In 1988, twenty years ago and in the fortieth year of the National Health Service (NHS) in the UK, England suddenly moved into an era of modern trauma care and started a Helicopter Emergency Medical Service (air ambulance) at the Royal London Hospital (London Air Ambulance).
It was the first in England and we were the last country in Europe to use helicopter transport of seriously ill injured patients directly to a specialised hospital. The government and its bureaucracy had previously decided that such a service was too costly and anyway it was “unnecessary” because there were adequate District General Hospitals (DGH) (200 or so) DGH and University Teaching Hospitals (about 20). This sleepy atmosphere was suddenly disturbed by an unexpected interfering outside event. A teaching hospital in the centre of London acting already as a DGH for the East End, but also with the Regional Specialties of neurosurgery, cardio-thoracic and plastic surgery accompanied by a good Intensive Care Unit (ICU) and regional blood transfusion centre expressed itself willing to specialise additionally in the generality of acute trauma. And they had accepted the kind offer of a helicopter from a private donor.
David STEVENS, Lord Stevens of Ludgate, Chairman of a national newspaper, the DAILY EXPRESS, bought a DAUPHIN helicopter for the flying ambulance service and agreed to fund its additional costs for the initial years. The helicopter arrived at Battersea heliport on 15 December 1988; a roof helicopter pad was built at the Royal London Hospital and opened on 30 August 1990. The Accident and Emergency Department was upgraded with an Emergency Room fitted with overhead X-ray (130 PDF)for the four bays in 1990 and a Siemens Somatom plus CT scanner bought with the help of the Wolfson Foundation in 1995. The Advanced Trauma Life Support (ATLS) system of doctor training from the USA was adopted without alteration from the American College of Surgeons. Additionally there was great help from the London Ambulance Service in regard to a) developing a triage system in their huge central call centre (one of the largest in the world) and b) the training of ambulancemen into paramedics to help in the helicopter originally and later as independent land based personnel.
This sudden change of a hospital into the modern era of trauma care was a surprise to the NHS bureaucrats. It went totally against the conservative plans of a monolithic organisation. The event can only be described as a sudden jump forward – THE BLACK SWAN event (read The Black Swan: The impact of the highly improbable by Nassim Taleb, Penguin 2008 The Black Swan (book). Such occasions are caused by the action of one man and come as a total surprise to the country, institutions and its inhabitants. That one person was Lord Stevens and on my rough reckoning the Daily Express gave about £7 million to fund the Royal London Hospital HEMS available without cost for all trauma patients in greater London, roughly 7 million people within the confines of the M25 motorway, the ring road that can be reached within 12 minutes of a call out. On a daily basis The London Ambulance Centre deals with about 2,000 calls of which four patients are triaged for the helicopter to carry either to the Royal London or other appropriate hospitals for proper care.
This emphasizes that the pre hospital care is an essential part of the life saving chain (138) which only ends after the hospital phase with rehabilitation (132 PDF , 133, 134 PDF)
Two hospital consultants, myself and Alastair Wilson of the Accident and Emergency Department, were the original enthusiasts who encouraged everyone interested to work together. This is described in several papers (105 PDF, 121 PDF, 122 PDF )which were written as we slowly tried to catch up experts and systems in other countries such as:
Germany: ADAC helicopter system throughout the whole country.
USA: R Adams Cowley Shock Trauma Center, Maryland, Dr Howard Champion and Dr Donald Trunkey, Oregon
South Africa: Ken Boffard
These are all described in TRAUMA CARE Ed RICHARD EARLAM 1997 (139) together with details of the different specialties of the RETTUNGSKETTE or Life Saving Chain. Each one of the links is essential and the patient’s survival depends on none of the links breaking. The life saving chain breaks at the weakest link so all of us must strengthen each link and ensure that they stay connected. They are all equally important together with the flying ambulance, the base hospital and rehabilitation.
In the USA the expertise of different hospitals for trauma care is divided into three levels, LEVEL 1, 2 and 3 as a trauma center. In the UK from 1948 the DGH was accepted as the standard hospital. In rough terms 200 would each look after 250,000 which would be enough for 50 million inhabitants (131 PDF). Originally the University hospitals were in the centre of cities where there was a university campus based on totally haphazard historical development. For instance Oxford and Cambridge were small medieval towns at a time when London and Norwich were Number 1 and 2 in population. Oxford then increased in size because of the motor car industry and Cambridge is only now increasing with the computer industry. Counties were based on cathedrals and the church. The Victorians under the influence of Alfred Waterhouse and Florence Nightingale then built their hospitals for the increased population of the industrial revolution. Such a brief history explains the almost random allocation of hospitals for general care. Similarly the recent specialties of neurosurgery, cardio-thoracic and plastic surgery were placed randomly, but usually well away from the University or Teaching Hospitals because these were already full up and on tightly restricted land sites. So plastic surgery (from The Second World War) went well into the countryside, and the others were built on totally separate sites in the centre of towns or in hospitals taken over from other usage. For example less than 10 of the present 40 neurosurgery departments are situated in a University or District General Hospital; the rest are isolated which is not optimum for either trauma care or for other emergencies in a neurosurgery unit (143 PDF , 144). It should be clear that longterm planning for the location of sites for these specialised units should have been achieved well before the 60th birthday in 2008 of the NHS, born in 1948. The Royal London Hospital is now accepted as a Level I (USA style) hospital. It must have more copies so that all the inhabitants of the UK can benefit.
There are 17 references of which 8 have a pdf file format for ease of access to further details. Two general books may be of value. The ABC of Major Trauma 3rd Edition 2000(145) is still in print and of general interest both to students and qualified doctors. There had been two previous editions (114, 136) and now one in Polish (151). Trauma Care was a limited edition printed privately in 1997 (139) with a first edition in 1992 (116). Its value is that it has contributions from people in other countries from whom we learnt much and details from those individuals whose help in the Life Saving Chain were so important and essential.
114. ABC of Major Trauma.
Editors: David Skinner, Peter Driscoll, Richard Earlam.
BMA publications London
ISBN 0-7279-0291-1. (1991)
116. The Royal London Hospital Daily Express Helicopter Emergency Medical Service.
Earlam R J
Saldatore, Bishop’s Stortford. ISBN 0-948047 – 02X (1992) Book
122. The Royal London Hospital Helicopter Emergency Medical Service: first phase 1990 (PDF)
Botha AJ, Earlam R J, Wilson AW, Dalton AM, Spalding T J, Warren C, Hodkinson S
Ann Roy Coll Surg 74:130-45 (1992) PMID 1416722
Brit J Surg 82: 71-3 (1995) PMID 7881963
133. Measurement of disability after multiple injuries: The Functional Independence Measure
Hetherington H, Earlam R J
Eur J Surg 161: 549-55 (1995) review PMID 8519870
134. The disability status of injured patients measured by the functional independence measure FIM and their use of rehabilitation services. (PDF)
Hetherington H, Earlam R J, Kirk C J
Injury 26: 97-101 (1995) PMID 7721476
136. The ABC of Major Trauma 2nd Edition.
Editors Skinner D, Driscoll P, Earlam R
BMJ Publishing Group, ISBN O 4727909177 (1996) Book
138. Pre-hospital care for trauma care.
Earlam R J Critical care of the Surgical Patient.
Editor Hanson G Companion volume to Bailey and Love’s Short practice of surgery. Chapman and Hall, London (1997) Chapter
139. Trauma Care. HEMS. London
Richard Earlam Ed
Saldatore, Bishops Stortford
ISBN O 948047 089 (1997) Book (www.londonsairambulance.com)
144. Shell-shock: a history of the changing attitude to war neurosis
Earlam R J
Brit Med J 316:1683A (1998) PMID 9603774
145. ABC of Major Trauma Third Edition
Driscoll P, Skinner D, Earlam R J
Editors BMJ Books, London ISBN:0-7279-1378-6 (2000) Book
151. ABC Postepowania W Urazach
Driscoll P, Skinner D, Earlam R
Gornicki Wydawnictwo Medyczne, Book Poland 2003
Polish Edition ABC of Major Trauma