ARRANGEMENT OF MEDICAL AID FOR VICTIMS OF ROAD TRAFFIC ACCIDENTS AT PREHOSPITAL STAGE OF MEDICAL EVACUATION
Northern State Medical University, Arkhangelsk, Russia
Yaroslavl State Medical University, Yaroslavl, Russia
Severodvinsk City Hospital of Emergency Aid #2, Severodvinsk, Russia
Road traffic injuries (RTI) are related to the characteristics of worldwide epidemy and are an important social and medical problem. According to the report of road traffic safety in the world in 2013 published by the World Health Organization, each hour 90 persons die as result of road traffic accidents (RTA), each day – about 2,200, each year – about 1.24 million [16]. In comparison with other injuries relating to external factors, RTA results in 12 times higher general mortality, 6 times higher disability and 7 times higher demand for hospital admission [2]. These findings determine the vital need for improving arrangement of medical aid for victims of RTA.
So far as the survival rate of victims of RTA is directly correlated with timeliness and strict adherence to the protocols of measures for arranging medical aid, it is necessary to improve it at prehospital stage. It is the exceedingly important problem of disaster medicine, because 2/3 of cases are lethal outcomes before arrival of emergency aid team to an accident site, and 2-11 % of cases are associated with transportation to medical facilities [3, 10, 14, 15, 21, 27, 29]. The main causes of lethal outcomes are severe traumatic brain injury, asphyxia, shock, severe associated and multiple injuries to the chest and abdominal organs. The additional causes of lethal outcomes are delayed initiation of medical aid for life threatening states, late arrival of emergency aid team, incorrect diagnosis and absent knowledge about first aid realized by bystanders, drivers and road police officers [46, 49, 31].
Considering low indices of staffing level in medical facilities and emergency aid stations, absence of necessary medical equipment, insufficient amount of medical and specialized teams, absence of neurosurgery departments in regions of most territorial and federal roads it is certainly that a chance of a favorable outcome is higher in road traffic accidents in a populated locality in comparison with remote regions [24]. According to the statistical data, severity of consequences on the federal roads is 3 times higher than in cities. Therefore, for reducing time of response of emergency services the underpopulated areas need for territorial centers of disaster medicine as a part of uniform dispatcher service [20, 37, 38].
In concordance with the federal law #32 3FZ, November, 21, 2-11, “About the foundations of health protection for citizens of the Russian Federation” in life threatening cases before arrival of emergency team the primary care is realized by police officers, rescuers of various categories, fire service employees, employees of Ministry of Emergency Situations and Ministry of Defense of the Russian Federation. The territorial centers of disaster medicine are responsible for education for the above mentioned categories of employees [7].
The special attention is related to regular education for drivers in terms of realizing primary care. The results of the studies showed high readiness for participation of drivers in primary care, but the causes of non-fulfilment of necessary measures are insufficient knowledge and fear of harm. We think it is necessary to implement control examination of rendering first aid at least one time per 10 years during exchange of driving license. In case of unsatisfactory level of knowledge, training and final exam are repeated out of the funds of drivers. Therefore, development and implementation of new educational programs, acquisition of skill and conduction of simple medical manipulations may significantly decrease level of disability and mortality in victims after RTA [12, 13].
Because road traffic accidents are mainly related to associated and multiple injuries, it is important to quickly and without injuries to separate some groups of main and life threatening injuries and to realize necessary and sufficient assistance for victims [4, 30, 39, 48]. The essential factor determining efficiency of medical provision in case of RTA is completeness and professionalism of realization of prehospital medical diagnostic measures. Estimation of severity of state, diagnostics of a leading symptomatic complex, airway management, temporary arrest of bleeding, adequate immobilization and anti-shock therapy present the unquestionable list of manipulations during rendering medical assistance for victims of RTA. These manipulations should be taken into special attention during education for physicians and paramedics at the basis of educational departments of territorial disaster medicine centers [6, 11, 34, 40].
The most difficult category of patients is patients with polytrauma [1, 35]. The volume of assistance for such patients should include necessary elimination of shock, i.e. the part of such assistance is appropriate transport immobilization. Kashtan anti-shock suit is included into the standard of realization of medical assistance for patients with polytrauma. This is an optimal measure for prevention and elimination of hypovolemic and traumatic shock, as well as for atraumatic transport immobilization. The experience of traumatologists in Yaroslavl offers an approbated and patented shield by Klyuchevskiy-Zaytsev. This shield is used both for transport immobilization and prevention of traumatic shock [23, 41]. The special attention should be given to correct organization of infusion therapy as one of the essential directions for weakening severe consequences of primary period of prehospital stage and elimination of shock [8, 22, 36, 42].
For subdivisions participating in rectification of consequences of RTA it is necessary to implement the protocol of equipping with special kits, immobilizing and transporting measures, and rescue technique. According to the experience, timely and qualitative realization of the above mentioned measures significantly increases survival rate and improves rehabilitation. Emergency assistance for victims of RTA is considered as continuous system of medical assistance from the moment of appearance of a life threatening state to the rehabilitation stage [26, 43].
The primary factor is promptness of medical aid at the accident site and during transportation to a medical facility. The concept of “the golden hour” (a temporary period from the moment of an injury to hospital admission) by R.A. Cowley is well-known. However some authors recommend the optimal time interval of 30 minutes, because of absence of medical aid within 1 hour increases amount of lethal outcomes after severe road traffic injuries by 30 %, absence of aid within 3 hours – by 60 %, within 6 hours – almost two times [19].
For significant acceleration of realization of medical aid, especially in remote regions, helicopter medical aviation teams are successfully used. So, usage of helicopters for transportation of medical employees to the accident site significantly reduces duration of “the phase without aid” and several times hastens collection of true information about operative medical situation [33]. There is a training center for preparing medical specialists who realize medical aid for victims of RTA with use of helicopters. The center functions on the basis of All-Russian Center of Disaster Medicine “Zashchita”.
In Russia one may observe some problems of making decisions (by dispatch services) about choice of a team for making assistance for victims of RTA. It is associated with the significant deficiency of staff and non-adequate estimation of a situation by bystanders and employees of special services. The additional measures for organizing and optimizing qualitative medical aid after RTA at remote regions of roads may be development of telemedicine technologies for distant consultative and diagnostic aid between facilities of different levels [45].
According to the results of the studies, the main principle for minimizing disability and mortality after RTA is making assistance by resuscitation medical teams of emergency services and admission to the specialized trauma center [17, 25].
In the Russian Federation the trauma centers of level 3 are created on the basis of central regional hospitals, which are able to realize qualified surgical and, in some cases, traumatological assistance. The level 2 trauma centers are city multi-profile hospitals and intermunicipal centers, which realize medical aid for patients with multiple and associated injuries from several neighboring regions, or emergency aid hospitals with capacity of realizing assistance for patients with injuries accompanied by shock. The level 1 trauma centers are usually developed as a part of national (regional) hospitals, emergency aid hospitals or other multi-field hospitals.
On the basis of the results of the analysis of RTA it was found that the most common defects in realization of medical aid at prehospital stage are insufficient analgesia, inappropriate transportation, underestimation of shock state, and, as result, insufficient infusion therapy [5, 40].
Besides incorrect diagnostic and curative prehospital measures, the risk factors of unfavorable outcomes are hospital admission at night time, age > 65, an associated injury to internal organs and severe concurrent pathology. Diagnostic and curative errors may result in 2-9-fold increase in risk of unfavorable outcome [18].
Considering that each four lethal outcome after RTA is conditioned by traumatic brain injuries, it is necessary to improve neurotraumatological aid at prehospital stage of medical evacuation [9, 28, 44].
For estimation of efficiency of medical aid, along with objective values, one should consider subjective opinions by victims, satisfaction with results of treatment, self-estimation of life quality after injuries [32].
Therefore, the analysis of the presented domestic and foreign authors shows that investigation of rates of road traffic injuries is an essential scientific direction. Currently, this problem does not have an appropriate solution, and requires further researching and improvement. Prehospital mortality after RTA is still significantly high that results in necessary development of new protocols and systematization of the existing protocols of medical aid.