THE PROBLEM OF MULTIPLE AND ASSOCIATED INJURY (POLYTRAUMA), THE WAYS OF SOLUTION AND THE ROLE OF DISASTER MEDICINE SERVICE
All-Russian Center of Disaster Medicine “Zashchita”,
Moscow, Russia
All-Russian public institution of experts in disaster medicine
The problem of arrangement of medical aid for patients with multiple and associated injuries (polytrauma) is associated with multivariable characteristics and is important for healthcare system in daily activity and in emergency situations (ES) [1, 13]. The significant level of mortality and disability after polytrauma puts this problem into the number of the important medicosocial problems of federal and public significance. It is undoubtedly that the measures for improvement of arrangement of medical aid for patients with polytrauma are associated with development of the system for arrangement of emergency aid for the population, especially for victims of road traffic accidents (RTA). In the Russian Federation the annual rate of road traffic accidents is 42-46 % of the total number of emergency situations with medicosanitary consequences (ES), and 50-52 % from the general amount of technogenic ES. The number of RTA victims is 42-48 % among victims of ES with medicosanitary consequences, and 64-68 % among victims of technogenic ES. The most severe group of RTA victims is patients with multiple and associated injury (polytrauma).
The great attention is given to improvement of the system of arrangement of medical aid for victims of road traffic accidents, particularly, for patients with polytrauma [1, 2, 3, 6, 9, 13]. The organizational and clinical approaches to tactics of management of patients are developed with consideration of three-level system of arrangement of medical aid in regions, and with consideration of possibilities of federal medical facilities [4, 6, 8, 10]. The number of trauma centers has increased significantly within the recent years. Moreover, 39 % (586) of them are trauma centers of level 1 and 2, which receive about 72 % of patients according to the data from the Russian Ministry of Health [6]. The prime importance relates to the issues of transportation of patients [2, 7, 9, 10] and are embodied in the orders of arrangement of medical aid: the order of arrangement of medical aid for patients with associated, multiple and isolated injuries which are accompanied by shock (confirmed by the order of Russian Health Ministry, November, 15, 2012), No.927n), the order of arrangement of emergency (including emergency specialized) aid (confirmed by the order by Russian Heath Ministry, June, 20, 2013, No.388n), the order of arrangement and realization of medical aid including realization of medical evacuation (the project has been developed and is being reviewed in the Ministry of Heath of Russia) etc.
Mobile emergency aid teams take the main role in arrangement of prehospital emergency medical aid for victims of RTA and transfer to medical facilities. In case of elimination of medicosanitary consequences of emergency situations such teams work in the system of disaster medicine [4].
It is necessary to note that the service of disaster medicine takes active participation in the system of arrangement and realization of emergency medical aid for victims suffered both in ES and in accidents of daily activity. In some subjects of the Russian Federation the territorial centers of disaster medicine include road medical services which are destined to reduce time of arrival of medical teams to RTA victims that is extremely important for salvation of life and health of victims. As of January, 1, 2016, there are 64 road subdivisions in subjects of the Russian Federation: Sverdlovsk region (12), Volgograd region (3), Samara region (2), Kurgan region (5), Ulyanovsk region (1), Novosibirsk region (2), Tyumen region (4), Omsk region (2), Nizhny Novgorod region (5), Perm region (2), Krasnoyarsk region (5), Republic of Dagestan (11), Buryatia (3), Ingushetia (2), Khanty-Mansiisk autonomous district (5). Staff formations of the territorial centers of disaster medicine (more than 70 teams of specialized medical team of disaster medicine services) take direct participation in arrangement of emergency medical aid for RTA victims on the federal roads and in 15 subjects of the Russian Federation: the regions of Bryansk, Voronezh, Lipetsk, Moscow, Yaroslavl, Kemerovo, Sverdlovsk, Astrakhan and Saratov regions, Altai Territory, Republic of Buryatia, Republic of Tyva, Tatarstan, Ingushetia and Stavropol region [3]. The great work in realization of emergency medical aid is realized by specialists of departments of emergency consultative medical aid and medical evacuation of the territorial centers of disaster medicine and leading multi-profile hospitals. Telemedicine is actively developing, which allows increasing the level of availability and quality of medical aid in hospital conditions.
Sanitary aviation is used in 63 subjects of the Russian Federation; 2/3 of cases relate to helicopter evacuation. 146 heliport decks are fully equipped [6]. Sanitary aviation is used both for medical evacuation from the accident site and for interhospital transfer to leading trauma centers. Training for specialists of aviation medical teams is realized on the basis of All-Russian Center of Disaster Medicine (307 persons completed their training in 2015) [3].
It is justifiably and reasonably to realize further active participation of the territorial centers of disaster medicine in the system of arrangement and realization of emergency medical aid (including aid for RTA victims) in coordination and monitoring of the issues of availability and quality of emergency medical aid at regional level, investigation of optimal routing, organization and monitoring of arrangement of medical aid, participation in realization of medical aid in RTA [2, 8]. According to our opinion, the active role of the territorial centers of disaster medicine in the system of arrangement and realization of emergency aid for the population in non-emergent situations will favor solution of the issues of availability and quality of emergency medical aid in the mode of daily activity, but also will increase the level of readiness to quick response and realization of medical aid in ES from the side of the territorial centers of disaster medicine and from the side of disaster medicine service at the level of a subject of the Russian Federation.
Considering the importance of the problem of polytrauma for disaster medicine, within a framework of activity of the All-Russian organization of specialists in the field of disaster medicine and the Profile commission of disaster medicine of the Russian Ministry of Health, “The Clinical Recommendations for Arrangement of Medical Aid for Victims with Polytrauma in Emergency Situations” have been developed and discussed in November 2015 (the executives in charge are Savvin Yu.N., MD, PhD; Kudryavtsev B.P., professor). The recommendations are presented at www.vcmk.ru [13, 15]. With consideration of the above-mentioned recommendations, 19 clinical recommendations for disaster medicine were developed and confirmed in 2015 (realization of medical aid in emergency situations). The following moments determine the necessity for their development and implementation. The basis for medical and evacuation provision of the population in emergency situations was and is the system of staged treatment of patients with their evacuation for the purpose intended [14]. However the number of stages of medical aid and evacuation should be minimized. In conditions of ES it is necessary to use special arrangement of activity of regulatory bodies in healthcare and medical facilities, as well as appropriate training and readiness of medical employees to fast response and realization of medical aid. Almost each ES has its own specific patterns of a medicotactical situation with influence on the process of organization and realization of medical aid for victims. The diversity of the possible factors and conditions of emergency situations does not allow complete standardization of delivery of medical aid. At the same time, the prepared recommendations for disaster medicine consider the whole range of circumstances such as possible enforced delay of medical evacuation, situational reduction or increase in volume of medical aid at all stages of medical evacuation, variants of delivery of medical aid in the filed multi-profile hospital [5, 11, 12, 13, 15].
The journal Polytrauma (issue 4, 2015) presents an article by Agadzhanyan V.V., MD, PhD, professor, “Arrangement of medical assistance for multiple and associated injuries (polytrauma). The clinical recommendations (the treatment protocol), (the project)” [1]. The project of the clinical recommendations, which is presented for discussion, contains the modern generalized organizational and clinical approaches to management of patients with polytrauma at prehospital and hospital stages. It is interesting that the own experience of treatment of polytrauma (more than 3,000 observed cases) is considered. The high priority objectives of the prehospital stage, the principles of medical aid at the accident site, the range of medicodiagnostic measures and tactics in hospital conditions have been determined. The measures for the period of medical evacuation to a medical facility have been systematized. At whole, according to our opinion, the presented treatment protocol includes the current substantiated medicodiagnostic measures and the organizational approaches to tactics of management of patients. Confirmation of the clinical recommendations will favor development of the uniform approaches to treating patients with polytrauma, increasing quality and availability of the modern types of medical aid for such patients.
CONCLUSION
The problem of delivery of medical aid for patients with polytrauma is actual for healthcare both in emergency situations and in daily activities. The main efforts for its solution from the side of medical facilities are directed to timely delivery of emergency medical aid for patients at the accident site (RTA), fast medical evacuation to a medical facility with appropriate measures for delivery of necessary medical aid, realization of further specific treatment and rehabilitation. The optimal condition for polytrauma is admission to a medical facility with level 1 trauma center.