G G Bodiwala MS F~CS FIC/~ Consultant in Accident & Emer¢~ne ...

@
B N Harrop FRCS
Re,.qistrar in Accident & Emergency
G G Bodiwala MS F~CS FIC/~
Consultant in Accident & Emer¢~ne¥
SUMMARY
This is a retrospective review of calls
made bv the Accident fiyingosqua d of
the Leicester Rova~ ~nfirmarvo between
! 978 and t981, Contrary to expectation,
the ft/ing~5~uad attended a ~ar~ number
of ~atients who had not ~uffered
accidents° The commonest reasons for
calls were ,ned accidents end card~ae
arrest,
The commonest t~eatments ~iven
were intravenous infusion, pain relief,
and maintenance of breathing°
Leicester Rova~ ~nfirmery
Present Address:*
Rova~ Gwent Hospit@
Newport
Gwen~ NPT 2UB
wou~d be accep~d from any mem~¢ of
the medical profe%ion outside hospital
from factories- or from the ~Hce or
fire brigade, ~n practice, most requests
are instigated by the ambulance crew
who first attend the scene, or, occasion °
airy, from a ~nera~ practitioner,
RESULTS
ember !981, @ ~ ~ttended
two hundr~ a~ th{~ ~ #~t~ents in
sudan iit~ ~nt~o Toe
condition ¢# ~:~1~ ~ ~nknown.
Table {1} ~ ~#’~ of calls
}nVO[V~ v8¢~ @f ~atients,
first fo’t ~1 ~, ~ ~ for road
#~set of th~
- L-
l@-~e than one
Tsb~e {2} ~@ ~ @®S reason"
for c~l}s° R~ m~.~nted ~o,

L
mp~e a~rw~V ~ ~I~ i~t~ ~
m was ~ ~ ~I Q~ven on
mpted t~1 ~ ~ ~v~ ~:~$~ents,
~he {o~o~e~ ~, ~d with
rts furth~ ~ ~ ~ ~t~ent~
red c~ ~ ~rrh~a~ at , TABL~ 3
TABLE 2
RE~ONS FOR-CAL~
No %
Tota~ 43 27
PAT~ ENT$ ~NVOLVED
Of o~e hundred and si×tV one
~;~en# a$~r~, s~×teen (10%) dg~d
at ~:~ ~r~. or ~n the resu~tat~o~ room,
d~oite treatn~nt 9~ven at the ~ne. Fu~
detai~s are ~ecking ~or four patients, one
of whom d~ed ~ the resu~itat~on room°
Of the one hundred and twenty ~even
{79%) patienl~ who surv~ved to ~eave the
re~JseD~t~on room, thirty one {24%)
were sent home with cuts and scratches.
EighW five (67%}, of whom fifty six
(~%} on~v received observation, were
admitted to the wards or treated in the
fracture cHnico TwenW four {19%}
patients were critically iHo Eighteen
{75%} of these had received treatment
outside hospital Ten {42%) were ad-
5G RO~ Accident ~3 ~1~1 P~t~)
F~H fro~ Height 5 4.5
~4 FaHia~ Ob]e~ 3 ~4 ~S~ 2,5
9 M~hinerv ~ 2°5
2 D~vin# 4 3
~Stab~b~iSh~ing)
Cot Thr~t 3 2.5
Spor~ 2 2
Ho~ F~rs I ~¢~ 1
Tota~ 11 ~ 73
w
freq~ueat cau~ ~ ~t~ ~8s ~ ~jurv;
eitlhe~ a~one o~ ~ 8 ~#~ ~h a
an ~ (1%) dged in t~ re~$ci~$[o~ h~o ACf {54~ ¢f
} mf~mat~mm
accidenl~, aH pe~r~ ~vive~ u~ ~ve
the re~i~oa ~#mo ~qh~ V ~n#i#~d
four un~n~ous ~tient~ with head
iniur~e~, and one ~ wh~h a fractured
femur. N~ne ~%} ~f the ~venteen
pe!~e~ who ~ ~nt~eated ou!~de
hospital, and thirty seven ~87%)of the
fifty five patients who bft the resusc}tation
room, were accompanied b~ at
least one o

I
~#~a of Tteat~#~ Comment
information !~ven at ~ne
23a ABCE
234 A B D
2 34 NH
234 A8CE
234 B
234
234
34
34
234
"AB
A B
A
*A
NI
3 ~ B
3 a F~#ed
34 BiD
e X
Treatm~nt~ give~ at scene:,
A Intravenous epiate
B Drip
C Fracture ~lntage
D Cewical ~oHar
tono×
CSF ot orrho~8
F ractut~ Zvgoma
Fr~ture Humaru5
Compound fr~ture t~biaifib@a
Abr~io#~
F ~4~U r~ femu~
F r@c~ure f~muf
Fr~ture femur
TFao~ oy ~3. No free1 #r8
Uncomgciou~ from head injury
Now atte~di~ you#% disabJed unit
Scs~p ~aceration
FraeAure femur No other ~n~uW recorded
Tetr~ia F/$ 8~i~ted with e×tractio~ from ~hlc~
Certified dead ~t sc~meo Trsp~:~d beneath lorry
Source of information:-
! Post mortem report
2 Case notes
3 A & E card
4 Flying°squad record
GP affeady in attendance
Laceration ~iv~r
@@~
Fr~ctsre peta#~
Head i~iu~ w~t~ ~4~
H~ t#jurV with a~ ::+
v " ~A"~ °, ::,
2
.

O
accidents fhs, fh ~-squdq S ~t~endaAca
< ILiFWIvI 3ut Ol~ 1won[r-lois ixi[ie£i[g
=u:e~,qeo SirE’ (t982, :;:onside;s [nat
ttH mos~ COSteffec v~e~ wa~, {J reouc~[tg
giJdt’}~ ~TtOF~a}~[y ?(0[~ Rt;ary d~ssase !s
~o ~rmn tn~ %ene~ai :sub, I( m caro~ac
~esugc! [at
we w~r~ ~}o~ ~IHa COLLINS {I~61
~sqa}red so Perform am:>cna~wnn ,.-q order
T~} re,ease any [rapp~u gatienL ne4her
ma we encou~[e~ an/ sm~at~on wners
like R£DDKH and LNTL£ (1973~. ,we
required to perform a {4enera~ anaesma.
ta: The relative nheq~encV of ~ndustNai
acqden~s ~nd the Possession by ~he [ire
serv;ce o~ qea% v u£r~ng and lacking 9ea~
a~e ~o ~m~rtarw farters wn ch may
eaoi;~n l:~e so.nee ot IU~" dra~r~atic
~ilrJelce. The Oh!~ IXI~K~DII O~
e$~M% at surgery ~r~orisle~ o~ ts~a
hospitai b~ our f~Y~ng-~ua~! was ~he
Performance of ~ ven~s ¢~-do~ On
the sang,~e occas~or where e pa~ent was
~rapped ,.~ a machine, h~s re~e~ ~e
t~ilitated oy Io~I anaesthe~iao Entoc~×
was u~d on ~ven oc~s~oos= during
release or during fracture splinters.
These patients rmght otherwise have
required genera~ anaesthes~m
T~ e PrOPOrtion nf ~nousl’~ dl
Patients attended represents en under
estimate ot the [rue vaaue of rIGs flyin@
squad’s funcl on because nsore than one
patient was attended durinq some caJfs
the additJona~ Patients wouad not ati
have reenter attention ~n their own
rignL When seriously iU ~tmnts ~ece~ved
no treatment, this was because of lhe
@ose prox~n-Ht~ of me hosoitat to the
aCCident or ~sndezvous. o~ because the
[t y mg%quad doctors lacked the ne@ssary
skil,. Inevitably some Pa~ents o~ed
before ~he flvMg-souad arrived. HOFF-
MAN [t9821 has shown now much
greater is the potentia~ say nl of Hfa [o
be re;ned by the intsrvennon of bystande~
o~ the crew of an ordinary
ambulance, n ~he interest before ~ns
ftyingosquad arNved. The majority of
>t’&’q~ ~1 e~qiraD~T~O~ IrIQ {o qN--~rry ~
%i&~ deDart~ne[~! by radio O! YA£ nurq~
IMO iplIai ~@quIt£Itent,s 0,~ hi£ !flints.
Thoegn ne must t! su~tab!v equg31
~1e ~ rarei~ required to ~rtorm che~t
dra{na~ o~ trace~e

,aspon~ib#itv ~e ~ ~e~reQ Fo~ an
,~pa~t~flt ~ ¢8~tt~y covered by
Av~ ~’~ ~ ~etary;
BASKET~, P J F, DIAMOND A W.
and COCHRANE D F
%Jrban mobde resuscr;at~n: Train
{1976~ 4& 377-385.
BOOtWALA. G G
"Fac~s b~h~sd the flyu~g-squads" p,
Wdson D H a~:~ Marsden A K ~Ed};
’~re ot the acutely ~II a.qo inlkJre~"
Chiches~e~= #~ile= 1982.
CASUALTY SURGEONS ASSOCIA-
TION: "Gu~dehnes for ~ttmg uo a
nosoitai-based flyml sauad’. Avail.
ab!e ~om Mr G G Bodawala Consu~tan~
m A/E Leicester Rova~ lafirmaryo
COLLINS, J~
~Ofganisa[~o~ an@ ~unC~lOn Ot 8n
accident fly~ng,.squad-, 8r Ned J,
t966, 2 578-580_
HOFFMAN. E;
- ’*-’~ ....... site’° t%ur7 I !, 90-~
6::

F’~ aci:i 7o~c:,,, o :7,’3i~ 766o
5i
Gu i cfe ’!
)
Car e:~ o

- ’ ’
~
707 .... I 0.
R

~ available, height as percentage of expected height for age,
based on the Boston standaxd. This is a measure of
¯ retardation and therefore of past malnutrition.
’ For the qualitative classification of seveze cases the Wellcome
system is proposed. In each group ad~ data should be
= recorded so far as poss~le. It is essenrlal that the criteria for
. including children in the classification should be clearly laid
,~i~ down.
International comparisons obtained by these methods would
be extremely valuable.
References
zation T~hm’ca/Rt~oorl Stri~, No. 477. Geneva, WA’LO., 9 .
, Bengoa, I. ~, w/~o C hr~., 1970, 24, ss2. .......
McCance and B. M. Wmaowmn. Lonaoa, t.aurcaub
:i~ 4 ~7HO Chronid~ 1972,26, 160.
,_ s Gomez~ F., a a/.¯~ounud of T~ Ped~i~ l~b 2, 77.
i ::Accident Flying Squad
~ ROGER SHOOK
X t d eea
:’: The c~mc.ept of this research project de~l_oped during the early
stages of working in an accident deparmtent in 1965, and further
Royal United Hospital, Bath
ROGEK SNOOK, U.D., Senior Casualty O~cer¯ .and Accidmt Medical
O~cer to Bath Ftre Brigade and Ambulance Savice
-
t Stuart, H. C., and Stevenson, S. S., in Textbook of P~atr~, ed. W. B.
NeLson, 7th edn., p, 12. Philadelphia, Saugde~L1959.. .....
Seo~ue, N., and Latham, M. C., yourna~ cJ 2 roplcal ~’~amtr~ aria
Enoiromnottal Cldld Health, 1971~ 17¯ 98.
s Waterlow¯ J. C.¯ and Alleyne¯ G. A. O.¯ Admm~ i~ Prouin CTunnimT,
1971¯ 25¯ 117 ....
¯ ~~¯ ~.¯ ,. ~ ~ ,.~ _~.,~ ~,..~
~ Mccaace and ~. M~ Wtddow~¯ t~ 91. ~.~¯.~.~,.~u
Ran¯ V. K.¯ and Singh, D.¯ AmericanJom~u O t,a~. ¯ ..... -~
~s Jell~e, 23¯ 83. D. B.¯ and Jell~e¯ B. F. P., ,4mo~anyourna/of C/in/m/Nutril~b
a Bmlte~¯ 1971¯ 24¯ H. 1377. J. I..¯ Malemlema, N. T.¯ snd Burge~ A. P., Troffiad and
Geographical Media’s¯ 1969¯ 21, 39- ...........
tt Tmwell, H. C.¯ Tr~ of tl~ ~rya~ ~’oaety o3 ¯ ropwat m~
and Hygiene, 1941¯ 35, 13. ........
ts Watedow¯ J. C.¯ Me.diad Resmrd~ _ .Gouna...l. ~ .p~a~ ~ort .zero., No . _.
t* Brock,.J. F.¯ and Autret, M.¯ World Health Organza,ion. monograph
Ser~¯ No. 8¯ 1952. .............
t~ GalTOW¯ J. S.¯ .4rehi~s Lmbmm~eanos ae Nutr~o~¯ t~o¯ z.o: ~. ..--
~’ McI.~m¯ D. S.¯ Pellet~ P. L.¯ and Read¯ W. W. C.¯ Lazar¯ t~¯ x¯ ~.
t¯ Lan~t¯ 1970¯ 2, 302. ....... ertl NL Younm/~ Nutritio~ 1964,
to Graham¯ G. C.¯ Cor(llmO¯ ~.¯ ana m ¯ h*’ -~
84,71.
Shat~, A., Dema~chi, M., and El-Milli, N., Lo~t, 1972, 2, 143.
~i~ British Me.tfi’¢a/~mrna/¯ 1972¯ 3¯ 569-574
accident services was widened by the fact that hospital equipmen,
was often incompatible with that of the ambulance service.
The project developed in fotw related stages--lecturing to the
- This paper d~’l~ the organization, evaluation, and
ambulance staff, the organization of an independently financed
costing of an indep~d~tly financed and operated
and operated accident flying squad, the introduction of hospital
training for the ambulancemen, and the investigation of ambu-
accident flying squad. 132 acctdenta involving 302 casuallance design.
ties were attended, six deaths were prevented, medical In 1966 there was Httle literature on the organization of
treatment contributed to the survival of a further four¯ medical attendance at accidents in Britain. Hall
and the condition or comfort of many other casualties
was improved. The calls in which survival was influonced
were evenly distributed throughout the three-and-a-halfyear
survey and seven of the I0 so aided were over 16
and under 30 years of age, all I0 being in the working
~ age group.
The time taken to provide the service was not excessive
and the expense when compared with the overall saving
was very small The scheme was seen to be equally
suitable for basing on hospital or general practice or
~ and Collins*
bad described hospital-based team.’, with medical or nursing
staff transported respectively by anab~ance and police car, and
Easton’s scheme involving general p~ctitioners, was npt
started until December 1967. s ¯ * The maj~ pubhcauon ¯ " " IN was.~m
English translauon’ descrFomg ~_of .e~or G681er s o rgm~a" ~n
in Heidelberg, West Germany. In this scheme medicaL~eato
ment at accidents was based on the introduction of a large
mobile operating theatre unit in 1957.
These three hospital-based schemes all involved the use of
spechdized transpot~ The alternative, therefore, was m investi-
both, and working as an integrated team with the ambugate the usefulness of one doctor attending accidents in his own
lance service. The use of specialized transport was found car and carrying his own equipment. Thh paper describes the
to be unnecessary. Other benefits of the scheme included organization¯ equipment¯ and evaluation of medical attendance
use of the experience of attending accidonta to ensure by me at the scene of accidents and the integration of this
relevant and realistic training for emergency service within the ambulance service during the three-and-a-ball-year
~rsonael, and an appreciation of the effect of ambulance period starting in November 1967 after a period of feasibility
! ~lgn oa the fremont.
study. On completion of the res~rch Bath City Council then
officially took over the scheme by making it a part of the City
Fire and Ambulance Scrvice~ including the creation of the
appointment of accident medical o~iccr.
¯ ~, impetm came from the experience ~ rhanco arrival at theOutline
of Scheme
’
,
scene of mad 8c~L~.,~t~. m t~e ~ department co~tact
w;th ~_.~ .-~r: oi the emergency services was frequent, and I ORGANIZATION
b~came tncre~n~y aware of the problems that they had to Initially my attendance at road accidents was more in the role of
face---in particular, cases for which the resuscitative measures an observe:, to study how the emet~cy services organized
required before admission to hospital were beyond both their
training and equipment. This gap between the ambulance and
themselves, how best to organize medical participation, and.to
build up gradually a relationship ~ the emergen, cY ser)nco
. ~ _
personnel. In fact, this approach set the Fa~ern In~H. ~ r..~
ship that was to continue. From the outer m.em
organized
and to combine
m be
as
available
part of their
m the
team
emergency
at the scene
~nces
of the/
o.n/
/
/

MO. 1--Fire brigade emergency equipment vehicle and accident flying squad car.
a set-up which encouraged a close and personal working relationship
in which the ambulance staff would actually participate,
to the benefit of all, including the patient. At the same time the
ambulanceman could be encouraged to improve his skill in
assessing priorities.
It was also policy to initiate any treatment and to stabilize
the patient at the scene, and then in most cases to allow the
ambulance staff to take over the responsibility for the patient
In the early stages medical equipment was-carried in several
cases. This was not satisfactory, howevers and so a resuscitation
box was designed to contain and display all the equipment and
stir be stable in a moving ambulance. Careful choice of equipment
kept the total weight down to 51 lb (23 kg) (37 lb (17 kg)
without the cardiac monitor), and this arrangement, described
in more detail elsewhere,’ was most successful in practice.
A list of the equipment carried, together with the cost, is given
in the Appendix.
COLLECTION OF RF~ULT$
Detailed records were kept of each call, including the date,
timings, distance travelled, diagram of the scenes vehicles and
casualties involved~ and equipment used. Case histories Were
followed up personally until the eventual outcome of treatment
was know~
The criteria used to categorize the casualties were those used
by the Ministry of Transport--that is, slight, seriomh and fatal.
Results
dently and so was available in case the patient’s con- DRIVING
dition deteriorated. In practice this policy worked well. Personal
No problems were encountered during the research. The
and vehicle identification was an important factor in ensuring
acceptance when approaching, working at, or leaving the scene.
Mediflash green light was found to give adequate vehicle
identification at night and during the day to oncoming traffic.
A short over-waistcoat of fluorescent and reflective material A brighter, detachable rotating beacon would, however, be-
was made and worn at all incidents, and the magnetic flashing
green light (Mediflash) was developed for use on the car when
more effective ff the lighting regulations were amended to
travelling to emergencies.
include doctor’s cars as emergency vehicles. Where indicated
Initially the ambulance control room was informed of my
visual identification was supplemented by the use of a pneu-
whereabouts by the provision of a timetable supplemented by
matic horn. The car was not involved in any accidcn~ and in
combination with the use of studded tyres in conditiom of ice
periodic telephone calls. This system was far from satisfactory and snow, all incidents were attended without difficulty. Vehicle
and involved only the first 12 calls, while awaiting delivery of a insurance was discussed with the insurance agency and no
radiotelephone; the latter completely transformed the scheme. extra premium was required for fully comprehensive cover.
Mobilization of medical aid was therefore through the control
room of the City of Bath’s joint fire and ambulance service.
The principal advantages of using one’s own car w¢~ avoidance
As the service also operated a special emergency equipment
of delay in mobilization due to waiting for transpo~ to arrive
vehicle (see Fig. 1) for releasing casualtiet trapped in any
and loading equipment, freedom of movement when ms call, and
accident situation, it seemed poindess to restrict medical
elimination of the cost of speciafized transport.
Whenever it was neo:ssary to travel to hospital in the ambu-
attendance to road accidents alone. Therefore any incident was lance with the patient a spare ignition key was given to the
attended where medical aid was thought to be required, either nearest policeman so that the car could be moved when desriag
on receipt of the initial 999 call or on the arrival of the first
the road. This proved necessary on 12 calls. On five occasions
vehicle at the incident. Similarly, availability was the police drove the car to the hospital and on the ~ se~n
limited to the Bath ambulance area, and the area covered
was gradually expanded, especially into the Somerset County
the ambulance service returned me to the scene. On all 12
ambulance area. This latter authority then provided a radio-
occasions this help was arranged without del~y and without
any personal intervention.
telephone on the county’s service wavelength.
Special protective clothing again*t ~*!~ was found to be
necessary on only one occasion, although a plastic mackintosh
EQUIPMENT
was used in heavy rain.
RADIO
The importance of radio contact with the ambulance ~rvice
cannot be overemphasized. Poor communications sooa create
problems in any situation, but even more so when tbere is a
degree of urgency, and can then lead to poor relationshlps
between departments. At first a simple radiotelephone was used,
but later a more elaborate installation included a selective
calling device to give automatic warning of an emergency call,
a portable radio, a "talk-through" switch to enable me to speak
direct to the accident ambulance, and a radio link to enable any
mobile user or ambulance control to talk direct to the accident o
department. The complete system was quickly accepted by
users and on one occasion (accident 6) contributed to a patient’s
survival, as ~ communication with the ambulance crew
l
i

)
#
4
r ._
!
t
!
0
"’enabled departure of the ambulance to be delayed until I
arrived at the scene. The radio link with the hospital also
eliminated the delay in calling out the accident flying squad,
which before installatim invelved at least six calls in delays
varying from two to eight minmea.
MEDICAL TREATMENT
Treatment at the scene principally involved having the necessary
equipment instantly available very close to the patient,
being completely familiar with its use, and having one person to
act as informed help. The adaptation of resuscitation techniques
to accidents has been described,’ as have the special problems
with the extrication of trapped casualties.’ During the project
it was found that the recognlticat of patterns of injury related to
vehicle damage was of value in assessing patients when examination
was limited by poor ligh~g, limited access, or fur
clothing. Entonox (50% oxygen and nitrous oxide) was used for
pain relief at the accident sces~ during extrication and in the
ambulance. Observatiom including pulse and blood pressure
readings were made in 17 cases. Pain relief was effective, rapid
in onset, and free from side effects. Muscle spasm was relieved,
bleeding from wounds was not promoted, and the pulse and
blood pressure readings showed no appreciable change. No
difficulties were encountered when Entonox was given to the
trapped patient held in the erect position.
Detailed analysis of the 132 calls showed that 17 were to
various incidents involving such locations as the river, civil
engineering excavations, sewage works, certain home accidents,
and a light aircraft crash. The remainder were to road accidents.
The outcome of calls received and my location on receipt of the
calls are shown in Tables I and IL
¯ tam.l z--Outcor~ of the 132CallJ
At incident before del~mre d amb~ ..........
R~ndezv~ with ambulance ............
83
No casualties found on arrival ......
16
ca~lt~ ~hay iniu~ ~ ~ "" ¯ ....... ~ ~ 9
Malldous false alarm ................ 4
Unable I0 reach accident in
1
Distance and time dehy in mI .............. 9
Time delay in call ............
Distance too great .... 5
~" ""
Po~ ommuni,:adom . "" "" ¯ ..... 2
W~oas ~a~a,atlon f:om ~ ~ ............ 2
oo .... oo .. oo |
~’T.e~...m~ "- .... ....
On~w~..ho, pi~(~.--"-)
",s
LRaa~ ~dt._~ November 1970 .. 5
f~d~,~ .~ .~m .,us~ .... ss
O~du~gaom "ml 108cab)~, ~ .~ ., -re.car ......
34,
( - troru~ ra~o~ ...... I
LTc~-p~me at ~ ~ .... 18
The cars were distributed fairly evenly throughout the project.,
averaging one call every 9-5 days. The incidence of cars
was highest around 12 nmm and between 5 p.m. and 7 p.m. and
11 p.m. and 12 midnigi~ and the incidence of calls was much
higher on Fridays and Saturdays (Figs. 2 and 3). The average
time taken to deal with ese2a call ~ 31 minm~b representing an
i
- ~o. 2--Dimilmtim of .a~ dmmShout the day.
z
30,
25,
20
~- 15
5
0 H T WT
D~
:7.;
a-(:.
?/.
J F H A H J J A SOND
Month
r~o. 3---Incidence of calls on different days and in different months
throughout the year.
571
average work load of 22 mmutes a week. The time taken to
clean equipment after use and make a weekly inspection averaged
43 minutes. The average time taken weekly to answer calls and
to clean and maintain equipment was therefore 65 minutes.
This is to be regarded as a minimum as it does not take into
account keeping records, following up case histories, correspondence,
and other duties.
The average time taken for the ambulance to reach the scene
was 8 minutes and for the accident flying squad 9-5 minutes
(Table III). When these figures are compared with the earfier
findings relating to the outcome of calls they show that where the
TASLe lll---M~an Time spent on Calls and Mean Distance Covtrcd
Time spent on each call ...... 31 (ranm- 4-143~ rain, ~--
Time ambulance took to teach scene "" 8 (range 1 20~" minuT w~
T.ime acci_d~lt flying squad took to reach scene :: 9"5 (range 1’22) minUt ~-~
~me spent az,s~e .. -._ ...... 14t (range 2-132) minutes
~tstan. ce traveuea to scene 4.~ (range 0"25o13-5) miles (7.5 (range 0-4-21.7) kin)
1oral cttstance travelled 10-3 (range 0-5-29.5) miles (16.5 (range 0-8-47-5~ kn0
call for medical aid was received at an early stage it was possible
to arrive in time to offer medical help in about 90% of the cases.
The closeness of the ambulance and accident flying squad
attendance times was due to the ability to mobilize rapidly
after an immediate alert.
Active medical treatment of casualties was undertaken on 22
occasions. In addition two calls involved meeting the ambulance
at hospital for treatment, seven included help in assessment of
handiing, one concerned advice in the management of bromine
burns and inhalation, and one call involved sorting priorities at a
coach crash." Advice was given at a further five accidents in
which casualties were trapped and injured but did not require
medical treatment.
Altogether there were 302 casualties, of whom 140 were
slightly injured and 128 seriously injured. Among the latter
there were 34 deaths~25 at the scene and 9 in hospital. No
patients died in the ambulance. Thirty-three accidents involved
41 casualties being trapped; of these 18 were seriously injured
and 8 fatally injured. Of the 37 casualties trapped in road
accidents 23 were held by the lower limbs, and the mean time
taken to release them was 29 minutes. Although many of the
accidents involved two or more seriously injured casualtiea)
only on one occasion was it particularly difficult to cope with t_~
problems encountered. In this instance three casmdties were
trapped and seriously injured, two in one vehicle and one in the
other, and this stretched medical resources to the limit. Medical
attendance was therefore of direct value at 38 accidents, or in
1 in 3.5 calls.
Patients who received definitive medical treatment can be
fm~daer aubdi~ded to show where it was probably possible to
prevent a fatal outcome. Six of the casualties would virtuafiy
certainly have died had they not received this early medical
tremanent, and in a further four cases medical treatment made a
major conm~bution to survival. In six instances resuscitation was
unsuccessful, and in six medical treatment was of value.
The type of treatment and advice given at the sc~es of the 22
accidents is shown in Table IV.

572
¯
:: :: :: :: :: :: :: 2
"" o. 2
Cardiac monitoring ..................
Endotracheai intubation ..........
4
4
nu~vcnous ~ ................
Surgery .. ., ..............
Amputa~on ....
5
6
1
Manipulation of fractug~ ................ 4
Entonox administration .............. ..
g
Aspiration of aizway .................. 11
Oxygen admln~tntion ................ 11
First aid before arrival of ambulance ............ 14
General advice .................. 15
Case Reports
MEDICAL TltBAT~ ~SPONSIBLE FOR SURVIVAL
Accident I.--A 56-year-old driver collapsed in his car. A displaced
denture plate partially obstructed his airway at first, then
completely, with deep cyanosls and muscle spasm holding the
teeth together. A gag, laryngoscope., and other instruments were
used m remove the obstruction, and the aspirator and oxygen
were also used. Final diagnosis: myocardlal infarction. He was
eventually discharged.
Accident 2.--A 16-year-old motorcyclist was found unconscious
beside his motorcycle and lying on his back on a steep incline.
Before the arrival of the ambulance and just after being turned
on to his side he vomited and the aspirator was required to clear
his airway. Outcome: complete recovery.
Accident 3.----A 51-year-old driver was trapped in a van after
a collision with a lorry (’Fig. 4). Injuries were: compound fracture
dislocation of talonavicular joint; compound comminuted fracture
of left u~ia and fibula, with extensive soft-tissue lacerations;
haemarthrosis of left knee; compound commlnuted fracture of left
femur; fractured acetabular rim, acetabulum, and pubic rami;
fractured ribs; lacerations of face, scalp, left hand, and right
knee. Treatment at scene: transfusion of I L of Macrodex, use of
other. Medical aid included l~andling of displaced compound
fractures and the use of the aspirator and oxygen. One Patient
was given 1 litra of intravenous Macrodex (and 5 bottles H blood
later) for injuries which included fractures of the right radius and
ulna, femur, tibia and fibula, ankle, and foot, closed fractu~s ot
the ribs, and lacerations or the left lower leg, right arm, and scalp.
The patients made good recoveries.
Accident 6.---A pedestrian aged 22 was in mllision with a car.
He was unconscious, and his injuries included a compound fracture
of the left tibia and fibula, gross disorganization of the soft :i~,
and right tibia and fibula, a compound ¢omn,Jn~ fractu~ of
the right femoral shah and pertrochtmtcric ~ of the neck
of femur, fractuz~ of the sculpula, ribs, and hand, and multiple
face and scalp lacerations. Tff.- ambulance was instructed personally
to await my arrival. An infusion was set up and 500 ml
of Macrodex pumped in. The severely damaged leg was wrapped
in a sterile sheet and placed in an inflatable, hdl-leg splint applied
at maximum pressure. During the journey to hospital the ambulance
had to be stopped when the systolic blood pressure dropped
from 70 to 50 mm Hg, and a further 500 ml of Macredex was
transfused rapidly. Further infusion in hospital included 2 bottles
of plasma and 7 bottles of blood. Amputation of the right leg
b.’Iow the knee was followed by full recovery.
MEDICAL TI~ATMID4T CO~uTnqG TO SURVIVAL
Accident 7.---A member of the emergency services collapsed
near a ruptured gas meter when on an emergency fire call and
was unconscious and breathing irregularly when brought out of
the gas-filled building. He was ventilated with oxygen and connected
to a cardiac monitor, which showed ischaemic changes.
The aspiiator was used m keep the airway clear and oxygen was
given by mask. A period of heavy, central chest pain was followed
by full recovery.
Accident 8.--A 19-year-old motorcyclist was in collision with
a pedestrian and was seen before the arrival of the ambulance.
He was unconscious and bleeding from the nose, chin, and broken
front tooth sockets. The airway was cleared with the aspirator
(the attending county ambulance was not equipped with an
aspirator). He eventually made a full recovery.
Accident 9.--Two motorcyclists were in collision. One aged
24 was unconscious from head injuries, and both had compound
fractures of the lower limba. One r~lUired the use of the aspirator
before arrival of the ambulance.
Accident IO.--A car driver aged 20 received severe facial injuries
in a collision with a lorry and was uncon_~-~-~ous. Repeated use
of the aspirator maintained the airway in tlg presence of compound
malar and mandibular fractures, displacement of teeth, and
severe facial lacerations. Oxygen was also used. The patient made
a full recovery.
OOMMLner
The opinion that Hves can be saved by early medical treatment
is supported by several necropsy studies. Mackay’ suggested
that 43% of fatally-injured casualties might have had a greater
chance of survival ff medical treatment had been available at the
scene of the accident within l0 minutes. A World Health
Organization report estimated that 15% of early road deaths
lqO. 4--Accide=t 3, showing rescue and resuscitation. (By kind were due to respiratory obstruction. Lauppi," in a Series of 300
permission of Bath Evenir~ Chroalde.)
necropsies on road-accident casualties dying within 48 hours of
mjury, reported that in 14"3% respiratory obswaction was the
aspirator and oxygen, manipulation of trapped and fractured legsole
cause of "death. In another series Ruffel-Smith
to permit earlier release, and application of long leg inflatable
splinL Outcome: full recovery after treatment, which included
transfusion of 2 bottles of plasma and 11 bottles of blood.
Accident 4.--A pedestrian aged 20 was struck by a car at night
and thrown through a hedge into a field. He sustained compound
fractures of the mandible and right tibia and fibula. He was
unconscious and cyanosed and the airway was full of frothy blood.
Immediate use of the aspirator followed by intubadon and tracheal
aspiration cleared the airway without stimulation of reflexes.
Oxygen was also given. He regained consciousness on the third
day and recovered fully.
Accident 5.--Three casualties aged between 25 and 35 were
trapped and seriously injured, two in one vehicle and one in the
t" showed
the incidence to be 5%. To the last three series could be added
casualties dying of blood loss and other reversible causes.
In a series of 34 fatalities it might be reasonably expected that
some deaths would be due to asphyxia or blood loss in the
absence of injury incompatible with survival. In reviewing the
necropsy series of this project no such evidence was found,
though if medical treatment had not been available at all the 132
accidents probably examples would then have been seen. Should
the figure of six casualties saved seem a high proportion allowance
must be made that not only is this a selected group of
accidents but also that it contains accidents in situations beside*
those occurring on the road.

O
mu-risH MEDXC.~ JOURNAL 2 ~ 1972
¯ Not all accidents in the hospital clinical area were attended,
and so eases not involved in this project could be regarded as a
form of "control." A review of all the necropsies in this series
was not possible, but from cases seen during normal hospital
employment there were three examples of patients who died
from reversible causes, one from asphyxia and two from blood
loss.
Cost
573
free passage through traffic, and good communications. The
policy of organizing mecLical aid to be available on request,
working at the scene with the ambulancemen, and training
them to help rather than taking a team of assistants was also
important. The area covered was principally that of one ambulance
service, though in the instance of accidents involving
multiple or trapped casualties the area that could be covered
was shown to be greatly extended. The average distance to the
accident scene was under 5 miles (8 kin), indicating that certain
patients could still benefit from medical attendance even though
The running expenses for the three-and-a-half-years are shown
in Table V.
When the capital cost of £927-19i for all the equipment
(see Appendix) is added to the running expenses for the threeand-a-half-year
period the total cost is £1,086.71~. Nevertheless,
r~ v--Rum, i~ Bxpema over the Thru-and-a-~-year Pm~d
the ambulance journey time to hospital was relatively short.
such a scheme, if hospital-based, could usefully act as the
nucleus of a scheme involving and supporting peripheral
general-practitioner schemes and would also have appfieation in
the field of motorway and "major accident" incidents.
The organization of such a scheme is seen as a logical development
of the properly established and independent accident and
emergency specialty, and shows that the patient’s arrival at the
accident department is not the earliest stage at which medical
P.,dioUc~cc ......
Radio maintemm~ ................
Inturanc* ...................
Batteriea ....................
Petrol ..................
~: -~ :~ :~ "" ::
Total
s-Ts involvement should be directed.
38.75
17"85 This research is based on an M.D. thesis accepted by the
16-80
56"44 University of Bristol in 1972 and supported by a grant from
the Peel Medical Research Trust. Acknowledgement is also due
159"52
to the support of the Bath City Council and the medical officer
of health, Dr. R. M. Ross, and the consultants and staff of the
accident departments of St. Martin’s and the Royal United
Hospitals, Bath, and the many firms that donated equipment
to the tcheme.
as all the items of equipment could reasonably be expected to
last for seven years at least, the capital cost could more realisticaily
be spread over that time. If the running expenses were to
continue at the same level the cost per year would be reduced
from £310-49. (over three-and-a-half-years) to £178-03 (over
seven years). Even the latter could be reduced to £103.60½ by
exclusion of six non-essential items (cardiac monitor, dictaphone,
camera, selective call option on. radiotelephone, tra~cfight
switch, and studded tyres)-
To these figures would have to be added the cost of medical
staffing. This is not easy to assess, however, as only 15% of
calls occurred when I was on duty. A more realistic comparison
could be made with the fees payable to a police surgeon.
With an average of 38 calls a year and an arbitrary fee of £5 a
call this would represent an attendance expense of £190 a year
and an annual retaining fee of £100 (at B.M.A. recommended
rates). This would result in a total cost per call of £15-86, which
compares very favourably with the average cost per emergency
ambulance call, calculated by the Department of the Environment
to be £15. Using the Road Research Laboratories costings
of road accidents n ts a comparison can be made between the
actual cost of saving a life by the provision of medical aid and
the overall saving to the community as a result of reclassifying
that casualty as a serious injury instead of a fatal injury. The
1970 costing, for fatal injury are £16,809 and for serious injury
£910. These figures represent medical expeusess loss of output,
atxd subj .e~.’ve losses, and the difference of £15,899 represents
the financial savmg that results from preventing a fatal outcome.
Only five of the six casualties saved in this series were in fact
involved in road accidents~ representing an annual saving of
1-43 fives. If the figure of £15,899 it multiplied by this factor
and then the total cost of providing these special medical services,
including feet and retainer, is the~ deducted the net annual
saving to the community in providing th/s sezvice can be
calculated m ~2,135. (T!aa rpl]dity of this costing interpretation
ha- ~.-m ~a~mled with the ~oad Research Laboratory.)
This scheme was easily organized, inexpemive, and effective.
Its orgtuimtion would allow it to be based on a hospital or
general practice and did not interfere with other employment.
Moreover, the esther involvement with the patient often made
the diagnosh and treatment less time consuming on return to
the hospk
The success ~ the scheme depended on rapid mobilization,
References
t Hall, H. H., Lancet, 1965, 1, 904.
¯Collins, J., British Medical Journal, 1966, 2, 578.
¯ J~aston, K., Community. Health, 1970, 2, 81.
: Gogler, E., Ro~.. Aeddents. Manchester, Geigy (U.K.), 1965.
, ",nook, R., M~.cal and Biological Illustration, 1971, 21, 66.
, S~oo.k, ~noot% it., R., lJriu’sh Bri~ Mech’cal ,U~ai~alyo,,.,a, Journal, 1969, 1~, 4, 4, 478.
s Mackay, G. M., British MedicalJournai, 1969, 4, 799.
." Laupptk E.,.S~_wd_z~sc.~ medizini~ gr~3totsd~’ft, 1954, 335
-- Kune~-.-,mim, ti. p., In/u-y, 1970, 2, 99.
84, .
tt Dawson, R. F. F., Cost of Road Aeddmlu in Grmt Britain, Road Research
Laboratory Report LR79. 1967.
Dawson, Kesoarcn .R.F.F., Latmratory Curr_em Report Cost_of LR 396, Road 1971.. Acddosts in Great Britain, Road
Appendix
Cost of Equipment (at Time of Purc.hau)
¯ Resuscitation box painted white with reflective ~ band and doct~ £
label.
~.....er and two Ysnkath~ msctio~ mmm~ ¯ ¯ 17.9~.
........
P map ~ mat~ mmmt-~ ~ .............. 1241
10.00
ro~ mtravenotm eannulae and mp.-tiem mthetmm ...... ¯ II-15
0.55J
~th intrave~m cannulae ( x @ .... ""
p ~ m~us~ (x @ :. :. .... Hs
M.S..A. elbow lmmobiltmr .......... "" "" 5.7o
¯
...........
~.~o
I~ve~ - practifio~nr ~ ........ "" "" 22~0
D ~.~. mnm~ ~ tim ........ um~ ........
-: .. .- .. ~
.... I.$4
.. ,. .. .. ..
Blood cro~mtch mb~ (ho~ml m.om~) .~ ...... 0-25
ecu’oct~ .. ¯ ......... 277.47j
t.om~ (pmmix~. nitrous ostdedogTgta ~ ~ tlk ~llmktt.
-
r2tepma,
vatve,
tic
mmr,,
splints
aria
.........
mou~ ....... " - - .... ---- 2"/-5@
. .~oen~.. ton burro drmin~ ..... : ......
7.~o
4-25
sp~a bom~U ma mm~ prm mmm~ m,~a mu~ :: :: -- ~v~

Blankets (I wool and. 1 hest-reudai~ foil) ..........
2-90
First-aid kit of dressms~ .btndage, stings, etc. ........
1.50
..
Rel~eggiv¢ w~.’$t¢oat-type.’l~t~ .... . 2" .... "fL. ..
5"00
4 Wm’ning trumgles (special p y K2.qt| gscnj .... 2-00
Large lured-torch ........ . "" -- "" " " " s~l
2"15
.Minor rescue equipment indudins: hacksaw, lemmy tn~ too~ mpem
oo oo oo .. oo oo oo
Mbestos Zloves 2-00
Fire extinguisher .......... .. .. .. 0"92t
12-voh floodlight ............
.. .. 12-00
blediflash ..................
6.30
Medical Aspects of Ambulance Design
ROGER SNOOK
British Medlc.alyoumal, 1972~ 3, 574-578
Summary
Various observations have shown that the interior layout
of many ambulances leaves much to be desired. The
lighting levels are inadequate, heat loss could be prevehicle
identification and passage through.
could be improved, and measurable differences
exist between the ride characteristics of commercially
available ambulances~ a prototype purpose-built ambulance,
and a private car. Moreover the condition of some
patients may be affected by the motion of the vehicle
either directly or indirectly. Even though they form a
small percentage of the total number carried, they
represent a very considerable financial risk. A personally
conducted survey of ambulance chief officers showed
a deep interest and involvement in the upgrading of the
service with a general dissatisfaction with many of the
vehicles currently available. Hence there is a market for
the purpose-built ambulance, which would benefit the
patient and the ambulanceman alike.
The inadequacies of many vehicles currently in use as
ambulances have been shown to work against the interests
of the patient requiring life support treatment~ and it is
suggested that this warrants urgent attention and action.
A more extensive research project involving medical
observations on the supine sick and injured, attendant
task performance, and instrumentation analysis of
ear and angular vehicle motions should enable the
~r
mful effects of ride motion to be identified.
None of these investigations, however, will be of any
value unless they are used in developing future ambulances.
Such development must also parallel an increase
in the awareness of the importance bf ambulance design
and its relation to the increased comfort and chance of
survival of the pade~te carried.
There has been relatively tittle research into medical aspects of
ambulance design. With the notable exception of Bothwell’s
patented ambulance specification ~’ most of the published
papers relate to general or outline specifications of future design
requirements or simply draw attention to the inadequacy of
existing design. London s has said, "although the need for
special ambulances is negligibly small on a commercial scale
this fact does nothing to ease the discomfort of the person
travelling in a vehicle designed without the least regard for the
effects of illness and injury." The Committee on Acute Medicine
of the American Society of Anaesthesiologist ss reported that
Accident and Ambulance Research, Dunkerton~ Bath
ROGER SNOOK,.M.D., Accident Medical Offlcer m Bath Fire Brigade and
Ambulance Servtce
"most vehicles presently /n ~ are uiI~thfa~ory fo~ life
support." ..... " -" .’,
Experience with travelling with patients in the ambulance
during the research project on providing medical aid at an
accident s and on interhospital emergency mmsfen indicated
that further investigations of the ambulance environment were
needed. This paper describes the results of personal observations
and investigations of such factors as the heating, lighting, sound
insulation, identification, and vehicle motion with reference to
the trearment~ comfort, or condition of the patient. The observations
were made on a variety of commercially available ambulances
in service with several local authorities.
The positions in the ambulances at which various instrament
readings were taken are indicated in Fig. 1.
FIG. 1--Positions in ambulancesuwhich various instrument readings were
taken. Measurements taken at pmdtms indi.cated .were:.l. T~’~. 2.
Light and sotmd. 3. Vibradon over axle. 4. Vtbrauon wmua wnecma . 5.
Vi[~ration on patiea~s leg. 6. Hot ak curtain updraught.
General Destgn
Ambulances transport a variety of patienub including sitting"
cases and routine and emergency stretcher case~ and so the
interior requirements of the vehiclea vary correspondingly.
The interior layout of most ambulances is inflex~ie and makes
treatment of the patient during .transit unnecessarily ditficult.
For example, when resuscitation or supportive measures are
required during a journey it is an advantage to have the m~cher
centrally mounted. In most presentday ambulances the attendant
either stands or kneels on the floor alongside the stretcher,
which is mounted along the sidewall of the patient ompartment
(Fig, 2).
Ideally the attending ambulanceman or doctor should be able
to sit at the patient’s head to operate aspiration or ventilation
equipment. To place this attendant’s seat so that it faces
rearward involves moving the patient nearer to or directly over
the rear axle. By reversing the position of patient and attendant
the former would remain within the wheelbase and the latter
would be able to see where he was going. This would make it
easier to perform delicate tasks such as inserting an aspirator
mount into the patient’s pharynx, besides reducing the likeli-
1
t

^
468 THE LANCe"T, FEBRUARY27) 1988

THE LANCET, FEBRUARy 27, 1988
469

578 3 September 1966 Medical Emigration-iSeale
eac~ subsequent year it has fallen at an accelerating rate. By
1965 there were 750 fewer general practitioners than in 1960,
but by 1965 the number from o~¢,seas had ~"2.., t: ~*150 (46%
aearly all of the fall occurring after 1962. In the early 1950s,
of the total).
Large-scale medical emigration has been a significant aspect
on300theto other400 perhand’year.the~ general practitioners were increasing by of British medicine for over 10 years, and is now a major factor =
¯ contr~uting to the dwindling supply of fully trained medical ~i¯ I
The number of consultants (excluding honorary staff and /
locumtenents) in England and Wales incttased by 1,034 manpower in Britain. In 1964 Professor Abel-Smith wrote
that the loss by emigration of the equivalent of nearly one-
:
between 1962 and 1965, but this was largely offset by a fall of
quarter of the output of the medical schools "’can be regarded ~
933 in the number of senior hospital medical officers in the
same period,
as a serious matter." In the year 1965 the rate appears to have
risen to one-third of the output of the schools.
In 1960 there were 8,100 junior hospital doctors of registrar ,,
. l
.
grade or below in England and Wales. ~y 1965 the number . ~~,
i _~ _ii~ had risen by 2,100, but 1,750 of this increase was due to an
increase in doctors born outside the British. Isles. Between Abel~aire~ B’dodi~G~(.lSCvtO. Brias/t Docaz,, a~ Hem, tad =
1962 and 1965 the number of British-born doctors of junior (1964b). B~. mad. Y.,~L
Brit. m,d. y. SutWt.o l~S2o 2, 15.
.
~xspital grades fell by 80. The increasing dependence of the Brit. r~d. y., 1964, 2, 1.
. - !!_
~ospital service upon doctors from overseas is shown by the Overi~diV~ra~on !k~rd (1965). Smiui~ ter 196, ~. ’. ~I42~, ~i."
:act that in 1960 2,890 junior hospital doctors in England and Scale, I. R. (1962). Brit. mad. y., !, 782. i~
::~ 3~~
~¢ales were born outside the British Isles (36% Of the total), ~ (1964). IbkL, L 1173, .,,
Whitfield, A. G. W. (1963). Lamel, 2. 874.
, " ""~’~4
@
tit. wed. 2F., 1966, 2, 578-.580
/ -.- , ;L |
Organization and Function of an Accident Flying Squad
JOHN COLLINS,* M.B., CH.B., M.ILC.S., L.R.C.P.
X’te first principle for dealing with the seriously in~ is to
xnmence treatment as soon as possible. This is most impor-
,nt when urgent resuscitation is required, as with the severely
rocked patient. The accident flying squad was developed
i this basis, but the team should also be capable of dealing with
~y emergency which requires treatment at the scene of the
cident. The team should be equipped to carry out essential
r~ry, but this should be limited to the minimum necessary,
obviously the place for surgery is under the ideal conditions
the o~.rating theatre.. The flying squad should reach ~he
dent ~luickly as poss~le with t~ necessary surgical aid.
The concept of the flying squad is not a new one. In
many, when the autobahnen were built the seve~ type of
ury which resulted from high-speed accidents demanded a
w organization for their treatment, and mobile operating
mires were developed. At one time a similar scheme was
roduced by, the Birmingham Accident Hospital. Apparently
: main drawbacks to these schemes were the size and relative
wness of the vehicles.
rhe history of the Derby flying squad dates from 1955.
a served by the Derbyshire Royal Infirmary is both urban and
¯ al, in which there are large industrial and mining concerns
well as agricultural communities. There are also important
works of roads and railways and an airport. Such an area,
h a population of almost half a milliqn, has a considerable
ident potentiaL Seriously injured patients may have long
lances to travel to ~ hospital, and it was considered reason-
: to organize an accident flying squad based at the hospital,
serve this community. Such "a team would be available to
o
aior Casualty O~icet, Derbyshire Royal Iafirmary.
deal with any patient who might be at risk, because of the time
delay, before reaching surgical aid. The Derby scheme differs
from the experiments in Germany and Birmin~_gham in that it is
designed to treat all types of accident cases ; in eleven years the
accent has been mainly on industrial injuries.
-r mmt
The first problem involved when organizing the flying squad
was to equip it adequalr.ly. There were no available standards
for guidance, and a omprelamsive list w’aa pzelxu~ to cover
all possible evennmfities. This list proved to be formidable, as
many articles weire suggested which might be ~ but were
. not essential. Capful pruning t~hmed the r~l~ts con- -
siderably, and eventually a list which appeared to be ~" ~,~.’:-~ i
adequate was agreed. The mggetad immmm drt ames- i
thetic equipment, dressing& splints, etc., were assembled to- :~ ....
g~er to assess the amount of spa~_ they would occupy.
This demonstrated that even further reduction was mcessary.
By obtaining compreased dressings and miniature equilanent, .i"
where possible, space was saved. Paeumati: plastic splints were "
found to be space--saving and fight. With experience and use -;"
some articles of equipment have been discarded and other) have ~ : ......
been added. By consultation with other departmema, improvemerits
in the equipment are onstantly being considered. On
the whole simple apparatus has been found to be the best because
of the ~ factors of transport and local conditiom. , It was
found convenient to di~da the equipment into two catelga’ies:
the material which must always be taken and the .~’~ial imms ,- !
which should be available when ~ ~eq~sd ~ =":: :’-:
exit equipment ShOuld be inspeclxal and checked at frecluent "":~
¯ ¯ ° , " .., ":L-" ¯
mtervah, the sur~cal instruments aad other such material ~ga-:

¯ 3 September 1966 " Accident FlyingSquad--Collins
579
- trial concerns, mines, and other vulnerable areas, and these are
always available to drivers.
The return journey can be, by comparison with the outward
journey, a much more leisurdy affair. Ambulances are obtained
¯ from the nearest station, and, although only moderate speeds
are necessary, as the patient is then on treatment, the police
complete their job by escorting the ambulance back to the
hospital.
Certain items of equipment are kept for special types of
incidents. The Siebe Gorman air-breathing apparatus is available
in the equipment cupboard for use when the team may be
called to work in contaminated or dangerous atmospheres, and
additional masks ax’e available for the use of patients. This is
the type of breathing apparatus used by the fire services.
Fluorescent suits for use on main roads and the motorway, as
well as helmets and overalls, are available for the protection of
the team when required. The Ambu ventilator and the footoperated
Ambu sucker, which are contained in a bold-all, are
very convenient and compact. The Brook airway is extremely
useful, and, as a result of its proved value to the Hying Squad,
Staff
all Derby Borough Police cars and ambulances are now equipped. The staff of the flying squad is supplied by the casualty
with it. The Beaver ventilator, which is reasonably small anddepartment,
with assistance from other departments. A member
portable, has been adapted for use at the scene of an accident. of the casualty unit, an anaesthetist or another doctor, and a
As it requires mains voltage, a portable box containing accumu- trained nurse comprise the team.
lators and a transistorized invertor, from which a 240-voh i- Each person must be familiar with his ~b and know what
ampere supply is obtained for several hours, has been developed. equipment is available. The anaesthetist is a useful member
Apart from these special items, there are metres of equip- of the team because the respiratory tract is often invoh~l,
merit which can be sent to the scene of a major accident such resuscitation may be required, or a trapped patient may require
as a train crash so that a casualty-clearing station cure be set up. an anaesthetic before he can be released. Immediate availability
These consist of extra instruments, and materials such as is essential, and a member of the casualty staff is always on
blankets, bowls, and other items.
call. .
Portability is a factor to be emphasized. This is particularly
important in the Derby area, as the squad has to deal with
mining accidents. The equipment has to be carried underground,
over long distances and where walking may be difficult.
Experience has shown that the containers should be robust and
easily carried by one person. Each container has a list of its
contents on the outside, and clear instructions are painted on
each box.
All equipment is constantly available and it is not used for
any other purpose, so that when there is a call for aid there
is no confusion in gathering it together. The only substance
that has to be taken from stock is plasma.
Transport
Speed being the ~ of the service, the idea of using
mobile operating theatres, vans, or ambulances was immediately
discarded. A large car was the obvious choice, and arrangements
were made to use a taxi should it be requ~d. The first
call ever received was to a seriously injured man who had been
taken to a distant cottage hospital and was unfit to travel anyfurther
by ambulance. The limitations of using a taxi were
soon apparent, as it was diff~dt to locate a taxi quickly and
I~ ~dvet ,.~a~ hinde~ by ~c ~mlatious.
The Derby Borough Police were consulted and as a result
it was suggested that the flying squad should be conveyed in
a police car. This has all the possible advantages, and the
equipment has been des~ned to fit into the boot of the car.
The team proceeds all the way in the "police car and where
possible a second police car supplies escort. The Derby Borough
Police have been most cooperative in this matter, and usually
a car is at the door oi the casualty deparmaent in from three t o
five minutes. Nowadays two cars always attend, and thus moreequipment
can be carded. The police have organized a system
..~ "--l~ww, w" for the squad. As soon as the call is received
police mobile teams are directed to man all oross-roads and
zebra .crossings and to clear trafl~ In this way, even during
times of heavy trkIfic congestion, a police car with sirens, loudhailer,
and lights can usually pass through the town at speed.
If more help or equipment is required extra police ca~ are
readily made a~le, and on one occasion whentwenw-nine
people were/n~,ed, some seriously, in a bus crash, fire borough
police cars were used. The Derby Borough Police Force
deserves great credit for their conm~oution to the service, and
indeed without it much of the efficiency would be lacking. The"
police have produced detailed maps of mutes to the chief indus-
Method of Call
Any person can request the assistmce of the team. In practice
this usually means that a doctor, nurse, police otFu:er, fire
officer, or ambulance crew has initiated the call. Certain special
arrangements have been made with large industrial concerns
and the airport for calling the flying squad. The person
requesting assistance is connected by telephone to the casualty
department and is asked to give the location and the approximate
number of casualties. Immediatdy on receipt of a call
the Borough Pofice are informed and the nearest patrol car is
directed to the hospital. A second car is available within
minutes, and this car may be used to collect a member of the
team who is on call but not in the hospital and take him direct
to the scene of the incident if the first car has loaded the other
members of the team and equipment from the hospital
Major Accidents
In preparation for a major accident or disasw.r, a scheme has
been drawn up indicating the action to be taken to deal with
multiple casualties. In this scheme the flying squad plays an ¯
important part. Immediately on receipt of a call the flying
squad would proceed to the scene of the accident and make
a reconnaissance_ The surgeon-in-charge would assess the
seriousness of the incident and report hack to the hmpkal by
radio. Further assistance and equipment could be requested
and a clearing station established, ff necessary. In the hospital
a plan for the evacuation of beds has been arranged whereby
the less seriously ill Patients would be transferred to other
hospitals to make room for the admission of casualties, who
would be received by a 1earn stationed in the outpatient departme~t.
This scheme for major accidents 1~ been published in the
hospital and circulated to all senior staff, wards and departments,
and to all other staff involved, including administrativ~
and clerical personnd.
In order to have a direct llnk with the hospital a multi-,
channel radio transmitt~/receiver was installed in the casualty
department. By a turn of the switch the different anilmlauce
services which serve the Derbyshire Royal Infirmary can b~.

J 3 September 1966 Accident Hying Squad--Collins
.-eached. That was the first radio of this type to be installed
a hospital in Great Britain, and the flying squad requirethe
patient has been made possible by meeting the ambuhnee W]
nears were responsible for its introduction. It is possible, byand
starting the treatment immediately. ~-
~ing this apparatus, for the team at the scene of an accident For smooth operation the team must work in ~ with -
o talk directly to the staff, in the casualty department, and bypolice,
fire, and ambulance
his means any possible errors or misinterpretation of messases
servaam " . It has been emp~ ~:~J ¢all z
to all authorities that, although a call will be answered witbmat some
vhich are rdayed by an ambulance controUer are avoided. It
s also possible for arranrcments for treatment to be made in
question, particularly when life is at stake, everyone requesting ...... 1951
help should bear in mind that the departure of the team to aa
~
,dvance of the arrival of a patient at the hospital. The radio
-~:., disct
accident deprives the hospital of medical and nursing perscmneL ! Law~
,as been used by ambulance crews to summon assistance to an By personal contact with responsible people and an explanation the
ccident, and advice can also be given to crews at the scene
,f an incident. The radio proved so successful that a second
of how the team functions, it has been possible to obtain co= ! diflSc
operation in the use.of the flying squad. It has been tmt~- ~: ! patie
eceivcr/trammittcr, on a different frequ~..cy, was installed soin
the eleven years of im existence that every od! has K~-.o ; toda:
hat the Derby Borough Ambulance service was brought into
iirect contact with the hospital
reasonable and no " f~" even-with good intent, have -~ | c,u g
been recorded. . .~. :~ ! adwa
.Calls
At first the number of calls on the service were comparatively
.-w, but they have steadily increased over the years. Up to 18
aUs per annum are received at present. In january 1966 there
,ere four calls, whereas in February 1966 there were none.
7ith the opening in December 1965 of the extension of the M.I
far as Kegworth, which is only eight miles away, an increase
t serious road accidents had been expected, but so far the.re
as o~n one call, to a seriously injured passenger trapped
l a l~lt.
The calls come from a wide variety of industries ; on~ call was
, release a man trapped in a printing press, and he required an
~aesthetic before being released. Another patient was trapped
; the wheel of a crane on an overhead gantry and his partially
vered foot had to be completely amputated to release him.
his was thirty feet above ground: Over the years there have
zn several calls to attend injured miners. The team goes down
.e pit to the coal-face or to wherever the injured man may be.
ccasionally it has been necessary to treat miners who have been
jured in machinery underground, and early commeacemeat
intravenous therapy, as well as surgical procedures, have been
zdertaken. Supervision of transport of the injured to pit-
~ad, particularly where spinal injuries are present, can reduce
e incidence of damage to the spinal cord. On several
casions there have been a number of patients to deal with ; at
:e bus accident 19, and at another 29 patients were involved.
ae team has deah with numerous accidents where people have
en trapped in vehicles, and in such cases the patient has often
m on phsma while being released. The team has been
lied to a doctor’s surgery to resuscitate an injured man who
d beena~aken there from work. He had .been injured by a
mper~Thenever a case of severe burning is notified to the
coop
"i ~ basic eq pment for the fly~g squad comprised surgical " - "7"’ adm!
instruments, drums, drugs, and dressings, and these were avail- --able
from stock. The carrying-cases and portable mains electric ¯
supply from batteries were made in the hospital workshops.
Special items were purchased to improve the service, and ’’"
examples of the more expensive of these are: Pye radio transmitter/receiver,
£200 ; Siebe Gorman breathing apparatus, £70 ;--:~:: !
Ambu resuscitator and sucker, £40 ; Beaver mark II respirator, "~-~ !
£215 ; equipment for testing for radiation hazards, £220. The 7~, i
police have not made any charge for their services.. - ~. ’
(~ha~
bilh3
Beva
to
and
that
in n
idea
If y(
: S~t~tnaty ..... .., ~-,~.:. ~.,~,. ! one
2~: me t
The flying squad in Derby has ~ in eadstmace for elevea - ~-- : begh
years.
--- the
Essentially the service is ~ion, but surgery has been~,..:~, we s
performed when necessary. -.~,~.:,~ .. Pu
Speed is of vital importance wlma proceeding to an accident..: :’~ " off E
The cooperation of the police is ~sirable and advantageous. ,~.~ ~ jUSt
Since its inception the squad has been called to deal with a Grat
great variety of accidents. " , _ that
’ Calls for the services of the Derby Flying Squad have smadily =,: ....
increased in numbers and the scopa of its work has gradually ,~
widened.
The success of early treatment of the injured by the flying L:-,~
squad has amply justified the efforts of the team. ,__
In Derby the flying squad has been found to be very useful) ~ :
and a plea is made that other areas should seriously consider ~-:~
the advisability of forming timilar teams. " ~’~-"~#-~ ~
:,. -
.
I:
tion
mov,
bein~
abRi~
soci~
T!
h~it~
it) f
little
HItiC
the
I5 y
Ithi
they
N.H
The
fiuar
I1
at~$
wog
tion

~ertension, renal disease, and heart failure
stressed the communities without hypertension, let me
again emphasize that most urban or periurban tropical communities
show blood pressure patterns similar to those seen in
the United Kingdom or in North America and have similar or
greater frequencies of individuals with "high blood pressure."
In most tropical clinics the majority of subjects seen with raised
blood pressures are classified as essential hypertension, particulariy
those over 40 years of age. A few cases are associated with
underlying renal disease, but it is this group of cases that produces
most of the severe hypertension problems admitted to
hospital. Thus impressions gained from hospital admission
studies tend to overemphasize the contribution of renal disease
to the community pattern of blood pressure.
A recent necropsy study from Uganda gives some perspective
on the problem, s* Over a three-year period some 3,000 necropsles
were carried out on patients who had died in the hospital;
only 84 cases were finally diagnosed at necropsy as hypertensive
heart disease, and these fell into four main groups (see Fig. 2).
Group 1.--Essential hypertension (25 cases). Most of these
¯ were elderly men with cerebrovascular disease as the commonest
single cause Of death.
!.
I0.
8
b
4
2
0
8
b
4
2
0
Essential hypertension (25} Dyelonephritis (I

808
e-’tergency which might arise. The service aims to supply an
xperienced accident team which can be mobilized rapid/y, can
travel rapid/y, and is equipped to do the minimum necessary
"in the field" before transporting the patient back to hospital.
The system now is well established, works very smoothly, and,
in our opinion, reduces both mortality and morbidity and well
justifies the time, money, and effort which it demands.
This paper analyses the calls received, the acti0n taken, and
the patients treated during the years 1967-71 inclusive.
Analysis of Calls
Mobilization and Duration.--Since two police vehicles are used
the mobilization time is divided. During 1971 the first vehicle,
carrying the team and immediately needed equipment, averaged
just under four minutes from receipt of the call to mobilization.
The average time for the second car (carrying late or extra
team members and the remainder of the equipment) was six
minutes. The duration of calls is measured from the time of
leaving the department to the time of return. During 1971 this
varied from 10 minutes to 140 minutes, the former being a call
with subsequent cancellation, and the latter being a road
traffic accident in which after treatment and release of the
tra~g~ed driver he was taken to a casualty department nearer to
.th~ene of the accident. Of.the 79 calls received during 1971,
however, 69 (88°.0) lasted less than an hour, the average time
being 44 minutes. The efficiency of the casualty department is
not greatly affected by the team members’ absence, and the slight
decrease in efficiency that does occur is more than balanced by
the speedier transfer of the patient to his final destination, most
of the initial resuscitation having been performed before his
admission to the department.
Number of Galls.--The number of calls increased dramatically
during 1971 compared with 1970--79 and 46 respectively (Fig. 1).
This was probably due to a combination of factors--an increase
70.
60,
50’
40,
I 30,
z
20’
IO,
.Year
FZG. 1--Yearly number of calls recdved by arc/dent
eying squad.
in the number of high velocity road .tam’tic accidents, and an
increasing awareness by the emergency services of the function
of the flying sq-a d. The team members are constantly advising
the services of the part they can play, and as a result relationships
with the emergency services are excellent and could not be
improved. No one is ever criticized for a call ~vhich later proves
to have been unnecessary, but they are occasionally reminded of
the service if in one’s opinion the squad should have been
but was not called to a seriously injured patient. This, of course,
leads to a number of unnecessary calls, though at present these
amount to only some 10% of the total. In addition the number
of aborted calls is increasing slowly. These signify early alert of
the flying squad but subsequent realization that they were
not required, either because the patient was dead or because
he was not as seriously iniured as originally appeared.
Location of Ca/L--Since the area served by the flying squad
mrrxsB ~ic~ jo~a. 30 s~rr~M~
stretches up to 30 miles (48 km) in some directions can-out is
not limited to trapped patients. The team often travels to meet
seriously injured patients in ambulances, and can thus make
the 40-minute journey less hazardous. The furthest distance
travelled has been 27 miles (43-5 kin) to reach a seriously ill
patient, but a high proportion of calLs (50°o) fall between 5 and
15 miles (8 and 24 kin), with about half of the remainder being
within a 5-mile radius. The outcome of calls received is sho~
in Fig. 2.
g
Z
40.
30.
20
I0
P
o ,967 ,47o ,9"7,
Year
FIG. 2---Outcome of calls attended by flying squad
Squad met -- ’~
ambulance
Type of CalL--The calls have been divided into four ~ main
groups---pit accidents, industrial (works) accidents, road traffic
accidents, and miscellaneous (including domestic, alerts to the
local airport, etc.). Ali the local pits have now closed, but at the
inception of the squad they constituted a large proportion of the
calls (Fig. 3). All the other groups are increasing, but none more
so than the road traffic accidents, which have registered a five.fold
increase in the past four years.
SO
4O
,o
o
"Z zo
io
0
Yea r
¯ Road traffic accidents /
x Miscelloneous
o Works
/
¯ Pits /
/ !
/
FIG. 3---Frequent7 of the four main types of calL
Seasonal DistnT~ution of Calk--Since road traffic accidents
account for about 65% of all flying squad calls it seems reasonable
for the total calls to be directly related to high-risk periods
on the roads--altar is, the winter months (Fig. 4). In fact, whzu
the type of accident is related to the time of year the we=h=
g
Z
20- ¯~/
~./
IS I
0
L
; : - ,.’.:., ¯
I
!
i k
"It
In(
"ck
in
r~
g~
g~
gn
tlu
T~
04(
O6.(
Z~-(
l&(
2O-(
1
p~1
I-Ic
th=
im fo~
10
mi
col
I~I1
- ¯ .< . im
i.,: II
/"1970
i ~ol
"----.., I/ ..... .
-J;a.- A~I- Jui~- O~:t.- ...........
March Ju~ Sept. Dec. ~ ’"
~o. 4--Se=.mal di~m’bution of all calh ~ce 1967.
I
i
~
TAm
WO
hd

,~ITI~ MEDICAL JOURNAL 30 SEFTEMBER 1972 8O9
3O
O
Road traffic
accidents /
/
/
/
Niscellaneo~us .~x
""---..~....x _..._..~.. x
Works ...~
Pits~ ,~
J..- Ap;,- Jui,- O;,.-
March June Sept. Dec.
tno. 5--Seuonal distribution of the four maln types
of call over a year.
factor is well demonstrated (Fig. 5), the road tra~c accident
total being the only one with a significant seasonal variation.
This also means that the team members are often working in
most adverse weather conditions and therefore have to be
clothed accordingly.
I
~L Time of Day.--When calls are broken down into the period
t which they originate the surprising fact that the total calls
reach a peak in the morning is found. In fact, all groups of
accident reach a peak during this time, though road traffic
accidents do present a higher peak around midnight. This latter
group of road traffic accidents are often the most severe, since
they usually involve multiple drunken patients.
TABLE I.--Timi~ of Calls throug]lout the Day (Dam for 1967-7I)
Thzw
Road
Accidents
Works
laneo~ i
30.01-04.00 hom~
~4~01-0&00 ho~s
~8.01-17.00 hours
12-01-16-00 hours
16-01-20-00 ho~s
20-01-24.00 hours
Total ..
-.
¯ .
.o
¯ .
..
16
8
22
19
29
120
I
II
I0
s2
o
1
12
966
34
Total
17
10
49
41
30
37
I 184
:~ Number of Patients per Coll.--Most calls involved only one
patient, particularly the works, pit, and domestic groups.
However, the road traffic accidents did tend to involve more
~v~
: patient requiring treatment--for example, 90 calls
one patient, 26 calls two patients, 16 carla three or
¯ ~ four patient~ 11 calls 5 to 10 patients, and one call more trmn
10 patients. Although patients in these accidents tend to have a
mixture of major and minor injuries the team has to be able to
cop~ in~ at least, with three or four seriously injm~d
patients. Extra equipment can always be obtained if necessary.
~ The call involving more than I0 patients was to an accident
involving ¯ bus. Ahhough ~ bus contained 37 injured people
l ha’.,~ ~__d.~d~l only the two seriously injured patients in the
~fiowing patient study.
~ ,~ .
Analysis of Road Traffic Accident Patients
During the years 196%71 inclusive, 280 patients were treated
by the flying squad. Of these, five were under the age of 10, the
ages of 14 were not obtained, and in three cases the time of
injury could not be checked. These patients are thus excluded
from further analysis. Seventy-three per cent of the patients
were male. Of the patients with known ages 60% were aged
15-30 years. Since such a large proportion of the patients were
young and had previously been fit they were potentially more
salvageable than, for example, patients served by a coronary
flying squad.
AGES OF PATIENTS RELATED TO TIME OF ACCIDENT
The striking difference in ages according to the time of day that
the road accidents occurred is shown by plotting the two
extremes graphically (Fig. 6)---namely, the 11-20 and 41-50year
age groups. This difference presumably reflects the social
habits of the tWO groups, carrying the vivid impression that
alcohol is a large contributor to the teenagers’ peak risk period
around midnight. The figures for all ages are given in Table II.
20
E = tO
Z
0
Time of day
I)
¯ |l-2yeorO/_/
too. 6--Correlation of time road accidents occur, with two
age groups of patiems.
TABLE II--,~$ of P~olt$ ¢orrel~ed t~it~ Tira~ of Day--Road Tra~¢
Accidents Occurred(Data for 1567-71)
¯ Age
(Years)
¯ 11-20 ..
21-30 ..
31-40 ..
41-50 ..
51-60 ..
61-70 ..
Total pttient~
"l’m~ of Day @Ioun)
00-01 04.01 08.01 12.01 16.01 20.01 Total
tO KO KO tO tO to Pc’dents
04.00 08.00 12.00 16.00 20.00 24.00
22 1
19 8
1 2
3 o
1 o
1 0
47 II
m~Parts Injured ar.wrdi~ to Type of Accident and (in the cme of Road Acddent~) Typt of Vehicle Involved
T~m,! ......
Had
83 4
1585
115
(~est
28 1121
Abdm~
8 23
2
o
15
Pelvis
9
3
1
o
1
14
6 14 11 26 80
11 13 9 14 74
11 5 4 4 27
9 11 7 9 -39
7 5 0 8 21
2 4 3 7 17
46 52 34 68 258
patients’ injuries have bee~ subdivided into body areas and
related to type of accident and, in the case of road accidents,
to the type of vehicle in which the patient was travgfiing.
Head injuries dearly constitute a large propo~’on of all injuries,
especially in car and motor-cycle travellers (Table III). Of all
One
14 2361
26
Arm
Both
3
o I
o
One
34 8672
57
Both
9
8
2 11
21
22 433o
32
Bums
o 1
o

the patients with head injury 60 had solely a head injury and 61
had head plus other serious injuries. The type of injury is
dictated by the vehicle (Table II). Motor-car injuries are made
up of head, chest~ and limb injuries. In lorry accidents the
patient (usually the driver) has lower limb injuries, and the
upper body is usually spared. This impression has been so vivid
in recent motorway incidents that the team now takes collapsible
Thomas splints to any injured lorry drivers. Among motorcyclists
and pedesu’ians head injuries predominate, and occasionally
limb injuries occur. Works accidents (apart from miners
with head injuries) usually involve one patient with one limb"
trapped in machinery, and this group is the one which normally
requires true surgical intervention---, for example, amputation.
TREATMENT AT SCENE
The flying squad aims to provide rapid, essential medical care
at the scene of an accid~mt. Obviously the ideal situation in which
to perform surgery or to induce anaesthesia or both is in
properly equipped hospital surroundings and not in a hostile
environment. There are, however, certain therapeutic measures
which must or should be instituted immediatelyNfor example,
efficient analgesia, blood volume replacement, tapping tension
~ othoraces, intubation and ventilation, and, rarely,
anaesthesia to allow surgery for otherwise impossible
release of a victim (Table IV).
T~ zv~Measura Instituted at Scene of Accidmt
Treatment No. of Occasions ] Treatment No. of Occasion~
Intravenous analgeaht, .. ,. 59 ] General anaesthesia for spfintage .. ,~.
Intramuscular analgesia ..... , Intubafion ........
Drip .. . ...... 104 Sedation ........
.. s~
2
General anaesthesm for release .. 4 ] Ventilation ......
"Anti-shock" measures are obviously the most common treatment
required. Our intravenous therapy initially consists of
plasma and dextran 70, with blood being obtainable if required.
MORTALITY
Of the 280 patients treated by the flying squad 73 die& These
are divided in Table V into deaths before arrival of the flying
squad, during attendance of the squad (including time spent in
the casualty department), and in hospital after admission.
Only three patients died during attendance of the flying
squad, and these were among 37 patients with severe multiple
injuries. (My definition of severe multiple injuries is where
three or more parts of the body are severely injured.) It is
TABIJ vwTime of the 73 Deaths
Type of accident
Pedest- Car
rien
efore arrival of squad 3 26
raring attendance of
squad .... 0 2
n hospital .. 2 10
Total .... 5 38
lion,/ Motor-! Works Mi~ l- Total
..]
cycle tram ts
4 3 6 (s 4S
0 1 0 ¯ 3
1 2 3 5" 22
5 6 I 8
TABLE VI--S~ ~ Pa6oas admitted to Hospital
tl "/3
Intensive care unit ....
Trauma ward ....
Discharged .... ::
" 43
156
30
,i N’o. of --,-b’~ i
1"~- "~ °ev’la
1O (23%)
7 (4-5%)
0
TABLE vn--lniured PavU of Patients who Died in Hospital
No. of i
patients 12
I Head Chest ^halomen
One Both
8 7 4 1 2 2 4 0 I
Arm ~ Mia~ ikma
One Beth
I i
doubtful if anyr2dng can be done for the patients dying before
arrival of the squad, but the figure of only 22 (11%) deaths out
of 199 viable patients seems a very reasonable one, since this
does not include routine road traffic cases. (The Heidelberg
Clinic reports a mortality of about 5% of all road traffic accident
cases admitted’)
The figures for deaths in hospital confirm that if the patients’
injuries are ~-ious enough to merit admission to any intensive
care unit then the chance of survival is greatly diminished
(Table VI). Analysis of the injuries of patients dying in hospital
(Table VII) shows that the most common injuries leading to
death are head, chest, and abdominal injuries (Gogier quoted
head injury as a cause of death in 70.2% of his patients) t.
Discussion
Although a selection of powerful analgesics is taken, our normal There have been many attempts to provide an efficient system
routine initial analgesia is pentazoc~" ¯ (Fortral) 60 rag intravenously.
We find it efficient, rapidly acting, and relatively
free of side effects, its duration of action if given intravenously
which would enable doctors to attend at the scene of a serious
accident. Complete mobile "hospitals on wheels" have been
abandoned because they are too slow in mobilization. Many
being about an hour. Thus it does not obscure the clinical groups of general practitioners have joined together and which
picture at subsequent examination by neurosurgeon or general ever is nearest to an emergency scene is mobilized to that scene.
surgeon.
This usually has the advantage of rapid gravel but suffers
Induction for general anaesthesia is implemented with a
~Oethrt.acting ohexitone non-barbiturate sodium (Brietal such Sodium). as propanidid If necessary (Epontol) or the
greatly through lack of equipment and finance and the necessary
continuing experience in the use of such equipment. It is
unreasonable to expect any doctor to intubato someone lying
anaesthetic can then be continued in routine fashion with on a dark, wet road when he has not inmbated a patient for
oxygen, nitrous o~de, and halothane delivered by our portable
miniature anaesthetic machine. There is no place in the equip-
perhaps several years. The compromise answer surely lies in
flying squads based on the major accident centxeb which can be
ment of the flying squad for Entonox, since they already have a financed by the hospital and can use trained ca~malty staff m
more adaptable form of gas mixing. I am sure, however, that it
is of great value in paramedical hands. It is interesting to note
that of the 13 patients given general anaesthesia under most
unsuitable circumstances (Table IV) only one died, the patient
whom emergencies are routine.
Apart from a weft-equipped team, speed of mebilizati~ and
speed of travel are essential. There is no point in a patie~
remaining at the scene if he can be safely tr~pm~ed to hospital
being an elderly woman with severe multiple injuries.
Of the 24 patients inmbated 11 died, these including five
who were probably already dead but in whom resuscitation was
attempted. Of the 15 patients given ventiiation on the .way to
hospital, surprisingly only seven died, these again including a
few hopeless cases.
in a shorte: time than k takes for the team to reach him. ¯
The figures show an increasing demand for such a service and
also prove that senior staff must always be ~ available,
although they need not necessarily be within the hospital It is
impossible to justify a flying squad’s existence statistically in
terms of mortaEty or morbidity. There are a few cases which
one can state categorically would have had a fatal outcome* but
for the flying squad’s attendance, but these are rare. However,
the clinical impression of anyone who travels to the scene or
receives the patients in hospital is that these patients benefit
greatly from appropriate early treatment.
References
: Collins, l, Brin’sh Me~’ca!yourna/, 1966, 2, 578.
t C~ler. E ¯ Unfallopfer im Stvassen~erkehv. Basle, Geigy, 1962.
¯Lit~Je, Y~’BnrisS M~i~your~, 19W, 2, VVT.
I t
|
t

622
clear pointer to possible pituitary deficiency and is an important
physical sign in newborn boys.
We thank Dr D Stone and Dr A J Franklin for permission to
report their patients. Plasma adrenocorticotrophic hormone was
kindly measured by Professor Lesley H Rees in the department of
chemical end?crinology at St Bartholomew’s Hospital, London.
Other hormone assays were performed in the department of chemical
pathology at the H~pital for_Sick Childrem. ~ London.
ReferenCes c ~ ~ ~ ,
I Wil~n ]D, Griffin JE, Qeorge _FN, Leshln M. The role _of-gonadal
- steroids in sexual differentiae/on. Recent Prog Horm Res 1981 i37:1-39.
Clements JA, Reyes EI, Winter JSD, Fairman--C. Studies on human
- .
.
.
For Debate,. ¯
Paramedics in the United Kingdom?
A D REDMOND
There is no doubt that until recently the United Kingdom
could boast the best ambulance service in the wood. This is
no longer’ the case: Standards have not fallen~indeed they
have risen. The rest of the world, however, has caught up and
in some places has overtaken us. These ambulancemen are no
better trained than our own but are better equipped and
allowed to do more. The obvious and best example to quote is
the ambulance system now developing in the United States of
America.
Twenty years ago there was no effective ambulance service
in.the United States. In many places any vehicle of suitable
dimension was used to transport a sick or injured patient to
hospital Ironically, the most suitable vehicle to hand was
usually the local hearse. It was no doubt difficult for the
mortician to separate the demands of his patient and the
demands of his profession. To overcome these problems many
local.ommunities developed a volunteer rescue squad. They
fought fires, rescued trapped victims, and transported people
to hospitaL. In an attempt to coordinate the many different
squads, a programme of training was introduced in the early
1970,. This is now widespread and very well organised. The
ambulancemen are referred to as emergency medical technicians,
or EMTs. The basic emergency medical technician has between
80 and 140 hours of training, which covers basic anatomy and
physiology and simple first aid. This "’simple first aid" does,
however, include a thorough training in cardiopulmonary
resuscitation. This emphasis on control of the airway and
belief in the positive effects.of early cardiopulmonary resuscitation
is a major contribution to the saving of life. A basic emer-
Stockport Infirmary, Stockport, Cheshlrc
A D REDMOND, MD, FaCSEB, consultant in accident and emergency
medicine
Correspondence and requests for reprints to: Mr A D Redmond.
BRITISH MEDICAL JOURNAL VOLUME 288 25 FEBru~.
sexual development III. Fetal pituitary and serum and
fluid concentrations of LH CG and FSH. J Clin Endocn,
1976 ;~! :9-19.
a Comblatt M, Schwartz R. Hypoglycemia in the neonate, in.
carbohydrate metabolism in infancy. 2rid ed. Philadelphia:
Co Ltd, 1976:178.
Lovinger RD, Kaplan SL, Grumbach MM. Congenital hypo
assooated with neonatal hypoglycemia and microphallus.
secondary to hypothalamic hormone deficiencies..7 Pediatj
1171-81¯
i Moncrief MW, Hill DS, Archer ], Arthur LJH¯ Congenital
pituitary gland and adrenal hypoplasla. Arch Dis Child 1971
’ Leblanc A, Odi~vre M, Hadchouel M, Gendrel D, Cha
Rappaport R; Neonatal eholestasis and hypoglycemia: possi
cortisoi deficiency, y Pediatr 1981 ;99:577-80.
Flatau E, Josefsberg S, Reisner SH, Bialik O, Laron Z: Penile si~
newborn rn-fant.JPediatr 1975;87:663-4.
_ (Accepted II AUgUSt 1983) ~-
gency medical technician can then do further trainin
an intermediate emergency medical technician. He has a
60 to 200 hours of training and will be able to insert
lines, obturator airways, and apply a medical antishock
suit. The obturator airway seals off the oesophagus and
allow air to go down only the trachea. There are many
with this device including misplacement in the trachea
inducement of vomiting. It is rapidly losing favour in
United Staies. The medical antishock trouser suit is an
flatable suit put over the legs of the patient in an eff0l
increase peripheral resistance and thereby raise the blood
sure. It will also stabilise pelvic fractures. Having
this training the emergency medical technician can then
for even further training. A cardiac emergency medical map
nician can do all the above, but in addition can give drugs
defibrillate patients. A paramedic emergency medical tcc~
does an extra 400 to 800 hours of training, and is then very
trained, and .can give help equivalent to that of a trained phy ’~qm
m emergencies. The paramedics can pass endotracheal tulm,
insert central venous lines, and interpret electrocardiograrm
the envy of many a medical registrar.
There are problems, however, with training techniciam aP
such a high level. As their knowledge and expertise is so m~
and their capabilities are so great the medical profession fed
need to keep a close eye on their activities. Strict and len~
rules are laid down for what they can do at the scene ol D
emergency, and usually any invasive action has to be pro:odd
by permission from the local hospital. In addition, therda~to
the colossal expense of training these people and equii~
them, radiocommunications there is the added with expense the hos,~ital of providing Furthermore sophisti ’ ~.1~ .
such a highly trained ,,l~.ramedic arrives at the scene, his ~
training and raison d ~tre is to apply those skills that
been so hard won. Hence the main drawback with such a sysU~
is delay¯ When the paramedic arrives at the scene he has ~,m
of all to work through a check list. This includes taking a hist~
and taking the patient s blood pressure, pulse, and an ekx-t~

_,*CAL JOURNAL VOLUME 288 25 FEBRUARY 1984
.a~diogram. Trapped or injured patients have to be stabilised
%n a backboard always. If an intravenous line is indicated then
the paramedic has to contact the hospital via radio or telephone,
which all takes time.. There is a growing concern that in the
treatment of trauma this may often be" inappropriate and in
fact life threatening. The main cause for concern is in the
treatment of penetrating injuries, particularly from gunshot
,ounds and stabbings. Though we are fortunate not to see
these wounds in Britain to the same degree as on the other
side of the Atlantic, they do provide us with an example, albeit
extreme, of what can happen when definitive treatment is delayed.
If a major vessel has been ruptured by a bullet, or some
other penetrating object, then the patient needs an operation.
Any delay may be fatal. Unless the wounds are so devastating
that the patient will die immediately or so trivial that there is
no risk of appreciable haemorrhage, then with penetration of a
major vessel the patient has only about 30 minutes in wHch to
set definitive surgery. This, however, is usually the time it
t~es for an ambulance to be called, the ambulance to arrive,
~d the paramedics to complete their check list. The patient
therefore arrives in the emergencyjj department having suffered
s cardiac arrest in the ambulance and cannot be resuscitated.
This can best be illustrated with an example. While I was
r/siting a distinguished medical school in the United States. the
following case was discussed at a surgical meeting:
At about 11 00 pm a man was shot during a garage hold up.
The incident was wimessed and the police were called. The
police arrived at 11 07 pro. The police then called the paramedics,
who.arrived at 11 17 pro. They noted that the patient
,lially conscious and complaining of pain around the wound
in~ abdomen. The paramedics then began to run through
their check lis% which included taking the patient’s blood pres-
,ure and pulse. Both these were difficult to do and several
attempts were made. An intravenous line was inserted and by
the time all this was done the patient was finally loaded into the
ambulance at 11 32 pro. At 11 42 pro--that is, only 10 minutes
l~ter--the patient arrived in the regional trauma centre. The
patient had, however, died in the ambulance and could not be
resuscitated. It is obvious from the times stated that ff the
policeman had: simply put the man in his car and taken him
straight to the hospita ! , which was only 10 minutes away, or if
the paramedics had taken him straight to the hospital then the
patient would have been talking and complaining of his abdominal
pain when he arrived in the trauma centre. The
necropsy showed a perforation of the small bowel and a laceration
to the common iliac vein. These lesions were treatable and
the patient would have lived.
It is becoming clear that in the management of trauma efforts
to improve out of hospital care can go only so far. Paramedics
,.re well trained, highly skilled, and well motivated. Their role
is that bystanders who initiate cardiopulmonary resuscitation
the moment a cardiac arrest has occurred make a major contribution
to the survival of that patient. An important success
with resuscitation of ventricular fibrillation taking place out of
hospital can be expected only if cardiopulmonary resuscitation
is started within four minutes of the event and defibrillation
accomplished within eight minute,. Furthermore, it is not
necessary to have a fully trained paramedic arrive on the scene;
a basic emergency medical technician who has received an extra
I0 hours of training in defibrillation can achieve similar results
if he gets there within the eight minutes:
The implications for the United Kingdom are obvious. We
already have a well established, well disciplined, and well
motivated ambulance service. They are experienced in the
extrication of patients from vehicles and, along with their fire
and police colleagues, perform an excellent service. The advance,
in mmmgement of trauma are to be made not in care
received out of hospital but in that received in hospital. The
American development of trauma centres bears witness to this.*
For patienta who have sutfered seriom trauma the most advantagcous
thing to do is "scoop mad run,’? mad our mnbulance
drivers are good at it. The patient must, however, be scooped
up and run to a trauma centre. Such a place must be.capable of
resuscitating that patient and providing mediate surgery by
senior surgeons experienced in trauma. If a smaller hospital is
passed en route then so be it. The United State, of America is
accepting this and designating certain hospitals as trauma
centres. We mtLst do this too.
The advancea in coronary cat,, howeverj are to be made
outside the hosp|tal: ~ tint is to train mo~ of the general
public to initiate cardiopulmonm’y r~tation within the
critical four minute,. Until our amb~ are equipped
With defibrillator% however, it is unlikely that patients in
ventrioalar fibrillation will be saved in any great numbers. An
ambulance will "probably arrive within eight minutes, but
ambulancer/len can only carry on cardiopulmonary resuscitation
and the ch~mces of that patient surviving are very poor. If the
ambulancemen had a defibrillator and could reverse ventricular
fibrillation then the day may come when a third of these patients
will be back home with their families, as they are in Seattle.
A relatively short time ago we had the best ~mbulance service
in the world. The basic structure and the quality of the personnel
still rcanains and indeed has improved. All that is lacking is the
provision of defibrillators and once again our ambulance service
will be the best. ..._---- "
o
References
*-Cobb LA, Hallstrom AP. Community rinsed cardiopulmonm’~ resuscimm
the treatment of trauma is, however, limited. The reverse is -_ tion--whnt have we learned ? ~nn N Y ~¢ad Sd 1982;38~:330-42~
-. _- t Trunkey DD. Trauma. Sd ~m 1983 ;2A9 :20-7.
true, or suddeii cardiac arrest. It has been deafly-sl~own-by
- the~rke~ in .~ttle that the provision of a highly sHllcd and (~e~xpud 13 October 1883)
fi~t~]~ramedic’team can ~eafly improve the outlook for cardiac
arrests out of hospitaL*
Present figures from S~ttle t~h~v that for episode, o[ventricular
fibrillatioiL outside hospitals, two thirds will be admitted
~,ith a pt~lse and b!ood pressure to hospital. Half of these
W~l go home. Seatde’is fortur~ate in that it has’n-enthusiastic
tnd underused fire service. The city burnt down in the1890s Does ahitud~ affect th~ reading of bloodpr~sure, dth~ with. a mercury
and has been determined never to repeat the episode. It has
or- toith an ana~roid sphygmomanom~t*r ? .....
therefore furnished itself with 32 fire stations for an-18 x6 mile Changes of aldmde may affect the l)Io~i pressure of an individual,
(~.>" 10 kin) city. Furthermore, it has" 14 major hospitals within but they do not have pronounced effects on the recording of that blood
tMs small area. When car_~’ac.arrest occurs it takes 2 minutes- pressure. The convendonai sphygn~, manometer is exposed at both
47 r~conds for a" fire engine and a-basic ern¢~rgency- medical " ends to prevailing_atmospheric pressure (it is not a barometer).
ttehnician to initiate cardiopulmonary r~uscitatinn. Two Similarly, the bellows of the anaeroid sphygmomanometer are ex-
minutes later the intermediate .emergency medical t .esOmici~ffiposed to ambient atmospheric pressure, as is the patient in whom
arrives, and two minutes after that a paramedic-emerget,cy the blood pressure is measured. Blood pressure is not an absolute
medical technician who passes an (mdotracheal tube, interprets value: it is the pressure difference between the circulatory system
and ambfent atmospheric pressure. Thus if systolic blood pressure is
electrocardiogram, and defibrillates when necessary. The 120 mm Hg and atmospheric pressure is 760 nun Hg absolute systolic
t~ramedic will also stabilise any arrhythmias before transport. pressure will be 880 nun Hg.~R THOMAS, physicist, Glasgow, and
~he other factor that the workers in Seattle have established F L~’tm, director, blood pressure unit, Glasgow.
623

5".."
THE LAN~T, AUG1
’q ....: ....’~ -’=:~z~::-:n-ch!cf, Dc:’a...n:que ~ ..... ~ar-.:v °
appreciated :he r,~u- ,.o, e.,.e,t ;, ,,, . for ra~id evacuv_tizn and early
~.a;~-q care when he set up ,’he ..... ’-*--
~te~
,~
"flying
ambulances’" in the first half of:he 19th century but it was
van in the latter part of the 1939-45 war that modern
techniques Of resuscitation came to be applied to wounded
peraonneL at ,he,place of iniury. Subsequently, during the
militar~’confliffts in Korea, Vietnam, the Middle East and
more~edentl~ in the Falklands, specifically trained
’para~c" soldiers provided basic medical care and rapid
eva~anon of the seriously injured. =:7=:.’ ¯ ...
The application of lessons learnt during War-time to
ci:51ian experience is often delayed. Nowhere is this more
powerfully exemplified than in the establishment of hospital.
based accident flying squads. In 1955 the first accident flying
squad was established by Collins" ’at the accident and
emergency department in Derby Royal Infirmary. 1 In the
early 1970s several other centres within the United Kingdom
began to appreciate the potential value of such squads, and
the number ofschemes has since increased rapidly. In 1982
there were 47 centres throughout the United Kingdom with
this facility, but less- than half of these were "active", with
10-100 call-outs per annum. ~
:i~: The two major prev~mbl~ ~ of
trauma are respiratory otmrm=ion and/or
ventilation, and ttypovolaemia. Several
made to quantify ~ components. Lauppi indicate,
14% of patients ~ho died ~6thin 2 dal~ ofth~ ~~5
because ofrespi~tory obstructiam. Raffndl-Smi~
the frequency of death from resph’atory ob~,~ ¯
5% ’ In a ma~or sm ........ ,,, ,..z~7~27-~,~ "~
.. . ~ aym i~oc.am~ty otncers fom~’obst~action
in 10.7% of patients who died as ~ ¢or,,~ec~
of trauma, but o~y in 0-7% of survivors. The~ alto
inhalavion or’blood ,,~d .............. ~ :-,.-’a~: "
rc;,5~ T:=;’:~,: 4J’i--=:i~’," ...... .... -~ . --~ ,
i-..,:~ .-:a:. v- ~’-~3~-,, ~,~ r_’,~:zents-~.::¯: :’-:.)sequent’- ~k-:~ "
obstructeci airway-at r~ scene of the acddeht.rl~ "%:~,
stud5, of deaths over a 5 y~r period, ofpatieam w~o d:~2 z
hospital as a cons equence oft rauma, " tt~ose wl’~ h~ ~--w~ ’~
obstpaction had less seven= injuries a~ meas~ed bya ~:scoring
system than did those without such obsar~-
This finding strongly implied that airway obstracti~in~
a context contributed to morta~. --~ --~’r"=~,; ~ -
The siva,ion
do c.umented. Hoffman showed tl~ for patim~::~
with associated blood Iwas, 59% died imtaml.v amt ~g~.
within 6 h, suggesting that perhaps 25% of d~ll~
hypovolaemia could have been l:a-~,ented; r ~_.~: It
suggested that ~3% of patients who died of trauma fi’ammag:.traffic
accidents did so because of’blood Imps and that lr-l~,Y
of these could have be~n saved by ~dequrae ~,,.~,.
infusion.9 ..........
Although these various studies have be= :~~7
grounds of irreproducibility and subjectivity, it w~-2 a .
nevertheless appear that there is a sizeable propanioa ~
pa:ients whose deaths cou~ have he~a prevr.ated l~tmar~
aid been immediately availabli:.- ...... ~ _ _
ORGANISATION OFFLYING~ADS -_::~ i
THE CASE FOR ACCIDENT FLYING SQUADS
Having decide~ Lhat flying squads have potenti~ wak~
In Gr~{ Britain approximately 6000 people die every year providing emergency medical care at the scene., mm ~-
as a result of road traffic accidents. Three times this number consider the type ofpersonaeI and equipment best suir~fm
of people are killed in accidents in other situations and nearly providing such a service. "::~.~:"
half a million people sustain major injuries each year from Snook has reported his experimaceofper~onal att~
trauma. It has been suggested tha~ 43°70 of motorcyclists and accident medical officer ~o the Bath Fire and
vehicle occupants who die as a result of road traffic accidents Service;
N’~ ~ ~reat,.r chance o~" ~urvival had medic:.l
..~ :: :. T -~= a,-dabie a~ th: scc.’,.e within ~0 r:aAn of the
.,~;:,~’. it, advocating a ro!e/br accident/lying squads it is
~here?ere essential to delineate those groups of patients who
would benefit from the provision of early emergency care.
l° however, a singl~handed ser~e of this ty:~e La
.1T~.tatlO . ""’" ; "’ : "" r~.;Z7 ":
consisting of senior ,a,?Jt ,~:s from the :tc~-d~::.t arid eme: ~ :department
together with 8ix:tinily trained at:rsk-:~: :’2 ,
should attend such calls. In Edintm~gh, where a fly~ag ~%°- : ,
has been functioning for the past $ years, the ~
O. $IMONEN AND O. LAITINEN; REFERENCES--Continual ~’~"~’"
17. C.a~ ILM, Croft JD, Petltim~ P, et al..~ ,ew bone formation in ost~oporo~is follo..ing
treatment with sodium fluo~de. A .oh Intcr~ M~d 1966; 118:11 I- 16.
18. Grove O, Halver B. Trcatracnt of paim’ul mteoporosis with fluo~id~ calcium and
cal¢/ferol. ~lkt~d Get, mot 1978; 8: 167-68.
19. Krokow~ki E. Sodium fluoride in tr~tm~nt ofo~mpormh. F~’t$¢f*rafed 1979i 97:
’ 1635-40.
20. Riggs BL, Hodgson SF, Hoffman DL, et al. Treatment of primary esteoporofis with
fluoride and c~lcium. JAM..! 1980; 24~: 446-49.
2 I. Ring JD, Kru~ HP. Kuhlen¢ordt F. ~xlium fluoride and calcium (n the treatment of
primary os~eoporosis. M#d Kli, 1982; 7"/ 86--89
22. Riggs BL, Seeman E, Hodpon SF, et al. Effect of the fioorid~/calcium regimen on
ce:t~bral fra~ure o~urr~c~ in po~tm~nop~us~l osleoporo~is. N E~I] Msd 1982;
:106: 446-50.
23.8 ikl ~ DD. Fluoride :teat meat ofost ~porosh: a ne’~ look at an old dru
s.
4nn Imtr~ M,’d
’9S3; ~: 1013-15.
-25. Dixo A 5;! ~. N on-hormonal treatment ofos~porosis. Br.W~] 1973; ~’87: 99~- 1000.
26. Dean HT, Arnold FA, Jay Jr P, Knutson JW, Studi~ on mass control of dental cari~
:hroogh fluoridation of the p, ublic water supply. Publ Hcahh R~p 19501 I~:
1403-08.
27..\ta~er FJ. Fluoridation of public water supplies. ] Am Water Works Ass. 1950; 42:
1120-32.

!
~ ’~EL,,.’~CET, at~3t~ST24,1985
_~~m~isea a senior member of medical staff(consultant or
"~"r~.g~’grar grade), one w~aior house officer, and one or more
:~:;¢~trienced nurses. A call-out would therefore deplete the
".~-’omplement of staff in the base dqmrtment if arrangements
7 .~rere not made to provide adequate cover. Accordingly most
2~:t,ccidem flying squads operate from large, usually teaching,
~]~spital accident and ,nmrgeamy departments which have
~N h staffing at senior level
~,Most centres operating st~ schemes use transport
.~ffovided by the ambulance service and only 6 centres in the
~Jjnited Kingdom have their own riving squad vehicle; these
!" vehicles have Usually been funded by public donation or the
~.trea health authority. Despite the crucial nature of
7~mmunication only 60% have their own radio links with the
-"emergency services. 2 Considerable experience has been
_.,-,2ned with respec~ to the nature of resuscitative equipment
r.ecessary for the provision of immediate medical care.
Yra~lly the equipment it assigned for use specifically by the
---rag squ~ and added for the vehicle that has been
_._-r2"ed for use Lw the team. Over the past decade such
_7:nee" na- 1-,eco,.v~ F’~’gr(~ssi’,’eiy more refined,
~:~mes th~ n:u:*, of ~n;.ova~;o~ made by members o:
:. i.-.g sq~. ~ ~.12 A comiderabie proportion of casualties are
., trap txed and extrication requires SlXCial equipment. This is
~ammally carried by fire service vehicles although several
i~h.-ua~ cari~ a limited range of hydraulicram, saws, shears,
¯ The roadside is not the place for complex medical o r
=~,~lmr#4:al imerventiou. Provided the basic priorities ofairway
~i~ency, ventilation, volume replacement, pain relief, and
(Wlmtage oaa be acIaie~ little more is required in the vast
_’~r.:iori~ of eases before tran~er to hospital. The corollary of
-~]s is that it is-not too expensive m ful!y equip a flying squad;
£~0 000-15 000 would be suff’miem today.
%
EFFIC&CY OF FLYING SQUADS
With the wisdom of hindsight, it seems extraordinary that
~0;~o a.~empt was made untit the early 1970s to assess the
:.~:~im~,uence of flying squads m rndmangmortality or morbidity.
~:~t= Cell!as" original paper in 1966, his conclusion that "the
- 7 ~c."t~s eft’early treatment of tim injured by the flying squad
amply justified 1he efforts of the team ’’l was not
supported by objective data. Snook judged that attendance by
_.

¯ 436 ¯ " ":". ÷’:.:~,:~:~ ,::. "-7~.?~’,,.~? :~ "
"rltEL’t.~CE"I
either by a member of one of the~emergency services or a
doctor. Secondly,’ the best results: in cardiopulmonary World Health Organisafion
resuscitation out ~ of hospital have occurred ,where lay
bystanders have initiated basic life-support and ~ontinued ; :
~his u.’.=il advanced, cardiac life support is available from APPROPRIATE TE~:I~IOI.OG¥ FOR BIRI’i~:..
speciaEsed services. : - , " -- ..... " ....
" ~ : ..... In April, the European regional office ofthe World R~" "
Organisation, the Pan American Health Organisadoa,
COSCLUSlONS. .............. _k .....
the WHO regional office oftheAmericas held a conf~
The .:didhy of blanket statements indicating that fl~ ~r’ inoo appropriate technology for bixth. The conference, hd~ . i) ~
~q=: ~ ¯’undoubtedly save lives ’m must remain severely Fortaleza, Brazil, was attended hy over 50 participle,
-~:~ ......,~_,e~Lon. Whir can, however, be stated with some re~re~en-.-.,- .~; :~,’:fer,,, o.% :0:r~z

mt Surgery VoL 14/No. 6
S. (1979) Rationalizing
cn ofacute ankle injur-
;ical examination ofthe
wet 2, 1167.
of minor fractures in
". Injury 5, 213.
~’niveOedical Center,
WI~O sub:
lld be an
chniques
ire of the
.?-
Evaluation of a hospital-based accident flying
squad using an injury scoring system
D. F. Gorman and J. Coals
Accident Unit, Chester Royal Infirmary
Summary
The records of 250 patients treated by a hospital-based
flying squad have been analysed retrospectively to
determine the value of such a unit in preventing death
following various types of accident. To facilitate
analysis two analytical methods have been used, one
of which showed that flying squad action saved two
lives. However, on clinical grounds we conclude that
measures taken at the scene unequivocally led to the
survival of 6 per cent of those alive at the scene.
S t 3
quantitative assessment made possible by using
the ISS.
PATIENTS AND METHODS
The Chester Royal Infirmary FS was inaugurated
in 1974. The Chester vehicle is a speciallymodified
estate car, carrying a full range of
resuscitative equipment, experienced nurse(s)
and an experienced doctor, usually ofconsultant
or registrar grade. The vehicle is driven by an
ambulanceman. The squad is summoned by the
emergency services or occasionally a local
INTRODUCTION
General Practitioner when more treatment is
THE value of a hospital-based flying squad in required at the scene of an accident than they
reducing morbidity and mortality from traffic can provide. Since the inception of the scheme,
accidents is difficult to assess. Some of the major the FS has also attended non-traumatic emer-
difficulties encountered in the epidemiology of gencies.
trauma arise because of the variety of mechan- The first 250 calls, which occurred between
isms causing injury and the large number of October 1974 and May 1981, have been
individual injuries and combination of injuries analysed retrospectively by referring to a log-
which can occur. Such variety prevents assignbook, accident unit notes, inpatient notes and,
ment of patients into large groups, thereby in the case of all those who died as a result of
making comparisons and statistically significant trauma, to post-mortem reports. The notes of
conclusions difficult to achieve. Scoring systems patients transferred to other hospitals have been
(AMA Committee, 1971, 1972; Baker et al .... examined in every case. All data were recorded
1974; Cowley et al., 1974; Baker and O’Neill, on individual patient record cards which pro-
1976) have therefore been devised in a’n~ttempt vided details of day, date and" times of call,
to facilitate such comparisons, despite the scores initiator of~call, geographical location, name and
being arrived at by summating different injuries. age of patient(s), type of incident, nature of
This paper seeks to utilize one off,systems, . injuries, tr~tment given, survival and post-
the Injury Severity Score ~l"(B’fiker, et al., mortem [indings. and details of nursing and
1974; Baker and O’Neill, 1976), to produce an medical attendants. In addition, the times of the
objective assessment of the efficacy of~mSpital- 999 calls;and FS call, turnout time, travelling
based Flying Squad (FS) in reducing mortality time and time spent at the scene of an accident
from traffic and other accidents. Conventional have been recorded in most cases.
analysis has been undertaken in addition to the An ISS was allocated to each patient attended

e
514 Injury: the British Journal of Accident Surgery VOL 14/No. 6
TaMe L Method of coding injuries on the Abbreviated Injury Scale
AIS Code Severity Example
1 Minor"
2
Moderate
3
Serious
4 Severe
5 Critical
6 Maximum injury virtually
unsurvivable
9 Unknown
Table II. Method of scoring AIS by type of injury
Superficial laceration
Fractured tibia
Displaced fracture of tibia
Ruptured spleen
Ruptured liver
Massive chest crush
Area Injury AIS AIS 2
Head Unconscious > 1 hour and < 24 hours 4 16
Fracture R transverse process of C7 2
Chest Pulmonary contusion 3 9
Abdomen Ruptured spleen 4 16
Limbs Fracture R superior & inferior public rami 2
Comminuted fracture L femur 3 9
Fracture L humerus, displaced 3
Fracture neck & shaft R humerus with 3
radial nerve palsy
External Laceration of L forehead 1
R cheek 1
R elbow 1
Face R conjunctiva 1
ISS=41 (16+16+9) Patient 203 Call 208
as well as any other patient whose injuries would
have merited a call and also received treatment
at the time.
severity scoring
system of scoring was developed by Baker
et al. 0974) and Baker and O’Neill (1976) from
the Abbreviated Injury Seale (AIS) and was
based on analysis of 2128 RTA victims (Baker
¢t al., 1974). For the purposes of scoring, the
body is divided into six regions--head and neck,
face, chest, abdominal and pelvic contents, limbs
and pelvic girdle, and external. Spinal injuries
are recorded within one ofthese regions. Within
each body region an AIS code of 1-6 or 9 is
allocated for each injury as set out in the
Abbreviated Injury Scale 1980 Revision (American
Association for Automotive Medicine,
1980). Some examples are given in Table I.
Having applied the AIS code to each injury,
the maximum single score for each of the six
regions is identified and the sum of the squares
ofthe highest AIS code in each ofthe three most
severely injured areas is the Injury Severity
Score (ISS). The maximum score for any one
body region is 25 (52) and the maximum ISS is
75 (25+25+25). Any one injury attracting an
AIS score of 6 is automatically awarded an ISS
of 75.
A fatality is not of itselfsufficient to attract an
AIS of 6, the severity of the injury must be
known. An example appears in Table II.
Excluding erythema burns score according to
the percentage ofthe body’s surface area affected
as determined by the Rule of Nines, for example
areas from 6--15 per cent score AIS 2; from
36--90 per cent score AIS 5. In addition, an inhalation
burn scores AIS 4 or 5 depending upon
whether artificial ventilation is required (AIS 5)
or not (AIS 4). The ISS takes no account ofoutcome
and is discontinuous, with 44 stages
between scores of I and 75; the gaps occur more
frequently as the score of 75 is approached.
i
Gorman and Coals" Evaluation o
Table III. The total number a
flying squad
Tom/m
Type of cat/ e/~
Trauma 15,
Medical
Surgical
Hoaxes
6;
Aborted I,
Missed rendezvous
Disaster exercise
Total
25q
Table V The number of dear
Cause h
Road traffic accidents
Industrial
Assault
Home
Suicide
Age weighting
It is obvious that older !~
than younger patients to
injuries. Baker, (1974) fol
arid 26 were associated wi
tality in the respective al
50-69 years and 70+ yt
Analysis to his data from
dent patients admitted
Accident Hospital in 196
mortality to age and ISS
closely with Baker’s, a
(mean+sd), 29-4+2"5 ;
associated with 50 per ce~
tire age groups 15-44 y~
65 + years. Stoner et al. (
mortality studies ISS mus
Yates (1977) corrected flu
the 45-64 age groups usiz
and included a predicted
his modification of Bull’s
age-correction ofall patie~
ate to the 45-64 age gro
study, as is the predicted
In a further publicatic
q

Surgery Vol. 14/No. 6
s 2
6
9
6
9
e
of the squares
0f the l~l~e most
InjurIIleverity
ore for any one
laaximum ISS is
try attracting an
awarded an ISS
ient to attract an
injury must be
Table II.
3re according to
ace area affected
aes, for example
re AIS 2; from
ldi~on, an inhalepending
upon
¢quired (AIS 5)
account ofout-
~th 44 stages
~ps occur more
pproached.
Gorman and Coals: Evaluation of a hospital-based flying squad 515
Table II1. The total number and types of calls to the
;flying squad
/ Type of call
Table IV The initial cause of injuries and total
number of patients involved
Total number Total number
of calls of patients No. of
Cause patients
-~;-~ Trauma 156 179 Road traffic accident 131
Medical 68 68 Industrial (including farming) 18
Surgical 3 3 Home 10
Hoaxes 2 0 Assault 5
Aborted 14 0 (20) Suicide attempt 4
Missed rendezvous 6 0 (6) Other 11
Disaster exercise I 0 Total
Total 250 250 179
Table V The number of deaths by cause
Cause No. of patients ISS range
Road traffic accidents 43 17-75
Industrial 8 20-75
Assault 3 16-57
Home 3 25-75
Suicide I 17
Table VI. Time and place of death
lime of death No. of patients ISS range
Dead when Flying Squad
arrived 14 16-75
Died at the scene 6 25-75
Died in transit 4 34-75
Died after arrival at
hospital and within 3
hours 18 26-75
Died 3-24 hours I0 26-75
Died later than 24 hours
after injury 6 17-43
Age weighting
]t is obvious that older patients are more likely
structed a grid ofexpected mortality for different
ISS at different ages above 15 years. Patients
than younger patients to die with less severe were divided into decades and ISS into equal
injuries. Baker, (1974) found that ISS of 41, 32 groups 0--4, 5-9, 10-14, etc. An approximate
and 26 were associated with a 50 per.cent mortality
in the respective age groups 0-49 years,
probability of mortality was obtained for each
age group and ISS, for example, age 15-24 years
50-69 years and 70+ years. Applying Probit with ISS of 35-39 had an approximate prob-
Analysis to his data from 1333 road ti’affic acciability of mortality of 0-4. This grid was based
dent patients admitted to the Birmingham on a further analysis of the 1333 road traffic
Accident Hospital in 1961, Bull (1975) related accident victims already referred to above (Bull,
mortality to age and ISS. His results compare 1975) and has been used in this paper to provide
closely with Baker’s, as-ISS of 39.7+2-9
another method ofdetermining predicted morta-
(mean+sd), 29-4+2-5 and 20-2+1-6 werelity
for patients treated by the FS.
associated with 50 per cent mortality in respective
age groups 15.-44 years, 45-64 years and RESULTS
65 + years. Stoner et al. (! 977) affirmed that in Table II! illustrates the types ofeall and Table
mortali~ studies ISS must be weighted for age.
Yates (! 977) corrected the ISS of his patients to
IV the precipitating cause of injury. Table V
the 45-64 age groups using Bull’s Probit Lines
describes the precipitating cause of death and
and included a predicted chance of survival in
Table VI the place and time of death.
his modification of Bull’s Probit Analysis. This
Two patients were not scored because in our
opinion the lesions sustained could not he scored
age-correction ofall patients to an ISS appropri- adequately using the ISS system. One patient
ate to the 45-64 age group is utilized in this had been struck by lightning and one was acci-
study, as is the predicted chance of survival. dentally hanged.
In a further publication, Bull (1977) con-
Three patients With relatively low ISS died.
al

O
516 Injury:. the British Journal of Accident Surgery Vol. 14/No. 6
The lowest scoring death (ISS= 16) was that of
a man who was already dead when the Flying
Squad arrived. He had been stabbed with
division of his right common carotid artery and
internal jugular vein (AIS 4). Two patients had
ISS=IT. One of these died from pulmonary
embolism i0 days aRer self-inflicted wounds of
his neck and forearm, the otller was dead before
the arrival of the Flying Squad and was subsequently
found to have suffered a massive
intra-abdominal haemorrhage due to a ruptured
spleen. He was known to suffer from chronic
lymphatic leukaemia.
Forty-four patients who subsequently died
were alive when the Flying Squad arrived. These
included patients who had fixed dilated pupils,
apnoea and absent major pulses, but on whom
resuscitation was attempted. Scrutiny of the
records of these 44 patients revealed that in
4 cases, earlier insertion of a chest drain Call 4
cases) or earlier intravenous infusion (! of the 4
who required a chest drain) might have led to
survival. The ISS scores of these patients were
34, 4 l, 5 l, 54 (chest drain) and 5 ! (IVl).
In regard to delay between the 999 call and the
call for the Flying Squad (mean 12 minutes and
12.6 minutes respectively), turn-out time (mean
3.9 minutes and 4.4 minutes respectively), or
travelling time (mean 8. ! minutes and 9.3 minutes
respectively), there was no great difference
between the patients who died and those who
survived. Mean time spent at the scene was ! 5.4
minutes for those who died and 27.2 minutes for
those who survived.
One hundred-and-twenty-one patients survived
their injuries. Two patients (mentioned
earlier) were not scored, leaving 119 survivors
who were scored. The highest score among the
survivors was 43. Fifty-one patients had scores
between that of the lowest score dying and the
highest score surviving. Close scutiny of the
records of these 51 patients was undertaken for
evidence that the Flying Squad improved the
chance of survival. 17 patients had evidence of
hypovolaemic shock and in i0 of these infusion
was considered to have improved the chance of
survival, whilst in another 4, such treatment was
considered to have saved life.
In addition, 2 patients with scores less than 16
were undoubtedly saved by the rapid administration
of large quantities of IV liquids. The first
was a 36-year-old man who had sustained a
traumatic amputation through the left shoulder
joint (AIS 3, ISS 9). When the Flying Squad
arrived he seemed to be moribund with no palpable
pulses. 3 units of Dextran were given
rapidly into a vein in his upper right limb as well
as 2 units of plasma and 2 units of O-ve blood
via a phlebotomy at his right ankle. It was
only alter receiving this quantity by infusion that
the wound began to bleed. Subsequent progress
was uneventful except for an ununited fracture
of his clavicle, which required bone glalting.
The second patient was a 33-year-old woman
who had fallen through a glass door at home,
sustaining an extensive wound on her left thigh,
with considerable blQodshed due to complete
division of her femoral artery and vein and long
saphenous vein at about the level of the adductor
opening (AIS 3, ISS 9). Two drips were set up
at the scene and 2 litres were given rapidly; a
further 2.5 litres of blood and plasma were given
within a short time of arriving at the accident
unit. Another hypovolaemic patient with an ISS
of less than 16 had his prospect of survival
enhanced by early infusion.
Twenty patients were unconscious or had an
impaired level of consciousness at the scene. Of
these, 2 required endotracheal intubation, 5
required insertion of an oral airway, 2 required
suction and/or clearing of debris from their airways,
and the remainder required supervision of
their airways, in 3 of these patientsappropriate
management of their airways was considered to
have saved their lives, whilst in another 7
patients the prospect of survival was enhanced
by early attention to their airways. Furthermore,
the patient who had been accidentally hanged,
had inhaled vomitus and was undoubtedly saved
by prompt treatment.
Thus 6 hypovolaemic and 4 unconscious
patients had their lives saved by the Flying
Squad (10/165, 6.1 per cent) while a further I !
hypovolaemic and 7 unconscious patients had
their chances of survival improved (I 8/! 65, 10-9
per cent). In addition, 4 patients who died might,
with different treatment, hav.e survived (4/165,
2-4 per cent), although 2 of them had an ISS
greater than the highest score of any survivor
and might well have died ultimately.
The distribution of ISS is shown in Fig. !
together with all scores corrected to age 45--64
years. Nine survivors aged less than 15 years and
2 patients less than ! 5 years who died, have not
had their scores age corrected because the Probit
Analysis described earlier is only applicable to
patients aged ! 5 years or more, thus leaving 166
patients whose ISS have been corrected to that
appropriate to the 45-64 age group.
Clearly it is not realistic to include patients
already dead in the assessment of the treatment
provided by the Flying Squad. Thus 14 patients
i
I
ooooooooooooooo 7S-
¯ ------- :... 10.
oooo¢ooo
oo
g.’gggl....
ooooooooooo
,$ur~KI {I lg} Died {581.
Uncocrected Scorm
Fig I. The distribution (
dead at the scene befot
Squad have been excl~
survival. Applying the
vival (Yates, 1977) to t
alive at the scene, ! i0
vive and ! 10 actually
Using the method de
predicted mortality w~
adult patients alive .
scored. By this me~
expected to die and 42
DISCUSSION
Generally we found tt
apply, except for the 2
not score. Also, sco~
lately our clinical im]
the exception of some
this series usually stal

"~t Surgery Vol. 14/No. 6
~er right limb as well
units of O-ve blood
ight ankle. It was
Ltity by infusion that
;ubsequent progress
n ununited fracture
bone grafting.
33-year-old woman
;lass door at home,
nd on her left thigh,
d due to complete
y and vein and long
level I e adductor
o drii~were set up
zre given rapidly; a
:i plasma were given
Ang at the accident
¯ patient with an ISS
rospect of survival
:onscious or had an
less at the scene. Of
"heal intubation, 5
I airway, 2 required
ebris from their airuired
supervision of
patients appropriate
,~ was considered to
hilst in another 7
~ival was enhanced
rways. Furthermore,
=ccidentally hanged,
s undoubtedly saved
md 4dLnconscious
wed llI~he Flying
.) while a further ! !
~scious patients had
)roved 08/165, 10.9
:nts who died might,
Lv.e survived (4/165.
)f them had an ISS
ore of any survivor
timately.
is shown in Fig. !
rected to age 45-64
than i 5 years and
who died, have po’.
d ~ccau~ ~h¢ P, obit
only applicable to
)re, thus leaving 166
~n corrected to that
group.
to include patients
~nt of the treatment
=d. Thus 14 patients
Gorman and Coals: Evaluation of a hospital-based flying squad 517
ISS
was developed from studying injuries sustained
"’’’’’’’’’’’ee" 75’
by road traffic accident victims, this apparent
drawback in regard to penetrating injuries is
70’
probably not surprising and has been remarked
upon by Baker et al. (1974) and Baker and
O’Neill (1976) and by Stoner et al. (1977).
Semmlow and Cone (1976), however, in their
e60"
study of 8852 patients from the Illinois Trauma
Registry (62 per cent of whom were not injured
in road accidents) held that the ISS could appropriately
be applied to non-vehicular trauma,
although in their series, only 4 per cent of 5502
¯o
patients not injured in road traffic accidents had
an ISS greater than 20, compared with 20 per
00¯40
cent of 3350 victims of road traffic accidents¯
ego
The ISS system allowed us to delineate a
ooo
group of 51 surviving patients in whom action
: °°:~ taken by the Flying Squad could have contri-
e¯
oo buted to survival or even saved life. However,
¯30’ ":e¯
using the ISS in conjunction with the predicted
e¯
eee ¯:.. eeee
o¯ ~::
ego
oooooo
ego chance of survival we were not able to demonstrate
a lowering of actual mortality in these 51
oo ~o
ego
!!:
":20.-o0o,
patients. There are several reasons why we were
gig
oo
go
¯go¯
go handicapped in this regard. Firstly, the small
sample sizes for any one ISS. Secondly, our in-
¯Do¯gooD¯go¯o¯
oooo
gOOD¯
sistence on assigning the lower AIS code whenever
doubt or argument arose in regard to
; ........ go¯co¯¯¯¯o¯ 10" ,::|~?|||~:¯=,
oo
oo
go
particular injuries. Thirdly, post-mortems were
,,=:~:~o...
oooq,.o
generally.macroscopic and were as a result in
goD¯O¯¯¯
some respects deficient for our purposes, for
ooooooooooo ¯DO¯De¯O¯
example, shearing injury of the white matter of
Survived 11191 Died (581. Survived (1101 Died 1561 the brain (AIS 5) was reported on only one
Uncorrected Scores Age~orrected Score= occasion from a total of 58 post-mortemg
Fig. I. The distribution of Injury Severity Score.
Fourthly, some of the patients who were found
with some or all ofthe signs such as fixed dilated
pupils, apnoea and absent major pulses, but for
whom resuscitation was nevertheless attempted,
dead at the scene before the arrival of’the Flyingwould
have been classified as dead by other
Squad have been excluded from the analysis ofworkers
and therefore not included as potential
survival. Applying the predicted chance of sursurvivors.
Fifthly, Bull used earlier versions of
vival (Yates, 1977) to the remaining ! 52 patientsthe
AIS in which some injuries were scored
alive at the scene, 110.12 were expected to sur- higher than in AIS 80, such as multiple, closed
vive and I i0 actually did survive. fractures of long b2nes which were previously
Using the method described by Bull (1977) theAIS
code 4 (Baker et al., 1974) now scored AIS
predicted mortality was determined for the 152code
3 American Association for Automotive
adult patients alive at the scene who wereMedicine
(1980), and multiple, open fractures of
scored. By this means 44-1 patients were long bones which were previously AIS code 5
expected to die and 42 actually died. (Baker et al., 1974) now scored AIS code 3
American Association for Automotive Medicine
DISCUSSION
(1980). These changes also probably help to
Generally we found the scoring system easy toexplain
why in both Baker’s and Bull’s series, the
apply, except for the 2 patients whom we couldsurvivor
with the highest scores had ISS=50,
not score. Also, scores seemed to reflect accu- while in our series the highest score ofany survirately
our clinical impression of severity with vor was ISS =43. These factors operate to lower
the exception of some penetrating injuries, inthe
ISS and therefore inappropriately increase
this series usually stabbings. Since the systemthe
predicted number of survivors and decrease

518
the difference between actual and predicted
survival.
These 5 points apply equally to the alternative
method for determining predicted mortality
(Bull, 1977). Application of this method suggests
that 2 lives were definitely saved by the actions
of the Flying Squad. Bull has pointed out, however,
that his probability of expected mortality
values are provisional and based on a single
limited series.
We consider the ISS to be a valid measure of
injury severity deserving wider use. It should be
possible to determine mortality for narrower age
groups than those defined by Baker and Bull.
The system might well be applicable to audit of
accident and emergency department work and
the assessment of new safety measures such as
the compulsory wearing of seat belts.
Acknowledgements
We wish to acknowledge assistance given by Mr
Michael Holloway, the late Coroner for West
Cheshire and South Clwyd, Drs T. D. S. Holliday
and H. Ingram, Consultant Pathologists to
the Chester Royal Infirmary and Mrs K. Gorman
and Mrs M. Ball for their typing of the
script.
Injury: the British Journal of Accident Surge~ Vol. 14/No. 6
REFERENCES
AMA Committee on Medical Aspects of Automotive
Safety (1971) Rating the severity of tissue damage.
I. The abbreviated scale JAMA 215, 277.
AMA Committee on Medical Aspects of Automotive
Safety (1972) Rating the severity of tissue damage.
II. The comprehensive scale. JAMA 220, 717.
American Association for Automotive Medicine
(1980) The Abbreviated Injury Scale, 1980 Review.
Baker S. P. and O’Neill B. (1976) The injury severity
score; an update. J. Trauma 16, 882.
Baker S. P., O’Neitt B., Haddon W. Jr. et al. (1974)
The injury severity score; a method for describing
patients with multiple injuries and evaluating
emergency care. J. Trauma 14, 187.
Bull J. P. (1975) The injury severity score of road
traffic casualties in relation to mortality, time of
death, hospital treatment time and disability. Accident
Analysis and Prevention 7, 249.
Bull J. P. (1978) Measures of severity of injury. Injury
9, 184.
Cowley R. A., Sacco W. J., Gill W. et al. (1974) A
prognostic index for severe trauma. J. Trauma 14,
1029.
Scmmlow J. L. and Cone R. (1976) Utility of the
injury severity score; a confirmation. Health Serv.
Res. I I, 45.
Stoner H. B., Barton R. N., Little R. A. et al (1977)
Measuring severity of injury. Br. Meal J. 2, 1247.
Yates D. W. (1977) Airway patency in fatal accidents.
Br. Med. J. 2, 1249.
Requests for reprints should be addressed to: Dr D. F. Gorman, Registrar, Accident Unit, Chester Royal Infirmary, Chester.
L
Injury. 14.519-522 P~fntet
F ra ctu res ,:
M. E. Blakemore
Birmingham Genera
Surrtrnary
Two cases of fracture, wh
for grafting are presente~
one the ilium. The impl
are discussed.
CASE REPORTS
Case I
A woman aged 63 was a
a height of about 3 fe~
comminuted fi-acture oft
with separation of the ti
the insertion of the anter
it was decided to operat~
cular surface, recognizin
preclude stable fixation
the shaft of the tibia. T}
articular fragments and 1
cruciate ligament were
(Fig. 2) and a supporting
opposite greater troctm~
then splinted in a plaste:
the patient was allowed
full weight on the teR h
brace hinged at the kn
limb.
Thirteen dad afker Ol
without pain for 6 da
veloped pain in the I
Radiography showed
originating at the hone
was treated with simpk
patient was then aflow~
from the original injur
4) fractures were ¢linic~
and the patient could t
unaided.
Case 2
A 57-yenr-old man w;
severe cervical spondyl
sion of the nerve root:
decompression and do~

i
I
i
"r"
I .
J i "
i
i
! It
|
! .:
Resuscitation 6, 243-248 { q’4z~.
Role of an accident flying, squad in medical
emergenctes
D, I. ROWLEY* and J. COLLINS
_4co’dent and Emem.]elwy Departmci~t. Dcrh).shirc Ro~’al h-,Jh’,zary, Le,zdua Road.
Derby. U.K.
Summary
A retrospective study of medical cases attended by the Derbyshire Royal Infirmary
Accident Flying Squad demonstrates that of 17 casds only two patients survived to
leave hospital. Nine cases of cardiac arrest have been studied in further detai!. In a’A of
these cases it was found that diagnosis of arrest had been made~fgre lhe Flying Squad
was called and that the situation had become extreme before the arrival of the medical
team, In every case the Flying Squad team took more than 3 rain to arrive, irrespective
of distance. Review of the literature appears to support the conclusion that medical
teams have been of li;tle value when called to cardiac arrest at any distance from the
hospital because of the time lag. It is suggested that more sophisticated primary care
should be available immediately, preferably by highly trained ambulance personnel.
Medical teams would give appropriate support to such primary care.
lutrodnetion
An Accident Flying Squad has been developing in Derby, England, sincc !955. The
purpose of this service has beeffsummarised by Collins (1966) and the practical
problems have been reviewed by Little (1972). The original emphasis was upon
industria! accidents but the service now embraces a whole range of accidents and
"emergenNes, amongst which the road traffic accident predominates. As illustrated in
Fig. 1, medical emergencies represent a significant part of the work of the Flying Squad.
There has been a steady increase in demand for the service over the past 4 years. The
aim of the present-study is to ana!yse the progress of medical cases a~tend,*d by the
DcrL.,,i..~:’e - Rexal - ~r.f:rci;r., Accic~er;:
. "r,’_
".c!-ir..z
a!~
Souad-i;,. !c’:7 a veto :r" \~t~.~:’,.
.... ~ .~ -A ~,~3~.CXlII~k,_L:2, cai~.
5
t_’,2LJ-[l.’tl, ,31 I|~;
Patients and methods -
The study is retrospecuve and the diagnoses are those recorded by the senior medica!
officer at the scene. Wherever possible these diagnoses have been confirmed by
Present address: Department of Surgery. Cl:.ase Wing, Enfield District Hospital, Enfidd, Middlesex. U.K.
%.
243 " . .... " ....
-: - - . : .:.._ - ~ "~,-~ 2~,2~,r~.~_~

@
I IIIIII 11 I I I II I
244 D. ROWLEY AND J. COLLINS
e,,karl
v’es
7O
60
50
4O
3O
20
10
i~] TOTAL
CALLS
M MEDICAL
CALLS
p
I !
r
1970 1971 1972 1973 1974 1975 1976 1977
YEARS
Fig. J. Distribut,on of calls to the Derbysh!re Royal Infirmary Accident Flying Squad during the years
studying the follow-up records or post-mortem reports on the patients. The details of
the Flying Squad sorties were recorded routinely by the senior medical officer and an
account of the journey was given by the drivers.
Cardiac arrest was confirmed by using a Cardio-Aid DMS 200 (Simonsen and Weel)
electrocardiograph/defibrillator. This device is a portable and recharge, able electrocardiogram
which will give a crude bipolar readout through the paddles or can be
converted to give a refined 12-line ECG readout. It also possesses the capability to
deliver a graded D.C. shock up to 400 joules (Fig. 2).
~ q
¯.
L;
c~.
in
A
d
-[

ACCIDENT FLYING SQUADS . 245
l’-~g. 2. Cardio-Aid DMS200 (Simonsen and Weel) electrocardiogram/defibrillator. This instrument
c.ombin~s a crude bipolar electrocardiographic readout with the facility of conversion to a full 12-line ECG
trace if req~gred.
In all cases, drugs and other equipment were available as follows: sodium
bicarbonate (8.4%) by intravenous infusion; adrenaline solution (1:I000). calcium
ct;]oride (iW,..). diazepam, dexamethasone, frusemide, hydrocortisone, isoprenaline.
ligntwane tl’~./.) a~_d practalo!: apparatus for cuffed endotracheal intubation with
-’ :~,,: p:ws,~:’~ vcnfik;tjon and 100’ ,, o~yge:,
Results
All the patients, excep~ for two children having their first fit, died ultimately (Table 1).
No patients were successfully resuscitated from a cardiac arrest as diagnosed by
electrocardiographic monitoring. The later nine cases are examined further in Table 2.
The results reflect the time delay from receiving the cal! to arriving at the scene, but
added to lhis is the time taken in deciding to call the Squad, which can oniy be guessed.
o- -.

246 D. ROWLEY AND J. COLLINS
1¯able 1. Analysis of 17 incidents involving calls for the flying squad,
~r,~i,qc 2rT2st
Carcia~ ~,uture
Aortic ane~arysm
Cerebrovascular
accident
No, of patients No, of pattents
~ho died at who died in No. of patients
No. of patients the scene hospital who went home
1
9 0
Table 2. Details of calls classified as card iac arrest. Journey times, from receipt of call to arrival at the scene,
and type of subsequent resuscttattve management are shown. D&T. Use of intravenous infusion and
endotracheal intubation.
Distance to scene Time for flying squad Action taken by
of cardiac arrest {miles) to arrive (min) flying squad
Discussion
3 8 Nil
2 5 Nil
8 -. 10 Nil
12 Not known D&T
10 15 D&T
1.5 3 D&T
l I Not known D&T
3.5 5 D&T
8 10 D&T
Sooriyaarachchi (1976/77) has examined t~:e cxi:cr~ences of a resident carmopulmonary
resuscitation team at a general hospital in the U.K. In his review of the
literature he notes that similar teams to his claim long-term success in 12-23~0 ofcases
attended. His own figures show that of 25 cases attended four survived to leave hospital,
even though a fully trained team was available to the personnel monitoring the patients
concerned.
The experiences of a mobile intensive care team outside the hospital are described by
Pantridge & Geddes 11967). They anticipated potential cardiac arrest in the case of
myocardial infarction by sending a team with at least one doctor and a specially
equipped ambulance with trained ambulance personnel to all cases of chest pain. On
i
l
2
0
tl
i
!

i
!
t
l
f.
\
ACCIDENT FLYING SQUADS 247
ten occasions the unit was present at the time of cardiac arrest and subsequently five of
those patients survived to leave hospital. Chamberlain, White, Binning. Parker &
Kimber (1973) have a similar organisation; their team attended 57 patients who were
already in ventricular fibrillation before the team’s arrival, and only one of these
survived. However, the team was already present at the time of corrlmencement of
ventricular fibrillation in a further eight cases, and five of these ultimately survived to
leave hospital.
From Table 2 it can be seen that on no occasion was it possible fo r the Derby team to
reach the scene in less than 3 min, irrespective of distance from the hospital to the scene
of the accident. This reflects the problems of having to travel most of the journey
tbrm.,~h a built-up area. At all the incidents involvin~ cardiac arrest the Fl)ing Squad
~mmcdmtc availability. On only two occasmns general practiuonm s ’,, ~ c ~,, ~.~¢m ......
scene, and only one of them had more than the most basic equipment. Ila all the other
cases the ambulance crew was the only primary care service available.
In the cases presented in this survey the ambulances were equipped with suction and
Minute Man ventilators. The crews had been trained on a standard 6-weeks ambulance
course and rome had had experience within the Accident and Emergency Department.
Unless it is intended to extend the services offered by the Flying Squad to attend al!
emergency calls, the basic primary care must be the central responsibility of the
ambulance organisations, Boughley (1968) has already highlighted the problems of
training and then maintaining a high standard of skill among ambulance personnel,
when the ambulance service workload normally contains 0.25,°/~ of potentially
dangerous situations. Baskett, Diamond & Cochrane (1976) have made a worthwhile
attempt to overcome the shortcomings of the present services and the delayed arrival of
a supporting medical team. Their use of highly trained ambulance men, with sufficient
traimng and skill to pass endotracheal tubes, insert intravenous cannulae and perform
cardiac defibrillation, seems to have gone some way to solving the problem. These
personnel are able to anticipate cardiac arrest and are fully equipped to deal with it at
the moment of recognition. They also have a doctor available if necessary and, since
1974 they have had the facility for electrocardiographic telemetry. There are severe
difficulties in getting an objective assessment of this particular scheme.
Suffuzient evidence seems to be accumulating from the different centres operating a
resuscitation service outside the hospital to suggest that a high standard of primary
care is required at the scene to compensate for the inevitable delays in mobilising a
medical team. A close working relationship between the paramedical and the Flying
~quad,~Accident and Emergency services is paramount. Furthermore, there seems to be
¯ a place for a group of people in the ambulance service possessing a high degree of
training and everyday experience of emergencies who can support life until intcnsive
c~:,e .:i ~ ,;,.~ ,-.~rvi,’e \Vc conc!ude the,:, a’, t~e presem time, there is little iustification in
~’7;.’q;~’, . . "g’-Y~:
~el’\;c~: can ~..g ({.\e.,-:.,,e~z.~ ...
Ackno~’ledgraeats
We arc grateful for the critical comments of our colleague, Mr W. A. Fraser-Moodie.
Mr Parsons contributed valuable information concerning equipment.
" " -. ’,.a ,i,:

248 D, ROWLEY AND J. COLLINS
References
Baskett. P. J. F,, Diamond, A. W. & Cochrane. D. F. ( t976} Urban mobile resuscitation: training and s~m’vi~,.
Br, ,L Anaes:h. 48, 377-385.
Bol~gh!ey. W. N. F. (1968) Accidents, emergencies, and ambulances: a surxey in Portsmouth. Brito Meal. J. i,
369-372.
Chamberlai.n, D. A., White. N. M., Binning, R.. Parker, W. S. & Kimber, E, R. (1973) Mobile coronary care
?ro.v;ded ~.~ "’mb.:?w.?=’ ~-r~uazeL ~ri;. ~,,e~.:r: ,.’. 35, 530~P’L
.,z:::, .~k. ,::-L) -’: ~q~¢ .f .taz :.,: ,i.~r,.: r’~"::.,g ~q~’.~d B,~: 5, 241-247.
° ,
I iI
t
i

#
r
Accident flying squads: an objective evaluation of their
role in trauma
D J Steedman" and C E Robertson"
An objective evaluation of an Accidcnt Flying Squad was
performed using an Injury Severity Scoring system. A
retrospective analysis of 73 trauma patients treated at the
scene failed to confirm the subjective judgement of the
benefits of treatment in this group. We recommend that
further studies should be carried out to determine whether
the failure to document reduction in mortality is due to
defects in the method of assessment and small patient
numbers or whether it genuinely reflects absence of
benefit of such squads.
There tins been a dramatic increase in the number of
hospital based Accident Flying Squads in the United
Kingdom since the tirst scheme was established by Collins
,’it Derby Royal hlfirmarv in 1955 ~ -~. Despite the recem
claims of "’the undoubted value of flying squads "’~ there ~s
a paucity of objective data to support the role of such
schemes in reducing mortality-and morbidity. Indeed it
has been suggested that it is impossible statistically to
justify a Flying Squad’s existence. Several workers have
reported on their experience in this field of cmergency
medical care. but although considerable detail has been
supplied in relation to call outs. evaluation has been based
on subjective assessment: -~,
One of the major difficulties encountered in assessing
treatment of traum,~ patients relates to the multiple
injuries which are sustained and to the effect of the
combination of these injuries, it is essential to define the
severity of injury in a quantitative way before any
statistically significant statement can be made about the
benctits of treatment ". One grading system for assessing
patacms with multiple injuries is the Injury Severity Score
(ISS) ~. has radio communication with the a:nbulance services
and carries a comprehensive range of resuscitative
equipment. The team usually consists of one or two
experienced numbers of nursing staff, a doctor of
Consultant or Registrar grade and one Senior House
Officer, while the van is driven by ambulance personnel.
The first 100 call-outs, which occurred between
January 1980 and February 1983, h:t\e been analysed
retrospectively, h~fi~rmation was obtained by reference to
the log-book, departmemal records, in patient notes and
(in all cases who died as a resuh of their injuries) to post
mortem reports, l)clails collected included: age and scx o1"
patient: type of i~cidem" nature of injuries: tre:mnent
given: and survi\’:d,
An injury seventy score was deri\ ed tk~r each patient
tended at the scene b\ the Flying Squad.
The Abbreviated Injury Scale and the injury severity
score
The Abbreviated In.iury Scale refers to the a’;s:gnmcnt of a
single code number on a scale I-6 for specific injuries, The 1980
revision of the AIS coma|m; more than 5t~} such injur~
descriptions, Five separate criteria lenergy dissipation, threat to
life. permanent impairment, treatment period and incidence}
were considered in the development of the AIS, Thus for each
body region, a rmnor injury would attract an AIS severity code
o1" I: .2 moderate injur~ 2: ,,t:rlous 3: se\erc 4: critical 5: and
Ul,~tXnlitnll injury (uusur\i\;d~lc ~ ilh CI.IFrClII It.’t.’Jllliqucsl f~. [hl
derived from the Abbreviated Injury Scale
tAIS)’. This system has been utilised in the present
analysis to evaluate the efficacy of the Accident Flying
Squad based at the Edinburgh Royal Infirmary in
response to trauma call-outs.
Patients and methods
"[’hc Accident and Emergency Department at the
Edinburgh Royal Infirmary is the central Accident Unit
rot the Lothian and Border regions with a population of
approximately 750,000, The Flying Squad was
established in 1980 and provides an emergency medical
and nursing team on a 24-hour basis. The Flying Squad
vehicle is a specially modified Bedford chassis van which
~,
numerical code I-8 is not a linear progression and therefore
does not allow for the taking of an arithmetic me~m ~hen
applied to multiple injuries ~,
The Injury Severity Sc~re is derived from the AIS and b;:~.cd
on ~malysis of 2128 road tratlie accident victims in Baltimore" ~.
I:or the purl~Scs of In.ltlry Scvcrit~ Scoring Ihe bo-,l\ I~
divided into ~ regiom;: head and neck: face: chest: ,~bdominal
and pelvic contents" limbs and pelvic girdle: and external. An
AIS code of I-h is tl:en assigned to each injury. The ISS is
calculated by adding the squares of the hlghcst AIS code in each
o1" the three most severely injured body regions. An example is
sho,wn n -F;ddc I. Fhc ftl:t\ulltun .,,core fi~r an~ one rcgloll i’, 2 ¢
(c\clndin~ tile AIS ¢odc of h). :rod Ilic highc~,t pos,4blc [SS I,;
I1111~, 75. AII~ patict:l alth :ul uliliry se\erc euollgh it~ aliracl all
AIS code ol’~ is aulou~aUc;.dl~ a~ artlcd ;m ISS of 75. The In.lur.~
¯ ~’,erity Set,re pro\~de~, su~t:ddc \\rightist,,’ ft~r the AIS and
all(~vs I~r the proper conlhnlltttt’ql ol" the effects t~l multiple
iujuries
111 mortality studies the ISS \aluc musl be x~cighto.I for age,
fbr older p~tients arc more likely to die from less ,,c\ere mjur~cs
Ih:lll ~ollllgCr i~;lllClltS. Ilulle’ used I)roh! m~;d\sis ~’’ it, linear~se
.......................................
I)cp;~rtment tff Accident and Emeq:ency Medicine, Royal
the mortality da{~ in sep~lr;llC age gro~lp,; tn rehll~oa to 13,13
rt~ad traflic accident patics|ts admitted to the Birmingham
hdirm:lry. I_auriston Pl~:ce, Edinburgh. AccidcnL Unil. lie found that an ISS tff 39.7 t 2?9 (mean r SD),
(’,~rrc’,l~t~ldt’nct.’ I~ |) .I Stcedmau. 29.4 ~ 2.5 and 20,2 r I.h ~cre asst~ialed with 5(.)% mort:dity in
80
Journal ~:¢’tht" Rovt~/ (’ollet, e of Surt~t’rm ~ o[ Edinhur.t,h

TABLE 1
Injury severity scorinH
I , I I,’~ I I.%
l{ ~lii~dll!’;ll h;ICm~llOltl;l
!~ ll*llll]’lll ~tll111l!l
l ]*,;q;[ C~lillll’,,lllll
I ~ t~rmc’ I ~ Fib~
llilN~.’I C;]li~" I;It’t’l’~ll roll
%lc~cnlcr-i~’ ~.’Olll u ~,iorl
I’~,. It ol~,-’l it or r,.:;ll li;icnl:H~m~:i
I lilCllll~.’ plrl~l~_’ l:lll]ll ~.
I ~Ic.,’riltio0 l’~ c~’i.’bri~’,\
I%S I- - u . I(~ 41 (’all Tu
UIC Fc,,)¢Ch\c ;IFc llrotl;~*, t. ~ 14 ~¢;.Ir~;, 45-64 )’cars al~tl
f~.~ - \ ca r-, ( there \~ crc" lll’-.tllli,,..’icill ,,.’;l,.,¢s Ill lh,~ 0 - 14 ;.I~.Ii." group
lol lh’,,bll .\rod\ ~4,4. hl our ,,lud.,, age ’,v¢ighiing was produced
b,, i.’orrc~’ling IIi¢ I~S ~;llti¢ oi" pallills IO thai appropriate for
the 4~ -h4 a,2¢ group using Yalc, s tnodilicaiion ~ el" Bull’s Probil
.mal’.,,i-, (lb-’ I i l:or t’i.;llll]~]C. ,i I’~;llk’[ll ;l~.’cl 71) v. iih illl l,~,~ i>,i"
?l) h,l’, an ~L’--’¢ ,~rr,.f,.’Icd ,;o~rc of 40. "l’;lleS im:ludcd a prcdicled
L’ll,lll~.’L’ ~II ~llr\ I\ ~II III hi’, lllodiliC;l(lOll ali’,.l \~.il~, t, iiliso.l in our
,,,’. n ;in.if\ ~I~ Io [)r,.’,.ll,..’l lh,: o~,.’r.O] ~.’hilllL’q of ~ur~,’i~,’~ll for those
l~;lllL’lll ’, llull
\~, II0 l~.%’l.q\ l.’d IFI~;IIIIIC[II ;II III,." ~.l.’t.’lil.’,
r-" al~u tlcri\i:tl a grid of CXlk’cicd nlorlalily for dill~:rthll
combitlalkm~, of ISS and age groups above 15 years based on
In,, inilial i.l’ll[l (Tahh: 21. P;llli.’lli’.; ~,\ cr¢ di,, idol inlo decade,, ;llld
I~,% mt{~ ,.-qlull group, O-4, 5-9. I0-14 tic, All al’~l’,roxunal

82 .\(I IIll \1 I I "ll\l) ~.)l \11~
TABLE 2
Approximate probability of mortality for different combinations of ISS and age"
~5
,1()
._
5O
35 4()
3O 35
25 3o
2(). 25
t5, 2u
Ī,t~c O’r)
!.H I.O I.O IA) I.() ! () I )
o.u (Lq I.o I.O I.() I () !,*)
I).7 ( ~ 1),9 l.I) I.D t,11 !31
I1.( (1. ? 1).~ (1. ~)
requiring such specilic air, ray management ,~ur,’ived, 43
patients who survived recdved an intr:|venous infusioll at
the scene, 24 of whom were-noted to have signs ot" hypo-
TABLE 3
Types of call
7"ntal mtmher
Ibtttl ,ttmbcr
l’vpe hi’call ql’c, lls ¢?llt¢tlit,ttt~
trauma 5~ SS
Mctlical 22 22
Aborted Ih (01
Airp~)r~ alert 4 10)
I H 1.11 I()
()¯ I 0.~ 11,(~ O,~ ~) I,I) I,(l
¯ ~ 0.3 0.5 0.6 1~ (19 t 1
(1.2 (), 2 0.2 ll.4 (L ? u s H.q
H, t I).l (1. t 11.2 (. ; (15 D.S
O 0 0 i).l (1. I I1.3 1),5
H (1 O l) 11 (11 t~
(I 11 () 11 (1 () 11.!
l) (1 0 1) 11 i) (1
*lhdl r:
volaenlie shock. This group hlclt~ded 7 p:|tle)]ts ~\ho..,e
transt’cr to the Accident alld t!mcrgency l)¢partment
was delayed bet."Ul,,e of ¢)ltr;.ipnlcnt. ")0 paticnt~ received
intravenous analgesia, including 16 patients reqtttring
extrication or release fronl imp’dement. 4 patients had a
chest drain in~crted. One patient died at the .scene (ISS
2t)), O)lt." patient died on rettlr)llnL, 1.o the Accident :1)1,,t
Emcrgcnc.~ l’)clmrtmcnt 11SS33) ’uld 2 paticnt~ died
folio\ring :~dmi,~.,,ion. ouc at 3 da.~s (ISS 2q)and one -)t ,,
tl;l\’n I IS,’q 57).
The distril’)utio)| o(" ISS is gi’,cn m Fig 2 togetl)cr ~=tl)
the corrected scores to the 45-64 age group. The Prt)bil
analysis ~s )1OI al)plit.’;Ihlc to p;lllC)lt’.; trader 13 ~car~.
thercfi~rc 5 children \\ho survived and 2 \vho dled ha~e
not had their score~ corrected. Of the 79 patients who did
............................................ have their scores corrected. 6 wcrc dead when the Flying
lblal O0 II0 Squad arrived and therefore were excluded fronl the
analysis.
TABLE 4
Precipitating cause of injury
Nlotlh(’r
of patit, uts
................................................
Road trallic accident 35 62
Industrial works 8 8
Domestic g I 1
Suicide ~ 6
Assault I
TABLE 5
Number of deaths by cause
.\’,), ~# I,~’,¥ rtl/lk~( ’
Road traOic acddent h 2q 75
I)omcsttc a 33 5 [)
Suicide 1 2o 57
Assault I 2()
7btal 5g 88 lbtul 23
Juurnal qf tlw R~o’al Colh’~,e o l’Sur~,e mx y" Edinh trgh

I) J S II II)M \% \%P (" I. ROIH:R I ~()N
If’h" Id’di’illh
TABLE 6
Time and place of death
\’o...f
I )llli’c’lll~i
IYs rlllli~c’
" I)ulld ,, hell ’]~.i,,~ ........................................
~quad arrived 6 51 --75
l)wd :it ,,’cnc ~ 2n 75
I),,cd ~alU. 2-I h,mr,
,I admJ..,m ? 33 75
24 i~,,m, < 2u 57
.\ppl3 m:- Ilk’ p~cdi,’lud chm]cc of ~ur\ ival described h~
’~ah’- h~ lhc IOn’alla!! ’. "7.1 p:divtH,,. ~’q.l ~\cre c\pCClu:l
I~ ",IH~ [\t.’ :illd 5 [) ;l,’lu;llb, MH ~l~.’d.
lhc predicted mortalih li~r lhe 73 p,lticnls alive when
" dw I’b m,.: Squ:Jd anli~{.d u,mg the Ill’.’lliltil.\ grid of Bull"
?3
~ :,~ 14.7 and t 4 patients actualt\ died.
Medical calls
r~enty t~o calls ~crc related to medical conditions. II
pattCllD, rccct\cd ~:ardiopuhnonary resuscitation at the
scene. 3 paucnts ~vcrc successfulh resuscitated, [h)wevcr.
one p;,ucnt ’mh’wquently died on rcu, rn to the Accident
and I’.mergcnc3 Dcpartmenl and the other 2 patients died
75.
70
60-
SO-
tO
o
]0-
20-
10-
¯ ¯¯ ¯¯¯¯¯
,I
O o ¯
o
ooo
OOOOO
800000000
-~OOOOOOOOOO
8
o
80
o
888888ooooo
~88ooooo
00000000
SURVIV[016LI 01[0 1221 SURVlV[0(S~I 01[01201
UN~ORR[CT[O SCOR[S C~R[U[O S~OR[S
Fig 2 l)iMribution of l~ur~ Sc~¢rily Scores.
4ptH 1986 1 "Ha n’h" 31 \ u,nher 2
"I
83
5 da\’s a11d t4 days following admisskm. In 2 further
"’cardiac arrest’" calls the patients had regained cardiac
output and \~crc ventilating spontaneously prior to the
arrival of the Flying Squad. Both patients survived to
leave hospital.
3 p;nticnts \vh~..i had sustained a myocardial infarction
rccci\cd trc=,tmcnt for arrhythmias and cardiac I~ilurc
before being transferred to the A & E Departments; 2
’,w\ivcd.
One patient who survived fqtlowing an acute drug
overdose rcquircd ¢ndotrachcal intuhation to maintain an
adctluatc p:ltcnt airway.
5 other mcdic;d patients who survived rccci\cd
trcatnlK’nt al dK’ st:Cllq Ii)r IIlllSSIVC pulmonary embolism.
;IdUtC hYl~o~:l_\ caemia and Matus ¢l~ilcpticus.
Discussion
rhis suktv i~ i)rc~cntcd as much for it~ method as Ior its
rcsvlts and highhghls the difficulties cncounlcrcd in
c\ah,atmg the immediate care pro\iCed hv Accident
Flying Squads ill relation to trauma. In 1982 a survey
indicated that there \yore 47 ¢cntrcs in the United
Kingdom which operate such schemes ~. For a method of
emergency care which has been available for 30 years, it
is disturbing that there has been little objective assessment
to confirm the many subJective judgements of benefit.
The ir~troduction of the InJury Severity Score has
facilitated research in this field: the first objective
evaluation of :m Accident Flying Squad was performed in
1983 by Gorman and Coals H from Chester. When the
predicted chance of survival was applied to 152 trauma
patients who received treatment at the scene. I I0.12 were
expected to survive and II0 actually survived, The grid
described by Bull was then used to predict mortality:
according to this, 44. I patients were expected to die and
42 actually died.
In our own study there was no obJective evidence
to confirm that treatment carried out at the scene of
the accident saved lives. Failure to demonstrate the
effectiveness of the Flying Squad may be due to
deficiencies in the assessment process rather than to the
use of the Squad per se.
The analytical method we used offers a basis of
comparison of outcome between the populations seen by
the Edinburgh Flying Squad and that used in Bull’s Probit
Analysis. However, there may be many differences
between the populations apart from the use of the Flying
Squad which =s our particular focus of interest. Certain
inconsistencies also arise in the use of the Injury Severity
Score. While the ISS is well validated for blunt trauma ,t
does not appear to reflect accurately the severity of injury
when applied to penetrating trauma". Injuries associated
with stabbings and gunshot wounds yield inappropriately
low scores us,ng such a scheme. Another situation in
which difficulty is experienced is in ass=gning scores to
asphyx,atmg-type injuries. It is possible that refinements
of the ISS are required before it can be justifiably
’~, 0"t~-~. ~’:7’-4 "~I~.~-~, ~g~. I ""
_ o
.\

-’~+’9 ~ "
84
:lpplicd t(~ ,\ccidcnt Flying Squads: indeed, it may be that
’cHill2 other scoring system ix ilt2dcss;.lr)’ E~.
Although most Flying Squads ore designated by the
prelix "’Accident", a .signilicant Prot~lortion of their
~t+rkl~+;Id is rt:l;itt:d It+ tllt+’d[t’~.li C+l~,t2g which acct+unled for
one third tel" call,+ respoi+dud tt+ during the period of this
study. Objective as’+essment el + their el+licacv in this area is
+\ca more diflicult to tlctcrlnin+, Rowley ~+ reported that
Incdic’al cases attended by the Derby Royal Inlirmary
Flying Squad represented 20’,% of all the calls, The
outcome for these medical eases was uniforn+ly dismal:
indeed, all ultimately died before discharge IYom hospital
except R+r 2 chihJret+ wll~+ h+ld had cpilcptifortn
¢onvtllgi(Ins.
Although the equipment and techniques involved in on-
site restl~Cltiltll)ll h;.l\C bcconlc i+rogl’cssi\el) more
sophisticated, it is rckitively mexpel+~ivc to equip a flying
",tluad---£10.O00 to £20.000 inchnding the vehicle
References
.\~. t’Itll \I I I ",I\ti M)t \lix
t;OvlCCfvlcd ~’’. RUlllliilg c’okts ~lre Illinilll[ll. hut dcpfct~i[lliOiI
of the’ t chicle used ~ill add to the’ t:osts ~ub~tailtialt\.
Nctertholo,s~;. if silt:l+ ~tluads c;.in bt2 shOXxll t’o ’qlttr
even o1+¢ life, the) would h~lve amply repaid both their
initial outlay ;rod sul+scqtlcllt running co,its, With ncarlx
500,000 persons sustaining major injury Iron’, trauma in
the UK each year, the potential u+c of Accident Flying
Squads is great +"
Ilowever, further ,.;ludies are indic:.ltcd to dt~tcrininc
whether the failure to document objective reductions in
mortality and morbidit.v is due to dcfcct.s in In.jury
Scoring assessment anti small patient numbers, or
whether it genuinely rellccts an absence of benefit in the
operatitm of .,+ueh .-,quads In rc.’+ponsc it+ traulna calls.
Acknowlcdgment..+, ()ur th~lllk,~ It+ Dr Kcith l.itt[e for hi,,
hell!lul advice illltl Itl .Sir J I)ou,71ax ,.\licit. ReTionii I i)r,~,ur;ttor
I:i~cal, I’tir i1elllllkSlOll IO t’t;lllllllt’ Ihc iltllOllx.k I’l?ptll’l~
BOI)IWAI.A (J (i. I:al.:tn hl211ind lhe Ilyin,g ktltliltlx, hi: (,+arc ill the aCtltcl\ ill lind iiutlred: Proc’cedint~ ill Vlh hilt’lll,ili~,ii,il
CoI+~IPC~ o1" I’]nicrgcncy Surgery ( 198 1 J. Edit ed hi’ %Vll~on l) I I aBd [tilar~tl’~n #% K. (’llichc’qcr: Jtillll \\"ilc.t

!
ORIGINAL CONTRIBUTION ."
cardiac.~rrest, suwival rates prehospital’
prehoso~tal care, for cardiac arrest
Considerations foX’Improving Survival From
Out-of-Hospital Cardiac Arrest
Since the implementation of a paramedic system in SPxlttle, yearly survival
rates from out-of-hospital cardiac arrest due to ventricular fibrillation have
a-~raged 25% without any significant increase over the years. Outcorr~ for
arrest associated with other rhythms has been poor: when asystole
first rhythm recorded, .only I% of patients survived; when elec.
tromechanical dissociation was initially present, only 6% survived. For
cases of electrornechanical dissociation, neither the type of rhythm nor the
rbate appear to influence outcome. ~$urvival from ventricular fibrillation can
e improved by shortening the delay to initiation of CPR and to defibrilla.
~m. When outcome in 244 witnessed arrests was related to the times to
beginning CPR and to initial defibrillation, mortality increased 3% each
minute until CPR was begun and 4% a minute until the first shock was
delivered. New strategies that rninimtze delays appear to have the greatest
promise for improving survival after cardiac arrest./Weaver WD, Cobb LA,
Hallstrom AP, Copass MK, Ray R, Emery M, Fahrenbruch C: Considerations
for improving survival from out-of-hospital cardiac arrest. Ann Ernerg Med
October 1986; 1,5:I181.II86.]
INTRODUCTION
A paramedic-staffed prehospital emergency care system has been active in
Seattle for more than a decade. Since its beginning we have monitored the
benefit of providing such care and have evaluated changes in the system
made in attempts to improve its efficiency. In this study, we compared survival
rates for cardiac arrest associated with ventricular fibrillation, asystole,
and e|ectromechanical dissociation, and examined the cases for factors that
cou~mprove outcome.
MLL~ODS
The Seattle Fire Department provides a tiered out-of-hospital system to
respond to medical emergencies. First responders are firefighters, most of
whom, until recently, were traiited only in first aid. Since 1984 the fire department
has sought to qualify all firefighters at the standard emergency
medical technician (EMT) level. 1 These first-responding firefighters are located
at 34 fire stations, The ~ response time of the first tier is approximately
three minutes, Paramedics, who are also firefighters, have been
trained extensively (more than 2,000 hours of didactic lectures and practical
experience] and are able to manage a wide variety of medical emergencies,
including cardiac arrest. Five pm’m’~edic-st~fed units are stationed at four
locations in the city and ha~ ~ ~erage :respotise time of six to seven minutes
following dispatch."
The fire department responds to approximately 36,000 emergency calls
each year, and two-thirds of the responses are for medical problems. Approxirnately
9,000 of the persons evaluated are transported by fire department
vehicles to a medical facility. Although there was a substantial increase in
the number of medical emergencies attended during the first ten years of
operation, the annual number of cases has been relatively stable since 1981
Paramedic standing orders atrthorize initial treatment in cases of cardiac
arrest or hypovolemic shock; all other care beyond first aid is initiated only
after consultation with a physician, who communicates directly w;th pars.
W Douglas Weaver. MD*
Leonard A Cobb. MD*
Alfred P Hallstrom. PhDt
Michael K Copass, MD*
Roberta Ray*
Michael Emery*
Carol Fahrenbruch. MS*
Seattle, Washington
From the Departments of Medicine* and
Biostatistics.t Harborview Medical Center
and the University of Washington, Seattle.
Received for publication May 28, 1985,
Revision received February 11, 1986
Accepted !or publication April 15, 1986.
Presented at the University Association for
Emergency Medicine Annual Meeting in
Kansas City, Missouri, May 1985.
Supported in part by a Grant.in.Aid from
the American Heart Association with
contributions in part by the American
Heart Association of Washington and the
Medic I -- Emergency Medical Services
Foundation.
Address for reprints: W Douglas Weaver,
MD, Division of Cardiology. Harborview
Medical Center, 325 Ninth Avenue.
Seattle. Washington 98104,
15:10October 1986 Annals of Emergency Medicine 1181/77

1
1
I
- I - 11111 ......................... i ii ................................
SURVIVAL FROM CARDIAC ARREST
Weaver et al
FIGURE 1. Survival rates from out-ofhospital
cardiac arrest due to VF in
Seattle, March 1970 through March
1985. The early improvement (1970-
1972) was produced by establishing
an initial response tier using fire
engine compames to provide CPR, increasing
the number of paramedic
units, and increasing the proportion of
cases receiving bystqnder-initiated
CPR.
FIGURE 2. Summary of survival from
out.of.hospital cardiac arrest m cases
w~th VF. asystole, and EMD in, different
EMS systems. Treatment is effective
only for cardiac arrest due to
VE3-Io.13
medics.
For 30 consecutive months, we attempted
to interview all bystanders
present at the time of cardiac collapse
in order to esumate the delay from
collapse to telephoning the 911 emergency
number and the delay to initiation
of bystander CPR for those patients
receiving such care. All emergency
vehicle response times and the
time of treatments delivered [such as
defibrillation) were recorded on magnetic
tape. These recordings permitted
determination of the time of imtiauon
of CPR by the fire department and the
time of the initial defibrillator shock.
Survival {hospital.discharge to home)
was tabulated from review of the medical
records. A logistic regression analysis
was used to determine the effect
of CPR and defibrillation delays on patient
survival rates.
Yearly survival rates for a five-year
period were determined for consecutive
patients who presented in cardiac
arrest and in whom the initial
rhythm was ventncular fibrillation
{VFI, asystole, or electromechanical
dissociation {EMDI. EMD was defined
as the condition in which a QRS
rhythm was present initially and a
state of pulselessness existed or occurred
during initial surveillance by
the emergency responders. Patients
who were found alert and who became
pulseless due to VF were excluded,
as were patients with cardiac
arrest associated with trauma. The
cardiac rhythm, as documented by
paramedics, and the initial hemodynamic
status of the patient with
ENID were determined from the narrative
report. Patient outcome was
compared for each initial rhythm and
for the initial hemodynamic condition
78/1182
Ventricula~ Fibrillatm~t
Asyst01e
2 ,,~ ~t~ ~,~
of the patient. Discrete variables were
analyzed using the chi-square test.
RESULTS
Cardiac Rhythm and Outcome
During the 30 consecutive months,
725 patients with VF were discovered
on arrival of paramedics. Tape recordings
of resuscitation efforts were available
in two-thirds of these cases (478~
The remainder were not recorded because
of technical malhmction or unavailability
of recorders. There also
was a small portion of cases in which
the response time of the emergeqey
vehicle was not known. I~w~ ~of
the patients had a wimessedlb, ardia~ ~’
arrest, and it is only from these cases
that an estimate of collapse could be
2
)6 "4~ 25 ,
343 ~
240 2~24
¯ \ ",,\"
Electromechamcai
Dissocmticm
in these 244 cases are representauve
of a!! patients with VF initially discovered
by paramedics.
The most common rhythm associated
with out-of-hospital arrest is
accounting ~or about half of all cases.
In the first 15 years of operation, survival
rates from cardiac arrest and VF
averaged 25%, and annual survival
rates have changed little since 1973
(Figure I~
a re~e~t
year period, resuscitation was at-
made. In these witnessed cases, 88% tempted m.1,059 patien~ in asystolk
cardiac arrest unretatea to trauma
of bystanders were intervaewed and an
estimate of the time of collapse was -: : One hun&ed fifty (14%1 of the vict~,’
made. Thus logistic regression was
were resuscitated and admitted to tl~
hospital, but only 13 ultimately w~,
based on 244 witnessed cases in disc2mrged alive -- a survival rate o
which all of these factors were known.
A comparative analysis of interviewed 1%. There were no survivors am~
witnessed cases with tapes versus
those found in asystolic arrest relat~
to trauma despite paramedic and ir
noninterviewed wimessed cases with- hospital attempts at resuseita
out tapes showed no sagnificant difference
in response time of emergency
vehicles. Thus we believe the findings
Annals of Emergency Medicine
tion,~:
The outcome for patients di,
covered in cardiac arrest and KI~
15:10 Octot~ 1~

e~
100"
80"
60"
40"
s"
,m ~ a, m, 7 mtn
4
| m~n
TI3URATION OF CPR min.[
I
TABLE 1. SurWval following treatment in 247 patients found in ENID
Initial Rhythm ,..
Supraventricular rate ,~ 60 beats/man
Supraventricular rate > 60 beats/man
Idioventricular or not specified.,,
rate ~ 60 beats/man
No. of No. Discharged
Patlent~ Alive (%)
58 0
33 4 (12)
110 4 (4)
2 °, 3 ° atrioventricular block ’:~ 26 1 (4)
i
Ventricular tachycardia ,~ 8 2 (25)
Paced rhythm 3 1 (33)
Unknown .... 9 3 (33)
; 247
TNOo~
15 (6)
the differences between g~oups are significant. The indicated rhythms are
those categorized by paramedics at the scene of the cardiac arrest,
i
dso was pooc In the same five years,
rely 15 of 247 patients (6%}. with
survived, despite vigorous tre~nent
(ventilation; tracheal intubl,ion~
and administtation of sodium~bi-
.arbonate, epinephrine, and someimes
calcium chloride or atropine~
V’hen patients with EMD were sttat-
Bed according to their initial hemo-
:ynamic status on paramedic arriv~
n additional 127 patients were identiied
(94 with both pulse and pre~ure
~itially found, 33 with detectable
ulse only} who subsequently develped
£MD while under paramedic sureillance.
Nine of the 94 patients
0%} discovered with both pulse and
[ood pressure and one of the 33 (3%}
’ho had only a palpable pulse sur-
:10 October 1986
2’o
rived. These survival rates are not significantly
different from the rate of
survival in the 247 patients who were
found at the outset to be in a pulseless
state. The type of initial rhythm, eg,
supraventricular or ventriculm; and initial
rate also appeared not to influence
survival rates (T~ble 1~
Time to CPR and DeBlnillation
and Survival
In a logistic regression analysis of
survival in 244 wimeased arrests with
VI-, both the delay until initiation of
basic life support and the delay until
defibrillation predicted mortality following
cardiac arrest. In witnessed
cases, survival rates decreased about
3% with each minute of delay until
Annals of Emergency Medicine
3
FIGURE 3. Mortality after cardiac at.
rest related to the delay until mitia.
tion of basic life support and to the
duration of CPR until the first defibrillatory
shock was delivered. The
results are from a logistic regression
analysis in 244 witnessed cardiac at.
rests in which VF was the first docu.
mented rhythm. The relationship of
mortality to four incremental delays
~n ~n~tiating basic life support is
shown, as is the effect of the delay un.
til delivery of the first defibr~llatory
shock. Mortality rates increase with
the delays until provision of both
basic and advanced life support. Prob.
ability of survival = ! +e -~.9~ -o.o~
Age --0,1787 min to CPR -0.1515 rain of
CPR to first shock).
initiation of CPR, and continued to
fall 14% each minutel during the period
after initiation of basic life support
to delivery of the first defibrillator,/
shock (Table 2, Figure 3~ When CPR
was begun within three minutes of
collapse and the first shock delivered
shortly thereafter, 23 of 33 such patients
(70%1 survived.
DISCUSSION
Factom shown to be ,u0c~ted with
high survival rates following treat.
ment for out-of-hospital cardiac arrest
are a wimessed collapse, bystanderinitiated
CPR, and a short resuscita.
tion e~lT.2,11,12 In fact, most patients
found in VF who ultimately survive
receive little care beyond initial defibrillation
attempts and usually require
three or fewer defibrillatory
shocks for resuscitatiou.2
Since initiatio~ of the tiered enter.
gency response system in 1972, yearly
rat~ for l~tiems
in cardiac arrest and VF have remained
relatively flat in Seattle, about
2~%. Al.though this may be perceived
as a mc~est success, most of the iraprovement
was achieved ten years ago,
and the emergency care system appears
to have had little effect on the
outcome of patients with asysmle or
EMD.
Asystole .and FAVlD ptolmblyl~n~
s~t mote tlum diffemneea in the ini.
tlal elecui~ ~ of me~ I~
most cases, they are the result of
lengthy delays until beginning re.
..m tative m._sures. It Rmm ltkel
mat many, such Imtienm may have
collapsed because of VF and tim these.
two conditions are the c~nusequence of
spontaneous defibrillation occmdng
1183/79

SURVIVAL FROM CARDIAC ARREST
"Weaver et al
FIGURE 4. An example of spontaneous
defibriUat~on oc.¢urrmg nine
mmute~ followfng the onset of VF in a
patient who had been resuscitated
previously from cardiac arrest and in
whom irrevocable cerebral injury occurred.
VF followed a short episode of
rapidly conducted atrml flutter. Resuscitative
efforts were not attempted
and spontaneous defibrillation re.
suhed in an idiovenmcuJar rhythm.
The rhythm gradually slowed and
asystole was present 31 minutes following
arr~t.
many minutes after collapse (Figure
4~ There are several pieces of evidence
to support this. In witnessed cardiac
arrest, VF is the primary rhythm documented
when victims are monitored
soon after collapse34-~z In our series
of patients discovered initially with
&systole, only 237 of 935 cases (25%)
were witnessed to collapse, compared
to two-thirds of patients discovered
with V1-.
A report from suburban King
County showed a 95% incidence of
VF in cases monitored within four
minutes after collapse,, decreasing to
71% for cases first monitored after 12
to 15 minutes.IS Spontaneous defibrillation
appears to occur from
three to 20 minutes or more following
the onset of ~ This has been documented
on Hoher tapes in victims
who were unattended at the time of
axrest or who received advanced life
support treatments after lengthy delayslS,19
"zl (unpublished data).
The low survival rates associated
with asystole and EMD also may ira..
ply that currently prescribed procedures
and treatments for these
rhythms are ineffective or possibly
even ~ There ~ a scasc~ty ’o(
mauroll~ s)udies that ~uate drug
ueaumm ~ the ~m~g ,4 card~ ar-
8011184
#
i
17:01 onset of VF
i
17:06 5 minutes later
cases, substantial gains may be realized
by reducing both the delay until
initiation of basic life support and defibrillation.
These reductions in delay
can most readily be accomplished by
encouraging further community training
in CPR and by providing first re-
sponders with the equipment and
skills to effect rapid defibrillation. In
several communities, bystander-initiated
CPR has been shown to be associated
with improved survival rates
from cardiac arrest.zA6, ~-aO Th~ effect
is espec~tly true for the subset of
witnessed cases of arrest. Because
most of the effect of bystanders is in
this subset, the finding attests to
treatment effectiveness and appears
not to be a result solely due to early
Annals of Emergency Medicine
Since 1972 more than 370,000
laypersons in our community have received
instruction in CPIL The traming,
sponsored by the fire department,
requires three hours and emphasizes
how to access the emergency system,
outlines the signs of heart attack and
cardiac arrest, and provides an oppozmmty
manikin.
rest, but t,~ available mmlts do not
~ t that q~neohxme, sodium bi-
~mOne, and calcium
r~ ~ Im~ly ~ to the
malor gains can
usual patient found in caxd~ anest
~:ted by sh, m~nj~ the time to
with awm~ or ~tD.2a,z~
fibrillation,
Thus most available data suggest
that &systole and EMD are more often summons of the emergency care sys-
pretezminal conditions, mherendy untem.2~
In communities with exresponsive
to any therapy, primarily tremely rapid emergency response
because of long delays prior to initia- times, the benefit of bystander-initition
of resuscitation. Efforts at inated CPR has not been demonstrate&2
creasing survival rates from cardiac ar- These studies lead us to conclude that
rest can, therdore, most profitably be it is not who initiates such care, but
directed toward improving the man- instead how quickly resuscitative
agement of patients with VF. In these efforts are begun.
in cases
15:10 Octol~r 1
I
""i ¸

i
,rTi
TABLE 2. Survival from out-of-hospital VF related to the delays until CPR and to the ~rst shock
Minutes From Collapse
to initiation of CPR
,~3
>3
Total
¯ Survival rates.
tp ~ ,0~ -- row comparison, u~ivarlant analysis.
*P =~ .01 -- column comparison, unlvariant analysis.
t
Minutes of CPR to Rrat Shock
,~ 6 7-12 > 12
23 (70%)* 20 (44%) 1 (7%)
42 (39%) 12 (31%) 2 (22%)
651141 (46%)1 33187 (38%)1 3123 (13%)1
| ~ich the response times of pars-
| ~cs are prolonged. For cases of witnessed
arrest in which CI’R h/d been
delayed by four minutes and parsmedic
response times.were nine rainutes
or more, eight of 13 victims
162%1 when first responders
mit~d shocks, compared to
seven of 9.6 (27%} when first re-~
slxmders delivered only basic life sup-
~X)ft. 31
rates using available treatments are
dismal and possibly unalterable.
CONCLUSION
Secondly, training r~en~ and
cost to extensively implement defibrillation
are prohibitive. In addition,
the relatively small number of uses
per rescuer is inadequate to maintain
rhythm recognition skills, Thus a
modified approach using automatic
external defibrillators is far more prac- REFERENCES
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Emergency Medical technician -- ambuhmce:
Basic training pmg~am. Instruc-
continued training and may prove tor’s lesson plans. Government Printing
useful provided that they are safe for Office, PUbl No. TD 2.208: EM 313, Wash-
~h victim and resene~ are efficient ington DC, 1970.
"~’recogtizing VI:, and can be imple-
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L, et al: Bystander CPR in prehospital
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minutes or more} can occu~
Med 1984; 13:1016-1020.
An-additional factor affecting ratis
treatment that reduces the
3. Weaver WD, Cobb LA, Copass MK, et
common problem of refibrillation dur-
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trial using 175-I and 320-I shocks.
ing resuscitation. The development N F.ngl /Med 1982~307:1101-II06.
and evaluation of pharmacological
~gents to prevent such epi~k)des so 4. Diamond N[ Schofferman T, Elliot W,r:
that peffmmg rhythms =re Factors in successful resuscitation by par-
likely to improve subamedics./ACEP 1977~6:42.46.
viva] rates in patients with VE There 5. Steuven H, Thompson BM, Apraha-
also appears to be promise in new apmian C, et al: Use of calcium in prethat
augment pedusion or
attenuate myocardial and cerebral
damage during CPR.
Unlike V~, in which several new
promising approaches to treatment ex-
ist, effective strategies aimed at imroving
outcome for patients dis-
~ered in cardiac arrest with asystole
or EMD are not obvious, and survival
d0 October 1986
Annals of Emergency Medicine
TOfM
44/92 (48%)~
57/159 (36%)t
pulmonary resuscitation in a paramedic
served metropolitan area. Am [ Public
Heahh 1983~ 73:766-769.
8. Amey BD, Harrison EE, Straub EJ~ Sudden
cardiac death: A retrospective and
prospective study./ACEP 1976;5:429-433.
9. Engman 1~, Campion BC, McBride W~
et al: Mobile coronmry care in the man-
~ement of preho~pital cardiac arrest. St
Paul, Minnesota, experience. MJnn Med
1976~59:833-835.
I0. BriEp RS, Brown PM, Crabb ME, et
al: The Brighton resuscitation ambulances:
A continuing experiment in
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11. Thompson I~, Hallstrom AP, Cobb
LA: Bystander-initiated c~rdiopulmonary
resuscitation in the matmgemont of ventricular
fibrillation. Ann Inters Med
1979;90:737-740.
12. Eisenberg MS, Bergner L, Hallstrom
AP: Who shall ltve~ Who shall dieL in
Sudden Cardiac De~th tn the CommtmJ.
ty. New York, Praeger Publishers, 1984, pp
48-49.
13. Harrison EE, Amey BD: The use of
calcium chloride in cardiac resuscitation
(abstract~ Circnlatio~ 1982~66:!1-348.
14. MeJd W~, ~ ~ Trombold IC, et
al: Successhtl resuscitation of two near Mmultaneous
cues of cardiac ar~st with a
review of fifteen cases occurring during
supervised e~ends~ Citcu/atioa 1976~53:
187-189.
15. Enns T, Tweed WA, Donen N: Prehospital
cardiac rhythm dotetiomtion in a
hospital cardiac arrest. Ann Emerg Med system providing only basic life support.
1983~ 12:136-139.
Ann Emerg Med 1983~12:478-481.
6. Myerberg R[, Conde CA, Sung R[0 et al: 16. Roth R, Stewart RD, Rogers K, et al:
Clinical, electrophysiolngic and hemo- Out-of-huspital cardiac arrest: Factors asdynamic
profile of patients resuscitated sociated with survival. Ann Emerg Med
from prehospital cardiac arrest. Am ~ Med 1984~ 13:237-243.
1980~68:568-576.
17. Liberthson KR, N~gel EL, Hirschman
7. Guzy PM, Pearce ML, Greenfield S: WC, et al: Pathophysiologic observations
The survival benefit of bystander cardio- in prehospital ventricular fibrillation =nd
118$/81

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P
SURVIVAL FROM CARDIAC ARREST
" Weaver et al
sudden death. Circulation 1974)49:
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18. Hallstrom AP, Eisenberg MS, Bergner
L: The persistence of ventricular fibrillation
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19. Nikolic G, Bishop RL, Singh JB: Suddenculauon
death 1982i66:218-225.
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20. Winke RA: Ambulatory electrocardiography
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Prog Cardiovas Dis 1980i
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21. Hinkle LE, Argyros DC, Hayes JC, et
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39:873-879.
22. Steuven HA, Thompson B, Apraha-
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chloride in refractory asystole. Ann
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23. Steuven HA, Thompson B, Aprahamian
C, et al: The effectiveness of calcium
chloride in refractory electrome.
chanical dissociation. Ann £merg Med
1985; 14:626-629.
24. Cobb LA, Hallstrom AP: Communi.
ty-based cardiopulmonary resuscitation:
What have we learned? Arm NY Acad Sci
1982)382:330-341,
25. Lund 1, Skulberg A: Cardiopulmonary
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Circulation 1977)56:901-905.
27. Eisenberg M, Bergner L, Hallstrom A:
Paramedic programs and out-of-hospital
82/1186 Annals of Emergency Medicine
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28. Twee~ WA, Bristow G, Donen N: Resuscitation
from cardiac arrest: Assessment
of a system providing only basic lit¢
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] 1980)122:297-300.
29. Ver teai L, Wilson L, Glick N: Cardiac
arrest: Comparison of paramedic and conventional
ambulance services. Can Med
Asso¢ ] 1983)128:809-813.
30. Cummins RO, Eisenberg MS: Prehospital
cardiopulmonary resuscitation.
Is it eff.ec~ive? ]AMA 1985~253:2408-
2412.
31. Weaver WD, Copass MK, Buff D, et ah
Improved neurologic recovery and survival
after,early defibrillation. Circ~at.fon
1984;69:943-948.
: ..,,, "
,÷’ T
’" L,
.,
i:

CHARLES M. BURNS, MD, FRCSC*
4. Accident-Injury Organization: Canadian Overview
Trauma from motor vehicle accidents is
a major health-care problem, resulting in
enormous economic losses to the coun-
~srYaand reason
is second
for hospitalization
only to heart
in
disease
Canada.
Funding for research and accident-injury
programs is critically low,
National and provincial trauma registries
must be developed to provide data
that can be used appropriately to plan
and monitor the strategy of accident
health-care and prevention programs,
Manitoba, which has in place a trauma
registry, has a province-wide trauma systern
comprising two comprehensive
trauma units and seven regional centras
located strategically In the catchment
areas of the major centres, A comparison
of the performance of this system with
that of hospitals in Baltimore has shown
that the Manitoba system provides an
equal level of care. The author recommends
that a trauma system be astal)fished
in regions of one to two million
population, Each region should have one
to three comprehensive trauma services
a number of regional trauma eerv-
~j~es
¯ each strategicaBy located.
W’rth appropriate funding for trauma
care. the propose d system would pay for
itself. "--
From the Department of Surgery, Health
Sciences Centre, University of Manitoba,
Winnipeg, Man.
Presented as part of a symposium on the
organization of trauma care at the 53rd
annual meeting of the Royal College of
Physicians and Surgeons of Canada by the
Royal College in cooperation with the
Trauma Association of Canada, the Canadian
Association of General Surgeons, the
Canadian Orthopaedic Association and the
Canadian Association of Plastic Surgeons,
Montreal, PQ, Sept. 11, 1984
*Associate Professor of Surgery, University
of Manitoba. Director of Trauma Services,
Health Sciences Centre, Winnipeg, Man.
Accepted for pubfication June 6, 1985
Reprint requests to: Dr. C.M. Burns, Rm.
160. Old Basic Sciences Building, 753
McDermot Ave., Winnipeg, Man. R3E 07"6
Lee treumatismas subis lore d’accidents
de le route repr6sentent un probl6me
majaur de loins de osnt6; lie r6sultent en
des pertas 6conomiques importantas
pour le pays st lie vlennent au second
rang derri6re les maladies cardlaquas
comme cause d’hospitalisotion au
Canada, N6anmoins lea subventions b le
recherche et aux progremmes de soins
aux victimea d’accidents sont critiquement
bas,
On dolt 6tablir des listes natlonale et
provinclalas des traumstismas subis lore
d’accidents afin d’accumuler las donn6es
qui permettront de pianifier et de surveillerle
stret6gie des soins aux victimes
d’accidents et calle des progremmas de
pr6vantion. Le Manitoba qui a une talle
lista, poes~le un syst6me de soins posttreumatiques
comprenant deux unit6s de
soinJ complsts pour traumatis6s et sept
centras r6gionaux situ6s strat6piquement
darts le circonacription des grands cantres.
Comparetivemant au syst6me qui
pr6vaut dens les h6pitaux de Baltimore,
on peut dire que le systkrne manitobaln
offre un nlveau de soins satisfaisant.
L’auteur recommande qu’un service de
soins pour traumatis6s solt 6tabli darts
chaque grand h6pital et qu’une unit6
r(q~omale soit raise sur pied dana chaque
r6glon comptant de un i deux millions de
population.
Avac les fonds approprkSs, le syst6me
propo~5 sereit rentable.
in a large increase in the total number of
fatalities and injured and disabled persons
over the past 30 years. Also the escalating
hospital costs, welfare and property
loss have seriously drained the Canadian
economy. To ease this burden, government
and foundation funding should support
the development of a national
trauma program.
The Canadian Picture
The total ~ars of life lost annually
through motor vehicle accidents is greater
than the total of all cardiac and respiratory
deaths,
Rushing the accident victim to the nearest
hospital and then finding a doctor is no
longer an acceptable way to manage a
traumatized patient. Modern data
processing, communications, transport,
and sophisticated pre- and inhospital
medical care should be coordinated to
provide a high standard of health care for
such victims. An accident-injury program
should be directed provincially and coordinated
nationally.
The rate of accident injuries has been
kept under reasonable control through the
efforts of government agencies, but the
greater numbers of motor vehicles and the
expansion of heavy industry have resulted
n Lawson in 1977 estimated
Canada’s yearly economic loss from accidents
to be $2.5 to $4 billion. 2 In 19~,4
these losses may well double that figure.
Motor vehicle accidents account for 30%
to 40% of the total accident deaths in
Canada annually. The risk of accident to
the Canadian driver is 20~0 greater than
that to the US driver and 50% greater by
miles driven. Less than 1% of the
research dollar goes to trauma research
and organization of a health-care program
for accident injury (Gordon J.
Gutelius JR: Unpublished data, I9"/5).
Between 1960 and 1975, the numben
of motor vehicle drivers and passengen
~jm~! k=zea~l~O~ ~=1 Zel/o fewe~ tivcly (Fig. 1), while the incidence of
motorcycle accident injury; inctea.u~l
almost 1000%) The relatively sm.,;l
increase in pedestrians injured attesu to
effective countermeasures. However.
these 20 000 victims are among the mo~t
severcly injured and sugain the mo~t
severe ongoing disability as a group.
The Traffic Injury Research Found~
don of Canada studied blood alcohol
levels of victims in 1647 fatal traffic accidents
in 1976 (Table 1). 3 impairment
levels (more than 17 retool/L) of blood
alcohol were found in 25~ to $2~ of ~"
tiros in the categories examined. The~e
figures are particularly important bec2"~
frequently innocent people in anodgg
vehicle
The incidence
are involved
of traffic
in the
accident
accident.
deatht
and injuries for 1977 is compared, by
province in Fig. 2. 3 It is notable that the
~= gVIRGERY

I i
J
!
number injured (i.e., anyone showing any
evidence of injury or complaining of pain)
is about 40 times the number of deaths.
While Ontario and Manitoba had among
’gO0
110
the lowest fatality rates, their injury rates
were among the highest. The development
of accident-injury programs in Ontario
and Manitoba may have contributed to
these favourable statistics.
Developing Organization for Trauma
Care and Prevention in Canada
Trauma Registries
The registry system is being studied at
seven hospitals across Canada. Trauma
registries that include injury severity
scoring 4.~ in addition to detailed records
of all fatalities and injuries for patients
admitted to hospital indicate clear priorities-for
research and strategy when
developing prehospital and inhospital
accident health-care programs. The
present incomplete estimates of the
impact of trauma on the Canadian economy
could be more accurately estimated.
Improved health-care programs for the
injured and appropriate preventive measures
would result in substantial savings
not to mention reduced suffering.
Table I-Blood Alcohol Content Among Fatally Injured Drivers
bV Vehicle Type. Seven Province* Aggregates. Canada, 1976
Blood alcohol level
Iminimum % of victims)
No. of fatal
i Drivers of accidents Positivet Impairedt
i Automobiles 1 119 47 38
Truclrs;v~ns 291 49 42
iMeto~cyc,~s 153 40 29
Tractor trai~ 32 25 25
. Snowmobiles 52 60 !
52
, "Prince Ed’ccerd Island, New Bnmswick, Ontario. Manitoba, Saskatchewan. Alberta and British Columbia.
, t> 2 mmolL
i*> 17 mr,~L
t Source: Traffic Injmy Remarch Foundation of Canada, Analysis of Fatal Traffic Crashes 1976.
o
Persons
,.,.,;.TT;O.rT
Killed.
Rate per 100 OO0 Population,
1977
Canada
:i~.~::.:i~:~::-~:-.:.!-:’::ii!ii~i%i:~::~:i::l~l Newfoundland
I J! ! , , ’~i Ii
Prince Edward !~ ~
’ Island
";L:Lb’:’:: +. :’::-:+v,.
I
Nova Scotia
New Brunswick
:
Quebec
Ontario
Manitoba
Persons Injured,
Rate per 100 OOO Population,
000 I:K)O
:i:~:::~::~:~:?l
Saskotchewan
L I I I I I
!
L ¯ ’: " : : .: . i
Alberta
I : I I
P’::: :. : ¯ "1 ]
i Br~sh Columbia
I I I I~ i I Yukon
Nm’thweot I Tecritodes
0 5 10 15 20 25 30 35 40 45 50 0 200 400 600 8001000 1200
FIG. 2--Incidence of traffic deaths and injuries by province for 197"/.
The data obtained from trauma registries
could be used to strengthen epidemiologic,
research and treatment programs,
to assess priorities in different geographic
regions, to develop appropriate prehospitat
health care, to define the strategy,
location and type of ambulance services
re~luired in each region and to decide on
the type of ambulance service to be used
regionally,
The Manitoba trauma registry.--Our
registry, the only one in Canada at
present, was developed using the
ICD.9.CM 6 Manitoba Health Services
Commission discharge data, which lists
all injuries, complications, procedures
and associated diseases for each victim
admitted to hospital.
The initial data is scored, assigning a
specific abbreviated injury score (AIS) to
each injury. ~ A computer algorithm was
developed to assign this AIS scale as a
score to single injuries, 1 and 2 being
minor injuries and scores of 3, 4 and 5
indicating life-threatening injuries. In the
patient with multiple injuries the injury.
severity score (ISS) ~ is automatically
scored by a computer program. Scores below
15 are considered minor injuries and
those above as life-threatening injuries.
The AIS/80 scoring of injuries: was
modified to reflect more accurately the
threat to life. The scoring table and the
computer algorithm were forwarded to
Professor E. MacKenzie, Johns Hopkins
University and seven trauma centres
across Canada for further de\elopment
and study: Every effort should be made
to maintain a uniform national scoring
system.
Prehospital Services in Canada
A Manitoba study (’Fig. 3) of 364 prehospital
deaths for 1980, 1981 and 1982
indicates thai 15~ of the victims had
minor-injur~ severity sco[es. Detailed
study is needed to establish why victims
with such low scores died during the prehospital
period and to determine methods
of prevention.
CA~Ea
0t r J]
im
FIG. 3--Prehospital deaths in Manitoba for
1980, 1981, 1982. White bars = those with
minor-injury severity score (ISS less than 15).
dolled bars : those with life-threatening injury
severity score (ISS more than I5).
VOLUME 28. NO. 6. NOVEMBER 1985 I THE CANADIAN JOURNAL OF SURGERY 483

O
O
Prehospital services in’ Canada are at
’ varyingstages of development. Ontario,
Manitoba, Saskatchewan and British
Columbia provide provincial funding for
ambulance services and programs for
training ambulance attendants to the
levels of emergency medical attendant
(EMA) I and II. Paramedic programs
(EMA III level) have been developed in
Vancouver and 12 centres in Alberta.
Saskatchewan, Manitoba and Ontario are
initiating training at this level. These programs
are of great value in treating acute
medical emergencies, in cases where
extraction of the victim from a motor
vehicle is prolonged and when delivery
time to the hospital is extended. Rural
areas would benefit most from such services.
Unfortunately, there are no largeregion
dispatching centres anywhere in
Canada at present. The German system
of regional dispatch should be studied for
adoption in Canada.
Ontario has in place, through its community
college system, an educational
program for the training of emergency
medical attendants in its ambulance services.
This is the first province-wide program
in Canada. Except for Montreal,
Quebec and the eastern provinces have
accomplished little in the development of
a coordinated prehospital-care system.
There, a physician is assigned to certain
high-risk ambulance runs. This system
may provide interesting data for comparison
with the EMA programs; it may
prove to be more effective and cost efficient.
A trauma registry, using a Standard
national scoring system, would allow for
valuable comparative studies between
centres using differing prehospital
systems.
The development of the emergency
physician specialty and the advanced
trauma life support (ATLS) course has
upgraded the lx)tential standard of injury
care in the fh’st hour after injury. Unfortunately,
the services resulting from these
developments are usually found only in
large urban centres. Regional trauma
units, strategically located, using data
from registry studies, would provide
appropriate resources for rural regions.
Air-ambulance systems exist in almost
every province and have provided a valuable
resource for the transport of trauma
victims long distances to sophisticated
trauma centres. These, however, are not
well coordinated and seldom carry
appropriately trained medical attendants.
Air-ambulance services are provided
almost entirely by fixed-wing aircraft,
which, in Canada, are probably the most
appropriate. Capital cost, maintenance,
available crew and distances in Canada
are factors that strongly support development
of fixed-wing ambulance services
first. Specific regions, isolated from fixedwing
evacuation where a high risk of acci-
dent injury has been demonstrated, might
be considered for helicopter services.
In northern Canada are now almost
250 000 people who are exposed to an
increasing incidence of accident injury
associated with heavy industry (oil exploration,
lumbering, mining). Army resct, e
units, which are available at four levels
of expertise and response in a number of
regions, could be strategically located to
provide rapid triage and evacuation of the
injured to appropriate centres in the
south. Regional trauma centres in Whitehorse,
Yellowknife and northern Quebec
might provide such services using army
paramedical attendants. The armed services
personnel would derive practical
experience and the population a valuable
service at no extra expense.
Trauma Cenlres
In 1977, the trauma committee of the
Canadian Association of General Surgeons
and now the Trauma Association
of Canada designated 21 comprehensivecare
centres. In addition, it is proposed
CASES
120
100
8O
6O
4O
1
4
?
that regional trauma centres, havm~
staff at least one surgeon experienced in
trauma care, be developed in each of the
catchment areas of the major centres. At
present, Manitoba is the only province
that has this system in place.
The trauma system was developed by
the medical profession not by legislation
It has had po deleteriou~ ,mp;.:~ on the
heath-care system as it was developed
during a phase when regionalization was
taking place.
The Manitoba system.--In Manitoba
the trauma hospital system includes two
comprehensive trauma units, both in
Winnipeg, and seven regional traunm
units across the province. Of patients ~,h
life-threatening injuries, 55% are admitted
initially to a trauma-unit hospital,
suggesting the appropriate strategic location
of these hospitals across the
province. Of the patients with lifethreatening
injuries who are not initi~,dly
admitted to the trauma-unit hospitals,
75% are referred into the system within
the first 48 hours after injury. Obviously
not all life-threatening injuries need be
¯CASE80EATH8
¢TU ~ 2S8 46
2 CTU (B) 87 14
$ RTU 61 1
4 01"HER WP~ IO0 ¯
8 011tER MAN (A) 44 t
6 OTHER MAN (B) 88
? NURSING 8TN. 7
¯
11-20 21~30 31-40 41-50 81&up
INJJRY SEVERffY SCORE
FIG. 4--Initisd admission of patients with multiple or life-threatening injuries (1SS more
than 15). Comprehensive trauma unit A, which includes trauma service, treats majority o| such.
patients. CTU = comprehensive trauma unit, RTU = t~llional trsums unit, WPG - wwmpeg,
MAN = Manitoba.
Injury
severity
score
11-20
21-30
31-40
41-50
>50
Table ,-Comparison of Comprehensive Trauma Units A and B by SundvaJ
Probability to Discharge and According to Injury Sevedty Score
Unit A Unit B _
No. patients Survival No. patients Sur~vd
(deaths) probability (deaths)
117 (1) 0.992 48 10) 1.000
89 118) 0.798 28 (7) 0.750
20 18) 0.600 915) 0.455
20113) 0.350 212) 0.000
916} 0.334 0 0.000 ..~
[

I
treated in a trauma-unit hospital; some
can be successfully and well treated outside
the system. However, those victims
suffering multiple injuries and almost
100% of those suffering head injury of
life-threatening severity (ISS more than
15) are immediately transferred to the
trauma-unit system (Fig. 4).
Of the two comprehensive trauma units
in Winnipeg, unit A has a special trauma
service, while unit B does not. Comparison
of survival probability at the two
units shows that in each injury severity
category except ISS 11 to 20, the probability
of survival was higher in unit A
(Table !I). This observation suggests that
it is important to have initial triage and
total trauma health care coordinated by
a team of trauma surgeons from the time
of admission throughout the critical
phase. Such a resource probably should
be available for every ! to 2 million population
group across the country.
While the statistical significance of
these figures may be questionable, the
actual numbers speak for themselves.
Numerous variables not included in
statistical analyses are controlled in a
large registry experience.
A comparison of the performance of
the Manitoba trauma health-care system
with that reported from six sophisticated
hospitals in Baltimore (Fig. 5) shows that
in both 0 to 49- and 50 to 69-year age
tUURY ~Vl~RtTy SCORE - MAtleTQtA
/ toe-. ~ ~ /
,,a’°’~loe)
a,.F!G. S--Comparison of performance (prob-
¯ -n,v m sursival) of trauma patients in
Manitoba ssstem and that of similar patients
in six Baltimore hospitals, l,DS0 (50% mortality
point) was used as measure of performance.
Patients dead on arrival at hospital
acre excluded. Dotted lines connect points
based on fewer than 10 cases. Circles = 0 to
49 )ears, triangles = 50 to 69 .~ears, squares
"~ "/0 )ears and older.
FOLUME 28, NO.
,
groups, the survival probability" in
Manitoba .was equal to or greater than
tor producing this result could be the
that in Baltimore as measured by the
provincial trauma program.
LDS0 (50% mortality point). Only in the Funding
over ?0-year age group did Baltimore rate
better than Manitoba. It is possible that
Trunkey
the smaller number of cases in this
category in Baltimore skewed the results.
Given the limitations of this gross measuremem
of standard of care, one might
conclude that the trauma-system program
in Manitoba is providing a satisfactory
level of care. If trauma registries, using
identical scoring systems, were available
in other provinces, comparisons could be
made. Since the Manitoba fatality rate by
miles driven and by number of vehicles
registered is the lowest in the country and
the injury rate is among the highest, a fac-
7 demonstrated the mismatch
of years of life lost and’the level of funding
in the United States for three
categories of disease (Fig. 6).
Trauma is concentrated in the under
39-year age group (our greatest natural
resource with the longest life expectancy).
Because of this, the costs of disability and
the loss of productivity are ongoing and
cumulative. This results in a great economic
drain on the country. In fact, the
discrepancy clearly demonstrates the
inappropriate level of support given by
"governments and research foundations to
develop health care for what is the major
pandemic affecting North American
society.
In Canada, the level of funding for
trauma care is likely to be much lower
than that in the US even though the risk
to the Canadian population as drivers of
motor vehicles is much higher than that
in the US. If we corrected this discrepancy
and did nothing more, the proposed
trauma health-care system would pay for
itself.
Conclusions
Provincial trauma registries and a
national trauma registry should be developed
to provide the uniforn: dam on
which to build a health-care system based
on logical strategy and health-care priorities.
Epidemiologic, basic and clinical
research programs should be developed
to monitor the performance of the accident
program and indicate where
improvement in strategy and health care
is needed.
Trauma services in comprehensive
trauma units and a regional trauma unit
should be developed in each area of ! to
2 million population density.
Federal, provincial and research foundation
funding priorities should be reexamined
and allocated where the growing
need is great. We cannot ignore the
projection made by Campbell and La~son
s that in the next 10 years there will be
64 000 lives lost and 3 000 000 injuries
suffered in Canada.
The Manitoba Accidem Injury Health Care
Project was supported by donations from the
following sources: Manitoba Health Services
Commission, Murphy Foundation inc.. W.
Garfield Weston Foundation, James Richardson
& Sons Ltd., McKeag Realty Ltd., General
Distributors of Canada, Dionian Industries
Ltd., Monarch Life Assurance Company,
Manitoba Medical Services Foundation. Inc.,
Great-West Life Assurance Company. Winnipeg
Clinic Research Institute& The Paul H.T
FIG. 6--Mismatch of )ears of life lost and Thorlakson Research Foundation. Inc...\loffat
funding for trauma in United States (after Communications Led., Monarch Industries
Trunkey DDT).
Ltd., Cargill Grain Company Ltd., P.L. &
A.M. Ashdown, Mrs. M.E. Mcimosh.
6, NOVEMBER 1985 / THE CANADIAN JOURNAL OF SURGERY 48~

[{e ferenees
I. Canada. Department of National Health and Welfare: A
"~’ew Perspective on the tleolth of Canadians. A K~orking
Docu,~, "nt. (,:at 82-538E). Department of Supply and Serv.
ices, Otta~a. 1974
2 L ,,~s ~O’~ J J: The costs of rt~d acciOems and [heir application
in ecc[ omic evaluation of safety programs. Present.
ed al [he Annual Conference of the Roads ,~,~
cidents. Poisoning. and Violence m Canada an Overview,
Department of Supply and Services. Ottawa. 1980
4. BAKER SP. O’NEILL Ii HADDON V." JR. LONG W11: The
injuPy se~rity ~’ore: a method for describing patients with
multiple injuries and evaluating emergency care. J Trauma
1974; 14:187-96
5. American Association for Automotive Med;.¢i~, Commhtee
on Injury Scaling: The Abbreviate~/ Injury Scale, 1980
Revision, American Association for Automotive Medicine,
Morton Grove, IlL. 1980
Trampprta[ion Assocultion of Canada. O~[awa. Sept. :978 6. International Classification of Diseases. 9th Rev.. Clini.
3. Canada, Department of National Heahh and Welfare: AS: .~.~ ca/Modification, Commission on Professional and Hosp-
HANS-J(~RG OESTERN, MD
Health Statistics. Ann Arbor, Mich., 1978
7. TRU,’,;KEV DD: Trauma. Accidental and intentional in iuties
account for more years of life lost in the i ¯ " . .~tn
cancer and heart disease. Among the ~r2,~rt~pd t’~rrtc~[~
are improved preventive efforts. ~ t:a~’y and further
research. Sci A, ’ .~; Z49(2): 28-35
8. CAMPBELL (’:[~. ~ ~,,’SON J J: Prospects for road safety
in the *P’~. P,’~sented at the Annual Conference of [he
p ~er’ ~-I Transportation Association of Canada, Win-
-.,~g. Sept. 1981
5. The German Model for Rescue of Traumatized Patients
Accidents and their sequelae are the
e main cause of death In Germany among
people under 40 years of age. The cost
in disability payments and lost work
averages $40 000 per injury. The author
describes the German system for trauma
rescue.
The aims of rescue care in Germany
are to reduce the interval between injury
and hospital admission and to bring the
patient to the right hospital, bypassing
smaller hospitals if necessary.
Ambulance rescue systems are of two
types: the stationary, in which the physician
travels with the ambulance, and the
rendezvous, in which the physician and
ambulance, travelling separately, meet at
the accident site. At the beginning of the
1970s the air-rescue system was started
and now comprises 32 stations and 25
BO-105 helicopters.
The Hannovar experience shows that
of the initial diagnoses made at the accie
dent site by helicopter rescue service,
51..9% of victims had head injuries,
35.5% fractures of extremities, 17.0%
From the Trauma Department, Hannover
,Medical School, Hannover, West Germany
Presented as part of a symposium on the
organization of trauma care at the 33rd
annual meeting of the Royal College of
Physicians and Surgeons of Canada by the
Royal College in cooperation with the
Trauma Association of Canada, the Canadian
Association of General Surgeons, the
Canadian Orthopaedic Association and the
Canadian Association of Plastic Surgeons,
Montreal, PQ, Sept. 11, 1984
Accepted for publication June 6, 1985
Reprint requests to: Dr. Hans-J6rg
Oestern, Professor of Surgery, Trauma
Department, Hannover Medical School,
Konstanty-Gutschow.Str. 8, 3000 Hannover
61. West Germany
thoracic trauma, 10.2% abdominal
trauma and 7.6% spinal fractures.
Because of respiratory insufficiency or
unconsciousness with danger of aspiration,
12.0% of the patients had to be
intubatad endotracheally. One hundred
and twenty-two patients with a clinicid
diagnosis of death were successfully
resuscitated at the accident scene. A
study comparing the efficiency of the
helicopter and ambulance systems
showed that as the severity of the injudes
Increases, the death rate is greater
in the group rescued by ambulance. Of
22 accidents involving rescue he,coptars,
7 (32%) resulted in at least one
death. Between 1973 and 1983. 16
doctors, pilots or attendants were killed.
En Aliemagne, los accidents at leurs
s~luelles sont les pdncipales causes de
chez les moins de 40 ans. Les
coots en paiements pour Incapacit~ et en
perta de travail atteignent an moyenne
40 0005 par bleesure. L’auteur dimdt le
syst&me allemand de sauvetage des traumatis6s.
Les buts des operations de seuvetege
an Aliemagne sent de r~Kluire I’intarvalle
6coul6 entre la bleesum et I’ardv6e il
I’h6pitai, at de dirigar le patient vars
I’h6pitei le plus appropri6 m6me a’li faut,
chemin feisant, ignoror de plus petite
h6pitaux quand cela s’av6m n6ceesaire.
Lea syst&mes de aauvetago arnbulancler
sent de deux types: atationnaire, alors
qua le m~decin voyage avec I’ambulance;
de rendez-vous, quand le ndtdecin
at I’ambulance, voyageant s6par~mant,
convergent vars le lieu de I’accident. Au
d~but des ann~ec 70, un syst~me de
sauvetage par air a ~t~ mis~ur pied; li
comprend maintenant 32 stations at 25
h6licopt&res BO-105.
L’exp~rlence de Hannovre d&montre
qua Iors du diagnostic initial felt sur los
lieux de I’accident par les services de
sauvetage par h~licopt~)re, 51.9% des
victimes souffraient de traumatismes cdtnlens,
35.5% de fractures des extr~mit~s,
17.0% de traumedsmes thoreciques,
10.2% de traumetismes
abdominaux at 7.6% de fractures spinales.
~, cause d’insuffisance respiratoire
ou de perte de conscience avec danger
d’espiration, 12.0% des patients ont dO
8tre intub6 par vole andotrach~mle. Cent
vingt-doux patients consicl0r~m clinicluement
comma morte ont pu ~tre r6anim~s
am rmu de I’acctdent. Une ~tude comparant
I’efficacit~ des systlm~es pe~ ambulance
at par h~licoptkre a montr~
qu’avec I’augmantation de la gravit~ des
blessures, la mortalit~ ~teit plus grande
¯ dens le groupe secouru par ambulance.
Dens 22 accidents impikluant des h~lF
coptAms de sauvatage, 7 (32%) ont
entrain~ ou moins une mortalitY. Entre
1973 at 1983, 16 ndtdectrm,.pilotes ou
inflrmlers ont 6t6 tu6s.
In Germany, motor vehicle accidents and
their sequelae are the main cause of death
amoag people under 40 years of age. The
death toll from trauma in 1983 in the
country was 50000, of which 11 747 were
from traffic accidents. Injuries in that
year totalled 500 691. The cost of these
injuries in lost work and disability is
alarming, amounting to an average of
$40 000 per injury.
There is statistical evidence of a correlation
betweer~ the time of the accident,
the start of treatment and the outcome;
that is, the shorter the rescue time, the
better are the results (Figs. I and 2). What
can we do to optimize the management
of acute injuries?
486 VOLUME 28, NO. 6, NOVEMBER 1985 / THE CANADIAN JOURNAL OF SURGERY

Aims of Rescue Care
In Germany our aims in the care of the
severely injured patient are as follows:
¯ Reduce the rescue interval; that is,
start treatment early at the scene of the
accident.
¯ Bring the patient to the right hospital,
bypassing smaller hospitals not
properly equipped to handle severe
trauma.
¯ Shorten the transportation time.
Rescue Systems in Germany
Our emergency ambulance service was
begun about 20 years ago. It brings the
doctor to the scene of the accident so that
he can start resuscitation immediately.
The service comprises two systems -- the
stationary and the rendezvous.
In the stationary system, an ambulance
is situated near the hospital and is dispatched
by the rescue control centre to
accidents within a radius of 8 km. The
obvious disadvantage of this system is
that it takes too long to arrive at the scene
of an accident any distance from the
hospital.
The rendezvous system is used mostly
in rural districts or in towns that have
only one emergency vehicle. A doctor on
call is delivered to the scene by a specially
equipped car manned by the local fire
department. He may, when necessary, use
his own car. Simultaneously, an ambu-
i i 1 I -
~ 10 18 20 25~
FIG. 1--Relation between survival and start
of treatment.
I
lance is sent to the scene of the accident.
This is an excellent system and a good
way to providt early medical help.
Rescue Helicopter Service
In the last year, 25 267 missions were
performed by rescue helicopters. The
Federal Republic of Germany started the
present air-rescue system during the
1970s. It now comprises 32 stations and
25 Be-105 helicopters. With an optimal
effective radius of 50 km, medical emergency
help is available to 90°70 of the
country’s population within 15 minutes.
Under the disaster control organiza-
tion, the pilots are provided by the Federal
Ministry of the Interior and medical
attendants by various private local rescue
organizations and fire brigades. Doctors
are assigned by the base hospitals. The
German automobile club is responsible
for administration and cost accounting of
the rescue flights. It also negotiates contracts
with the insurance organizations.
Operating costs are reimbursed by accident
and health insurance organizations
within the communities and cities to the
respective doctor.
i I
I
!I
I
FIG. 3--Lines of communication to rescue
control centre. ADAC = German automobile
club. Dotted lines represent radio ommunt.
cation, solid lines telephone communication..
75% /
-" .,-!--- #7--. _,4z___
/ /7 .7
"1 Y ,y /
°%i/I , /, , /I , J I l
30sec 1rain 2 3 5 10 15 30 1hour 2 5 10 15
FIG. 2--Relation between different types of emergency, interval without treatment and
OUtcome.
f
All emergency calls are channelled to
the rescue control centre in the area,
which is in four-channel contact with the
police. The control centre coordinates and
activates all ground-rescue vehicles and
the rescue helicopter within its area of
responsibility (Fig. 3). A paramedic and
an emergency care physician are assigned
to each helicopter, which is equipped for
safeguarding the vital functions of the
injured victim, treating shock and providing
initial treatment of injuries, and also
providing safe transport to the hospital.
The important factor of air rescue by
helicopters compared with conventional
land-bound ambulance rescue, is that
through the early application of medical
measures by a physician the interval
without therapy is greatly shortened.
An investigation carried out in 1971
showed that even in a large city like Hannever,
it took more than 20 minutes to
get 64070 of accident victims to the hospital
by ambulance. In 26%, more than 30
minutes elapsed before they were treated
by a doctor in a hospital and in none of
these cases was effective treatment
initiated before admission. The rescue
helicopter reached the accident site in less
than 10 minutes after being notified in at
least 60% of cases.
Treatment at the Accident Scene
The initial diagnoses made at the accident
scene for the years 1972 to 1983 are
shown in Table I. Head injuries were the
most common. Almost 65070 of the
patients were in shock. In cases of extensive
hypovolemia, two or three large-bore
catheters are used and the patient is
infused, preferably with crystalloid solution.
If necessary, 2000 mL or more of
fluid may be infused before the victim
reaches hospital.
The procedures carried out at the accident
scene by either the ambulance or
helicopter-rescue system are listed in
Table II. Because of respiratory insufficiency
or unconsciousness with danger of
aspiration, 12.007o of the patients had to
be intubated endotracheally. So as not to
restrict the availability of the rescue
helicopter, only 31070 of the victims were
thus transported during the period 1972
to 1983. They were patients who required
continuous medical observation or had
injuries, such as vertebral fractures,
requiring smooth transport.
Table I-Injmles Diagnosed at
Accident Scene, 1972 to 1983
Injury %
Head injury 51.9
Fractures of extremities 35.5
Thoracic trauma 17.0
Abdominal trauma 10.2
Spinal fractures 7.6 i
VOLUME 28, NO. 6, NOVEMBER 1985 / THE CANADIAN JOURNAL OF SURGERY 487

Helicopter versus Ambulance
cue in Hannover and more than 13 000
missions, the effectiveness of this system
To compare the effectiveness of for all involved is without question.
helicopter versus ambulance rescue, we However, there is increasing criticism
carried out a prospective study of 48 trau- from laymen and doctors and a resistance
matized patients. The study was restricted to the establishment of new centres on the
to patients with one or more injuries caus- grounds of pollution and cost control. So
ing shock and an estimated blood loss of the question is frequently asked, how
1000 mL in the first hour. Children under many lives have really been saved by the
15 years old and patients with cranio- helicopter? This question cannot be
cerebral trauma were excluded. answered accurately.
In group 1, aggressive treatment was One hundred and twenty-two patients
started at the site of the accident by the with a clinical diagnosis of death were
doctor from the rescue helicopter. In successfully resuscitated at the accident
group 2, patients were transported by site. There are certainly more positive
ambulance, without a physician, to the effects from prompt on-the-scene treat-
nearest hospital, but because of the severe ment, using helicopter rescue, than from
injury were transferred to our hospital. spectacular resuscitations of moribund
open fracture. Naturally, the time factor
has a significant bearing on the end result
regardless of the quality of primary care.
Risks of Helicopter Rescue
How safe is the rescue helicopter sYstem?
Between 1973 and 1983, 146 300 rescue
missions were carried out in the Federal
Republic of Germany and there were
22 accidents involving rescue helicopters
-- a rate of i accident per 6648 missions.
Of the 22 helicopter accide"-t~, t (32°70)
resulted in at least f, ne death each. Durhag
this period, :6 doctors, pUots or attendant~
were killed.
Causes of Helicopter Accidents
It was noted that group 1 patients patients. Life-threatening complications
reached hospital in less than half the time at the site of the accident and during Nearly 60% of these accidents were due
despite the fourfold greater distance from transport are prevented, especially to human failure and the remainder were
the hospita! to the site of the accident obstructions of the airway, and through secondary to technical failure. The higher
(Table III). In these patients, an average adequate early and aggressive treatment, risk associated with rescue helicopter
of 711 mL of fluid was infused before complications resulting from shock are flights was due to lack of extensive
arrival at hospital, while patients in group decreased.
navigatory preparation, landings in
2 received an average of 230 mL and
unfamiliar or narrow areas, busy streets,
many of them received no infusion at all. Management of Open Fractures and and housing developments, flights made
Accordingly, the systolic blood pressure Infection
in poor weather conditions, undue haste,
of group 2 patients on admission to our
and extensive involvement of the crew
clinic was only 92.3 mm Hg. On average, A cardinal rule at the accident scene is associated with increased risk.
the shock index (heart rate divided by to avoid further soft-tissue injury. We Critics of air rescue note the restricted
systolic pressure) in this group was 1.18. strongly recommend that fracture/ be conditions in an aircraft and the limited
The levels of the helicopter group clearly realigned or reduced where possible at the possibilities for therapy during flight.
show the results of better primary treat- scene to relieve pressure on the injured This is only partially true, and external
ment -- an average systolic pressure of soft tissues. Swelling and the spread of heart massage can be performed during
119.4 mm Hg and shock index of 0.88. hematoma are reduced by placing a sterile flight in extreme cases. On the other
To find out the effects of this circula- dressing over the wound and immobiliz- hand, the speed of the rescue helicopter
tory replacement, the subsequent course ing the extremity in a pneumatic splint. allows a patient early treatment accord-
of the patients was immstigated. Twa In our clinic, 59°7o of the open fractures hag to individual requirement in a special-
patients of group 2 died in the emergency have already received field treatment ized hospital even when it is not the
department. Almost half of the patients within about 20 minutes of injury from nearest one. True contraindications to
in this group had to be treated in an inten- a resident who accompanied the rescue
sive care unit longer than 10 days. In com- vehicle to the scene. The benefits of this
Table V-Cause of Death
parison, almost two thirds of group 1 early care are substantial: a 3.507o infec- Cause Group 1 Group 2
patients could be moved out of the intention rate when primary care was
sive care unit after 1 to 3 days. The aver- administered by air ambulance personnel
Adult respiratory
age duration in the intensive care unit was as opposed to a 22.2070 rate in patients
distress syndrome - 3
Sepsis 2 3
only half as long in group 1 as in group who reached the trauma centre by way of E~tion 1 2
2 (Table IV).
another hospital within 10 hours of
With respect to cause of death, a high
injury. In the latter case, infection
Totals 3 8
Overall death rate, % 11.8, 38.0
rate of respiratory insufficiency was noted occurred in every fifth patient with an
in group 2. This complication is generally
recognized as a result of inadequately
treated hypovolemic shock. The overall
Table Ill-Comparison of the Effactivemss of Helicopter
and Ground Rescue Methods in Trauma injuries in Germany
death rate in group 2 was more than 3.5
times that in group I (Table V).
After almost 12 years’ use of air res-
Factor
Distance from accident site to hospital, km
Interval between injury and initial treatment, min
Volume replacement during transport, mL
Group 1
28.1
22.2
711
Group 2
7,2
47.0
230
Table II-Procedures Performed at Accident
Scene, 1972 to 1983. by ~ or Rescue.
HeScoptor personnel
% of
Procedure patients
Volume replacement 31.3
Control of bleeding 29.1
Splinting of fractures 18.7
Intubation and ventilation 12.0
Resuscitation 4.9
Duration of
treatment, d
Table W-Duration of Treatment in ~ Care Unit*
Group 1. % Group 2. %
1- 3
4-10
11-20
> 20 I
62.9 14.3
14.8 33.3
7.4 28.5
14.8 14.4
*9.5% of patients in group 2 died within 1 h of arrival M hospital.
488 VOLUME 28, NO. 6, NOVEMBER 1983 / THE CANADIAN JOURNAL OF SURGERY

f
helicopter transport, such as an unresolved
pneumothorax, are rare.
Condudons
Our rescue system works and without
a doubt in the densely populated areas of
Europe such a system of air rescue could
be used in the same way as in Germany
and Switzerland. For less-densely populated
areas, an extended " numbers of missions can be flown. quickly? Perhaps it requires only the
The questiom of political and econom- initiative of independent or private
ical value is not easy to answer, because organizations. The Federal Republic of
it is difficult to estimate the financial Germany’s helicopter air rescue system
value of a rescued life. Even with thiswas
initiated by the German automobile
reservation, the political economist Baum club which, together with the Federal
(personal communication) calculates the Ministry of the Interior, started the first
favourable value of the air-rescuesystem rescue helicopter service in Munich.
to be at least comparable to that of using Today, this club still acts as an impetus
seat belts.
for further development of air rescue and
missions radius Why are air-rescue systems in wealthy supplies valuable help with administration
should be considered, so that sufficient industrial countries not instituted more and accounts.
ATLAS OF STOMAL PATHOLOGY. A.
Fnmchini, B. Cola and PJ.d’E. Stevens.
112 pp. lUnst. Raven Press, New York,
1~3. $70. ISBN 88-85937-37-2.
The surgical literature contains much information
on the technical aspects of creating stomas.
In spite of this, stomas are often carelessly or
improperly fashioned, with resultant morbidity,
embarrassment and distress to patients.
This book, written from a pathologic rather
than a surgical perspective, provides a valuable
addition to the literature. It properly and
comln~he~.siveiy descrihes the consequences of
poorly constructed stomas and illustrates in
detail the gamut of other processes that affect
stomas.
The book is well organized into 10 chapters,
2 of which deal comprehensively with primary
and secondary stomal conditions. The chapter
on primary stomal conditions deals with
such problems as poor site, edema, ischemia,
¯ .’t~ction, prolapse, hernia and skin lesions.
Each one is well illustrated with co[our photographs.
This is perhaps the strongest attribute
and raison d’etre of the book, for, as
Professor Brian Brooke emphasizes in his
preface, "Stomas have to be seen to be
believed...for stoma problems all too often
beggar description".
Other chapters cover such topics as stomal
problems in radiotherapy, gynecology and
obstetrics, and pediatrics. There are also chapters
on problems of obtaining a continent
stoma and special problems of ostomates,
including psychic and metabolic disturbances.
This book is not a comprehensive treatise
coveting all aspects of stomai management -nor
does it claim to be. However, as a beautifully
illustrated atlas of morbid conditions
affecting stomas, it fills a void in the literature.
it would make a worthy addition to the library
of surgeons or residents involved in the care
of ostomates and would he a valuable reference
for enternstomai therapists.
WILLIAM G. POLLETT, MD, FRCSC
Assistant Professor of Surgery,
Memorial University of Newfoundland,
St, John’s, Nfld.
AIB 3V6
Canada Limited, Toronto, 1984. $46.20.
ISBN 0-’/216-9081-S.
For surgeons practising solo at a distance from
a University centre, where residents help the
staff to keep abreast of the current literature,
it is a pleasure to find a book of this calibre
that presents the current thinking of many
authorities on a problem that plastic surgeons
must deal with on a regular basis.
The first few chapters cover care of the burn
wound in general and serve as an excellent
review for all members of the burn team. The
chapter on inhalation injury is superb, while
chapters that deal with specific treatment of
the various elements of the face provide a reference
and put the latest state-of-the-art ideas in
perspective. These chapters are also an excel.
lent source of detailed information for members
of the profession who do not deal with
fa~ burns on a regular basis. The three chapters
dealing with nursing, and physical and
occupational therapy reinforce the concept of
a team approach, which is essential in the care
of any burn victim. The bibliography is an outstanding
source of material for further detailed
reading and represents an excellent literature
review.
The only criticism of the volume lies in its
illustrations, some of which are out of place.
In some areas, more detailed follow-up photngraphs
would have added considerably to the
flow of the book.
This text should he on the bookshelves of
all plastic surgeons and, more importantly, in
the library of every emergency room regardless
of the size of the hospital.
DUNCAN R. BROWN, MD, FRCSC
No. 7, Endeca Place,
402-5th Avenue S,
Lethbridge, Alta.
TIJ 0T5
CURRENT SURGICAL THERAPY
1984-1985. John L. Cameron. 613 pp.
illust, C.V. Mnsby Company Ltd.,
Toronto, 1984. Price not stated. ISBN
0-941158-20-9.
This text was designed to update surgical
BURNS OF THE HEAD AND NECK. management for the practising general surgeon.
Thomas L. Wachtel and David H. Frank. It is well organized and is easy and interesting
216 pp. Illust. W.B. Sanaders Company to read. Most of the contributors are recog-
VOLUME 28, NO. 6, NOVEMBER 1985 / THE CANADIAN JOURNAL SURGERY OF
Ill I II I I II
nized authorities in their fields. Some sections
are better written than others, which is not
unusual for multiauthored texts, but the overall
quality of the presentations is good. Illustrations
have been kept to a minimum and there
are many instances where an informative illus-
. tration or table would have streamlined the
text. For example, a table listing antibiotics,
with indications, doses, toxicity and drug interactions
as an appendix would have saved a
search of the text for the information. Some
authors discussed only their own approach to
a problem but others included other options
for evaluation and comparison. It would have
helped the reader if some references to suggested
approaches were cited so that the source
material could be reviewed. Some authors,
however, did include selective references that
were helpful. A few sections, such as those on
small-bowel tumours and bowel diverticula,
were too detailed in relation to their importance.
There should have been a section on surgical
jaundice with new methods for diagnosis
and treatment.
In general, this text provides a practical
approach to new techniques in surgery and
should be of interest to the clinical surgeon as
¯ well as the surgeon in training. It is not meant
to replace standard texts, which include anatomy
and pathophysiology as well as a comprehensive
coverage of a subject.
HARVEY H. SIGMAN, MD, FRCSC, FACS
Department of Surgery,
The Sir Mortimer B. Davis-Jewish
General Hospital,
3755 C&e Ste-Catherine,
Montreal, PQ
H3T IE2
KAPLAN’S FUNCTIONAL AND SURGI-
CAL ANATOMY OF THE HAND. 3rd
ed. Morton Spinner. 446 pp. Illust. J.B.
Lippincott Company, Philadelphia, 1994.
$87.50 (US). ISBN 0-397-$9593-3.
The first two editions of Kaplan’s text were
published in 1953 and 1965 respectively. Dr.
Kaplan had asked Dr. Morton Spinner to help
with this third edition, but when he died before
its completion, Spinner became the editor. Ten
contributors participated.
continued on page 544
489

The Problem of Cardiac Arrest in
the Community
RICHARD CRAMPTON, DM
Out-of-hospital cardiac arrests constitute 350,000 cases yearly
in the United States and 60,000 in the United Kingdom. Prompt
resuscitation (CPR) by lay persons and fast defibrillation by paramedics
have had epidemiologic consequences on both sides of
the Atlantic. In Seattle there are 20.6 and in Brighton 10.0 longterm
life-saves yearly per 100,000 persons. In Piedmont Virginia,
coronary deaths fell 16% for persons 30-69 years old and 25%
for those of all ages; prehospital life-saves accounted for 23%
and 8% of each respective reduction. Since CPR by lay persons
~
ow triples the long-term survival rate when coupled with preospital
defibrillation, favorable benefit-to-cost ratios can be effected
by adding advanced life support and citizen CPR to an
extant ambulance system. Meticulous direct and indirect medical
control by the physician assures the highest quality of CPR and
early cardiac care (ECC). Diagnostic procedures like electroprovocation
identify high-risk patients. Changes of behavior and
diet, new drugs, new operations, and external and implantable
automated devices reduce sudden deaths. In the future, automated
defibrillation by first responders and trained lay persons
(including members of families of hlgh-dsk patients) should increase
the number of early survivors who become candidates for
long-term therapy with drugs, operations, and devices. (Am J
Emerg Med 1984;2:204-209)
In the 18 years since the introduction of mobile intensive
care in Belfast, Northern Ireland, ~’2 thousands
of lives have been saved and morbidity decreased by
this type of emergency service. 3’4 Application of Pantridge’s
conceptt-3 upgraded American emergency
~ ervices and thereby affected the national toll of
50,000 deaths yearly from cardiac arrest. Improvements
in ambulance services in Brighton ~ and
Edinburgh6 reviews quantifiable effects of the implementation of
mobile coronary care upon sudden cardiac death in
the community, in the United States and Europe.
EMERGENCY CORONARY CARE IN THE
VIRGINIA PIEDMONT
In 1970, a retrospective survey of the frequency,
time, duration of symptoms, and site of deaths in the
city of Charlottesville and Albemarle County, Virginia,
for I%3-1%9, indicated that two hospital coronary
care units introduced in 1966 did not reduce community
mortality from coronary disease
likewise reduced the yearly total of 60,000
out-of-hospital cardiac arrests in Britain. This paper
From the Division of Cardiology, and Emergency Medical Service,
University of Virginia, Charlottesville, Virginia.
Supported in part by the Charles A. Frueauff Foundation, New
York City; by the Robert Wood Johnson Foundation Emergency
Medical Communications Network, project 1420; and by the
Thomas Jefferson Emergency Medical Services System, DHEW
project 03-H-000, 366-02.
Presented at the First International Conference on Cardiac Arrest
and Resuscitation, Brighton, England, October 19-21,
1982.
Address reprint requests to Dr. Crampton: 158 Medical Center,
University of Virginia, Charlottesville, VA 22908.
7 (Fig. I); the
survey confirmed an earlier report. 8 From 1967 to 1969
there were 677 coronary deaths, 382 in the hospital
and 295 out of the hospital. Using Pantridge’s utopian
predictions from observations in Belfast, 9 and estimating
from a retrospective survey the theoretically
preventable coronary deaths during the first two hours
of symptoms, it was hypothesized that riaobile coronary
care might reduce mortality in the community by
27%} 0 From 1971, volunteer ambulance workers provided
emergency transport and cardiopulmonary resuscitation
(CPR), and physicians and nurses provided
emergency cardiac care (ECC). Initially, the system
added to the extant ambulance systemtt-t6 was modeled
on Pantridge’s system begun in I%6 at the Royal
Victoria Hospital, Belfast, t’2 and later modified in the
light of experiences reported from medical, paramedic,
and basic emergency systems in Miami, Seattle,
Columbus, New York, Los Angeles, and Virginia
Beach. t7-26
In 1971-1973, the predicted reduction of 27% in
community mortality from coronary disease nearly
matched the observed 25% reduction. No significant
fall occurred in 1974 despite the apparent maintenance
of reduced numbers of coronary deaths. Only 8% of
the life-saves in persons aged 30 to 99 years were attributable
to prehospital resuscitation with long-term
survival. 4 However, in persons aged 30-69 years, survival
after prehospital resuscitation constituted 23%
of the 16% fall in coronary deaths. If prehospital lifesaves
were discounted, no significant change would
have taken place in prehospital coronary deaths for
the cohort described. 4 As a consequence of earlier outof-hospital
emergency care, preventable deaths when
the patient is received by the ambulance and taken to
the emergency department should contribute, theoret-
Key Words: Cardiac arrest, community, defibrillation, medical
control, resuscitation, sudden death.
204

i.
ically, to the reduction of mortality from coronary disease.3.9,
t t- 16
The reason for the decline in coronary deaths in the
Charlottesville-Albermarle community remains unclear.
A concomitant spontaneous decline associated
with a national American trend appeared unlikely, because
coronary deaths in Virginia simultaneously rose
by 6%. 4 Very early ECC may have had an effect by
averting cardiopulmonary arrest due to ventricular fibrillation
or asystole, as was first predicted by
Pantridge 9 and as has been subsequently demonstrated.
3
uJ 400
_J
13.
0
LU
bl-t/.~,Mt-"l LJN ¯ ,CARDIAC ARRES1 IN IHE COMMUNITY
" 350 ...............................
g
EMERGENCY CORONARY CARE IN THE COMMUNITY
Data from the United Statestr,zT-35 and Europe36-48 suggest that prehospital ECC in the community has a
favorable effect (Figs. 2 and 3). Likewise, study of agespecific
prehospital life-saves (Fig. 4) suggests that
cost/benefit analyses might prove useful. Physicians
and nurses no longer provide prehospital ECC in most
American communities, despite the fact that these
professionals participated in many feasibility trials.
The performances of paramedics, intermediate emergency
medical technicians (EMTs), and basic EMTs
have been evaluated, and the latter personnel appear
less effective than the former two groups. 3t.33 Brief
training of EMTs in recognition of ventricular fibrillation
and in the delivery of transthoracic direct current
countershocks has increased the number of longterm
survivors. 3t,33 Nevertheless, clinical therapeutic
principles such as correcting acute dysautonomia, relieving
the pain of ischemia, and stabilizing rhythm
should not be abandoned, since prevention of cardiac
arrest due to ventricular fibrillation or asystole also
reduces morbidity and mortality. 3’9’t3-tr,49
Long-term survival after out-of-hospital cardiac arrest
has considerably increased because of prehospital
CPR by members of the public (Fig. 5, Table I). Two
to six life-saves per I00,000 were achieved by CPR
alone with transport to the emergency department for
defibrillation, in Washington’s King County, 31’33 Winnipeg,
4° and Reykjavik and suburbs. ~ Basic life support
(CPR) provided 4 minutes or less after collapse
from ventricular fibrillation, combined with direct current
countershoek administered 8 minutes or less from
the time of collapse, 5° yielded 50% long-term survival.
Clearly, CPR did not replace advanced life support.
Maximum impact was attained only when the two procedures
were combined. For ventricular fibrillation,
immediate defibrillation would be the ideal therapy.
However, despite the system delays of ambulance response
plus return, it remains a remarkable achievement
of aggressive prehospital CPR that delayed defibrillation
in the emergency department had significant
impact. 31"33"4°’~
200
6061 62636465666768 697071 72 73 74
YEAR
FIGURE i. In Charlottesville and Aibemarle County, Virginia,
observed community coronary deaths (black bars), paired with
yearly expected deaths (white bars), rose significantly in 1964 (P <
0.01) and fell significantly in 1971-1973 (P < 0.005, < 0.005, <
0.0001). Hospital coronary care units, opened in 1966, had no impact.
Prehospital basic and advanced life support begun in 1971 thus
reduced deaths significantly.
Nagel suggested that prehospital ECC contributed
5% to reduction of coronary mortality in the USA, st
but this figure seems low. In Seattle, 90 to I00 resuscitated
victims of ventricular fibrillation survive each
year, constituting a reduction of about 10% in coronary
mortality for that community. 52 The paramedic
service in King County, Washington, reduced coronary
mortality in the community by 8.4%. 32 In piedmont
Virginia, a 16% to 25% reduction took place (Fig.
I). 4 The end point of resuscitation and defibrillation
with long-term survival is easy to measure. Indubitably,
when prevention of death occurs, although it is
exceedingly difficult to estimate, it certainly contributes
significantly to the efficiency of prehospital coronary
care. 3,9,t6
Estimates of costs and benefits in prehospital ECC
are difficult if not impossible. In piedmont Virginia,
prehospital CPR and ECC doubled admissions to the
community’s hospital coronary care units, t3"52 Both
theoretic53 and pragmatic ~ models for assessing the
impact of prehospital ECC yielded measurably favorable
economic impact. The cost of adding prehospital
ECC to an extant ambulance system provided a complementary
cost/benefit ratio of 40:1. =6 However, no
costs and benefits of CPR by citizens were budgeted.
In the Seattle assessment, the expense of CPR begun
by lay persons was incorporated. 54 If Acton’s
assessment53 is applied, CPR by lay persons in Seattle
favorably influenced a large number of life-saves and
yielded a cost/benefit ratio of 1:7. 3"55 Future investigation
of community age-specific life-saves (Fig. 4)
might yield even higher ratios with greater economic
leverage. Such studies are urgently needed if emer-
250
205

AMERICAN JOURNAL OF EMERGENCY MEDICINE ¯ Volume 2, Number 3 ¯ May 1984
ILl
J
ILl 13.
O
O
16
12
ILl
> 4
STL COLKCW SA C-A MIA LA CIN MIN
l-,z
LIJ
0
LIJ
0 BR RO RE GO ED CO BE HE Wi DU NO
ILl
Lk
.J
O O
CH-ALB EDNBRG RYKJVK HLSNKI OSLO L ANG SETL SETL WlNN REYK
FIGURE 2 (above, left). American prehospital life-saves per 100,000 people per year from basic and advanced life support in Seattle (STL),
Columbus (COL), King County, Washington, (KCW), San Antonio (SA), Charlottesville and Albemarle County (C-A), Miami (M[A), Los
Angeles (LA), Cinnicinati (C[N), and Minneapolis (M[N). (Data derived from references 16 and 27-35.)
FIGURE 3 (above, right). European and Canadian prehospital life-saves (black bars) and averted cardiac arrests (hatched bar) per 100,000
people per year from basic and advanced life support in Brighton (BR), Rotterdam (RO), Reykjavik (RE), Gotenberg (GO), Edinburgh (ED),
Copenhagen (CO), Belfast (BE), Helsinki (HE), Winnipeg (WD, Dundee (DU), and Nottingham (NO). (Data derived from references 36-48.)
OF[GURE 4. Age-spcc~c life-saves per 100,000 people per year for Charlottesville and Albcmarle County (CH-ALB), ages 30 to 69 years
(black bar), F_,din~r~ (EDNBRG), ages 20 to 69 years (hatched bar), Reykjavik (RYKJVK), ages < 91 years (white bar), and Helsinki
(HLSNKD, ages < 65 years (cross-hatched bar). (Data derived from references 15, 38, 39, and 46.)
FIGURE 5. Survival rates with (black bars) and without (white bars ) cardiopulmonary resuscitation by lay persons in Oslo, Los Angeles
(L ANG), Seattle suburbs (SE]’L*), Seattle city (SETL**), Winnipeg (W[NN) and Reykjavik (REYK). (Data derived from references 27.40,
46, 50, 70, and 71.)
gency services and lay CPR programs are to receive
their fair share of community resources.
MEDICAL CONTROL OF EMERGENCY CORONARY CARE
The medical profession is obligated to sustain a high
quality of prehospital ECC. Medical control comprises
direction by the physician of all emergency care rendered
by basic and intermediate EMTs, paramedics,
and nurses and physicians in the field, and direction
of personnel, such as ambulance dispatchers, involved
in emergency communications. Indirect functions of
the physician consist of development and use of protocols
for treatment, review of cases, and assessment
206
45
30
15
of results; development of programs for training
EMTs, paramedics, dispatchers, nurses, and physicians;
and development of programs for citizens in
CPR. The physician becomes the direct medical controller
when supervising, by radio or telephone, the
on-the-spot provider of ECC before and during ambulance
transport. 56 By exercising both direct and indirect
control, the physician can guarantee a high
quality of prehospital ECC with maximum favorable
results: 7
Supervision by the physician includes developing a
citizenry trained to perform CPR. Given the frequency
of sudden cardiac death and the favorable cost/benefit
ratio, sufficient numbers of persons in neighborhoods

TABLE 1.
CRAMPTON ¯CARDIAC ARREST IN THE COMMUNITY
Influence of Prehospital Cardiopulmonary Resuscitation by Lay Persons on Discharge from the Hospital
Community No. of Cases
Osl°rl
Suburban Seattle
631
so
487
SeattleZr
Los Angeles
316
72
120
Winnipeg
170
.4°
226
Reykjavik’46 222
Total 217-’---2
* Defibrillation limited to hospital emergency department.
should learn CPR. 58 Families of persons at high risk
of sudden cardiac death should have members trained
to render CPR. First responders such as police, fire,
rescue squads, and custodians also should become
providers of CPR, as should selected persons working
in offices, stadiums, factories, theaters, concert halls,
and major transportation carriers and terminals. Since
external automated defibrillation may soon become
feasible for use by lay persons, they should be trained
m this technique as well. This is particularly true for
families of persons at high risk of sudden cardiac
death. 59
The future appears promising and exciting. Recognition
and understanding of sudden death are improving
60-62 After out-of-hospital cardiac arrest, prediction
of recovery, z7,63 determinants of survival, 64 and
selection of antiarrhythmic therapy 65,66 can be approached
rationally. Change of behavior and diet, and
new drugs, operations, and automated implantable 67
and external6S, 69 devices, have already reduced sudden
cardiac deaths. Improvement in prehospital resuscitation
and emergency services should augment this
trend. 7° The diagnostic procedure of electroprovocation
of cardiac arrhythmias has delineated management
of the population at risk of a second sudden car-
o diac death.65,66 Automated defibrillation by EMTs,
first responders, and trained lay persons, including
members of families of high-risk patients, should increase
survivors who become candidates for long-term
therapy with drugs, operations, and devices. =.69
Out-of-hospital ECC has reduced death and morbidity
from coronary heart disease in selected communities
in the western world. It appears to be cost
effective as an emergency measure. Its efficacy trebles
when combined with CPR by lay persons. Meticulous
medical control by the physician will provide and sustain
a high quality of ECC. Thus, the physician responsible
for medical control holds the key to effective
ECC for the community in the future.
Long-term Survival
Cardiac Episode Lay CPR No Lay CPR
Not documented 27/75 43/556
All cardiac arrests 25/108 451379
Ventricular fibrillation 471109 43/207
Ventricular fibrillation 12/49 4/71
Not documented 9/55 3/115
Ventricular tachycardia 16/65 8/161
and fibrillation
All cardiac arrests 16/38 5/184
152/499 151/1673
(30.5%) (9.0%)
The author thanks T. W. B. Crampton for the illustrative computer
graphics and Drs. W. M. O’Brien, J. Alexander, and D. L.
Kaiser for statistical help.
REFERENCES
1. Pantridge JF, Geddes JS. Cardiac arrest after myocardial
infarction. Lancet 1966;1:807-808.
2. Pantridge JF, Geddes JS. A mobile intensive care unit in the
management of myocardial infarction. Lancet 1967;
2:271-273.
3. Pantridge JF, Adgey AAJ, Geddes JS, et al. The Acute Coronary
Attack. New York: Grune & Stratton, 1975.
4. Crampton RS. Prehospital coronary care in the Virginia
piedmont and United States, in Adgey AAJ (ed). Acute
Phase of Ischemic Heart Disease and Myocardial Infarction.
The Hague, Boston, London: Martinus Nijhoff,
1982:119.
5. Macintosh AF, Crabb ME, Grainger R, et al. The Brighton
resuscitation ambulances: Review of 40 consecutive survivors
of out-of-hospital cardiac arrest. Br Med J
1978;1:1115-1118.
6. Vetter N J, Pocock S, Julian DG. Measuring the effect of a
mobile coronary care unit upon the community. Br Heart
J 1979;41:418-425.
7. Stillerman R, Aldrich RF, McCormack RC, et al. Coronary
artery disease (CAD): Death in a community before and
after the advent of hospital coronary care units. Circulation
1970;42(Supp1111):202.
8. Oliver MF, Julian DG, Donald KW. Problems in evaluating
coronary care units: Their responsibilities and their relation
to the community. Am J Cardiol 1967;20:465-474.
9. Pantridge JF. Mobile coronary care. Chest 1970;58:229-
234.
10. Aldrich RF, Stillerman R, McCormack RC, etal. Sudden coronary
artery disease (CAD): Death in a community and
the prospective role of mobile coronary care (MCCU). Circulation
1970;42(Supp11111:83.
11. Crampton RS, Stillerman R, Gascho JA, et al. Prehospital
coronary care in Charlottesville and Albemarle County. Va
Med Month 1972;99:1191 - 1196.
12. Crampton RS, Aldrich RF, Stillerman R, et al. Prehospital
cardiopulmonary resuscitation in acute myocardial infarction.
N Engl J Med 1972;286:1320-1321.
13. Crampton RS, Aldrich RF, Gascho JA, et al. Reduction of
prehospital, ambulance and community coronary death
207

AMERICAN JOURNAL OF EMERGENCY MEDICINE ¯ Volume 2, Number 3 ¯ May 1984
rates by the community-wide emergency cardiac care
system. Am J Med 1975;58:151-165.
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,the patient. Lancet 1978;1:1145-1146.
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16. Crampton RS. Prehospital advanced cardiac life support:
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17. Nagel EL, Hirschman JC, Mayer PW, et al. Telemetry of
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18. Nagel EL, Hirschman JC, Nussenfeld, SR et al. Telemetrymedical
command in coronary and other mobile emergency
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coronary care unit. Circulation 1970;41-42(Supp1111):144.
Baum RS, Alvarez H, Cobb LA. Survival after resuscitation
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1974;50:1231-1235.
Lewis RP, Fulkerson PK, Stang JM, et al. The Columbus
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1979;75:391-394.
22. Grace W J, Chadbourn JA. The mobile coronary care unit.
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23. Lambrew CT. Experience in telemetry of the electrocardiogram
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24. Lewis A J, Criley JM. An integrated approach to acute coronary
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units: Implementation and justification. Adv Cardiol
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26. Edwards BW. Medical control and the volunteer rescue
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28. Lewis RP, Lanese RR, Stang JM, et al. Reduction of mortality
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patient activation of mobile coronary care system. Am
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30. Hoffer EP. Emergency medical serv=ces. N Engl J Med
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31. Eisenberg MS, Bergner L, Hallstrom A. Out-of-hospital cardiac
arrest: Improved survival with paramedic serv=ces.
Lancet 1980;1:812-815.
32. Eisenberg M, Bergner L, Hallstrom A. Paramedic programs
and out-of-hospital cardiac arrest: I1. Impact on community
mortality. Am J Public Health 1979;69:39-42.
33. Eisenberg MS, Copass MK, Hallstrom AP, et al. Treatment
of out-of-hospital cardiac arrests with rapid defibrillation
by emergency medical technicians. N Engl J Med
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34. Myerburg RJ, Conde CA, Sung R J, et al. Clinical electrophysiologic
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35. Rockswold G, Sharma B, Ruiz E, et al. Follow-up of 514
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the hospital. JACEP 1979;8:216- 220.
208
36. Webb SW. Mobile coronary care. Lancet 1974;1:559-560.
37. Macintosh AF, Crabb ME, Grainger R, et al. The Brighton
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of out-of-hospital cardiac arrest. Br Med J
1978;1:1115-1118.
38. Vetter N J, Pocock S, Julian DG. Measuring the effect of a
mobile coronary care unit upon the community. Br Heart
J 1979;41:418-425.
39. Siltanen P, Sundberg S, Hytonen I. Impact of a mobile coronary
care unit on the sudden coronary mortality in a
community. Acta Med Scand 1979;205:195-200.
40. Tweed WA, Bristow G, Donen N. Resuscitation from cardiac
arrest: Assessment of a system providing only basic life
support outside of hospital. Can Med Assoc J 1980;
122:297-300.
41. McNeill GP, Bouchier lAD, Watson H. Mobile coronary care
available to the general public. Lancet 1979;1:975.
42. Hill JD, Hampton JR, Mitchell JRA. A randomized trial of
home-versus-hospital management for patients with suspected
myocardial infarction. Lancet 1978;1:837-841.
43. Hampton JR, Dowling M, Nicholas C. Comparison of results
from a cardiac ambulance manned by medical or nonmedical
personnel. Lancet 1977;1:526-529.
44. Studd C. The Brighton experience with resuscitation ambulances.
Am J Emerg Med 1984;2:275-276.
45. Hart HN. Integrated approach to prehospital coronary care
=n Rotterdam. Am J Emerg Med 1984;2:225-229.
46. Gudjonsson H, Baldvinsson E, Oddsson G, et al. Results of
attempted cardiopulmonary resuscitation of patients
dying suddenly outside the hospital in Reyjavik and the
surrounding area, 1976-1979. Acta Med Scand
1982 ;212:247- 251. ""
47. Holmberg S, Wennerblom B. Out-of-hospital cardiac arrest:
Effect of special ambulances in G6teborg on mortality.
Am J Emerg Med 1984;2:222-224.
48. Pedersen A. In Copenhagen. Brighton Conference Abstracts.
London:British Heart Foundation, 1982:38.
49. Crampton RS, Michaelson SP, Aldrich RF, et al. Prehospital
care for myocardial infarction. N Engl J Med 1974;
291:418.
50. Eisenberg MS, Bergner B, Hallstrom A. Paramedic programs
and out-of-hospital cardiac arrest: I. Factors associated
with successful resuscitation. Am J Public
Health 1979;69:30-38.
51. Nagel EL. Prehospital care as a cause for coronary heart
disease mortality decline, in Havlik RJ, Feinleib M (eds).
Proceedings of a Conference on the Decline in Coronary
Heart Disease Mortality. Washington, DC: DHEW Publ No
(NIH) 79-1610, 1979.
52. Adgey AAJ, Crampton RS. Hospital or home for acute myocardial
infarction: Another look at whether or not we
should bother to care. Am Heart J 1981 ;102:473-477.
53. Sidel VW, Acton J, Lown B. Models for the evaluation of
prehospital coronary care. Am J Cardiol 1969;24:674-
688.
54. Hallstrom A, Eisenberg MS, Bergner L. Modeling the effectiveness
and cost-effectiveness of an emergency service
system. Soc Sci Med 1 981 ;15C:13-17.
55. Crampton RS. The role of organized medicine in providing
education about cardiopulmonary resuscitation, in
Greenberg HM, Dwyer EM Jr (eds). New York, Ann NY
Acad Sci 1982;382:324-329.
56. Committee on Emergency Medical Services. Medical Control
in Emergency Medical Services Systems. Washington,
DC: National Academy Press 1981.
57. Pozen MW, D’Agostino RB, Sytkowski PA, et al. Effectiveness
of a prehospital medical control system: An analysis

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p
of the interaction between emergency room physician
and paramedic. Circulation 1981 ;63:442-447.
58. McEIroy CR. Citizen CPR: The role of the lay person in prehospital
care. Top Emerg Med 1980;1:37-46.
59. Friedberg CK. Introduction: Symposium, myocardial infarction
(Part 1). Circulation 1972;45:179.
60. Sonneblick EH, Lesch M (eds). Sudden Cardiac Death. New
York: Grune & Stratton, 1981.
61. Greenberg HM, Dwyer EM Jr (eds). Sudden Coronary Death.
Ann NY Acad Sci 1982;382:1-484.
62. Adgey AAJ (ed). Acute Phase of Ischemic Heart Disease and
Myocardial Infarction. Boston: Martinus Nijhoff, 1982.
63. Longstreth WT, Diehr P, Inui TS. Prediction of awakening
after out-of-hospital cardiac arrest. N Engl J Med 1983;
308:1378-1382.
64. Swerdlow CD, Winkle RA, Mason JW. Determinants of survival
in patients with ventricular tachyarrhythmias. N Engl
J Med 1983;308:1436-1442.
65. Ruskin JN0 DiMarco JP, Garan H. Out-of-hospital cardiac
arrest: Electrophysiologic observations and selection of
long-term anti-arrhythmic therapy. N Engl J Med
1980 ;303:607-13.
CRAMPTON II CARDIAC ARREST IN THE COMMUNITY
66. Garan H, Ruskin JN, DiMarco JP et al. Electrophysiologic
studies before and after myocardial revascularization in
patients with life-threatening ventricular arrhythmias. Am
J Cardiol 1983;51:519-24.
67. Mirowski M, Reid PR. Mower MM, et al. Termination of malignant
ventricular arrhythmias with an implanted automatic
defibrillator in human beings. N Engl J Med
1980;303:322-324.
68. Jaggarao NSV, Heber M, Grainger R, et al. Use of an automated
external defibrillator-pacemaker by ambulance
staff. Lancet 1982;2:73-75.
69. Diack AW, Welborn WS, Rullman RG et al. An automatic
cardiac resuscitator for emergency treatment of cardiac
arrest. Med Instrum 1979;13:78-81.
70. Jacobsen S (ed). Resuscitation. Clinics in Emergency Medicine.
New York: Churchill Livingston, 1983.
71. Lund I, Skulberg A. Cardiopulmonary resuscitation by lay
people. Lancet 1976;2:702-704.
72. Guzy PM, Pearce ML, Greenfield, S, et al. Effectiveness of
citizen cardiopulmonary resuscitation during out-of-hospital
emergencies in metropolitan Los Angeles. Circulation
(Suppl II) 1979;60:46.
2O9

908
Occasional Surve!
Management of cardiac arrest
of resuscitation services
ROGER- H JONES
Abstract .... ~ - - -
A survey of the English health regions identified nine
ambulance based resuscitation schemes. Their structure
and function are heterogeneous and their impact on
patient survival is often speculatlve.~There is considerable
medical, paramedical, and lay enthusiasm for
resuscitation schemes but this cannot be harnessed until
medlcolegal uncertainties are removed and guidelines
for development are set out. Better documentation of
the benefits of existing schemes should be undertaken
so that. advanced training of ambulance personnel can
proceed rationally.
Introduction
I
Every year in England and Wales over 100 000 people die from
ischaemic heart diseaseF Many of these deaths are sudden or
unheralded, and over half of the victims die before they reach
hospital. Figures from the United States/are similar, with
650 000 deaths each year, and, "since 60-70% of sudden deaths
caused by cardiac arrest occur before hospitalisation it is clear
that the community. ,,s deserves to be. regarded as the ulumate"
coronary care umt. The community, and the primary health
care team in particular, has clear educational, preventive, and
therapeutic responsibilities in relation to ischaemic heart disease
but when these measures fail, how are we to respond ?
elSelc9e76~sD;mP era~ed~h~ft ~:l~us~r~:;eSmaut;dq~tp;n d ~a m
bulances manned by ambulancemen who have received training
in advanced techniques significantly affects the overall mortality
rate of patients suffering from acute myocardial infarction" and
recommended that "authorities are advised to defer the introduction
of new and the extension of existing advanced training
schemes for ambulance.men." No further directives have been
issued since then; none the less several schemes are in operation.
While attempting to set up a local resuscitation scheme, we
found that basic information about the exf, ent of resuscitation
schemes in England was not available, and there is certainly no
consensus view about the most effective way in which schemes
should be organised. A survey was undertaken to try to answer
these questions. (R H Jones, Upjohn Travelling Fellowship
Report, 1982.*)
*Copies may be obtained from the librarian, Royal College of General
Practitioners, 14 Princes Gate, Hyde Park, London $W7 1PU.
Andover) I-lant$ SPI0 3LD
ROGER H JONES, MRCr, bmcor, general practitioner
Correspondence and requests for reprints to: 56 Junction Rd, Andover,
Hants SP10 3QU.
I IIIIIII I
BRITISH MEDICAL JOURNAL VOLUM~ 287 I OCTOBE
in the community: a survey
Methods - -
Because it seemed likely that most resuscitation schemes woui
based on the ambulance service, initial approaches were mad
letter to the regional ambulance officers Of the 11 English reg
ambulance set-ices (the four 71~ames regions in Greater L~
are served by one ambuFance service). Contact was also made ~:
headquarters and branch representatives of the Associati~
Emergency Medical Technicians (AEMT) and the British Associi
of Immediate Care Scheme (BASICS).
When the replies from the regional ambulance officers
available ambulance based schemes in their regions were visited
documented, using a structured interview. During this inqui~
discovered several other schemes in the early stages of developr{
but, with the exception of the new Nottingham coronary ambul, ~
scheme, these are not included in the analysis. Throughout
survey all my inquiries were answered and I received-the fti
cooperation from everyone concerned.
W~sltcrn ) ~.
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J
.CAL JOURNAL vOLUME 287 1 OCTOBER 1983
//ever, it is instructive to comment briefly on the regions in
,~ere are no resuscitation ambulance schemes.
:EGIONS WITH NO RESUSCITATION SCHEMES
Northern region--The question of resuscitation schemes never
ceres to have arisen here.
North western region--Except for a coronary ambulance service
~ascd on Wythenshawe Hospital, Manchester, which closed down
,ccause of lack of funds, there have been no schemes in this region.
rhere is certainly an awareness of the potential medicolegal problems
rising because of lack of national direction.
Mersey reglon--Aithough advanced training for ambulancemen has
,een started in Liverpool, there have been no resuscitation ambulance
chemeS.
West Midlands region--There was a "limited training exercise" in
esuscitation in the Hereford and Worcester area, which has now
:nded, and an advanced training scheme operates in Warwickshire.
East A nglla region--The possibility of developing advanced training
.chemes in Cambridge was mooted some years ago but the idea
"oundered on the question of medicolegal responsibility.
London region--Some years hgo the London Ambulance service
vas moving towards the training of ambulance personnel in the use
ff monitoring and defibrillation equipment, but these proposals
vere abandoned because of the DHSS circular mentioned above, s
S, dvanced training in intubation and intravenous infusion techniques
aas, however, continued. A rather unusual coronary ambulance
;ervice~h~ed on the cardiology department at St Bartholomew’s
,qospit~rves the City of London between 9 am and 5 pm from
~ondays "rom the cardiology to Fridays. or The .accident coronary d epartme..nt, ambulance a is nurse statT tr.om ed by me a accalae=t regi.~rar"
tepartment, a technicum from the medical elcctrontca aepartm...,
md sometimes a medical student. Each year the ambulance ss called
mt between 300 and 400 times and about 20 casualties are defibrillated.
Leeds--This scheme was started iust before the 1976 DHSS
:ircular ’~ was issued; it was an experimental scheme based on electro-
:ardiogram radiotelemetry and speech links between specially staffed
and equipped vehicles and the coronary care unit at Leeds General
Infirmary. The trial was limited and failed to Show any benefit for
pauents. It was possibie to provide cover only between 9 am and
5 pro, and during the 15 month trial period six patients were defibrillated,
none of .whom survived. The DHSS circular discouraged
extension of this experiment.
REGIONS WITH RESUSCITATION SCHEMES
Eight centres were examined in detail to document the activities
of ambulance based resuscitation schemes: Alton, Andover, Avon,
Bcighton, Gloucester, Nottingham, Oxford, and York.
A It o n
This new scheme is in Alton, a country town of 15 000 inhabitants
that is 15 miles from the nearest general h.ospital. The scheme was
set up by a general practiti-oner and.training is open to all ambulance
personnel. In 18 months three patients have been-successfully
resuscitated with nine further unsuccesgful attempts. The r~dicolegal
position of ambulance personnel remains ambiguous, however, but
*he scheme is at present proceeding as a pilot project.-.
Andover ._
The Andover scheme developed because of the successful activities
m nearby Alton. It is based on a country town of 35 000 inhabitants
which is also about 15 miles from the nearest district hospital. The
scheme, once again, was developed by a general practitioner and is
supported by charitable funds. The administrative and medicolegal
problems here, however, are even more complex, and at present,
although monitoring and defibrillation equipment is carried in the
ambulances, ambulance personnel may use only the monitors;
defibrillators are used only by general practitioners.
A yon
Avon has a longstanding, advanced training scheme developed by
a consultant anaesthetist at Frenchay Hospital. Almost a quarter of
the region’s ambulance personnel have been trained, and electrocardiogram
monitoring and defibrillation equipment is now available
at 10 of the county’s 11 ambulance stations. In addition, three mobile
resuscitation units with fixed electrocardiographic and defibrillation
equipment carry a range of fluids and intravenous drugs. In 1981
cardiac arrest was treated 49 times, and 37 patients were defibrillated.
Brighton
The well known Brighton coronary ambulance programme 4j
originally set out to provide a specially equipped ambulance and a
doctor to travel rapidly to suspected coronary victims. It was quickly
appreciated that it was more appropriate to train the ambulance
personnel, and there are now over 30 well trained ambulancemen
who are expert in interpreting electrocardiograms, skilled at intubation,
defibrillation, and intravenous therapy, and able to administer a
variety of intravenous drugs. In 1981 31 out of 128 defibrillations
were successful. In addition to this advanced training programme, a
successful exercise in community education in cardiopulmonary
resuscitation is under way--the Brighton Save a Life Campaign~
which has already instructed about 18 000 members of the public.
Gloucester
969
Gloucester has an advanced training scheme with many similarities
to the Avon scheme, although some details of the training programme
differ. About a quarter of the ambulance staff in the county have
received advanced training, and there are 15 mobile resuscitation
units at 10 of the 12 stations. This scheme interacts with an immediate
care scheme based on 20 general practitioners in west
Gloucestershire.
/
Nottingham
The Nottingham experimental coronary ambulance schemes were
started in 1973 when a single ambulance with cardiac monitoring
equipment and a defibrillator came into service; over the next’few
years the efficacy of this scheme was tested experimentally, firstly,
with comparisons of the responses of ordinary ambulances and
coronary ambulances to emergencies, then with th~’ixaclusion of a
hospital doctor in the ambulance crew on alternate days, and, finally,
with the exclusion of general practitioner initiated calls and assessment
of the effect of the service in response to 999 calls only.’ This
study showed no difference in prchospital mortality between patients
carried by coronary ambulances and those carried by_ routine ambulances.
At the end of~tliis study the .coro~tary ambulance service
was discontinued.
The scheme is now being redeveloped. The lessons learnt from the
experiments in the past eight years include the sugges-tiOn tb_at
detailed training in drug administration and endotracheal intubation
are probably less important than early "monitoring and-defibrillation
for Victims of myocardial infarction. The new scheme will.cover a
population of about 500 000 with !0 emergency vehicles. A coro_nary
register is being established in N’oitingha-m so-that-d_caths from
ischaemic heart disease can be recorded before the scheme becomes
operational and reviewed after the scheme has started. There-are
further plans to develop a pi-ogramme of community education in
cardiopulmonary resuscitation. - -
Oxford
The Oxford scheme, a more recent countywideadvanced training
scheme, started in 1978. The thorough training programme has
produced 48 trained personnel out of an establishment of 142 in
Oxfordsbire. There are 16 monitor-defibrillator units in use throughout
the county and 39 accident and emergency vehicles. In 1981
23 patients were defibrillated. A community cardiopulmonary

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970
resuscitation scheme in Oxfordshire began in 1981, and 52 instructors
and almost 1000 members of the public have now been trained. In
1981 36 patients required intubation and 23 were defibrillated.
York
All 42 ambulance personnel in York have been trained to use their
monitor-defibrillators, of which six are availablein the city ambulances.
The emphasis, as in the proposed Nottingham scheme, is on early
defibrillation rather than detailed training in intubation and infusion
techniques, Between 1970 and 1981 13 of the 181 defibrillations
resulted in ultimate recovery.
The table summarises the features of these corofiary ambulance
schemes. General practitioner involvement refers to th e cooperation
of general practitiof:ers in trainingand in the dayto day-running of
the-scheme. The~ two Hampshire schemes were started by general
practitioners and the Gloucester scheme interacts with a group of
immediate care doctors, but the remainder have little contact with
local primary care doctors, although there are BASICS groups in
Oxfordshire, Somerset, and Bristol.
OTHER SCHEMF.$
Association of Emergency Medical Technicians (AEMT)
The Association of Emergency Medical Technicians is an association
for paramedical personnel interested or active in emergency care.
About 700 ambfi]ancemen are members of AEMT, which has 43
branches throughout the country. The training programme is quite
separate from the ambulance service advanced training programme
and is organised on guidelines which have been agreed with BASICS.
In addition the AEMT provides an insurance indemnity for £500 000
against malpractice claims.
British Association for Immediate Care (BA SIC.S)
/
The British Association for Immediate Care is an organisation of
medical practitioners who have an interest in immediate care. At
present about 1350 belong to the 44 schemes in England. Each scheme
is organised in response to local needs, but in general BASICS sets
out to deal with accidents rather than medical emergencies. A survey
of the 14 largest BASICS groups, accounting for over 60% of the
total membership, suggests that ready access to electrocardiogram
monitoring and defibrillation equipment is the exception rather than
the rule.
Discussion
Provision of mobile resuscitation facilities for dealing with
cardiac arrest occurring outside hospital is patchy, and if not
chance then serendipity seems to have guided their development.
Clearly non-clinical determinants operate in the development
of coronary ambulance and mobile resuscitation programmes;
taken together with evidently widely differing
perceptions of the role of the ambulance service an unevenness
of approach is inevitable.
What is perhaps most unsatisfactory about the development of
resuscitation strategies is their uncertain value, both in the
Some features of resuscitation ambulance schemes
BRITISH MEDICAL JOURNAL VOLUME 287 I¯:OCTOBER 1983
absolute sense of saving life and in the relative sense of the
appropriateness of diverting funds and energies which might be
better used elsewhere. Few attempts have been made to tackle
this difficult and important question. There seem to be three :
different approaches to managing out of hospital cardiac arrest,
exemplified in the various schemes which have been surveyed: -
firstly, a perception of chest pain and myocardial infarction as a -
medical emergency requiring urgent medical attention and
hospital admission; secondly, an attempt to provide a much~
wider range of skills to deal with ffauma and medical and
surgical emergencies as well as cardiac arrest; xhirdly, the _ ~
provision O f less advanced but equally mob!le expertise With the
emphasis on early defibrillation and basic life support.
The emphasis in the Brighton Scheme is0n the first of these, ~-~
although the resuscitation ambulances respond to a variety of- =other
life threatening emergencies; the second is the basis for -
the Oxford, Avon, and Gloucester schemes; and the-third ~-.
underlies planning for the new Nottingham scheme and is the ~
basis for the York city ambulance scheme and also of the
general practitioner related schemes in Alton and Andover. The
third must also be taken as the rationale for those general
practitioner based- immediate care groups having access to
defibrillators. - -
The Brighton resuscitation ambulance programme is probably
the best known and most widely reported, although the
home versus hospital question of the management of myocardial
infarction remains unresolved and there are commonsense
reasons for regarding flashing blue lights and high
technology as arrythmogenic. There is a sense, too, in which
primary care is bypassed when chest pain means a 999 call and
hospital admission. The Brighton ambulance personnel are
probably the best trained in cardiac care and their expertise
and ability to administer drugs may contribute greatly to the ~
management of cardiac arrest, although Hampton and his
colleagues have cast some doubt on the impact on survival of
these abilities. 7 The resuscitation ambulances also respond to
other, non-cardiac emergencies, such as drowning, trauma,
drug overdose, and hypoglycaemia.
The second approach to managing cardiac arrest outside
hospital forms one element of a much more comprehensive
view of the value of paramedical training for ambulance personnel.
Although good documentation would massively enhance
their credibility, the mobile resuscitation units and the staff
with advanced training in Avon, Oxford, and Gloucester are a
most impressive development. Correction of hypovolaemic
shock before admission to hospital, for example, must be judged
a potentially life saving contribution, and the versatility of these
ambulance crews, evident when reviewing the reports of
patients whom they have helped, is beyond doubt. In distinction
to a "pure" coronary care approach these schemes appear to
require no justification, although their revenue consequences
are not inconsiderable. Unfortunately th1976 DHSS circular
acted as a damper on advanced training of this type."
Thirdly, limited resuscitation by early defibrillation (assumed
to be performed in a setting of basic cardiopulmonary resuscitation
capabilities) avoids some of the training, organisational, and
financial consequences of more elaborate schemes. This seems
a second best buy for the ambulance service but is probably
ideal when cooperation between the ambulance service and
Brighton and
Alton Andover Avon Hastings Gloucester Nottingham Oxford York
No of years running 2 1 10 8 10 4 12
No of trained personnel 12 11 50 43 55 ~ 48 42
Intubatlon-infusion trained
+
+ +
} + 0
Able to administer drugs 0 ~ ~ + ~)
0
0
Specially fitted vehicles 0 0 + + + 0 +0 +
Significant charitable funding + ÷ + + + 0 + ÷
Community cardiopulmonary resuscitation
programme
0 0 0 0
General practitioner involvement
÷ 0 +0 o 0 0

oDICAL JOURNAL VOLUME 287
I OCTOBER 1983
¯ practice is good. It does seem more sensible, however,
clatively expensive and bulky electrocardiogram monitoring
.d defibrillation equipment to be carried by the ambulances
rather than being handed from general practitioner to general
practitioner in an immediate care scheme. On the other hand, a
recent report on the management of myocardial infarction by
,,immediate care doctors ’’8 stated that an appreciable number
to3 out of 511) of patients died in the presence of their general
practitioner. This, it was suggested, argued for the wider use of
defibrillators by general practitioners.
This may be one way in which primary care doctors can
contribute to "the ultimate coronary care unit" but there are
others. At present general practitioner and ambulance based
resuscitation schemes make only a small impression on the
number of sudden deaths in the community. The reason for
the delay in developing more widespread advanced training for
ambulance personnel has already been mentioned but there
seems little doubt that when political, financial, legal, and
attitudinal difficulties have been overcome, greater opportunities
for dealing with out of hospital cardiac arrest will arise. This
survey showed that in many areas, particularly country districts,
there is great potential for fruitful cooperation between general
practitioners and the ambulance service. This might be expressed
as involvement in immediate care arrangements,
contribution to training, and support of proposals for extending
the role of ambulance personnel.
On a wider front, tl~.e potential of any resuscitation scheme
cannq~ realised without widespread training of the public in
the p~ffciples of cardiopulmonary resuscitation. In Seattle
about one third of the population have received such instruction
and this probably accounts for the high success rate of the
resuscitation there which undoubtedly saves about 100 lives
each year.* Despite this, only in Brighton and Oxford have
resuscitation ambulance programmes acted as a stimulus for
public education in cardiopulmonary resuscitation, and this is a
further area in which general practitioners may contribute to
the out of hospital management of cardiac arrest.
Are antiprostaglandins of any value in treating the irritable bwwel
~yndrome ?
Possibly, but it is too early to be sure. Diarrhoea is the predominant
feature in a few patients with the irritable bowel syndrome. These
patients often have raised concentrations of prostaglandin E, in their
: jcjunaL,[luid,, and in six such patients an uncontrolled trial 9 f ~dometh~25
mg four times-daily cut the stool volume and frequency
by ha1~q’hese preliminary results need to be confirmed in a placebo
controlled trial since many patients with the irritable bowel syndrome
respond well to placebos. Meanwhile, it may be relevant that in
’ patients with this syndrome who develop diarrhoea in response to
specific foods.the co. ncetitration of prostaglandin E~ in rectal fluid
rises when they are challenged with the food in-question.* Again,
these are early findings, and the precise role of prostaglandins in
the i-rritable bowel syndrome with diarrhoea is far from clear.~
g llEgXOi% reader in medicinei Bristol.
- : Bukhave H Rask-Mad~n J=Prostaglandin E, in jejunal fluids and its potential
-. "" diagnostic value for selecting patient¯ with indomethacm-sen¯mve dmrrhoea.
.i. EurJClln lwuest1981;U:191-3. . " - ...... - "~ ~ood
Juries VA, McLaut~hlan l r, Shormouse .M,’worgman e,, taunter j~. r
intolerance- a major factor in the pathogene¯i¯ of irrttable bowel ¯ynurome.
Lancet 1982]ii:U15-7. ~ "
What is the risk of a person ~vho has had one coronary thrombosis having
another attack ?
For the purposes of this reply I will assume that the subject has
survived their first myocardial infarction by at least one month. The
Framingham study indicates that for men, the average annual
mortality will be 5% a year for the next 10 years, between three and
971
There is obviously a great deal of enthusiasm among doctors
and ambulance staff who want to contribute to the prehospital
care of the critically ill. Whereas on one hand it will be a waste
if this enthusiasm remains untapped and unchannelled for want
of national direction, on the other, the DHSS is unlikely to
support extension of resuscitation services unless they can be
shown to represent money well spent.
I am grateful for the support of a Royal College of General Practitioners
Upjohn Travelling Fellowship which enabled me to undertake
this study, and for the help and hospitality extended by all
whom I contacted, in particular Dr Hugh Bethell (Alton), Mr Cliff
Beaver (Avon), Mr R Grainger and Mr L Relf (Brighton), Mr
George James (Gloucester), Professor John Hampton (Nottingham),
Mr Geoff Plumb and Mr Peter Scott (Oxford), and Mr Eddie Semon
(York).
References
t Office of Population Censuses and Surveys. Mortallty statistics 1979:
England and Wales. London: HMSO, 1981.
¯ American
monary resuscitation
Heart Association.
and emergency
Standards
care.
and guidelines
JAMA 1980;244:453-509.
for cardiopul-
s Department of Health and Social Security. Health Servic~ Development.
Ambulance Serolce: advanced training for ambulancema~. London:
DHSS, 1976. (HN(76)204.)
4 Briggs RS, Brown PM, Crabb ME, et al. The Brighton resuscitation
ambulances: a continuing experiment in prehnspital care by ambulance
staff. Br Med J 1976;ii:1161-5.
i Mackintosh AF, Crabb ME, Grainger R, et al. The Brighton resuscitation
ambulances: review of 40 consecutive survivors of out-of-hospital
cardiac arrest. Br MedJ 1978;i:1115-8.
¯ Hampton JR1 Nicholas C. Randomised trial of a mobile coronary care unit
for emergency calls. Br MedJ 1978;i:1118-21.
7 Hampton JR, Dowling M, Nicholas C. Comparison of results from a
cardiac ambulance manned by medical or non-medical personnel
Lancet 19771i:526-9.
8 Rawlins DC. Study of the management of suspected cardiac infarction
by British immediate care doctors. Br MedJ 1981;282:16T7-9.
* Thompson.RG, Hallstrom AP, Cobb LA. BysumderTim~tiat.e! :1 ..c~.diopulmonary
resuscitanon m the management ot venmcmar nonttatton.
Annals Intern Med 1979;90:737-40.
four times that of the general population, t Women have a higher
mortality in the first year but fare similarly thereafter. Most of the
deaths will be cardiac. Thirteen per cent of Framingham men and
40% of women had a further non-fatal myocardial infarction within
five years of the first attack. The Framingham data are important
because they include all eases of myocardial infarction occurring in a
defined community irrespective of whether they were admitted to
hospital. Considerably more informatiofi is available from studies of
subjects discharged from hospital after myocardial infarction. Lurla
assembled 10 069 subjects who had recovered from acute myocardial
infarction from various studies and noted that five year mortality
dusters at 30% to 35%.* Many of these studies, however, included
subjects with previous episodes of_myocardia! infaretinn. A recent
study from this side of the Atlantic reported -on the mortality of men -
under 60 surviving tbeir first myocardial infarction or episode of
unstable angina b~- at least 28 days. ~ For m3ioeardial infaretlon2
five, 10, and 15 year mortality percentages were 2,2, 40, and 59, rather
more than three times that of the general population. This paper
contains a review of 22 other studies of postinfarction mortality.
Subjects more likely to die after myocardial infarction are older;
those with larger infarcts as evidenced by complications such as
heart failure; hypertensive subjects; and those who continue to
smoke. Beta-blockade may improve survival in suitable subjects but
this effect is modest and probably less than the effect of stopping
smoking.~t M GRAHAM, consultant cardiologist, Dublin.
t Kannel WB Sorlic P McNamara PM. Prognosis after initial myocardial infarction:
the Fram~ngham study. AmJ Cardlol 1979;44:53-9.
t Lurla MH, Knoke JD, Wach¯ JS, Luria MA. Survival after recovery from acute
myocardial infarction. Two and five year prognostic indices. Am ~ JVled 1979;
Graham 67:7-14. I, Mulcahy R, Hickey N, O’Neill W, Daly L. Natural hi¯tory of coronary
heart disease: a study of 586 men surviving an initial acute attack. Am HeartJ
1983; 105:249-57.

Who scores
in trauma?
David Steedman and Colin R0berts0n
Trauma is the commonest cause of death
between the ages of I and 34 years in the
United Kingdom¯ I Improvements in
prehospital care and trauma management
within hospital are necessary if reductions
are to be achieved." Quantitative measures
of the severity of injury, of proven
reliability and validity, are essential to
permit appropriate resource allocation, the
prediction of outcome and the evaluation
of emergency medical care, 3’4
Estimatesofinjury severity appear in the
earliest known surgical text, the Smith
I’apyrus. s in World War !! a system was
,~ i~tcwhich sments of depended blood loss, on clinical but it was crude,
ult to apply and lacked a numerical
scale/’The first widely recognised injury
~calc was developed for investigation of
light aircraft accidents7 and later applied to
road traffic accidents by the Cornell
Injuries Research Group.S Over the next 20
years a variety of systems emerged from
multidisciplinary crash investigation
teams, but they were often not comparable
and each had limitations. ~ An attempt to
establish a uniform rating system and
standardise the language used in describing
injuries led to the development of the first
Abbreviated lnjurv Scale (AIS) in 1971. ~(~
The latest revision’AIS 85 ~l contains more
than 1201) separate injury descriptions.
¯ Abbreviated’ refers to the assignment of
a single code number on a scale of I (minor
injury) to 6 (major injury--unsurvivable
with current techniques) for specific
injuries. The AIS is non-linear and has
when applied to patients with
~ ationS
pie injuries as it is not possiblc to
derive an anthmchc mean value. "
However it is utilised in the derivation of
the lnjurv Severity Score (ISS) to assess
multiply injured patientsfl ~
The ISS is the most widely used system
for measuring the cumulative effects of
¯ 14
injuries. For scormg purposes, the bodyis
divided into six regions: head and neck:
face; chest; abdominal and pelvic contents;
limbs and pelvic girdle; and external.
Within each body region an AIS code is
assigned to each injury¯ The ISS is
calculated by summing the squares of the
highest A IS code in each of the three most
Dr Steedman is a ,Senior Registrar and Dr
Robertson a Cort~ultant in the Departments
of Accident and Emergency Medicine of the
Royal infirmary and Western (;eneral
l lospital, Edinburgh.
severely injured body regions. The ISS has
been shown to correlate closely with
morbidity and mortality from road traffic
is
accidents " and other types of blunt
trauma. 1~,,17 The importance of age
weighting in mortality studies has been
confirmed by Bull; Ls and by using Probit
analysis ’LD 50" values can be derived for
different age groups, based on the ISS.
Effective systems for prehospital triage
are fundamental to the provision of
emergency care for trauma patients,
Indices of severity based on physiological
parameters,~S 2°obtainable at accident
scenes, assist in identifying high risk
patients and permit appropriate allocation
of available resources. One such system,
the Trauma Score (TS) devised by
Champion and co-workers, 2~ combines
cardiorespiratory parameters and the
Glasgow Coma Scale 22 and has been
correlated with patient outcome in nearly
40110 trauma patients. 23 An important
application of the Trauma Score is in
comlfination with the Injury Severity
Score, when comparisons can be made
between predicted and actual patient
outcome, thus providing a useful index of
patient care--the TRISS metbodok~gy
(Traun~a Score, ISS, age combination
index).-’4
Trauma constitutes a major health
problem in the United Kingdom: however
research in this field has]acked the
necessary fin anci al support de spite cl aims
that the quality of patient care is less than
2~ 26
optimal. -’ While’thecurrently available
,scoring systems are not perfect (for
example difficulty arises in scoring
penetrating injury using the ISS) future
refinements in their methodology and
application will improve their accuracy.
Even so: thcy provide powerful clinical and
research tools. Their adoption by research
z7 i
¯
teams, ntensl "v" ists zs and Accident and
Emergency clinicians29 will facilitate audit
and direct improvements in the
management traum a victims.
References
I. Office of Population Census and Surveys.
Deaths by cause. 198.5. I.,ondon:
Government Statistical Service, 1986.
2. Tnmkey 1). Trauma. Scientific American
1983; 249: 2(I--7.
3. Gibson G. Indicesofseverity for emer’gency
medical evaluative studies. Int J Health Serv
1981 : I I: 597-5,,22.
4. Caytcn (’(;, Fvans W, Severity indices and
their implications for Ihc cmcrgency medical
services research and evaluation. J Trauma
1979; lq: 98-102.
5. Breasted JH. 1"he Edwin Smith Papyrus.
Chicago: The University of Chicago Press,
19~).
6. Grant RT. Ment’orandum on the
ob~rvat ions required in cases of wound
shock. BMJ 1941; 2: 332-6.
7. DeHaven H. The site. frequency and
dangerousness of injury sustained by g00
survivors of light plane accidents. Crash
injury research. New York: Cornell
University. 1952.
8. Ryan G A. Garret JW. A quantitative scale of
impact injury. Publication CA I. No.
VT- 1823- R34. Buffalo: Cornell I Iniversity,
1968.
9. Petrucelli E. States JD, Haines LH. The
Abbreviated Injury Scale: evolution, usage
and future adaptability. Accid Anal Prey
1981 ; 13: 29-35,
10. Committee on medical aspects of automotive
safety. Rating the severity of ti~ue damage
I : The Abbreviated Scale, JA MA 1971 ; 215:
277-80,
11. Committee on injury scaling. The
Abbreviated Iniury Scale: 1985 Revision.
American Association for Automotive
Medicine, 1985.
12. BulIJP. Measuresoftheseverityofinjury,
Injury 1978; 8:184-7.
13. Baker SP, @’Neill B, Hadden W, Jr Long
WB. The Injury ,Severity ,Score: a method for
de~ribingpatients with multiple injuries and
evaluating emergency care. J Trauma 1974;
14: 187-96.
14. Baker SP, O’Neill B. The Injury Severity
Score: an update. J Trauma 1076; 16: ~82-5.
15. Bull JP. The Injury Severity Score of road
traffic casualties in relation to mortality,
time of death, hospital treat meat time and
disability. AccidAnal Prev 1975; 7: 24q-55.
16. SemmlowJ.L,Cone R. Utilityofthe Injury
Severity Score: a confirmation, lteahh Serv
Res 1976; I I: 4.5-52.
17, Stoner liB, Barton RN, Little RA. Yates
DW. Measuring the ~verity of injury¯ BMJ
1977; 2: 1247-9.
18. Kirkpatrick JR. YoiJmans RL. Trauma
Index¯ An aide in the evaluation of injury
victims. J Trauma 1971 ; I I : 71 I- 14.
19. Champion HR, Sacco WJ. tlannan DS,
Leppcr RI,, el al, A~scssment of injury
severity: The Triage Index. (’tit (’are Med
1980;8:201-8.
20. Gormican SP. CRA MS Scale: field triage of
trauma victims. Ann Emerg Med 1982; I 1:
132-5.
21. Champion H R, Sacco WJ. Camazzo A J,
Copes W, Fouty WJ. Trauma Score. Crit
CareMed 1981 ;9: 672-6.
22, TeasdaleG.Jennet B. As~smentofcoma
and impaired qonsciousne~s: a practical
scale. Lancet 1974; 2: 81-4.
23. Champion HR. Field triage 0ftrauma
patients. Ann Emerg Med 1982; I 1 : 160-1.
24. Champion HR, Sacco WJ. Hunt TK,
Trauma severity scoring to predict mortality.
WorldJ Surg 1983" 7:4--11.
25, The responsibility of emergency medicine
towards the prevention of road accidents.
Arch Emerg Med 1986, 3: 157-76.
26. Trunkey D. Towards optimal trauma care.
Arch Emerg Med 1986: 2: 181-95.
27. Little RA, Frayn KN, Randall PE. Stoner
HB. Maycock PF. Plasma catecholamine
concentrations in acute states of stress and
trauma. Arch Emerg Med 1985; 2: 46-7.
28, MorganCJ, Branthwaite MA. Severity
scoring in intensive care. BMJ 1986; 292:
1546.
29. Steedman D J, Robertson CE. AOUADS:
an objective evaluation of
their role in trauma. J Roy ColI Surg Ed
1986; 31 : 80--4.
-- (’ARI OI:TIII:CRrFR’AI I YII I MAY/JI.INE 11:/87 VOI.3NO3

e
e
ORIGINAL CONTRIBUTION
emergency medical services, cardiac arrest, in-hospital resuscitation;
resuscitation, cardiac arrest
In-Hospital Resuscitation Following
Unsuccessful Prehospital Advanced
Cardiac Life Support: ’Heroic Efforts’
Or an Exercise in Futility?.
From our emergency department logbook we identified 281 consecutive patients
transported to the Regional Medical Center at Memphis following
failed prehospital advanced cardiac life support (ACLS). Medical records
were obtained for 240 cases (85.4%). Initial cardiac rhythms in the EL) included
ventricular fibrillation or pulseless ventricular tachycardia (29%),
electromechanical dissociation (18%), and asystole (51%). Thirty-two patients
(13.3%) were successfully resuscitated in the EL), but only four (1.7%)
survived to hospital discharge. Two patients had good neurologic outcomes;
both degenerated to cardiac arrest shortly prior to arrival in the EL). The
remaining two survivors were discharged to nursing homes with severe neurologic
deficits. Of the 41 cases for whom no medical records could be
found, 39 were noted in our logbook to have died in the EL). No record of
subsequent hospital admission could be found for the other two. Both are
presumed to have died. Failure to respond to prehospital ACLS predicts nonsurvival
and may warrant cessation of efforts in the field. Future programs
and research efforts in the management of out-of-hospital cardiac arrest
should be focused on optimal provision of prehospital care prior to the onset
of irreversible deterioration. [Kellermann AL, Staves DR, Hackman BB: Inhospital
resuscitation following unsuccessful prehospital advanced cardiac
life support: ’Heroic efforts’ or an exercise, in futility? Ann Emerg IVied lane
1988;17:589-594.]
INTRODUCTION
Despite two decades of dramatic advances in emergency cardiac care, a
majority of victims of out-of-hospital cardiac arrest fail to respond to prehospital
efforts at resuscitation.Va In many metropolitan areas, paramedics
emergently transport patients who fail to respond to prehospital advanced
cardiac life support IACLS) to the nearest hospital for continued efforts at
resuscitation.
A decision to transport a patient in refractory cardiac arrest commits a
paramedic crew to hazardous high-speed driving. The emergency department
must rapidly mobilize available personnel to continue the attempt of resuscitation.
Any patient successfully resuscitated then is admitted to an intensive
care unit, often for a stormy hospital course.
Reports have failed to focus on this important subgroup of patients. Information
regarding the clinical outcomes of these patients has been scant. No
studies have directly examined the personnel and monetary costs associated
with decisions to continue resuscitation efforts despite unsuccessful prehospital
ACLS. Our study was conducted to examine these issues.
METHODS
The Regional Medical Center at Memphis is a 435-bed, adult, acute care
hospital supported, in part, by the government of Shelby County, Tennessee.
The hospital and its ED are staffed by residents and faculty of the University
of Tennessee, Memphis. The ED at the Regional Medical Center averages
65,000 visits annually and is the point of entry for three-quarters of all nonobstetric
admissions.
Emergency medical services {EMS) for the City of Memphis are provided
by the Memphis Fire Department {MFD) EMS Bureau. The Bureau operates
14 ambulances staffed by two paramedics each, who are authorized to pro-
17:6 June 1988 Annals of Emergency Medicine
Arthur L Kellermann, MD, MPH
Diane R Staves, MD
Bela B Hackman, MD
Memphis, Tennessee
From the Departments of Medicine
and Community Medicine, University
of Tennessee, Memphis, Tennessee.
Received for publication August 20, 1987.
Revision received January 18, 1988.
Accepted for publication February 10.
1988.
Presented at the Society for General
nternal Medicine National Meeting in
San Diego, California. April 1987.
Address for reprints: Arthur Kellermann,
MD. MPH, Division of Emergency
Medicine, Department of Medicine. 877
Jefferson. Room G071. Memphis.
Tennessee 38103.
589/63
I

OA
~p
UNSUCCESSFUL PREHOSPITAL RESUSCITATION
Kellermann, Staves & Hackman
FIGURE 1. Outcome of refractory prehospital
carch’ac arrest.
vide ACLS under the medical control
of on-line physicians. All units carry
defibrillators. Since 1979, all units also
have been equipped with-automatic,
oxygen-powered cardiopulmonary resuscitators.
Paramedics are authorized
to perform endotracheal intubation
and administer a wide range of cardiac
drugs. MFD paramedic response times
for emergency runs average five minutes
from call to arrival on scene.
During the study interval, all MFD
paramedic units followed the 1980 to
1986 guidelines for cardiac resuscitaion
developed by the American Heart
ssociation.4 In cases involving ven-
tricular fibrillation or pulseless ventricular
tachycardia, paramedics were
authorized to deliver up to three defibrillatory
shocks prior to establishing
contact with an on-line physician.
Additional resuscitative measures meluded
immediate endotracheal intubation,
hyperventilation with oxygen,
establishment of peripheral venous
access, and administration of IV epinephrine,
lidocaine, and/or atropine as
indicated.
According to MFD statistics, onscene
time in cases involving unsuccessful
prehospital resuscitation averages
approximately 22 minutes. S Unfortunately,
comprehensive records of
each prehospital cardiac resuscitation
were not kept during the study interval.
Therefore, case-specific data regarding
individual cardiac arrest cirumstances
and details regarding each
rehospital resuscitation attempt were
unavailable. During the study interval,
all MFD cardiac arrest patients who
failed to respond to prehospital ACLS
received continuous mechanical CPR
during emergency transportation to
the nearest hospital.
We retrospectively identified,
through our ED logbook, all adult
patients transported to the Regional
Medical Center at Memphis by ambulance
following nontraumatic, outof-hospital
cardiac arrest who arrived
without a palpable pulse or blood
pressure between November 11, 1983,
and January 6, 1986. A total of 219
cases were identified. In addition, we
prospectively identified 62 cases between
January 7 and December 15,
1986. Patients who arrived by automobile
and patients who sustained a
cardiac arrest only after arrival in the
64/590
1
¯ Died in ED
28 (11.7%)
ED were excluded. Painstaking file
searches through medical records
yielded 240 of 281 charts (85.4%).
All available records were reviewed
by one of the authors to identify the
presenting cardiac rhythm in the ED,
total time of the ED resuscitation
effort, major ED management, and ED
outcome. We defined a "successful" resuscitation
as reestablishment of a
pulse and blood pressure sufficient to
sustain life and permit admission of
the patient to an ICU. For patients resuscitated
in the ED and admitted to
the hospital, we noted length of hospital
stay, hospital outcome, and disposition.
Functional status at discharge
was determined using implicit criteria
(ie, good recove~ able to return home
without significant deficits; moderate
disability’ able to return home but requiring
assistance with some aspects
of daily life; severe disability" dependent
on others for daily support).
Estimates of ED personnel use were
calculated using documented durations
of ED resuscitation and conservative
estimates of the total number
of personnel involved. ED charges for
cardiac resuscitation are the same regardless
of the duration of the resuscitation
attempt or the total number of
personnel involved. ICU and ward bed
charges were calculated based on documented
lengths of stay and standard
hospital room charges. Medications,
Annals of Emergency Medicine
(n = 240)
4 (1.6%)
208 (86.7%)
[] Died in hospital [] Survived to discharge
supplies, and professional fees were
not included. All charges are expressed
in 1986 dollars.
RESULTS
Absence of a pulse was confirmed
on arrival to the ED in all 240 cases in
which documentation was available.
Two hundred eight of 240 patients
(87%) were intubated successfully prior
to arrival; the remainder were being
ventilated by esophageal obturator mrway
or bag-valve-mask. Endotracheal
intubation was completed m all cases
within two minutes following arrival
in the ED.
Presenting cardiac rhythms in the
ED included ventricular fibrillation or
pulseless ventricular tachycardia in 69
cases (29%), electromechanical dissociation
(EMD) in 43 (18%), asystole
in 122 (51%), and other rhythms in six
(2.5%). Following arrival, resuscitation
efforts followed 1980 to 1986 ACLS
guidelines. 4 Transthoracic or transvenous
pacing was attempted in 30
cases (13%); successful capture was
noted in 19 (8%), but pulses were established
in only three (1%). Pericardiocentesis
was attempted in 19 (8%)
cases, but transient clinical benefit
was noted in only one.
In the ED, physicians were able to
successfully reestablish a pulse and
blood pressure in 32 of 240 cases
(13.3%). Patients found to be in ven-
17:6 June 1988
i

e
e
Cases
12
10
8
6
4
2
0 1
(N = 32)
[] Survived to discharge ¯ Died during hospitalization
7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Number of days 2
TABLE 1. ED and hospital room charges following refractory prehospital
carch’ac arrest
(N = 281)
ED $284/case x 281 cases - $ 79,804
ICU $554/day x 119 days - $ 65,926
Ward $212/day x 70 days -$ 14,840
Total $160,570
Charges expressed ~n 1986 dollars; excludes charges for drugs, laboratory, supplies.
and professional fees.
tricular fibrillation or pulseless ventricular
tachycardia on arrival to the
ED were resuscitated more often than
patients found in other rhythms (22%
vs 9.9%; chi-square P < .02). All patients
successfully resuscitated were
admitted to an ICU.
Only four patients (1.6%) survived
to hospital discharge (Figure 1). Despite
more frequent initial resuscitation,
patients who presented to the
ED with ventricular fibrillation or
pulseless ventricular tachycardia were
no more likely to survive to hospital
discharge (two of 69 [2.9%] vs two of
171 [1.2%]; chi-square P = .22). One
of these four survivors actually responded
to prehospital ACLS with reestablishment
of a pulse and blood
pressure at the scene but had a second
cardiac arrest less than two minutes
prior to arrival at the Regional Medical
Center. A second patient deteriorated
en route from ventricular tachycardia
with a pulse and blood pressure
to ventricular fibrillation shortly before
arrival. Both were resuscitated
and subsequently discharged home
with good neurologic outcomes.
The remaining two patients failed
to respond at any point to prehospital
ACLS but were resuscitated successfully
in the ED. Both were eventually
17,6 June 1988
discharged to nursing homes with severe
neurologic deficits following
prolonged hospital stays (Figure 2).
Of the 41 patients for whom no record
could be found, 39 were noted in
our logbook to have died in the ED. In
the remaining two cases, no specific
ED outcome was recorded. A search of
inpatient files and ICU admission logbooks
failed to reveal the name of
either patient within 24 hours of arrival
in the ED. Both are presumed to
have died.
Resuscitation attempts were continued
in the ED a mean of 33.2 +
16.6 minutes (range, six to 163 minutes).
The responding team usually
consisted of a staff physician, a resident,
one to two interns, two ED
nurses, a ward clerk, and an anesthesiologist
or certified nurse anesthetist.
Total personnel time spent in resuscitation
attempts exceeded 1,100 personhours.
During our study interval the standard
hospital charge associated with
an ED resuscitation at the Regional
Medical Center was $284, regardless
of the duration of the resuscitation or
consumption of supplies. The 32 patients
successfully resuscitated in the
ED spent a total of 119 days in an ICU;
70 days were spent on general medical
Annals of Emergency Medicine
;FI;
FIGURE 2. Outcome of refractory prehospital
cardiac arrest -- length of
hospital stay.
wards. The 1986 room rate for a day in
the ICU was $554; the room charge
for a ward bed was $212. Based on
these figures, total ED and hospital
room charges for the study group exceeded
$160,000 (Table 11.
DISCUSSION
Since the pioneering work of Pantridge
and Geddes,6, 7 prehospital
emergency cardiac care has become
established in many major metropolitan
centers. Cobb, 8 Nagel,9 Eisenberg,
lo and others n have shown that
well-trained paramedics can reliably
deliver defibrillatory shocks, start IV
lines, perform endotracheal intubation,
and successfully resuscitate
many victims of out-of-hospital cardiac
arrest. In 1980, Eisenberg, Copass,
Hallstrom, et all2 demonstrated the
superiority of prehospital ACLS in
comparison to basic EMT services.
Of the variables that have been
shown to be associated with suecessful
resuscitation following cardiac
arrest, the most important one amenable
to system intervention is the
total duration of time to defibrillation.2,
a In cases involving delays to defibrillation
of more than three to four
minutes, early prowsion of CPR improves
the chances for s:lbsequent resuscltation,3,4,1a,
14 Most patients who
respond to prehospital emergency cardiac
care do so early in a resuscitation
effortA5 Few survive resuscitation attempts
lasting longer than 30 minutes.
16
Given these clearly developed principles,
it is no surprise that patients
who fail to respond to prehospital
ACLS rarely survive emergency trans-
591/65
I
|

~ tudy
UNSUCCESSFUL PREHOSPITAL RESUSCITATION
Kellermann, Staves & Hackman
portation to the hospital for subsequent
efforts at in-hospital resuscitation.
Fewer still survive to hospital
discharge. While patients in our study
arriving in ventricular fibrillation or
ventricular tachycardia were more frequently
resuscitated in the ED, it appears
that the prolonged period of
CPR associated with these cases precluded
long-term survival with good
neurologic function. If the two patients
in our series who maintained a
spontaneous pulse and blood pressure
until two minutes prior to arrival at
our hospital are excluded, no patient
in our series could be considered to
have had a satisfactory outcome.
Several potential limitations to our
deserve comment. All of our
atients were adult victims of nontraumatic
cardiac arrest. Conclusions
based on a series of adult patients may
not apply to prolonged resuscitation
attempts involving pediatric patients..
Likewise, persons sustaining cardiac
arrest following penetrating trauma
have been shown to benefit from a
combination of aggressive prehospital
care, rapid transport, and immediate
in-hospital surgical managementAz Conventional wisdom and several
case reports dictate that hypothermic
patients warrant determined efforts at
resuscitation and adequate rewarming~
because an unknown number of victims
of severe hypothermia may respond
to prolonged resuscitation and
survive with good neurologic function.
1 S- 20
Prior to June 1986, comprehensive
data regarding the prehospital manement
of cardiac arrest were not col-
~g
lected or maintained by the MFD. We
are, therefore, unable to comment on
the specific circumstances surrounding
each cardiac arrest episode or the
precise quality of prehospital cardiac
care. We believe, however, that any mtercommunity
differences m the quality
of prehospital cardiac care are likely
to be reflected in varying rates of
prehospital resuscitation, rather than
in different rates of subsequent in-hospital
resuscitation.
Some may consider our poor rate of
survival following unsuccessful prehospital
ACLS to be specific to the
MFD EMS bureau or our study institution.
In a subsequent review of
the literature, we have identified
seven additional studies from six cities
or metropolitan counties in which
patients failing to respond to prehospital
ACLS were transported to the
66/59")
nearest hospital. 9,21-26 Of 1,164 patients,
six (0.5%) were noted to survive
to hospital discharge (Table 2).
Four of these six initially responded to
prehospital ACLS but sustained a second
cardiac arrest shortly before arrival
in the ED. The functional status of
these survivors at discharge was not
specified.
Based on our data and the results of
others, we conclude that failure to respond
to prehospital ACLS on the
scene with reestablishment of a blood
pressure and pulse is highly predictive
of death prior to hospital discharge.
Combining our results with those
noted, only ten of more than 1,440 patients
(0.69%) have been reported to
have survived to hospital discharge
after arriving in cardiac arrest following
prehospital ACLS. 9,21-26 Six of
these ten survivors actually had a
pulse and blood pressure at the time
the decision to transport was made. In
individual cases, failure to respond to
emergency cardiac care may reflect
long down times without CPR, delays
to defibrillation, long EMS response
times, refractory initial arrythmias
(eg, asystole), or perhaps other unspecflied
factors. Regardless of the factor(s)
associated with failure to respond in
any given case, patients unsuccessfully
resuscitated at the scene rarely survive
to hospital discharge.
A decision to transport a patient to
the hospital following unsuccessful
prehospital ACLS is associated with
high costs and considerable risks.
More than 1,100 hours of skilled ED
personnel time were involved in our
series, a number approximately equal
to one person working 40 hours a
week for more than six months. The
32 patients resuscitated in our ED accounted
for an additional 189 bed-days
of ICU and ward hospitalization. ED
and hospital room charges alone exceeded
$160,000.
In contrast to the ten survivors of
refractory out-of-hospital cardiac arrest
identified by our study and literature
review, 159 motor vehicle deaths
involving ambulances in emergency
use were reported to the National
Highway Traffic Safety Administration
between 1977 and 1985.27 Many of
these deaths involved pedestrians,
drivers, or passengers of non-EMS vehicles.
The National Association of
State EMS directors recently has
noted that 25 EMTs and paramedics
nationwide died as a result of highspeed
ambulance driving between Jan-
Annals of Emergency Medicine
uary 1, 1983, and May 31, 1986. 28 C
of these deaths involved a MFD par,
medic who died in an ambulance accident
in 1984.29 While the annual toll
of serious but nonfatal injuries as a result
of ambulance-related motor vehicle
accidents is undoubtedly higher,
the magnitude of this figure is unknown.
A few EMS systems have adopted
policies that permit paramedic units
to cease efforts in the field in selected
cases of refractory out-of-hospital cardiac
arrest after consultation with an
on-line physician, za,2s Based on our
data, we believe these policies justified.
They should be more widely implemented
by well-supervised EMS
systems offering comprehensive prehospital
ACLS.
Both of the patients in our study
who survived with good neurologic
outcomes and four of the six survivors
identified by our literature review had
a pulse and blood pressure at the time
the decision to transport was made.
Initial response to prehospital ACLS
appears to select those patients who
are likely to benefit from continued
emergency cardiac care, because virtuaUy
all ultimately successful resuscitations
following out-of-hospital cardiac
arrest are accomplished at the
scene.lS,3o CPR alone rarely sustains
cardiac and cerebral function long
enough to permit successful transport
to an in-hospital resuscitation teamA2
Despite consistent CPR by automatic
resuscitation devices, more
than 70% of our patients were in
asystole or electromechanical dissociation
by the time they arrived in
our ED. Given the inevitable deterioration
that occurs during prolonged
CPR, it appears that little is gained
from transporting patients in refractory
cardiac arrest to expensive hospitalbased
technology.
EMS policies that mandate transport
to the nearest hospital in cases of
refractory out-of-hospital cardiac arrest
may actually compromise a patient’s
chances for survival by encouraging
a "load and go" approach rather
than determined efforts at prehospital
ACLS. Many of the 32 patients resuscitated
in the ED during our study
might have responded sooner and had
better outcomes if efforts had been
continued in the field beyond the
point that a decision to transport was
made. In other than exceptional cases,
high-speed transport to the hospital
should never be considered an accept-
17:6 June 1988

e
e
Miami8
1970-73
TABLE 2. Outcome of patients presenting to the ED in cardiac arrest despite prehospital ACLS
Brighton, England .18
1974-76
Miami19 235
1975-78
Suburban Kansas City 2o 225
1979
Sacramento County 21 4601-
1979-81
San Francisco 22 49
1986
Milwaukee 23 93
1986
Memphis 281
1984-87
No. Patients
Survived to
Discharge Comments
102 0 Explicit policy to transport nonresponders. Total includes
only patients in refractory ventricular fibrillation following
unsuccessful prehospital emergency cardiac care. An
unknown percentage of 199 additional patients shocked
into asystole or EMD. These are not included in group
total.

@
UNSUCCESSFUL PREHOSPITAL RESUSCITATION
Kellermann, Staves & Hackman
pears to be litde justification for policies
that encourage rapid transport to
the hospital following unsuccessful
prehospital ACLS. In the vast majority
of cases, failure to reestablish spontaneous
cardiac activity at the scene
sufficient to generate a pulse after determined
prehospital efforts at resuscitation
warrants cessation of efforts in
the field and pronouncement of death.
On the other hand, initial response to
treatment followed by recurrent cardiac
arrest warrants continued efforts,
including transport to the nearest hospital
ED.
Given our present understanding of
the physiologic limits of prolonged
cellular ischemia, we question the
wisdom of continued research into
costly hospital-based technology for
the management of refractory out-ofhospital
cardiac arrest. We believe further
investments in trainmg~ program
development, and clinical research
should be focused on the optimal
provision of prehospital emergency
cardiac care, prior to the onset of irreversible
deterioration.
We are indebted to the internal medicine
housestaff of the University of Tennessee
and the nurses and unit assistants in the
emergency department of the Regional
Medical Center at Memphis, without
whom this study would not have been
possible. We are also indebted to Carol
Conway for preparation of this manuscript.
REFERENCES
I. Lown B: Sudden cardiac death: The major
problem confronting contemporary cardiology.
Am ] Cardiol 1979;43:313-328.
2 Eiscnberg MS, Bergner L, Hallstrom A~, et al:
cardiac death. Sci Am 1986~245:37-43.
Standards and guidelines for cardiopulmo.
mary resuscitation ICPRJ and emergency cardiac
care IECCJ. lAMA 1986;255:2905-2914.
4. Standards and guidelines for cardiopulmomary
resuscitation (CPR) and emergency cardiac
care (ECCJ. lAMA 1980i244:453-509.
S. Unpublished data, Memphis Fire Depart.
merit, EMS Bureau, 1987.
6. Pantridge JE Geddes IS: Cardiac arrest after
myocardial infarction. Lancet 1966;1:807-808.
7. Pantridge JF, Geddes IS: A mobile intensive
care unit in the management of myocardial infarction.
Lancet 1967;2:271-273.
8. Cobb LS, Baum RS, Alvarez H, et al: Resuscitation
from out-of-hospital ventticular fibrillation:
Four-year follow-up. Circulatl’on 1975;52
68/504
(suppl III~:223-228.
9. Liberthson PR, Nagel SL Hirschman JC, et
al: Prehospital ventricular defibrillation: Prognosis
and follow-up course. 1V Engl I Med
1974;291:317-321.
I0. Eisenberg MS, Bergner L, Hallstrom AP:
Out-of-hospital cardiac arrest: Improved survival
with paramedic services. Lancet 1980;1:
812-816.
II. Hearn T: The development of emergency
medical services, in Eisenberg MS, Bergner L,
Hallstrom AP (edsl: Sudden Cardiac Death in
the Community. New York, Praeger Publishing,
1984, p 29-43.
12. Eisenberg MS, Copass MK, Hallstrom AP, et
al: Management of out-of-hospital cardiac arrest:
Failure of basic emergency medical techni.
clan services, lAMA 1980;243:1049.1051.
13. Eisenberg MS, Bergner L, Hallstrom AP:
Cardiac resuscitation in the community: Importance
of rapid provision and implications for
program planning, lAMA 1979;241:1905.1907.
14. Cummins RO, Eisenberg ME, Hallstrom AP,
et al: Survival of out-oLhospital cardiac arrest
with early initiation of cardiopulmomary resuscitation.
Am I Emerg Med 1985;3:114.118.
15. Weaver WD, Cobb LA, Hallstrom A~, et al:
Considerations for improving survival from outof-hospital
cardiac arrest. Ann Emerg Med
1986;15:1181-1186.
16. Smith pl- Bodai BI: Guidelines for discontinuing
prehospital CPR in the emergency department
-- A review. Ann Emerg Med
1985; 14:1093 - 1098.
17. Copass MK, Oreskovich MR, Bladengroen
MR, et al: Prehospital cardiopulmomary resuscitation
of the critically injured patient. Am l
Surg 1984;148:20-26.
18. Southwick FS, Dalgfish PH: Recovery after
prolonged asystolic cardiac arrest in profound
hypothermia. A case report and literature review.
lAMA 1980;243:1250-1253.
19. Bristow G, Smith R, Lee J, et al: Resuscitation
from cardiopulmonary arrest during accidental
hypothermia due to exhaustion and exposure.
Can Med Assoc I 1977;117:227-279.
20. Siebke H, Rod T, Breivik H, et al: Survival
after forty niinutes submersion without cerebral
sequelae. Lancet 1975;1:1275-1277.
21. Mackintosh AI., Crabb ME, Grainger R, et
al: The Brighton resuscitation ambulances: Review
of 40 consecutive survivors of out-of-hospital
cardiac arrest. Br Med I 1978;1:115-118.
22. Myerburg RI, Conde CA, Sung RJ, et al:
Clinical, electrophysiologic and hemodynamic
profi!e of patients resuscitated from prehospital
cardiac arrest. Am I Meal 1980;68:568-576.
23. Szczygiel M, Wright R, Wagner E, et al:
Prognostic indicators of ultimate long-term survival
following advanced life support. Ann
Eraerg Med 1981jI0:566-570.
24. Smith pl, Bodai BI: Guidelines for discontinuing
cardiopulmonary resuscitation in the
emergency department after prehospital, nonparamedic
directed cardiac arrest. West l Med
1985;143:402-405.
Annals of Emergency Medicine
L
25. Geehi EC, Lewis FR, Auerbach PS: Fa~ure
of open-heart massage to improve survival after
prehospital non-traumatic cardiac arrest {letterL
N Engl ] Med 1986;314:1189.1190.
26. Aprahamian C, Thompson BM, Gruchow
H~, et al: Decision making in prehospital sudden
cardiac arrest. Ann Emerg Med 1986;15:
445-449.
27. Luchtar S, personal cOmmunication, National
Highway Traffic Safety Administration,
1987.
28. Hume El~ personal communication, Center
for Health and Regulation, Council of State
Governments, 1987.
29. Phillips JB: A matter of equity. IEMS
1986~ 11:6-7.
30. Eisenberg MS, Cummins RO: Termination
of CPR in the prehospital arena {editotialL Ann
Eraerg Med 1985; 14:1106-1107.
31. White DJ: Transthoracic pacing in cardiac
asystole. Am I Emerg Med 1983;3:264-266.
32. Hedges JR, Syverud S, Delsey WC: Develop-
.ments in transcutaneous and transthoraclc pacing
during bradysystolic arrest. Ann Emerg Med
1984; 13:822-827.
33. Cobb LA, Werner IA, Tronghbangh BG: Sudden
cardiac death I: A decade’s experience with
out-of-hospital resuscitation. Modern COncepts
Cardiovasc Disease 1980;49:31.36.
34. Eisenberg MS, Copass MK, Hallstrom A~, et
al: Treatment of out-of-hospital cardiac arrest
with rapid defibrillation by emergency medical
technicians. N Engl ] Med 1980;302:1379.1383
35. Stultz K, Brown D, Shug V, et al: Prehospital
defibrillation performed by emergency medical
technicians in rural communities. N Engl IMed
1984;310:219-223.
36. Phillips SI, Ballentine B, Slonine D, et al:
Percutaneous initiation of cardiopulmomary bypass.
Ann Thorac Surg 1983;36:223-225.
37. Levine R, Gorayeb M, Safar P, et al: Emergency
cardiopulmomary bypass after prolonged
cardiopulmonary resuscitation basic life support
in dogs improves survival labstract L Ann
Emerg Med 1986;15:627.
38. Martin GB, Nowak RM, Carden DL, et al:
Femoro-femoro cardiopulmomary bypass in the
atrreraest~t ent of prolonged canine cardiopulmonarv
6~. nt lanstraetL Ann Emerg Med 1986j15":
39. Weaver WD, Copass MK, Hill DL, et al:
Cardiac arrest treated with a new automatic external
defibrillator by out-of-hospital first responders.
Am ] Carddiol 1986;57:1017-1021.
40. Cummins RO, Eisenberg MS, Litwin PE, et
al: Automatic external defibrillators used by
emergency medical technicians: A controlled
clinical trial, lAMA 1987;257:1605-1610.
41. Stults KR, Brown DD, gerber RE: Efficacy
of an automated external defibrillator in the
management of out-of-hospital cardiac arrest:
Validation of the diagnostic algorithm and initial
clinical experience in a rural environment.
Circulation 1986;73:701-709.
42. Eisenberg MS, Hallstrom AP, Carter WB, et
al: Emergency CPR instruction via telephone.
Am I Public Health 1985;75:47.50.
17:6 June 1988

I
I
i
t
J
i
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i
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II 1
International Notes
The Brighton Resuscitation Ambulance Service has
been in operation since 1971. The service covers a
population of 300,000, which rises to half a million
during the summer months, and serves an area within
a five-mile radius of Brighton and Hove. This coastal
resort is a popular retirement area and has a high percentage
of elderly residents.
OPERATIONAL DETAILS
Trained Personnel
The service currently has 30 advanced life support
trained personnel, two thirds of whom are based at the
Hove Ambulance Station and the remainder at the
Brighton Ambulance Station. The operational target is
to maintain four ambulances, each manned with a minimum
oi ~ one paramedic and one ambulanceman; in
reality, there are often two paramedics per vehicle.
These highly trained paramedic ambulancemen are
under the control of the East Sussex Ambulance
Headquarters in Eastbourne.
Operational Coordination
Emergency calls from medical practitioners and
calls to the 999 phone number are routed by British
Telecommunications directly to these headquarters.
From the headquarters control room, an appropriate
duty paramedic is beeped. Upon returning to his vehicle,
which may be in or returning to a station or at
a standby location, he receiVes a direct radio message
gwmg the location of the emergency.
From the Department of Cardiology, Royal Sussex County Hospital;
Brighton, England.
Presented at the First International Conference on Cardiac Arrest
and Resuscitation, Brighton, England, October 19-21,
1982.
Address reprint requests to Dr. Studd: Department Of Cardiology,
Royal Sussex County Hospital, Brighton, England BN2
5BE.
Key Words: Ambulance, emergency medical service, paramedic,
resuscitation.
Equipment
The Brighton Ex pperience with
Resuscitation Ambulances
CLIVE STUDD, MD
Standard equipped ambulances are used (these ambulances
normally carry a comprehensive range of
equipment) plus ECG/defibrillator and the personal resuscitation
kit of the individual paramedic. Recently,
Heart Aid ® and Pace Aid® devices have been carried
and are undergoing evaluation.
Selection and Training of Personnel
Ambulancemen with at least two years of service
may be scheduled for advanced training if they achieve
a satisfactory result in a basic anatomy and physiology
examination organized by the ambulance headquarters.
Advanced training starts with a six-month period,
during which lectures in resuscitation are given once
a week. This is followed by a one-month full-time attachment
to the coronary care unit and the intensive
therapy unit of the Royal Sussex County Hospital.
Success in the examination at the end of this training
permits the personnel to undertake defibrillation. Following
a six-month period of further field work, personnel
undertake five days’ training in intubation and
intravenous cannulation. Satisfactory performance
during this training permits the ambulancemen to function
as fully trained personnel. Annual refresher periods
of five days are tailored to individual requirements,
and continual review of individual performance
is undertaken through regular meetings and discussion
of specific cases.
Principles of Training
The following principles of training have been applied:
1. Ambulancemen should be able to deal effectively
with all common life-threatening emergencies.
2. Invasive procedures capable of causing great
harm should be avoided.
3. Drug therapy should have a wide margin of
safety.
4. The course of instruction should be sufficiently
275

AMERICAN JOURNAL OF EMERGENCY MEDICINE ¯ Volume 2, Number 3 ¯ May 1984
comprehensive to generate confidence within the ambulancemen
of their ability to cope with all but the
most unusual cases.
5. Their competence should enable them to perform
without recourse to telemetry or central radio control.
RESULTS
The average number of calls per day handled is 33,
with a response time (from receipt of call by headquarters
to arrival at the scene) of 21% by 4 minutes,
40% by 5 minutes, 61% by 6 minutes, 75% by 7 minutes,
and 82% by 8 minutes, with a mean response
time of 5.4 minutes. These figures are well within the
Department of Health and Social Security recommended
times, but of course are somewhat slower
than one would ideally like to see.
Of approximately 12,000 emergency calls in 1981,
O
O
29 attempted resuscitations were made for out-of-
hospital cardiac arrest. Ten of these cardiac arrests
occurred in the presence of ambulance staff, and all
those patients were subsequently discharged from
hospital in satisfactory condition. Retrospective analysis
has shown that 21 of the 129 patients were considered
unresuscitable. This leaves 98 patients who
were thought to be resuscitable. Of these 98, 21 survived
and the remainder died, Of these 21 survivors,
52% received basic cardiac life support (BCLS) before
the arrival of the ambulance. Of the 77 patients who
died, only 28.6% received BCLS. The total of 31 survivors
from our population represents approximately
10 per 100,000.
As a measure of the efficiency of our resuscitative
measures, we have established that of the 31 patients
276
receiving BCLS, 26 received BCLS within 4 minutes
and advanced cardiac life support (ACLS) within 8
minutes, and I l survived. This survival figure for this
subgroup is 43%, which is comparable to the figure
quoted by Eisenberg et aL l
Of those 33 receiving bystander CPR, there was no
significant difference in the adequacy of CPR between
survivors and nonsurvivors.
We are, of course, interested in long-term survival.
From our 1974- 1976 records, we know that of 18 patients
under the age of 65 who were working before
out-of-hospital arrest, 14 returned to work. From the
31 survivors in 1981, 26 were alive at five months, and
long-term follow-up of previous years’ survivors has
shown a 77% survival at two years.
CONCLUSIONS
I. The implementation of comprehensive advanced
training of ambulancemen is feasible.
2. The use of advanced trained ambulancemen
working independently in emergency vehicles is effective
and not costly.
3. The pattern of survival when related to the use
of BCLS and ACLS supports the extension of CPR
training into the community.
4. Improved ambulance response times would be
beneficial to those patients denied BCLS.
REFERENCES
1. Eisenberg MS, Bergner L, Hallstrom A. Survivors of out-ofhospital
cardiac arrest: Morbidity and long-term survival.
Am J Emerg Med 1984;2:189-192.

~t
L,~9-03-09 16;.,30 01 383 6418 B M J EDITORIAL 014
@
*It
A full list of authors is given
at the end ofthis paper
Correspondence to: Mr M J
Allen, L¢i¢~teJ Royal
! nfirmary, Leicester
LEI 5WW
Br Mt~+? 19~t9.2~I 65 |.4
MIDDLES
FOR THE URGENT AI7ENTION
..... e ..J
FROM ....... ....
NUMBER OF SHEETS...-~-. ......
BMJ FAX 01 383 6418
BMJ PI1ONE
01 383 6355
Coping with the early stages of the MI disaster: at the scene and
on arrival at hospital
Staff of the accident and emergency departments of Derbyshire Royal Infirmary, Leicester Royal
Infirmary, and Queen’s Medical Centre, Nottingham
Last month Kirsh et al reported how the 88 initial to prevent leaking fuel from igniting. This made the
survivors of the Boeing 737 aircrash were treated inembankment
extren~ly slippery. Ropes, ladders, and
hospital and on the outcome three weeks after the steps dug by mountain rescue teams proved extremely
crash.’ Here we describe how the three main hospitals’ useful for the qgik., lllumination was poor at first. As
accident and emergency services coped with the the rescue operation progressed, with removal of
disaster in its initial stages: at the scene of the accident victims and wreckage cavities of 3-5 m appeared in the
and on arrival at hospital.
tail and rear fuxlage, necessitating the use of ropes to
At 8 26 pm on Sunday 8 January 1989 a Boeing 737 lower doctors to patients.
with 126 passengers and crew on board crashed into
the western embankment of the Ml motorway just
south of junction 24 after an attempt to make an
emergency landing at East Midlands airport. The crash
occurred on the borders of three counties: Derbyshire,
Leicestershire, and Nottinghamshire (fig 1). Thus
plans for dealing with a major accident were activated,
entailing police, fire, ambulance, and medical services
Nottinglutm
from each of the counties. This had the adva.ttage that
more thai, ~deq~mt¢. hcadth care ~rvloee were avadabte @
but th~ disadvantage of complex organisafional and
communication problems. Coordination was essential
to the rescue operation.
Initial response
At about 830 pm the accident and emergency
departments of the three main hospitals (Derbyshire
Royal Infirmary, Leicester Royal Infirmary, and
Queen’s Medical Centre, Nottingham) were alerted
about an aircraft attempting an emergency landing at
Past Midlands airport (a common call for any hospital
in the vicinity of an airport).
There was tome confusion and initial confirmation
of a major disaster was not received at any centre. As
the crash happened during a peak time for people to
v~atch television the early news flashes prompted the
response of most of the staff who came into the
"departments thus byparadng the telephone call in
system for major ditaster=.
Flying squads were sent from the three hospitals,
and subsequently two back up =quads with extra
equipment wer= dispatched from Leicetter Royal
Infirmary and Derbyshire Royal Infirmary.
The accne
On impact the aircraft broke into three sections: the
tail, main fuselage, and cockpit (fig 2). Victims were
trapped by twisted wreckage in the flipped tail and the
front and rear sections of the fuselage. In the main
fuselage the floor had collapsed into the cargo hold and
injured people were trapped by collapsed seat frames,
which had concertinaed.
Access to the aircraft and victims was difficult for
several reasons. The embankment sloped about 30 ° to
the horizontal and was thickly wooded. The airport fire
services had sprayed foam on to the aircraft and hillside
B.Vi] vo~ t’~t: 298 11 MARCH 1989 651
rm I-,tl~,~’omJ.
Memben of the ~ing uluads divided into teams ofa.
doctor and a nurse. The team from Derby operated in
the tail section, that from Nottinsham in the adjacent
~1 and rear fuselage u~:tion, and that from Lek:euer
in the main fuselage and cockpit. Equipment was
limited to what could be carried in e pocket and
treatment restricted by access until patients wee=
partially or completely extricated from the wreckage.
Coordination among the teams became established
once all the squads were on site, although there was
some delay because of the difficulty in identifying
medical staff. In addition, the nature and location of
the wreckage made communication among the teams
extremely diffk’~|t.

@
Triage point
¢,~a.z tt - lwfiCt, a.,xfi~ a’orn in #J ~d~u
Th. tiros ~wmvuatton of aLa~ut 40 patients was tO a
triage point on the motorway, but rapid transport
to Queen’s Medical Centre by ambulance crews on
instruction f~rn their control centre and the demand
for medical ’teams on the aircraft caused this triage
point to disappear. Once the triage point was reestablished,
equipped, and staffed it became the focal
point for the medical services. Patients were reassessed
at this point before being transferred to hospital,
although conditions were less than ideal.
Types of in|uries
Most of the survivors had multiple pelvic and leg
injuries attd to a lesser extent trauma to the skull,
spree, alsd chest. Abdonfinal injuries were rare.
A subsequent analysis of all injuries showed that 83
.i~tie!:ts sustained 324 separate injuries (table I). These
mjurtes were coded according to the 1985 revision of
the abbreviated miury scale.’ The grades of injury
were tabulated against the six body regions that were
used for the calculation of iniury severity scores.’
Although the scoring system originated from statistics
from road traffic acddents, it has become the univerully
prefcrrod system for assessing the severity of
impact injuries. Table II shows the mean score and the
?Aatz t--Abbrepimod iajury teals (AIS) ~ode for 324 injuria in B3
patWnt~ 1 ’slues ar~ nambers of inj~rrics ’
AI$ code
Bed.~ ~eJ,,~ ! 2 3 4 ~ Thud
Hced o, neck
F~c¢
2 4 5 2 2
4
I S
Cheer 2
4 ?
6
? 4 22
L ~. I¢ pclCiC ¢t’~t ents " trcmitica ~r Ixdvi¢ Iprdh: |0 S ! I 17
.!
Iczlcrnal
84 68 ] }}-
104 4 I 109
Total 117 111 86 7 ~ ~.4
injury .~verity Score
Unit
Umv~ndt). Hmpilal, Noctingl~m
Derbyshire Royal Infirmary
[.t’kesler Royal lnRrmery
No tsrp~tiet~ls
38
2~1
20
Ransc
l.,T~
1-34
| .43
M¢lm
9.6
12" I
14.5
Nn ~f patk’nts
with scott. ~ :6
9
7
6
Total
S3 1-4~ ! t "5 22
range and the numbers of put..’ngs with scores o’
greater than ]6 for each centre.
Treatment
Treatment was focused on the patients who were
trapped in the aircraft as those who were not trapped
were rapidly transferred to hospital bythe initial
wave of ambul.m~.., crews. PYiorities were ~---’l~,o
.~rways, estabhshing access to the circulation "1~
intravenous fluids and analgesia, and applying splints
when possible. The victims were reassessed at the
triage point, once it was re-established, with regard to
life threatening injuries and the above priorities.
Transfer to hospital was then organised.
With the pattern of injuries from this incident large
supplies of intravenous fluids, administration sets,
analgesia, and splints were required. Further requirements
for these items were relayed to the base hospitals,
but they took some time to arrive. Some supplies were
never received.
’rrll~apofl ~" *
The initial coordination el" the three ambulance
Evacuation by ambulance ~o Queen’s Medical C.¢ntr~
and Derbyshire Royal Infinmu? was comparatively
easy as they were the aearest cemres on the least
congested routes.
As the rescue became oqlmised it was controlled by
the chief ambulance of’ricer oa tit:. ,As tufa-marion w~s
relayed at, the dlstributiot; of patients among the three
hospitalg, fln.th4~1.1 ~il~s were.redirected accordingly.
The roads had become ongested by this time and
helJcopter~, two Sea Kin~p and two Wes~xes, were
used to transport injured peup]e to Leicester Royal
Infirmary (flying time nine minutes). This was despite
the patients’ obvious concern about further air travel.
Communication
in one centre excellent direr communication was
achieved between staff at the scene and thr.~e at the
base hospital by the use of a cellular telephong.
This, however, did not Wevent confusing rumours
spreading ft’m~ mher ~ Communication between
the site and the other two hospitals was thought
to be inadequate, althotlgh the cellular telephone was
used to a~ertain where the i~ured people had been
taken and to redire~ them accordFu~iy. As far as we arc
aware there was no intercommunication between the
three hospitals.
As with all disasters, cmmmmlcadou was criticis~l.
It should be ~ed, however, tim com0entional, day
to day methods of taxnmmimk~a mano~ be used
when a di~aer has o¢cmr~. ~g’t’¢a hmutrt.d people
were on site throtigll~t varle~ ~ of the regu¢
operation and had a lot of~ to relate.
Communicatio~ betwem tl~ aizgraft and the triap
point was ~mm~y dil~ah, IP.aq~,st~ for equipment
had to be relayed verlxdly md could berune quite
distorted. Comidem~ time mid be lint by nurses
climbing dowh from the upper nadtes of the emMnkment,
where ti~: ¢ociq~t real freat fuselage section
were located, to the triage ~ to ~ for equipment.
The only method of mahmtk~ an update on the
rescue operation was toclimbmd scramble around the
aircraft. This took about 20 w.i~utea.
Initial respom~ of hospttaib
USE OF .~AFF
All three ho~. "utls found that they had more than
enough med:cal staffand in some instances an excess.
BMJ VOLUg~ 298 I I M^ReH 1989

~ .-..
@
@
,~ . ,.~nt,~:,:~t~ m~" grade and sl.~:alty
of both doctors and nurses.
[n each hospital one consultant in accident and
emergency medicine took charge of the triage point
and another the resuscitation room. The doctors in the
accident snd emergency departments formed teams
and in one centre were clearly identified with tabards
and sashes. Each team worked in a designated area.
The specialty coordinator retained a supervisory role
and did not participate in treating individual patients.
Once the initial resuscitation procedures had been
carried out patients were then transferred to the
admitting teams. The flow of patients through the
departments was too rapid in some instances owing to a
lack of information on numbers of patients and the
severity of their injuries. The automatic response was
to treat patients rapidly+ keeping the accident and
emergency departments clear. The initial transfer of
patients from the scene was extremely fast, thus
applying pressure on thc deparunents to treat the
patients as quickly as possible.
More than one entrance point to the department also
caused confusion at one centre.
t30~:U~X’rlON
Difficulty was encountered in the documentation of
the patients and the deciphering of rapidly made notes
in the accident and emergency departments. Each
hospital used its own system of documentation at the
scene of the crash, which proved confusing. Often
triage labels were absent on admission, and the
information contained in those present was of little
value,
Having only one copy of notes with each patient
caused problems at the base hospitals.
Lessons to be learnt
In general the three centres dealt with the survivors
extremely well. The following points were thought to
be important.
AT "riie SCENE
(1) The identification of key staff should be
improved, which would make coordination and communication
much easier.
(2) On arrival of the first flying squad teams an
assessment should be made of the pattern and type of
injuries requiring treatment. Appropriate equipment
accompanied by a nurse should be requested and transferred
to the scene. Specific specialist staff requirements
could sis0 b¢ mobilised at this point.
(3) The triage point should be clearly identified and
illuminated, with one nurse in charge of all of the
equipment.
(4) A tmified system of categorising patients would
be advantageous. At this incident each hospital had its
own particular methods of labelling, which ~aus~
problen~. Such a unified system should be extended
throughout the oumry because of the constant movemeat
ofjunlor staff from place to place.
(S)Evl~-uetlon by helicopter proved to be extremely
useful. The helicopters used could handle up to 10"
patient~l on stretchers, medical staff being able to
eccot~pany them and give treatment with comparative
ease. m addition, relief staff and additional equipment
could be easily transferred to the. scene.
(6) Provision should be made for the changeover of
medical staff if the time required at the scene of the
disaster is prolonged.
(7) The cellular telephone was invaluable, allowing
direct communication between the scene of the disaster
and the base hospital. When more than one centre
is concerned, however, methods should exist for
communication between hospitals.
~8; ltand held radios with transmitting and ret’eiving
capabilities would have been btneficial fo~ asking for
equipment and staffand passing on information on the
numbers of patients and the stages of extrication. To
have had more than four sets (three for the aircraft and
one for the triage point)+ however, would have created
havoc on the airwaves.
(9) When more than one centre is concerned with
receiving the survivors of a disinter the patienus
should be appropriately distributed hat--ares.
This would require regular communication betweea~
hospitals aswell as between the hospitals and the scene:
(10) In any major disaster hazardo0s conditions may
exist; in this instance the hazards were 77 000 iitres of
aviation fuel and the slippery terrain. Provision should
therefore be made for treating possible injuries tO
rescuc teams, and care should be taken not to clo~ the
incident too soon.
AT THE HOSPITAL
(11 The call out I~r~tCln should be looked at closely.
Perhaps each specialty concerned should be responsible
for its own call out of staff.
(2) In this-pprticular disaster there were over 80
injm, ed people and one hospital alone would probably
not have been able to cope with tremin 8 the,t all.
Provision should therefore be made in disaster
planning for lxmlble ooperation with neighbouring
hospitals and plans formulated on how communications
would take place.
(3) A good method for the Identification ~ medical
and nursing staff would be useful and allow a more
effectiV~ ~ 6f’tl~lP~kllis,., ~: -+
(4) A simple’diagram to illustrate the in juri~ ~misht
have been helpful. $imi~Hyil,l,lcordnnhm+t,h,boxes
to tick for tetanus and antibiotic prophylaxis along
with the analgesia given might have been beneficial.
(5) Communications within the hospital proved
difficult. The u~e of "walkie talkies" by key sufffwould
improve the flow of patients.
(6) A systemised approach to the ~tatton of
patients is required, and a copy of the notes should be
left for the records of the accident and emergency
departments.
(7) A consultant radiologist should be included in
each major disaster team and in the call out system.
Discussion
¯ Each disaster presents its own problems. Disaster
practice exercises tend to con~ntrate on airports or
major industrial complexes, where the potential exists
for many people to be hurt. There should, however, be
an element of flexibility to cater for the unexpected. In
this incident the aviation fuel fortunately did not ignite
and alter the pattern ofinjuri~.
A major disaster stretches tl~ remurg~ of the
emergency servk’~t tu an exLren~. The extremity was
not reached at this incident bqa:ause of the capabilltigs
of three major disaster plans.
The six’~"ficity of the phms ~ frota day to day
routine. Thu~d~hl 0¢t~’"tiid~ what should
h, ve h*ppen~l ~ wha did +~. ThJ. led to
crittclsm at debriefing sessions; mine crilktsms may be
justified, song impossibl© to relolve. &lthotqgh dug
theo behind em in
this can be di~R. to ~:~0 Im~mse of the
unfamiliarity and devlatlon fi-0m ~lim:.
At the scene chaos and confusion were commlled
more by regularity than by the disaster plan. The first
40 patients transferred to Queen’s Medical C~tre,
Nottingham, had little triage or tr~tng’m at the scene
becau~ of the sheer numbers of ambulances available
to "scoop and run." This they did ss is their normal
practice. They cannot be expected to wait for the
~tO qwISO±IO~ " ~ ~ Rtbo gqg 10 Zg:gt 60-g0-6~6t
6.~

O
L
arrival of medical teams with organised triage points.
To the receiving hospital this was a considerable izhqux
of patients who had not received prehospital care, and
staff in the hospital did not know how many more were
to come or the extent of their injuries as they had no
communications with those at the scene. This applied
pressure on the accident and emergency departments
to process the patients as fast as possible. The conditlon
of several patients deteriorated in the x ray
department and may not have done so had this
pressure on rapid assessment and management not
been present.
To have many doctors available on site was an"
advantage. To have volunteers present who were not
from the flying squad system, although admirable, did,
however, cause some concern to the site medical
officer, who was not aware of their capabiJiti~ or
lidlhatione in an unsupervised environment in which
communication was bad. Had the triage point been
~mtabllsh.d e~Lier, or the :sh~: mcd.[~al o[fi~cr I:~u
more ldenfifiablc, better control could have existed.
The triage point could be recognised from boxes of
colloid, administration sets, and familiar faces in the
crowd of luminous jackets.
The flying squad functioned well in a situation uot
far removed from their usual practice by splitting into
teams of two to treat the trapped’patients in various
sections of the wreckage in cramped, awkward, and
dangerous conditions. The extent of their role can be
gauged from the supplies used~ The familiarity and
ease with which they operated in this incident empha.
s/seal one of the arguments for their existence.
Despite the arguments and criticisms this incident
has produced within the medical profession the casualties
received treatment that would be extremely
NHS Review
Radical change of policy on NHS pay
Roger Dyson
.
This is tl’~ fourth in I
series ofanides which ,~
comment on the whit~
~=y~k’~. ~r .
~m~mum~ll~
i~m~
~_.._~’r~.
~
TI~. s~_ie~
The government’s review of the NHS confirms a trend
towarda . pay devolution alread Y underway
in Whitley
~il agreements and offers self governing hospitals iraqi .~St ~n~ted li~ onaitiOnS scope to~t Of emnlovment independently | Tk..~. in setting
devglopments constitute a rem~ka’ble ch~uge in" "~’";
~ philosophy that will do more to chan~ the
(s~u4~ ¯ r ,. ~ on Is ~e~
"" ¯
~ of the NHS than other more immedia !
~si~ smtherev’ ’ ~ y
~. ..... ~ ~
~ew. In parucular the rapid
~xums~on-o~ pay devolution raises a longer term
..... ether health professionals.
"r +
’’~ J At mational level the review makes clear that "the
Iovernment’s objective throughout the service is progrestively
to introduce greater flexibility in order to
allow managers to relate pay rates to local labour
markets and to reward individual performance." This
process has already started and inc/udes both grading
and pay flexibility.
~. Department of Aduh sad
~".umstinuial Education,
UM~y of Keela, Kse~,
Su,5ord~hh~ $T5 5~G
Rog~ Dymn, I’HD, director
Two major grading flexibility agreements were
introduced in 1988 for nurses and for medical laboratory
scientific officers. Despite many faults, the clinical
grading review in nursing has introduced a structure
with several opportunities for grading flexibifity and
h~gher pay in the future. The introduction of more
&M~] ~*-~m:+s¢.s primary nursing and clinical nursing specialist posts is
654
difficult to improve upon, given the disastrous nature
of this incident. Lessons have been learnt. We empha.
sise that such good medical care would not have been
possible without the excellent ooperation, deification,
and help from our olleagues from the f~e, polk~, and
am~ servk~s as well as ~ helicopter crews and
mountain rmc~ teams.
Wc dmak the deporuments of medical ~u~on
l~’rb)~hite and L,ekater Royal hb~mnri,.s for ~ help~
and ~ BmT~ for his editorial help.
S ~--,, -. m ~eene [at me scene); Dr D Baker, Dr N ,
Boucher, Dr S Dave, Dr A Dove, Dr S Dexter, Dr N French,
Dr J Mason, Dr D Miller, Dr ] Vanuim, Dr D Virdee, Dr T:
. parua~.~; ,.,~:mre ~a/l~.: Dr A Morris, Dr S i~
remain, Mr P Prltty, Ms Jme Warn (phmoBrapher) Oft the .....
scene); D~ M Dco~, Dr l Gordon, Dr W Malone, Dr L
OIi-,~r, Dr A Watt, Dr D qC~Ul~, Dr J’ W~st~a, ~ A leja~4.-
Moodie (in the depsrunent); L¢iccuo Royal l~rmary: Dr L
Beaumont, Dr C Harper, Dr I Hume, Dr S Mard©., Dr M
Mowbnty, Dr M Underwood, Mr M Allem, Mr D Barton, Mr
J Harper (at the scene); Dr V Cheppel, Dr J Dive, r, Dr A
McCaskie, Dr G Siqlh, Dr M Thompson, Mr G Bodiwals,
Mr D D~Cruz, Mr i Pimir, Mr D Qumu~ (in the depsn.
meat).
s~n’ad~
,,,- ,,mmuou:. ~ pay flexibifiw has already been
proposed to the nurses’ pay review body in the
mantgcmcnt side’s evidence, and in the current negotiations
with the administrative and clerical Whidey
ouncil the management’s representatives are pressing
for some local pay devolution on the back of a
completely new and more flexible grading structure, In
these negotiations the Department of Health gives
the impression of being determined to press ahead
irresp~tive of the opposition of the staff sial. F to the
principk of local pay devolution.
Much has yet to be decided about the range of pay
~J VOLUME 298 l I ~4A~CH 1989
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