Current status of patients with gastrointestinal bleeding transported by physician-staffed helicopter in Japan
Original Article

Current status of patients with gastrointestinal bleeding transported by physician-staffed helicopter in Japan

Youichi Yanagawa1 ORCID logo, Tatsuro Sakai1, Noriko Tanaka1, Chihiro Maekawa1, Yukinori Hirooka1, Kenji Kawai1, Michika Hamada1, Soichiro Ota1, Hiroaki Taniguchi1, Hiromichi Ohsaka1, Hiroki Nagasawa1, Tadashi Ishihara2, Kazuhiko Omori1

1Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Shizuoka, Japan; 2Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Urayasu, Chiba, Japan

Contributions: (I) Conception and design: Y Yanagawa; (II) Administrative support: Y Yanagawa; (III) Provision of study materials or patients: Y Yanagawa, K Omori; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: Y Yanagawa, K Omori; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Youichi Yanagawa, MD, PhD. Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295, Japan. Email: yyanaga@juntendo.ac.jp.

Background: Currently, there is very limited analysis of cases where acute gastrointestinal (AGI) bleeding patients have been transported by helicopter. This descriptive study aims to share the Japanese experience with other air ambulance providers.

Methods: We retrospectively analyzed data from the Japan doctor helicopter (DH) registry system (JDRS), which was prospectively collected in Japan from April 2015 to March 2020. Inclusion criteria were all cases registered in the JDRS with a diagnosis of gastrointestinal bleeding. Exclusion criteria were cases with unknown outcomes after one month. The following details of the dispatch activity of the subjects were collected: age, sex, vital signs at emergency medical technicians (EMTs)’ contact, DH staff’s contact, and at the receiving hospital, cardiac arrest at EMTs’ contact, DH staff’s contact, and at the receiving hospital, dispatch type, contents of the medical intervention, and the final outcome.

Results: During the investigation period, 235 cases were treated as subjects. Males were dominant. The heart rate and shock index at the EMTs’ contact were significantly higher than those at the DH staff’s contact. The respiratory rate and shock index at the DH staff’s contact were significantly higher than those at the hospital. There were 11 cardiac arrests at the DH staff’s contact and 5 (45.5%) of them obtained spontaneous circulation at the hospital. The fatality ratio within one month was 10.6%.

Conclusions: This report describes the current status analysis of AGI bleeding cases transported by the DH. Following air evacuation, unstable vital signs improved, and approximately half of the patients achieved return of spontaneous circulation from cardiac arrest.

Keywords: Acute gastrointestinal bleeding (AGI bleeding); doctor helicopter (DH); vital signs


Received: 20 July 2024; Accepted: 10 October 2024; Published online: 12 December 2024.

doi: 10.21037/jeccm-24-105


Highlight box

Key findings

• The present study showed that males were dominant, unstable vital signs improved after air evacuation, 45.5% obtained return of spontaneous circulation from cardiac arrest.

What is known and what is new?

• This is the first report to describe the current status analysis of the transportation of acute gastrointestinal bleeding cases evacuated by the doctor helicopter in Japan.

What is the implication, and what should change now?

• This is primarily a descriptive study that will help share the Japanese experience with other helimedevac providers.


IntroductionOther Section

The physician-staffed helicopter emergency medical service (HEMS), called the doctor helicopter (DH) in Japan, transports a flight doctor and flight nurse to the scene of an emergency during the daytime (HEM-Net, https://hemnet.jp/en). As of April 2022, 57 DHs have been deployed in 47 prefectures across Japan.

There are two main types of the DH dispatch in Japan: the DH dispatched to a predesignated rendezvous point near the scene that evacuates patients from the rendezvous point and the DH for interhospital transportation (1). In the majority of cases, interhospital transportation is performed to transfer patients to medical institutions that provide more advanced medical care. When the DH is dispatched to the predesignated rendezvous point near the scene, there are two dispatch subtypes: dispatch after emergency medical technicians (EMTs) contact with a patient and determine the severity of the patient’s condition and dispatch based on key words based on the contents of an emergency call to execute early requests for DH dispatch and facilitate early medical intervention by physicians.

Acute gastrointestinal (AGI) bleeding, especially upper gastrointestinal (GI) bleeding, is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality (2-5). Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with GI bleeding (2). Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients (2).

In Japan, cases of AGI bleeding are generally transported to facilities capable of emergency endoscopy. However, such facilities are limited to those available 24 hours a day. Moreover, in cases of hemorrhagic shock, where comprehensive management is also necessary, the number of suitable facilities is further restricted. Consequently, many cases of unstable AGI bleeding are transported to emergency medical centers (5-10). In some instances, they are transported by the DH in Japan (11). Currently, there is very limited analysis of cases where AGI bleeding patients have been transported by helicopter (12-14). Therefore, we conducted a current status analysis of the transportation of AGI bleeding cases using a data bank provided by the Japan DH registry system (JDRS) executed by the Japanese Society for Aeromedical Services to provide future reference material for cases transported by helicopters. We present this article in accordance with the STROBE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-105/rc).


MethodsOther Section

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by Juntendo Shizuoka Hospital review board (approval No. 733) and individual consent for this retrospective analysis was waived.

The JDRS prospectively collected data on dispatches to rendezvous points near the scene (including the final outcome at one month) registered from the all DH base hospitals in Japan from April 2015 to March 2020. The collected data became available to each base hospital in December 2022. We analyzed these data retrospectively.

Inclusion criteria were all cases registered in the JDRS with a diagnosis of GI bleeding. Exclusion criteria were cases with unknown outcomes after one month.

The following details of the dispatch activity of the subjects were collected: age, sex, vital signs at EMTs’ contact, DH staff’s contact, and at the receiving hospital [Glasgow Coma Scale (GCS), systolic blood pressure, heart rate, respiratory rate, and shock index (heart rate divided by systolic blood pressure)], cardiac arrest at EMTs’ contact, DH staff’s contact, and at the receiving hospital, dispatch type of the DH before EMTs made contact with the patients (key word) or after, contents of the medical intervention (securing airway, infusion, transfusion and/or infusion of drugs), and the final outcome [cerebral performance category (CPC) at one month and the survival outcome: CPC1, good cerebral performance; CPC2, disabled but independent; CPC3, conscious but disabled and dependent; CPC4, vegetative state; CPC5, dead]. CPC 1 and 2 were classified as good outcomes, while CPC 3–5 were classified as poor outcomes. We also investigated the duration from the first call to the EMTs’ contact, from the EMTs’ contact to the DH staff’s contact, and from the DH staff’s contact to arrival at the receiving hospital.

Statistical analysis

The data were analyzed using one-way analysis of variance to assess changes in vital signs between the EMT contact, DH staff contact, and arrival at the receiving hospitals. The Chi-squared test was used to analyze the number of cardiac arrests between the EMT contact and the DH staff contact, and between the DH staff’s contact and arrival at the receiving hospitals. Statistical analyses were performed with the JMP software program (SAS Institute Inc., Cary, NC, USA). P values <0.05 were considered statistically significant. Data are shown as the mean ± standard deviation or median with interquartile range.


ResultsOther Section

During the investigation period, a total of 41,592 patients were registered in the JDRS. Among them, there were 273 cases of AGI. The all 273 cases were evacuated by the DH from the predesignated rendezvous point near the scene. After excluding 38 cases with unknown outcomes after one month, the remaining 235 cases were treated as subjects.

The background of the subjects is shown in Table 1. Males were dominant. The fatality ratio within one month was 10.6%.

Table 1

Background of subjects (n=235)

Variable Values
Age (years), mean ± SD 70.3±15.3
Male/female, n 160/75
Keywords, n (%) 90 (38.3)
Medical interventions provided by emergency medical technicians, n (%)
   Infusion 43 (18.3)
   Transfusion 0 (0.0)
   Tracheal intubation 1 (0.4)
   Administration of adrenaline 2 (0.9)
Medical interventions provided by doctor helicopter staffs, n (%)
   Infusion 220 (93.6)
   Transfusion 4 (1.7)
   Tracheal intubation 19 (8.1)
   Administration of vasopressor 15 (6.4)
   Adrenaline 2 (0.9)
Final outcome in month, n (%)
   Good 192 (81.7)
   Survival 210 (89.3)
Duration (minutes), mean ± SD
   From the first call to the EMTs’ contact 4.9±76.0
   From the EMTs’ contact to the DH staff’s contact 35.2±67.6
   From the DH staff’s contact to arrival at the receiving hospital 27.7±11.2

SD, standard deviation; EMTs, emergency medical technicians; DH, doctor helicopter.

Table 2 describes the changes in vital signs between the EMT contact, DH staff contact, and at the hospital. There were no significant trends in heart rate and GCS. While, systolic blood pressure had a significantly increased trend, and respiratory rate and shock index had a significantly decreased trend.

Table 2

Changes in vital signs at the EMTs’ contact, the DH staff contact and hospital (n=235)

Vital signs The EMT The DH staff At hospital P value
Respiratory rate (breaths per minute), mean ± SD 22.5±6.7 21±8 20.1±6.4 0.001
Heart rate (beats per minute), mean ± SD 93.9±27.2 92.1±27 90±27.5 0.28
Systolic blood pressure (mmHg), mean ± SD 100.5±32.3 107.6±32.6 114.5±31.3 <0.001
Shock index, mean ± SD 1.01±0.39 0.93±0.37 0.84±0.30 <0.001
Glasgow Coma Scale, median (interquartile range) 15 (14, 15) 15 (13, 15) 15 (13, 15) 0.73

EMTs, emergency medical technicians; DH, doctor helicopter; SD, standard deviation.

Table 3 describes number of cardiac arrests between the EMTs’ contact and the DH staff contact. There were six cardiac arrests at the EMT contact and 2 (33.3%) of them obtained spontaneous circulation at the hospital. While among 229 non-cardiac arrest at the EMT contact, 5 subjects (2.2%) became cardiac arrest at the hospital.

Table 3

Number of cardiac arrests between the EMTs’ contact and the DH staff’s contact

Cardiac arrest EMT In total P value
Yes No
DH staff <0.001
   Yes 4 5 9
   No 2 224 226
In total 6 229 235

EMTs, emergency medical technicians; DH, doctor helicopter.

Table 4 describes number of cardiac arrests between the DH staff contact and arrival at the receiving hospitals. There were 11 cardiac arrests at the DH staff contact and 5 (45.5%) of them obtained spontaneous circulation at the hospital. While among 224 non-cardiac arrest at the DH staff contact, 3 subjects (1.3%) became cardiac arrest at the hospital after transportation. These differences were significant (P<0.001).

Table 4

Number of cardiac arrests between the DH staff’s contact and arrival at the receiving hospitals

Cardiac arrest DH staff In total P value
Yes No
At hospital <0.001
   Yes 6 3 9
   No 5 221 226
In total 11 224 235

DH, doctor helicopter.


DiscussionOther Section

This is the first report to describe the current status analysis of the transportation of AGI bleeding cases evacuated by the DH in Japan. In summary, the present study showed that males were dominant, unstable vital signs improved after air evacuation, 45.5% obtained return of spontaneous circulation from cardiac arrest, but 1.3% newly went into cardiac arrest after the DH staff contacted the patients, and the final fatality ratio was 10.6%. Accordingly, the patients with AGI evacuated by the DH from the scene might contribute to the improvement of the patients’ vital signs.

In this study, it was revealed that vital signs improved by the EMTs were further enhanced by the DH staff. In Japan, the EMTs can secure peripheral intravenous access only when there is a possibility of cardiac arrest or transitioning to cardiac arrest (15). Apart from adrenaline administration for cardiac arrest, other drug administrations are not permitted (15). Therefore, the rate of intravenous access by the EMTs is lower compared to the DH. On the other hand, the EMTs can elevate blood pressure through shock positioning, primarily using this technique to improve vital signs. Conversely, the DH staffs can achieve further improvement in vital signs for shock patients because they can secure both peripheral and central venous access, leading to a higher frequency of fluid administration compared to the EMTs. Additionally, the DH staffs were more experienced in handling AGI bleeding than the EMTs (16). Furthermore, although less frequent, the ability to administer blood transfusions, hemostatic agents, and vasopressors also likely contributed to the improvement in vital signs. Moreover, the higher rate of endotracheal intubation during cardiopulmonary arrest (CPA) by the experienced staff of the DH, compared to the EMTs, is presumed to have contributed to the difference in cardiac arrest recovery rates (17-19). It could be criticized that the difference is of little clinical relevance, e.g., the difference in systolic blood pressure of 7 mmHg, a slight increase in blood pressure as a physiological response to the noisy, vibrating helicopter environment, because the stress of emergency transport could release catecholamines, resulting in an increase in blood pressure, heart rate and respiratory rate. However, the most sensitive data in response to catecholamine was respiratory rate (20). This study showed a decreasing trend in respiratory rate and no significant change in heart rate during air evacuation. Accordingly, the effect of the stress response on vital signs may have been minimized in this study. In addition, even though a mean difference of 7 mmHg in systolic blood pressure was small, the increased trend in blood pressure and the increase in spontaneous circulation were clinically important.

Despite being transported by the DH, three cases experienced new cardiac arrest. Firstly, a key issue with the DH response lies in the inability to directly manage bleeding sites through procedures such as intra-helicopter endoscopy, arterial embolization, or surgical interventions (13,21,22). Therefore, early transfer to a facility capable of definitive treatment is crucial for achieving hemostasis (13). Additionally, the low transfusion rate is problematic in comparison to other countries (23-26). For patients with ongoing hemorrhage, simple intravenous access and fluid administration alone may worsen outcomes (27). It is considered necessary to improve pre-hospital transfusion rates, focusing on early transfusion as a primary intervention for patients suspected of hemorrhagic shock due to AGI bleeding. While this may be true for massive crystalloid transfusion in a tertiary setting, in an austere pre-hospital setting with a mean time from DH contact to arrival at base hospital of 27.7 minutes in this study, crystalloid administration is indicated and necessary for patients with ongoing bleeding and should not be withheld for fear of worsening outcomes/dilutional coagulopathy, especially given such rapid transfer to tertiary hospital (28,29). Early transfusion would be beneficial, but we must remember that in a limited and austere in-flight environment, the priority would be on early stabilization and early transfer. Establishing transfusion in-flight may be secondary to other pressing clinical considerations that may arise during transfer. The first line of resuscitation will always be crystalloid resuscitation.

Several limitations associated with the present study warrant mention. It is unclear from where AGI bleeding (upper, lower, variceal vs. non-variceal) originates. Specific drug names used by DH staff are unknown, and treatment details at receiving facilities are also unclear due to undisclosed facility names, making further investigation difficult. There is no comparison with cases transported by ground, and cost evaluation of helicopter transport has not been conducted. Because there was no nationwide clinical database in Japan for patients with AGI transported by ground ambulance. Therefore, future prospective studies should aim to address these issues.


ConclusionsOther Section

This report describes the current status analysis of AGI bleeding cases transported by the DH in Japan. Following air evacuation, unstable vital signs improved, and approximately half of the patients achieved return of spontaneous circulation from cardiac arrest.


AcknowledgmentsOther Section

Funding: This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from The Promotion and Mutual Aid Corporation for Private Schools of Japan.


FootnoteOther Section

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-105/rc

Data Sharing Statement: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-105/dss

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-105/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-105/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by Juntendo Shizuoka Hospital review board (approval No. 733) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


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doi: 10.21037/jeccm-24-105
Cite this article as: Yanagawa Y, Sakai T, Tanaka N, Maekawa C, Hirooka Y, Kawai K, Hamada M, Ota S, Taniguchi H, Ohsaka H, Nagasawa H, Ishihara T, Omori K. Current status of patients with gastrointestinal bleeding transported by physician-staffed helicopter in Japan. J Emerg Crit Care Med 2025;9:2.

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