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SURVIVORS AFTER CATASTROPHIC PREHOSPITAL ILLNESS: LONG-TERM OUTCOME AFTER PREHOSPITAL LIFE-SAVING TREATMENT.

N.K. Schønemann and A.M. Christensen.

Mobile Emergency Care Unit. Department of Anaesthesiology and Intensive Care, Aarhus Amtssygehus, Aarhus University Hospital, Aarhus. Department of Anaesthesiology and Intensive Care, Randers Centralsygehus, Randers. Denmark.

Introduction:

Early advanced treatment in cases of severe injury or severe acute medical disease is essential, not only for immediate survival but also for prognosis in a long term view.In Denmark, the prehospital emergency system generally works according to the Scoop and Run principle, and only in a few urban areas can medical support be requested. There is limited documentation on the long term effects of advanced prehospital treatment. The purpose of this study is to describe the long-term outcome of prehospital life-saving procedures, which brought the patient to the hospital alive.

The prehospital service in Denmark

Ambulance crew in Denmark is trained to give a number of medications and perform basic life support with defibrillation. The medication that can be given is salbutamol inhalation for astma, nitroglycerin for centrally located chest pain, rectally given diazepam for convulsions, EpiPen for anaphylactic reactions and Entonox for pain relief.

The MECU-staff (Mobile Intensive Care Unit) in Denmark consist of an anaesthesiologist and a specially trained rescuer. The MECU is equipped to perform advanced life-support to most medical cases and trauma. Starting May 1997 a twotiered prehospital emergency system was initiated in Aarhus City covering a population of 330.000 people inside a radius of 25 km.

Methods:

Retrospective analysis of data collected by the MECU doctors on a standardized chart from 1 January 1998 to 31 December 1999 and data received from a central hospital database with focus on survival data. The MECU database  contains tentative diagnosis, clinical evaluation,haemodynamic and respiratory values, Glasgow Coma Score, specific treatment and administration of medicine as well as an estimate of the effect of treatment. The MECU-doctor estimate the condition after  treatment as: 1) Unchanged 2) Improved 3) Considerable improved 4) Life-saving 5) Worse 6) Dead. In case of life-saving treatment, this statement is given, when the evaluation is that the patient would not have reached the hospital alive, unless treatment was given on scene. It is difficult to isolate the treatment given by the MECU from that given by the ambulance crew, because generally the performance must be evaluated as a team procedure. A medical audit of the MECU doctors evaluation concluded that in all the cases evaluated, the audit commission agreed with the statement of MECU-doctors.

Statistics: chi-square and t-test.

Results:

From 1 January 1998 through 31 december 1999 the MECU was dispatched 9386 times. In 158 cases the treatment was estimated as been life-saving. One hundred and twelve of these patients were discharged from hospital and 103 was alive one year after. The six  diagnostic groups were veneficium, cardiac arrest, trauma, respiratory diseases and other cardial diseases. The sixth group contains several different diagnosis, among which are anaphylactoid shock, cerebral diseases and metabolic disorders. Sixty seven of the 158 patients were intubated on scene. All patients recieved some sort of medication/treatment, which the ambulance crew are not alloved to give.

* Comparision with patients who died in hospital. (p<0,05)

Conclusion:

To reduce death from prehospital catastrophic illness, early and effective treatment is crucial and procedures performed by the MECU-staff are essential in this setting. The MECU is capable of performing advanced life-support to most medical cases and trauma on scene. The results indicate that even with catastrophic illness in a prehospital setting, good long-term results can be achieved with dispatch of medical personnel. A MECU organisation is expensive, and a certain population size is nedeed to justify this. The actual setting with a population of 330.000 inhabitants, and about 4500 dispatches a year seems appropiate.

           The six main diagnostic groups :