There was no follow-up after 24 hours of admission, so actual survival until hospital discharge was unknown. The reason for this was the transportation of patients to hospitals out of the primary HEMS region. Conclusion The HEMS of the eastern part of the Netherlands provides essential additional medical expertise not provided by the EMS. The only formal paediatric indication for HEMS at this moment is the paediatric cardiopulmonary resuscitation. This study calls for a lower threshold for HEMS activation in any serious incident involving

children, preferably based on the type of primary emergency call. Sixty-five percent of Inhibitors,research,lifescience,medical the vitally compromised children received a preclinical medical procedure restricted to a physician, 78% received a medical procedure for which a physician was more experienced. The majority of all patients encountered by the HEMS had a NACA score of IV-VII. As Inhibitors,research,lifescience,medical the younger patients had a higher NACA score, special attention should be given to training and the provision of advanced life support procedures for younger children. Successful endotracheal intubation Inhibitors,research,lifescience,medical and subsequent appropriate ventilation in children is a difficult task for EMS paramedics; preclinical

endotracheal intubation of children calls for an experienced physician. The use of intraosseous access devices and the use of analgesics by EMS paramedics could be improved. Further investigation into the pre-hospital care for vitally compromised children is necessary. Key Messages • The HEMS of the eastern part of the Netherlands provides essential additional Inhibitors,research,lifescience,medical medical expertise not provided by the EMS. • The majority of all patients encountered by the HEMS had a NACA score of IV-VII. • A substantial proportion of all

endotracheal intubations by EMS paramedics resulted in potentially Inhibitors,research,lifescience,medical lethal complications. • The use of intraosseous access devices and the application of analgetics in the field can be improved. Abbreviations EMS: Emergency Medical Service; HEMS: Helicopter Emergency Medical Service; NACA: National Advisory Committee for Aeronautics; SPSS: Statistical Package for the Social Sciences; ALS: Advanced life support; GCS: Glasgow Coma Scale; CPR: Cardiopulmonary resuscitation; SD: Standard deviation. Competing interests The authors declare that they have those no competing interests. Authors’ contributions BMG: main author, INK 128 in vitro design of study. AS: data acquisition, design of research data base. BJP: statistical analysis, scientific structure. GJS: expert in anaesthesiology and critical care, medical reviewer. JMD: expert in emergency paediatric care, medical reviewer. All authors read and approved the final manuscript. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-227X/10/6/prepub Acknowledgements No acknowledgements, no funding or grant was received for this study.