Cost effectivness of HEMs

[mickjoebill]

The costs and benefits of helicopter emergency ambulance services in England and Wales. (http://jpubhealth.oxfordjournals.org/content/18/1/67.full.pdf)

This apparently detailed and well researched report into the cost effectiveness of Helicopter Emergency Ambulance services published in 1996 concluded that;
"There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved."

14 years on, do HEMs do any better and if so, how?



Mickjoebill

[bolkow]

Two things come to my mind,
1. We are in a recession

2. Who commissioned this report? I am always suspicious about possible hidden vested interests.

Just my two cents worth, I am a suspicious person by nature! LOL

[Coconutty]

14 years on, do HEMs do any better and if so, how?

Answer : YES - How ? - Because they have 14 years more experience :ugh:

Question : Why do you ask :rolleyes:

http://i34.photobucket.com/albums/d129/coconut11/Coconutty.jpg

[helisdw]

2. Who commissioned this report? I am always suspicious about possible hidden vested interests.

I believe the article cited by mickjoebill was an academic article by a research group in Sheffield (UK) - vested interests (or conflicts of interests) may be many/varied but this particular paper appears to have been commissioned by the Department of Health. It is quite an old paper (published 1996) and the financial figures quoted are certainly outdated. In addition, some of the paper's points no longer fully reflect the pre-hospital practices of the UK.

A more contemporary discussion about HEMS has recently been published by the Emergency Medicine Journal - "Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence" Butler et al., Emerg Med J 2010;27:692-701.

The article can be downloaded for free by following the link below and selecting your download option from the right of the screen:
http://emj.bmj.com/content/27/9/692.abstract (http://emj.bmj.com/content/27/9/692.abstract)

This is a systematic review (i.e review of published literature rather than de-novo research) which goes through the HEMS debate step by step. Whilst I personally believe there are some methodological flaws to this paper, and I'm not convinced about the results generated by some of the papers they have selected, it is still an interesting read. As usual, no definitive conclusions are drawn and the debate as to the merits of HEMS will continue...

What is clear is that the crux of many arguments as to HEMS effectiveness rest on:
1) the geography of any given country;
2) how you judge effectiveness (?morbidity ?mortality ?return to tax payer status);
3) how you staff your aircraft.

I could go on but I think this post is long enough as it is!

Simon

[Thud_and_Blunder]

Further to helisdw's excellent reply, I would recommend reading Ben Goldacre's "Bad Science" book, and ideally the other document mentioned in his (Goldacre's) bibliography about "How to Read an Academic Paper" along with the last study. Helps to sort out the spin from the substance.

[Foggy Bottom]

The main thing to me is, "Are pilots employed"? HEMS equals jobs! Let the bean counters sort everything else out...

[Bertie Thruster]

14 more years of local, solid financial support for every HEMS unit. 14 more years of local people confirming: "This is what we want".

The HEMS services of England and Wales exist only because of local public support. They were created at local level by local demand, as additional support to the existing ambulance services.

Why do people like to supplement in this way (at an average cost of 50 pence per adult per year) their local ambulance service directly out of their own pockets?

What makes a small but delicious cherry on the icing of a large cake cost effective in the eyes of the consumer?

It does not matter. HEMS gives the people what they want (and choose to pay for)

[griffothefog]

Bertie,

Nice one.

All I know is, that we came into the lives of hundreds of families in Cornwall during my time there and they were determined never to let us go.

Did we really save the life of that baby that was choking and had turned blue, had stopped breathing and was 30 mins from the nearest hospital?

Or the boy that had drowned in a swimming pool, was resuscitated and in ITU within 6 mins?

That guy pulled from a crumpled car with a ruptured spleen during a blizzard that prevented an ambulance from attending.....

I don't know for sure, but we thought we had and so did the families and the registrars and the ITU nurses and that's the reason it has been publicly funded since 1987.

God bless all who sail in her these day's...:ok:

[Bertie Thruster]

Coming into my last of 11 years of HEMS (damn that 60th birthday!) after what has been the most satisfying flying job in 30 years of rotary.

Meeting recovered 'customers' is also a bonus. For example last month I met a 25 year old girl who, in 2005, we had airlifted to A+E after she suffered horrendous injury in a nasty riding accident. She arrested (her heart stopped) during the 10 minute flight. (point to note: both medics can attend a very critical patient in the back of the chopper...in a land ambulance one of them has to drive).

She had fully recovered and was the picture of health and brimming with the positivity of life. She is a champion for the air ambulance and has raised thousands for the charity.

She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.

[ShyTorque]

She had fully recovered and was the picture of health and brimming with the positivity of life. She is a champion for the air ambulance and has raised thousands for the charity.

She shyly confided to me that she has a photo of the pilot and the 2 paramedics on the ceiling of her bedroom, above her bed.

Bertie, I was going to say she's obviously had a good whip round for the boys....

But no, let's not go there.... ;)

[Jack Carson]

Helisdw made a good point when citing local geography. Having worked in remote areas of the US we found, that having a helicopter at their disposal, local first responders, would call the helicopter as a means of allowing for continued 1st responder support of their local areas. Using a ground transport would take them out of the local area for six to eight hours. The helicopter would be back in the area in 2 hours without a break in 1st responder coverage.

[homonculus]

Whilst I fully empathise with local communities and those on the machines, it is I regret to say a disgrace that after 14 years so much money has been spent, from whatever source, on a new medical innovation with no true peer reviewed audit or evidence of efficacy.

It is hard to think of any other area in medicine where this could apply let alone does apply.

In the early days we had considerable resistance from the ambulance authorities who seemed worried that the evidence would be delivered, forcing them into additional expenditure. As time went on services became more ambulance as opposed to physician orientated which also suppressed research.

We have demonstrated interhospital ITU transfers by helicopter save lives and I believe the same could be done with primary transfers. The result might be more efficient tasking especially in less rural areas, but my post is supposed to be a reflection of an opportunity lost, which increases the risk in the future to at least some services, not a dig at HEMS itself

[helisdw]

The examples cited by griffothefog and Bertie Thruster are some of the many anecdotes (and I don't mean that in a derogatory way) that are told about HEMS work. Unfortunately, the scientific evidence base does not conclusively support these findings at the present time - how you measure/judge effectiveness plays a large part in the value you lend to HEMS operations.

As funding follows proven treatments (which in the UK is decided on by NICE), HEMS will never get Government backing whilst it remains an uncertain entity. The cynic in me would say, why should the Government pay for something it gets for free, especially in these times of austerity? I'm fairly sure that if SAR could be funded by local donors, the Government would be delighted in not having to sign a costly contract...

What amazes me about UK HEMS is the overall lack of national organisation. Individual charities have been known to squabble over geographical fund raising boundaries with publicly aired grievances over collecting practices. HEMS operators have sprung up in each county in the UK but are they best placed to serve the local population or are they a product of convenient placement to fit within said geographical boundaries? Why is there no over arching structure on a national basis?

Some may suggest this is just wishful thinking, but you only have to look at the RNLI to see that a charitable organisation can run a hugely successful nation-wide operation. Further more, their annual income generation allows for the funding of an enviable training facility to hone the skills of their staff/volunteers and some advanced technology on their boats. Surely it is not outwith the realms of feasibility for HEMS to emulate this?

Rant over... for now!

Simon

[helisdw]

May I offer a little light relief for all those involved in HEMS...

You have to stay tuned for the helicopter appearance, but I think it's worth it!

YzYxz_uvtSI&feature=related

Simon

[Helinut]

Thank you, Simon. :)

[206 jock]

Well, I spent all day yesterday (Wednesday) at a meeting attended by 115 people, consultants, physicians, paramedics and a few managers from air ambulances from all over the country, reviewing case studies from all areas of the UK.

Very sobering it was, from paediatric incidents to serious RTA's and everything in between, with a range of outcomes. I was astounded by the frankness and honestly shown.

To cover a few of your points above:

- the different air ambulance outfits do talk and learn from what others have done
- Cases are subject to peer review
- different outfits have different capabilities and resources
- sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly

[chopjock]

- sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quicklyAre you talking about, as an example, getting a paramedic to the scene of an accident quickly? (To stabilise the patient until an ambulance arrives).
If so, we could have lots of smaller, cheaper helicopters all over the country. Now that could be cost effective.

[mickjoebill]

Well, I spent all day yesterday (Wednesday) at a meeting attended by 115 people, consultants, physicians, paramedics and a few managers from air ambulances from all over the country, reviewing case studies from all areas of the UK.

Was there any discussions about cost effectiveness? Was a consensus reached on any subjects?

A databases of cases were patient outcomes were significantly approved by HEMS would help researchers.



Mickjoebill

[helisdw]

Helinut - I only wish I had the IT skills and imagination to put something like that together!

206 jock - apologies if my previous post came across as disparaging (this wasn't the intention). The UK HEMS charities do an impressive job of fund raising and joint meetings can only serve to help ensure best clinical practice. My point about a national coordinating body was meant as a suggestion to help build on the current success (cost savings, shared governance, etc.).

Regarding your last point:
sorry guys, your lovely shiny helicopters are just a way to get the people that matter, where they're needed, quickly I'm not sure if that relates to getting medical staff to the patient quickly or getting injured patients to hospital quickly. Perhaps both. In either case, the academic paper (EMJ) alluded to previously looks at both aspects and still doesn't reach a firm conclusion. Whilst I don't doubt that those presenting at the meeting you attended have operational figures and some excellent results/outcomes, the complexity of this area of research means that achieving statistical significance (which is the bottom line for those that hold the purse strings) is very challenging.

As mentioned before, the value of HEMS all comes down to how you quantify its success and is intrinsic to the research challenges highlighted above. I suspect that this will remain the case for some time...

Simon

[Daysleeper]

Talk about trying to do something with old and inconclusive evidence.

A brief (well it is 7am and I'm having breakfast) search of some academic journals for "HEMS Cost Effectiveness" comes out with 400 ish responses. I'll look a bit more later but, for instance....for HEMS in Holland, (not a country noted for its remote terrain or great distances between cities.)


Results:
The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0·70 versus 0·71 respectively. The incremental cost–effectiveness ratio for HEMS versus EMS was €28 327 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between €16 000 and €62 000.

Conclusion:
In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective.
Polinder et al in the British Journal of Surgery Society Ltd Vol 96 Issue 11. Published by John Wiley & Sons, Ltd.


That said the attempts at a meta analysis are thwarted by the great diversity of what HEMS actually IS.

From "A systematic review of the costs and benefits of helicopter emergency medical services" in Injury (Vol 41 Issue 1)
the cost and effectiveness of HEMS varied considerably between studies. Despite generally being more expensive than ground transport, a number of studies found HEMS to be cost-effective. However, given the variation in the intervention design, context and study methods between studies it was not possible to assess the cost–effectiveness of HEMS in general. Given the variation inherent in the health systems in which HEMS operate, synthesis and extrapolation of study findings across differing health environments is difficult. To address economic and clinical evidence in relation to HEMS, future research that is tailored to account for local system factors is required.

S

[206 jock]

Chopjock,

The cheaper helicopter - that's something I brought up half in jest. Not so much paramedics, as most people at the conference were running the doctor/paramedic model. It wouldn't be impossible to imagine a scenario where an R44 was used to deliver the medical team to the scene of an accident, they then do their work in preparation for a land ambulance transfer. It does happen quite often now

In seriousness though, there are a number of problems with this approach, including:
- what about landing in urban areas?
- a high number of accident victims do need transferring to specialist units, where the heli transfer is a must

Helisdw

No problem - I do believe that while there may be cases where the fundraising teams are in 'competition' with others (although this has improved markedly in the 5 years I have been associated with the AA service), the medical teams have always been keen to learn from one another.

I don't believe that you can relate the RNLI model to HEMS (or air ambulance) services. Local 'ownership' is key, a national structure would be too large to administer effectively and would lose the local enthusiasm. What does frustrate me slightly is that similar helicopters having completely different medical fits, for what seems to be local preference only. To the extent that one operator now has a 'spare' aircraft of a popular type, but has no idea what to fit it out with!

Mickeyjoebill

The audience there on Wednesday weren't really interested in their cost-effectiveness, they were much more into providing a service:p

You know that this is the holy grail, but I don't see how anyone will ever be able to definitively prove that 'this patient would have died if it wasn't for the air ambulance'. But my gut feel (with lots of anecdotal evidence) is that it's sure worth it. That's why I'm happy to invest so much of my time, which could be much better spent earning me a few extra quid!

[Helinut]

Chopjock,

Banging the same old drum I see (as you have re: police air operations). Do you have any evidence that more "cheaper" helicopters (and their crews- presumably first aiders would do) would be better than fewer more expensive setups? You need to bear in mind what the rules will allow you to do. For instance, most trauma centres with helipads in the UK are unavailable to singles, because they are in built-up areas.

There are pros and cons to central control or local control and I do not think either route has absolute advantages. A system that has "county by county" separate organisations, but with close liaison and communications and information exchange covers some of the bases. Central control tends to reduce the development of new ideas, kit and modes of operation, some of which may point the way forward. It may also be true (I think it probably is) that the best answer will vary depending upon geographical location (rural v major conurbation).

Cost effectiveness is not an easy thing to get an accurate handle on. If you start trying to place everything on a money basis, you need to take account of lots of factors, some of which are not amenable to that sort of treatment. It is the same argument that just because it is not easy to quantify something in terms of money, does not mean it is not significant. You would need to draw the boundaries of your analysis pretty widely, and you have some ethical questions to wrestle with too. In the London area, the NHS is sufficiently convinced of the value of the London HEMS to contribute a major part of its costs to the charity that operates it. I understand they believe it saves them money, as the length of stay in hospital is reduced. Other regions of the NHS do not do the same though. How do you evaluate the value of a life saved?

The RNLI is not all wonderful. They spent a lot of money on an expensive training hotel and a lot of effort in training their volunteer crews who currently usually have little knowledge of matters marine: pretty much a necessity now that the UK has no fishing industry to speak of. However, at present they are being left behind in many areas to do with lifeboats (by comparison with other charitable lifeboats societies) as they do not have the cash to develop better, new generation boats.

[BobbyBolkow]

Cost effectiveness is not an easy thing to get an accurate handle on.

AMEN to that!
However, before I digress (which I just know I will! :ugh:), lets get back to the original question. The 'Sheffeild report' was, at the time of publication, a blow to existing Air Ambulance operations in this country who relied heavily on the generosity of public donations to survive. This is still the case today, apart from the Scottish service. Fortunately the report was discredited as flawed and, some say, being given direction to it's conclusions. There have been many more valid papers/reports since then and, as suggested before, if you're that interested, just google!

Are we cost effective?................How long is a peice of string?
It is very difficult to evaluate a service that has no defined outcome (except when they come and see us to say thank you!). To expand on that, ALL UK Ambulance service targets are set by the government, and those targets are SOLELY based on 'time to get a response to an incident'. HEMS will rarely make this standard so do not count towards the ORCON standard of response times. However, there are moves by government to expand the targets to include PATIENT OUTCOME ( how long did they spend in hospital? How much did their care cost? Did they walk out or in a box?) that sort of thing. If patient outcome becomes a factor, then there will be concrete evidence which, we hope, will be the basis for any future studies as to cost effectivness of HEMS operations. Until then things will still be very subjective.

Briefly, to touch on a couple of other points:-

Yes we do talk to each other. The 'triple A' (Air Ambulance Association) is growing in strength as a forum for all UK Air Ambulances.

You cannot make a direct comparison between the RNLI and Air Ambulances. Two totally different operations IMHO!

The equipment levels are different between different operations because that is how they've evolved, mostly through trial and error. You will not get standardisation of equipment until you have a national Air Ambulance service. And, if I may suggest, before that we would need a national Ambulance service, and dare I suggest, a national Police force! Now there's a topic to get those ASU boys going!



GRIFFO me old mate. You'll be pleased to hear those Kernow boys are still doing you proud! :ok:

[Brilliant Stuff]

All I shall add is that the Germans worked out a long time ago that for every Deutschmark they spend on the Air Ambulances / HEMS they saved three in the hospital.

And no sadly I do not have any references to prove this, maybe our German brethren can shed some light on this. Why else would their country be littered with Air Ambulances????

[Bertie Thruster]

Autobahns?

[Geoffersincornwall]

I had the pleasure of setting up the UK's first AA in 1986/7 so perhaps can shed some light on the deliberations we went through to justify the concept.

When I was doing the basic research in the autumn of 1986 I went to the Chief Officer (Len Holden) of what was then my nearest Ambulance Service - Cornwall - to gather inside information rather than tackle the 5 Chief Officers that managed the services in what was our original target base - Staverton (20 minute radius of Staverton covers 5 independent areas). Len asked me to consider Cornwall as the target base because they desperately needed a solution to what was a dual problem. One was logistical and the other clinical. The quality of care delivered by CAS was, by today's standards, poor given that the concept of the paramedic was in its infancy in the UK and they had no formally qualified paramedics but did have a programme to introduce what were called 'extended trained' ambulancemen some of whom had paid for their own training.

The NHS resources the ambulance services of the time on a 'per capita' basis thus we had a large rural (comparitively) underpopulated area that had very meagre resources compared with the land area to be covered. Also, as a peninsular we had just one neighbour (Devon) to help out at the perimeter of our area and of course we had just one General Hospital with a fully equipped A&E in Truro. We bandy about the question of response times without bearing in mind that the invisible part of the equation (that is never measured and analysed) is the time taken to deliver the patient to hospital and return the ambulance to normal service. In those days there was no telephone-triage so literally every call was answered by a fully equipped Emergency Ambulance and valuable, well trained crews, would spend many hours out of the loop with what we would consider as non-emergency cases today.

The Air Ambulance offerred the prospect of being able to assist with any and all situations, major and minor, as long as it contributed to the overall efficiency of the organisation. It also meant that the few highly trained crews available could be deployed county-wide. I hate to think of the number of times I sat in control during the months preceding our start-up and watched as one by one, in a completely random way, the ambulances disappeared from our state-board as they responded to the various 999 calls and we were literally left completely devoid of any ability to react. We would agonise with fingers crossed as eventually the resources came back on-line and we could breath again. Nobody keeps those statistics but if they did they would realise just what a powerful tool the AA is. I wish we had made a note of every time the only asset available was the AA for that kind of statistic is NEVER revealed for if the people of the UK knew just how often their ambulance services had run out of resources they would be up in arms. When it does come to public notice it makes the headlines but the one asset never discussed is how much we depend on Lady Luck to cover our arses.

People seem to get up-tight about carrying non-urgent patients in the AA but you have to bear in mind that the next call, the one the road crew miss, maybe a heart attack that a local crew could have responded quickly to but now, instead, they are on a long trip to hospital (1.5 hours worst case) with a minor injury. This could take the asset out of service for half a shift (4 hours) whilst it delivers the patient, re-stocks and returns (no blues and twos) to its operating area.

We developed 3 levels of mission. Primary (direct to mission site), Secondary ( rendezvous with ambulance, relieve them of the patient and deliver same to hospital. We could do in 10 or 15 minutes what would have taken far far longer). Tertiary (inter-hospital transfer).

When we make bold statements like 'we saved a life' we often need to modify that to 'we were part of a team that saved a life' but I, like Griffo, remember a few cases where the AA made it possible for that team to have the chance to save a life and without the AA the patient would not be here today.

My plea is not to get hung-up on response times or even outcomes because this approach never considers the overall logistical contribution to the overall effort and the fact that the reason why the road crew were able to save a life was because the AA had made it possible for them to be there and not heading for a far off A & E with a non-urgent patient. The fact is that an Ambulance Service WITH an AA is better placed to win the battle than one WITHOUT.

G :ok:

[fly911]

Geoffersincornwall, thank you for your early pioneering efforts. Many are here today because of those efforts. (I mean the patients. Not us pilots:-)
Thanks again.

[helisdw]

Geoffersincornwall - thank you for the insight into how the UK HEMS model was born. Interesting to read where/how it all began!

I guess the conclusion that can be drawn is that in the UK, cost effectiveness is not really an issue. As the operations are charitably funded, and the public at large are happy to donate without any proven benefit (as might be defined by a health economist), it doesn't really mater what the statistical data may or may not demonstrate. Perceived benefit, which is hard to quantify, drives the UK HEMS market. This typifies the problem of quantitative versus qualitative data inherent to all types of health research.

From my experience, "life saving" is rare but does occur; "life changing" (i.e mitigating morbidity) is more common; "easing of suffering" (i.e shorter on-scene time/easier egress) is a near daily occurrence. What price you put on each of these 'commodities' is largely subjective. For the injured individual, it is often priceless, hence the ongoing public support for UK HEMS.

Of course, for other countries that seek government support or utilise private insurance payments, cost effectiveness is (for better or worse) the crux of the matter...

You only have to look at the UK's Police ASUs to see how proven worth is likely to drive future funding. Again, quantifying benefit is largely subjective and attracts a variety of opinions. Should the public decide to start charitable collections for their local police helicopter, cost effectiveness would become irrelevant, as it would appear to be for HEMS.

Simon

[Shell Management]

Should the question not be the 'patient benefit' not 'cost benefit'?

[Geoffersincornwall]

The fascinating thing about arguments that focus on cost effecrtiveness are that we never had that discussion in the UK because we were never allowed to. The NHS is funded like a Christmas Cake. The central government decide on the size of the cake and the current players fight over the size of their 'slice'. God help you if you have something new to offer for you will not be suprised to find the current recipients doing whatever is necessary should you threaten to take some of their slice. They will do you down and bad mouth you and generate good reasons why you are a waste of money.

The reality was that thanks to the press coverage in Cornwall at the time many knew that our 3-month trial would go away for lack of money so I was literally being handed 50 pence coins by bystanders at road crashes etc. Armed with the awareness that there was a burgeoning support for the service I helped some friends set up an embryonic charity to harvest this support. Unfortunately the man in charge of our project thought such a charity was a threat to his power-base and forced me to close it on pain of dismissal. Fortunately for Cornwall another group started the charity that now runs the CAA and because it was outwith his control he did indeed eventually have to cede power to the trustees.

The NHS could never have funded a nationwide AA service for it would have cost too many people too large a slice of their precious cake. Now we argue over cost effectiveness and clinical effectiveness when in the round we all know that as a 'force multiplier' the helicopter is very powerful resource for anyone dealing with the rapid delivery of a specialist service be it the AA, the SAR or the cops. As one who has worked in each of those services I am acutely aware that the laws of supply and demand are imperfect when you stick the politicians in the equation as pay-masters. Without the politicians the public would get what they want but between the public and the government are the so-called experts who only use the statistics they have to hand not the ones that tell the real story.

G. :ok:

[jayteeto]

One of the dangers of judging us by the outcomes of our jobs is already being demonstrated in other parts of the NHS. Labour came up with a 'deaths' league table to show the public which hospitals are the 'best'. All that happened was that some hospitals refused to operate on the more seriously ill patients, to keep their mortality rate down. The hospitals who helped everyone were punished because of their poor positon in the death league. If you start judging AA units on their outcomes, then please don't send us to jobs where someone might die....... doh, you mean our daily routine!
By the nature of what we do, we tend to get the worst jobs. We get help to injured parties quickly. Those who state that patients who go by AA are at scene longer should talk to the clinical managers (or watch helicopter heroes). It is often preferred to take specialist care to the patient and do MORE at scene, rather than transport ASAP and delay elements of critical care until in A&E. You CAN NOT judge police and AA effectiveness by the same standards as the production line in a factory. Statistics are absolute tosh in this type of work. I have only been doing this for 9 months and have already done many jobs where the patient would simply not have survived. The beancounters on this thread will say 'yes, but at what cost per job?'. The public who donate don't care, as long as we save some of them!! What cost a life? I'm sure the beancounters would think differently if one of their relatives was saved.............

[skadi]

Autobahns?

The "Autobahns" are one of the safest roadtypes, you have no crossings, no opposite traffic and only a minority are without speedlimit. Due to the improving carsafety, the HEMS-missions involving trafficaccidents aren't the majority. Most missions are for internal deseases like heartattacks, strokes and so on. And there is a difference in the german HEMS-system: One member of the crew is allways an emergency doctor so many missions are just to deploy a doctor to the scene.

skadi

[Landroger]

When my late and still much missed friend Graham Budden was one of G-HEMS pilots - off the roof of the Royal London in Daily Express times - I invited him to come to my Scout Troop to tell my then kids about HEMS.

He brought photographs of and told the story to one of the busiest days HEMS had flown to that time. Nine 'shouts' to points all over London out as far as the M25. I believe he was PNF (is that right? Pilot Not Flying?) that day and just happened to have his camera. No blood and gore, just images of G-HEMS parked in outlandish places around the capital.

Along with his story of the day, told with his characteristic stutter (or is it stammer, I never knew the difference) which mysteriously disappeared when wearing 'the cans', my Scouts were spellbound. To them he was a real, live hero and not far short of that for me, even though I had known him since he was a Scout.

The point being that, he was at great pains to correct the common (then and now) misapprehension that G-HEMS was an 'Air Ambulance'. Because they carried Doctors, surgical instruments and all the bells and whistles of 'battlefield surgery', they were and are a mobile primary treatment service. Although there were operational reasons why they did not often do so, the main reason why they seldom carried their casualties back to 'The Whitechapel', was because the HEMS medics had stabilised their injuries, prepared them for transport and left them for the 'regular' LAS to take them to the nearest appropriate hospital by road.

Graham never lost sight of the fact that his job, as driver of the 'H' part of the team, was to get the 'EMS' part to the scene quicker than any road vehicle could do. Public opinion is not always right. Sometimes they are so completely wrong it is little wonder that decision makers ignore them. But when it comes to HEMS and even Police ASUs, they know instinctively that helicopters are the dog's bo11ocks. :ok:

Roger.