OPTIMIZATION OF EMERGENCY MEDICAL CARE FOR VICTIMS OF ROAD TRAFFIC ACCIDENTS Baranov A.V., Grzhibovskiy A.M., Mordovskiy E.A.
Northern State Medical University, Arkhangelsk, Russia,
Cherepovets State University, Cherepovets, Russia,
West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan,
M.K. Ammosov North-Eastern Federal University, Yakutsk, Russia
The progressive increase in road traffic accidents, especially in highly-populated countries and cities, has significantly changed the structure of injuries in patients. In the world, the first place has been taken by high-energy severe concomitant and multiple injuries, in which it is impossible to separate injuries to locomotor system and internal organs to the chest, abdomen and pelvis.
Objective − to characterize the practice of providing emergency medical care to victims of road traffic accidents at the present stage and to identify possible ways to improve it.
MATERIALS AND METHODS
The analysis of results of domestic and foreign studies and regulatory documents for the problem of arrangement of medical care for persons injured in road traffic accidents was conducted. The literature was searched in special search systems (eLibrary, PubMed, Scopus) with the key words: emergency medical care, prehospital stage, road traffic injuries, road traffic accident. The analysis included articles which were published in 1990-2020. The sources with old or unreliable information were excluded from further analysis. Some studies were found with use of links to used sources in publications selected for the analysis.
RESULTS
Rapidness of emergency medical care at the site of a road traffic accident (RTA), and the fastest transportation to regional medical facilities for realization of specialized medical care were considered as the most important factors for survival of injured [12, 27, 30].
Currently, the time interval of 60 minutes is recommended for realization of emergency medical care. Failure to provide medical care within this "golden hour" (the term was introduced by R.A. Cowley) and untimely transportation to specialized hospital can result in intense worsening of condition and increasing probability of death [8, 38].
The most evident way for reduction of absolute number of deceased persons in road traffic accidents and related mortality is providing appropriate and qualitative medical care at site, as well as time of medical transportation to regional medical facilities [18]. Specialists of emergency medical team (EMT) need to estimate severity of patient's condition and to diagnose the main symptom complex at the accident site. At the prehospital stage, it is importantly to arrest venous or arterial bleeding, to provide airway management, to carry out transport immobilization, to conduct adequate analgesia, to make contact with a vein and to realize anti-shock infusion therapy. These procedures, if performed timely and correctly, highly increase the probability of survival of patients [4, 22].
The analysis of the volume of medical procedures and quality of their realization by specialists of EMT at the prehospital stage can identify some serious defects, i.e. analgesia, which does not correspond to injury severity, non-performance or incorrect performance of transport immobilization of injuries and fractures, incomplete arrest of external arterial or venous bleeding (or, conversely, application of the tourniquet over long time), absence of appropriate venous approach, insufficiency of infusion therapy volume or incorrect selection of solutions for its realization that can be determined by unsatisfactory professional preparation of medical staff [2, 23]. In road traffic accidents with lethal outcomes, correction of circulatory and respiratory disorders could save about half patients. Severe pattern of injuries in RTA requires for special professional skills and competence in making fast and objective decisions at prehospital stage [9, 10, 11, 42].
There are some other risk factors, which increase the probability of poor outcome in patients at the prehospital stage. Along with incorrect diagnosis and incomplete volume of medical procedures, they can include age > 70, unconsciousness, dementia, a night time call. Moreover, the errors in diagnosis of injuries increase the risk of lethal outcomes [24, 39].
There are some special algorithms for providing medical care at the prehospital stage. They present a set (an algorithm) of simple manipulations, realization of which usually gives a good result for the concrete injury. Usually, they are reduced to solving of the following tasks: examination of a patient in conditions of limited time, identification of the main symptom complex, which can result in a lethal outcome, and determination of volume and subsequence of realization of medical procedures [3, 28].
All-Russian Service of Disaster Medicine "Zashchita", headed by the academician of RAS S.F. Goncharov, conducts full-featured analysis of medico-sanitary consequences of road traffic accidents in Russia, identifies disadvantages in arrangement of medical provision for patients and the causes, and develops recommendations for strategies of actions for physicians in any emergency situations [19]. With participation of "Zashchita" and Territorial centers of disaster medicine of regions of Russia, some studies of problems of road traffic accidents were conducted, and their results were used for development of guidelines for improvement in medical care for patients [5, 6, 37, 44]. Also these studies present the experience of urgent response teams, estimation of efficiency of adherence of medical facilities to definite parts of federal and regional roads. It was found that appropriate scatteration of these teams is the basis for efficient urgent response of medical forces in cases of emergency situations on the roads. The necessity for their provision with special equipment for extraction of victims from damaged vehicles, and the need for provision with devices of urgent mobile and satellite communication has been noted [36].
One can observe the evident deficiency of qualified medical specialists in the Russian Federation at the present time. It complicates making a decision by an emergency station dispatcher in relation to selection of a team, which is sent to the accident site. In most subjects of the Russian Federation, the emergency medical care stations include the dispatcher service as the important element of complex system for provision for victims of RTA and other emergency situations. The dispatcher or the senior physician have the right to give recommendations for RTA bystanders according to realization of first medical care before arrival of EMT. Therefore, there is a necessity for realization of obligatory training of medical staff of dispatcher services for development of "the list of clues for actions" for bystanders at the accident site who can carry out first aid before arrival of physicians [16].
To reduce time of medical transportation of RTA victims to the specialized trauma center, it is necessary to create the system of interaction between emergency medicine service and road police, Federal Rescue Service and other emergency services of a subject of the Russian Federation. Such system is characterized by obligatory mutual change of information on number of patients, presence of under-age persons (also in real time mode) and organization of priority road traffic for emergency vehicles with special signals, as well as to admit injured persons to regional trauma centers where the admission unit has been already informed by the dispatcher of emergency station in terms of arrival of patients, their amount and severity of injuries [25, 33, 34].
Considering the quite specific territorial, climatic and geographic features of regions of our country, which mainly present the territories of Russian Arctic, realization of sanitary-aviation evacuation of victims presents one of the most priority factors for survival and health preservation. The use of sanitary aviation for fast delivery of medical staff to the site of emergency situation with subsequent medical evacuation of injured persons to specialized trauma centers significantly increases the survival rate [13, 14, 15, 26, 43, 45].
At the prehospital stage, specialists of emergency medical team or disaster medicine have to perform primary examination, collect anamnesis data, and, if he or she is alert, to determine a degree of condition severity and to initiate anti-shock procedures. All manipulations (diagnostic and therapeutic) should be performed with maximally sparing and careful manner. In obligatory manner, primary examination identifies the signs of external and internal bleeding, estimation of respiration, blood circulation, neurological status, presence of injuries to the chest, abdomen, pelvis and locomotor system [29, 48].
A degree of condition severity is mainly determined by the main dominating injury (the symptom complex), which can cause death within a short time interval. The most severe multiple and concomitant injuries are usually associated with a victim falling through the wind screen of a car, presence of death of one of passengers or driver, a car hitting the body or head of a pedestrian, motorcyclist trauma, and road traffic accidents on federal roads since they are associated with very high speed leading to high-energy injuries [21, 41].
If polytrauma is suspected, it is very important to separate the dominating injury during primary examination since it determines the order of anti-shock therapy. The main aspects of anti-shock therapy are competent transport immobilization of available injuries, infusion therapy with anti-shock agents and appropriate analgesia. If one of these aspects is absent, the condition of an injured persons worsens significantly, and death can happen [1, 7, 17, 20].
The Kashtan anti-shock suit or its local analogues present the standard of delivery of prehospital emergency care for patients with polytrauma in various regions of the Russian Federation. This suit is efficient for prevention of shock condition and for realization of atraumatic transport immobilization [40].
DISCUSSION
Currently, there is not any effective mechanism of accumulation and interchange of actual information on medico-sanitary consequences of road traffic accidents between regional medical facilities. Quite complete and reliable information is given by population registers, which have been developed and tested in multiple fields of medical sciences, where they are used now [35, 46, 47].
To eliminate negative consequences of road traffic accidents in our country, it is necessary to develop and realize the systemic register of medico-sanitary consequences of road traffic injuries. This register creates some conditions for formation, storage and preparation of big data on injuries, diagnosis and treatment of patients at the prehospital and hospital stages of medical evacuation. It traces the condition of medical evacuation and quality of medical aid in real time mode and allows the analysis of causes of lethal outcomes. Also this register will allow estimating the scale of the rate of road traffic injuries in the specific region and in Russia at whole and will help to develop and correct the available schemes of transportation of patients.
After hospital discharge, the offered Form of registration of medical care delivery for a victim of RTA should be made. This form is registered in a medical information analytic center of a subject of the Russian Federation. The form includes 4 information blocks: 1 − general findings, 2 − circumstances of RTA, 3 − prehospital stage of care, 4 − hospital stage of care.
Introduction of this register into practice will allow giving real estimation and monitoring of medico-sanitary consequences of road traffic injuries, create a mechanism for information exchange in healthcare system, and, in middle and long term perspective, create conditions for persistent reduction of negative consequences of road traffic injuries.
We offer the following aspects for realization of emergency medical care:
− Regular training of medical staff of emergency medical services and disaster medicine with use of the algorithm of action in presence of high amount of patients during training courses of emergency medical care delivery for patients with polytrauma, especially with traumatic and hemorrhagic shock.
− Creation of the clear system of interaction between emergency medical and disaster medicine services, road police, Emergency Situations Ministry and other emergency services of Russia. This system consists in obligatory exchange of information about number of deceased persons and patients, presence of children etc. in real time mode, as well as in organization of road traffic for emergency service cars with working special signals, with organization of "green wave" on their way.
− In cooperation with municipal and regional authorities of a subject of the Russian Federation, to develop special road lanes for urgent movement of teams of emergency care or disaster medicine.
− Transportation of patients from the accident site on the Federal road to predetermined trauma centers, where the admission unit is informed by an emergency station dispatcher about near arrival of patients, their amount, injury severity and preliminary diagnosis.
− Implementation of the systemic register of medico-sanitary consequences of road traffic injuries into daily practice of medical facilities of the Russian Federation.
CONCLUSION
Therefore, the results of the literature review of the problem of emergency medical care delivery for RTA victims determined the range of weak points in organization and professional competence of specialists (especially in the aspect of severe multiple and concomitant injury). The ways for optimization of organization of prehospital emergency medical care have been presented.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.