- Email: [email protected]
Management of Mass Casualties Using Doctor Helicopters and Doctor Cars
Air Medical Journal xxx (2017) 1e4
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Case Report
Management of Mass Casualties Using Doctor Helicopters and Doctor Cars Hiromichi Ohsaka, MD, PhD, Kouhei Ishikawa, MD, Kazuhiko Omori, MD, PhD, Kei Jitsuiki, MD, Toshihiko Yoshizawa, MD, Youichi Yanagawa, MD, PhD a b s t r a c t At approximately 10 o'clock in September 2015, a minibus carrying 18 people accidentally slid backwards because of a malfunctioning brake system while climbing a steep incline on Togasayama Mountain, colliding with a van (Toyota HiAce wagon) carrying 11 people that was situated behind the minibus. Togasayama Mountain is located 1 hour by car and 10 minutes by helicopter from our hospital. The minibus slid off a roadside cliff at a height of 0.5 m and rolled over after colliding with the van. There were 7 victims with yellow tags and 22 with green tags. Two Doctor Helicopters and 1 Doctor Car cooperated with the fire departments by providing medical treatments, selection of medical facilities, and dispersion transportation. In this mass casualty event, there were no mortalities, and all of the victims recovered without sequelae. The coordinated and combined use of Doctor Helicopters and Doctor Cars in addition to the activities of the fire department in response to a mass casualty event resulted in appropriate triage, medical treatments, selection of medical facilities, and dispersion transportation. Copyright © 2017 by Air Medical Journal Associates
According to HEM-net (http://www. hemnet.jp/english/index.html), the Doctor Helicopter (Dr. Heli) system has been in use in Japan since June 2007. As of October 2016, 47 Dr. Heli bases in 39 of 47 prefectures have been established in Japan. More than 37 prefectures had established neighboring-prefecture agreements for cooperation during mass casualty incidents or overlapping requests for Dr. Helis by 2013.1 The crews of Dr. Helis generally consist of a pilot, a mechanic, a doctor, and a nurse. The use of Dr. Helis is limited to the daytime and fair weather. In case of mass casualties, the medical staff can be increased to 2 doctors and 2 nurses. Dr. Helis can accommodate up to 1 severely ill
Supported by the Ministry of Education, Culture, Sports, Science and Technology (MEXT)-Supported Program for the Strategic Research Foundation at Private Universities, 2015-2019 concerning the constitution of total researching system for comprehensive disaster, medical management, corresponding to wide-scale disaster. 1067-991X/$36.00 Copyright © 2017 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2017.02.014
patient and 1 mildly ill patient who can sit on their own per flight. Two Dr. Helis have covered all of Shizuoka Prefecture since 2004, with an arrival time within 20 minutes.2 Our hospital (Shizuoka Hospital, Juntendo University) serves as the base hospital and is responsible for the eastern region of Shizuoka Prefecture located near Tokyo, including the Izu Peninsula. This region, approximately 4,090 km2 in area, has a population of approximately 2 million, is mountainous, and only contains a few hospitals. The journey from the southern tip of the peninsula to the critical care medical center of our hospital takes 1.5 hours by ambulance but only 15 minutes by helicopter. Shizuoka Prefecture established a neighbor prefecture agreement with both Kanagawa and Yamanashi Prefectures for the use of Dr. Helis in summer 2014. In Japan, there is no nationally established training program for Dr. Heli staff; each base hospital has its own training program.3 Our hospital's training program
includes on- and off-the-job training. Offthe-job training involves immediate cardiac life support, prehospital trauma care and evaluation, and an advanced trauma evaluation and care course; the training is relevant to the Japanese setting.4,5 After a minimum of 40 missions of on-the-job training, besides clinical skills (such as tracheal intubation, securing an infusion route, the insertion of a chest tube, cricothyroidotomy, and ultrasound techniques), the ability to cooperate with fire departments, leadership, and followership under a command control system, safety management at the scene, and communication skills inside and outside the Dr. Heli (including using wireless, appropriate triage, and the selection of appropriate medical facilities) are evaluated by supervisors. Each day, all of the Dr. Heli activities are discussed by all of the Dr. Heli staff members who were on duty for the day. Each month, each of the activities is evaluated by all of the Dr. Heli staff members. The problematic cases are discussed by all
2
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 1. A photograph taken at the scene. In the upper left is the minibus, and in the lower right is the van. The minibus dropped 0.5 m off a roadside cliff and rolled over after the collision.
Table 1 The List of Victims With Yellow Tags No.
Color of Tag
Age
Sex
Diagnosis
1 2 3 4 5 6 7
Yellow Yellow Yellow Yellow Yellow Green / yellow Green / yellow
64 66 57 77 56 80 0
Female Female Female Female Male Female Male
Thoracic spine fracture, lung contusion Multiple rib fractures with hemothorax Lumbar spine fracture Back contusion Abdominal contusion, wrist sprain Left rib fracture Head contusion
of the medical facilities, fire departments, and the administration personnel of Eastern Shizuoka Prefecture a few times a year in an attempt to reduce preventable deaths. Concerning Doctor Cars (Dr. Cars) in Japan, 2 systems have been established. One involves the base hospital itself having its own ambulance, which is dispatched to the scene with medical staff and evacuates and transports patients to the base hospital in cooperation with the fire department. Alternatively, an ambulance owned by the fire department parks at a hospital, picks up the medical staff, and is dispatched to the scene where patients are evacuated and transported to the appropriate hospital. Our hospital is the base for the Eastern Shizuoka Dr. Heli, and it is also the base for the Dr. Car program. The Dr. Car is an emergency vehicle that is sent to sites requiring emergency medical treatment that are relatively close to our center or when weather conditions do not allow the use of the Dr. Heli. Case Presentation At approximately 10 o'clock on a cloudy day in September 2015, a minibus carrying 18 people accidentally slid backwards
because of a malfunctioning brake system while climbing a steep incline on Togasayama Mountain, which is a rural area, colliding with a van (Toyota HiAce wagon) carrying 11 people that was situated behind the minibus. Togasayama Mountain is located 1 hour by car and 10 minutes by helicopter from our hospital. All of the victims belonged to the same religious organization and were heading to a temple located on Togasayama Mountain. The minibus slid off a roadside cliff at a height of 0.5 m and rolled over after colliding with the van (Fig. 1). Higashi Izu Fire Department received a 119 call that 2 adults had been injured in a traffic accident at 10:35 AM. After receiving this call, the Higashi Izu Fire Department dispatched 1 ambulance and requested the dispatch of the Eastern Shizuoka Dr. Heli at 10:46 AM. The Dr. Heli took off with 2 doctors and 2 nurses but failed to reach the rendezvous point near the accident site because of cloudy skies. On the back way to the base (Juntendo Shizuoka Hospital), the base staff requested the dispatch of the Kanagawa Dr. Heli at 11:11 AM because the weather in Kanagawa Prefecture was fine, making it easier for the Kanagawa Dr. Heli to reach the rendezvous point. The ambulance arrived at the scene
at 10:57 AM and noticed that this accident was a mass casualty event. Higashi Izu Fire Department obtained information on the mass casualty event, requested ambulances be dispatched from Ito Fire Department near Higashi Izu City at 11:12 AM based on the disaster relief agreements between the 2 local governments, and sent information on the mass casualty event to Juntendo Shizuoka Hospital. The staff at Juntendo Shizuoka Hospital then decided to dispatch a Dr. Car with 2 doctors to the rendezvous point at 11:16 AM. At the scene, all of the passengers and the drivers of the minibus and van underwent triage by emergency medical technicians from 11:00 to 11:39 AM. Ultimately, there were 5 victims with yellow tags (Table 1) and 24 with green tags. All 5 victims with yellow tags had been on board the minibus. Those with yellow tags were transported by ambulances sequentially, and those with green tags boarded an intact minibus provided by the religious organization and traveled to the rendezvous point. The Kanagawa Dr. Heli arrived at the rendezvous point at 11:38 AM. When the first victims with yellow tags arrived at the rendezvous point at 11:55 AM, the medical staff of the Kanagawa Dr. Heli checked them sequentially. The Dr. Car also arrived at the rendezvous point at 12:02 PM and cooperated with the staff of the Kanagawa Dr. Heli and Fire Department (Fig. 2). One victim with a green tag was upcoded to yellow by the doctor (patient no. 6 in Table 1). After reviewing the 5 people with yellow tags, the Kanagawa Dr. Heli evacuated the most severely injured victim with a yellow tag (patient no.1 in Table 1) to the general hospital of Tokai University at Kanagawa Prefecture at 12:40 PM. During triage and management, the sky cleared, and the Eastern Shizuoka Dr. Heli was requested to be dispatched again, this time successfully reaching the rendezvous point at 12:48 PM. The Eastern Shizuoka Dr. Heli evacuated the victim with a yellow tag to Juntendo Shizuoka Hospital (patient no. 2 in Table 1). Three of those with yellow tags (patient nos. 3, 4, and 6) as well as 1 with a green tag (they were family) were transported to Ito Municipal Hospital by ambulance separately. The remaining victim with a yellow tag (patient no. 5 in Table 1) was transported to another hospital in Atami City, next to Ito. After evacuating those with a yellow tag, the category of a 2-month-old male baby was changed from green to yellow because the baby was deemed vulnerable (patient no. 7 in Table 1). The Eastern Shizuoka Dr. Heli picked up the baby (patient no. 7) with his parents (who had a green tag) and
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 2. A map of the Izu Peninsula. The building indicated by a red cross is a hospital. The yellow circle indicates people with yellow tags, and the green circle indicates those with a green tag. Dispersion transportation was selected for victims with a yellow tag.
returned to Junendo Shizuoka Hospital (Fig. 3). An examination at the hospital revealed that the baby whose category was upgraded from green to yellow was intact. Excluding the 5 people with a green tag who refused to be transported to a medical facility, the remaining 14 victims with green tags were transported to local clinics and other distant hospitals in cars provided by the fire departments. In this mass casualty event, there were no mortalities, and all of the victims recovered without sequelae. Discussion We herein report the use of Dr. Helis and Dr. Cars in a mass casualty event caused by a traffic accident. There is a large amount of data supporting the evacuation of patients by helicopter during mass casualty events. Air medical benefits include response within a large geographic area, the highest level of prehospital medical care, identification of hospitals able to treat trauma patients, and facilitation of transport even in rural areas.6 A recent report also showed the efficacy of transportation by helicopter in comparison with ground ambulance, especially in cases of major trauma.7-9 In addition, Andruszkow et al10 reported that trauma patients benefited from helicopter emergency medical service (HEMS) rescue with in-hospital survival as the main outcome parameter. However, patients who were middle-aged and older, those who had suffered low-energy trauma, and patients with injuries of minor severity showed the highest survival benefit when rescued by HEMS.10 Furthermore, in cases of mass casualties, dispersion transportation beyond the typical
treatment capacities of a given medical facility is required, which is easily executed by the HEMS.11 Unfortunately, this case study lacked critical patients, whose inclusion would have helped to effectively test the efficacy of physician staffing. However, our medical staff manning the Dr. Helis and Dr. Cars also provide triage, medical treatments, selection of medical facilities, and dispersion transportation, in addition to the activities of the local fire department in rural areas. There are many controversies about who can provide the best medical care for critically ill patients in the prehospital setting. In general, the Anglo-American concept is to provide well-trained paramedics to fulfil this task, whereas in some European countries, this care is provided by emergency medical service physicians, similar to Japan.12 Previous studies have compared the morbidity and mortality between patients who received prehospital care from paramedics and patients who received prehospital care from a physician. Garner13 investigated all of the articles that examined the survival rates of prehospital trauma patients who were treated by physician versus paramedic teams in the context of helicopter transport in 2004. Ten of the 12 articles showed that prehospital management by a physician was associated with a survival benefit.13 In that report, because paramedics in Australia possessed many of the same procedural skills as physicians, Garner hypothesized that the lower mortality in physician-staffed units was associated with decision-making ability and not procedural skills. Recent studies have also suggested that prehospital management by a physician is associated with a
3
potential reduction in mortality in trauma patients in comparison with trauma patients who are managed by paramedics alone.14,15 Jung et al15 emphasized that better treatment outcomes were expected if dedicated trauma resuscitation teams actively intervened in the medical treatment process from the transport stage and if patients were transported to a hospital to receive definitive care within 3 hours after injury. In Japan, paramedics (who can secure a venous route, secure an airway with instruments, and inject adrenaline for patients in cardiac arrest) have been allowed to inject adrenaline for patients with anaphylactic shock, infuse glucose to patients with hypoglycemia, and secure a venous route for patients with unstable circulation. However, they are still not allowed to administer sedatives or painkillers, insert a chest drain tube or perform thoracentesis, or secure an airway before cardiac arrest, which are tasks that they would routinely perform in other counties.16-18 Accordingly, we routinely dispatch emergency physicians to the scene by helicopter and ambulance in the early stage, especially in cases of accidents involving trauma that occur in rural areas, similar to the present case. Dr. Cars or rapid response type doctor cars are often considered ineffective for treating distantly located severe trauma cases because of the inherent delay in receiving medical intervention. However, Abe and Ochiai19 reported a severely traumatized case who obtained a favorable outcome thanks to the cooperation between a Dr. Car and local medical facilities. In addition, Nakstad et al20 reported that a Dr. Car was essential in certain situations, especially when Dr. Helis cannot fly; indeed, among 4,777 requests for dispatch of Dr. Helis, 181 patients among 752 dispatches received lifesaving treatment from the staff of Dr. Cars instead of Dr. Helis. Accordingly, they concluded that Dr. Cars increased the availability of advanced prehospital life support offered by helicopter emergency medical services in Norway.20 From the standpoint of providing adequate medical resources for mass casualty events, we decided to dispatch Dr. Cars in light of the nonflying conditions for the Eastern Shizuoka Dr. Heli, on which only 2 doctors and nurses can board. Fortunately, the present mass casualty event did not involve multiple severely wounded victims. As a result, dispatch of the Dr. Heli and/or Dr. Car did not influence the ultimate outcome of the patients in the present event. However, when it is difficult to judge the severity of a mass casualty event, we must assume that the patients' condition and the event are severe because
4
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 3. A picture from the rendezvous point. The medical staff of the Dr. Car cooperated with emergency medical technicians from the fire department to triage victims with a green tag and had them transported in an intact minibus.
the Dr. Heli has been reported to be effective in treating patients with severe extrinsic medical conditions as a result of early medical intervention. Dr. Helis serve purposes beyond simply early transportation to a hospital, so overtriage by requesting a Dr. Heli is allowed in Eastern Shizuoka. In severe mass casualty events, all available resources are needed to obtain an early favorable outcome. The coordinated and combined use of Dr. Helis and Dr. Cars along with the help of the local fire department in response to a severe mass casualty event can help ensure appropriate triage, medical treatments, selection of medical facilities, and dispersion transportation, which can significantly reduce human suffering. References 1. Ministry of Health, Labour and Welfare. Current status of Doctor Helicopter [in Japanese]. 2015 May 29. 2. Omori K, Ohsaka H, Ishikawa K, et al. Introduction of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture in Japan. Air Med J. 2014;33:292e295. 3. Matsumoto H, Kanemaru K, Hara Y, et al. Development of an educational program for the helicopter emergency medical services in Japan. Air Med J. 2013;32:84e87. 4. Okudera H, Wakasugi M. Immediate Cardiac Life Support (ICLS) course developed by Japanese Association for Acute Medicine [in Japanese]. Nihon Rinsho. 2011;69:684e690. 5. Hondo K, Shiraishi A, Fujie S, Saitoh D, Otomo Y. In-hospital trauma mortality has decreased in
6.
7.
8.
9.
10.
11.
12.
13.
14.
Japan possibly due to trauma education. J Am Coll Surg. 2013;217:850e857. Stohler SA, Jacobs LM, Gabram SG. Roles of a helicopter emergency medical service in mass casualty incidents. J Air Med Transp. 1991;10: 7e13. Andruszkow H, Lefering R, Frink M, et al. Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients. Crit Care. 2013;17:R124. Taylor C, Jan S, Curtis K, et al. The costeffectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia. Injury. 2012;43:1843e1849. Galvagno Jr SM, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012;307:1602e1610. Andruszkow H, Schweigkofler U, Lefering R, et al. Impact of helicopter emergency medical service in traumatized patients: which patient benefits most? PLoS One. 2016;11:e0146897. Postma IL, Weel H, Heetveld MJ, et al. Patient distribution in a mass casualty event of an airplane crash. Injury. 2013;44:1574e1578. Timmermanna A, Russoa SG, Hollmann MW. Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the AngloAmerican concept. Curr Opin Anesthesiol. 2008;21:222e227. Garner AA. The role of physician staffing of helicopter emergency medical services in prehospital trauma response. Emerg Med Australas. 2004;16:318e323. Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management
15.
16.
17.
18.
19.
20.
by paramedics only. Emerg Med J. 2015;32: 869e875. Jung K, Huh Y, Lee JC, et al. Reduced mortality by physician-staffed HEMS dispatch for adult blunt trauma patients in Korea. J Korean Med Sci. 2016;31:1656e1661. Ishikawa K, Omori K, Takeuchi I, et al. A comparison between evacuation from the scene and interhospital transportation using a helicopter for subarachnoid hemorrhage. Am J Emerg Med. 2016 Dec 10 [Epub ahead of print]. Andrew E, de Wit A, Meadley B, Cox S, Bernard S, Smith K. Characteristics of patients transported by a paramedic-staffed helicopter emergency medical service in Victoria, Australia. Prehosp Emerg Care. 2015;19:416e424. Caldow SJ, Parke TR, Graham CA, Munro PT. Aeromedical retrieval to a university hospital emergency department in Scotland. Emerg Med J. 2005;22:53e55. Abe T, Ochiai H. Rapid response doctor cars for cases of severe trauma in remote locations: a life saved owing to cooperation between a doctor car and a physician from a local medical facility. J Rural Med. 2016;11:25e29. Nakstad AR, Sørebø H, Heimdal HJ, Strand T, Sandberg M. Rapid response car as a supplement to the helicopter in a physician-based HEMS system. Acta Anaesthesiol Scand. 2004;48: 588e591.
All authors are affiliated with the department of acute critical care at Shizouka Hospital, Juntendo University in Shizouka, Japan. Hiromichi Ohsaka, MD, PhD, is Assistant Professor. Kouhei Ishikawa, MD, is Teaching Associate. Kazuhiko Omori, MD, PhD, is Assistant Professor. Kei Jitsuiki, MD, is PhD Course Student. Toshihiko Yoshizawa, MD, is Teaching Associate. Youichi Yanagawa, MD, PhD, is Professor and can be reached at [email protected].
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Case Report
Management of Mass Casualties Using Doctor Helicopters and Doctor Cars Hiromichi Ohsaka, MD, PhD, Kouhei Ishikawa, MD, Kazuhiko Omori, MD, PhD, Kei Jitsuiki, MD, Toshihiko Yoshizawa, MD, Youichi Yanagawa, MD, PhD a b s t r a c t At approximately 10 o'clock in September 2015, a minibus carrying 18 people accidentally slid backwards because of a malfunctioning brake system while climbing a steep incline on Togasayama Mountain, colliding with a van (Toyota HiAce wagon) carrying 11 people that was situated behind the minibus. Togasayama Mountain is located 1 hour by car and 10 minutes by helicopter from our hospital. The minibus slid off a roadside cliff at a height of 0.5 m and rolled over after colliding with the van. There were 7 victims with yellow tags and 22 with green tags. Two Doctor Helicopters and 1 Doctor Car cooperated with the fire departments by providing medical treatments, selection of medical facilities, and dispersion transportation. In this mass casualty event, there were no mortalities, and all of the victims recovered without sequelae. The coordinated and combined use of Doctor Helicopters and Doctor Cars in addition to the activities of the fire department in response to a mass casualty event resulted in appropriate triage, medical treatments, selection of medical facilities, and dispersion transportation. Copyright © 2017 by Air Medical Journal Associates
According to HEM-net (http://www. hemnet.jp/english/index.html), the Doctor Helicopter (Dr. Heli) system has been in use in Japan since June 2007. As of October 2016, 47 Dr. Heli bases in 39 of 47 prefectures have been established in Japan. More than 37 prefectures had established neighboring-prefecture agreements for cooperation during mass casualty incidents or overlapping requests for Dr. Helis by 2013.1 The crews of Dr. Helis generally consist of a pilot, a mechanic, a doctor, and a nurse. The use of Dr. Helis is limited to the daytime and fair weather. In case of mass casualties, the medical staff can be increased to 2 doctors and 2 nurses. Dr. Helis can accommodate up to 1 severely ill
Supported by the Ministry of Education, Culture, Sports, Science and Technology (MEXT)-Supported Program for the Strategic Research Foundation at Private Universities, 2015-2019 concerning the constitution of total researching system for comprehensive disaster, medical management, corresponding to wide-scale disaster. 1067-991X/$36.00 Copyright © 2017 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2017.02.014
patient and 1 mildly ill patient who can sit on their own per flight. Two Dr. Helis have covered all of Shizuoka Prefecture since 2004, with an arrival time within 20 minutes.2 Our hospital (Shizuoka Hospital, Juntendo University) serves as the base hospital and is responsible for the eastern region of Shizuoka Prefecture located near Tokyo, including the Izu Peninsula. This region, approximately 4,090 km2 in area, has a population of approximately 2 million, is mountainous, and only contains a few hospitals. The journey from the southern tip of the peninsula to the critical care medical center of our hospital takes 1.5 hours by ambulance but only 15 minutes by helicopter. Shizuoka Prefecture established a neighbor prefecture agreement with both Kanagawa and Yamanashi Prefectures for the use of Dr. Helis in summer 2014. In Japan, there is no nationally established training program for Dr. Heli staff; each base hospital has its own training program.3 Our hospital's training program
includes on- and off-the-job training. Offthe-job training involves immediate cardiac life support, prehospital trauma care and evaluation, and an advanced trauma evaluation and care course; the training is relevant to the Japanese setting.4,5 After a minimum of 40 missions of on-the-job training, besides clinical skills (such as tracheal intubation, securing an infusion route, the insertion of a chest tube, cricothyroidotomy, and ultrasound techniques), the ability to cooperate with fire departments, leadership, and followership under a command control system, safety management at the scene, and communication skills inside and outside the Dr. Heli (including using wireless, appropriate triage, and the selection of appropriate medical facilities) are evaluated by supervisors. Each day, all of the Dr. Heli activities are discussed by all of the Dr. Heli staff members who were on duty for the day. Each month, each of the activities is evaluated by all of the Dr. Heli staff members. The problematic cases are discussed by all
2
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 1. A photograph taken at the scene. In the upper left is the minibus, and in the lower right is the van. The minibus dropped 0.5 m off a roadside cliff and rolled over after the collision.
Table 1 The List of Victims With Yellow Tags No.
Color of Tag
Age
Sex
Diagnosis
1 2 3 4 5 6 7
Yellow Yellow Yellow Yellow Yellow Green / yellow Green / yellow
64 66 57 77 56 80 0
Female Female Female Female Male Female Male
Thoracic spine fracture, lung contusion Multiple rib fractures with hemothorax Lumbar spine fracture Back contusion Abdominal contusion, wrist sprain Left rib fracture Head contusion
of the medical facilities, fire departments, and the administration personnel of Eastern Shizuoka Prefecture a few times a year in an attempt to reduce preventable deaths. Concerning Doctor Cars (Dr. Cars) in Japan, 2 systems have been established. One involves the base hospital itself having its own ambulance, which is dispatched to the scene with medical staff and evacuates and transports patients to the base hospital in cooperation with the fire department. Alternatively, an ambulance owned by the fire department parks at a hospital, picks up the medical staff, and is dispatched to the scene where patients are evacuated and transported to the appropriate hospital. Our hospital is the base for the Eastern Shizuoka Dr. Heli, and it is also the base for the Dr. Car program. The Dr. Car is an emergency vehicle that is sent to sites requiring emergency medical treatment that are relatively close to our center or when weather conditions do not allow the use of the Dr. Heli. Case Presentation At approximately 10 o'clock on a cloudy day in September 2015, a minibus carrying 18 people accidentally slid backwards
because of a malfunctioning brake system while climbing a steep incline on Togasayama Mountain, which is a rural area, colliding with a van (Toyota HiAce wagon) carrying 11 people that was situated behind the minibus. Togasayama Mountain is located 1 hour by car and 10 minutes by helicopter from our hospital. All of the victims belonged to the same religious organization and were heading to a temple located on Togasayama Mountain. The minibus slid off a roadside cliff at a height of 0.5 m and rolled over after colliding with the van (Fig. 1). Higashi Izu Fire Department received a 119 call that 2 adults had been injured in a traffic accident at 10:35 AM. After receiving this call, the Higashi Izu Fire Department dispatched 1 ambulance and requested the dispatch of the Eastern Shizuoka Dr. Heli at 10:46 AM. The Dr. Heli took off with 2 doctors and 2 nurses but failed to reach the rendezvous point near the accident site because of cloudy skies. On the back way to the base (Juntendo Shizuoka Hospital), the base staff requested the dispatch of the Kanagawa Dr. Heli at 11:11 AM because the weather in Kanagawa Prefecture was fine, making it easier for the Kanagawa Dr. Heli to reach the rendezvous point. The ambulance arrived at the scene
at 10:57 AM and noticed that this accident was a mass casualty event. Higashi Izu Fire Department obtained information on the mass casualty event, requested ambulances be dispatched from Ito Fire Department near Higashi Izu City at 11:12 AM based on the disaster relief agreements between the 2 local governments, and sent information on the mass casualty event to Juntendo Shizuoka Hospital. The staff at Juntendo Shizuoka Hospital then decided to dispatch a Dr. Car with 2 doctors to the rendezvous point at 11:16 AM. At the scene, all of the passengers and the drivers of the minibus and van underwent triage by emergency medical technicians from 11:00 to 11:39 AM. Ultimately, there were 5 victims with yellow tags (Table 1) and 24 with green tags. All 5 victims with yellow tags had been on board the minibus. Those with yellow tags were transported by ambulances sequentially, and those with green tags boarded an intact minibus provided by the religious organization and traveled to the rendezvous point. The Kanagawa Dr. Heli arrived at the rendezvous point at 11:38 AM. When the first victims with yellow tags arrived at the rendezvous point at 11:55 AM, the medical staff of the Kanagawa Dr. Heli checked them sequentially. The Dr. Car also arrived at the rendezvous point at 12:02 PM and cooperated with the staff of the Kanagawa Dr. Heli and Fire Department (Fig. 2). One victim with a green tag was upcoded to yellow by the doctor (patient no. 6 in Table 1). After reviewing the 5 people with yellow tags, the Kanagawa Dr. Heli evacuated the most severely injured victim with a yellow tag (patient no.1 in Table 1) to the general hospital of Tokai University at Kanagawa Prefecture at 12:40 PM. During triage and management, the sky cleared, and the Eastern Shizuoka Dr. Heli was requested to be dispatched again, this time successfully reaching the rendezvous point at 12:48 PM. The Eastern Shizuoka Dr. Heli evacuated the victim with a yellow tag to Juntendo Shizuoka Hospital (patient no. 2 in Table 1). Three of those with yellow tags (patient nos. 3, 4, and 6) as well as 1 with a green tag (they were family) were transported to Ito Municipal Hospital by ambulance separately. The remaining victim with a yellow tag (patient no. 5 in Table 1) was transported to another hospital in Atami City, next to Ito. After evacuating those with a yellow tag, the category of a 2-month-old male baby was changed from green to yellow because the baby was deemed vulnerable (patient no. 7 in Table 1). The Eastern Shizuoka Dr. Heli picked up the baby (patient no. 7) with his parents (who had a green tag) and
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 2. A map of the Izu Peninsula. The building indicated by a red cross is a hospital. The yellow circle indicates people with yellow tags, and the green circle indicates those with a green tag. Dispersion transportation was selected for victims with a yellow tag.
returned to Junendo Shizuoka Hospital (Fig. 3). An examination at the hospital revealed that the baby whose category was upgraded from green to yellow was intact. Excluding the 5 people with a green tag who refused to be transported to a medical facility, the remaining 14 victims with green tags were transported to local clinics and other distant hospitals in cars provided by the fire departments. In this mass casualty event, there were no mortalities, and all of the victims recovered without sequelae. Discussion We herein report the use of Dr. Helis and Dr. Cars in a mass casualty event caused by a traffic accident. There is a large amount of data supporting the evacuation of patients by helicopter during mass casualty events. Air medical benefits include response within a large geographic area, the highest level of prehospital medical care, identification of hospitals able to treat trauma patients, and facilitation of transport even in rural areas.6 A recent report also showed the efficacy of transportation by helicopter in comparison with ground ambulance, especially in cases of major trauma.7-9 In addition, Andruszkow et al10 reported that trauma patients benefited from helicopter emergency medical service (HEMS) rescue with in-hospital survival as the main outcome parameter. However, patients who were middle-aged and older, those who had suffered low-energy trauma, and patients with injuries of minor severity showed the highest survival benefit when rescued by HEMS.10 Furthermore, in cases of mass casualties, dispersion transportation beyond the typical
treatment capacities of a given medical facility is required, which is easily executed by the HEMS.11 Unfortunately, this case study lacked critical patients, whose inclusion would have helped to effectively test the efficacy of physician staffing. However, our medical staff manning the Dr. Helis and Dr. Cars also provide triage, medical treatments, selection of medical facilities, and dispersion transportation, in addition to the activities of the local fire department in rural areas. There are many controversies about who can provide the best medical care for critically ill patients in the prehospital setting. In general, the Anglo-American concept is to provide well-trained paramedics to fulfil this task, whereas in some European countries, this care is provided by emergency medical service physicians, similar to Japan.12 Previous studies have compared the morbidity and mortality between patients who received prehospital care from paramedics and patients who received prehospital care from a physician. Garner13 investigated all of the articles that examined the survival rates of prehospital trauma patients who were treated by physician versus paramedic teams in the context of helicopter transport in 2004. Ten of the 12 articles showed that prehospital management by a physician was associated with a survival benefit.13 In that report, because paramedics in Australia possessed many of the same procedural skills as physicians, Garner hypothesized that the lower mortality in physician-staffed units was associated with decision-making ability and not procedural skills. Recent studies have also suggested that prehospital management by a physician is associated with a
3
potential reduction in mortality in trauma patients in comparison with trauma patients who are managed by paramedics alone.14,15 Jung et al15 emphasized that better treatment outcomes were expected if dedicated trauma resuscitation teams actively intervened in the medical treatment process from the transport stage and if patients were transported to a hospital to receive definitive care within 3 hours after injury. In Japan, paramedics (who can secure a venous route, secure an airway with instruments, and inject adrenaline for patients in cardiac arrest) have been allowed to inject adrenaline for patients with anaphylactic shock, infuse glucose to patients with hypoglycemia, and secure a venous route for patients with unstable circulation. However, they are still not allowed to administer sedatives or painkillers, insert a chest drain tube or perform thoracentesis, or secure an airway before cardiac arrest, which are tasks that they would routinely perform in other counties.16-18 Accordingly, we routinely dispatch emergency physicians to the scene by helicopter and ambulance in the early stage, especially in cases of accidents involving trauma that occur in rural areas, similar to the present case. Dr. Cars or rapid response type doctor cars are often considered ineffective for treating distantly located severe trauma cases because of the inherent delay in receiving medical intervention. However, Abe and Ochiai19 reported a severely traumatized case who obtained a favorable outcome thanks to the cooperation between a Dr. Car and local medical facilities. In addition, Nakstad et al20 reported that a Dr. Car was essential in certain situations, especially when Dr. Helis cannot fly; indeed, among 4,777 requests for dispatch of Dr. Helis, 181 patients among 752 dispatches received lifesaving treatment from the staff of Dr. Cars instead of Dr. Helis. Accordingly, they concluded that Dr. Cars increased the availability of advanced prehospital life support offered by helicopter emergency medical services in Norway.20 From the standpoint of providing adequate medical resources for mass casualty events, we decided to dispatch Dr. Cars in light of the nonflying conditions for the Eastern Shizuoka Dr. Heli, on which only 2 doctors and nurses can board. Fortunately, the present mass casualty event did not involve multiple severely wounded victims. As a result, dispatch of the Dr. Heli and/or Dr. Car did not influence the ultimate outcome of the patients in the present event. However, when it is difficult to judge the severity of a mass casualty event, we must assume that the patients' condition and the event are severe because
4
H. Ohsaka et al. / Air Medical Journal xxx (2017) 1e4
Figure 3. A picture from the rendezvous point. The medical staff of the Dr. Car cooperated with emergency medical technicians from the fire department to triage victims with a green tag and had them transported in an intact minibus.
the Dr. Heli has been reported to be effective in treating patients with severe extrinsic medical conditions as a result of early medical intervention. Dr. Helis serve purposes beyond simply early transportation to a hospital, so overtriage by requesting a Dr. Heli is allowed in Eastern Shizuoka. In severe mass casualty events, all available resources are needed to obtain an early favorable outcome. The coordinated and combined use of Dr. Helis and Dr. Cars along with the help of the local fire department in response to a severe mass casualty event can help ensure appropriate triage, medical treatments, selection of medical facilities, and dispersion transportation, which can significantly reduce human suffering. References 1. Ministry of Health, Labour and Welfare. Current status of Doctor Helicopter [in Japanese]. 2015 May 29. 2. Omori K, Ohsaka H, Ishikawa K, et al. Introduction of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture in Japan. Air Med J. 2014;33:292e295. 3. Matsumoto H, Kanemaru K, Hara Y, et al. Development of an educational program for the helicopter emergency medical services in Japan. Air Med J. 2013;32:84e87. 4. Okudera H, Wakasugi M. Immediate Cardiac Life Support (ICLS) course developed by Japanese Association for Acute Medicine [in Japanese]. Nihon Rinsho. 2011;69:684e690. 5. Hondo K, Shiraishi A, Fujie S, Saitoh D, Otomo Y. In-hospital trauma mortality has decreased in
6.
7.
8.
9.
10.
11.
12.
13.
14.
Japan possibly due to trauma education. J Am Coll Surg. 2013;217:850e857. Stohler SA, Jacobs LM, Gabram SG. Roles of a helicopter emergency medical service in mass casualty incidents. J Air Med Transp. 1991;10: 7e13. Andruszkow H, Lefering R, Frink M, et al. Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients. Crit Care. 2013;17:R124. Taylor C, Jan S, Curtis K, et al. The costeffectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia. Injury. 2012;43:1843e1849. Galvagno Jr SM, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012;307:1602e1610. Andruszkow H, Schweigkofler U, Lefering R, et al. Impact of helicopter emergency medical service in traumatized patients: which patient benefits most? PLoS One. 2016;11:e0146897. Postma IL, Weel H, Heetveld MJ, et al. Patient distribution in a mass casualty event of an airplane crash. Injury. 2013;44:1574e1578. Timmermanna A, Russoa SG, Hollmann MW. Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the AngloAmerican concept. Curr Opin Anesthesiol. 2008;21:222e227. Garner AA. The role of physician staffing of helicopter emergency medical services in prehospital trauma response. Emerg Med Australas. 2004;16:318e323. Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management
15.
16.
17.
18.
19.
20.
by paramedics only. Emerg Med J. 2015;32: 869e875. Jung K, Huh Y, Lee JC, et al. Reduced mortality by physician-staffed HEMS dispatch for adult blunt trauma patients in Korea. J Korean Med Sci. 2016;31:1656e1661. Ishikawa K, Omori K, Takeuchi I, et al. A comparison between evacuation from the scene and interhospital transportation using a helicopter for subarachnoid hemorrhage. Am J Emerg Med. 2016 Dec 10 [Epub ahead of print]. Andrew E, de Wit A, Meadley B, Cox S, Bernard S, Smith K. Characteristics of patients transported by a paramedic-staffed helicopter emergency medical service in Victoria, Australia. Prehosp Emerg Care. 2015;19:416e424. Caldow SJ, Parke TR, Graham CA, Munro PT. Aeromedical retrieval to a university hospital emergency department in Scotland. Emerg Med J. 2005;22:53e55. Abe T, Ochiai H. Rapid response doctor cars for cases of severe trauma in remote locations: a life saved owing to cooperation between a doctor car and a physician from a local medical facility. J Rural Med. 2016;11:25e29. Nakstad AR, Sørebø H, Heimdal HJ, Strand T, Sandberg M. Rapid response car as a supplement to the helicopter in a physician-based HEMS system. Acta Anaesthesiol Scand. 2004;48: 588e591.
All authors are affiliated with the department of acute critical care at Shizouka Hospital, Juntendo University in Shizouka, Japan. Hiromichi Ohsaka, MD, PhD, is Assistant Professor. Kouhei Ishikawa, MD, is Teaching Associate. Kazuhiko Omori, MD, PhD, is Assistant Professor. Kei Jitsuiki, MD, is PhD Course Student. Toshihiko Yoshizawa, MD, is Teaching Associate. Youichi Yanagawa, MD, PhD, is Professor and can be reached at [email protected].