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Injury Severity of Air versus Ground Transported Trauma Patients: Implications for Scene Evacuations and Interhospital Transfers Kimball I. Maull, MD, B. Wall, C. Dover, The Trauma Centerat Carraway and the Carraway Injury Control Institute, Carraway Methodist Medical Center, 1600 Carraway Blvd., Birmingham, AL 35234, USA Purpose: To compare the severity of injury of patients transported by air and ground and determine differences, if any, between helicopter patients evacuated from the scene or transported interfacility. Material and Methods: The Life Saver database and the trauma registry at The Trauma Center at Carraway were reviewed for the period of January 1, 1996, through December 31, 1999, inclusive. Gender, age, origin of transport, means of transports, and injury severity scores (ISS) were calculated. Data were subjected to statistical analysis. Results: Trauma patients make up 53% of Life Saver flights. Virtually all injured adult patients flown from the scene and 62% of injured patients transported from other hospitals are returned to Carraway Methodist Medical Center, an American College of Surgeons-verified Level 1 trauma center. During the 4year period ending December 31, 1999, 5310 injured patients were admitted for evaluation and treatment. Helicopter transports accounted for 1744 trauma admissions (33%). Of this number, 1322 (75%) arrived directly from the scene, and 422 (25%) were transferred by air from another hospital. There were 3451 men (65%) and 1859 women (35%) with an age range from 4 to 95 years. ISS for injured patients arriving by ground ranged from 1 to 50 with a mean ISS of 9.1. ISS for injured patients arriving by helicopter ranged from 1 to 50 with a mean ISS of 15.2. (P < 0.001). Differences between scene evacuated patients and interfacility transfers did not reach statistical significance. Conclusion: The severely injured make up a significant proportion of patients transported by air from the scene and between referring hospitals and the trauma center. However, the range of injury severity is broad for both scene and interfacility transports. While scene circumstances (entrapment) often determine the need for air evacuation, educational programs directed at improvement in injury assessment at the referring hospital may provide an opportunity to reduce unnecessary interfacility flights and improve cost-effectiveness. The Difference Between Ambulance Helicopter and HEMS Helicopter: a Legal Fallacy? Christoph Breitenbach, ADAC, M~nich, Germany Legal provisions are to be passed when state of facts have to be regulated. They should serve to establish clear, unambiguous, and comprehensible rules for the special circumstances and facts as they exist at a given time. In air traffic the reasons will invariably or generally be the maintenance or improvement of air traffic safety. Can the legal differentiation between ambulance helicopters and HEMS helicopters contribute to enhanced safety, or will it rather produce unnecessary complexity, new insecurities, and an unwarranted restriction of operational options? Medically, and as far as mission tactics are concerned, the requirements for ambulance and HEMS helicopters may differ and may be defined differently so that one or the other helicopter, owing to its equipment or operationability, is better equipped for one or the other purpose. Nevertheless, the helicopter, due to its technical properties, generally is suited to both types of operation and, in practice, is used for-both opera108
tions. Legal standardizations must meet these technical facts and must not constitute a confining harness to the multifacetted spectrum of helicopter operations in the area of ambulance and HEMS, unless compelling factual reasons require a distinction in the legal sense.
The Law and Aeromedical Work Peter d'Ambrumeni/, MD, Aeromedical Ltd., United Kingdom Today, foreign travel is taken for granted, and as people travel, they become sick and injured. In the wake of this, the medical professions travel to repatriate and recover these poor souls, often oblivious to the legal ramifications that follow. First and foremost it needs to be remembered that registration in one state rarely bestows the privileges of registration in another. Hence traveling to that other state renders the professional libel to be treated as just another member of the public. From this follows a range of highly significant consequences that rarely are even considered and in most cases never have a bearing on the practice of the professional. There are two major factors to be mindful of. First, if one treats a patient in a jurisdiction where one holds no registration, any treatment will of necessity be an assault. Secondly and directly consequent on this, any treatment given is almost certainly not covered by the professional indemnity insurance. This alone should be enough to make the subject quiver in anticipation of the consequences of an adverse court judgment. Whatever else is done or not done, carefully compiled, accurate, and comprehensive records made at the time of treatment and retained by the escort will comprise the most effective defense against any clinical negligence claim. Incorporating notations about observations on maters such as the nature of emergency and response and a careful note of the controlled drugs owned and carried by the patient in the form of a log will do much to protect the escort when things go wrong. It is legal to carry controlled drugs across international borders only if one possesses a license from both the country one is leaving and the country one is entering. In most cases if the doctor is in possession of a license from his home jurisdiction and declares the drugs openly, usually there is no problem, but this is not a presumption one can safely make. The prudent will always carry a license from the home jurisdiction and in all but the most unusual cases will carry one from both the visited country and any transited. Such licenses usually are obtained through the government department of the country concerned, which is charged with drug control. Having covered these topics, the question of jurisdiction raises its head again because it is not unusual for an escort to pick a patient up in another country. In these circumstances the practitioner has no rights or even privileges that attach to a registered medical or nursing practitioner--hence no right to treat and worse, as a result, probably no insurance coverage. Any treatment carries major risks, including charges of assault or actions for trespass against the person. Again the reality is somewhat more relaxed, but the wise will always attempt to entrain the cooperation of a local doctor or nurse to undertake any active intervention or treatment. Only if impossible will the escort put life, limb, and career at risk. Having dwelled on the dangers of practice, it is only right and proper to address the Good Samaritan Act. If competent and able to administer treatment in an emergency, you should never be deterred from doing so if you are the only qualified person. Also remember that there are jurisdictions where it is a civil tort or even a criminal offense to fail to render treatment in an emergency. To date I know of no cases where such Good Samaritan treatment has been rewarded with an adverse result, July-September 2000 19:3 Air Medical Journal
but beware and see if your professional indemnity insurance can be extended to cover such incidental risks. Massive numbers of patients are carried each year on commercial flights, and only a few give rise to concern. The escort must appreciate that he owes a duty of care to the aircraft, crew, and passengers, and he should never allow any incident to occur that would jeopardize the safety or comfort of any other person. Thus, careful attention should be given to airline stipulations as to the conditions under which such patients are carried, and compliance with any requirements should be absolute. Psychiatric patients should never be allowed to declare their condition, patients should never be offensive to the senses, and the escort should endeavor to ensure that he never needs to divert an aircraft from its destination due to the condition of a patient being carried. Escorts bear a personal responsibility for this and cannot rely on their principal's judgment as justification for the carriage of a given patient. The escort is and will remain totally personally responsible for the patient in his charge.
The Issue of Landing Sites at Hospitals in Connection with JAR-OPS3 and ICAO-Annex14
Werner Gelhausen,ADAC-LuftrettungGmbH, M[Jnchen, Germany Compliance with JAR-OPS 3 creates substantial problems in the area of helicopter emergency medical service (HEMS) in terms of size of available landing sites at hospitals. Previously, diverging provisions concerning the licensing of helioports were used in Europe. Germany, for example, was based on NFL I (News for Aviators Part One, 1969). The dimensions were sufficient, and at the present state of knowledge, in more than 30 years of air reed activity, there have been no engine failures during takeoff or landing from or on hospital landing sites. Now heliports are to come up to the requirements of the ICAO Annex 14, which are almost of airport design. Thus, up to 80% of the hospitals no longer could be served by helicopters, which would also affect priority hospitals. In this connection, three types of helicopter landing sites currently are described according to JAR OPS 3, which have to be absolutely connected to the classification of the helicopter designs employed. This creates another difficulty that can be resolved only with the assistance of the helicopter manufacturer. The classification of the helicopter designs and the type of landing sites can be shown and explained clearly through a figure. Concluding the presentation, a practical example and photographs will illustrate the overall issue.
Legal Aspectsof Aeromedical Transports--The German Point of View Insurance Policy Conditions versus Medical Care?
Michael Linden, MD, Meyersrenken & Rheingantz, Cologne, Univeritaetsstrasse 1, Colonge, Germany50937 Purpose: The presentation tries to point out some legal aspects that, especially with regard to travel-insurance contracts, were fully examined in a doctoral thesis published in 1998. The main reason for that investigation was first the absence of detailed investigations (in Germany) of the legal aspects of repatriation, but furthermore the fact that the indication of repatriation and the cost-interest of the insurer, pursuant to the General Policy Conditions of travel-insurance contracts, must not necessarily correspond with the medical care and interest of the patient. The indication of repatriation, according to General Policy Conditions, is subject to its "medical necessity" or "medical sense." However, which standard is decisive: the standard of the medical treatment abroad, in the domestic country, or which is inAir Medical Journal
19:3 July-September 2000
ternationally accepted? Is the insurer able to decide pro and contra a transport on its own without being advised by a physician, or is it still sufficient to trust the opinion of the foreign physician attending the patient? Moreover, the presentation wants to focus the view to liability of the insurer. The presentation describes the importance of the "doctor-doctor call" and the qualification of the physician who takes medical care during the repatriation flight. It will be described that the physician should be specially qualified for the problems that could occur during the flight concerning the special physiological and vital conditions. International legal (contractual and noncontractual) problems can especially be a result of the doctor's and the sick person's nationality or residence, the national statute of the airplane, and/or the law the insurance contract is subject to. Methods: The investigation considers the main German Law Codifications (civil law, international private law) and jurisdiction (civil and medical malpractice jurisdiction). Results: Not only for health reasons of the (insured) patient but also for the reason of liabilty, the insurer has an obligation to be advised by a domestic ("home") physician to get the final decision about the medical necessity/medical sense of the indication to repatriate a patient. The indication of repatriation and the mode of conveyance (car, ambulance, or [regular] stretcher flight) cannot (only) be evaluated by the physician attending the patient abroad. His or her medical opinion can be only an indication but no objective evaluation because his/her decision is substantiated with respect to the medical standard being practiced in the foreign country. If otherwise or if the insurer decides on his own and the patient is injured (eg, the insurer decides against the necessity of repatriation or decides in favor of the wrong mode of conveyance), the insurer will be liable. The medical necessity of repatriation has to be answered by a "neutral" physician. It is necessary to compare the medical treatment abroad with the domestic or generally accepted medical standard. The "doctor-doctor call" is decisive to know whether the Policy Conditions have been complied with. The physician mandated with this call evaluates the medical situation, decides on the indication of repatriation and the patient's health ability of being repatriated, or the necessity of further and other medical treatment abroad or in another country to get the "correct" medical condition. The attending physician during the repatriation has to be fully qualified as a specialist because the medical treatment during the repatriation is comparable with an inpatient treatment. The organization mandated with the repatriation and the insurer may be liable in the event the patient should be injured by a nonqualified medical crew (physician, nurse, or paramedic). Under special conditions--if the insurer or the organization repatriates the patient according to contractual obligation with an airplane--it is possible that he is liable as a contractual "air carrier" in the case of an accident according to air traffic acts and international conventions. If the parties have the same nationality, the rights between them are under the same statutes. Otherwise, the main problems can arise from noncontractual claims because of the fact that the lex loci delictiwill be decisive for the applicable law. Conclusion: An insurer has to be advised by a physician who has come to a decision about the medical necessity/medical sense of the indication to repatriate a patient. This applies to ambulance flights and stretcher flights. The opinion of the physician abroad can indicate only the answer pro and contra the indication of repatriation. Medical treatment of a patient during a repatriation (with an ambulance flight) can be compared with an inpatient treatment. According to this, it is neces109
tions. Legal standardizations must meet these technical facts and must not constitute a confining harness to the multifacetted spectrum of helicopter operations in the area of ambulance and HEMS, unless compelling factual reasons require a distinction in the legal sense.
The Law and Aeromedical Work Peter d'Ambrumeni/, MD, Aeromedical Ltd., United Kingdom Today, foreign travel is taken for granted, and as people travel, they become sick and injured. In the wake of this, the medical professions travel to repatriate and recover these poor souls, often oblivious to the legal ramifications that follow. First and foremost it needs to be remembered that registration in one state rarely bestows the privileges of registration in another. Hence traveling to that other state renders the professional libel to be treated as just another member of the public. From this follows a range of highly significant consequences that rarely are even considered and in most cases never have a bearing on the practice of the professional. There are two major factors to be mindful of. First, if one treats a patient in a jurisdiction where one holds no registration, any treatment will of necessity be an assault. Secondly and directly consequent on this, any treatment given is almost certainly not covered by the professional indemnity insurance. This alone should be enough to make the subject quiver in anticipation of the consequences of an adverse court judgment. Whatever else is done or not done, carefully compiled, accurate, and comprehensive records made at the time of treatment and retained by the escort will comprise the most effective defense against any clinical negligence claim. Incorporating notations about observations on maters such as the nature of emergency and response and a careful note of the controlled drugs owned and carried by the patient in the form of a log will do much to protect the escort when things go wrong. It is legal to carry controlled drugs across international borders only if one possesses a license from both the country one is leaving and the country one is entering. In most cases if the doctor is in possession of a license from his home jurisdiction and declares the drugs openly, usually there is no problem, but this is not a presumption one can safely make. The prudent will always carry a license from the home jurisdiction and in all but the most unusual cases will carry one from both the visited country and any transited. Such licenses usually are obtained through the government department of the country concerned, which is charged with drug control. Having covered these topics, the question of jurisdiction raises its head again because it is not unusual for an escort to pick a patient up in another country. In these circumstances the practitioner has no rights or even privileges that attach to a registered medical or nursing practitioner--hence no right to treat and worse, as a result, probably no insurance coverage. Any treatment carries major risks, including charges of assault or actions for trespass against the person. Again the reality is somewhat more relaxed, but the wise will always attempt to entrain the cooperation of a local doctor or nurse to undertake any active intervention or treatment. Only if impossible will the escort put life, limb, and career at risk. Having dwelled on the dangers of practice, it is only right and proper to address the Good Samaritan Act. If competent and able to administer treatment in an emergency, you should never be deterred from doing so if you are the only qualified person. Also remember that there are jurisdictions where it is a civil tort or even a criminal offense to fail to render treatment in an emergency. To date I know of no cases where such Good Samaritan treatment has been rewarded with an adverse result, July-September 2000 19:3 Air Medical Journal
but beware and see if your professional indemnity insurance can be extended to cover such incidental risks. Massive numbers of patients are carried each year on commercial flights, and only a few give rise to concern. The escort must appreciate that he owes a duty of care to the aircraft, crew, and passengers, and he should never allow any incident to occur that would jeopardize the safety or comfort of any other person. Thus, careful attention should be given to airline stipulations as to the conditions under which such patients are carried, and compliance with any requirements should be absolute. Psychiatric patients should never be allowed to declare their condition, patients should never be offensive to the senses, and the escort should endeavor to ensure that he never needs to divert an aircraft from its destination due to the condition of a patient being carried. Escorts bear a personal responsibility for this and cannot rely on their principal's judgment as justification for the carriage of a given patient. The escort is and will remain totally personally responsible for the patient in his charge.
The Issue of Landing Sites at Hospitals in Connection with JAR-OPS3 and ICAO-Annex14
Werner Gelhausen,ADAC-LuftrettungGmbH, M[Jnchen, Germany Compliance with JAR-OPS 3 creates substantial problems in the area of helicopter emergency medical service (HEMS) in terms of size of available landing sites at hospitals. Previously, diverging provisions concerning the licensing of helioports were used in Europe. Germany, for example, was based on NFL I (News for Aviators Part One, 1969). The dimensions were sufficient, and at the present state of knowledge, in more than 30 years of air reed activity, there have been no engine failures during takeoff or landing from or on hospital landing sites. Now heliports are to come up to the requirements of the ICAO Annex 14, which are almost of airport design. Thus, up to 80% of the hospitals no longer could be served by helicopters, which would also affect priority hospitals. In this connection, three types of helicopter landing sites currently are described according to JAR OPS 3, which have to be absolutely connected to the classification of the helicopter designs employed. This creates another difficulty that can be resolved only with the assistance of the helicopter manufacturer. The classification of the helicopter designs and the type of landing sites can be shown and explained clearly through a figure. Concluding the presentation, a practical example and photographs will illustrate the overall issue.
Legal Aspectsof Aeromedical Transports--The German Point of View Insurance Policy Conditions versus Medical Care?
Michael Linden, MD, Meyersrenken & Rheingantz, Cologne, Univeritaetsstrasse 1, Colonge, Germany50937 Purpose: The presentation tries to point out some legal aspects that, especially with regard to travel-insurance contracts, were fully examined in a doctoral thesis published in 1998. The main reason for that investigation was first the absence of detailed investigations (in Germany) of the legal aspects of repatriation, but furthermore the fact that the indication of repatriation and the cost-interest of the insurer, pursuant to the General Policy Conditions of travel-insurance contracts, must not necessarily correspond with the medical care and interest of the patient. The indication of repatriation, according to General Policy Conditions, is subject to its "medical necessity" or "medical sense." However, which standard is decisive: the standard of the medical treatment abroad, in the domestic country, or which is inAir Medical Journal
19:3 July-September 2000
ternationally accepted? Is the insurer able to decide pro and contra a transport on its own without being advised by a physician, or is it still sufficient to trust the opinion of the foreign physician attending the patient? Moreover, the presentation wants to focus the view to liability of the insurer. The presentation describes the importance of the "doctor-doctor call" and the qualification of the physician who takes medical care during the repatriation flight. It will be described that the physician should be specially qualified for the problems that could occur during the flight concerning the special physiological and vital conditions. International legal (contractual and noncontractual) problems can especially be a result of the doctor's and the sick person's nationality or residence, the national statute of the airplane, and/or the law the insurance contract is subject to. Methods: The investigation considers the main German Law Codifications (civil law, international private law) and jurisdiction (civil and medical malpractice jurisdiction). Results: Not only for health reasons of the (insured) patient but also for the reason of liabilty, the insurer has an obligation to be advised by a domestic ("home") physician to get the final decision about the medical necessity/medical sense of the indication to repatriate a patient. The indication of repatriation and the mode of conveyance (car, ambulance, or [regular] stretcher flight) cannot (only) be evaluated by the physician attending the patient abroad. His or her medical opinion can be only an indication but no objective evaluation because his/her decision is substantiated with respect to the medical standard being practiced in the foreign country. If otherwise or if the insurer decides on his own and the patient is injured (eg, the insurer decides against the necessity of repatriation or decides in favor of the wrong mode of conveyance), the insurer will be liable. The medical necessity of repatriation has to be answered by a "neutral" physician. It is necessary to compare the medical treatment abroad with the domestic or generally accepted medical standard. The "doctor-doctor call" is decisive to know whether the Policy Conditions have been complied with. The physician mandated with this call evaluates the medical situation, decides on the indication of repatriation and the patient's health ability of being repatriated, or the necessity of further and other medical treatment abroad or in another country to get the "correct" medical condition. The attending physician during the repatriation has to be fully qualified as a specialist because the medical treatment during the repatriation is comparable with an inpatient treatment. The organization mandated with the repatriation and the insurer may be liable in the event the patient should be injured by a nonqualified medical crew (physician, nurse, or paramedic). Under special conditions--if the insurer or the organization repatriates the patient according to contractual obligation with an airplane--it is possible that he is liable as a contractual "air carrier" in the case of an accident according to air traffic acts and international conventions. If the parties have the same nationality, the rights between them are under the same statutes. Otherwise, the main problems can arise from noncontractual claims because of the fact that the lex loci delictiwill be decisive for the applicable law. Conclusion: An insurer has to be advised by a physician who has come to a decision about the medical necessity/medical sense of the indication to repatriate a patient. This applies to ambulance flights and stretcher flights. The opinion of the physician abroad can indicate only the answer pro and contra the indication of repatriation. Medical treatment of a patient during a repatriation (with an ambulance flight) can be compared with an inpatient treatment. According to this, it is neces109