Acute care systems
These largely depend on the economic development of the country. Pre‐hospital care, acute hospital care and quality assurance are classified using the WHO Trauma System Maturity Index in four levels, from 1 (least mature) to 4 (most mature). In the majority of high‐income countries, well‐developed and mature acute pre‐hospital and trauma care systems have been established. Different EMS participate within these systems, some of which have helicopters (helicopter emergency medical service, HEMS) or even fixed‐wing aircrafts at their disposal to provide care [5]. Dispatch operators regularly manage regular EMS and additional, physician‐staffed assistance by (helicopter) mobile medical teams, as part of an integrated chain of pre‐hospital care. However, in low‐income countries, trauma systems are typically level 2/3 and there is a lack of dedicated trauma centres and teams [6]. An essential factor in these additional modes of transport is that they are incorporated into regular care [5, 7, 8]. In the Netherlands, 65% of the population has access to specialist medical care within 20 min, provided by one of the four available HEMS‐teams 24 h per day. These teams are deployed by the emergency dispatch service, which runs in parallel to ground ambulances, as either primary deployment or secondary deployment on request of the EMS personnel at the scene. The ultimate goal of helicopter transport is to bring additional specialist medical care to the scene of the critically ill or injured patient. If, after initial assessment, the EMS nurse judges that specialist medical care is unnecessary, the HEMS‐deployment is cancelled. Within the Dutch system, the medical crew comprises of a physician (anaesthetist or trauma surgeon) and a specialist nurse who is also a HEMS crew member. Other European HEMS teams may have a different composition of personnel.
The HEMS team has a large operational range and can help in decisions around how to transport the patient to the most appropriate hospital either by air or ground using the correct consideration in terms of safety, availability and utility [9, 10]. The decision about whether to transport a medical crew or patient by ground or air depends on the available options and can be a highly complex one, dependent on organisational and patient factors. Time is always of critical importance in the treatment of a severely injured patient. Factors such as road conditions, traffic, weather and location of the trauma centre all influence the choice of transport. Geographical information systems may support this decision, impacting patient outcome and also healthcare expenditures [11].
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In selected patients with severe thoracic injury or traumatic brain injury, there is a significant survival benefit when transported by HEMS physicians, even when paramedic ground‐based transport might be faster [12, 13]. These patients probably benefit from advanced airway and chest trauma management [14, 15]. The requirement for lifesaving interventions during transport is also an important factor in decision‐making. In the cramped and noisy working space of a helicopter, it is not easy to perform tracheal intubation, thoracostomy or resuscitative thoracotomy in a patient who is initially stable but deteriorates during transport. If immediate lifesaving damage control surgery is required, air transport can be time‐ and lifesaving.
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