Accurate endotracheal intubation for patients in extremis or at risk of physiologic decompensation is the gold standard for emergency medicine. Field intubation is a complex process and time to intubation, number of attempts, and hypoxia have all been shown to correlate with increases in morbidity and mortality. Expanding laryngoscope technology which incorporates active video, in addition to direct laryngoscopy, offers providers improved and varied tools to employ in management of the advanced airway. Over a nine-year period a helicopter emergency medical services team, comprised of a flight paramedic and flight nurse, intended to intubate 790 patients. Comparative data analysis was performed and demonstrated that the introduction of the CMAC video laryngoscope improved nearly every measure of success in airway management. Overall intubation success increased from 94.9% to 99.0%, first pass success rates increased from 75.4% to 94.9%, combined first and second pass success rates increased from 89.2% to 97.4%, and mean number of intubation attempts decreased from 1.33 to 1.08.

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Safety in transport is a major concern. Air medical crashes are in the public eye, but a greater risk of transport may be in the clinical care provided along the way. While the media focuses on the drama of helicopters landing on scene, the greatest and most common risk actually occurs during inter-hospital transport. For too long, transport has been a black hole in clinical medicine and the real rate of adverse events is unknown. New work from the University of Pennsylvania should make us all breathe a little easier.Dr Seymour and colleagues [1] present us with an important new look into adverse events in transport. While the majority of studies on safety of transport focus on the risk to patients of injury or fatality incurred by the transport modality itself [2-6], a less reviewed but probably more important risk profile is that of the actual care delivered to critically ill patients during transport. Transport is often a black hole in medicine. The transport interval, however, is among the least measured and highest risk time periods for patients. As noted in a recent publication of evidence on the safety of care by the Agency for Healthcare Research and Quality [7], the care of critically ill patients routinely requires both intra-and inter-hospital transport of high risk patients and "practices to reduce or minimize this necessary risk represent a potentially important area of patient safety research."The study of Seymour and colleagues [1] is retrospective and thus limited to reported clinical events rather than all possible technical complications of transport, and, as noted by the authors, has some limitations resulting from the particular patient cohort studied (patients transferred by a single helicopter program from the University of Pennsylvania to a single referral center). It is, nonetheless, a valuable addition to help better our understanding of a particularly vulnerable population, mechanically ventilated medical patients undergoing inter-hospital transfer by helicopter, a growing subset of acutely ill patients.Hospital care systems throughout the world are undergoing massive structural changes to concentrate tertiary care. Cost efficiency, low numbers of specialist physicians, increasing demand, and improving quality are all factors in this rapid transformation of hospital systems. The effects of these policy changes have only just begun to be analyzed. One result is the dramatic increase in the number and acuity of patients needing transfer to tertiary care. As an example, in our system of 36 acute care hospitals in the state of Maine, the number of Emergency Medical Services (EMS) records increased 26% in the 8 year period from 1998 to 2005, while the number of emergency inter-hospital transports increased by 56% [8]. Similar use rates are found throughout the world and it is expected that the numbers of patients needing timedependent, high-acuity transfer will continue to grow rapidly.The use of medical helicopters, as a strategy to overcome time and geographical barriers of access ...

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