With figures of approximately 3'500 fatalities and 45'500 seriously injured patients per year resulting from trauma due to Road Traffic Accidents (RTA) in the United Kingdom (UK). There is need for a user friendly assessment tool that hastens the patients evacuation to Definitive Care, but provides universal capabilities for indicating patient conditions. This article describes the JETTA Rating method for patient assessment that has evolved through personal experience of present methods of management scoring in the pre-hospital environment. This form of assessment if found to be efficient may also be used to dictate, as to a receiving hospitals management approach for fully implementing quality management of the trauma patient.

There have been several introductions of triage and scoring aids for the assessment of traumatised patients, since the early seventies. However these methods haven't been adopted by paramedics in the UK, which would strongly suggest that there is still need for a system of scoring that can be done as part of a Global Survey at the accident scene without need for calculations or initial documentation of readings. The introduction and widespread adoption of assessing a patients level of consciousness by use of the AVPU response is evidential that when an assessment tool is user friendly it will feature strongly in the pre-hospital medic's arsenal of trauma management techniques.

The Triage Revised Trauma Score (TRTS) was introduced into the UK emergency medical forum having been used in the United States (US) as the benchmark for pre-hospital trauma scoring. Though successfully used to evaluate a patients destination to differing levels of trauma facility in the US the TRTS proved to be more of a hindrance to UK paramedics who, due to a number of factors, are reluctant to bypass a General Hospital facility. The present ad-hock method for patient assessment and reporting is a mixture of the paramedic's estimated opinion of, Mechanism of Injury, patient's obvious injuries and any variations in the patient's vital signs. Thus an acceptable verbal report from an accident scene might be. "Two vehicle RTA, bumper damage only, one patient with cuts and bruises, all vital signs OK." However the intention of scoring methods was to remove the potentiality for misinterpretation of a patient assessment as the evaluation is passed from one source to another and so on.

The introduction of new procedures to the pre-hospital environment is usually due to existing practises within the confines of the hospital emergency department, as was the introduction of the Capillary Refill Time (CRT). The CRT featured for several years as a main assessment on major incident triage cards due to its believed speed of application. However once out of the comfortable surroundings of the Accident & Emergency (A&E) Department, the CRT would only have useful meaning once other factors have been taken into account such as age, existing medical conditions and environmental conditions. This necessity to evaluate several factors in order to gain just one piece of an observational jigsaw rendered the CRT inaccurate for roadside triage. The observational aids that prove to be most suited to pre-hospital use are those methods originated in the field and usually consist of simple visualisations or actual aid devices such as colour coding and algorithms.

In the adrenaline fuelled midst of a resuscitation or the debris of a multiple casualty car smash, the ability to calculate simple tasks is near impossible. Evaluating a trauma patient's condition, adequately enough to meet the requests of a receiving hospital whilst in transit, is a task few hospitals have little appreciation for. The paramedic, while busy attending to the patient, usually has to pass observations verbally to the driver who is supposed to then understand and relay the paramedics assessment via radio at the same time as having to concentrate on the task of negotiating the ambulance

through traffic at speed. It's little surprise to find that receiving A&E departments feel that they would prefer better alert messages as to the nature of incoming patients.

It became evident during the sixties and seventies that trauma patients needed to be in the hands of Definitive Care no greater than 60 minutes from the time of injury, to benefit from the highest survivability outcome from serious injury. The Advanced Trauma Life Support (ATLS) program was introduced in the United Kingdom (UK) in 1988 for doctors. The Pre-Hospital Trauma Life Support (PHTLS) course was developed for paramedical personnel, both military and civilian, and introduced to the UK by the mid-nineties, enabling the Emergency Medical Services (EMS) an insight into there co-ordination with the ATLS theory and practices of the Doctors they supply patients too. The aim of these trauma life support courses is to teach a uniformed approach to the care of patient's with emphasis on a speedy assessment of severity of injury and the subsequent decisions of prioritisation of treatment and indications for minimising the On Scene Time (OST) of the patient.

Unfortunately even after the introduction of PHTLS guideline into the UK, patients are still receiving little benefit from reductions in Incident to Definitive Care Time (IDCT). The recommended time spent on scene by EMS while dealing with trauma patients should be ten minutes, known as the "Platinum Ten Minutes". Evidence from West Yorkshire, although before full PHTLS implementation, gives average OST as greater than twice that recommend, which is probably fair representation of all UK services. The preferred evidence would be that, suggesting; minimal OST for patient, less than ten minute OST for EMS and a possible increase in Time On Route to Hospital, indicating a shift towards directly accessing Definitive Care.

EMS isn't the only sector of trauma care that needs to re-evaluate it's practises, when serious trauma patients are delivered to the General Hospital A&E department, their potential IDCT instantly takes on an often catastrophic new time parameter. General Hospitals appear to adopt a reluctance to the possible appearance of "crying wolf" in their assessment of patients with high suspicion of serious trauma due to the presenting Mechanism of Injury. Thus until serious traumatic injuries are found in the assessment of a trauma patient, their referral to a more appropriately equipped facility widens the IDCT into hours rather than minutes. The rule in Trauma Life Support is. "It's The Patients Golden Hour, not the Medics".

The ATLS Guidelines used in the United States clearly state that, Mechanism of Injury overrides any clinical evaluation, yet despite significant Mechanism of Injury, A&E Departments in the UK are still subjecting patients to hours of assessment and re-evaluation. Unfortunately it isn't unusual that each year trauma patients evaluated as acceptable to be admitted by General Hospitals die from unforeseen complications several hours later despite these complications having been indicated at the time of the accident by the Mechanism of Injury. Having disregarded the involvement of significant Mechanism of Injury in it's evaluation to act as Definitive Care rather than immediately transfer a trauma patient, has the initial receiving hospital breached it's legal duty of care to that patient?

The pre-hospital evaluation and management of the trauma patient by either Paramedic or Immediate Care Doctor consists of a stepwise approach of Primary Survey of the patient's Airway, Breathing, Circulation and Level of Responsiveness (ABC&LOR). Attempts to rectify any deficits found in the Primary Survey are done as and when they are found without moving to the next sector, finally ending with categorisation of the patient into Critical, Potentially Critical or Non Critical. This final categorisation takes into account problems encountered with the patient's ABC's & LOR, Mechanism of Injury and the presence of serious injuries.

Initial Assessment or "The Global Survey" is the first, subconscious tool employed by the medic as he arrives at the scene of an accident, and will prove to be a big factor in the final evaluation of an accident scene and the patients involved. At the Road Traffic Accident scene, Mechanism of Injury is often the first observation, due to the wreckage being visually central of any accident scene. This is often the reason for the notorious occurrence of pillion passengers being missed by rescuers dealing with motor cycle accidents. Without proper scene management attention gets focused on treating the motorcyclist found near to the debris of the bike, but failure to find the passenger who has been ejected over a country hedge. Regardless of how good a patient may seem after extensive assessment, the pre-hospital medic isn't going to ignore the alarming site of a car once containing the patient, now spread across twenty metres of carriageway in two separate pieces. The patient's management will be immobilisation on long board, administration of 100% Oxygen via trauma mask and speedy removal to hospital.

Stealing research into Cardiopulmonary Resuscitation we find that assessment of a pulse can take upwards of thirty seconds for an adequate assessment as to the quality of circulation and this adequate pulse check will be further undermined by both circulatory impairment and weather conditions. The latest Basic Life Support guidelines for lay rescuers now favour in replacing the pulse check with a minimum ten second visual assessment for "Signs of Life". If used on the trauma patient this observation for "Signs of Life" in the hands of experienced medics can actually provide a phenomenal amount of information especially if hearing isn't hampered by noise pollution from other sources at the accident scene. Anyone who has experience of using systems for giving Basic Life Support instructions to telephone callers having dialled 999, will know the value of patient's breathing noises, described by a bystander or having the telephone handset placed near to the patient which is a method adopted by many relatives.

Auscultation of a patient's respiratory effort is recommended practice in the Primary Survey of both medical and trauma patient. However although a medical patient may be asked to attempt to breathe briskly through an open mouth, as an aid in the auscultation of respiratory sounds, the trauma patient is often not able to assist in this way. At the scene of an accident it would be a foolish medic who evaluates respiratory complications through auscultation and instigates any respiratory intervention in a trauma patient without any other evidential observations being present. Auscultation for chest sounds as a stand-alone observation is probably as useful as auscultation for bowel sounds; other assessments are needed to evaluate complications.

Respiratory interventions such as, Intermittent Positive Pressure Breathing (IPPB) should only be commence following no improvement after administration of 100% Oxygen via non re-breathing mask otherwise known as a "Trauma Mask" because of it's customary use on all moderate to serious cases of trauma. Thus respiratory inefficiency with enough evidence to warrant intervention will tend to be visually and externally audible to the medic and initial intervention would be administration of 100% oxygen which tends to have already found it's way onto the patient as a reflex action by either medic or firefighter.

Regardless of it's cause the onset of central pallor in a patient, acts as an amazing physiological S.O.S. When initially confronted by a patient who is deathly pale, Doctors Nurses Paramedics and even Medical Receptionists instantly think, "Something's Wrong!" When this presenting vision is at the reception of an Accident & Emergency (A&E) Department, hasty movements often acknowledge it as the patient is whisked into a chair and is heading for a cubicle or resuscitation area with triage questions on route.

Basic physiology lessons teach us that signs & symptom are the effect of our body's marvellous defensive, Compensatory Mechanisms, enabling maintenance of haemostasis and alerting others to the predicament of our condition. Strangely, as most parents will confirm, children of school age have differing physiological laws that rarely exhibit signs of illness alongside symptoms during weekday mornings. Experience of assessing the condition and colour of an ill or injured patient's skin, gives the experienced medic substantial indications as to a patient's condition long before test results are available.

In the pre-hospital setting, the pale waxy texture of an un-rousable diabetic should never be de-emphasised by normal or high blood glucose readings, nor should the deathly pale patient complaining of chest pain be ignored due to a normal electrocardiograph. The classic signs & symptoms of shock relating to the skin, include sweaty and clammy texture, however in practise these are not reliable in the pre-hospital setting due to influence by the environmental conditions and can be misleading should the rescuer arrive on scene within a few minutes of the accident.

The management and evacuation of the trauma patient from the scene of an accident surprisingly is rarely altered by the findings of the Primary Survey or even the Secondary Survey if initiated at the scene. The only real alteration to "Immobilise, Oxygenate and Evacuate", is in cases where presence of significant external haemorrhage is evident or when the 10 second assessment for "Signs of Life" has revealed a patient to be quite probably in a state of cardiac or respiratory arrest.

Pre-Hospital Trauma Life Support guidelines suggest that the Primary Survey should last no longer than 90 seconds yet adopting the visual assessment for "Signs of Life" as opposed to the pulse check will significantly reduce that initial survey. Checking the pulse in the trauma patient is going to influence minimal change to the subsequent initial management should "Signs of Life" have already been confirmed. In the ten seconds it's taken to evaluate the presence of "Signs of Life" we have also noticed the initial appearance of the patient's skin and with possible exception of response to painful stimuli evaluated an initial Level of Responsiveness.

Research into the significance of a patient's colour revealed that a third of all patient's admitted to a Trauma Centre presenting with pallor subsequently died. The observations of Patient Appearance, Level of Responsiveness along with Mechanism of Injury, should be all that is needed to "Immobilise, Oxygenate, and Evacuate". Secondary Survey can commence the moment that the back doors of the ambulance are shut and the vehicle starts to move. The "Platinum 10 Minutes" achieved. It isn't a failure to have arrived at the receiving hospital having not fully completed a Secondary Survey, as the trauma team will make their own assessment of the presence of injuries. "Diagnosis isn't the job of the pre-hospital medic."

The value of visual patient assessment can be best demonstrated by practical experiment, every single day, we come into contact with other people to whom we have never seen before and probably will never see again. Despite no real purpose, human curiosity draws us to build a picture of someone thus we stare, but staring in the Western World often is perceived as intrusive so we don't stare to long. Over the years we have developed the ability to glance at someone, process a mass of detail and look elsewhere before being caught staring. To stare at a complete stranger on a bus or the tube train for 10 seconds will feel painfully long, give you more than enough detail to absorb all their features and probably be rewarded by a stern glance back.

The visual assessment of Mechanism of Injury, Patient Appearance, and Level of Responsiveness should warrant enough justification for being able to have categorised the patient as Critical, Potentially Critical or Non Critical. Now commencement of the necessary process of preparing and evacuating the patient from the accident scene can begin and appropriate Definitive Care can be presumed by use of the JETTA Rating method. The absence of Life Threatening signs and symptom or serious injury is absolutely no authorisation to abandon the "Platinum Ten Minutes" in cases involving Significant Mechanism of Injury.

Three sections each containing four categories each of which is colour coded from "Green" being least serious, through Amber, Red and finally Blue indicating most serious. Four categories is the minimal needed to provide sufficient detail without creating the need to start having to remember lists in order of importance and then having to document findings. Again if a scoring method isn't user friendly it won't become widely used, and if it's use is insisted upon, will probably cause a delay in the patient's evacuation.

The use of colour coding each of the categories should assist in the universal capability of the rating, making it less likely to suffer from "Chinese Whispers" when being passed from differing agencies and via radio communication. Verbal patient assessment would simply consist of approximate age, sex and then the three corresponding colours. I.e., "Young teenager, female, Jetta Rating of BLUE, RED, AMBER". Receiving hospital staff may initially feel, that a "Hospital Alert Message" consisting of a JETTA Rating would provide little knowledge of what to expect, yet it's simplicity actually provides greater detail than a long ad-hock radio message.

The only delay in evacuation or extrication should be if a patient has scored a "Blue" rating in either Patient Appearance or Level of Consciousness. This will probably be due to the patient either having a problem with respiration or may be in cardiac arrest. The Mechanism of Injury will give high level of suspicion as to the cyanotic cause, and if traumatic, is likely to require intervention to aid the patients breathing if available on scene. If the unresponsive patient is found to be in traumatic cardiac arrest, suspected due to high rating Mechanism of Injury, then "Resuscitation Triage" needs to be employed if there are other patients who may be jeopardise if delayed. Any pulseless patient however should be assessed for Ventricular Fibrillation and treated with Defibrillation if found.

The Mechanism of Injury is the priority observation relating to the trauma patient, and it is vital to correctly assess this observation because once evaluated the Mechanism of Injury shouldn't be complicated by deterioration or improvement. This is best illustrated when there are casualties from separate vehicles. Matching the patient's to the correct debris needs some quick investigative questioning, the visibly unhurt gentleman speaking to the Police and looking at the damaged wind of a Range Rover is unlikely to be the occupant of the mangled Fiesta on it's roof in a ditch. However presumption needs to be clarified by questioning.

Damage to the fascia of the motor vehicle, but not actually causing damage to the structure of the vehicle, I.e.: bumpers, panels, light clusters, tyre damage.

Damage to the actual structure of the vehicle, this will often mean the vehicle is beyond a driveable state, i.e. inner wing damage, axle displacement, damage intruding into the engine bay or boot space. Damage to windows may be included in this section but caution should be used due to windows being part of the passenger compartment, especially sunroofs.

Any damage causing intrusion into the passenger compartment or any damage caused inside the passenger compartment. I.e.: damage to foot wells, door pillars, roof supports, internal features such as seats interior panelling, dashboard and especially the steering wheel.

This category applies to any unrestrained patients or a pedestrian who has been subjected to kinetic forces substantial enough to project them through the air. I.e.: motor cyclist and pillion passenger thrown through the air, unrestrained occupants who have been projected within the passenger compartment or ejected, and pedestrians who have been projected by the force of impact,

This category applies to any patient who initially appears to be of normal colour.

This category applies to any patient who may cause concern regarding their colour and includes any patient who may be peripherally pale due the climatic condition at the accident scene.

This category applies to any patient who immediately appears to be obviously pale and has central pallor, (Note: in dark skinned patients the palms, lips and gums) and may have associated clammy sweaty skin.

Any patient who presents with the appearance of either central or peripheral Cyanosis.

Any patient who is Alert & Orientated to who they are? Where they are? & What has happened? They are also acting in a normal behaviour for the situation they're involved in.

Any patient who does not initially seem to be alert and Orientated but needs Verbal Stimuli for them to respond to yourself or others. Or are acting in an inappropriate behaviour for the situation they're involved in. (The quiet patient).

Any patient who is not Alert and Orientated and is only Responsive to Painful Stimuli whether their response is either verbal sounds or movement.

Any patient who is on initial observation Unresponsive to any form of stimulation whether they are breathing or not.

Occupants of motor vehicles tend not to dress appropriately for the weather conditions they intend to drive in, the road traffic accident patient's environment may have changed from complete comfort in shirt and tie to suddenly being in a windowless wreckage in poor weather conditions. Although climatic factors can influence the patient's appearance it is worth noting that the shocked patient will definitely, further deteriorate subjected to cold conditions. Thus no chances should be taken when considering climatic influence on the patients appearance.

The reluctance of paramedical personnel to by-pass District General hospitals in favour of centres of Definitive Care is due significantly to lack of confidence in being able to provide sufficient care in transit with the present level of monitoring capabilities of present day ambulances. There is also a reluctance to endure the potential situation where a patient deteriorates to the point where they die in the care of the paramedical staff. This is very likely the case in patient's serious enough to warrant direct access to Definitive Care and who are likely candidates for dying even if the nearest facilities is actually the centre of Definitive Care. If there is further medical representation on the vehicle such as when immediate care doctors decide to travel with the trauma patient from an incident, the paramedic is less likely to be scape-goated by grieving relatives should the quest for Definitive Care prove futile.

All Accident & Emergency (A&E) Departments have "Flying Squads" of differing capabilities whom when requested will mobilise to assist the pre-hospital management of certain incidents. However this provision of assistance from the hospital is purely on the assumption that the patient is returning to the Flying Squad's home department, even when the attending Flying Squad has clearly evaluated the patient is in need of definitive care elsewhere.

If a pre-hospital medic evaluates that a patient needs direct access to Definitive Care they will receive no assistance from other hospitals other than the one they intend to travel too, thus the ludicrous situation arises where one hospital's Flying Squad may even encroach into another hospitals area, to meet an incoming patient. Any hospital if not able to provide Definitive Care should be able to provide an Immediate Transfer Team consisting of at least an Anaesthetist who will respond to emergency Medical Service request for any patient deemed to be in need of Definitive Care by JETTA rating.

Even if an ambulance has to detour to collect an Immediate Transfer Anaesthetic Team (ITAT), the patient will reach Definitive Care sooner than is presently happening and the General Hospital will be spared an intensive care position until the trauma patient is adequately stabilised to return to the General Hospital. Any patient arriving at a hospital thought to be a border-line case should not enter the building for further assessment, but should be assessed on the ambulance in view of minimising the patients eventual journey to Definitive Care.

If any improvement in the survivability from serious trauma is going to occur it will probably be due to better management of the minutes following the accident. This will largely be due to the patient arriving in a facility capable of providing Definitive Care for their particular injury. This task, although a collective effort is going to have the Emergency Medical Services (EMS) as the backbone of the operation and thus any beneficial changes will need to be strongly influenced by EMS capability and compatibility.

Scoring and Triage devices such as JETTA Rating or others that are EMS conceived need to be tested for both accuracy and user friendliness. Hospitals need to trust the pre-hospital personnel to evaluate the seriousness of a patient's condition and act accordingly to EMS request, for assistance without first wanting to evaluate for themselves a patient's condition. Hospitals that do not have full range of Definitive Care capabilities need to be in close consultation and possibly directly answerable to the regional facilities of Definitive Trauma Care. Only when this practise is in place will there be a marked improvement in survivability from serious trauma.

At present there is still a great lack of pioneering research and development into Pre-hospital emergency medical procedures thus the quest for improvement in patient management is restrained by existing protocols. Unfortunately present audits seem to be indicating only where Emergency Medical Services are coming from as opposed to where they should be heading as we enter the millennium. An audit needs to begin within a Pre-hospital Trauma Life Support trained, United Kingdom ambulance service to evaluate the percentage of Road Traffic Accident (RTA) patients having been spinal immobilised on long-board, are successfully transported from scene within the recommended "Platinum Ten Minutes". The evidence from such an audit is predicted to indicate a very poor success level, despite the service in question being PHTLS orientated. This may then be used in comparison to any audit on the evaluation of JETTA Rating style management of the same criteria patients.

Although this suggestion for the use of JETTA Rating is being applied to patients involved in RTA incidents, there is only slight hindrance to this system being used for other types of traumatic injury. The Mechanism of Injury would need simple adjustment to the presenting incident, however at present this is not suggested due to the conceptual goal of presenting a triage system simple enough for memorisation only.

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