| 摘要: | 前言：空中緊急醫療轉送已經成為現代創傷處理系統的重要部分。經由這個後送系，將創傷病患從離島偏遠地區缺乏處置能力的醫療單位轉送至有處置能力的醫學中心，迅速的給予正確的診斷，並給予及時的治療，包括緊急的手術或是加護病房的內科治療，目前已經成為頭部外傷的標準治療準則。
目地：本論文分析台灣離島偏遠地區民眾頭部遭受外傷並經由空中緊急醫療轉送就醫病患的流行病學統計，並分析各離島偏遠地區頭部外傷民眾接受直升機後送前的昏迷指數，是否有在轉送前予以氣管插管，以及送至後送接受醫療單位治療後的情況，包括是否接受頭部外傷損害相關的手術治療，以及病患轉送之後的預後狀況，是否三日內離院，以及是否在追蹤期間死亡等，評估空中緊急醫療的效益。
方法：本研究為回溯性敘述分析研究，作者檢視行政院衛生署空中轉診審核中心資料，將病患因頭部外傷並經過緊急空中醫療轉送的資料加以分析，資料的時間為民國九十一年十月一日起，至民國一百零五年十二月三十一日止，共計十四年有三個月，合計443位病患。患者是由離島偏遠地區後送台灣本島有能力處理頭部外傷的醫療院所，分析相關患者的基本資料，並予以統計分析。
結果：研究計劃中包含的十四年又三個月期間，共接獲台灣離島偏遠地區申請空中緊急醫療轉送的病患共計4,236件（核准3,701件，未核准與自動取消共535件，核准比率87.37%）。其中因為頭部外傷經由空中緊急醫療轉送返台或轉送就醫的病患共計443位。民國九十一年至民國一百零五年每年度轉診人數分別為4人、21人、49人、29人、31人、41人、42人、61人、32人、21人、29人、23人、28人、17人、15人。各離島轉診人數分別為金門157人、澎湖113人、蘭嶼65人、綠島62人、連江縣35人，其他地方11人。每千人口的空中轉診人數為: 金門1.16人、澎湖1.09人、馬祖2.78人、蘭嶼12.8人、綠島16.7人( 依照2015年人口數估算 )。這443位病患平均年齡42.69±21.27歲，年齡最小六個月、年齡最大97歲；男性320位、女性123位；病患就醫時平均意識狀態GCS分數為10.09±3.45分；
結論：
1.申請轉診地區區分:以申請量多少排序，以金門最多，其次是澎湖，蘭嶼，綠島，連江，以及其他地區。其案件申請年齡層分布最主要和人口數有關。從金門，澎湖轉送的病患，較綠島，蘭嶼，連江和其他地方轉送的病患比，其疾病嚴重度較高，轉送前插管比率高，接受外科手術治療比率高，三日內離院比率低。顯示離島人口較多且有地區醫院資源者具有較優之醫療品質。
2.比較申請轉送病患之年齡: 雖然在數值上有差異，但是經過分析後可以發現各年齡層在GCS嚴重度，插管比率，追蹤期死亡率並沒有明顯差異，有統計學上顯著差異的是各年齡層接受外科手術的比率，46-60歲這一組接受手術的比率最高。
3.比較插管的情況: 插管與否，和病患的年紀無關，而是和患者的GCS嚴重度，是否接受手術，以及追蹤其死亡率有統計上的差異。沒有插管的病患平均GCS為12.08±2.42分，有插管的病患平均GCS為6.78±2.34分。如果嚴重度愈高(GCS分數越低)，則插管比率愈高，而這些嚴重度較高的病患，其接受外科手術治療，和死亡的比率也較高。影響因素最主要與嚴重度的相關，插管與否，代表維持生命現象之必要處置。
4.分析病患死亡: 死亡與否，跟患者的年齡分層，是否接受外科手術治療，沒有統計上的意義。頭部外傷越嚴重，則死亡比率上升。存活的患者裡面，GCS平均分數10.81(SD 2.99)，死亡的患者，平均的 GCS分數5.04 (SD 1.85)。死亡的病患，插管的佔多數，主要是因為病情嚴重的需要插管。
5.分析病患是否接受外科手術治療: 患者是否接受手術治療，跟患者的年齡分層，是否插管，還有GCS嚴重程度有關, 40-60 歲年齡層的患者接受手術治療比率最高。其平均的 GCS平均分數為8.4±3.07；採取內科治療的患者，其GCS平均分數為11.06±3.28。跟患者是否死亡沒有統計學上的相關性。
6.分析病患是否三日內離院: 患者是否三日內離院，跟患者的年齡層，是否有氣管插管沒有相關；跟患者的GCS嚴重程度有相關。最主要分布在輕度頭部外傷和重度頭部外傷，都達患者人數20%以上。GCS嚴重度為重度之患者，佔比之所以很高，是因為有32位之中有31位為三日內死亡或是病危自動離院。輕度則是因為轉診後進一步檢查沒有需要長期住院治療或是開刀的需要，因此出院。這些都屬於資源的浪費。
7.分析頭部外傷嚴重度:頭部外傷的嚴重度和病患的年紀並沒有相關性，而頭部外傷嚴重程度愈高，插管比率愈高，死亡率也愈高，且接受外科手術治療的比率也愈高。
Introduction: Head injury (Traumatic brain injury) is a common injury that takes place every day in emergency department. To secure lives, patients who appear to have head injury should be given immediate and correct diagnose and treatment. However, residents with diagnose of head injury in remote islands (isles) and areas can rarely receive the instant medical treatment due to an obvious lack of medical resources and accessibility in these areas. Emergency Air Medical Transport (EAMT) in the cases can play an extraordinary role in the patient transfer system to assure on-time and appropriate medical treatment for the patients.
Objective: This thesis focuses on the analysis of the epidemiology of head injury patients who were transferred via EAMT system from remote islands to regional trauma centers of Taiwan. It aims to study head injury patients’ pretransfer intubation condition, medical treatment in the process, and the prognosis.
Methods: This study adopts a retrospective and statistical approach. The author reviewed and analyzed both digitized files and records of head injury patients transferred via EAMT during 1 October 2002 and 31 December 2016. The studied remote islands and areas include Penghu, Kinmen, Lienchiang, Lanyu, Lyudao, Liouciou, and Dongsha Islands and Taitung. The data was collected from National Aeromedical Approval Center.
Results: In the fourteen years and three months studied period, a total number of 4,236 applications were applied for EAMT from remote islands or areas, among whom 3,701 were approved for transferral, and 443 out of the transferred patients appeared to have symptoms of head injury. The number of head injury for each of the fourteen years was 4,21,49,29,31,41,42,61,32,21,29,23,28,17 and 15 respectively. Geographically, 157 of the head injury patients were from Kinmen, 113 from Penghu, 35 from Lienchiang, 65 from Lanyu, 62 from Lyudao, 11 from other places including Liouciou, Dongsha Island and Taitung. The per thousand population of the transferred head injury patients in each island was 1.16 in Kinmen, 1.09 in Penghu, 2.78 in Lienchiang, 12.8 in Lanyu, 16.7 in Lyudao. Finally, Lyudao and Lanyu appeared to have the densest head injury patients among the remote islands.
Demographically, the average age of the total head injury patients was 42.69±21.27 years old. The youngest was 6 months old and the oldest was 97 years old. Male predominated the head injury patient populations. The number of male, 320, was doubled than that of female, 123. Patients aged between 16 and 30 years old comprised the majority (30%). The average Glasgow Coma Scale score of the 443 patients in emergency department was 10.09±3.45. Moderately injured patients comprised 33.4% (n=144), among whom 31 were intubated (21.5%). Severely injured patients comprised 35% (n=155) and 134 were intubated (86.5%).
Conclusions:
(1)The average severity of head injury in different remote islands was discrepant: patients transferred from Penghu and Kinmen had lower GCS than patients transferred from Lanyu and Lyudao. It revealed that remote islands with larger population size and better hospital resources could have better medical quality.
(2)While age was a distinguishable factor in the transferred patients, it was not statistically relevant in the GCS severity, intubation and mortality rates.
(3)For intubation, mean GCS for intubated patients was 6.78±2.34, and 12.08±2.42 for non-intubated patients. Intubation rate and mortality rate increased in patients with lower GCS.
(4)For mortality, age and surgery were not statistically correlated with mortality. Mortality was more directly related with head injury severity.
(5)For surgery intervention, age, intubation, and the severity of GCS were all significant factors. Patients aged between 40-60 years old accepted relatively higher surgery rate.
(6)Patients who were discharged from hospital within 3 days had two totally different conditions, either very ill and expired in 3 days, or mild head injury. The later specifically can be unnecessary medical transfer.
(7)Overall, severity of head injury is the main factor influencing intubation, mortality and surgery intervention rate. Higher head injury severity significantly increases intubation, mortality and surgery intervention. |
