Br.J. Anaesth.
(1977), 49, 651
TRANSPORT OF THE INJURED PATIENT
Past, present and future
R. SNOOK
From biblical times onwards it has been recorded
that man has transported his stricken fellow being to
shelter or to centres of healing. The transport was
often provided by a litter which is denned in the
Concise Oxford Dictionary as "a framework with
couch for transporting sick and wounded . . . and
carried on man's shoulders or by beasts". Later in
the development of healing the litter could also be
transported on a cart drawn by a horse or other
animal. Such methods must have been used to move
the ill and injured to the early religious centres such
as those that began the long traditions of the St John
organization.
During times of hostility, man's inhumanity to
man eventually provoked the emergence of organized
compassion for the wounded soldier. The father-
figure of this movement was M. Henri Dunant out of
whose ceaseless efforts was fashioned the Red Cross.
Early documents record the organization of moving
hospitals following the armies and the use of horse-
drawn vehicles for the collection and evacuation of
the wounded. Interestingly the word "ambulance"
describes either the moving hospital or the vehicle
used for transporting the patient. With the passage of
time the horse gave way to steam and then to the
internal combustion engine and the design of am-
bulances evolved with this change of motive power.
Pictorial evidence suggests that this change was slow
and documents in the archives of the British Red
Cross Society record dissatisfaction with the design
of those early ambulances.
In the years between the World Wars improve-
ments in the transport of patients were largely
limited by the states of development of motor
engineering and medical technology.
In the second half of the 20th century technical
advances on both these fronts have allowed the
standards of emergency patient care to advance more
rapidly. Vehicles were built specifically as ambu-
lances; in the United Kingdom local communities
were obliged by Act of Parliament to organize
ROGER SNOOK, M.D., M.B., CH.B., Accident and Emergency
Department, The Royal United Hospital, Combe Park,
Bath BA1 3NG.
ambulance services and medical techniques were
beginning to evolve that would enable treatment to
begin at an earlier stage in the care of the patient.
THE PROBLEM
The movement of the injured has long been recog-
nized as a problem. Pain inhibits movement. Move-
ment can worsen the effects of injury, deepening
shock and damaging vital structures. Vital functions
may be affected by the position of the patient, but the
position may have to be altered to allow treatment
and movement. Treatment and movement may be
influenced by distance and time, and time can
influence morbidity and mortality.
Ideally these problems should be identified and
their effects measured. This should allow minimum
standards of care to be defined, implemented,
assessed and brought further up to date. Reality is
often less ordered, however, and advances in am-
bulance design and first aid have often been made
empirically and in isolation. For example, Thomas
developed his famous leg splint at the time of the
First World War. It was used with great effect in the
latter stages of that war and again in the 1939-45
conflict. However, the adoption of the same principle
in civilian practice awaited the introduction of modi-
fied splints in the 1970's (MacMahon, 1974).
In considering the problems of the transport of the
injured several distinct divisions may be recognized:
reaching the patient; evacuating the patient to the
ambulance; the ambulance journey and transfer to
hospital.
Reaching the patient
McKay (1969) analysed the time of survival in
fatal accidents. He suggested that 43% of riders or
vehicle occupants might have had a greater chance of
survival if some medical treatment had been available
at the scene of the accident within 10 minutes. It is
important for both medical and humanitarian reasons
that those caring for the injured should reach them as
rapidly as is compatible with safety.
To this end in the United Kingdom we have an
efficient national emergency communication system
652
which links the public with the emergency services
by the "999" telephone call system and the various
emergency services by the "flash" call system. The
response to such an emergency call is to mobilize an
ambulance either from a base or by sending the
nearest available mobile unit.
To avoid delay in reaching the patient the ambulance
is identified externally by several means. Most am-
bulances are white and are equipped with one or
more blue flashing lights and an audible warning
device. Snook (1972a) found that the size of the
beacon is important and that alternating horns are
preferable to sirens. To reduce the time taken to
reach the patient it is now technically feasible to fit
the ambulance with a small device that will switch
traffic lights to favour the passage of the emergency
vehicle (Snook, 1972b). Such a system is of practical
use and is relatively inexpensive, adding approxi-
mately 5% to the cost of the traffic light installation.
Evacuating the patient to the ambulance
Once the patient has been reached the process of
history taking, examination, diagnosis and treatment
can begin. An understanding of the patterns of injury
and of special rescue techniques is important in this
phase of patient care (Snook, 1974).
In order to come to a provisional diagnosis it has
been found useful to consider the mechanisms of
injury and, in the case of road accidents, to recognize
patterns of vehicle damage and consequent occupant
injury.
Except where there is a definite danger of addi-
tional injury, the patient should always be assessed
before being moved. In addition, vital functions
should be protected or supported. Anything from
simple procedures to full cardiopulmonary resuscita-
tion may be indicated.
Special equipment may be required to release a
trapped patient. In the United Kingdom this is
generally the responsibility of the Fire Service and is
accomplished using comprehensive sets of cutting,
lifting, jacking and lighting equipment which are
often carried on rescue tenders. Whenever possible
the principle used is to move the structures from the
patient rather than vice versa.
Further down the list of priorities is the relief of
pain. Preferably, this should be undertaken before
moving the patient. An exception will be a patient
with a spinal iniury where pain can offer a sign
guarding against injudicious movement. For these
patients a spinal backboard splint of the U.S.A.
Farrington pattern or the U.K. Tynemouth Spinal
BRITISH JOURNAL OF ANAESTHESIA
Splint type should be applied first and then analgesia
can be given.
In the phase of provisional diagnosis it is often
safer and more useful if pain relief can be controlled
and modified. Baskett and Withnell (1970) and Snook
(1974) found that Entonox (50% nitrous oxide in
oxygen) gives safe, effective and controllable anal-
gesia in the early management of injured patients. It
is now available in the majority of emergency
ambulances in the United Kingdom.
Pain relief may be followed by the splinting of
fractures using conventional bandaging, inflatable
splints or traction splints (for example, Hare and
Tauranga splints) where applicable. These last two
forms of splint involve some degree of reduction of
the fractures so that some pain relief will be necessary
before they are applied.
After splinting, a blanket lift or special rescue
stretcher may be required to lift the patient from the
accident site onto the ambulance trolley stretcher. In
difficult situations such as cave, mountain and coastal
rescue special stretchers may be used. These can be
adapted to the needs of the casualty and the situation,
and may include sledge, wheel or sling attachments,
provision for thermal insulation and even for an
attendant to ride alongside the stretcher. Two of the
most widely used rescue stretchers are the canvas-
and-bamboo "Neil-Robertson" and the tubular
metal and plastic "Paraguard" stretchers. The latter
has the particular virtue of folding to half-size for
ease of storage. In addition to the rescue stretcher,
special transport systems may be involved in bridging
the gap between the accident site and the ambulance.
Helicopters, hovercraft, Landrovers or lifeboats may
be needed.
The ambulance
It would seem that little serious attention was given
to the ambulance until Bothwell (1959) described a
patent ambulance. In a paper given to the Institute
of Mechanical Engineers, London (1968) observed
that ambulances were often designed without the
least regard for the effects of illness and injury. Also
in 1968 the Committee on Acute Medicine of the
American Society of Anesthesiologists stated that
most vehicles in use were unsatisfactory for life
support.
In 1967, Cullen, Douglas and Danziger reported
that there was clinical evidence of an adverse response
of patients to movement in an ambulance. Similar
observations were made by other workers who also
expressed disquiet about the "mortality of the am-
TRANSPORT OF THE INJURED PATIENT
bulance ride" and other effects related to the transport
of the patient (Mann, 1961; Glover, 1967; Gurling,
1967; Heald, 1967; Horton, 1967; Lamont, 1967;
Stewart, 1967; Strange, 1967; Storrs and Taylor,
1970; Young, 1971; Snook, 1972c). In spite of these
disquieting relevations there was little evidence of any
serious effort to improve the situation.
Snook (1972c) investigated the problems in detail
and found that the interior design and layout of many
emergency ambulances in current use left much to be
desired. The illumination was found to be inadequate;
heat loss occurred (although it could be prevented);
the interior noise levels were often too high and
vehicle identification and passage through traffic
could be improved. Measurable differences in the
vibration of the ride existed between the commer-
cially available ambulances, a prototype purpose-built
ambulance and a private car. The ride in the am-
bulance also affected the performance of simulated
patient life-support tasks. There were measured
failure rates of up to 14% for external cardiac
massage and 17% for artificial ventilation. Evidence
that this was an international problem came from
France where Pichard (1970) described a series of
430 ambulance journeys. In 6% of these there were
disturbances in the cardiovascular systems of the
patients which could be related to movement. These
disturbances included decreases in arterial pressure,
cardiac arrhythmias and cardiac arrest. Collectively,
these findings question some of the factors which
have hitherto influenced ambulance design.
At present the following constraints limit ambulance
design:
(1) The requirement that the vehicle shall fulfil a
dual-purpose role carrying at one extreme one
seriously ill patient with an attendant and at the other
six to eight patients together with wheel chairs,
crutches and luggage! To be able to accommodate
the large group the vehicle springs have to be too
hard for transporting the single sick patient.
(2) Routine work forms 85% of ambulance jour-
neys and emergency work only 15%.
(3) There are economic restrictions favouring the
use of a cheaper commercial van conversion rather
than a purpose-built vehicle which would be more
expensive. It should be noted that this saving on
capital costs involves additional costs to the com-
munity from the mortality and morbidity of the
ambulance journey. (Dawson (1971) estimated that
an average road accident fatality cost the community
approximately £16 800.)
53
653
(4) There are no measurable minimum standards
of noise, heating, lighting and vibration in ambulances.
(5) There are no ergonomic standards relating to
the performance of life-support tasks within the
vehicles.
Collectively, these constraints have been respon-
sible for the poor state of the development of the
ambulance, which in many respects is little more
than a transport van rather than a purpose-designed
patient care system. None of the problems is in-
surmountable. It is possible to design a chassis and
suspension system that gives a ride closely approaching
that of a good saloon car and maintain that standard
over a varying load with a variable-rate suspension
system (Snook, 1972c). Similarly, it is possible to
measure and design optimum environmental con-
ditions within the vehicle to cover light, sound, heat
and vibration. The ergonomic considerations for the
attendant with his patient and equipment could easily
be met by redesigning the interior layout of the
patient compartment (N.R.D.C. Report, 1969;
Smallhorn, 1970).
Sadly, since the demise of the Daimler ambulance
in the late 1950's (fig. 1) no British company has been
able to produce commercially a purpose-built am-
bulance chassis. There is little doubt that this is a
result of the failure of ambulance authorities to
appreciate the need for such vehicles, rather than of
cost or engineering problems. At least two attempts
have been made recently to produce such a vehicle,
taking design to the point of a pre-production proto-
type (fig. 2). But these appear not to have been
evaluated adequately by the authorities then respon-
sible for purchase and use of ambulances.
Moreover, certain design concepts still have not
been agreed. For example, a reversal of the direction
of travel of the stretcher patient, so that he travelled
feet first, would have many advantages. This direction
would be more physiologically appropriate for changes
in the speed of the vehicle, with the decelerating
forces always exceeding the acceleration forces. This
position would also allow the patient to be carried
within the wheelbase of the vehicle, thereby reducing
vibration. Ergonomically, the attendant could care
for his patient more easily in the moving environ-
ment, being positioned at the head of the patient on
a secure seat with forward visibility to prevent
motion sickness.
In European countries the situation would seem to
be much the same as that in this country. It has led
to research at Delft University in Holland in a
different direction. Instead of designing a new vehicle,
654: BRITISH JOURNAL OF ANAESTHESIA

FIG. 1. The fleet of four Daimler Emergency Ambulances operated by the City of Bath Ambulance
Service in the 1950's. (Photograph by kind permission of Mr L. Roberts.)

FIG. 2. The Dennis F.D.4 experimental pre-production prototype emergency ambulance used in
the University of Bristol computer analysis trials (Snook, 1972c). The quality of the ride approached
that of a good family saloon car. (Reproduced by kind permission of the Editor of Commercial Motor.)
TRANSPORT OF THE INJURED PATIENT 655

FIG. 3. The floating stretcher support fitted to a conventional ambulance for patient and instrument
trials. A vibration transducer attached to the "patient's legs" is coupled to a tape recorder and
oscilloscope for later computer analysis of the ride characteristics. (Copyright Accident and
Ambulance Research, Bath.)
656
they have concentrated on the stretcher inside the
ambulance. A separate suspension system has been
devised to carry the stretcher and isolate it from the
floor of the ambulance. This device was known as the
"Vleugelbrancard" or "Floating Stretcher Support"
(fig. 3). Two pre-production prototypes were made
by 1969 and by 1973 the units were in commercial
production. The first unit in this country was lent to
the City of Bath Ambulance Service for a patient-
subjective assessment trial and computer analysis of
the characteristics of the ride. The results (Snook
and Pacifico, 1976) showed a statistically significant
improvement in the ride as assessed by the subjects.
The computer analysis demonstrated that the vibra-
tion to which the patient is exposed could be reduced
by up to two-thirds.
Such a solution to ambulance transport is ad-
mittedly a design compromise. An ambulance which
could give the same reduction in vibration would
have advantages over stretcher isolation. Estimates
suggest that the two systems cost similar amounts,
but the stretcher suspension system is commercially
available whereas a purpose-built ambulance has yet
to be designed.
Is there another answer ? If patients were resusci-
tated, stabilized and relieved of pain before the
journey this might partly obviate the need for a
specialized vehicle. Clinical research into methods of
pre-hospital emergency patient care (Snook, 1972c,
1974) showed that morbidity and mortality can be
reduced and that this can also be "cost effective".
Methods have been developed to investigate the
effects of ambulance transport in critically ill patients
(Waddell, Scott et al., 1975; Waddell, Stuart et al.,
1975). There were measurable changes in the arterial
pressure and arterial carbon dioxide tension during
and immediately after movement of patients by
ambulance. It was noted that "resuscitation before
transfer, continuing medical care during the journey
and hence a slower, smoother journey seemed to be
important factors in the management of these
patients".
There are several ways of providing such "im-
mediate care". The advanced training of ambulance
men in cardiopulmonary care (comparable to but not
the same as the American Paramedic and Emergency
Medical Technician schemes (Stewart, 1977)) is one.
Others include the provision of care by general
practitioners organized in specially equipped groups
(Easton, 1970) and hospital-based flying squads
(Snook, 1972d). The general practitioner schemes are
voluntary and supported by public donations: there
BRITISH JOURNAL OF ANAESTHESIA
are about 36 in the country at the moment, based
largely in rural areas. The hospital flying squads are
necessarily based in urban areas; there are about 10
around the country.
There can be little doubt that a higher standard of
patient care must improve morbidity and mortality.
As a start every ambulanceman should be trained in
the use of, and equipped with, a laryngoscope so that
he can see what he is doing with a sucker. This one
improvement would do much to improve both patient
care and the motivation of ambulance crews. Simi-
larly, every ambulance should carry infusion apparatus
and fluids for a doctor or advanced ambulanceman to
use in an emergency. The necessary training in hos-
pitals of the ambulance staff and the medical personnel
could be easily provided in conjunction with anaes-
thetic and accident and emergency departments. In
many cases self-instruction methods can be used
(Baskett et al., 1976).
Transfer from ambulance to hospital
Little need be said about this phase except to draw
attention to one of the few papers discussing the
movement of critically ill patients within hospitals
(Waddell, 1975). He described renewed bleeding
from a fractured pelvis, cardiac arrhythmias and
other cardiovascular effects of movement. There were
also difficulties in continuing treatment during move-
ment and a plea was made for a greater awareness of
the hazards of moving the critically ill.
The movement of individual patients on stretchers
is another area for improvement. A universal stretcher
top compatible with ambulance, accident area and
operating theatre equipment would save much
patient disturbance but would have to include such
considerations as resistance to glass fragments, radio-
translucency and electrical conductivity for the dis-
charge of static, defibrillation and diathermy charges.
The concept of a universal interchangeable trolley
could include the universal top. There are further
problems with the universal trolley in the conflicting
requirements of the ambulance and hospital services.
The ambulance trolley needs to be low, compact and
light to allow it to be lifted and accommodated in a
limited space; the hospital need is for strength, a
standard work height and the ability to accept
attachments such as large Entonox and oxygen
cylinders, dripstands, cotsides, arm boards, etc.
A universal trolley top system, can however, be
made to fit the various needs for the several stages of
patient care and is exemplified by the West German
Automobile Club (A.D.A.C.) system with com-
TRANSPORT OF THE INJURED PATIENT
patability between helicopters, ambulances and the
receiving emergency units.
Alternative transport systems
Road vehicles are used for the majority of emer-
gency journeys in this country, but situations arise
where alternative methods are needed, at least for
part of the journey. Lifeboat and inshore rescue
boats, together with the rescue helicopters of the
armed services, provide much of the coastal transport.
Fixed-wing aircraft are most usually used for the
planned transfers of patients over long distances or
difficult terrain. Hovercraft have not yet been used to
any extent.
The helicopter has particular advantages for eva-
cuating patients from coasts and the sea and is also of
use where road transport is impractible because of
floods, heavy snow and earthquakes. The use of
helicopters in evacuating front-line casualties in the
Korean and Vietnam wars (Neel, 1968; White, 1971)
received considerable attention. Whilst the results
were impressive, much of the success must be in part
related to the continuous occurrence and the limited
distribution of the casualties.
Efforts to translate the lessons of war into benefits
for peacetime civilian communities have been made
in several countries. In Maryland in the United
States the centralization of the emergency services
together with the distances involved in travel from
the rural communities led to the development of a
helicopter evacuation service (Adams Cowley, 1973).
To make the maximum use of the helicopters and to
minimize costs other public services are also pro-
vided, with the understanding that rescue takes
precedence. There was a measurable reduction in
mortality as the service expanded and Adams Cowley
stated that "for every 30 min that elapses between the
accident and the time the patient gets definitive care,
the mortality can be expected to increase threefold".
In West Germany the A.D.A.C. initiated an inte-
grated service using helicopters and conventional
ambulances. They claim a saving of 700 lives in a
4-year period involving the treatment of 7500
casualties (Burghart, 1974). In Toulouse in France
the S.A.M.U. Flying Medical Unit uses helicopters
to evacuate casualties from the accident site. It
involves the integration of the gendarmes in traffic
control to allow landing on the highway adjacent to
the crash (Lareng, 1973).
The necessary equipment for aeromedical transport
is described by Moylan and Pruitz (1973) of the
United States Army Institute of Surgical Research.
657
Wider accounts of the medical and physiological
constraints of air transport are given by Snook (1974)
and Oxer (1975).
In the United Kingdom the use of helicopters in
civilian patient care is limited by four factors: the
sparse distribution of helicopter bases, the wide
scatter of accidents, the system of charging for in-
dividual flights and the delays in administrative
sanction of individual journeys. These last two help
perpetuate the low rate of use, whether by accident
or design!
CONCLUSION
Perhaps, in the past, we have been too ready to leave
the transport of the injured (and ill) to the ambulance-
man without supporting him with the necessary
research, training and equipment to enable him to
offer the highest standards of patient care. This state
should not be allowed to continue and yet the
Department of Health and Social Security (1976)
and the Royal College of Physicians (Joint Working
Party, 1975) have recently published diametrically
opposing views on the subject. The Department has
decided to limit advanced training for ambulancemen
whilst the College supports the concept in the field of
coronary care!
What of the future? Research is continuing at
various centres investigating human response to
vibration and the patient response to the ambulance
ride. Existing ambulance design is being improved,
ambulanceman training programmes advance and the
medical rescue or immediate care schemes expand.
The results are being evaluated clinically and statistic-
ally. The specialities of anaesthesia and accident and
emergency medicine can and should continue
developments in this field. Both are involved in
intensive care both as an actual hospital area and as a
concept of continuing patient care. Regrettably, this
area of patient care is starved of funds, hence die rate
of progress is not that which is technically feasible.
Nevertheless, substantial progress has been made in
the last decade.
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