- Email: [email protected]
The golden hour and pre-hospital trauma care
Injury Vol. 26, No. 3, pp. 215-216. 19% Copyright 0 19% ElsevierScienceLtd Printed in Great Britain. All rights reserved 0020-1383/95/ $10.00 + 0.00
Letters to the Editor
Injury, Vol. 26, No. 3, 215-216,
1995
Piggy back technique for relocation dislocation of the hip
of posterior
I was pleased to see Marya and Samuel’s reminder’ of a method of treating posterior dislocation of the hip that I had used for some years before I recommended it for ‘those of small stature and indifferent strength”. I venture to suggest that those that can remember how men used to carry and empty sacks of coal will regard ‘coalman’s heave’ as a more appropriate description than ‘piggy back, which is a way of carrying a person in a sitting position, with the legs astride the carrier’s trunk.
P. S. London
References I Marya SKS and Samuel AW. Piggy back technique for relocation of posterior dislocation of the hip. Injury 1994; 25: 483. 2 London PS. A Practical Guide to the Care of the Injured. London and Edinburgh: E. & S. Livingstone, 1967, Fig. 18.9.
The golden hour and pre-hospital trauma care Mr McNicholl’s paper’ on the golden hour and prehospital trauma care raises some interesting points. Medical audit of ‘time critical’ trauma suggests following ATLS guidelines but the primary survey should be restricted to assessment of the airway (with cervical spine control), breathing and circulation at the scene with the placement of an intravenous infusion on the way to hospital, where the travelling time is short. Increasingly ambulance services are adopting this policy, particularly, as there is evidence to suggest that the pre-hospital average volume infusion is ineffective. The paramedics role becomes increasingly important in entrapment where the correction of hypoxia and hypovolaemia is mandatory. The skills necessary for airway maintenance, oxygen therapy and intravenous infusion are common to medical emergencies and should not pose a problem from the point of view of skill retention. Hussain and Redmond’ have show that up to 37 per cent of prehospital trauma deaths are preventable. The development of British Association for Immediate Care Schemes (BASICS) in Northern Ireland may, in conjunction with the ambulance service, enhance available skills and response times to the scene and therefore optimize potential for reducing morbidity and mortality of trauma. Scott3 has shown that medical input can enhance patient care beyond normal paramedic protocols in 26 per cent of cases. The
attendance of an appropriately trained BASICS doctor may enhance care particularly in airway management (surgical airways), the management of major chest injuries, including needle and tube thoracocentesis and difficult vascular access. Although this study has concentrated on patients with an ISS of greater than 15, paramedic ALS skills will enhance the quality of treatment and resuscitation in patients with lesser injury severity scores, particularly in entrapment and delayed on scene times.
K. M. Porter
References 1 McNicholl BP. The golden hour and pre-hospital trauma care. Injury 1994; 25: 251. 2 Hussain and Redmond. Br Med J1994; 308: 1077. 3 Scott J. ]Acc Amerg Med 1994; 11: (Suppl I), 21.
We read with interest the paper by McNicholl’. In our opinion this work ranks amongst the most important that is currently available in the UK literature on the subject of prehospital trauma care. We have at our disposal parallel information concerning the prehospital care of a cohort of 175 injured patients treated by the trauma team at a single British district general hospital over a recent 12 month period. In addition, we are privy to interim data from the pre-hospital subset of the UK Major Trauma Outcome Study (MTOS). We should like to offer the following comments. Firstly, the overall picture for mainland UK concerning pre-hospital time intervals may not be as optimistic as that suggested by McNicholl’s data. Inspection of the available MTOS data suggests that the average total pre-hospital time exceeds 1 h for all centres included in the pre-hospital phase of the study. We would also take issue with the effectiveness of standby calls in getting experienced personnel to the patient quickly - our experience does not reflect the author’s. However, rather than quibble over matters of detail, we should prefer to offer a further analysis of the data presented by McNicholl. It is indeed a salutary experience to re-read Trunkey’s oft quoted editorial2 a full decade after it was published. His comments are as pertinent today as then and the issues he discussed remain largely unresolved. There are, however, significant developments on the horizon. In our opinion, there are only three issues that are of importance in the prehospital care of the critically injured: control of the airway with maintenance spinal immobilization 0 effective triage. l l
of oxygenation
The data that McNicholl presents on the source of material in patients who aspirate prior to their arrival in hospital (i.e. that
Letters to the Editor
Injury, Vol. 26, No. 3, 215-216,
1995
Piggy back technique for relocation dislocation of the hip
of posterior
I was pleased to see Marya and Samuel’s reminder’ of a method of treating posterior dislocation of the hip that I had used for some years before I recommended it for ‘those of small stature and indifferent strength”. I venture to suggest that those that can remember how men used to carry and empty sacks of coal will regard ‘coalman’s heave’ as a more appropriate description than ‘piggy back, which is a way of carrying a person in a sitting position, with the legs astride the carrier’s trunk.
P. S. London
References I Marya SKS and Samuel AW. Piggy back technique for relocation of posterior dislocation of the hip. Injury 1994; 25: 483. 2 London PS. A Practical Guide to the Care of the Injured. London and Edinburgh: E. & S. Livingstone, 1967, Fig. 18.9.
The golden hour and pre-hospital trauma care Mr McNicholl’s paper’ on the golden hour and prehospital trauma care raises some interesting points. Medical audit of ‘time critical’ trauma suggests following ATLS guidelines but the primary survey should be restricted to assessment of the airway (with cervical spine control), breathing and circulation at the scene with the placement of an intravenous infusion on the way to hospital, where the travelling time is short. Increasingly ambulance services are adopting this policy, particularly, as there is evidence to suggest that the pre-hospital average volume infusion is ineffective. The paramedics role becomes increasingly important in entrapment where the correction of hypoxia and hypovolaemia is mandatory. The skills necessary for airway maintenance, oxygen therapy and intravenous infusion are common to medical emergencies and should not pose a problem from the point of view of skill retention. Hussain and Redmond’ have show that up to 37 per cent of prehospital trauma deaths are preventable. The development of British Association for Immediate Care Schemes (BASICS) in Northern Ireland may, in conjunction with the ambulance service, enhance available skills and response times to the scene and therefore optimize potential for reducing morbidity and mortality of trauma. Scott3 has shown that medical input can enhance patient care beyond normal paramedic protocols in 26 per cent of cases. The
attendance of an appropriately trained BASICS doctor may enhance care particularly in airway management (surgical airways), the management of major chest injuries, including needle and tube thoracocentesis and difficult vascular access. Although this study has concentrated on patients with an ISS of greater than 15, paramedic ALS skills will enhance the quality of treatment and resuscitation in patients with lesser injury severity scores, particularly in entrapment and delayed on scene times.
K. M. Porter
References 1 McNicholl BP. The golden hour and pre-hospital trauma care. Injury 1994; 25: 251. 2 Hussain and Redmond. Br Med J1994; 308: 1077. 3 Scott J. ]Acc Amerg Med 1994; 11: (Suppl I), 21.
We read with interest the paper by McNicholl’. In our opinion this work ranks amongst the most important that is currently available in the UK literature on the subject of prehospital trauma care. We have at our disposal parallel information concerning the prehospital care of a cohort of 175 injured patients treated by the trauma team at a single British district general hospital over a recent 12 month period. In addition, we are privy to interim data from the pre-hospital subset of the UK Major Trauma Outcome Study (MTOS). We should like to offer the following comments. Firstly, the overall picture for mainland UK concerning pre-hospital time intervals may not be as optimistic as that suggested by McNicholl’s data. Inspection of the available MTOS data suggests that the average total pre-hospital time exceeds 1 h for all centres included in the pre-hospital phase of the study. We would also take issue with the effectiveness of standby calls in getting experienced personnel to the patient quickly - our experience does not reflect the author’s. However, rather than quibble over matters of detail, we should prefer to offer a further analysis of the data presented by McNicholl. It is indeed a salutary experience to re-read Trunkey’s oft quoted editorial2 a full decade after it was published. His comments are as pertinent today as then and the issues he discussed remain largely unresolved. There are, however, significant developments on the horizon. In our opinion, there are only three issues that are of importance in the prehospital care of the critically injured: control of the airway with maintenance spinal immobilization 0 effective triage. l l
of oxygenation
The data that McNicholl presents on the source of material in patients who aspirate prior to their arrival in hospital (i.e. that