Helicopter emergency medical services in sudden-onset major incidents: Patterns of use


Keywords: helicopter emergency medical services, HEMS


Major incidents happen infrequently and challenge the health care system by demanding more resources than are readily available. Critically injured patients need rapid treatment and swift transport to the right hospital to prevent unnecessary death and disability.

Helicopter emergency medical services (HEMS) are incorporated into emergency medical systems in Norway and other countries around the world. Anecdotally, HEMS have become integrated in the immediate management of sudden-onset major incidents and case reports depict that helicopters may play a key operational role. Although the amount of research on benefits and challenges of HEMS is rapidly growing, the optimal use in major incidents remains unanswered.

The main aim of this thesis is to explore the use of HEMS in sudden- onset major incidents in a systematic way from different angles. The thesis focus on optimizing HEMS role in sudden-onset major incident management by sharing experiences for policy makers to improve major incident preparedness. This is done through four studies, a systematic review, a cross-sectional study, a Delphi study and a retrospective observational study.

With these studies, we found that previous research published on HEMS role in sudden-onset major incident management are mainly case reports and that little systematic research has been done. In the cross-sectional study and the retrospective observational studies, we found that HEMS participation in sudden-onset major incidents are rare in Norway. The cross-sectional study showed that HEMS personnel were experienced but only a little more than half of the crew members had attended a major incident within the previous five years. Further, the retrospective observational study showed that in a major incident, HEMS treat more patients on-scene than they transport to definite care. In this complex environment, the participation of multiple emergency services that not necessarily cooperate on a daily basis makes communication and coordination (including with HEMS) challenging. These challenges deserve focus in major incident training and planning.

To provide a better knowledge base for future research, data collection from major incidents and major incident exercises should be done systematically. The template developed in the Delphi study would enable other clinicians and researchers to submit structured open access reports, to share lessons learnt, collate data and compare major incident responses.

The lack of a universally accepted definition of major incidents and removal of barriers in recruiting reports to the template remain important areas for future research. To enhance the knowledge on HEMS in major incidents, it remains pivotal that the pre-hospital environment acknowledges and address these challenges.

Author Biography

Anne Siri Johnsen

University of Stavanger, Faculty of Health Sciences
Norsk Luftambulanse


1. Luftambulansetjenesten. Våre baser. [Available from: http://luftambulanse.no/våre-baser.] Accessed 24.04.21.

2. Sollid S, Rehn M, Nakstad AR, Tomlinson AE, Strand T, Heimdal HJ, et al for Collaborating group. Oslo government district bombing and Utøya island shooting July 22, 2011: The immediate prehospital emergency medical service response. Scand J Trauma Resusc Emerg Med. 2012;20:3.

3. Rommundstad L, Sundnes KO, Pillgram-Larsen J, Røste GK, Gilbert M. Challenges of Major Incident Management When Excess Resources are Allocated: Experiences from a Mass Casualty Incident after Roof Collapse of a Military Command Center. Prehosp Disaster Med. 2004;19:179-84.

4. Brandstrøm H Sedig K, Lundalv J. Socialstyrelsen. Kamedo 77. MS Sleipners förlisning. 2003. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/2003-123-7_20031238.pdf] Accessed 24.04.21.

5. Thomas SH, Harrison T, Wedel SK, Thomas DP. Helicopter emergency medical services roles in disaster operations. Prehosp Emerg Care. 2000;4:338-44.

6. Shah MN. The formation of the emergency medical services system. Am J Public health. 2006;96:414-23.

7. Munro D. The Use of the Aeroplane in the Medical Services in War. Proc R Soc Med. 1924;17:7-12.

8. Meier DR, Samper ER. Evolution of Civil Aeromedical Helicopter Aviation. South Med J. 1989;82:885-91.

9. Landreau F, Valcarcel O, Noir J, Pernia G, Orzabal ML, Martinez S, et al. Helicopter Emergency Medical Services in Buenos Aires: An Operational Overview. Air Med J. 2018;37:367-70.

10. Tase C, Ohno Y, Hasegawa A, Tsukada Y, Shimada J, Ikegami Y. Helicopter Emergency Medical Services (Doctor-Helicopter) in Fukushima Prefecture: Present State and Problems. Fukushima J Med Sci. 2010;56:71-9.

11. Kruger AJ, Skogvoll E, Castren M, Kurola J, Lossius HM, ScanDoc Phase 1a Study G. Scandinavian pre-hospital physician-manned Emergency Medical Services--same concept across borders? Resuscitation. 2010;81:427-33.

12. Jones A, Donald MJ, Jansen JO. Evaluation of the provision of helicopter emergency medical services in Europe. Emerg Med J. 2018;35:720-5.

13. Rasmussen K, Roislien J, Sollid SJM. Does Medical Staffing Influence Perceived Safety? An International Survey on Medical Crew Models in Helicopter Emergency Medical Services. Air Med J. 2018;37:29-36.

14. Thomas SH, Blumen I. Helicopter Emergency Medical Services Literature 2014 to 2016: Lessons and Perspectives, Part 1- Helicopter Transport for Trauma. Air Med J. 2018;37:54-63.

15. Thomas SH, Blumen I. Helicopter Emergency Medical Services Literature 2014 to 2016: Lessons and Perspectives, Part 2- Nontrauma Transports and General Issues. Air Med J. 2018;37:126-30.

16. Spoelder EJ, Tacken MCT, van Geffen G-J, Slagt C. Helicopter transport of critical care COVID-19 patients in the Netherlands: protection against COVID-19 exposure-a challenge to critical care retrieval personnel in a novel operation. Scand J Trauma Resusc Emerg Med. 2021;29:41.

17. Zakariassen E, Osteras O, Nystoyl DS, Breidablik HJ, Solheim E, Brattebo G, et al. Loss of life years due to unavailable helicopter emergency medical service: a single base study from a rural area of Norway. Scand J Prim Health Care. 2019;37:233- 41.

18. Norwegian ministry of foreign affairs. Minifacts about Norway 2015 [Available from: https://www.ssb.no/en/befolkning/artikler-og- publikasjoner/_attachment/225814?_ts=14d005aeb20.] Accessed 24.04.21.

19. Statistics Norway. Key Figures of the population. [Available from: https://www.ssb.no/en/befolkning/nokkeltall/population.] Accessed 24.04.21.

20. Luftambulansetjenesten. About the National Air Ambulance Services of Norway [Available from: http://luftambulanse.no/about-national-air-ambulance-services- norway.] Accessed 24.04.21.

21. Helse og omsorgsdepartementet. NOU 2015:17 Først og fremst - Et helhetlig system for håndtering av akutte sykdommer og skader utenfor sykehus. [Available from: https://www.regjeringen.no/no/dokumenter/nou-2015- 17/id2465765/] Accessed 24.04.21.

22. Luftambulansetjenesten. Raske fakta om luftambulansetjenesten. [Available from: http://luftambulanse.no/raske-fakta-om-luftambulansetjenesten.] Accessed 24.04.21.

23. Forsvaret. Luftforsvaret. [Available from: https://www.forsvaret.no/aktuelt-og-presse/aktuelt/norges-nye- redningshelikopter.] Accessed 24.04.21.

24. Reid BO, Haugland H, Rehn M, Uleberg O, Kruger AJ. Search and Rescue and Remote Medical Evacuation in a Norwegian Setting: Comparison of Two Systems. Wilderness Environ Med. 2019;30:155-62.

25. Hovedredningssentralen. Håndbok for redningstjenesten. [Available from: https://www.hovedredningssentralen.no/redningshandboken-er- endelig-her/] Accessed 24.04.21.

26. Luftambulansetjenesten. Prosedyre for varsling og kommunikasjon mellom AMK-LA og luftambulansetjenesten. [Available from: https://www.helsedirektoratet.no/veiledere/nodnett-i- helsetjenesten/vedlegg/prosedyre-for-varsling-og- kommunikasjon-mellom-amk-og-la-tjenesten] Accessed 24.04.21.

27. Glomseth R, Gulbrandsen FI, Fredriksen K. Ambulance helicopter contribution to search and rescue in North Norway. Scand J Trauma Resusc Emerg Med. 2016;24:109.

28. Johnsen AS, Sollid SJ, Vigerust T, Jystad M, Rehn M. Helicopter emergency medical services in major incident management: A national Norwegian cross-sectional survey. PLoS One. 2017;12:e0171436.

29. Det kongelige sosial- og helsedepartement. St.mld. 43 Om akuttmedisinsk beredskap. [Available from: https://www.regjeringen.no/contentassets/6d416043caa545e1ac e76fef809637f8/no/pdfa/stm199920000043000dddpdfa.pdf] Accessed 24.04.21.

30. Zakariassen E, Uleberg O, Roislien J. Helicopter emergency medical services response times in Norway: do they matter? Air Med J. 2015;34:98-103.

31. Nystoyl DS, Hunskaar S, Breidablik HJ, Osteras O, Zakariassen E. Treatment, transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study. Scand J Prim Health Care. 2018;36:397- 405.

32. Fattah S, Rehn M, Lockey D, Thompson J, Lossius HM, Wisborg T, et al. A consensus based template for reporting of pre-hospital major incident medical management. Scand J Trauma Resusc Emerg Med. 2014;22:5.

33. Major Incident Medical Management and Support. 3. ed. West Sussex, UK: Wiley-Blackwell. 2012.

34. Lennquist S. Medical response to major incidents and disasters. Berlin Heidelberg: Springer; 2012.

35. Jersin E. SINTEF rapport. Storulykker i Norge 1970 - 2001. 2003. [Available from: https://www.sintef.no/globalassets/upload/teknologi_og_samfun n/sikkerhet-og-palitelighet/rapporter/stf38-a02405.pdf] Accessed 24.04.21.

36. Valutakalkulator. [Available from: https://www.valutakalkulator.net/index.html.] Accessed 24.04.21.

37. Smarte Penger. Inflasjonsberegning. [Available from: https://www.smartepenger.no/kalkulatorer/939- inflasjonskalkulator.] Accessed 24.04.21.

38. Danish Emergency Management Agency. Crisis Management in Denmark. 2021. [Available from [Available from: https://brs.dk/globalassets/brs--- beredskabsstyrelsen/dokumenter/krisestyring-og- beredskabsplanlagning/2021/-crisis-management-in-denmark-.pdf] Accessed 24.04.21.

39. Socialstyrelsen. Socialstyrelsens termbank. [Available from: https://termbank.socialstyrelsen.se/#results.] Accessed 24.04.21.

40. Helsedirektoratet. Nasjonal veileder for helsetjenestens organisering på skadested. 2016. [Available from: https://www.helsedirektoratet.no/veiledere/helsetjenestens- organisering-pa-skadested] Accessed 24.04.21.

41. CRED. EM-DAT The international Disaster database. [Available from: https://www.emdat.be.] Accessed 24.04.21.

42. The International Federation of Red Cross and Red Crescent Societies. What is a disaster? [Available from: https://www.ifrc.org/en/what-we-do/disaster- management/about-disasters/what-is-a-disaster/.] Accessed 24.04.21

43. United Nations Office for Disaster Risk Reduction. Disaster terminology. [Available from: https://www.undrr.org/terminology/disaster.] Accessed 24.04.21

44. DECISION No 1313/2013/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 17 December 2013 on a Union Civil Protection Mechanism. Official Journal of the European Union. [Available from: https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=CELEX:32013D1313&from=EN.] Accessed 24.04.21.

45. Calder A, Bland S. Chemical, biological, radiological and nuclear considerations in a major incident. Surgery. 2015;33:442-8.

46. CRED. [Available from: https://www.cred.be.] Accessed 25.04.21.

47. Pallardy R. 2010 Haiti Earthquake. Encyclopaedia Britannica. [Available from: https://www.britannica.com/event/2010-Haiti- earthquake.] Accessed 24.04.21.

48. Gupta AK, Tyagi P, Sehgal VP. Drought disaster challenges and mitigation in India: strategic appraisal. Curr Sci. 2011;100:1795-806.

49. CRED. Technological disasters. Cred Crunch. 2020(60).

50. CRED, UNDRR. Human cost of disasters. An overview of the last 20 years. 2000-2019. 2020. [Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/Human% 20Cost%20of%20Disasters%202000-2019%20Report%20-%20UN%20Office%20for%20Disaster%20Risk%20Reduction. pdf] Accessed 24.04.21.

51. Ministry of Petroleum and Energy. Gjerdrum-utvalget. [Available from: https://nettsteder.regjeringen.no/gjerdrumutvalget/] Accessed 24.04.21.

52. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health response. Am J Public Health. 2008;98:435-45.

53. Hunt P, Greaves I. Oxford manual of major incident management. 1. ed. Oxford, UK, Oxford university press: 2017.

54. Lechat MF. The epidemiology of disasters. Proc roy Soc Med. 1976;69:1-6.

55. PreventionWeb. International Decade for Natural Disaster reduction. [Available from: https://www.preventionweb.net/organizations/2672.] Accessed 24.04.21.

56. Centers for Disease Control and Prevention. Disaster Epidemiology. [Available from: https://www.cdc.gov/nceh/hsb/disaster/epidemiology.htm] Accessed 24.04.21.

57. Malilay J, Heumann M, Perrotta D, Wolkin AF, Schnall AH, Podgornik MN, et al. The Role of Applied Epidemiology Methods in the Disaster Management Cycle. Am J Public Health. 2014;104:2092-102.

58. Wisner B, Adams J, editors. Environmental Health in Emergencies and Disasters: A Practical Guide. Geneva, Switzerland: World Health Organization; 2002.

59. Safety Investigation Authority Finland. [Available from: https://turvallisuustutkinta.fi/en/index.html.] Accessed 25.04.21.

60. Embætti landlæknis, Sóttvarnalæknir, Sóttvarnalæknir Rikislögreglustjórinn, almannavarnadeild, Landspítali. Heilbrigðisþjónustan og almannavarnir - Handbók 2 ed 2017.

61. CRED. Disaster year in review 2019. Cred Crunch. 2020(58).

62. Xu D, Luo P, Li S, Pfeifer R, Hildebrand F, Pape HC. Current Status of helicopter emergency medical services in China: A bibliometric analysis. Medicine. 2019;98:e14439.

63. Guha-Sapir D. EM-DAT, CRED / UCLouvain, Brussels, Belgium. [Available from: public.emdat.be] Accessed 25.04.21.

64. Schenk E, Wijetunge G, Mann NC, Lerner EB, Longthorne A, Dawson D. Epidemiology of mass casualty incidents in the United States. Prehosp Emerg Care. 2014;18:408-16.

65. Kuisma M, Hiltunen T, Maatta T, Puolakka J, Boyd J, Nousila- Wiik M, et al. Analysis of multiple casualty incidents - a prospective cohort study. Acta Anaesthesiol Scand. 2005;49:1527-33.

66. WHO. World report on road traffic injury prevention. 2004. [Available from:https://www.who.int/publications/i/item/world- report-on-road-traffic-injury-prevention] Accessed 25.04.21.

67. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223.

68. WHO. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2016. [Available from: https://www.who.int/news-room/fact-sheets/detail/the-top-10- causes-of-death#.WxENceAghy4.email.] Accessed 25.04.21.

69. Brandsjø K, Haggmark T, Kulling P, Lorin H, Lundin T, Skjoldebrand A. Socialstyrelsen SoS-rapport 1997:15 Estoniakatastrofen. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/1997-3-15.pdf] Accessed 25.04.21.

70. Almersjø O, Ask E, Brandsjo K, Brokopp T, Hedelin A, Jaldung H, et al. Socialstyrelsen. SoS-rapport 1993:3. Branden på passagerarfärjan Scandinavian Star den 7 april 1990. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/1993-03-3.pdf] Accessed 25.04.21.

71. Bryne H, Lorin H. Katastrofmedicinska studier i Nordsjøn. Förlisningen av bostadsplattformen Alexander L. Kielland den 27 Mars 1980. (KAMEDO) Rapport XLIV 1981.

72. Lorin H. Socialstyrelsen SoS-rapport 1999:4. Katastrofmedicinska studier under 35 år. Erfarenheter från KAMEDOs verksamhet 1963-1998. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/1999-3-4_1999034.pdf] Accessed 25.04.21.

73. NRK. Ble møtt av en øredøvende stillhet 2011. [Available from: https://www.nrk.no/tromsogfinnmark/15-ar-siden- operafjellulykken-1.7768645.] Accessed 25.04.21.

74. The aircraft accident investigation board/Norway (AAIB/N). Rep.:07/99. Report on the accident to Vnukovo airline's Tupolev TU-154M RA 85621 near Svalbard airport Longyear, Norway on 29 August 1996. 1999. [Available from: https://reports.aviation-safety.net/1996/19960829-0_T154_RA- 85621.pdf] Accessed 25.04.21.

75. Lockey DJ, Mackenzie R, Redhead J, Wise D, Harris T, Weaver A, et al. London bombings July 2005: the immediate pre- hospital medical response. Resuscitation. 2005;66:ix-xii.

76. López Carresi A. The 2004 Madrid train bombings: an analysis of pre-hospital management. Disasters. 2008;32:41-65.

77. Raux M, Carli P, Lapostolle F, Langlois M, Yordanov Y, Anne- Laure F-P, et al. Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury. Intensive Care Med. 2019;45:1231-40.

78. NOU. 2012:14. Rapport fra 22. juli-kommisjonen. [Available from: https://www.regjeringen.no/contentassets/bb3dc76229c64735b4 f6eb4dbfcdbfe8/no/pdfs/nou201220120014000dddpdfs.pdf] Accessed 25.04.21.

79. Helsedirektoratet, DSB, Politiet. Nasjonal prosedyre. Nødetatenes samvirke ved pågående livstruende vold. PLIVO. 2019;4.0.

80. DSB. Analyser av krisescenarioer 2019. [Available from: https://www.dsb.no/globalassets/dokumenter/rapporter/p180877 9_aks_2018.cleaned.pdf.] Accessed 25.04.21.

81. Buck DA, Trainor JE, Aguirre BE. A Critical Evaluation of the Incident Command System and NIMS. J Homel Secur Emerg Manag. 2006;3.

82. Rimstad R, Braut GS. Literature review on medical incident command. Prehosp Disaster Med. 2015;30:205-15.

83. Tsai JC, Chi CSF. Cultural Influence on the Implementation of Incident Command System for Emergency Management of Natural Disasters. J Homel Secur Emerg Manag. 2012;9:29.

84. Socialstyrelsen. Inriktning och samordning inom hälso- och sjukvården vid särskild händelse. 2020. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/2020-1-6569.pdf] Accessed 25.04.21.

85. Helsedirektoratet. Nasjonal veileder for masseskadetriage. 2020. [Available from: https://www.helsedirektoratet.no/veiledere/masseskadetriage] Accessed 25.04.21

86. Nasjonal Kompetansetjeneste for traumatologi. Traumeplan 2019. [Available from: https://traumeplan.no] Accessed 25.04.21.

87. Nasjonalt kompetansesenter for NBC-medisin, Oslo Universitetssykehus. Håndbok i NBC medisin. 3 ed. 2012.

88. Thompson J, Rehn M, Sollid SJM. EHAC medical working group best practice advice on the role of air rescue and pre hospital critical care at major incidents. Scand J Trauma Resusc Emerg Med. 2018;26:65.

89. Rouhi N, Gorji HA, Maleki M. Nongovernmental organizations coordination models in natural hazards: A systematic review. J Educ Health Promot. 2019;8:44.

90. OCHA. What is the cluster approach? [Available from: https://www.humanitarianresponse.info/en/about-clusters/what- is-the-cluster-approach] Accessed 25.04.21.

91. WHO. Partners and Networks. [Available from: https://www.who.int/emergencies/partners] Accessed 25.04.21

92. T Kirsch T, Sauer L, Guha Sapir D. Analysis of the International and US Response to the Haiti Earthquake: Recommendations for Change. Disaster Med Public Health Prep. 2012;6:200-8..

93. OCHA. United Nations. [Available from: https://www.unocha.org.] Accessed 25.04.21

94. North Atlantic Treaty Organization. Euro-Atlantic Disaster Response Coordination Centre 2020. [Available from: https://www.nato.int/cps/en/natohq/topics_52057.htm?] Accessed 25.04.21

95. Khorram-Manesh A, Lönroth H, Rotter P, Wilhelmsson M, Aremyr J, Berner A, et al. Non-medical aspects of civilian- military collaboration in management of major incidents. Eur J Trauma Emerg Surg. 2017;43:595-603.

96. European Civil Protection and Humanitarian Aid Operations. EU civil protection mechanism. [Available from: https://ec.europa.eu/echo/what/civil-protection/mechanism_en.] Accessed 25.04.21

97. European Civil Protection and Humanitarian Aid Operations. The largest EU civil protection operation helps Sweden fight forest fires 2018. [Available from: https://ec.europa.eu/echo/news/largest-eu-civil-protection- operation-helps-sweden-fight-forest-fires_en. ] Accessed 25.04.21

98. Beredskapsstyrelsen. Retningslinjer forindsatsledelse. 2018. [Available from: https://brs.dk/globalassets/brs--- beredskabsstyrelsen/dokumenter/indsats---retningslinjer- o.l/2020/-retningslinjer-for-indsatsledelse-2018-.pdf] Accessed 25.04.21

99. Stockholm läns landsting, Enhet för katastrofmedicinsk beredskap. Regional katastrofmedicinsk beredskapsplan för Stockholm läns landsting. [Available from: https://www.sll.se/globalassets/6.-om-landstinget/styrande- dokument/2-verksamhetsstod/sakerhet-och-beredskap- informationssakerhet/regional-katastrofmedicinsk- beredskapsplan2.pdf] Accessed 25.04.21

100. Socialstyrelsen. Kapaciteten i sjukvården - att hantera kritiska lägen. 2018. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/2018-12-1.pdf] Accessed 25.04.21

101. Helsedirektoratet. Nødnett i helsetjenesten. 2018. [Available from: https://www.helsedirektoratet.no/veiledere/nodnett-i- helsetjenesten] Accessed 25.04.21.

102. Urquieta E, Varon J. Mexico City's Petroleos Mexicanos explosion: disaster management and air medical transport. Air Med J. 2014;33:309-13.

103. Henninger S, Thompson J, Newman R. Defense Technical Information Centre. Rotorcraft Use in Disaster Relief and Research and Development Service Mass Casualty Incidents - Case Studies. 1990. [Available from: https://apps.dtic.mil/sti/pdfs/ADA229569.pdf] Accessed 25.04.21.

104. Federal Aviation Administration. Advisory Circular 00-59. Integrating Helicopter and Tiltrotor Assets Into Disaster Relief Planning. 1998. [Available from: https://www.faa.gov/documentLibrary/media/Advisory_Circula r/AC_00-59.pdf] Accessed 25.04.21.

105. Stohler SA, Jacobs LM, Gabram SG. Roles of a helicopter emergency medical service in mass casualty incidents. J Air Med Transp. 1991;10:7-13.

106. Buerk CA, Batdorf JW, Cammack KV, Ravenholt O. The MGM Grand Hotel Fire. Arch Surg. 1982;117:641-4.

107. Robinson BR, Johnson D. For Emergency Medical Service Helicopter Pilots, All Wind Is Local. Air Med J.28:232-6.

108. Butler B. Helicopter Emergency Medical Services and Weather- Related Accidents. Air Med J. 2014;33:84-5.

109. Spano SJ, Campagne D, Stroh G, Shalit M. A Lightning Multiple Casualty Incident in Sequoia and Kings Canyon National Parks. Wilderness Environ Med. 2015;25:43-53.

110. Fenn J, Rega P, Stavros M, Buderer NF. Assessment of U.S. Helicopter Emergency Medical Services' Planning and Preparedness for Disaster Response. Air Med J. 1999;18:12-15.

111. PreventionWeb. Resilience. [Available from: https://www.preventionweb.net/risk/resilience. ] Accessed 25.04.21.

112. UNDRR. What is the Sendai Framework for Disaster Risk Reduction? [Available from: https://www.undrr.org/implementing-sendai-framework/what- sendai-framework] Accessed 25.04.21

113. WHO. Definition: emergencies. [Available from: https://www.who.int/hac/about/definitions/en/] Accessed 25.04.21.

114. Wulff K, Donato D, Lurie N. What is health resilience and how can we build it? Annu Rev Public Health. 2015;36:361-74.

115. Matheson J, Hawley A. Making sense of disaster medicine. London, UK, Hodder Arnold Publishers Ltd: 2010.

116. Vlok N, van der Berg J. Helicopter Emergency Medical Services Response to a Major Incident. Air Med J. 2020;39:506- 8.

117. Thomas SH, Arthur AO. Helicopter EMS: Research Endpoints and Potential Benefits. Emerg Med Int. 2012;2012:698562.

118. Thomas SH, Cheema F, Wedel SK, Thomson D. Trauma helicopter emergency medical services transport: Annotated review of seleted outcomes-related literature. Prehosp Emerg Care. 2002;6:359-71.

119. Risgaard B, Draegert C, Baekgaard JS, Steinmetz J, Rasmussen LS. Impact of Physician-staffed Helicopters on Pre-hospital Patient Outcomes: A systematic review. Acta Anaesthesiol Scand. 2020;64:691-704.

120. Galvagno Jr SM, Sikorski R, Hirshon JM, Floccare D, Stephens C, Beecher D, et al. Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev. 2015:CD009228.

121. Thomas SH, Thomas SW, Thomas SA, Pathan S. Helicopter Emergency Medical Services Literature 1972-2017: Characteristics and Trends. Air Med J. 2019;38:115-24.

122. Timbie JW, Ringel JS, Fox DS, Pillemer F, Waxman DA, Moore M, et al. Systematic review of strategies to manage and allocate scarce resources during mass casualty events. Ann Emerg Med. 2013;61:677-89 e101.

123. Kim CH, Park JO, Park CB, Kim SC, Kim SJ, Hong KJ. Scientific framework for research on disaster and mass casualty incident in Korea: building consensus using Delphi method. J Korean Med Sci. 2014;29:122-8.

124. Kayano R, Chan EY, Murray V, Abrahams J, Barber SL. WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network (TPRN): Report of the Kobe Expert Meeting. Int J Environ Res Public Health. 2019;16:1232.

125. Noji EK. Disasters: Introduction and State of the Art. Epidemiol Rev. 2005;27:3-8.

126. Dominici F, Levy JI, Louis TA. Methodological Challenges and Contributions in Disaster Epidemiology. Epidemiol Rev. 2005;27:9-12.

127. Taylor CB, Stevenson M, Jan S, Middleton PM, Fitzharris M, Myburgh JA. A systematic review of the costs and benefits of helicopter emergency medical services. Injury. 2010;41:10-20.

128. Fattah S. Systematic reporting of pre-hospital major incident medical management - identifying needs, a suggested solution and assessing implementation. UiT Munin: Tromsø; 2017.

129. Hardy S, Fattah S, Wisborg T, Raatiniemi L, Staff T, Rehn M. Systematic reporting to improve the emergency medical response to major incidents: a pilot study. BMC Emerg Med. 2018;18:4.

130. Englund L. Sjukvård och medier i samspel vid allvarlig händelse: Erfarenheter från KAMEDO-rapporter under 20 år. Kunskapscentrum för katastrofpsykiatri, Uppsala universitet: Uppsala, Sverige.; 2018.

131. Leiba A, Schwartz D, Eran T, Blumenfeld A, Laor D, Goldberg A, et al. DISAST-CIR: Disastrous incidents systematic analysis through components, interactions and results: application to a large-scale train accident. J Emerg Med. 2009;37:46-50.

132. Turris S, Rabb H, Chasmar E, Munn MB, Callaghan CW, Hutton A, et al. Measuring the Masses: A Proposed Template for Post-Event Medical Reporting (Paper 4). Prehos Disaster Med. 2021;36:218-26.

133. Equator network. Enhancing the QUAlity and Transparency Of health Research [Available from: https://www.equator- network.org.] Accessed 25.04.21

134. Simera I, Altman DG, Moher D, Schulz KF, Hoey J. Guidelines for reporting health research: the EQUATOR network's survey of guideline authors. PLoS Med. 2008;5:e139.

135. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLOS Med. 2009;6:e1000100.

136. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.0. Cochrane, 2019.

137. Elm Ev, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806.

138. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32:1008-15.

139. Johnsen AS, Fattah S, Sollid SJM, Rehn M. Impact of helicopter emergency medical services in major incidents: systematic literature review. BMJ open. 2013;3:e003335-e.

140. Setia MS. Methodology Series Module 1: Cohort Studies. Indian J Dermatol. 2016;61:21-5.

141. Levin K. Study design III: Cross-sectional studies Evid Based Dent. 2006:24-5.

142. Kesmodel US. Cross-sectional studies - what are they good for? Acta Obstet Gynecol Scand. 2018;97:388-93.

143. Williams PL, Webb C. The Delphi technique: a methodological discussion. J Adv Nurs. 1994;19:180-6.

144. Jick TD. Mixing Qualitative and Quantitative Methods: Triangulation in Action. Adm Sci Q. 1979;24:602-11.

145. Denzin. The research act. 2. ed. New York: McGraw-Hill; 1978.

146. EUPHOREA. [Available from: http://www.euphorea.net.] Accessed 25.04.21.

147. J Jamieson S. Likert scale. Encyclopaedia Britannica. [Available from: https://www.britannica.com/topic/Likert- Scale.] Accessed 25.04.21.

148. Raatiniemi L, Mikkelsen K, Fredriksen K, Wisborg T. Do pre- hospital anaesthesiologists reliably predict mortality using the NACA severity score? A retrospective cohort study. Acta Anaesthesiol Scand. 2013;57:1253-9.

149. McDonald J. Handbook of Biological statistics. 3.ed ed. Baltimore, Maryland: Sparky House Publishing; 2014.

150. World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310:2191-4.

151. Mezinska S, Kakuk P, Mijaljica G, Waligora M, O'Mathuna DP. Research in disaster settings: a systematic qualitative review of ethical guidelines. BMC Med Ethics. 2016;17:62.

152. Johnsen AS, Fattah S, Sollid SJ, Rehn M. Utilisation of helicopter emergency medical services in the early medical response to major incidents: a systematic literature review. BMJ Open. 2016;6:e010307.

153. Lavon O, Hershko D, Barenboim E. Large-Scale Airmedical Transport from a Peripheral Hospital to Level-1 Trauma Centers after Remote Mass-Casualty Incidents in Israel. Prehosp Disaster Med. 2009;24:549-55.

154. Malik ZU, Pervez M, Safdar A, Masood T, Tariq M. Triage and management of mass casualties in a train accident. J Coll Physicians Surg Pak. 2004;14:108-11.

155. Nia MS, Nafissi N, Moharamzad Y. Survey of Bam Earthquake Survivirs' Opinions on Medicaland Health Systems Services. Prehosp Disaster Med. 2008;23:263-8.

156. Nicholas RA Oberheide JE. EMS Response to a Ski Lift Disaster in the Colorado Mountains. J Trauma. 1988;28:672-5.

157. Nocera A, Dalton M. Disaster alert! The role of physician- staffed emergency medical services. Med J Aust. 1994;161:689- 92.

158. Bovender Jr JO, Carey B. A week we don't want to forget: lessons learned from Tulane. Front Health Serv Manage. 2006;23:3-12, 25-30.

159. Martchenke J, Lynch T, Pointer J, Ropoker N. Aeromedical Helicopter Use Following the 1989 Loma Prieta Earthquake. Aviat Space Environ Med. 1995:359-63.

160. Franklin JA, Wiese W, Meredith JT, Lalikos JF, Dolezal JM, Brigham D, et.al. Hurricane Floyd. Response of the Pitt County Medical Community. N C Med J. 2000;61:384-9.

161. Nates JL. Combined external and internal hospital disaster: Impact and response in a Houston trauma center intensive care unit. Crit Care Med. 2004;32:686-90.

162. Pokorny JR. Flood Disaster in the Czech Republic in July, 1997- Operations of the Emergency Medical Service. Prehosp Disaster Med. 1999;14:32-4.

163. Matsumoto H, Motomura T, Hara Y, Masuda Y, Mashiko K, Yokota H, Koido Y. Lessons Learned from the Aeromedical Disaster Relief Activities Following the Great East Japan Earthquake. Prehosp Disaster Med. 2013;28:166-9.

164. Felix Jr WR. Metropolitan aeromedical service: state of the art. J Trauma. 1976;16:873-81.

165. Yi-Szu W, Chung-Ping H, Tzu-Chieh L, Dar-Yu Y, Tain-Cheng W. Chest Injuries Transferred to Trauma Centres After the 1999 Taiwan Earthquake. Am J Emerg Med. 2000;18:825-7.

166. Cocanour CS, Allen SJ, Mazabob J, Sparks JW, Fischer CP, Romans J, et al. Lessons learned from the evacuation of an urban teaching hospital. Arch Surg. 2002;137:1141-5.

167. Cassuto J, Tarnow P. The discotheque fire in Gothenburg 1998. A tragedy among teenagers. Burns. 2003;29:405-16.

168. Ammons MA Moore EE, Pons PT, Moore FA, McCroskey BL and Cleveland HC. The Role of a Regional Trauma System in the Management of a Mass Disaster: An Analysis of the Keystone, Colorado, Chairlift Accident. J Trauma. 1988;28:1468-70.

169. Schwartz D, Bar-Dayan Y. Injury patterns in clashes between citizens and security forces during forced evacuation. Emerg Med J. 2008;25:695-8.

170. Martin TE. The Ramstein Airshow Disaster. J R Army Med Corps. 1990;136:19-26.

171. Assa A, Landau DA, Barenboim E, Goldstein L. Role of air- medical evacuation in mass-casualty incidents--a train collision experience. Prehosp Disaster Med. 2009;24:271-6.

172. Bland SA. HEMS training and the 7th July 2005: a personal perspective. J R Nav Med Serv. 2006;92:130-5.

173. Lavery GG, Horan E. Clinical review: communication and logistics in the response to the 1998 terrorist bombing in Omagh, Northern Ireland. Crit Care. 2005;9:401-8.

174. Stohler SA, Jacobs LM, Gabram SG. Roles of a helicopter emergency medical service in mass casualty incidents. J Air Med Transp. 1991;10:7-13.

175. Lyon RM, Sanders J. The Swiss bus accident on 13 March 2012: lessons for pre-hospital care. Crit Care. 2012;16:138.

176. Song JW, Chung KC. Observational studies: cohort and case- control studies. Plast Reconstr Surg. 2010;126:2234-42.

177. Lov om pasient- og brukerrettigheter §1.1. [Available from: https://lovdata.no/dokument/NL/lov/1999-07-02-63] Accessed 25.04.21.

178. Furbee PM, Coben JH, Smyth SK, Manley WG, Summers DE, Sanddal ND, et al. Realities of Rural Emergency Medical Services Disaster Preparedness. Prehosp Disaster Med. 2006;21:64-70.

179. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine. 2006;3:e442-e.

180. Delgado RC, Gómez CN, Álvarez TC, González PA. An epidemiological approach to mass casualty incidents in the Principality of Asturias (Spain). Scand J Trauma Resusc Emerg Med. 2016;24:18.

181. P ark JO, Shin SD, Song KJ, Hong KJ, Kim J. Epidemiology of Emergency Medical Services-Assessed Mass Casualty Incidents according to Causes. J Korean Med Sci. 2016;31:449-56.

182. WHO. Global Health Observatory Data. Number of road traffic deaths. [Available from: https://www.who.int/gho/road_safety/mortality/traffic_deaths_n umber/en/.] Accessed 25.04.21.

183. Rising WR, O'Daniel JA, Roberts CS. Correlating Weather and Trauma Admissions at a Level I Trauma Center. J Trauma. 2006;60:1096-100.

184. Røislien J, Søvik S, Eken T. Seasonality in trauma admissions - Are daylight and weather variables better predictors than general cyclic effects? PloS one. 2018;13:e0192568-e.

185. Kottmann A, Carron PN, Theiler L, Albrecht R, Tissi M, Pasquier M. Identification of the technical and medical requirements for HEMS avalanche rescue missions through a 15-year retrospective analysis in a HEMS in Switzerland: a necessary step for quality improvement. Scand J Trauma Resusc Emerg Med. 2018;26:54.

186. Rosser JC, Jr., Vignesh V, Terwilliger BA, Parker BC. Surgical and Medical Applications of Drones: A Comprehensive Review. JSLS. 2018;22:e2018.00018.

187. Luftambulansetjenesten. Landingsplasser. [Available from: http://www.luftambulanse.no/landingsplasser.] Accessed 25.04.21.

188. Sykehusbygg. Tilpasse nye helikopterlandingsplasser. [Available from: https://sykehusbygg.no/byggeprosjekter/nasjonale-prosjekter/tilpasse-nye-helikopterlandingsplasser.] Accessed 25.04.21.

189. Okumura T, Suzuki K, Fukuda A, Kohama A, Takasu N, Ishimatsu S, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med. 1998;5:613-7.

190. Kapucu N. Interorganizational Coordination in Dynamic Context: Networks in Emergency Response Management. Connections. 2005;26:33-48.

191. Moles TM. Emergency Medical Services Systems and HAZMAT major incidents. Resuscitation. 1999;42:103-16.

192. Thompson J, Rehn M, Lossius HM, Lockey D. Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature. Crit Care. 2014;18:521.

193. Waugh Jr WL, Streib G. Collaboration and Leadership for Effective Emergency Management. Public Adm Rev. 2006;66:131-40.

194. Khorram-Manesh A, Berlin J, Carlström E. Two Validated Ways of Improving the Ability of Decision-Making in Emergencies; Results from a Literature Review. Bull Emerg Trauma. 2016;4:186-96.

195. Stiftelsen Norsk Luftambulanse. Tverretatelig akuttmedisinsk samarbeid. [Available from: https://norskluftambulanse.no/vart- arbeid/kurs/tverretatlig-akuttmedisinsk-samarbeid-tas/] Accessed 25.04.21.

196. Rådestad M, Nilsson H, Castrén M, Svensson L, Rüter A, Gryth D. Combining performance and outcome indicators can be used in a standardized way: a pilot study of two multidisciplinary, full-scale major aircraft exercises. Scand J Trauma Resusc Emerg Med. 2012;20:58.

197. Brem A, Viardot E, Nylund PA. Implications of the coronavirus (COVID-19) outbreak for innovation: Which technologies will improve our lives? Technol Forecast Soc Change. 2021;163:120451.

198. Grynszpan D, Murray V, Llosa S. Value of case studies in disaster assessment? Prehosp Disaster Med. 2011;26:202-5.

199. Hamberger B, Kulling P, Riddez L. Experiences from the Swedish Organization for Studies and Reports from International Disaster (KAMEDO). International Journal of Disaster Medicine. 2003;1:74-6.

200. Iselius L, Nilsson PÅ, Rosvall M. Socialstyrelsen. Kamedo-79. Tågolyckan i Tyskland 1998. [Available from: https://www.socialstyrelsen.se/globalassets/sharepoint- dokument/artikelkatalog/ovrigt/2004-123-3_20041233.pdf] Accessed 25.04.21.

201. Kelly J, Sadeghieh T, Adeli K. Peer Review in Scientific Publications: Benefits, Critiques, & A Survival Guide. EJIFCC. 2014;25:227-43.

202. CASP. Systematic Review Checklist. 2018. [Available from: https://casp-uk.net/wp-content/uploads/2018/01/CASP- Systematic-Review-Checklist_2018.pdf] Accessed 25.04.21.

203. CASP. Cohort Study Checklist. 2018. [Available from: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Cohort- Study-Checklist_2018.pdf] Accessed 25.04.21.

204. Onwuegbuzie A. Expanding the Framework of Internal and External Validity in quantitative Research. Annual Meeting of the Association for the Advancement of Educational Research; Ponte Vedra, FL, USA2000. [Available from: https://files.eric.ed.gov/fulltext/ED448205.pdf] Accessed 25.04.21.

205. Golafshani N. Understanding Reliability and Validity in Qualitative Research. Qual Rep. 2003;8:597-607.

206. Roberts P, Priest H. Reliability and validity in research. Nurs Stand. 2006;20:41-5.

207. Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth. 2017;11:S80-S9.

208. Keeney S, Hasson F, McKenna HP. A critical review of the Delphi technique as a research methodology for nursing. Int J Nurs Stud. 2001;38:195-200.

209. Hasson F, Keeney S. Enhancing rigour in the Delphi technique research. Technol Forecast Soc Change. 2011;78:1695-704.

210. Cornick P. Nitric oxide education survey - Use of a Delphi survey to produce guidelines for training neonatal nurses to work with inhaled nitric oxide. J Neonatal Nurs. 2006;12:62-8.

211. Littell JH CJ, Pillai V. Systematic reviews and Meta-Analysis. Oxford New York: Oxford University Press; 2008.

212. Sackett DL. Bias in analytic research. J Chron Dis. 1979;32:51- 63.

213. Draugalis JR, Coons SJ, Plaza CM. Best Practices for Survey Research Reports: A Synopsis for Authors and Reviewers. Am J Pharm Educ. 2008;72:11.

214. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Human Relations. 2008;61:1139-60.

215. Mackway-Jones K, Carley S. An International Expert Delphi Study to Determine Research Needs in Major Incident Management. Prehosp Disaster Med. 2012;27:351-8.

216. Goodman C. The Delphi technique: a critique. J Advanced Nurs. 1987;12:729-34.

217. Wilson N, Morales A, Guy N, Thomson G. Marked decline of sudden mass fatality events in New Zealand 1900 to 2015: the basic epidemiology. Aust N Z J Public Health. 2017;41:275-9.

218. Shafer SL, Dexter F. Publication Bias, Retrospective Bias, and Reproducibility of Significant Results in Observational Studies. Anesth Analg. 2012;114:931-2.

219. Regjeringen. Ny personopplysningslov. 2019. [Available from: https://www.regjeringen.no/no/tema/statlig- forvaltning/personvern/ny-personopplysningslov/id2340094/] Accessed 25.04.21.

220. Kulling P, Birnbaum M, Murray V, Rockenschaub G. Guidelines for reports on health crises and critical health events. Prehosp Disaster Med. 2010;25:377-83.

221. Debacker M, Hubloue I, Dhondt E, Rockenschaub G, Rüter A, Codreanu T, et al. Utstein-style template for uniform data reporting of acute medical response in disasters. PLoS Curr. 2012;4:e4f6cf3e8df15a.
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