EMS might be a detriment to surviving trauma

[AnthonyM83]

Thought I'd have a cool article waiting for ya, didn't you?

I'm actually wondering if anyone could provide any articles on this.

It's been brought up before, but I've never been able to find actual journal articles about this.

Apparently, in some urban settings, your survival chance as a trauma patient increases if you transport to hospital by private vehicle. I believe the study was done in LA.

Anthony

[AZCEP]

Check PubMed for the OPALS trial.

[AnthonyM83]

Thanks. Totally blanked on PubMed. Here it is for all:

Arch Surg. 1996 Feb;131(2):133-8. Links

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.

Department of Surgery, Los Angeles Medical Center, Los Angeles, USA.

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.

[Chief1C]

Wow. Victims of Trauma were being transported in hearses and make shift ambulances, and doctors cars; and that was horrible. How could the richest and most powerful country in the world have such conditions. Death in a ditch; so EMS was born. Now it's better to skip the ambulance and go back to the car? Where did we go wrong?

[JPINFV]

The problem is time. Look at it this way:

	   [EMS]



	   Person calls 911 Ambulance dispatch field treatment/packaging	transport arrive at hospital



Accident



	   Homeboy's crew put's home boy in car		 transport	Arrive at hospital  



	   [Homeboy Ambulance Company]

Combine this with the numerous studies that show that code 3 transport on average saves very little time [statistically significant? yes. Clinically significant? Generally no] and homeboy's crew will win any race. They don't need to worry about onscene treatment, packaging, or anything else. It is a true "load and go" system.

[AnthonyM83]

Well, we need further studies to be sure, but the most pervasive explanation seems to be that we take too long to "stay and play".

Scenario #1:

-Person is shot (or accident)

-Friends call 911

-In LA likely hold-time, CHP dispatch gets brief call synopsis, then forwards you to municipal dispatch, which might transfer you again to EMS dispatch, you re-explain the story

-Medics receive call, another minute or two to get out in the ambulance (depending on system & time of call), wait for it to be dispatched on air (in my system), might need to map it out, then they take off. Response time 4-6 minutes, but sometimes 8 depending on call volume at the time.

-Arrive on-scene, unload gurney/first-on bag/backboard, ask overall questions on what happened (this is if they haven't had to stage)

-Primary physical with clothes cutting and handling c-spine, then strapping patient to board, possiblely look for IV access, putting board on gurney (with everyone trying to keep IV and O2 lines untangled)

-Get patient in ambulance, in LA contact base hospital, bla bla bla, receive same orders we always do, THEN we can take off.

-Enroute, efforts to increase blood pressure with IV when patient is still bleeding might worsen him

-Arrive at hospital, unload, and wheel in to waiting trauma team

Scenario #2:

-Person is shot

-Friends rush to help/carry victim to their car

-Friends basically drive code 3 to hospital anyway...depending on traffic might be faster or slower than if really going code 3 in a big ambulance

-Friends drive right up to ER and help/carry patient in...trauma team assembles pretty quickly

Obviously, there's a lot of things that can go wrong with Scenario 2...cspine injury, lack of proper hemorhage control, patient could code enroute THEN they'd have to call 911, friends might not properly keep patent airway, and they might crash b/c not thinking about safety and consequences. So, those who died as a result of those things would contribute some personal vehicle transport deaths...but overall more people seemed to survive.

Things to slow down scenario 1:

-Call forwarding

-Response times

-Lack of as much rushing/running (which is of course a good thing, overall)

-Primary assessment and interviewing patient/bystanders

-On-scene tx like IVs/O2/cpine/proper patient loading

-Driving slow enough to going code 3 so you can brake to clear the intersection without knocking crew off their feet/seats (even if they're green lights, could turn red) and with due regard

Seems like funding and proper training could reduce a lot of these...

[tniuqs]

Check PubMed for the OPALS trial.

As to why the OPALS study is flawed... author: a letter writing man.

Although it claims to have been a before and after study that noted the changes in patient outcome with ALS, its before data is skewed as to its numbers. Were these same numbers gathered from the 17 OPALS communities before the ALS medics were trained and sent out to practice in the community? NO, the 17 base hospitals were not collecting such data before 1994.

Lets compare apples to apples. What is the survival rate of cardiac arrests that enter the ER and take place in the ER in these same communities when the study question asks the benefit of ALS in the field? There was not a study in this area that gathers the ER data, thus would any improvement in the ALS save rate not be beneficial? No data that compares this.

There was an improvement in save rate from 3.9% to 5.2% with in-the-field rapid defibrillation, but only an improvement of 5.0% to 5.1% with ALS treatment. Hmmm... compared to what? Give me relevant data to compare it with. And was there a bias in the researchers focus towards supporting CPR, rapid defibrillation, or relating such data to physicians in the ER (see note A below)? Objectively speaking, all data in trying to raise the dead is poor so why compare ALS medics to God when the stats are not available for the docs in the ER where the save rate would be questionably worse.

All the reported OPALS data to date is geared to rate objective information. This is better than subjective study analysis in its validity, but is there a study that can rate how well a psychiatrist works with their patients? No, its all subjective unless one counts how many people out of the total actually commit suicide, bodily harm, or other crimes with the therapy of a psychiatrist verses without one.

Has OPALS researched the subjective outcomes of patients who improve in their ischemic chest pain, improve in their state of respiratory distress from asthma or chf, improve in their state of hypoglycemic coma, improve from their narcotic induced coma, or improved in their state of oxygenation from hypoxia or an occluded airway? No! How does a drug company know that their NSAID is affective with arthritis pain? They ask the patients. Has an ALS medic ever performed an act that has improved the patients short or long term outcome? How would the outcome have changed if ALS was not available? As patients were not questioned, such relevant supporting data is not available.

In response to note A - No improvement in the dead patients with ALS translates into what? And when compared to what? The investigator gives the notion to its readers in the conclusion that ALS bares no assistance in VSA patients so spend your tax dollars elsewhere. Hmmm... why didn't the investigator submit the results on chest pain, diabetic emergencies, or shortness of breath before the results that were obviously going to appear poor before the eyes of the public and its financial caretakers?Lastly, does the question of the study results translate into a taxpayer's bag for their buck in any way or fashion? A tax payer is always more worried about who is going to pick up their garbage on Tuesday morning verses the training of paramedics that pick them up, as nobody anticipates that need for an ambulance. But, ask those after the fact of receiving such care and the improvement that incurred during such care and they will be the ones to say more ALS medics.

Note A - Conclusion statement of cardiac arrest study "There was no improvement in the rate of survival with the use of advanced life support in any subgroup. The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems."

[tniuqs]

Wow. Victims of Trauma were being transported in hearses and make shift ambulances, and doctors cars; and that was horrible. How could the richest and most powerful country in the world have such conditions. Death in a ditch; so EMS was born. Now it's better to skip the ambulance and go back to the car? Where did we go wrong?

We didn't go wrong at all!

Scenario #3:

*Headline News*

Homeboy shot in a drug deal gone wrong is Rushed to Hospital by Homies.

Kills an Entirely Family of 5, in Intersection Collision.

Investgators file lawsuit for "stupidity" for publishers and researchers of a Study that "Driver" homeboy reads in magazine.

Arch Surg. 1996 Feb;131(2):133-8. Links

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.

Do you think that all studies are well researched....this study proves the point that some studies are simply a waste of breath.

[Ridryder 911]

As well it does not describe level of trauma in comparison, and speak of the EMS unit being diverted (how many times ?) before arriving at a Trauma Center ? (National average is EMS unit gets diverted every 11 minutes) So, yeah I presume they get in faster in the trauma bay, when homeboys presents them to the ER.

I am beginning to think this "Golden Hour" is a myth, after reading more and more of the studies that was performed. I believe it is a good standard to judge by, but MOI, amount, where, that all adds up on the trauma severity index score is really the indicator of outcome.

R/r 911

[Chief1C]

We didn't go wrong at all!

I was being mildly sarcastic.. Although, I can see where the time is eaten up, doing things the 'old fashion' way.

http://julieraeengelsman.com/scratch.htm