Despite an increasing use of civilian aeromedical transport

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1 The Journal of TRAUMA Injury, Infection, and Critical Care When Is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times Marco A. Diaz, MD, Gregory W. Hendey, MD, and Herbert G. Bivins, MD Background: A retrospective analysis of 7,854 ground ambulance and 1,075 helicopter transports was conducted. Methods: The 911-hospital arrival intervals for three transport methods were compared: ground, helicopter dispatched simultaneously with ground unit, and helicopter dispatched nonsimultaneously after ground unit response. Results: Compared with ground transports, simultaneously dispatched helicopter transports had significantly shorter 911-hospital arrival intervals at all distances greater than 10 miles from the hospital. Nonsimultaneously dispatched helicopter transport was significantly faster than ground at distances greater than 45 miles, and simultaneous helicopter dispatch was faster than nonsimultaneous at virtually all distances. Ground transport was significantly faster than either air transport modality at distances less than 10 miles from the hospital. Conclusion: Ground ambulance transport provided the shortest 911-hospital arrival interval at distances less than 10 miles from the hospital. At distances greater than 10 miles, simultaneously dispatched air transport was faster. Nonsimultaneous dispatched helicopter transport was faster than ground if greater than 45 miles from the hospital. Key Words: Aeromedical transport, Prehospital transport, Emergency Medical Services transport times. J Trauma. 2005;58: Despite an increasing use of civilian aeromedical transport for Emergency Medical Services (EMS) since the 1970s, a consensus in the literature on its indications has not been reached. 1 Some authors have questioned the overuse of aeromedical transport in prehospital care, citing costs, safety issues, and the lack of a clear survival benefit. 2 6 Others have suggested that helicopter transport can decrease mortality by as much as 21% to 52% on the basis of TRISSpredicted probabilities of survival Although not always in agreement, expert panel reviews have also suggested that air transport provided a medical benefit over ground transport in 11% to 26% of cases If a true survival benefit exists, one analysis concludes that helicopter use is cost effective for treating trauma patients. 15 The dilemma for EMS dispatchers lies in determining when to request costly helicopter transport with the limited information available from a 911 caller. Some suggest that triage criteria such as prolonged extrication or poor vital signs may identify those likely to benefit from air transport, because the most severely injured trauma patients tend to show the greatest benefit. 9,10,16 19 Unfortunately, obtaining this information requires an on-scene evaluation by EMS personnel, which may further delay dispatch decisions. However, the distance from the scene to the hospital is information that Submitted for publication July 16, Accepted for publication January 20, Copyright 2005 by Lippincott Williams & Wilkins, Inc. From the Department of Emergency Medicine, St. Mary Medical Center (M.A.D.), Long Beach, and Department of Emergency Medicine, UCSF Fresno, University Medical Center (G.W.H., H.G.B.), Fresno, California. Address for reprints: Gregory W. Hendey, MD, FACEP, Emergency Medicine, University Medical Center, 445 South Cedar Avenue, Fresno, CA 93702; DOI: /01.TA is generally available at the 911 call time, and knowing what effect this has on transport time is useful in these dispatch decisions. In other words, at what distance does the helicopter become faster than the ambulance? Intuitively, tasks such as takeoff, arrival, and patient loading and unloading at the scene and at the hospital take longer for a helicopter than for a ground ambulance. However, at some distance, the faster travel speed of a helicopter must translate into a shorter overall EMS time when compared with a ground ambulance coming from the same location. Nonetheless, if air transport is a few minutes faster, it has not been clearly demonstrated that a time savings of several minutes has any effect on outcomes for most patients. One approach to limit helicopter use involves dispatching a ground unit first, which then calls for a helicopter if a speedier transport is deemed necessary. Although this method likely improves the selection of critical patients for air transport, it inherently adds a delay in helicopter dispatch when compared with the model of simultaneous air and ground dispatch. Our objective was to compare the 911-hospital arrival interval between ground transports, simultaneously dispatched (SD) air transports, and nonsimultaneously dispatched (NSD) air transports at various distances from the hospital to determine at what distance the helicopter becomes a faster method of transport in a representative urban and rural area. MATERIALS AND METHODS We performed a retrospective analysis of data collected from the EMS database in a two-county system. The study was approved by the hospital institutional review board. Fresno County and Kings County constitute the regions serviced by dispatch. The nearest appropriate receiving hos- 148 January 2005

2 Comparison of Helicopter and Ground Ambulance pitals are recommended by dispatch as outlined by local EMS policy and procedure guidelines. 20 The terrain studied is largely flat within the California Central Valley, with neighboring mountainous areas approximately 45 miles to the north and east. There is a single Level I trauma center in central Fresno, several other medium sized receiving hospitals without trauma center designations, and several small hospitals in small neighboring towns that are distributed throughout the predominately rural regions surrounding the Fresno metropolitan area. Patients meeting trauma center criteria are transported to that destination, whereas critically ill medical patients are generally transported to the nearest appropriate hospital. During the study period, patients with a Trauma Score of 13 or less were transported to the only Level I trauma center. Populations served in our system are approximately 800,000 in Fresno County, and 130,000 in Kings County. The counties span 5,900 and 1,400 square miles, respectively. Helicopter requests are coordinated through the EMS communications center and are recommended for major trauma, spinal cord injury, severe thermal burns, cardiovascular instability, extended transport time, or on base hospital physician approval. 20 Approximately 80% of patients transported by helicopter from a scene are trauma patients. Simultaneous dispatch of both air and ground units is recommended by local policy when the patient s location is outside the metropolitan area, prolonged extrication is anticipated in a motor vehicle crash, multicasualty incidents are reported, or the patient is thought to be critically ill. There are three helicopters available for dispatch, all with advanced life support capabilities. Aircraft are triaged on the basis of need and availability. The majority of the flights (85%) in this series were transported by the Skylife aeromedical program, and the California Highway Patrol Helicopter transported the remainder. During the study period, Skylife operated a Bell 222UT twin-engine, turbinepowered helicopter, capable of transporting up to two patients, with a cruise airspeed of approximately 120 knots and a top airspeed of 150 knots. It is capable of landing in rough or uneven terrain with its skid-type landing gear, and is also equipped with a high-powered searchlight capable of illuminating a large area for nighttime remote area landings. The crew consists of a flight nurse and a paramedic. Helipads and landing zones are designated throughout the counties, and the helicopters are based at the centrally located airport, 3 miles from the trauma center. The primary provider of both air and ground EMS transports in the area are owned and operated by the same parent company. They operate under a single set of EMS policies, and share the same dispatch center, medical director, and many of the same personnel. Patient care records are collected and stored in a common EMS database. Data for all completed ground ambulance transports between June 1996 and June 2000 and all completed helicopter transports between January 1997 and July 2000 were stored in a Microsoft SQL server database. All time intervals were recorded by a central, standardized clock at dispatch headquarters at the time of transport. All prehospital times recorded and the intervals calculated conformed to the Utstein style as studied and reported elsewhere The 911-hospital arrival interval was defined as the time in minutes from the initial 911 time of call receipt to the time the transporting unit arrived at the receiving hospital. The dispatch interval was defined as the interval between the 911 call and the time of response vehicle notification. The transport distance was defined as the straight-line distance between the scene location and the receiving hospital. Ground distances were recorded from odometer readings for each transport. The authors have previously reported a correction coefficient for translating odometer miles into straight-line flight miles within our EMS system. 25 Using this correction factor of approximately 1.3 odometer miles per straight-line mile, the transport distance was calculated from the recorded odometer mileage and entered into the database. The transport distances for helicopter flights were recorded using an onboard global positioning system. Patientloaded flight miles as measured by global positioning system were tabulated as the transport distance. In the event of a rendezvous transport (where the patient is passed off between a ground unit to the helicopter), mileage for both transports was included in the total transport distance. Such transports were included in the helicopter transport times as simultaneous or nonsimultaneous as described below. The database was queried for all completed transports with a dispatch priority of one or two. In our system, ambulances are dispatched by priorities one through seven, corresponding to the acuity of the call. Priorities one and two are reserved for the most emergent cases, including major trauma, burns, shootings, stabbings, cardiac arrest, airway compromise, shock, and so forth. All such calls require the nearest unit to respond with lights and sirens. Priority one calls also require the dispatch of a first responder such as a basic life support unit or fire department, to maximize the speed of response and number of personnel available to help. Priorities three through seven include presumed nonemergencies, interfacility transfers, and scheduled transports not necessitating a rapid lights and sirens response. Therefore, the study population included patients who were critically ill or injured, necessitating rapid transport to the trauma center (for trauma patients) or closest appropriate facility (for medical patients). Helicopter data were divided into two groups: simultaneously and nonsimultaneously dispatched transports. Simultaneous dispatch was defined as any time a helicopter and ground ambulance were both dispatched to the scene within 5 minutes after the initial 911 call. EMS policy discourages transport by helicopter of patients already in cardiac arrest, exposed to hazardous material, or displaying violent behavior per local EMS policy. 26 Interfacility transports were excluded. Transports that were canceled, those of a less emergent priority than one or two, or Volume 58 Number 1 149

3 The Journal of TRAUMA Injury, Infection, and Critical Care those missing critical time or distance data were excluded. Furthermore, entries with impossible time data (i.e., hospital arrival before arrival on scene) were excluded if they could not be resolved by review of the original records. Three methods of transportation were compared: ground transports, SD helicopter transports, and NSD helicopter transports. Distance data were grouped into 5-mile increments, and for each of the three transport groups, time from 911 call to hospital arrival was calculated for each 5-mile distance interval. Numerical time and distance values were entered into a computerized spreadsheet (Microsoft Excel), and data analysis was performed by a statistician using the SPSS software. The mean time for each method of transport at each distance interval was calculated. This information was graphed using Microsoft Excel, with error bars designating the 95% confidence interval around each mean. A two-way analysis of variance was used to compare mean times for methods of transport, distance intervals, and their interaction. The interaction between the two factors and the two main effects were all significant with p Bonferroni multiple comparisons were used to determine statistically significant differences at each distance interval, with significance set at the 0.05 level. RESULTS During the period January 1997 to May 2000, a total of 3,247 requests for helicopter transport were made by dispatch. Of those, 1,776 were canceled and 1,471 were completed transports. Of the completed transports, 362 were excluded as transfers and 34 were excluded for missing mileage data, leaving 1,075 helicopter transports with complete data for study inclusion. There were 715 SD and 360 NSD helicopter transports. During the period June 1996 to June 2000, there were 8,314 completed priority one or two ground transports. Two hundred seventy-two were excluded as transfers and 188 cases were excluded for data entry errors containing impossible time entries. Thus, 7,854 ground ambulance runs were available for analysis. Of the 8,929 transported patients included in the study, 30% were trauma patients and 47% were transported to the regional Level I trauma center. Dispatch intervals were short for the ground transport group and SD helicopter transport group, and substantially longer for the NSD group (Table 1). Ground ambulance transports were much more frequent in Fig. 1. Frequency of air and ground transports, by scene distance from the hospital. The study population was gathered between June 1996 and June the metropolitan regions at shorter distances, whereas the majority of helicopter transports were greater than 20 miles away from the receiving hospital (Fig. 1). The 911-hospital arrival intervals were plotted as a function of the distance from the hospital (Fig. 2). Ground transports were significantly faster than NSD helicopter transports at distances under 20 miles. Between 20 and 44 miles, there was no significant difference, and at distances greater than 45 miles, NSD helicopter transport was significantly faster than ground transport, with mean 911-hospital arrival interval of versus minutes, respectively (p ; 95% confidence interval, ). SD helicopter transport became significantly faster than ground transport at distances greater than 10 miles from the hospital. At the 10- to 14-mile interval, SD helicopter transports had a mean 911-hospital arrival interval of 42.2 minutes. This was significantly shorter than the mean ground time of 46.7 minutes for the same distance interval (p 0.001; 95% confidence interval, ). SD helicopter 911-hospital arrival intervals were shorter than those of NSD helicopter transports at all distances studied. As suggested by previous studies, ground transport was faster than both air transport modalities for distances less than 10 miles from the hospital. Mean 911-hospital arrival interval Table 1 Dispatch Interval (911 Receipt to Vehicle Notification) and Call-Response Interval (Time of 911 Call Receipt to Time Vehicle Stops at Scene), Mean (95% Confidence Interval) Dispatch Interval Call-Response Interval Ground transports (min) 1.14 ( ) 7.43 ( ) Helicopter transports Simultaneous dispatch (min) 1.52 ( ) ( ) Nonsimultaneous dispatch (min) ( ) ( ) 150 January 2005

4 Comparison of Helicopter and Ground Ambulance Fig. 2. Time from 911 call to hospital arrival versus distance from hospital, for ground, nonsimultaneously dispatched (NSD), and simultaneously dispatched (SD) helicopter transports. Each bar represents the mean time from 911 call to hospital arrival, in minutes, with 95% confidence intervals. *SD helicopter (42.2 minutes) versus ground (46.7 minutes), p **NSD helicopter (111.3 minutes) versus ground (170.7 minutes), p for the 5- to 9-mile interval for ground, SD, and NSD helicopter transports were 37.8, 41.7, and 50.4 minutes, respectively. All means were significantly different by Bonferroni multiple comparisons (ground vs. SD, p 0.018; ground vs. NSD, p ; SD vs. NSD, p 0.004). At distances greater than 50 miles, these trends continued to diverge, but the number of ground transports became too small for meaningful comparisons. DISCUSSION The overuse of air ambulances for noncritically injured patients is an increasing criticism of EMS systems. Simultaneous dispatch occurs immediately after the 911 call is received, so the decision to send an air unit in this setting must be made on the basis of minimal information, before evaluation by medical personnel. Although this approach leads to rapid air response times, it may also lead to the air transport of patients without serious injuries. The other option is to delay helicopter dispatch until after the patient has been assessed by the responding ground unit. 27 This approach likely improves the selection of the most critically ill patients for air transport, but it adds precious time to the EMS phase of care, and was the slowest method of transport within 45 miles of the hospital in our study. Several noteworthy observations emerged from our data. First, within 10 miles of the hospital, ground transport yielded the shortest 911-hospital arrival interval. Second, greater than 10 miles away from the hospital, the quickest way to transport the patient to the hospital was to dispatch the helicopter simultaneously with the ground unit, immediately after the 911 call. Third, when helicopter dispatch was delayed until after ground personnel assessed the patient, helicopter transport did not become faster than ground until the distance from the hospital was greater than 45 miles. Others have previously reported ground to be faster than air in short-distance urban transports, attributing this to more accessible roadways; nearby ambulance stations; and delays associated with helicopter dispatch, landing, and loading. 5,8,21,28,29 The time advantage for longer distance transports may explain the trends toward mortality reductions seen in trauma patients in rural areas evacuated by helicopter, as well as the lack of benefit noted when air-transported patients had no time advantage over their ground-transported counterparts. 2 6,30 Should EMS systems routinely employ SD helicopter transport for all patients at distances greater than 10 miles from a hospital? There are important considerations that arise with such an approach. First, it has not been clearly established which patients derive benefit from air transport. Several studies have demonstrated reduced mortality in trauma patients transported by air However, the benefit seems to exist only in the most critically injured patients. 9,10,18,19 Also, air transport is a costly resource, with patient charges that may exceed 5 to 10 times that of ground transport. For economic, availability, and safety reasons, air transport should be allocated with discretion. Although air transport is expensive, the marginal cost of additional flights when the helicopter and crew are already in place is not. We estimate that the direct operating costs of fuel and maintenance are $650 per flight hour. In our series, 74 of 1,075 flights were less than 10 miles. If we eliminated all flights under 10 miles, with an average of 30 minutes of total flight time each, we would have saved $24,050 in direct operating costs over the 3-year period. The decision should not be made on the basis of cost alone, however, because there may be some benefit in delivering a higher level of care to a scene even if transport is not faster. Also, when there is prolonged extrication of a patient from a vehicle, air transport to the hospital is faster even at very short distances, because the helicopter may arrive at the scene before the patient is ready for transport. SD helicopter transport may also lead to an unacceptably high cancellation rate. We documented a 55% cancellation rate during simultaneous helicopter dispatch in our study, which is higher than that reported by others, and can threaten the financial viability of an air program. 21 Unfortunately, we have been unable to effectively reduce our high cancellation rate because the same dispatch criteria that lead to a high percentage of cancellations also lead to a large number of completed air transports. Other authors have used calculations to estimate when air transport should be faster than ground transport. For example, on the basis of linear regression and predicted ground transport times, Nicholl et al. concluded that helicop- Volume 58 Number 1 151

5 The Journal of TRAUMA Injury, Infection, and Critical Care ter transport should provide on average 10 minutes faster transport in roughly half of their air-transported patients. 21 Smith et al. acquired sample time measurements of EMS transports and used them in mathematical formulas to solve for distances at which air transport should be expected to be faster than ground transport. 16 Although these studies do provide for good approximations, they did not directly compare measured ground and helicopter EMS times as a function of distance from the hospital. Lerner et al. used an elegant geospatial mapping program specific to their region, which defined zones from which air transport was significantly faster than ground transport. 5 Although this method seems ideal for an individual EMS system, it is so unique that information from one system cannot be readily applied to another. Our approach should be easily generalized to other similar areas with an urban center and rural surrounding areas. We chose to compare three transport and dispatch modalities in terms of 911-hospital arrival interval, or total EMS time. Intuitively, the important interval is that which has elapsed since the time of injury to the time of definitive care. The 911-hospital arrival interval used in our study approximates this start time and encompasses all possible prehospital delays: the time to notify a unit; the time for the unit to respond, reach the scene, and make patient contact; the time spent on scene; and the transport time from the scene to the hospital. We included only transports that were designated as priority one or two (lights and sirens) so that in all cases a perceived emergency existed, making it likely that the most direct route was taken to the hospital, as quickly as possible. Lower priority calls and interfacility transfers were excluded because of their variable times for transport request from time of injury and the unknown effect on transport urgency. 30 The use of a single standardized clock at dispatch headquarters to measure all time intervals eliminated discrepancies between unsynchronized prehospital recorded times or inaccurate estimates by prehospital personnel The distances observed in this study are similar to those reported in other systems, with the vast majority of all transports in this study occurring under 50 miles (Fig. 1). 5,8,34 There are a number of limitations to our study. Because the data were studied retrospectively, missing data points or erroneous data entry may have skewed our data in one direction or another. Odometer miles were converted into straightline miles to compare distances equally. This required a conversion factor as previously reported. 25 A small degree of error may exist in this conversion, offsetting distance comparisons, but we found a high degree of correlation between odometer mileage and straight-line mileage, as previously reported. This correction was performed in an effort to compare air versus ground transports from scenes that were the same straight-line distance away from the hospital. A superior method might have been to compare the times of encounters when multiple patients were transported by air and ground from the exact same location. Although this could have been accomplished, the sample size would have been far smaller. The unique topography and road system found in this system may limit applicability of our results to other systems. However, our system is likely similar to many others, with centrally located receiving hospitals in an urban area surrounded mostly by rural and distant mountainous regions. Air travel may not always be straight line because of airfield restrictions, or natural and structural barriers. Ground travel is impacted by many factors such as traffic congestion, road design, and proximity to freeways. Air transport might be faster at very short distances in a densely populated urban area with traffic, or might not be feasible if landing zones are unavailable. These factors must be taken into account by planning personnel in extrapolating our results to other systems. Finally, and most importantly, our study was a comparison of EMS times, but many important questions remain. Does air transport improve clinical outcomes? If so, which patients benefit, and is the benefit attributable to shorter transport times, extended scope of practice, or other factors? We hope that our study adds a small step toward answering this complex issue. In summary, when the scene distance is greater than 10 miles from the hospital, simultaneously dispatched air transport yields a shorter 911-hospital arrival interval than ground transport. However, ground transport is faster than or equal to nonsimultaneously dispatched helicopter transport at distances less than 45 miles away. Whether these time differences translate into clinically significant differences requires further investigation. ACKNOWLEDGMENTS We thank Lisa Epps, Erik Peterson, American Ambulance, Skylife, Tricia Soliz, Brandy Snowden, and Ronna Mallios for their assistance. REFERENCES 1. Hendey GW. Ground and air emergency transport. In Schwartz G, ed. Principles and Practice of Emergency Medicine. 4th ed. Baltimore: Williams & Wilkins; 1998: Brathwaite CEM, Rosko M, McDowell R, Gallagher J, Proenca J, Spott MA. A critical analysis of on-scene helicopter transport on survival in a statewide trauma system. J Trauma. 1998;45: Owen JL, Phillips RT, Conaway C, et al. One year s trauma mortality experience at Brooke Army Medical Center: is aeromedical transportation of trauma patients necessary? Mil Med. 1999;164: Arfken CL, Shapiro MJ, Bessey PQ, Littenberg B. Effectiveness of helicopter versus ground ambulance services for interfacility transport. J Trauma. 1998;45: Lerner EB, Billittier AJ IV, Sikora J, Moscati RM. Use of a geographic information system to determine appropriate means of trauma patient transport. Acad Emerg Med. 1999;6: 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;28: January 2005

6 Comparison of Helicopter and Ground Ambulance 7. Baxt WG, Moody P, Cleveland HC, et al. Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study. Ann Emerg Med. 1985;14: Rhodes M, Perline R, Aronson J, Rappe A. Field triage for on-scene helicopter transport. J Trauma. 1986;26: Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: air versus ground. J Trauma. 1989;29: Moront ML, Gotschall CS, Eichelberger MR. Helicopter transport of injured children: system effectiveness and triage criteria. J Pediatr Surg. 1996;31: Baxt WG, Moody P. The impact of a rotorcraft aeromedical emergency care service on trauma mortality. JAMA. 1983;249: Nijs HG, Bleeker JK, Van Der Waal MA, Casparie AF. Need for consensus development in prehospital emergency medicine: effect of an expert panel approach. Eur J Emerg Med. 1998;5: Urdaneta LF, Sandberg MK, Cram AE, et al. Evaluation of an emergency air transport service as a component of a rural EMS system. Am Surg. 1984;50: Hotvedt R, Kristiansen IS, Forde OH, et al. Which groups of patients benefit from helicopter evacuation? Lancet. 1996;347: Gearhart PA, Wuertz R, Localio AR. Cost-effectiveness analysis of helicopter EMS for trauma patients. Ann Emerg Med. 1997;30: Smith JS, Smith BJ, Pletcher SE, Swope GE, Kunst D. When is air medical service faster than ground transportation? Air Med J. 1993; 12: Burney RE, Fischer RP. Ground versus air transport of trauma victims: medical and logistical considerations. Ann Emerg Med. 1986;15: Cunningham P, Rutledge R, Baker CC, Clancy TV. 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: Moylan JA, Fitzpatrick KT, Beyer AJ III, Georgiade GS. Factors improving survival in multisystem trauma patients. Ann Surg. 1988; 207: Fresno/Kings/Madera EMS Policies and Procedures. Patient Destination. Effective 4/18/83. Revised 4/01/00. Policy #547: Nicholl JP, Beeby NR, Brazier JE. A comparison of the costs and performance of an emergency helicopter and land ambulances in a rural area. Injury. 1994;25: Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. Ann Emerg Med. 1991;20: Meislin HW, Conn JB, Conroy C, Tibbitts M. Emergency medical service agency definitions of response intervals. Ann Emerg Med. 1999;34: Spaite DW, Valenzuela TD, Meislin HW, Criss EA, Hinsberg P. Prospective validation of a new model for evaluating emergency medical services systems by in field observation of specific time intervals in prehospital care. Ann Emerg Med. 1993;2: Diaz M, Hendey G, Winters R. How far is that by air? The derivation of an air-ground coefficient. J Emerg Med. 2003;24: Fresno/Kings/Madera EMS Policies and Procedures. Helicopter Dispatch. Effective 10/10/86. Revised 11/01/00. Policy #408: Jones JB, Leicht M, Dula DJ. A 10 year experience in the use of air medical transport for medical scene calls. Air Med J. 1998;17: Tortella BJ, Lavery RF, Kamat M, Ramani M. Requiring on-line medical command for helicopter request prolongs computer-modeled transport time to the nearest trauma center. Prehospital Disaster Med. 1996;11: Stanhope K, Falcone RE, Werman H. Helicopter dispatch: a time study. Air Med J. 1997;16: Freilich DA, Spiegel AD. Aeromedical emergency trauma services and mortality reduction in rural areas. N Y State J Med. 1990; 90: Slack D, Koenig K, Bouley D. Paramedic accuracy in estimated time of arrival: significance in the managed care environment. Acad Emerg Med. 1995;2: Jurkovich GJ, Campbell D, Padrta BS, Luterman A. Paramedic perception of elapsed field time. J Trauma. 1987;27: Propp DA, Rosenberg CA. A comparison of out-of-hospital estimated time of arrival to an emergency department. Am J Emerg Med. 1991;9: Fischer RP, Flynn TC, Miller PW, Duke JH Jr. Urban helicopter response to the scene of injury. J Trauma. 1984;24: Volume 58 Number 1 153

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