Original article 103
Helicopter emergency medical services response to equestrian accidents Richard M. Lyona,b, Ben Macauleyb, Sarah Richardsona, Richard de Coverlyb, Malcolm Russellb and on the behalf of Kent, Surrey & Sussex Air Ambulance Trust Background Horse riding is a common leisure activity associated with a significant rate of injury. Helicopter emergency medical services (HEMS) may be called to equestrian accidents. Accurate HEMS tasking is important to ensure appropriate use of this valuable medical resource. We sought to review HEMS response to equestrian accidents and identify factors associated with the need for HEMS intervention or transport of the patient to a major trauma centre. Methods Retrospective case review of all missions flown by Kent, Surrey & Sussex Air Ambulance Trust over a 1-year period (1 July 2011 to 1 July 2012). All missions were screened for accidents involving a horse. Call details, patient demographics, suspected injuries, clinical interventions and patient disposition were all analysed. Results In the 12-month data collection period there were 47 equestrian accidents, representing B3% of the total annual missions. Of the 42 cases HEMS attended, one patient was pronounced life extinct at the scene. In 15 (36%) cases the patient was airlifted to hospital. In four (10%) cases, the patient underwent prehospital anaesthesia. There were no specific predictors of HEMS intervention. Admission to a major trauma centre was
Introduction Equestrian activities for both competitive sports and leisure purposes have continued to gain in popularity throughout the past 30 years, with the most recent British Equestrian Trade Association National Survey (2010–2011) indicating that 3.5 million people ride a horse each year (6% of the population) [1]. Because of the nature of the sport, inherent risks are associated with horse riding and have been well described in the literature [2–6]. Horses weigh B500 kg, riders are unrestrained and the rider’s head is typically 2.5–3 m from the ground while travelling at speeds of up to 40 mph. The horse’s movements can be irregular and unpredictable, resulting in a high risk of ejection and falls [2]. Following a fall, the rider’s head and torso can experience g-forces of up to 300 g [3], resulting in significant potential for multiple and extensive injuries. An additional well-recognized risk of injury comes from the possibility of the horse either landing on or trampling the rider after the fall [3,7]. c 2015 Wolters Kluwer Health, Inc. All rights reserved. 0969-9546 Copyright
associated with the rider not wearing a helmet, a fall onto their head or the horse falling onto the rider. Conclusion Equestrian accidents represent a significant proportion of HEMS missions. The majority of patients injured in equestrian accidents do not require HEMS intervention, however, a small proportion have lifethreatening injuries, requiring immediate critical intervention. Further research is warranted, particularly regarding HEMS dispatch, to further improve accuracy of tasking to equestrian accidents. European Journal of c 2015 Emergency Medicine 22:103–106 Copyright Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:103–106 Keywords: emergency medical services, equestrian, helicopter emergency medical services, trauma a Emergency Medicine Research Group, Edinburgh and bKent, Surrey & Sussex Air Ambulance Trust, Kent, UK
Correspondence to Richard M. Lyon, MBChB(Hons), MD, MRCP, DipIMC, (RCS Ed), Kent, Surrey & Sussex Air Ambulance Trust, Marden, Kent TN12 2QJ, UK Tel: + 44 7967 731172; fax: + 44 1622 833 448; e-mail: [email protected] Received 1 September 2013 Accepted 2 December 2013
In contrast to other high-risk sports, participants are mostly female, with a high percentage of riders under the age of 19 and the majority of equestrian-related injuries occurring during noncompetitive [3] or recreational riding [8]. Although recent data have emerged suggesting that the rate of injury is relatively low in the context of the millions of participants involved in the sport, the rate of severe injury is much higher than that of other high risk sports such as American football, motorcycle and automobile racing [3,9]. Despite the literature consistently finding that orthopaedic extremity injuries are the most commonly sustained, head injuries have been found to be the most common cause of death due to horse riding [3]. However, deaths associated with neck and head injuries have significantly reduced since the introduction of protective head gear [10], with a study suggesting a five-fold decrease in head injuries [3] and another noting that 86% of patients involved in an equestrian accident were DOI: 101097/MEJ?0000000000000105
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
104
European Journal of Emergency Medicine 2015, Vol 22 No 2
wearing a helmet at the time [11], compared with 42% in 1971 [12]. Helicopter emergency medical services (HEMS) provide advanced prehospital medical care to victims of major trauma. Kent, Surrey & Sussex Air Ambulance Trust (KSS) is a HEMS service that provides advanced prehospital care to the southeast of England. Two helicopters, located at separate bases, provide prehospital medical and trauma care to three counties (population B4.5 million) and undertake B1400 missions per year. Approximately 70% of missions are for trauma and 30% for acute medical illness. The HEMS team consists of a pilot, a prehospital doctor, from an anaesthesia or emergency medicine background, and a critical care paramedic. In our region, HEMS provide the ability to perform prehospital anaesthesia, which is not performed by local road ambulance crews. HEMS regularly receive calls to equestrian accidents due to the inherent rural nature of the sport, resulting in poor access for conventional road ambulance crews, as well as the potential for significant injury. A HEMS flight paramedic in the ambulance control centre screens incoming emergency calls for HEMS suitability. This model of dispatch differs from standard ambulance dispatching in that the HEMS paramedic does not need to follow fixed clinical pathways and has the ability to telephone back the caller if more detailed clinical information is required. No fixed criteria exist for dispatching HEMS to equestrian incidents. Accurate HEMS tasking is important to avoid unnecessary standdowns and also to ensure critical care is delivered to those patients who require advanced intervention. Equestrian incidents resulting in injuries that can be managed by road ambulance crews need to be differentiated from those where the patient has sustained a major injury that may require time-critical intervention. We sought to review equestrian incidents attended by HEMS and determine whether any incident factors associated with the need for HEMS intervention could be identified at dispatch.
Methods The study took place during a 12-month period from 1 July 2011 to 30 June 2012. All mission records from KSS HEMS were reviewed retrospectively and activations to suspected equestrian incident selected. Missions where HEMS was stood-down en route were included. For missions where the HEMS team attended a patient, the HEMS patient record form was reviewed. Mission timings, incident details, patient demographics, suspected injuries, medical interventions performed and patient disposition were noted and entered onto a Microsoft Excel (Microsoft Inc., Redmond, Washington, USA) database, analysed and reported. The study met National Health Service criteria as a service evaluation.
We assessed each mission for markers of severity that may predict HEMS intervention or the need to transport the patient to a major trauma centre (MTC). These included horse-kick to the head, kick to the body, no helmet worn, landing on head, horse landing on patient, unable to mobilize following accident, witnessed seizure, landing onto hard ground and loss of consciousness.
Results Missions
In the 12-month data collection period there were 47 equestrian accidents, representing B3% of the total annual missions for Kent–Surrey–Sussex HEMS. Of the 47 activations, HEMS was stood-down en route in five (11%) cases, leaving 42 cases for inclusion. In 19 (45%) cases the HEMS team arrived on-scene but subsequent patient management and transport was left to the attending road ambulance crew. Of the 42 cases HEMS attended, one (2%) patient was pronounced life extinct at the scene. In 15 (36%) cases the patient was airlifted to hospital. The remainders were transported by land ambulance with the HEMS team in attendance. The majority of patients were female (n = 30, 71%) with a mean age of 33 (range 6–72). The timings of HEMS response to equestrian incidents are shown in Table 1. Injuries
Data regarding mechanism of injury was available in 37 cases (88%). Five (12%) patients had sustained a kick to the head and five (12%) a kick to the body. Twelve (29%) patients had suffered a loss of consciousness, eight (19%) were noted to be confused during the 999 call, with one (2%) patient being noted to have had a seizure. When asked about the fall during the 999 call, 13 (31%) patients were noted to have had a hard landing (not in horse arena with sand), three (7%) patients were thought to have landed on their head, and six (14%) had the horse land on top of them. Information regarding the wearing of a helmet was noted in 16 cases. Of these, 12 (75%) were wearing a helmet when they fell. Initial Glasgow Coma Score (GCS) on arrival was documented in 40 cases, with four (10%) patients having GCS of 8 or less [2 (50%) of these patients had a GCS of 3]. A GCS of 14 was noted in a further five (12.5%)
Timings of helicopter emergency medical services response to equestrian incidents
Table 1
Time interval
Median (min)
IQR (min)
19 30 32 98
9–29 22–45 26–44 81–114
999 call–HEMS activation 999 call–HEMS on-scene HEMS on-scene–leave scene 999 call–arrival at hospital
HEMS, helicopter emergency medical services; IQR, interquartile range.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
HEMS response to equestrian incidents Lyon et al. 105
patients, with the remaining 31 (77.5%) patients assessed as GCS 15 upon HEMS arrival. Prehospital injury description was available for 39 (93%) of the patients. Of those with data available, seven (18%) were documented as having no injury. Multiple injuries were documented in 13 (33%) cases. Patients’ injuries are shown in Fig. 1. Helicopter emergency medical services intervention – prehospital anaesthesia
To assess the patients that may have benefitted from HEMS intervention we analysed patients who underwent prehospital anaesthesia. Four patients (10%) required prehospital anaesthesia at the scene. These patients are shown in Table 2. Two of the four patients had severe chest injuries requiring prehospital anaesthesia followed by chest decompression with open thoracostomy on-scene. Markers of severity
Each mission was analysed for possible markers of severity. As no validated makers of injury severity from equestrian injury exist, we adopted pragmatic indicators. Reports of the horse landing on the patient, the rider being kicked in the head or lack of a riding helmet and the rider landing on their head were associated with the highest rates of direct transport to a MTC, as shown in Table 3.
12 10 Number of injuries
This study shows the equestrian accidents represent a significant proportion of HEMS missions, although the incidence of prehospital anaesthesia is low. There appeared to be a large variation in the injury severity of equestrian patients attended by HEMS – these ranged from minor limbs injuries requiring ambulance transport to a minor injuries unit to complex major trauma requiring urgent prehospital intervention. In this cohort, we did not identify any factors that could objectively be associated with a clinical HEMS intervention, although the study cohort is relatively small and further research in this area is warranted. Neurotrauma and suspected internal haemorrhage were the commonest suspected significant injuries. Accurate tasking of HEMS to these cases can allow advanced prehospital intervention in the form of prehospital anaesthesia and facilitate rapid transport to an appropriate hospital, including passing a prealert to the MTC in cases of suspected major haemorrhage. In contrast to other studies in this area [10], we observed a higher rate of injured equestrian patients being transported to an MTC. Overtriage by the HEMS team is likely, as are cancellations following initial activation. The optimum HEMS stand-down rate is not known but 30% if often deemed a reasonable compromise between inappropriate activations and potentially missing cases. Further prospective research including the exact nature and severity of equestrian patient injury would inform the overtriage rate. We did not specifically examine equestrian accident cases with limited patient access due to geography, other options of patient transport, such as off-road vehicle, can be considered for patients with nontime critical injuries. The use of the helicopter to access or transport equestrian accident patients in remote geographical locations with nontime critical injuries should probably be considered on a case-by-case basis. Such patients may not require time-critical, high-end medical intervention but may have an improved patient experience if airlifted from scene.
Fig. 1
8 6 4 2 0 Head
Table 2
Discussion
Chest
Spinal Abdomen Pelvic Suspected injury region
Lamb
There was a large variation in HEMS activation time to equestrian incidents during the study period. This is likely to represent the HEMS dispatcher either activating
Equestrian injury patients undergoing prehospital anaesthesia
Patient Age
Sex
999 call to HEMS activation (min)
999 call to HEMS onscene (min)
GCS on arrival of HEMS
1
18
Male
25
47
3
2
25 Female
63
74
14
3
30 Female
15
34
4
30 Female
68
83
Mechanism of injury Unclear
Suspected injuries
Horse fell onto patient
Severe intra-abdominal haemorrhage Head and chest injury
5
Unclear
Head injury
3
Rider fall striking head on ground
Head injury
GCS, Glasgow Coma Score; HEMS, helicopter emergency medical services; MTC, major trauma centre.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Outcome Died at scene Flown to MTC Flown to MTC Flown to MTC
106
European Journal of Emergency Medicine 2015, Vol 22 No 2
Table 3 Severity markers of equestrian accidents attended by helicopter emergency medical services and transport rate to a major trauma centre
Severity marker Kick to the body Kick to head No helmet worn Landing on head Horse landing on patient Unable to mobilize after accident Witnessed seizure Landing on hard ground Loss of consciousness
Total number of patients with injury severity marker 5 5 4 3 6 26 1 13 12
Number of patients transported to a major trauma centre [n (%)] 1 4 3 2 5 11
(20) (80) (75) (67) (83) (42)
0 5 (38) 4 (33)
Patients may have had more than one severity marker and can therefore figure in several categories.
equestrian accidents do not require HEMS intervention, however, a small proportion have life-threatening injuries, requiring time-critical intervention. The rider not wearing a helmet, falling onto their head or the horse falling on the riders were associated with a high risk of MTC admission. Further prospective research is warranted to identify which patients, injured in equestrian accidents, are likely to benefit from HEMS intervention.
Acknowledgements B.M. and R.M.L. was responsible for compiling the initial data set. All authors were involved in planning, data review and manuscript preparation. R.M.L. acts as guarantor. Conflicts of interest
the aircraft immediately from the available information or waiting for the arrival of a land ambulance on-scene to gather further information. The role of the dispatcher in HEMS activation is important in ensuring the HEMS teams are dispatched to missions likely to benefit from early critical intervention. Further prospective research is warranted on HEMS input to equestrian accidents to identity factors likely to improve accuracy in tasking. This study has several limitations. The sample size is relatively small and may not be large enough to detect specific trends related to equestrian injuries. We did not have access to the actual voice recordings of calls or patient follow-up at hospital. Both of these may have added valuable data to the study. Detailed physiological data, Injury Severity Score, patient injuries identified on hospital arrival, length of hospital stay and patient outcome should all be collected as part of future work in this area to actually inform HEMS tasking to equestrian incidents. Conclusion
Equestrian accidents represent a significant proportion of HEMS missions. The majority of patients injured in
There are no conflicts of interest.
References 1
BETA National Survey 2010-2011. Available at: http://www.beta-uk.org/. [Accessed 1 May 2013]. 2 Carillo EH, Varnagy D, Bragg SM, Levy J, Riordan K. Traumatic injuries associated with horseback riding. Scan J Surg 2007; 96:79–82. 3 Ball CG, Ball JE, Kirkpatrick AW, Mulloy AH. Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries. Am J Surg 2007; 193:636–640. 4 Havlik HS. Equestrian sport-related injuries: a review of current literature. Curr Sports Med Rep 2010; 9:299–302. 5 Paix BR. Rider injury rates and emergency medical services at equestrian events. Br J Sports Med 1999; 33:46–48. 6 Jagodzinski T, Demuri GP. Horse-related injuries in children: a review. WMJ 2005; 104:50–54. 7 Murray JK, Singer ER, Morgan KL, Proudman CJ, French NP. Risk factors for cross-country horse falls at one-day events and at two-/three-day events. Vet J 2005; 170:318–324. 8 Hamilton M, Tranmer BI. Nervous system injuries in horseback-riding accidents. J Trauma 1993; 34:227–232. 9 Smartt P, Chalmers D. A new look at horse-related sport and recreational injury in New Zealand. J Sci Med Sport 2009; 12:376–382. 10 Bleetman D. The equestrian sport-related injury workload in a regional doctor-led air ambulance unit. Injury 2012; 43:2023–2025. 11 Pueschel V, Michaelsen U, Glensch M, Lockemann U, Meenen NM, Hessler C. The question of safety in horse-riding sports. Sportverletz Sportschaden 2012; 26:59–163. 12 Barber HM. Horse play: survey of accidents with horses. BMJ 1973; 3:532–534.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Helicopter emergency medical services response to equestrian accidents Richard M. Lyona,b, Ben Macauleyb, Sarah Richardsona, Richard de Coverlyb, Malcolm Russellb and on the behalf of Kent, Surrey & Sussex Air Ambulance Trust Background Horse riding is a common leisure activity associated with a significant rate of injury. Helicopter emergency medical services (HEMS) may be called to equestrian accidents. Accurate HEMS tasking is important to ensure appropriate use of this valuable medical resource. We sought to review HEMS response to equestrian accidents and identify factors associated with the need for HEMS intervention or transport of the patient to a major trauma centre. Methods Retrospective case review of all missions flown by Kent, Surrey & Sussex Air Ambulance Trust over a 1-year period (1 July 2011 to 1 July 2012). All missions were screened for accidents involving a horse. Call details, patient demographics, suspected injuries, clinical interventions and patient disposition were all analysed. Results In the 12-month data collection period there were 47 equestrian accidents, representing B3% of the total annual missions. Of the 42 cases HEMS attended, one patient was pronounced life extinct at the scene. In 15 (36%) cases the patient was airlifted to hospital. In four (10%) cases, the patient underwent prehospital anaesthesia. There were no specific predictors of HEMS intervention. Admission to a major trauma centre was
Introduction Equestrian activities for both competitive sports and leisure purposes have continued to gain in popularity throughout the past 30 years, with the most recent British Equestrian Trade Association National Survey (2010–2011) indicating that 3.5 million people ride a horse each year (6% of the population) [1]. Because of the nature of the sport, inherent risks are associated with horse riding and have been well described in the literature [2–6]. Horses weigh B500 kg, riders are unrestrained and the rider’s head is typically 2.5–3 m from the ground while travelling at speeds of up to 40 mph. The horse’s movements can be irregular and unpredictable, resulting in a high risk of ejection and falls [2]. Following a fall, the rider’s head and torso can experience g-forces of up to 300 g [3], resulting in significant potential for multiple and extensive injuries. An additional well-recognized risk of injury comes from the possibility of the horse either landing on or trampling the rider after the fall [3,7]. c 2015 Wolters Kluwer Health, Inc. All rights reserved. 0969-9546 Copyright
associated with the rider not wearing a helmet, a fall onto their head or the horse falling onto the rider. Conclusion Equestrian accidents represent a significant proportion of HEMS missions. The majority of patients injured in equestrian accidents do not require HEMS intervention, however, a small proportion have lifethreatening injuries, requiring immediate critical intervention. Further research is warranted, particularly regarding HEMS dispatch, to further improve accuracy of tasking to equestrian accidents. European Journal of c 2015 Emergency Medicine 22:103–106 Copyright Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:103–106 Keywords: emergency medical services, equestrian, helicopter emergency medical services, trauma a Emergency Medicine Research Group, Edinburgh and bKent, Surrey & Sussex Air Ambulance Trust, Kent, UK
Correspondence to Richard M. Lyon, MBChB(Hons), MD, MRCP, DipIMC, (RCS Ed), Kent, Surrey & Sussex Air Ambulance Trust, Marden, Kent TN12 2QJ, UK Tel: + 44 7967 731172; fax: + 44 1622 833 448; e-mail: [email protected] Received 1 September 2013 Accepted 2 December 2013
In contrast to other high-risk sports, participants are mostly female, with a high percentage of riders under the age of 19 and the majority of equestrian-related injuries occurring during noncompetitive [3] or recreational riding [8]. Although recent data have emerged suggesting that the rate of injury is relatively low in the context of the millions of participants involved in the sport, the rate of severe injury is much higher than that of other high risk sports such as American football, motorcycle and automobile racing [3,9]. Despite the literature consistently finding that orthopaedic extremity injuries are the most commonly sustained, head injuries have been found to be the most common cause of death due to horse riding [3]. However, deaths associated with neck and head injuries have significantly reduced since the introduction of protective head gear [10], with a study suggesting a five-fold decrease in head injuries [3] and another noting that 86% of patients involved in an equestrian accident were DOI: 101097/MEJ?0000000000000105
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
104
European Journal of Emergency Medicine 2015, Vol 22 No 2
wearing a helmet at the time [11], compared with 42% in 1971 [12]. Helicopter emergency medical services (HEMS) provide advanced prehospital medical care to victims of major trauma. Kent, Surrey & Sussex Air Ambulance Trust (KSS) is a HEMS service that provides advanced prehospital care to the southeast of England. Two helicopters, located at separate bases, provide prehospital medical and trauma care to three counties (population B4.5 million) and undertake B1400 missions per year. Approximately 70% of missions are for trauma and 30% for acute medical illness. The HEMS team consists of a pilot, a prehospital doctor, from an anaesthesia or emergency medicine background, and a critical care paramedic. In our region, HEMS provide the ability to perform prehospital anaesthesia, which is not performed by local road ambulance crews. HEMS regularly receive calls to equestrian accidents due to the inherent rural nature of the sport, resulting in poor access for conventional road ambulance crews, as well as the potential for significant injury. A HEMS flight paramedic in the ambulance control centre screens incoming emergency calls for HEMS suitability. This model of dispatch differs from standard ambulance dispatching in that the HEMS paramedic does not need to follow fixed clinical pathways and has the ability to telephone back the caller if more detailed clinical information is required. No fixed criteria exist for dispatching HEMS to equestrian incidents. Accurate HEMS tasking is important to avoid unnecessary standdowns and also to ensure critical care is delivered to those patients who require advanced intervention. Equestrian incidents resulting in injuries that can be managed by road ambulance crews need to be differentiated from those where the patient has sustained a major injury that may require time-critical intervention. We sought to review equestrian incidents attended by HEMS and determine whether any incident factors associated with the need for HEMS intervention could be identified at dispatch.
Methods The study took place during a 12-month period from 1 July 2011 to 30 June 2012. All mission records from KSS HEMS were reviewed retrospectively and activations to suspected equestrian incident selected. Missions where HEMS was stood-down en route were included. For missions where the HEMS team attended a patient, the HEMS patient record form was reviewed. Mission timings, incident details, patient demographics, suspected injuries, medical interventions performed and patient disposition were noted and entered onto a Microsoft Excel (Microsoft Inc., Redmond, Washington, USA) database, analysed and reported. The study met National Health Service criteria as a service evaluation.
We assessed each mission for markers of severity that may predict HEMS intervention or the need to transport the patient to a major trauma centre (MTC). These included horse-kick to the head, kick to the body, no helmet worn, landing on head, horse landing on patient, unable to mobilize following accident, witnessed seizure, landing onto hard ground and loss of consciousness.
Results Missions
In the 12-month data collection period there were 47 equestrian accidents, representing B3% of the total annual missions for Kent–Surrey–Sussex HEMS. Of the 47 activations, HEMS was stood-down en route in five (11%) cases, leaving 42 cases for inclusion. In 19 (45%) cases the HEMS team arrived on-scene but subsequent patient management and transport was left to the attending road ambulance crew. Of the 42 cases HEMS attended, one (2%) patient was pronounced life extinct at the scene. In 15 (36%) cases the patient was airlifted to hospital. The remainders were transported by land ambulance with the HEMS team in attendance. The majority of patients were female (n = 30, 71%) with a mean age of 33 (range 6–72). The timings of HEMS response to equestrian incidents are shown in Table 1. Injuries
Data regarding mechanism of injury was available in 37 cases (88%). Five (12%) patients had sustained a kick to the head and five (12%) a kick to the body. Twelve (29%) patients had suffered a loss of consciousness, eight (19%) were noted to be confused during the 999 call, with one (2%) patient being noted to have had a seizure. When asked about the fall during the 999 call, 13 (31%) patients were noted to have had a hard landing (not in horse arena with sand), three (7%) patients were thought to have landed on their head, and six (14%) had the horse land on top of them. Information regarding the wearing of a helmet was noted in 16 cases. Of these, 12 (75%) were wearing a helmet when they fell. Initial Glasgow Coma Score (GCS) on arrival was documented in 40 cases, with four (10%) patients having GCS of 8 or less [2 (50%) of these patients had a GCS of 3]. A GCS of 14 was noted in a further five (12.5%)
Timings of helicopter emergency medical services response to equestrian incidents
Table 1
Time interval
Median (min)
IQR (min)
19 30 32 98
9–29 22–45 26–44 81–114
999 call–HEMS activation 999 call–HEMS on-scene HEMS on-scene–leave scene 999 call–arrival at hospital
HEMS, helicopter emergency medical services; IQR, interquartile range.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
HEMS response to equestrian incidents Lyon et al. 105
patients, with the remaining 31 (77.5%) patients assessed as GCS 15 upon HEMS arrival. Prehospital injury description was available for 39 (93%) of the patients. Of those with data available, seven (18%) were documented as having no injury. Multiple injuries were documented in 13 (33%) cases. Patients’ injuries are shown in Fig. 1. Helicopter emergency medical services intervention – prehospital anaesthesia
To assess the patients that may have benefitted from HEMS intervention we analysed patients who underwent prehospital anaesthesia. Four patients (10%) required prehospital anaesthesia at the scene. These patients are shown in Table 2. Two of the four patients had severe chest injuries requiring prehospital anaesthesia followed by chest decompression with open thoracostomy on-scene. Markers of severity
Each mission was analysed for possible markers of severity. As no validated makers of injury severity from equestrian injury exist, we adopted pragmatic indicators. Reports of the horse landing on the patient, the rider being kicked in the head or lack of a riding helmet and the rider landing on their head were associated with the highest rates of direct transport to a MTC, as shown in Table 3.
12 10 Number of injuries
This study shows the equestrian accidents represent a significant proportion of HEMS missions, although the incidence of prehospital anaesthesia is low. There appeared to be a large variation in the injury severity of equestrian patients attended by HEMS – these ranged from minor limbs injuries requiring ambulance transport to a minor injuries unit to complex major trauma requiring urgent prehospital intervention. In this cohort, we did not identify any factors that could objectively be associated with a clinical HEMS intervention, although the study cohort is relatively small and further research in this area is warranted. Neurotrauma and suspected internal haemorrhage were the commonest suspected significant injuries. Accurate tasking of HEMS to these cases can allow advanced prehospital intervention in the form of prehospital anaesthesia and facilitate rapid transport to an appropriate hospital, including passing a prealert to the MTC in cases of suspected major haemorrhage. In contrast to other studies in this area [10], we observed a higher rate of injured equestrian patients being transported to an MTC. Overtriage by the HEMS team is likely, as are cancellations following initial activation. The optimum HEMS stand-down rate is not known but 30% if often deemed a reasonable compromise between inappropriate activations and potentially missing cases. Further prospective research including the exact nature and severity of equestrian patient injury would inform the overtriage rate. We did not specifically examine equestrian accident cases with limited patient access due to geography, other options of patient transport, such as off-road vehicle, can be considered for patients with nontime critical injuries. The use of the helicopter to access or transport equestrian accident patients in remote geographical locations with nontime critical injuries should probably be considered on a case-by-case basis. Such patients may not require time-critical, high-end medical intervention but may have an improved patient experience if airlifted from scene.
Fig. 1
8 6 4 2 0 Head
Table 2
Discussion
Chest
Spinal Abdomen Pelvic Suspected injury region
Lamb
There was a large variation in HEMS activation time to equestrian incidents during the study period. This is likely to represent the HEMS dispatcher either activating
Equestrian injury patients undergoing prehospital anaesthesia
Patient Age
Sex
999 call to HEMS activation (min)
999 call to HEMS onscene (min)
GCS on arrival of HEMS
1
18
Male
25
47
3
2
25 Female
63
74
14
3
30 Female
15
34
4
30 Female
68
83
Mechanism of injury Unclear
Suspected injuries
Horse fell onto patient
Severe intra-abdominal haemorrhage Head and chest injury
5
Unclear
Head injury
3
Rider fall striking head on ground
Head injury
GCS, Glasgow Coma Score; HEMS, helicopter emergency medical services; MTC, major trauma centre.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Outcome Died at scene Flown to MTC Flown to MTC Flown to MTC
106
European Journal of Emergency Medicine 2015, Vol 22 No 2
Table 3 Severity markers of equestrian accidents attended by helicopter emergency medical services and transport rate to a major trauma centre
Severity marker Kick to the body Kick to head No helmet worn Landing on head Horse landing on patient Unable to mobilize after accident Witnessed seizure Landing on hard ground Loss of consciousness
Total number of patients with injury severity marker 5 5 4 3 6 26 1 13 12
Number of patients transported to a major trauma centre [n (%)] 1 4 3 2 5 11
(20) (80) (75) (67) (83) (42)
0 5 (38) 4 (33)
Patients may have had more than one severity marker and can therefore figure in several categories.
equestrian accidents do not require HEMS intervention, however, a small proportion have life-threatening injuries, requiring time-critical intervention. The rider not wearing a helmet, falling onto their head or the horse falling on the riders were associated with a high risk of MTC admission. Further prospective research is warranted to identify which patients, injured in equestrian accidents, are likely to benefit from HEMS intervention.
Acknowledgements B.M. and R.M.L. was responsible for compiling the initial data set. All authors were involved in planning, data review and manuscript preparation. R.M.L. acts as guarantor. Conflicts of interest
the aircraft immediately from the available information or waiting for the arrival of a land ambulance on-scene to gather further information. The role of the dispatcher in HEMS activation is important in ensuring the HEMS teams are dispatched to missions likely to benefit from early critical intervention. Further prospective research is warranted on HEMS input to equestrian accidents to identity factors likely to improve accuracy in tasking. This study has several limitations. The sample size is relatively small and may not be large enough to detect specific trends related to equestrian injuries. We did not have access to the actual voice recordings of calls or patient follow-up at hospital. Both of these may have added valuable data to the study. Detailed physiological data, Injury Severity Score, patient injuries identified on hospital arrival, length of hospital stay and patient outcome should all be collected as part of future work in this area to actually inform HEMS tasking to equestrian incidents. Conclusion
Equestrian accidents represent a significant proportion of HEMS missions. The majority of patients injured in
There are no conflicts of interest.
References 1
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