhakal for their contribution in the statistical work; their support in the medical record division is immense. We also thank Dr. Monika Brodmann Maeder, Department of Emergency Medicine, University of Bern, Bern, Switzerland, for her encouragement and Daniel J. Sprinkle for his support in preparing the paper.
© 2021 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.