Circulating Folate and Folic Acid Concentrations: Associations With Colorectal Cancer Recurrence and Survival.

BACKGROUND: Folates, including folic acid, may play a dual role in colorectal cancer development. Folate is suggested to be protective in early carcinogenesis but could accelerate growth of premalignant lesions or micrometastases. Whether circulating concentrations of folate and folic acid, measured around time of diagnosis, are associated with recurrence and survival in colorectal cancer patients is largely unknown. METHODS: Circulating concentrations of folate, folic acid, and folate catabolites p-aminobenzoylglutamate and p-acetamidobenzoylglutamate were measured by liquid chromatography-tandem mass spectrometry at diagnosis in 2024 stage I-III colorectal cancer patients from European and US patient cohort studies. Multivariable-adjusted Cox proportional hazard models were used to assess associations between folate, folic acid, and folate catabolites concentrations with recurrence, overall survival, and disease-free survival. RESULTS: No statistically significant associations were observed between folate, p-aminobenzoylglutamate, and p-acetamidobenzoylglutamate concentrations and recurrence, overall survival, and disease-free survival, with hazard ratios ranging from 0.92 to 1.16. The detection of folic acid in the circulation (yes or no) was not associated with any outcome. However, among patients with detectable folic acid concentrations (n = 296), a higher risk of recurrence was observed for each twofold increase in folic acid (hazard ratio = 1.31, 95% confidence interval = 1.02 to 1.58). No statistically significant associations were found between folic acid concentrations and overall and disease-free survival. CONCLUSIONS: Circulating folate and folate catabolite concentrations at colorectal cancer diagnosis were not associated with recurrence and survival. However, caution is warranted for high blood concentrations of folic acid because they may increase the risk of colorectal cancer recurrence.

Paramedic specialization: a strategy for better out-of-hospital care.

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level.

Helicopter emergency medical services utilization for winter resort injuries.

INTRODUCTION: Helicopter and ground emergency medical services (EMS) units are frequently called to transport patients from winter resorts to area trauma centers. OBJECTIVE: The purpose of this study was to examine helicopter EMS (HEMS) utilization for such patients, and to investigate out-of-hospital clinical variables that might help providers determine the most appropriate utilization of HEMS. METHODS: The study included patients aged ≥ 12 years who were transported by ground EMS (GEMS) or HEMS to a regional trauma center with an acute injury sustained at a winter resort. The decision to transport via HEMS was based on field provider judgment. Injury information was prospectively obtained and combined with emergency department (ED) and hospital data abstracted from trauma registry and hospital records. For the purpose of this study, appropriate HEMS utilization was defined according to two different schemes. Limited utilization of HEMS was defined as the need for an emergent ED or out-of-hospital intervention (intubation, chest tube or needle thoracostomy, central line placement, or cardiopulmonary resuscitation). Expanded utilization of HEMS was defined as the need for an emergent intervention and/or an Injury Severity Score (ISS) ≥ 16 and/or need for emergent nonorthopedic surgery. Provider judgment alone was compared with results of recursive partitioning to predict the need for HEMS. RESULTS: Of 815 patients enrolled between 2006 and 2009, 65 (8.0%) patients met the expanded criteria for appropriate HEMS utilization. Of these, 30 (46.2%) were transported by GEMS and 35 (53.8%) were transported by HEMS. Twenty-seven of the 65 patients (41.5%) required an emergent ED or out-of-hospital intervention. Activation of HEMS by out-of-hospital providers was (at best) 55.6% sensitive and 89.1% specific (85.2% overtriage rate) for predicting the need for an emergent out-of-hospital or ED intervention. Recursive partitioning, using a Glasgow Coma Scale score (GCS) ≤ 13 or pulse oximetry value <89%, was superior to provider judgment in predicting the need for an emergent procedure (57.9% sensitive, 98.6% specific, 45% overtriage rate). CONCLUSION: Use of a simple prediction rule was superior to provider judgment in predicting the need for an emergent ED or out-of-hospital procedure in patients injured at winter resorts. If validated, this rule may be a resource to help out-of-hospital providers decide when to activate HEMS in these unique areas.

Air medical transport of prisoners.

INTRODUCTION: The medical problems of the incarcerated population often require emergent transport to medical facilities via air or ground. The transport of this population, however, can be logistically challenging because of the potentially dangerous nature of the patients and requirements for accompanying security personnel. METHODS: A retrospective chart review was conducted of prisoners transported by our air medical service from January 1, 2000 to December 31, 2008. We examined demographics, reason for call, type of patient, procedures performed by air medical crews during transport, and disposition from the emergency department. RESULTS: Twenty-nine patients (0.3%) of the 11,448 helicopter transports during the study period were transported from correctional facilities, 17 of which were medical in nature and 12 of which had a traumatic mechanism. Fifteen (51.7%) were admitted to the operating room or intensive care unit after emergency treatment. The median scene time for these transports was 20.7 minutes and was significantly different from that of both scene and interfacility transports (median scene times of 13.7 and 31.0 minutes, respectively). CONCLUSION: Medical and traumatic problems of this transported population spanned a large variety of emergency complaints. Scene times reflected the nature of these transports and were not excessively long. Air medical programs should be aware of the medical problems of these patients and take measures to protect their crew when transporting this population.

Air ambulance transport times and advanced cardiac life support interventions during the interfacility transfer of patients with acute ST-segment elevation myocardial infarction.

OBJECTIVES: To characterize transport times for the interfacility air ambulance transport of patients with acute ST-segment elevation myocardial infarction (STEMI), to estimate the proportion of patients at risk of in-transport clinical decompensation, and to explore associated risk factors for such. METHODS: The electronic medical records of 35 air ambulance programs in the United States from December 2003 through December 2008 were reviewed. We defined clinical decompensation during transport as the combined outcome of either cardiopulmonary arrest or the receipt of any of a prespecified set of advanced life support (ALS) interventions. Multiple logistic regression employing generalized estimating equations to model autocorrelation of measures within air ambulance programs was used to explore the relationship between time from dispatch to transport and the outcome of interest. RESULTS: Three thousand seven hundred sixty-seven transports of STEMI patients were identified during the period of interest. Eighty-five percent of rotor wing transports (median 80 minutes, interquartile range [IQR] 66-104) and 7% of fixed-wing transports (median 162 minutes, IQR 142-210) attained a total transfer time of < or = 2 hours. Clinical decompensation in transport occurred in 182 of 3,767 (4.8%, 95% confidence interval [CI] 4.2-5.6%) transports. The most frequent critical ALS interventions were the administration of antiarrhythmics and the initiation of vasopressors. The odds ratios (ORs) for clinical decompensation comparing higher pretransport time quartiles with the lowest quartile (i.e., Q1: 6-50 minutes) were as follows: Q4: 82-1,500 minutes, OR 2.5 (95% CI 1.3-4.8, p = 0.007); Q3: 64-81 minutes, OR 1.9 (95% CI 1.0-3.6, p = 0.0499); and Q2: 51-63 minutes, OR 1.45 (95% CI 0.7-3.1, p = 0.34). Cardiac arrest or need for an ALS intervention prior to transport and a history of diabetes were also predictive of the outcome of interest. CONCLUSIONS: The majority of interfacility rotor-wing air ambulance transfers of patients with STEMI achieved a total transfer time of < or = 2 hours. Clinical decompensation requiring ALS treatment occurred in a small percentage of patients. Diabetes, prior arrest or decompensation, and delays to transport were associated with clinical decompensation in the air. Efforts to reduce delays to transport may reduce this risk in transported patients.

Location of airway management in air medical transport.

BACKGROUND: Prehospital providers are constantly challenged with the task of managing airways in unpredictable and often inhospitable environments. Air medical transport (AMT) crews must be prepared to work in restrictive spaces with limited resources while in the aircraft. This study examines flight crew success rate and circumstances surrounding airway management in different locations. METHODS: This was a retrospective analysis of intubations performed by a university-based air medical transport team from January 1, 1995, to May 31, 2007. Patient records and prospectively gathered airway management quality assurance data were reviewed for location of intubation, patient characteristics, and success rates. Success was defined as placing a cuffed tube in the trachea nonsurgically. RESULTS: Nine hundred thirty-eight patients required 939 advanced airway management procedures, and 936 cases had information sufficient for analysis. Six hundred twenty-seven (67%) of these intubations took place on scene, 235 (25.1%) at the referring hospital, 67 en-route (7.2%), and seven (0.7%) at the receiving hospital. The overall intubation success rate was 96% and the highest rate was for hospital intubations (98.8%), followed by scene (94.9%) and en-route (89.6%) airway encounters. Intubation success was more likely in the hospital setting (odds ratio [OR] = 8.7, 95% confidence interval [CI] 2.2-35.0, p = 0.002] and on the scene [OR = 2.3, 95% CI 0.95-5.7, p = 0.065] compared with those en-route. Unanticipated patient deterioration was noted as the most common reason for in-flight airway management. Type of aircraft was not significantly associated with intubation success (p = 0.132). CONCLUSIONS: Airway management was performed with a high success rate in a variety of locations and patient characteristics by our air medical crew. When in the hospital environment, flight crew success rates were comparable to those of other emergency personnel. Caution should be used, however, when considering intubating in-flight because of slightly lower success rates.

Cricothyrotomy in air medical transport.

BACKGROUND: Airway management is an essential skill for air medical transport (AMT) providers. The endpoint of airway maneuvers is a cricothyrotomy which may be live-saving if other measures fail. We reviewed cricothyrotomy cases in our AMT program to evaluate the success rate and the circumstances surrounding the procedure. METHODS: This was a retrospective review of cases in which a cricothyrotomy was performed at the University of Utah AirMed flight program during the years of 1995 to 2004. Data included incidence, indications, complications, neurologic outcome, and success rates of the procedure. RESULTS: Of the 14,994 transports during the study period, 17 cricothyrotomies were performed. Airway obstruction by blood and/or vomit was the most frequent indication (47%) followed by airway edema/distorted anatomy (24%). The total number of cricothyrotomies decreased during the study period. Seven (41%) patients survived with a reasonable neurologic outcome. The remaining 10 patients died during initial treatment or subsequent hospitalization. Success rate of the procedure in our series was 100%. These results were compared with those of other cricothyrotomy studies. CONCLUSION: Cricothyrotomy has become less common as an emergency rescue technique. However, AMT personnel have a high success rate when performing the cricothyrotomy procedure. This rate is as high as or higher than other emergency personnel.

Outcomes of pediatric trauma patients transported from rural and urban scenes.

OBJECTIVES: Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes. METHODS: Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records. RESULTS: Total mileage, flight times, and scene times were significantly longer for rural flights (P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients. CONCLUSIONS: Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.

Outcomes of blunt trauma victims transported by HEMS from rural and urban scenes.

OBJECTIVE: Mortality differences exist between victims of urban and rural trauma; however, it is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, length of hospital stay, and discharge status of adult blunt trauma victims transported by HEMS from rural and urban scenes to regional trauma centers. METHODS: Retrospective review of all adult (age >/= 15) HEMS transports in 2001; 271 urban and 141 rural blunt trauma patients were identified from HEMS transport records and the trauma registries at three level one trauma centers. Demographic data, scene and hospital interventions, as well as discharge status of the two groups were examined. RESULTS: Total mileage [27 +/- 12 vs. 119 +/- 64, p < 0.001], total flight times (minutes) [30 +/- 10 vs. 79 +/- 40, p < 0.001], and scene times (minutes) [16 +/- 8 vs. 21 +/- 14, p < 0.001] were significantly longer for rural flights. There were no significant differences between the groups with regard to age, gender, receiving hospital, and initial HEMS vitals. Injury Severity Score, ICU length of stay (LOS), total hospital LOS, and hospital mortality did not differ between the two groups. After controlling for age, gender, and ISS, there were no significant mortality differences between the two groups (p = 0.074). CONCLUSIONS: Despite longer flight and scene times for rural patients, adjusted in-hospital mortality rates were similar for patients transported from urban and rural scenes. Factors prior to HEMS arrival may contribute to increased mortality rates of rural blunt trauma victims documented nationally.

Use of a triage pain protocol in the ED.

PURPOSES: This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED). BASIC PROCEDURES: Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage. MAIN FINDINGS: Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior. PRINCIPAL CONCLUSIONS: Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.

Pelvic antishock sheeting.

The authors present a brief technique guide for the application of pelvic antishock sheeting. In the hypotensive blunt trauma patient with discernible pelvic instability, this field-acceptable measure may help to attain some degree of retroperitoneal hemostasis via indirect tamponade. The technique is explained and existing literature reviewed.

Scene transport of pediatric patients injured at winter resorts.

OBJECTIVE: To examine the characteristics of pediatric patients (age =16 years) injured at winter resort scenes and transported by helicopter emergency medical services (HEMS) or ground EMS (GEMS) ambulance services to regional trauma centers. METHODS: Between 1997 and 2001, a total of 119 patients (GEMS = 69; HEMS = 50) were identified from trauma registries and HEMS transport records. Demographic data, initial vital signs, hospital interventions, and discharge status of the two groups were examined. RESULTS: The distributions of gender, initial vital signs, Injury Severity Score (ISS; either = or > 15), intensive care unit (ICU) length of stay (LOS), total hospital LOS, and home discharge status were similar between the two groups (p = 0.05). Patients transported by HEMS were older (14 +/- 2 vs. 10 +/- 4, p < 0.001), less likely to be admitted to the hospital (73% vs. 98.5%; p < 0.001), and more likely to have multiple injuries [13 (27%) vs. 8 (11.6%), p = 0.032]. The GEMS patients had a higher rate of isolated extremity [33 (80.5%) vs. 8 (19.5%)] and thoracoabdominal [11 (73.3%) vs. 4 (26.7%)] injuries. The high orthopedic injury rate in the GEMS patients contributed to a higher rate of surgery in this group (45% vs. 24%, p = 0.028). Regardless of transport mode, patients requiring immediate interventions (intubation, chest tube placement, or blood product administration) had either a depressed level of consciousness (GCS = 12) on emergency department arrival or thoracoabdominal injuries. No deaths were recorded. CONCLUSIONS: Patients transported by HEMS and GEMS had similar hospital characteristics but different injury patterns. A prospective study examining the initial triage of pediatric patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.

Transport of winter resort injuries to regional trauma centers.

INTRODUCTION: This study examined the epidemiology of winter resort injuries presenting to regional trauma centers by helicopter (HEMS) or ground (GEMS) ambulance. METHODS: Five hundred seventy-five patients (GEMS 289; HEMS 286) were identified from trauma registries and HEMS transport records. Demographic data, hospital interventions, and discharge status were examined. RESULTS: HEMS patients had a significantly lower Glasgow coma score (GCS) and trauma score (TS), longer intensive care unit (ICU) length of stay (LOS), and more deaths than did GEMS patients (P < 0.05). Despite this, significantly more HEMS patients were discharged home from the emergency department (24.5% vs. 4.8%; P < 0.001). HEMS patients had more isolated head/facial injuries and multiple injuries, with less isolated extremity injuries than did GEMS patients (P < 0.05). Regardless of transport mode, patients with multiple injuries, thoracoabdominal injuries, or head injuries with a GCS < or = 13 were more likely to require immediate interventions (intubation, chest tube, blood products). Patients with isolated extremity injuries rarely needed immediate care. CONCLUSION: HEMS patients had a higher acuity and different injury pattern when compared to GEMS patients. Approximately 24.5% of HEMS patients were discharged home from the ED. This reflects significant overtriage of patients to HEMS. A prospective study examining the initial triage of patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.

Changing attitudes about pain and pain control in emergency medicine.

Oligoanalgesia continues to be a large problem in the ED. An attitude of suspicion, a culture of ignoring the problem, and an environment that is not conducive to change in practice combine to present formidable obstacles for effective pain management in the emergency setting. Overcoming these obstacles for effective analgesia in the ED is not beyond the capabilities of the individual ED, the emergency physician, or the specialty of emergency medicine. Changing the attitudes of emergency medical providers about pain assessment and management will require attention in several areas of research, education and training. Oligoanalgesia remains a global problem within emergency medicine; however, this awareness is often not felt to be present "in my ED." Individual ownership of the problem may contribute to improvements in pain control. The last 15 years have seen a substantial increase in ED research focused on pain and pain management. Continued research efforts and focused clinical application of these efforts are still required. A better understanding of patient needs and expectations for pain relief, as well as continued efforts at patient education regarding pain, will also improve our treatment of pain in the ED. Recognition by providers of the ethnic, cultural, and gender differences in the expression, reporting, and expectations for treatment of pain should also continue to be a priority in changing attitudes toward pain and pain control. These goals must be realistic within the chaotic and unpredictable environment that defines emergency medicine. Practical and time-sensitive approaches to pain and pain management will continue to bea challenge to enact and enforce in our EDs. The stigma of opioids, in combination with the transient nature of the emergency physician/patient relationship, may be the largest hurdles to overcome for effective pain management not only in the ED, but also following ED discharge. Improvement in provider education of the realities, myths, and misunderstandings of opioid management may provide insight into this problem. The consequences of oligoanalgesia in the ED are not insignificant. To improve our treatment of pain in the ED, a fundamental change in attitude toward pain and the control of pain is required. This is unlikely to occur until pain is adequately addressed and treated appropriately as a true emergency.

Air medical rapid sequence intubation: How can we achieve success?

Airway management is an essential component of the air medical transport of critically ill or injured patients. Many controversies surround the use of rapid sequence intubation (RSI) in the prehospital setting. The challenges of establishing an airway in this environment may exceed those in the hospital. However, it is clear that the same high standards for success demanded in the hospital must be applied to RSI in the prehospital setting for the practice to be accepted and result in positive outcomes. Given their volume of high acuity patients, air medical providers are ideal candidates for performing prehospital RSI. Undertaking this responsibility requires commitment to training and quality improvement. We present the components required to establish and maintain a successful air medical RSI program.

Correlation of change in visual analog scale with pain relief in the ED.

OBJECTIVES: To evaluate the validity of change in visual analog Scale (VAS) as a measure of pain relief using a verbal descriptor Scale (VDS) of change in pain. METHODS: A prospective observational study of emergency department patients measured pain with VAS and recorded verbal report of change in pain. RESULTS: One thousand four hundred ninety patients yielded 1999 comparisons between change in VAS and VDS. Correlation of change in VAS and VDS of change in pain was rho = 0.667 ( P < .001). A wide range of change in VAS, large standard deviations for the mean change in VAS, and discordance in the direction of change in VAS were present within each verbal descriptor category. CONCLUSIONS: Change in VAS is moderately correlated with a VDS of change in pain. Wide variability in change in VAS and discordance with a VDS demonstrate that change in VAS is not a valid indicator of pain relief for individual patients.

Comparison of etomidate and midazolam for prehospital rapid-sequence intubation.

OBJECTIVE: This study compares etomidate with midazolam for prehospital rapid-sequence intubation (RSI). METHODS: The authors conducted a retrospective review of consecutive intubations at a university-based air medical program from January 1995 to December 2000. Exclusion criteria were patients not undergoing RSI, age <15 years, and incomplete chart data. Outcome measures included intubation success, incidence of hypotension, and percentage of change in heart rate (HR) and systolic blood pressure (SBP). RESULTS: The intubation success rate was 110 out of 112 (98%) with etomidate, and 96 out of 97 (99%) with midazolam. Mean ages, patient gender distributions, and initial SBPs and HRs did not differ between the two groups. The mean dose of etomidate was 24 mg, the mean percentage of change in HR was -1% (95% confidence interval [CI], -6 to 4), and the mean percentage of change in SBP was 2% (95% CI, -3 to 7). The mean dose of midazolam was 3.5 mg, the mean percentage of change in HR was 1% (95% CI, -5 to 7), and the mean percentage change in SBP was 3% (95% CI, -3 to 9). The number of hypotensive episodes with etomidate (7 out of 74) compared with midazolam (3 out of 56) did not differ significantly (Fisher's exact test, p=0.51). CONCLUSION: Intubation success rate was very high with both etomidate (98%) and midazolam (99%). There was no statistically significant mean percentage of change in SBP or HR with either agent. The authors found a low incidence of hypotension with both agents, although the mean dose of midazolam used was considerably less than typically recommended for induction.

Patient expectations for pain relief in the ED.

The objective of the study was to assess patient expectations for pain relief in the ED. A convenience sample of 522 patients with pain and 144 patients without pain were enrolled in a prospective observational study at a university ED. Patients reported a mean expectation for pain relief of 72 % (95% CI 70-74). Eighteen percent expected complete (100%) pain relief in the ED. Patient expectations for pain relief were poorly correlated (r = 0.150) with initial pain intensity. Patients without pain reported a mean expectation for pain relief of 74% (95% CI 71-77) if they had presented with pain. There were no differences in patient expectations for pain relief based on age or gender. Patients expect a large percentage of their pain to be relieved in the ED, and many expect complete analgesia. Patient expectations for pain relief do not vary based on age, gender or pain intensity.

The 2003 Air Medical Leadership Congress: findings and recommendations.

To address important concerns facing the air medical community, 149 air medical transport leaders, providers, consultants, and experts met September 4-6, 2003, in Salt Lake City, Utah, for a 3-day summit-the Air Medical Leadership Congress: Setting the Health Care Agenda for the Air Medical Community. Using data from a Web-based survey, top air medical transport issues were identified in four core areas: safety, medical care, cost/benefit, and regulatory/compliance. This report reviews the findings of previous congresses and summarizes the discussions, findings, recommendations, and proposed industry actions to address these issues as set forth by the 2003 congress participants.

Comparison of the intubating laryngeal mask airway versus laryngoscopy in the Bell 206-L3 EMS helicopter.

INTRODUCTION: The purpose of this study is to compare intubation success rate and time to intubation for the intubating laryngeal mask airway (I-LMA) versus direct laryngoscopy (DL) using a manikin model during a simulated in-flight scenario. SETTING: The setting for the study was a University hospital-based air medical program. METHODS: This was a prospective, randomized, crossover trial. Eight nurses and 7 paramedics were randomly assigned to perform 3 intubations with either the I-LMA or DL first and then 3 intubations using the alternate technique. Descriptive statistics, 95% confidence intervals (CIs) of means, and Fisher's Exact test were conducted for comparisons. RESULTS: Fifteen set-ups and 45 intubations were performed with each technique. Previous experience was 74 mm (95% CI 64-84) with DL and 18 mm (95% CI 9-27) with the I-LMA. Set-up time was 33 seconds (95% CI 26-40) for DL and 40 seconds (95% CI 29-50) for I-LMA. Time to intubation was 12 seconds (95% CI 10-14) for DL and 39 seconds (95% CI 31-48) for I-LMA. Success rate was 100% for DL and I-LMA placement and 98% for intubation through the I-LMA. Crew rated difficulty of DL 13 mm (95% CI 6-20), placing the I-LMA 23 mm (95% CI 13-32), and intubating through the I-LMA 17 mm (95% CI 10-24). CONCLUSION: Intubation success was very high for both DL and the I-LMA, despite less flight crew experience with the I-LMA. Total time to intubation was longer with the I-LMA but still less than 1 minute. The flight crews considered both techniques easy to perform. The I-LMA appears to be a useful adjunct for airway management in the Bell 206-L3 helicopter.