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There was a study not too long ago (Journal of Trauma I think) that compared mortality in major trauma victims who arrived to the ED/Trauma Center via EMS vs Taxi. Those who arrived via EMS fared worse than those who arrived by Taxi. Seems the biggest contributor to mortality was time wasted on scene which EMS did a lot and Taxi drivers did very little. yes, injury severity was comparable in both groups.
In the continuing debate among emergency medical services personnel regarding the best prehospital management for trauma patients, a new study by Johns Hopkins and the University of Southern California raises the bar on the importance of time.
In a study of 103 people, the most critically injured patients transported by private means arrived at Los Angeles County + USC Medical Center, a Level 1 trauma center, in nearly half the time of their counterparts transported by EMS--an average of 15 minutes vs. 28 minutes between time of injury and hospital arrival. Despite this difference, deaths, complications and length of hospital stay were similar between the non-EMS- and the EMS-transported patients. There was, however, a trend toward better outcomes for those who arrived at the trauma center more quickly following injury.
A 1996 retrospective study of 5,782 patients admitted to that center over a two-year period found that trauma patients transported by EMS had death rates twice as high as those transported by private means (28.2 percent vs. 17.9 percent).
Results of the current study--the first to look at the non-EMS group in detail--were published in the March issue of Archives of Surgery.
"One might think that the importance of time is obvious, intuitive and, thus, not worth studying," says Edward E. Cornwell, lead author of the study and chief of trauma at Hopkins. "But just two years ago, we heard reports that Princess Diana was at the scene of the accident for 45 minutes and had a slow transport to the hospital."
About 4 to 15 percent of all major trauma patients arrive at a sampling of large, urban trauma centers by means other than EMS, Cornwell says. These patients represent the purest form of "scoop and run," the philosophy that says EMS should rush patients straight to the hospital rather than first treating them on the scene. Others believe EMS should stay on scene awhile and resuscitate patients with intravenous fluids or other means, then bring them to the hospital, a procedure known as "stay and play."
The best way for EMS to treat patients probably varies with the setting and circumstances of injury, Cornwell says, be it a gunshot wound vs. injuries sustained in an auto crash, for example. Proximity to a trauma center also is a factor.
"Paramedics adhere to pre-established protocols in transporting trauma patients, so our studies showed an amazing consistency in the injury-to-hospital-arrival time interval regardless of the severity of injury," Cornwell says. "By contrast, in the non-EMS group, the more critical the injury, the quicker patients got themselves to the emergency department, almost as if they recognized the severity of their own injuries."
For the current study, patients were enrolled between January and October 1997. Estimated time of injury and outcome for 38 patients who arrived at the center by private means were matched to those of 38 patients of similar ages and injuries who were transported by EMS. Twenty-seven random patients transported by EMS also were studied as a control. The general population was approximately 85 percent male, 80 percent Hispanic and 10 percent African American.
The majority of patients had an injury severity score of 13 or more on a 75-point scale. The ISS is calculated by dividing the body into quadrants and assigning a number to each quadrant based on severity of the injuries in each, then squaring those numbers and adding them together. An example of an ISS of 13 would be a gunshot wound to the chest and abdomen with injuries to the lung and a hemothorax (blood in the chest) and an injury to a peripheral segment of the liver.
Researchers created a model to assess the time of injury in each patient by interviewing the patient and any witnesses or friends and combining their answers with data obtained from police, sheriff and medical examiner reports. No significant differences were observed in the two groups regarding mortality, length of hospital stays, days in the intensive care unit, complications or infections.
Cornwell is continuing his studies of patient injuries, transport time to the hospital and outcomes.
The study was supported by the federal Centers for Disease Control and Prevention in Atlanta.
and from http://www.trauma.org/archives/scooop.html
Paramedic vs private transportation of trauma patients. Effect on outcome.
Demetriades D; Chan L; Cornwell E; Belzberg H; Berne TV; Asensio J; Chan D; Eckstein M; Alo K
Arch Surg, 131: 2, 1996 Feb, 133-8
BACKGROUND: Prehospital emergency medical services (EMS) play a major role in any trauma system. However, there is very little information regarding the role of prehospital emergency care in trauma. To investigate this issue, we compared the outcome of severely injured patients transported by paramedics (EMS group) with the outcome of those transported by friends, relatives, bystanders, or police (non-EMS group). DESIGN: We compared 4856 EMS patients with 926 non-EMS patients. General linear model analysis was performed to test the hypothesis that hospital mortality is the same in EMS and non-EMS cases, controlling for the following confounding factors, which are not affected by mode of transportation: age, gender, mechanism of injury, cause of injury, Injury Severity Score (ISS), and severe head injury. Crude, specific, and adjusted mortality rates and relative risks were also derived for the EMS and non-EMS groups. SETTING: Large, urban, academic level I trauma center. PATIENTS: All patients meeting the criteria for major trauma. RESULTS: The two groups were similar with regard to mechanism of injury and the need for surgery or intensive care unit admission. The crude mortality rate was 9.3% in the EMS group and 4.0% in the non-EMS group (relative risk, 2.32; P < .001). After adjustment for ISS, the relative risk was 1.60 (P = .002). Subgroup analysis showed that among patients with ISS greater than 15, those in the EMS group had a mortality rate twice that of those in the non-EMS group (28.8% vs 14.1%). After controlling for confounding factors, the adjusted mortality among patients with ISS greater than 15 was 28.2% for the EMS group and 17.9% for the non-EMS group (P < .001). CONCLUSIONS: Patients with severe trauma transported by private means in this setting have better survival than those transported via the EMS system. Large prospective studies are needed to identify the factors responsible for this difference.
Urban trauma transport of assaulted patients using nonmedical personnel [see comments]
Branas CC; Sing RF; Davidson SJ
Acad Emerg Med, 2: 6, 1995 Jun, 486-93
OBJECTIVE: To describe one urban trauma transport system to clarify the impact of transport by nonmedical personnel on patient outcome. METHODS: Retrospective data were assembled over a six-year period through the use of the state trauma registry for an urban county served by seven state-accredited trauma centers. A subset of 4,767 consecutive assaulted patients was analyzed using the TRISS method to estimate survival probability. An unexpected death index (UDI), calculated as the difference between expected (TRISS method) and observed death rates, also was determined. Outcomes for patients transported by fire medics (FMs) vs nonmedical, police personnel (NPs) were compared. RESULTS: FMs transported 2,108 (44%) and NPs transported 1,356 (29%) of the injured assault victims. The FM-transported patients had a lower expected probability of survival than had the NP-transported patients (p < 0.001). This also was true within the penetrating-injury subgroup (p < 0.001), but not the blunt-injury subgroup. The observed death rate was higher for all the FM-transported patients than it was for the NP-transported patients (15% vs 11%; p < 0.01). The UDIs were not different overall, although the NP-transported patients who had blunt trauma had a significantly lower UDI (p < 0.01). CONCLUSIONS: NP transport of assaulted patients is generally associated with equivalent outcomes in comparison with FM transport in this urban environment. However, these data also provide evidence of an on-scene implicit triage with more severely injured patients generally transported by FMs.
a few things to conisder:
1. Urban environment close to a level 1 trauma center - I doubt the rural or even semi-rural (>20 min transport time) would have the same outcome.
2. Pt.s were probably able to maintain adequate airway during "private" transport - if you're five minutes away from a level 1 and are not in need of airway management, then the taxi is probably fine.
3. What about the patients who ended up at the "wrong" (no trauma center) hospital?
4. How about a study that includes time to OR between differing trauma centers?? If time is the issue in EMS, lets see what 20 or 30 minutes wasted in the trauma bay does to the mortality rate.
5. If a few minutes difference does
make a difference, then let the EMS agencies utilize true "scoop and run" - No c-spine immob, No IV, NO VS, No calling the hospital and having to repeat the story 3 times to the non-listening person on the other end just to be asked at the end, "Does the pt. have an IV started" (man, if I had a dime for every time..) and all the other "time consuming" tasks that the taxi drivers are not required to perform - and then
make a comparison between an EMS agency that provides only airway assistance to find out where the emphasis needs to be placed - time vs. procedure.