Shaydarov M. Z. Dubitsky A.A. Aldongarov A.S. Tursynbetov E.A.

Medical university Astana, Kazakhstan

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.

Tab No. 1. Tariffs for services SA in RK

Name	2011	2012
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 tenges

On 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 Қазақстан" 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 (№ 2): 265–271.

11. Wigman L.D., van Lieshout E.M., de Ronde G., Patka P. et al. Trauma-related dispatch criteria for Helicopter Emergency Medical Services in Europe // Injury. 2011 May; 42 (5): 525–533.