The optimal staffing of helicopter emergency medical services (HEMS) is uncertain. An intensive care paramedic-staffed HEMS has operated in the state of Victoria, Australia for over 28 years, with paramedics capable of performing advanced procedures, including rapid sequence intubation, decompression of tension pneumothorax, and cricothyroidotomy. Administration of a wide range of vasoactive, anesthetic, and analgesic medications is also permitted. We sought to explore the characteristics of patients transported by HEMS in Victoria, and describe paramedic utilization of their skill set in the prehospital environment.A retrospective data review was conducted of patients transported by the HEMS between 1 July 2012 and 30 June 2013. Data were sourced from the Ambulance Victoria data warehouse and the Victorian State Trauma Registry. Interhospital transfers were excluded.HEMS attended 1,519 cases during the study period. A total of 825 primary transport cases were included in analyses. Most patients were male (69.5%) and the majority of cases involved trauma (86.1%). Rapid sequence intubation (RSI) was performed in 36.8% of pediatric and 29.9% of adult major trauma patients, with a procedural success rate of 100%. Ketamine was administered to 18.5% of all trauma patients. The proportion of patients with a severe pain score (≥7) decreased from 33.8 to 3.2% (p < 0.001) between initial and final paramedic assessments. A clinically significant pain reduction of ≥2 points was achieved by 87.0% (95% CI 82.9-90.4%) of adult trauma patients who had an initial pain score >2 points and a valid final pain score. In-hospital mortality following major-trauma was 7.6% (95% CI 5.0-11.0%).The skill set of HEMS intensive care paramedics in Victoria is broad, including a large number of prehospital critical care procedures commonly utilized by physician-staffed HEMS in other jurisdictions. A high RSI procedural success rate was observed across the study period, as were significant improvements in patient physiological parameters and pain scores.