Characteristics of severely injured trauma patients transported by helicopter emergency medical services in Switzerland: a retrospective cohort study

DOI: https://doi.org/https://doi.org/10.57187/s.4502

Introduction

Background

Helicopter emergency medical services (HEMS) are a cornerstone of trauma care in most Western countries and have been shown to reduce mortality after trauma and shorten rescue time, particularly in rural or geographically challenging areas like the alpine regions of Switzerland, which cover over 50 percent of the country [1–8]. Due to these challenging geographical conditions, fast and efficient rescue is often only possible by helicopter. As a result, helicopter emergency medical services are more established in Switzerland than in many other European countries and respond to around 6% to 10% of all emergency calls [9, 10]. This is also reflected in the finding that a smaller proportion of patients were transported by helicopter emergency medical services in Europe. In Switzerland, around 35% of seriously injured people are transported to a hospital by helicopter [11]. Differences in trauma outcomes according to sex have already been identified, with most studies showing that women appear to be relatively advantaged compared to men when looking at overall mortality [12]. Researchers are increasingly exploring new sex-specific perspectives in acute care medicine, particularly in the fields of trauma and resuscitation. However, systematic reviews and meta-analyses of sex-based disparities in trauma sample only a small proportion of the published literature, which biases conclusions. Few studies on trauma outcomes present data by sex, and the bias against publishing negative studies persists. It is therefore important to address sex-specific issues in trauma and resuscitation.

Recent papers from the Netherlands and Denmark have reported data on patients transported by helicopter emergency medical services, looking into the characteristics of trauma- and non-trauma patients, and comparing the characteristics of trauma patients by mode of transportation (helicopter emergency medical services vs ambulance) [13, 14]. To our knowledge, there exists no similar information on trauma patients transported by helicopter emergency medical services in Switzerland.

Objective

The aim of this study was to provide an overview of severely injured trauma patients transported by helicopter emergency medical services in Switzerland, with a particular focus on differences between men and women. This information can help to better understand trauma patients transported by helicopter emergency medical services and to further improve prehospital trauma care. 

Methods

Study design and setting

In Switzerland, deployment of helicopter emergency medical services is organised either by regional medical emergency call centres or directly by the national operation centre of the Rega (Rettungsflugwacht/Guarde Aérienne). The entire Swiss helicopter emergency medical services operation area is accessible within 15 minutes of flying time day and night by a helicopter at one of the four main Swiss helicopter emergency medical services providers: Rega, Air-Glaciers, Air Zermatt and Alpine Air Ambulance. A helicopter emergency medical services team comprises at least a pilot, a paramedic and an emergency physician, usually an anaesthetist or intensive care doctor with a specialisation in prehospital emergency medicine. All helicopter emergency medical services providers conduct primary missions to aid patients in need of emergency medical treatment, search and rescue missions and in addition offer rapid transfer of critically ill patients between hospitals.

In this retrospective multicentre cohort study, we analysed data from the Swiss Trauma Registry (STR) on severely injured trauma patients transported by helicopter emergency medical services. The Swiss Trauma Registry plays a crucial role in the advancement of trauma care by collecting, providing and reviewing data on critically injured trauma patients. All twelve level 1 trauma centres in Switzerland are obliged to document trauma patients aged ≥16 years with an Injury Severity Score (ISS) ≥16 and/or Abbreviated Injury Score (AIS) Head ≥3 in the Swiss Trauma Registry [15, 16]. The Swiss Trauma Registry excludes patients with isolated burns or in whom the burn is the clear primary injury, as well as patients who have experienced suffocation, hanging or drowning without any accompanying injuries. Patients who reached the emergency department without signs of life are also excluded if either no or only very limited diagnostic or treatment measures have been performed. Patients who meet the criteria mentioned above are then registered by the trauma centres in the Swiss Trauma Registry, which forms the basis for coordinated clinical care and research in Switzerland by, in return, providing participating clinics with data on severely injured trauma patients for further research [17].

The Swiss Trauma Registry has been systematically collecting a wide range of trauma data in a pseudoanonymous manner since 2015 [15]. The registry includes detailed demographics, injury characteristics, prehospital and admission parameters, medical interventions and various outcome measures. Data entry follows standardised protocols, ensuring consistency across all participating level 1 trauma centres in Switzerland. Clinicians and trained registry personnel collect patient data from health records, prehospital emergency reports and hospital documentation. To ensure data integrity and accuracy, the Swiss Trauma Registry performs regular internal validation checks [15].

The present review is published in accordance with Swiss Trauma Registry publication guidelines under STR-ID 19 and uses STROBE reporting guidelines [18, 19].

Eligibility criteria

For our study, we identified all patients in the Swiss Trauma Registry admitted by helicopter emergency medical services between January 2018 and December 2022. This starting point was selected because we believe that from this time onward, data quality in the Swiss Trauma Registry is sufficiently high to ensure reliable analysis. The endpoint was determined by the latest fully available year of data at the time of study initiation.

We excluded all open cases, all non-primary admissions, all cases with an unknown accident date or where the accident date was more than one day prior to admission, and all cases without a documented ISS. We also excluded all patients with an ISS <16 to ensure that only severely injured patients were analysed.

Statistical methods

All statistical analyses were conducted using STATA 18.1 (StataCorp, College Station, TX, USA). Descriptive statistics for categorical variables are presented as frequencies and corresponding percentages. For continuous variables, either medians with interquartile ranges (IQR) or means with standard deviations (SD) are reported, depending on the results of normality testing (Shapiro-Wilk test). P-values were calculated using the Wilcoxon rank-sum test for non-normally distributed data and the unpaired t-test for normally distributed data. For categorical variables, p-values were obtained using the chi-squared test. A p-value of <0.05 was considered statistically significant.

Creation of graphical cohort description

To visually represent the Swiss helicopter emergency medical services severe trauma cohort, a 3D deformed human figure – referred to as the Swiss helicopter emergency medical services severe trauma “traumunculus” (a portmanteau word formed from trauma and homunculus) – was constructed, inspired by the well-known 3D sensory/motor male and female homunculus [20, 21]. The traumunculus integrates various cohort trauma characteristics, including the proportion of males, mean age, trauma severity, relative frequency of injuries to each body region and trauma type (e.g. penetrating trauma). Its construction is detailed in the appendix.

Ethics approval and consent to participate

The cantonal ethics committee of St. Gallen (EKOS) reviewed the study design, classified it as a quality evaluation analysis and granted permission for using patient data without individual consent (BASEC Nr. Req-2022-01540 EKOS 22/198).

Results

Study population

In total, 3652 primary helicopter emergency medical services cases were identified in Swiss Trauma Registry database between January 2018 and December 2022, of which 3469 were closed cases. After applying the previously stated exclusion criteria, 2714 cases were analysed in the present study (figure 1).

Figure 1Study flowchart. * Excluding patients with an Injury Severity Score (ISS) of less than 16 results in the omission of individuals with severe head trauma (Abbreviated Injury Score [AIS] Head ≥3) who have an overall ISS below 16. ED: Emergency Department; HEMS: Helicopter Emergency Medical Service; STR: Swiss Trauma Registry.

Baseline characteristics and admission data

Table 1 shows patient demographics, trauma characteristics and vital signs at hospital admission for men, women and the entire cohort. The median age of all patients was 54 years (IQR: 35–67). Patient numbers declined with increasing age, from 1022 in the youngest age group to 363 aged 75 years or over. Women accounted for approximately one-quarter of patients across all age groups except those aged >75 years, where the percentage of female patients rose to 36.6%. Overall, male patients were slightly younger than female patients (median age 53 years [IQR: 35–66] vs median age 55 years [IQR: 36–70], p = 0.007).

Most injuries originated from blunt trauma (93.6%) with traffic accidents (43.5%) or falls of any height (43.3%) being the predominant causes of injury. Further analysis of traffic accidents revealed that 14% of all patients had been involved in a motorcycle crash, 11.8% in a car or truck accident, 10.4% in a bicycle accident, 3.6% had been a pedestrian at the time of the accident and 1.3% were involved in an e-bike or e-scooter accident. Falls were further divided into three groups according to height: 22% of all patients fell from a height greater than 3 metres, 16.8% from a height less than 3 metres and 2% fell at ground level. In 68 patients, a fall was reported but no specific height documented.

Men were more frequently involved in motorcycle accidents (16.5% vs 6.9%, p <0.001), whereas women were relatively more often involved in accidents as pedestrians (6% vs 2.7%, p <0.001) and were more likely to experience a fall from a height below 3 metres (22.9% vs 14.7%, p <0.001).

When comparing vital signs at hospital admission between the two sex groups, statistically significant differences in systolic blood pressure, respiratory rate, temperature and oxygen saturation were noted.

Injury characteristics

The most common and severe injury among all patients was trauma to the thorax (67%, median AIS: 3.0 [IQR: 0–3]), followed closely by head trauma (66.7%, median AIS: 2.0 [IQR: 0–4]) and spine trauma (50.3%, median AIS: 1.0 [IQR: 0–2]). The median ISS in our cohort was 24.0 (IQR: 19–30).

Men suffered relatively more thoracic injuries than women (68.9% vs 61.9%, p = 0.001) and the median AIS Thorax for male patients was significantly higher than for female patients (3.0 [IQR: 0–3] vs 2.0 [IQR: 0–3], p <0.001). A considerably higher proportion of men than women had concomitant lung injuries (30.1% vs 23.6%, p = 0.001), haemo- or pneumothorax (38.8% vs 34.5%, p = 0.041) and rib fractures (55.5% vs 51.2%, p = 0.046).

Women suffered more pelvic fractures than male patients (29.3% vs 21.5%, p <0.001), as well as more fractures of long bones of the upper extremities (22.2% vs 15.7%, p <0.001), with more fractures of the humerus (9% vs 5.3%, p <0.001) and fractures of forearm bones (16% vs 11.9%, p = 0.005). There was no significant difference in the median ISS between men and women (24.0 [IQR: 19–30] vs 25.0 [IQR: 18–30], p = 0.780) (table 2).

Traumunculus

Figure 2 visualises the Swiss helicopter emergency medical services severe trauma traumunculus as described in the “Methods” section based on a 52-year-old (mean of cohort) with a 72% male appearance (proportion of males) base mesh. The size of its body parts reflects the prevalence of injury, the colour reflecting mean AIS and black holes denoting penetrating injury per body region (one percent per hole).

Figure 2Swiss helicopter emergency medical services (HEMS) severe trauma traumunculus.

Outcome

Overall, 405 of 2714 patients (14.9%) died during their hospital stay, and 14 patients died after discharge but within 28 days after trauma. The lowest mortality rate was observed in the population aged 16–45 years (8.7%). The rate of mortality increased with age, reaching 38% in the group of individuals aged over 75 years (appendix table S1).

There was no statistically significant difference between male and female patients in hospitalisation length, intensive care unit (ICU) stay, duration of mechanical ventilation, 28-day mortality or in-hospital mortality (table 3, appendix table S2).

Discussion

To our knowledge, this is the first analysis of severely injured trauma patients transported by helicopter emergency medical services in Switzerland. In our cohort, these patients are predominantly male, and although some trauma mechanisms and injury characteristics vary between male and female patients, outcome parameters are similar between the two groups.

Sex distribution of accidents

We can only hypothesise why men make up almost three quarters of the patients in this cohort. Past and ongoing research assumes that men tend to engage in riskier activities and behaviours than women, especially in younger years [22]. This has led to the term “young male syndrome”, although it has been questioned by more recent studies [23, 24]. They also suffer more injuries with potentially grave consequences during work in hazardous jobs such as construction work or when handling heavy machinery [25]. According to one paper, men’s higher prevalence of risk-taking behaviour results in an overall non-fatal injury incidence of 10.1/100 for men in the United States, compared with 8.5/100 for women. Age-adjusted mortality rate from trauma was three times higher for men than for women [26]. According to a publication in 2024 by the Momentum Institute, relying on data from the Austrian national statistical system, male drivers caused two-thirds of all traffic accidents in 2023, of which almost a quarter occurred under the influence of alcohol or drugs, compared with 9% of accidents with female drivers [27]. We agree that riskier behaviour and greater activity in potentially hazardous jobs, along with other factors, may contribute to higher numbers of male patients in our study. We found that men were more involved in motorcycle crashes, which could underline more involvement in hazardous activities. The Swiss Council for Accident Prevention (Beratungsstelle für Unfallverhütung [BFU]) highlighted in its 2021–2025 action programme that motorcycles are particularly popular among young men and that, despite accounting for only 2% of all vehicles on the road, motorcyclists (both male and female) represent 30% of all severely injured road users – a figure that closely aligns with our own findings. The BFU also addresses the role of peer pressure among young men as a contributing factor to risk-taking behaviour. With numerous action plans and programmes, the BFU aims to prevent non-work-related severe injuries in Switzerland and to mitigate the impact of this major public health concern. Non-work-related accidents account for approximately one million incidents annually, leading to 36,000 severely injured patients, 2400 fatalities and 12 billion Swiss Francs in material damage [28].

Our study’s results further emphasise the need for targeted prevention campaigns to reduce the burden of severe injuries, particularly among young men. Potential preventive strategies might include (a) traffic safety campaigns, (b) mandatory advanced rider training, (c) peer-driven interventions, (d) further enforcement of traffic laws, (e) infrastructure improvements (road safety modifications) and (f) early public health education starting as early as primary school.

Injury characteristics

Regarding the consequences of trauma, men seemed to experience thoracic trauma more frequently and with a significantly higher Abbreviated Injury Score (AIS) Thorax, including greater incidence of lung injuries, rib fractures and haemo- or pneumothoraxes. Severe thoracic injuries can originate from high-energy trauma, possibly reflecting men’s higher prevalence in motorcycle accidents. Women in our cohort suffered pelvic and upper extremity fractures, including humerus and forearm fractures, more frequently. While pelvic fractures are also associated with high-energy trauma, another factor increasing the fracture rate in women may be underlying osteoporosis, which is most prevalent in older female patients [29, 30]. After the age of 50, women are five times more likely to develop osteoporosis than the general population. This, coupled with the effects of ageing, frailty and more frequent falls, can significantly increase the likelihood of hip fractures in women over 70 years of age. The incidence of forearm fractures also rises, but not as sharply [31, 32].

Sex-based differences in quality of care

Published data suggests that the quality of prehospital care varies between men and women due to sex-related factors. A 2012 retrospective cohort analysis of severely injured patients in Canada looked at sex-based differences in direct transport by emergency medical services to trauma centres, as well as secondary transfer from non-trauma centres to trauma centres. The study revealed that female patients were less likely to be directly admitted or transferred to a trauma centre than male patients [33]. A 2016 retrospective observational study from Stockholm underlines these results. The study showed that severely injured female trauma patients were given less priority in prehospital care and more often did not receive direct transport to a trauma centre compared to their male counterparts [34]. In accordance with our study, they also reported that women suffered more injuries from falls than men and that mortality between the male and female groups did not differ significantly.

A possible explanation for this sex gap in triage and admission might be that elderly female patients more frequently suffer from “less spectacular” mechanisms of trauma, such as falls, and despite being severely injured, may be more likely undertriaged due to the apparent “low-energy” mechanism of trauma. Men, who more often suffer serious injuries from eye-catching high-energy trauma mechanisms such as motorcycle crashes might be more likely to be directly transported to a trauma centre because of the obvious accident mechanism. However, it is important to point out that diagnosis in the prehospital setting, particularly during helicopter emergency medical services missions, can be very challenging. Evidence without regard to sex groups shows that even trained professionals can miss severe chest and pelvic injuries in these situations [35, 36].

There is conflicting data on patient outcomes when focusing on sex in emergency medicine. The evidence so far does not indicate a difference in mortality when male and female trauma patients are compared [34, 37–39]. On the other hand, research has shown that sex can influence medical treatment and outcome in various conditions such as myocardial infarction, stroke care and triage to the ICU [40–50]. A recent nationwide registry study from Switzerland with 41,733 cardiac arrest patients, 34.9% of whom were women, concluded that female patients were less frequently admitted to an ICU after cardiac arrest. In addition, fewer advanced treatment measures were taken, and their risk of ICU mortality was higher compared to their male counterparts, especially after out-of-hospital cardiac arrest [50].

In our study, there were no significant differences between the two sex groups in terms of outcome parameters; mortality was similar between men and women, as was their duration of hospital stay and other outcome data. Nevertheless, more and more data with a special focus on sex differences is emerging and future research will play an important role in unearthing or denying inequality in medical care between male and female trauma patients. It is important for helicopter emergency medical services crew members to acknowledge this potential sex bias and to keep it in mind on missions, ensuring that all patients receive equal high-quality care regardless of their sex.

Limitations

Our cohort does not represent all patients admitted to Swiss level 1 trauma centres with comparable injury severity as helicopter emergency medical services tend to operate in more remote regions than ground emergency medical services (GEMS). In Switzerland, ground emergency medical services provide emergency medical aid in more densely populated areas. Here helicopter emergency medical services are mostly dispatched for additional support of ground emergency medical services, for example if a physician is needed on-site, to provide rapid transport to a medical centre further away or if no ground emergency medical service is available. Further research comparing Swiss trauma patients transported by helicopter emergency medical services and ground emergency medical services, such as that published by Blok et al. with data from a Danish helicopter emergency medical services provider, would be needed to gain insight into potential differences [31].

Furthermore, this study only analysed severely injured trauma patients, excluding those with a lower Injury Severity Score (ISS), which limits its significance for all trauma patients. We also excluded patients who were transferred to a trauma centre after primary admission to a non-trauma centre, thus not enabling us to provide data on the correct triage of male and female trauma patients by the crews on the scene as has been described in other studies and mentioned in our discussion. Another limitation of this study is of course its retrospective design and analysis of data. Due to the summarised nature of the dataset, we were not able to compare the baseline characteristics of the two sexes with their injuries, mechanisms of accidents and outcomes, preventing us from drawing conclusions about relationships between these variables such as injuries or injury mechanisms suffered predominantly in certain age groups of the two sexes.

Conclusion

The data provided by the Swiss Trauma Registry enabled us to present an overview of the patients encountered by medical professionals on their helicopter emergency medical services missions in Switzerland. Although differences between women and men were observed in terms of trauma mechanisms and injuries, no significant differences in outcome parameters were noted.

An illustrative and short summary of the results can be found in figure 3.

Figure 3Summary of the results. ISS: Injury Severity Score.

Data sharing statement

The complete and deidentified dataset used to create any tables and figures in the current study is available from the corresponding author upon reasonable request.

Acknowledgments

Author contributions: UP designed the study. MM built the database. PM, MM and SJ analyzed the data. All authors performed the literature search. MM and DAJ wrote the structure of the manuscript. PM, SJ and DAJ wrote the first draft of the manuscript. All authors contributed to the interpretation of the data and writing of the final manuscript and approved the final version of the manuscript.

Special thanks go to the Swiss Trauma Registry, which provided the data. The publication of this review has taken place in accordance with the Swiss Trauma Registry publication guidelines under the STR-ID 19.

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Appendix

The appendix is available in the pdf version of the article at https://doi.org/10.57187/s.4502.