The sky is a limit: Errors in prehospital diagnosis by flight physicians

The medical records and air evacuation reports of 186 trauma patients were examined to determine the type and characteristics of missed diagnoses. More than 35% of all cases of hypovolemic shock were not identified, nor were two cases of respiratory distress. Although unconsciousness was always identified correctly, almost 7% of all cases with partial unconsciousness were not recorded. Of 443 diagnoses, 337 were correctly recorded by the flight physician, slightly more than 76%. The flight physicians missed 10 critical diagnoses, all of which were feasible, 56 important diagnoses, 42 of which were feasible, and 40 relatively marginal diagnoses, 27 of which were feasible. Injuries to the head, face, and limbs were usually diagnosed correctly, and were missed only in a few cases. Of considerable clinical relevance was the observation that flight physicians missed a significant number of critical and important feasible diagnoses of five types: (1) more than half of all feasible diagnoses in the eyes; (2) a third of feasible diagnoses of cervical spine injuries; and a significant percentage of injuries to the (3) abdomen, (4) chest, and (5) pelvis. Blunt diagnoses were missed more often than penetrating injuries. Feasible diagnoses were missed in two of the four cases of paralysis, approximately one third of all crush injuries, and one quarter of all fractures. This study illuminates preventable errors of physicians during air evacuation and indicates particular types of serious, feasible diagnoses that flight physicians are prone to miss. Medicine in the sky may pose limits to our diagnostic abilities but the limits could be pushed further.