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Injury severity of air versus ground transported trauma patients: Implications for scene evacuations and interhospital transfers
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
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