127015*
Ahilbekov
N.S.
Republican center of
sanitary aircraft of Ministry of health and social development of the Republic
of Kazakhstan, Astana.
VALUE OF DISPATCHING
SERVICE IN THE CHOICE BETWEEN LAND OR AIRMOBILE MEDICAL CREWS FOR THE DIRECTION
TO THE PLACE OF ROAD TRANSPORT INCIDENTS
In the Republic of Kazakhstan the special
attention is paid to questions of preservation and strengthening of health of
the population. Further improvement of service of sanitary aircraft for
rendering emergency medical care is one of the most important conditions of
ensuring these processes.
In recent years in Kazakhstan one of key
divisions in structure of service of emergency medical care – sanitary aircraft
became active to develop. Use of air transport for the medical purposes in our
country has the much important mission for preservation of health of citizens
of the Republic of Kazakhstan.
The president of Kazakhstan Nursultan
Nazarbayev in the Message to the people of Kazakhstan «Let's construct the
future together» I charged to the government to provide till 2015 creation not
less than 16 helicopters for needs of sanitary aircraft [1].
Also it was entrusted is accelerated to
resolve issues of creation of route medical aid saving stations on abnormally –
dangerous sites of roads of republican value for expeditious rendering medical
care to victims in road transport incidents [2].
«The transport medicine is very actual for Kazakhstan, and we will
develop it». Evacuation of patients on the aircraft from peripheral hospital in
a city hospital was carried out not always and didn't treat priority problems
of sanitary aircraft. The helicopter equipment practically was never used for
rendering emergency on-site assistance of incident and urgent transportation of
victims in a hospital.
In compliance with articles 49 and 50 of
the Code of the Republic of Kazakhstan of September 18, 2009 «About health of
the people and health system» the Government of the Republic of Kazakhstan
decides to approve enclosed Rules of rendering an emergency medical service and
medical care in the form of sanitary aircraft [3].
Now the situation significantly changed.
The sanitary aircraft (especially it belongs to helicopters) is even more often
applied to the fastest delivery of crew of emergency medical care directly to
victims at the place of accident, usually to the place of a road accident.
Thus, the doctor of helicopter crew
usually appears the first physician rendering the emergency help to victims,
and makes the decision on expediency of their evacuation in a hospital. In this
regard functional duties of the doctor of helicopter crew practically don't
differ from those at the doctor of land crew of an emergency medical service.
The main distinctions concern the speed of movement of
land and helicopter crews, and also the cost
of acquisition and operational costs on vehicles.
To other differences of sanitary aircraft from land
ambulance it is possible to refer certain restrictions to performance of
flights on the loading capacity, weather conditions, and in not which cases and
on time of day. Separate models of helicopters demand rather a lot of time for
preparation for a departure. At last, in many countries there was a practice of
attraction in aviation medical crews more the qualified personnel which usually
have special preparation and practical experience in the field of
anesthesiology and reanimation [4.5].
With development of service of sanitary aircraft in a
number of regions of the country there was a situation when for assistance to
victims in road transport incidents can be directed both helicopter, and land
crews.
Use of helicopter crews is capable to reduce
significantly time in a way (and in the conditions of transport jams it can be
the unique way to reach the place of accident), but the cost of service of
patients at the same time sharply increases.
So far, in Kazakhstan official criteria which could
form a basis for decision making on a crew choice (land, aviation medical) at
the solution of a question on its direction to the place of road transport
incident aren't developed. Moreover the specified problem isn't to our country
inherent only: in many states with considerably wide experience of use of
medical helicopters for rendering the emergency help to victims in road
transport incidents it isn't found the optimum solution of the matter [6.7].
At separate options of an automobile trauma still
remains not clear, whether there are reliable distinctions in the end results
of the treatment begun on a scene by crews of land and helicopter emergency
medical care [8]. Lack of large-scale researches on this subject doesn't allow
to give a definite answer to this question [9,10].
For the majority of the countries the choice of a type
of the vehicle for the direction on a scene is a prerogative of the dispatcher
to whom demands for calls from the population are flown down. These powers
bring a role of the dispatcher to one of key positions in the organization of
emergency medical care. The price of a mistake of the dispatcher is high – even
not long work of the helicopter manages very expensively: inappropriate use of
this vehicle will quickly devastate the budget of local service of sanitary
aircraft.
Tariffs for services SA in RK
Transport services in 1 hour
1. Helicopter 400 000 tenges 456 069 tenges
2. AN-2 plane 80 000 tenges 121 300 tenges
3. AN-24/30 plane 80 000 tenges 508 003 tengesOn the
other hand, unreasonable refusal in the direction of the helicopter those cases
when it is really necessary, is accompanied by considerable deterioration of
the forecast of a disease at the victim (the well-known rule «gold hour»). The
problem of acceptance by the dispatcher of the right decision at a crew choice
for rendering the emergency help to victims in road transport incidents has one
more aspect. It is obvious that in the work the dispatcher is compelled to be
guided by information received from casual eyewitnesses of a car accident. But
whether it is reliable? In most cases the person causing crew of the emergency
help, doesn't possess even the minimum medical knowledge, allowing to carry out
at least the most rough estimate of weight traumatized. Often to the dispatcher
calls from eyewitnesses who even close didn't approach to victims in road
transport incidents arrive, and observed accident consequences from long
distance: for example, from windows of the car.
Quite often there are difficulties even with
examination, where exactly there was a road transport incident. For example, in
Kazakhstan even on large highways not all sites of roads are equipped with
kilometer indexes. Whether there is at the dispatcher an opportunity to make
the reasonable decision in such situation?
What criteria are used by dispatchers in foreign
countries at a choice of option of crew of emergency medical care when
receiving a signal of road transport incident with victims? There are two
approaches to creation of dialogue between the dispatcher and the called
eyewitness of accident.
The first approach is based on rather free style of
communication between participants of dialogue: the dispatcher asks questions
which to him seem the most important for an assessment of a concrete situation
and acceptance of a final decision.
At this approach the volume and reliability of
received information in many respects is defined by professionalism of the
dispatcher.
In the second case dialogue lies in line with in
advance prepared questionnaire.
Task of the dispatcher is obtaining answers to
everything or at least the majority of sections of this document. As a result
the dispatcher has an opportunity to prove the choice between options of crews
(land, helicopter) simple calculation of positive and negative answers calling
on the asked questions. Both methods have positive and negative sides. It is in
any case specified that pledge of effective work of service of the emergency
help is the good knowledge the dispatcher of the territory for which it is
responsible [11].
This knowledge at least assumes ability quickly to
estimate availability of the
place of accident to land transport and estimated time
at ways (taking into account load of roads at the time of receiving a call),
technical capability of implementation of landing of the helicopter directly on
a road surfacing or near its cloth (the distance from the helicopter to victims
in road transport incidents shouldn't exceed 50–100 m), a distance from a scene
to a profile hospital, existence of the equipped airfield for the helicopter in
close proximity to a reception [5]. At technical capability to send the
helicopter to a road accident place the dispatcher is guided by representation
that the factor of time is priority at victims in a critical condition, and it
is powerful argument
in favor of aviation medical crew.When using
helicopter decrease in time of rendering to the hospital emergency help is the
most obvious at remoteness of a place of road transport incident from the area
of basing of aviation equipment on distance of 35-150 km.
The following group of criteria concerns an assessment
of weight of a condition of victims. In favor of the helicopter direction to
the place of accident with victims in a critical condition forms the general
basis not only saving of time, but also need for rendering medical care of
higher qualification level. As it was mentioned above, a priori is considered
that the structure of helicopter crew includes experts with higher level of
professional knowledge and practical skills, and level of equipment of
helicopters medicines and the equipment at least doesn't concede to land
resuscitation cars.
For more objective assessment of probable severity of
the patient the dispatcher of emergency service has to be able to incline the
eyewitness of road transport incident calling it to cooperation. As a rule, the
eyewitness will have to inspect both scenes, and the victim and to transfer
seen information to the dispatcher. In certain cases before arrival of team of
professional physicians the eyewitness under the leadership of the dispatcher will
have to carry out a complex of vitally rescuing actions.
At such remote assessment of weight of a condition of
the patient the dispatcher needs to establish existence of external
manifestations of insolvency of haemo dynamics (plentiful external blood loss,
pallor of integuments, strong sweat, a frequent and low pulse) and
insufficiency of breath (frequent or rare breath, violations of depth of
breath, asymmetry of respiratory movements of a thorax, etc.).
After this existence becomes clear:
- absence of consciousness;
- spasms;
- losses of sensitivity or active movements in
extremities;
- pluralities of injuries of a bone skeleton;
- getting wounds of a stomach, breast, neck, skull;
- at patients 12 years are younger than traumas or are
more senior than 55 years;
- external manifestations of pregnancy at the victim
with an automobile trauma.
To burdening circumstances refer burns a flame or the
storage electrolyte, especially being localized in a face, necks, hands,
genitals or exceeding 20% from a body surface. Auxiliary diagnostic value has
the fact of loss of the victim from the car as a result of accident; presence
of victims in the same car where the victim went; falling as a result of
failure of the car with passengers from height more than 2,5 meters. As a rule,
to serious consequences lead collisions of pedestrians with cars and
motorcycles, and also motorcyclists and cyclists with cars.
It is possible to consider that the direction of
helicopter crew to the victims answering to above-mentioned criteria is
justified. To patients in rather stable condition, not having the obvious
symptoms menacing to life, it is possible to direct a land ambulance crew at
the increased readiness of helicopter crew for a departure [7, 8].
Nevertheless it is necessary to carry out work on
development of algorithms of work of the dispatching service, providing uniform
approaches to the organization to the hospital emergency help joint forces of
land and helicopter service of emergency medical care.
Offers on SA development in the Republic of
Kazakhstan:- creation of a uniform vertical of service of an emergency medical
service and sanitary aircraft of RK;
- creation of the dispatching center (Call-center);
- introduction of system of monitoring of tracking for
land and the RK air vehicles;
- training of the personnel of an emergency medical
service and sanitary aircraft of RK according to the international programs;
- creation of conditions for involvement of the
outsourcing company for rendering transport services of sanitary aircraft;
- rendering mentor services for the personnel of
service of sanitary aircraft (joint flights, etc.)
Literature:
1. The decree of the President of the Republic of
Kazakhstan of September 13, 2004 N 1438 «About the State program of reforming
and development of health care of the Republic of Kazakhstan for 2005-2010».
2. The decree of the President of the Republic of
Kazakhstan of November 29, 2010 N 1113 about the State program of development
of health care of the Republic of Kazakhstan «Salamatta Қàçàқñòàí» for 2011-2015.
3. The code of the Republic of Kazakhstan «About
health of the people and health system on September 18, 2009 No. 193-IV ZRK
(with changes and additions as of 10.07.2012).
4. Berns K.S., Caniglia J.J., Hankins D.G., Zietlow
S.P. Use of the autolaunch method of dispatching a helicopter. Air Med. J.
2003; 22 (3): 35–41.
5. Lerner E.B., Billittier A.J., Sikora J., Moscati
R.M. Use of a geographic information system to determine appropriate means of
trauma patient transport //Acad. Emerg. Med. 1999; 6: 1127–1133.
6. Petrie D.A., Tallon J.M., Crowell W., Cain E. et
al. Medically appropriate use of helicopter EMS: the mission acceptance/triage
process // Air Med. J. 2007; 26 (1): 50–54.
7. Ringburg A.N., de Ronde G., Thomas SH, van Lieshout
EM et al. Validity of helicopter emergency medical services dispatch criteria
for traumatic injuries: a systematic review // Prehosp. Emerg. Care. 2009
Jan–Mar; 13 (1): 28–36.
8. Ringburg A.N., Frissen I.N., Spanjersberg W.R., Jel
G., Frankema S.P. et al. Physician-staffed HEMS dispatch in the Netherlands:
Adequate deployment or minimal utilization? // Air Med. J. 2005 Nov-Dec; 24
(6): 248–251.
9. Thomas S.H., Cheema F., Wedel S.K., Thomson D.
Trauma helicopter emergency medical services transport: annotated review of
selected outcomesrelated literature // Prehosp. Emerg. Care. 2002; 6:359–371.
10. Thomson D.P., Thomas S.H. Guidelines for air
medical dispatch // Prehosp. Emerg. Care. 2003 April–June; V. 7 (¹ 2): 265–271.
11. Wigman L.D., van Lieshout E.M., de Ronde G., Patka
P. et al. Traumarelated dispatch criteria for Helicopter Emergency Medical
Services in Europe // Injury.-2011 May; 42 (5): 525–533.