The impact of a new regional air ambulance service on a large general hospital

Background: Helicopter air ambulance crews are influenced in their selection of the destination hospital for their patients by several factors including: distance from the scene; facilities, on site specialties, and senior cover of the receiving hospital; and the proximity of the helicopter landing area to the emergency department (ED). Only a limited number of hospitals have landing sites adjacent to the ED from which patients can be taken directly into the department (primary landing sites). Helicopter crews will often elect to over fly hospitals that do not have primary landing sites because secondary land transfers will add delays in delivering patients. Birmingham Heartlands Hospital has an elevated helideck adjacent to the ED. In October 2003, the Warwickshire and Northamptonshire Air Ambulance (WNAA) service was launched; the hospital sits on the western periphery of the area served by the service. Methods: Prospective data was collated on all patients brought by WNAA to Heartlands Hospital between 1 October 2003 and 31 August 2004. Results: In the 10 month period after the launch of the service, the helicopter delivered 83 patients to the ED; 74 of these were "off patch". This additional workload generated 163 ward days, 19 operative procedures, and 85 intensive care unit, high dependency unit, or coronary care unit days. The direct costs of this additional workload approached £160 000. Conclusions: In future discussions on the cost effectiveness of air ambulances, it will be important to consider both the direct and indirect costs to the receiving hospitals arising from the redistribution of emergency workload. Abbreviations: ED, emergency department; HDU, high dependency unit; HEMS, helicopter emergency medical service; ICU, intensive care unit; ISS, injury severity score; WNAA, Warwickshire and Northamptonshire Air Ambulance; WMCAA, West Midlands County Air Ambulance

Wounding patterns and human performance in knife attacks: optimising the protection provided by knife-resistant body armour

Stab attacks generate high loads,1 and to defeat them, armour needs to be of a certain thickness and stiffness.2,3 Slash attacks produce much lower loads and armour designed to defeat them can be far lighter and more flexible.Methods and subjects: Phase 1: Human performance in slash attacks: 87 randomly selected students at the Royal Military College of Science were asked to make one slash attack with an instrumented blade on a vertically mounted target. No instructions on how to slash the target were given. The direction, contact forces and velocity of each attack were recorded. Phase 2: Clinical experience with edged weapon attacks: The location and severity of all penetrating injuries in patients attending the Glasgow Royal Infirmary between 1993 and 1996 were charted on anatomical figures.Results Phase 1: Two types of human slash behaviour were evident: a ‘chop and drag’ blow and a ‘sweep motion’ type of attack. ‘Chop and drag’ attacks had higher peak forces and velocities than sweep attacks. Shoulder to waist blows (diagonal) accounted for 82% of attacks, 71% of attackers used a long diagonal slash with an average cut length of 34 cm and 11% used short diagonal attacks with an average cut length of 25 cm. Only 18% of attackers slashed across the body (short horizontal); the average measured cut length of this type was 28 cm. The maximum peak force for the total sample population was 212 N; the maximum velocity was 14.88 m s−1. The 95 percentile force for the total sample population was 181 N and the velocity was 9.89 m s−1. Phase 2: 431 of the 500 patients had been wounded with edged weapons. The average number of wounds sustained by victims in knife assaults was 2.4. The distribution of wounds by frequency and severity are presented.Conclusions Anti-slash protection is required for the arms, neck, shoulders, and thighs. The clinical experience of knife-attack victims provides information on the relative vulnerabilities of different regions of the body. It is anticipated that designing a tunic-type of Police uniform that is inherently stab and slash resistant will eventually replace the current obvious and often bulky extra protective vest. Attempts at making a combined garment will need to be guided by ergonomic considerations and field testing. A similar anatomical regional risk model might also be appropriate in the design of anti-ballistic armour and combined anti-ballistic and knife-resistant armour

Performance characteristics of five triage tools for major incidents involving traumatic injuries to children

Context Triage tools are an essential component of the emergency response to a major incident. Although fortunately rare, mass casualty incidents involving children are possible which mandate reliable triage tools to determine the priority of treatment. Objective To determine the performance characteristics of five major incident triage tools amongst paediatric casualties who have sustained traumatic injuries. Design, setting, participants Retrospective observational cohort study using data from 31,292 patients aged less than 16 years who sustained a traumatic injury. Data were obtained from the UK Trauma Audit and Research Network (TARN) database. Interventions Statistical evaluation of five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to predict death or severe traumatic injury (injury severity score >15). Main outcome measures Performance characteristics of triage tools (sensitivity, specificity and level of agreement between triage tools) to identify patients at high risk of death or severe injury. Results Of the 31,292 cases, 1029 died (3.3%), 6842 (21.9%) had major trauma (defined by an injury severity score >15) and 14,711 (47%) were aged 8 years or younger. There was variation in the performance accuracy of the tools to predict major trauma or death (sensitivities ranging between 36.4 and 96.2%; specificities 66.0–89.8%). Performance characteristics varied with the age of the child. CareFlight had the best overall performance at predicting death, with the following sensitivity and specificity (95% CI) respectively: 95.3% (93.8–96.8) and 80.4% (80.0–80.9). JumpSTART was superior for the triaging of children under 8 years; sensitivity and specificity (95% CI) respectively: 86.3% (83.1–89.5) and 84.8% (84.2–85.5). The triage tools were generally better at identifying patients who would die than those with non-fatal severe injury. Conclusion This statistical evaluation has demonstrated variability in the accuracy of triage tools at predicting outcomes for children who sustain traumatic injuries. No single tool performed consistently well across all evaluated scenarios

Effects of heat on cut mark characteristics.

Cut marks on bones provide crucial information about tools used and their mode of application, both in archaeological and forensic contexts. Despite a substantial amount of research on cut mark analysis and the influence of fire on bones (shrinkage, fracture pattern, recrystallisation), there is still a lack of knowledge in cut mark analysis on burnt remains. This study provides information about heat alteration of cut marks and whether consistent features can be observed that allow direct interpretation of the implemented tools used. In a controlled experiment, cut marks (n=25) were inflicted on pig ribs (n=7) with a kitchen knife and examined using micro-CT and digital microscopy. The methods were compared in terms of their efficacy in recording cut marks on native and heat-treated bones. Statistical analysis demonstrates that floor angles and the maximum slope height of cuts undergo significant alteration, whereas width, depth, floor radius, slope, and opening angle remain stable. Micro-CT and digital microscopy are both suitable methods for cut mark analysis. However, significant differences in measurements were detected between both methods, as micro-CT is less accurate due to the lower resolution. Moreover, stabbing led to micro-fissures surrounding the cuts, which might also influence the alteration of cut marks

National survey of variations in practice in the prevention of surgical site infections in adult cardiac surgery, United Kingdom and Republic of Ireland

Background: Currently no national standards exist for the prevention of surgical site infection (SSI) in cardiac surgery. SSI rates range from 1% to 8% between centres. Aim: The aim of this study was to explore and characterize variation in approaches to SSI prevention in the UK and the Republic of Ireland (ROI). Methods: Cardiac surgery centres were surveyed using electronic web-based questionnaires to identify variation in SSI prevention at the level of both institution and consultant teams. Surveys were developed and undertaken through collaboration between the Cardiothoracic Interdisciplinary Research Network (CIRN), Public Health England (PHE) and the National Cardiac Benchmarking Collaborative (NCBC) to encompass routine pre-, intra- and postoperative practice. Findings: Nineteen of 38 centres who were approached provided data and included responses from 139 consultant teams. There was no missing data from those centres that responded. The results demonstrated substantial variation in over 40 aspects of SSI prevention. These included variation in SSI surveillance, reporting of SSI infection rates to external bodies, utilization of SSI risk prediction tools, and the use of interventions such as sternal support devices and gentamicin impregnated sponges. Conclusion: Measured variation in SSI prevention in cardiac centres across the UK and ROI is evidence of clinical uncertainty as to best practice, and has identified areas for quality improvement as well as knowledge gaps to be addressed by future research

Immediate thoracotomy for penetrating injuries: Ten years' experience at a Dutch level I trauma center

Background: An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center. Method: Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed. Results: Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0. 001), lower pre-hospital RTS and hospital triage RTS (p < 0. 001 and p = 0. 009, respectively), and a lower SBP (p = 0. 038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0. 002). Survivors had lower ISS (p = 0. 011), lower rates of pre-hospital (p = 0. 031) and hospital (p = 0. 003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0. 002). Conclusion: The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained

National Survey of Variations in Practice in the Prevention of Surgical Site Infections in Adult Cardiac Surgery, United Kingdom & Republic of Ireland

Currently no national standards exist for the prevention of surgical site infection (SSI) in cardiac surgery. SSI rates range from 1% to 8% between centres. The aim of this study was to explore and characterise variation in approaches to SSI prevention in United Kingdom(UK) and Republic of Ireland (ROI)

Safety standards for police body armour

Assaults on the Police continue to increase. Of particular concern is the threat of injury from edged weapons. Shootings remain rare. The Home Office has embarked on a program to provide all police officers with suitable body armour. Body armour has been on general issue to police officers in America for over twenty years and has a superb record in saving lives from shootings. Little is known about its ability to prevent serious stab wounds from knives, as this is a much less common threat in the American policing environment. Therefore the specification for armour for police use in this country must be set to provide protection against the threats in the UK policing environment. Current knife-resistance standards are based on animal experimentation and have not been examined by any other model. To understand the protective requirements of armour, it is necessary to understand the weapon threat, the assailant’s method of delivery, and the vulnerability of the target. The biophysics of human stabbing (the assailant’s method of delivery), is the subject of ongoing investigation, and is outwith the scope of this thesis. In this thesis, the history and development of body armour is reviewed. An overview of the materials and properties of modern armour is presented. To understand the threat, the epidemiology of assaults on police officers and civilians is described. To determine the ideal protective qualities of body armour for issue to the police, two studies are presented. The first is a retrospective cohort study of 500 civilian victims of penetrating injury. The frequency of wounding, and the severity of wounding by body region is plotted on anatomical charts. This will demonstrate the vulnerability, and hence the protection requirements of each body area to penetrating injury. No previous study has measured the depth of the internal organs from the skin. A CT study is presented. It describes the accessibility of the internal organs to the passage of a blade by measuring the shortest distances from the skin. By applying the results of these two studies to the location of the internal organs (which lie in fairly constant relation to surface anatomy landmarks), the ideal protective qualities of armour panels over corresponding areas of organ vulnerability are plotted. The case for adopting three levels of knife resistance protection is made. The ballistic protective requirements of body armour are discussed. Finally, proposals for zoned body armour are presented and ergonomic and production issues are described. The model presented in this thesis has been accepted in principle by the Police Scientific Development Branch of the Home Office with a view to establishing a zoned body coverage requirement for police body armour

"The increasingly Barmy European court of human rights": The use of political euroscepticism in human rights reform in the United Kingdom

This thesis explores the use of Political Euroscepticism in British domestic reform in response to adverse rulings by the European Court of Human Rights. Contradictory to what previous research has posited, this paper finds that the use of Euroscepticism by British political elites cannot be predicted or explained by the nature of the topic in question as the reality is far messier. Furthermore, despite assumptions to the contrary, this is not an exclusively Conservative Party tool and is sometimes used by Labour politicians in more covert and subtle ways. Through a process of reform tracing, this paper finds that Euroscepticism is a political tool employed inconsistently by British politicians when faced with calls for reform by the European Court of Human Rights. It is used in three main ways in the British political sphere: To prevent reform in line with the European Court of Human Rights' rulings altogether; to prevent reform from being fully effective; and to downplay the fact that the impetus for reform came from a European institution. The implications for this creates a problematic environment for human rights in the United Kingdom where human rights reform depends, to a large extent, on the whims of politicians to use Euroscepticism as a reason for non-compliance.Cette thèse explore l'utilisation de l'euroscepticisme politique dans les réformes de politique intérieure britannique en réponse à des décisions rendues défavorables à la Cour européenne des droits de l'Homme. Contrairement à ce que des études antérieures on pu montrer, cette dissertation constate que l'utilisation de l'euroscepticisme par les élites politiques britanniques ne peut être anticipée ou expliquée par la nature du sujet en question, la réalité étant bien plus complexe. De plus, contrairement aux hypothèses inverses avancées, il ne s'agit pas d'un outil exclusivement utilisé par le parti conservateur ; il est parfois utilisé par les hommes politiques du parti travailliste, de façon plus dissimulée et plus subtile. Au moyen d'un traçage des réformes, cette dissertation démontre que l'euroscepticisme est un outil politique employé de manière incohérente par les hommes politiques britanniques face à des appels à la réforme de la Cour européenne des droits de l'Homme. Il est utilisé à trois principales fins dans la sphère politique britannique : pour prévenir les réformes conformes aux décisions de la Cour européenne des droits de l'Homme ; pour éviter que la réforme ne soit pleinement efficace ; enfin, pour dissimuler le fait que la réforme a été impulsée par une institution européenne. Cela crée un environnement problématique pour les droits de l'Homme au Royaume-Uni, où la réforme de ces droits dépend, en grande partie, des caprices d'hommes politiques pour lesquels l'euroscepticisme s'avère être un motif de non-conformité