The costs and benefits of helicopter emergency ambulance services in England and Wales

BACKGROUND: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex. METHODS: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken. RESULTS: 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. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London. CONCLUSION: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.     

Disposal of Arsenic-Laden Adsorptive Media: Economic Analysis for California

Due to California’s stringent hazardous waste (HW) classification regulations, high-capacity adsorptive media (AM) used for the removal of arsenic from potable water are likely to be classified as HW if operated to breakthrough. An alternative is to prematurely retire the AM, avoiding generation of HW. The impact of waste classification of spent AM on annual costs for arsenic systems was investigated. For a typical small water system (SWS), the media replacement cost alone was predicted to range from $0.80 to $2.00 per 1,000 L treated, in comparison to the average cost of tap water in the U.S. of $0.53 per 1,000 L treated, highlighting the financial burden for SWS. The costs of media replacement dominated over costs for transport and disposal regardless of whether spent media were designated as HW or non-HW. Media costs and influent arsenic concentration were more significant factors than transport distance or disposal fees. Under typical conditions for SWS, it was found to be cost effective to load the media to exhaustion as long as the arsenic loading at replacement was greater than 560-mg arsenic/kg AM, a situation readily obtained with commercially available high-capacity iron oxide adsorbents.     

Mode of referral to hospital of patients with heart attacks: relevance to home care and special ambulance services

Out of 1250 consecutive patients brought to hospital with heart attacks 956 (76%) were at home when their symptoms began. Of these, 587 (61%) called their general practitioner, and for the remainder an ambulance was summoned by a member of the public. Of the 294 patients who were away from home when the attack occurred 291 were brought to hospital by ambulance. Of these, only 70 (24%) were attended by a general practitioner. Patients for whom ambulances were called by a general practitioner had had their symptoms significantly longer and had significantly lower prehospital and hospital mortalities than those for whom ambulances were summoned by members of the public. Special "cardiac" ambulances appear to be inappropriate for patients who have been seen by a general practitioner, and for this group home care may well be as effective as hospital admission.     

Pediatric ambulance utilization in a large American city

During our routine dissection studies we encountered an anomalous digastric muscle with three accessory bellies and one fibrous band in one embedded cadaver. All of these structures were attached to the mylohyoid raphe. This anomaly should be considered during surgical procedures involving this region.     

Testing a medically-staffed ambulance in Aarhus. A pilot study

As an attempt to assess the value of a medically-staffed mobile emergency care unit in Aarhus City, we carried out a seven-day experiment (17 hours per day) with an anaesthesiologist and a nurse on duty in a fully equipped vehicle. Aarhus City is an area of approximately 300 km2, with a population of 330,000. The unit responded to emergency calls in 106 patients (38% of all emergency calls during this week). In 31% of all cases the response-time was less than five minutes. Medical disease was diagnosed in 73 patients. Twenty-three patients were suffering from trauma and in three cases the reason for the emergency call was attempted suicide. Fifty-seven percent were treated immediately by the emergency unit, and in 4% of these the treatment was lifesaving. Twenty percent of the patients had their treatment completed outside the hospital. Eighty percent were brought to hospital, 47% with medical assistance. We conclude that there seems to be a basis for a medically-staffed mobile emergency care unit in Aarhus City.     

Coccidioidomycosis in free-living California sea lions (Zalophus californianus) in central California

Coccidioidomycosis is described in seven California sea lions (Zalophus californianus) admitted to The Marine Mammal Center, Sausalito, California (USA), between January 1986 and December 1994. Diagnoses were confirmed by histology in all seven cases, culture in three cases, and serology in one case. These are believed to be the first published cases of coccidioidomycosis in free-ranging California sea lions.     

Spirochetosis in California game chickens

An outbreak of spirochetosis occurred in a flock of 75 game chickens in California during fall 1991. Affected birds were weak and anemic. Many had greenish diarrhea. Spirochetes were seen on Giemsa-stained blood smears and in silver-stained tissue sections of kidney, liver, and spleen. Splenomegaly, which is reported to be characteristic of fowl spirochetosis, was not observed in two acutely infected chickens.     

Recent mortality patterns in California

Mortality among people with developmental disabilities was reviewed using recent data obtained from the California Department of Developmental Services. The time interval for this report was 1991-1995. We defined two study cohorts: one beginning in January 1991 and a second in April 1993. The latter period represented the years of implementation of the Coffelt settlement. Our primary interest was in the Coffelt period cohort. Statistically significant association with increased rates of mortality was found for community residence. A trend of declining mortality was noted for the community facilities from 1991-1995, but not for the developmental centers.     

Emergency ambulance assistance in The Netherlands: is the Dutch situation optimal?

The system of prehospital trauma care in the Netherlands is the subject of great concern. Although many improvements have been achieved in the last decade, there are still some deficits. Legislation concerning the minimal level of education for ambulance attendants was recently upgraded to 'registered nurse', a standard which must be achieved by 1997. Standardization with regard to extrication techniques, equipment and methods of treatment in prehospital trauma care does not yet exist. Although aware of the fact that large regional differences exist throughout the USA, a system of care in accordance with the advanced trauma life support (ATLS) standard of the American College of Surgeons (ACS) and by means of prehospital and advanced trauma life support (PHTLS) given according to the standards of the National Association of Emergency Medical Technicians (NAEMS) was considered to be the 'golden standard'. Nineteen ground ambulance and two helicopter services in different states of the USA, working according to ACS/NAEMS standard, were visited to analyse the system of care, with special reference to (para)medical education, communication, logistics, and immobilization materials and techniques. In the Netherlands all 41 central post ambulance services (CPAs) were asked to return a questionnaire. This resulted in a 90% (37 out of 41) response. The deficits of the Dutch system of care related to the PHTLS/ATLS standard are pointed out, resulting in recommendations to improve the Dutch system. The requirements of the dispatcher are far inferior to the optimal situation, which, together with the lack of technical equipment, results in serious communication problems. The Dutch ambulance attendant education, in which in the present system the education level reaches 'registered nurse' in only 91% and specialized courses are not mandatory, should be upgraded to the PHTLS level of care.     

Aerial fallout of DDT in southern California

Ender's method of intramedullary fixation of intertrochanteric and subtrochanteric fractures is described. Ender's nail is a pre-bent flexible steel nail with a diameter of 4.5 millimeters. Three to five of these nails are inserted from a small incision proximal to the medial epicondyle of the femur into the medullary canal. They are passed through the femur across the fracture site and into the head of the femur, where they diverage. They are in the lines of force and therefore are not subjected to bending moments. The fracture fixation allows immediate weight-bearing. This method of fixation was used in a series of 203 patients. Their average age was sixty-eight years; the mortality rate was 10.3 per cent. In 3.9 per cent superficial infections occurred, but in no case was there a deep infection involving the bone. Functional return (walking) was achieved in all of the survivors who were able to walk at the time of injury, and there were no nonunions.