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Trauma care in Belgium 1 (version 11-06-2003)
Trauma care in Belgium.
Stefaan J.B. Nijs, MD and Paul L.O. Broos, MD, PhD, FRCS
(Dpt. of Traumatology, U.Z. Gasthuisberg, K.U. Leuven)
Corresponding author:
Dr. Stefaan Nijs
Dpt. Of Traumatology
U.Z. Gasthuisberg
Herestraat 49
3000 Leuven (Belgium)
Phone: +32 16 34 46 66
Fax: +32 16 34 46 14
e-mail: [email protected]
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Trauma care in Belgium 2 (version 11-06-2003)
Geography and demography
Belgium is situated in the west of Europe, bordered to the north by the
Netherlands, to the east by Germany and the Grand Duchy of Luxembourg
and to the south and the west by France. Although its surface area of 32,545
km2makes it a small country, its location has made it the economic and
urban nerve centre of Europe. "Belgium, heart of Europe" is not just a catch
phrase: the geographical centre of the 15 countries of the European Union is
actually located in Belgium and more precisely in Oignies-en-Thirache
(Viroinval), in the province of Namur .[1]
The Belgian state has a federal structure. The decision-making power in
Belgium is no longer exclusively in the hands of the Federal Government
and the Federal Parliament. Nowadays, the management of the country falls
into several partners, which exercise their competences independently in
different fields. The state is divided in three communities based on linguistic
and cultural issues: the Flemish-, the French- and the German-speaking
community. Furthermore, the country is divided in three regions on a more
historical and economical base: the Flemish region, the Brussels capital
region and the Walloon region. The federal state retains important areas of
competence including: foreign affairs, defence, justice, finances, social
security, important sectors of public health and domestic affairs, etc. The
regions and communities are entitled to run foreign relations themselves in
those areas where they have competence. The public health and social
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Trauma care in Belgium 3 (version 11-06-2003)
security competence are not only shared by the federal and regional
governments, but they are within each structure also shared by different
ministries. This partition of competences in different persons and levels
makes it often difficult to interact with the government.
On 1st January 2001, Belgium had 10.263.414 inhabitants. This means a
population density of 336 inhabitants/km2 which makes Belgium one of the
most crowded countries of Europe. Flanders has 5.952.552 inhabitants (440
inhabitants/km2), the Walloon Region 3.346.457 (198 inhabitants/km2) and
the Brussels Capital Region 964.405 (5953 inhabitants/km2) [1]. These
differences reflect on the development of the regions. Flanders is
characterized by a spread of the population over the entire surface. Even in
the more rural regions, the streets are bordered by houses, which are not
concentrated in villages alone. This makes that there is a close interaction
between traffic and living space over the entire surface. Wallonia has a more
rural aspect. Its population lives more concentrated in towns and villages.
On the other hand, it traditionally has the heavier industries, which are
related to a relatively higher number of and more serious labour accidents.
The Brussels Capital Region is a typical city region with a dense interaction
between the living space and traffic at a lower speed, but also by relatively
more criminality. This means that the need for trauma care is relatively
different in the three regions.
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Trauma care in Belgium 4 (version 11-06-2003)
Traditionally the French-speaking community is oriented on the French
culture, the Flemish more on the Anglo-American and German culture. This
is also reflected in the scientific - including the medical - world, where
Flemish medicine is based on an Anglo-American and German (Central-
European) and Walloon medicine on a French (Southern-European)
tradition.
Pre-hospital care
Before 1956, there was no organized medical field support. The local doctor
tried to give some support to the trauma victim. Although some local
hospitals offered transportation using their own ambulances, the most often
used means of transportation were taxis and private cars. In 1956, the first
governmental organisation of medical transport was founded, creating the
national rescue service for transportation of poliomyelitis patients. The
law of 8th April 1958 obliged the municipalities to provide transportation to
all persons in need of urgent medical care caused by accidents or illness on
a public road or public space. A public space was defined as all places that
cannot be considered as a private home [2].
The same year, an investigation researching the needs and conditions to start
up a national service for urgent medical support was initiated. The process
was urged after some painful experiences, such as the disaster in the mari pit
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Trauma care in Belgium 5 (version 11-06-2003)
Roosberg in Zichem-Zussen-Bolder. On 23rdDecember 1958, the pit
collapsed and seventeen workers got isolated. It took a long time before any
rescue operation was initiated, all workers died and only four corpses could
be retrieved. The event was considered as a national disaster and the King
and the minister of public health, Paul Meyers, did visit the area. On his way
back to Brussels, the minister witnessed a serious accident in which a
female pedestrian was hit by a car. Again, it took a long time before any
rescue service reached the scene. Some sources mention that the Minister
would have stated that such thing should not happen again and that he
ordered his administration to give the development of a national service for
urgent medical support highest priority [3].
In 1959, the first help centre 900 became active in Antwerp. Nationwide,
15 extra centres were installed between 1959 and 1963. It was recognized
that the municipalities didnt have the possibilities to organise the urgent
medical support and the transportation of injured and acute ill persons did
become a task of the Department of Home Affairs starting from 1stJuly
1965. A central telephone number, 900, could be used nationwide to
activate the rescue system. In that way, one of sixteen help centres, located
in fire stations and manned by firemen was reached. Although the 900
help centres were legally only responsible for the evacuation of ill or injured
persons on public spaces, they soon started giving support to all medical
emergencies. In 1986, 50% of all interventions in the region of Hasselt were
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Trauma care in Belgium 6 (version 11-06-2003)
interventions in private homes. Only in 1998, this situation was recognised
in a changed law. Starting from 1st
January 1998, all emergency
interventions are legally the domain of the 100 intervention teams. In
November 1987, the number 900 changed into the number 100 because
of technical reasons. Beside the number 100, the European rescue
number 112 is in use since 1996 [4].
At the moment, 10 help centres 100 are active in Belgium, one per
province. They are almost all localised in a fire station. This means that six
of the initial sixteen centres have been closed in 1997. This has been an
issue of intense debate and still is discussed by some officials. The
Department of Home Affairs is - as already mentioned - responsible for the
arrangement and the functioning of the help centres. The Ministry of Public
Health and Environment is responsible for the organisation, the medical
equipment and the teaching of the EMTs (Emergency Medical Trainee).
All calls to the 100 or 112 centres are recorded on tape, mentioning
hour and date. All the 100 centres are connected and deal with the calls
making an intervention of the fire-brigade, EMTs and the Civil Protection
necessary. They are also a pivot in the provincial disaster management
planning. When one calls the 100, the telephone operator will send all
necessary help to the scene: EMTs, MUG (Mobile Emergency Team), fire
brigade, . The help centre will also inform the police over a direct line
when estimated necessary. Operators are firemen, most of them lacking a
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Trauma care in Belgium 7 (version 11-06-2003)
specific training. They use a standard protocol gathering the necessary
information [5].
In case of accident or illness, the operator can send an ambulance with at
least a driver and an helper on board. Both are trained EMTs. This means
they need to have a basic EMT training (120 hours, of which 18 hours
dedicated to the treatment of the injured patient) and to follow additional
trainings (24 hours/year) in recognised provincial training centres on a
regular base. Every five year, the EMT has to prove his theoretical and
practical skills in a test. Law has defined the external characteristics of the
ambulance. The equipment is not defined, because the European Standard
for Medical vehicles and their equipment which was introduced in 2000
got no legal character yet. Until recently, the Ministry of Public Health
provided the different 100 services with ambulances. This policy has been
abandoned because of budgetary reasons. Now, every 100 service has to
buy its own ambulances, according to its financial possibilities. Ambulances
are managed and manned by hospitals, private enterprises, the Red Cross
and in the first place by the fire brigades. Both professionals and volunteers
man the ambulances. In Brussels, an ambulance and MUG team of the army
intervene in those cases where severe burns are expected since the burn unit
is located in the military hospital [6].
In those cases where the operator expects that urgent medical support is
needed, he can send a doctor at the scene. The operator has the right to send
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Trauma care in Belgium 8 (version 11-06-2003)
no matter what physician at the scene to provide first medical support, but
he will preferentially send one of the recognized MUGs (mobile emergency
team). These MUG teams are linked to a recognized emergency department
of a hospital [7]. It consists at least of an in emergency medicine trained
medical doctor and a trained (male) nurse. Apart from criteria for the
external characteristics, the equipment is also legally defined. The mission
of these MUG services was designated by the Order in Council of 10 th April
1995 stating: the MUG is a hospital function, the aim of a MUG is the
reduction of the therapy free interval by going at the scene on the demand of
the 100 operator, the execution of all necessary medical and nursing care at
the scene and the supervision during hospital transport [8]. The function of
the MUG is further organised according to the Order in Council of 10th
August 1998 stating that the recognition of a MUG service can only be
awarded to an hospital with a recognised specialized emergency department
[9]. The medical head of the department must be a medical specialist in
emergency medicine. To becomea medical specialist in emergency
medicine, one must follow an additional training of 2 years after a
successfully completed training in internal medicine, anaesthesia or surgery.
The head nurse responsible for the nursing tasks must have a postgraduate
training in emergency and intensive care medicine. The medical doctor
leading an intervention must be a medical specialist in emergency medicine,
a specialist in training to become specialist in the emergency medicine or at
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Trauma care in Belgium 9 (version 11-06-2003)
least to have obtained the certificate acute medicine. This is an additional
training consisting of a theoretical training of 120 hours and a practical on-
site training of 240 hours, including at least 10 potentially life saving pre-
hospital interventions.(Ministerial Council of 12th November 1993). The
nurse must have a postgraduate training in emergency and intensive care
nursing or have at least five years of experience (gained before 1998) in an
emergency department. The personnel in active MUG service should be
immediately available and although they may have active duties in the
emergency department they should immediately be replaceable in these
duties by equally trained personnel. At the moment, 79 MUG services are
active. According to the programmation legacy, this number should be
reduced to 72, but the current minister of Public Health declared he couldnt
accept this reduction and wanted to augment the number to 81 [10]. The
programmation of MUG services according to the Order in Council of 10th
August 1998 foresees 1 MUG per administrational district and an additional
1 per 150.000 citizen.
According to the Order in Council of 10th August 1998, the victim has to be
transported to the nearest hospital with a recognized emergency department
[9]. The medical doctor of the MUG can ask the 100 operator to make an
exception on this rule in case of:
1. a disaster leading to an overwhelming of the caring capacities of thenearest hospital.
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Trauma care in Belgium 10 (version 11-06-2003)
2. when the victim or ill is - because of his/her medical condition - inneed of specific diagnostic and/or therapeutic means as mentioned in
the protocol (article 4, 6, Order in Council 10th August 1998)
3. when the treating physician, present by the ill, confirms that the illhas a medical record concerning the specific pathology of which
he/she actually suffers, in a hospital of the intervention region and
this hospital has a recognised emergency department.
This exception should be granted by the 100 operator according to the
protocol and according to the available means [11]. The nearest hospital is
meant in time as stated in the Order of Council of 08 th July 1999. The
protocols mentioned have to be drawn up by the provincial commissions on
urgent medical help. These commissions were founded in 2000 and started
functioning in 2001. The form HA 01 of the provincial commission for
emergency medical help in the province of Antwerp which is in use since
05thNovember 2001 mentions as reasons for exception: CO-intoxication,
Neurosurgery, Invasive Cardiology, Burns, Obstetrics and Paediatrics[12].
Notice that neither polytrauma nor any other trauma related causes (except
neurosurgery) are mentioned in the list! The physician of the MUG service
does not have to use this form and can ask for further exceptions.
A function specialised emergency department was created by the order of
Council of 27th April 1998 [13]. In this order, a number of structural,
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functional and organisational requirements are listed. One of the aims was
to limit the number of recognised - and thus in the 100-system functioning -
emergency departments. This should lead to improved care by concentrating
patients, experience and means, and should economize because of the same
reasons. Discussing the structural and functional requirements goes beyond
the scope of this article. Mentionable are the necessity of an ICU-unit of at
least 3 beds, a polyvalent operation theatre, a radiography department and
clinical biology. The head of the department should be, as for the MUG
function, a medical specialist in emergency medicine. Both functions (head
of the specialized emergency department and head of the MUG) can be
gathered in one person. A specialist in emergency medicine, a trainee in
emergency medicine or a physician having obtained the certificate acute
medicine should secure the medical supervision of the department 24 hours
a day. The physician supervising the function specialised emergency care
cannot supervise any other function at the same time with the exception of
the supervision of the MUG, when he can be replaced by a physician on
call, having the same qualifications, within 15 minutes after leaving the
emergency department. As long as this physician on call does not replace
him, the physician supervising the ICU should replace him. The supervision
should be guaranteed 24 hours a day. The supervising physician should
always be able to call a physician in one of the listed specialities:
internal medicine
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Trauma care in Belgium 12 (version 11-06-2003)
surgery
anaesthesiology
radiology paediatrics orthopaedic surgery gynaecology obstetrics otorhinolaryngeology
ophthalmology
psychiatry neurology
The physicians mentioned in this list should be available on call. It is
nowhere mentioned that they should be only on call for one hospital! In the
praxis, they often are on call for more than one emergency department.
Concerning the nursing staff, it is stipulated that the head nurse should have
a postgraduate training in emergency and intensive care nursing or should
be head of the emergency nursing staff for more than five years. Every
moment, at least two nurses should be present, one of them having a
postgraduate training in the emergency and intensive care nursing or having
an experience of at least 5 years in one of these departments on the moment
of the Order in Council. Although it was the aim to limit the number of
specialised emergency departments to 70 100 departments nationwide,
actually 148 departments got recognised.
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Trauma care in Belgium 13 (version 11-06-2003)
Intra-hospital care
Apart from the above-mentioned recognition criteria for the specialized
emergency department no legislation whatever on intra-hospital triage,
treatment and/or inter-hospital transfer of the injured exists. It is left to the
sole judgement of the physician what he should or should not treat.
Concerning this judgement, one should notice the fact that the Belgian
medical rewarding system is strictly act-related and that the technical act is
rewarded far more than the intellectual one .
No specific trauma-surgery is legally recognised or protected. In most
hospitals an ad hoc formatted group of physicians treats the injured. The
formation of this group passes too often ad random or at least unstructured.
Only some hospitals have a specific trauma surgery unit or a trauma team.
Even a structural trauma protocol fails to exist in most hospitals.
After the hospital stay, specific revalidation possibilities are scarce. Some
hospitals do have a specific revalidation unit, but in this unit cardio
revalidation, stroke revalidation, orthopaedic and trauma revalidation all get
mixed. The therapy is guided depending on the available place and the
interests of the leading physicians and physiotherapists.
Results
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Trauma care in Belgium 14 (version 11-06-2003)
Only partial information on incidence, treatment and outcome of trauma in
Belgium is available. The best source of information are the statistics of the
Belgian Institute of Traffic Safety (BIVV) [14]. Data on home, work and
sports related trauma are completely lacking. No national trauma
registration exists. Medical insurance information is distributed over a lot of
participants and not available for research.
Traffic related mortality in Belgium is high. During the year 2000, 1470
people died on the Belgian roads. This averages 4 a day! It means that
13.9/100000 citizens/year die on the road. When we compare this to our
neighbouring countries Belgium scores badly (table 1). When we look at the
trend since 1972 (last year before the global energy crisis and important
safety measures), we see that the number of deaths halves although the
number of vehicles doubles and the number of vehicle-kilometres almost
triples.(table 2) Important measures in the reduction of trauma deaths were
the safety belt obligation, speed reduction, alcohol testing, airbags, EBS, car
safety improvement and structural traffic changes resulting in speed
reduction. Intense sensitisation campaigns (fig. 1) have made the public
aware of the problem of traffic related trauma and may have contributed to
the reduction of traffic related mortality and morbidity. Recently, the
government made the reduction of traffic related mortality and morbidity
one of its main topics. They want to increase traffic control and - by
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Trauma care in Belgium 15 (version 11-06-2003)
augmenting the detecting chance and the penalties - reduce the driver
induced traffic risks.
The lack of drivers responsibility is one of the main causes of traffic related
mortality and morbidity. In 4168 out of 49065 accidents (i.e. 8.5%) in 2000,
ethanol intoxication was one of the contributing factors. When we look at
the accidents with at least one fatality or severely injured victim, we see that
in 949 out of 9346 (i.e. 10.2%) accident ethanol intoxication in one of the
drivers was recorded. Ethanol intoxication as a cause of an accident causing
fatality or severe injuries is time dependent. On week days it is only
recorded in 5.1%, on weekend days in 10.8%, on week nights in 18.5% and
on weekend nights even in 23.8%. These figures underestimate the situation
as in many fatal accidents no blood probe could be obtained. Apart from
ethanol intoxication, narcotic drug abuse plays an increasingly important
part in traffic accidents [15]. Surprisingly, the highest percentages of
ethanol intoxications in fatality or severely injury related accidents are not
seen in the younger age groups, but in the group 30-39 years. Even the
group 50-59 years scores as high as the group 25-29 years and higher than
in the group 18-25 years.(table 3)
Speeding with secondary loss of control is the cause of 642 out of 1356 (i.e.
47.3%) fatality related accidents in which the cause could be detected. Not
giving priority is the second most frequent cause in 16.8% of cases [14].
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Trauma care in Belgium 16 (version 11-06-2003)
Looking at the ascertained traffic infractions, we notice that speeding leads
with 346501 infractions followed by parking infractions (32236), not
wearing the safety belt (42033 infractions), ethanol intoxication (15030
infractions), neglecting traffic lights (14059 infractions) [14].
Discussion
Looking at the available data, one could be pleased with the Belgian
situation. Although the number of driven kilometres almost tripled since
1972, the number of traffic deaths halved. Of course this is not a bad
statistic. When looking over the borders of our country, statistics are
however not so positive anymore. In the year 1999, traffic related mortality
was 13.7 deaths pro 100000 citizens. Looking at our neighbours Germany
scored 9.5/100000, the Netherlands 6.9, Luxembourg 13.7 and France 14.4
[14].
Of course progression is made due to structural changes on car safety
(safety belt obligation, car safety, ABS, air bags, ) and on speed reducing-
safety augmenting structural changes (traffic islands, refuges, rotundas, ).
The influence of organisation of the pre-hospital care cannot be detected in
the available data yet.
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Trauma care in Belgium 17 (version 11-06-2003)
However, one cannot neglect the fact that reducing traffic related mortality
and morbidity has to be based on three pillars: reducing the accident risk,
reducing the impact forces and amelioration of the care for the victim.
Reducing the accident risk can be accomplished by sensitisation of the
driver resulting in decreased risk-behaviour. Beside this sensitisation one
should implement structural changes making traffic safer for all participants
(traffic islands, separated biking roads, rotundas, ) and augment
repression by intense controlling. This is in the first place a governmental
duty. Structural changes reducing impact forces and protection of all
participants in traffic are an industrial challenge. The medical part of the
challenge is to improve the care for the injured. A well-organised pre-
hospital care is crucial in this care for the injured. Although the initial goals
of structural organisation could not be reached, whether or not influenced by
lobbying groups, Belgium has a fairly good organisation of the pre-hospital
care. A slight reduction of the recognised emergency departments could
reduce costs and improve the experience through a broader exposure.
The problem of trauma care in Belgium is the total lack of coordinated intra-
hospital care. Too often ad hoc organisation, leading to unclear procedures
and loss of crucial time, has to be established. Many reports from all over
the world have documented the reduction in overall mortality, preventable
death and morbidity after installation of a regionalized and well-organized
trauma system [21, 22, 23, 24, 25, 26]. Unpublished data demonstrate the
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Trauma care in Belgium 18 (version 11-06-2003)
fact that trauma care in Belgium can also reach high standards of care for
the injured if in the setting of an organised Trauma Team, where trauma
dedicated surgeons work together with specialists in the emergency
medicine, intensive care and revalidation [16]. Standards comparable to
those reached in the centres participating in the American and British
MTOS (Major Trauma Outcome Study) studies [17, 18] and those reported
by the German DGU (Deutsche Gesellschaft fr Unfallchirurgie) [19].
Although trauma is the third leading cause of death after malignancies and
arteriosclerosis and even the leading cause of death in the population under
40 years of age, it remains the neglected disease [20]. Beside its high
mortality, it is responsible for a whether or not permanent loss of function in
an immense group of patients. Adequate trauma care can - as demonstrated
by many other countries - lead to a decrease in mortality and improved
outcome. It is no longer acceptable that inappropriate trauma care is
established because of lacking experience and/or means, because of
financial reasons (a too large spread of the offered pathology) or because of
a lack of interest for those institutions where all means are available (lack of
fashionable).
When the Belgian politicians want to halve mortality due to traffic accidents
by 2010, as they stated, Im afraid that sensitisation, repression, structural
changes and safer cars alone will come short. The implementation of a well-
organized trauma system, starting from excellent pre- hospital care and
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Trauma care in Belgium 19 (version 11-06-2003)
ending in excellent revalidation facilities, should be an integral part of this
policy. The coordination of such teams cannot be born in amateurism or ad
hoc interest, but should be supported by well-trained, experienced trauma
specialists (surgeons) working in close relation to the other intra-mural
cooperates (emergency specialists, ICU (Intensive Care Unit) specialists,
revalidation physicians, neurosurgeons, ) and to each other in a
regionalised and echelonised trauma system.
In my opinion, we should come to a European standard for trauma care,
where every inhabitant of the European community can get the same well-
organised care based on the best available experience within the community.
Mortality should no longer range between 21.1/100000/year (as in Portugal)
and 6.0/100000/year (as in the UK).
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Trauma care in Belgium 20 (version 11-06-2003)
Table 1: Evolution of the traffic related mortality/morbidity.
Year Deaths
30 days
Deaths 30 days +
severely injured
Victims (deaths 30
days + injured)
Motor vehicles (on
1st
August)
Vehicle Kilometres (in
milliard)
1972
1975
1980
1985
1990
1995
2000
3.101
2.346
2.396
1.801
1.976
1.449
1.470
26.711
21.735
22.325
18.533
19.455
14.166
11.317
106.538
84.478
84.700
76.315
88.160
71.754
69.431
2.732.677
3.136.909
3.753.745
3.970.866
4.594.058
5.136.342
5.735.034
32,69
38,01
47,96
53,64
70,28
80,26
90,04
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Trauma care in Belgium 21 (version 11-06-2003)
Table 2: Traffic related mortality in Europe (1999)
Country Number of deaths per 100.000 inhabitants
Belgium
Germany
France
Luxembourg
The Netherlands
United Kingdom
13.7
9.5
14.4
13.5
6.9
6.0
Source: IRTAD-International Road Traffic and Accident Database (OECD)
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Trauma care in Belgium 22 (version 11-06-2003)
Table 3: Alcohol intoxication in accidents with deaths/severely injured.
Age Number of drivers
involved
Number of drivers
involved under the
influence of alcohol
%
18-24
25-29
30-39
40-49
50-59
60-69
70+
2.287
1.453
2.337
1.676
987
597
537
170
118
216
145
79
22
12
7,4
8,1
9,2
8,7
8,0
3,7
2,2
Total 10.204 787 7,7
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Trauma care in Belgium 23 (version 11-06-2003)
Figures
Fig. 1: Example of a sensitisation campaign.
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Trauma care in Belgium 24 (version 11-06-2003)
References
1. www.fgov.be2. http://members.tripod.com/Brandweer_Lommel/klini/klini01.html3. http://limburg.kbbf.be/links/100/hc100_geschiedenis01.htm4. Survey on implementation of 112, document of the European
Commission, dated 06th January 1999.
5. http://www.brandweer.org/ambulance/achtergronden/belg_she.html6. Handboek voor de hulpverlener-ambulancier van het Ministerie van
Sociale Zaken, Volksgezondheid en Leefmilieu, Bestuur van de
Gezondheidszorgen-Dienst Geneeskundige Hulp aan de
Burgerbevolking
7. http://www.emerbel.org/brevet/documenten/Bronselaer K.-WetgevingDMH-.pdf
8. Belgian Law Gazette, 10th May 19959. Belgian Law Gazette, 2ndSeptember 199810.http://www.agalev.be/code/nl/page.cfm?id_page=193811.http://www.vhp.be/uhak/dmh01.htm12.http://www.vhp.be/uhak/dmhha01.htm
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Trauma care in Belgium 25 (version 11-06-2003)
13.Belgian Law Gazette 19th June 199814.Jaarverslag 2000 Verkeersveiligheid, Belgisch Instituut voor
Verkeersveiligheid (BIVV).
15.Belgian Toxicology and Trauma Study (BTTS): a study by theBelgian Society of Emergency and Disaster Medicine (BeSEDiM),
the Toxicological Society of Belgium and Luxemburg (BLT) and the
Belgisch Instituut voor de Verkeersveiligheid (BIVV), 1995-1996.
16.Van Camp LA, Vanderschot PMJ, Sabbe MB et al. The effect ofhelmets on the incidence and severity of head and cervical spine
injuries in victims of motorcycle and moped accidents: a prospective
analysis based on Emergency Department and Trauma Surgery data.
Eur J Emer Med 1998; 5(2):269-271.
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