Significant mechanisms of injury in trauma continue to be a major cause of morbidity and mortality in the United States. In school, EMS providers learn the relationship of timely interventions and transport to survivability. Although debunked, the principle of the Golden Hour still applies in major trauma – our job is to expeditiously and safely transport the critically injured patient to a trauma center.
After decades of trying to determine whether advanced level interventions could improve trauma survivability, the current philosophy that seems to work best is to scoop and run to the trauma center. While en route, protect the patient’s airway, support breathing and stop external major bleeding at a primarily basic level. There’s likely to be exceptions to the rule (there’s always exceptions!) but current evidence supports this approach.
So it should come as no surprise that a large, multicenter study concluded that, in urban areas where transport times are presumably short, a gunshot or stabbing victim who is transported by private vehicle to a level I or 2 trauma center fared better than those who were transported by EMS. The evidence reinforces earlier studies that showed similarly injured patients transported by police also survived their injuries better than those transported by ambulance.
In the study, the authors make the case for training citizens living in areas prone to penetrating violence to drive victims to their nearest trauma center, rather than wait for EMS.
It’s about time … to transport
EMS providers have taken umbrage at the conclusions drawn by the researchers. Certainly, there is a case for concern for such radical suggestions, as I’ll speak to. But one certainly has to consider that the evidence coming from an incredibly large study population would be compelling and a solid jumping off point for debate and discussion.
Ultimately, the interval of time from when the patient experiences the point of impact, to when airway, breathing and circulation compromise can be corrected, is a major contributor to outcomes. Minimizing the effects of hypoxia, hypercarbia and hypoperfusion reduces the likelihood of shock. The shorter that time period, the better off the patient will be.
So, I would believe that the data speaks to this. But there’s much to be explored. Here are three questions raised by the study:
1. Where did the transport initiate?
What’s clearly not addressed in the data is where the patients originated from. How close were they to the trauma center at the time of injury? Could that have been a factor in the decision to throw the victim into a car rather than wait for EMS? Did the ambulances in the control group transport patients from further distances, potentially making a difference in outcomes?
2. What’s the effect on specific injuries?
We know that major bleeding must be stopped quickly to reduce the chance of shock. We also know that severe hypoxia contributes to mortality. Does the data go deep enough in these injury types to show time to trauma center outweighs immediate onsite care that could be delivered by EMS?
3. What is the danger to the driving public?
What dangers are posed by the driver in a private vehicle who rushes a victim to a hospital? What would be the public policy ramifications and liability of a death or serious injury incurred by another motorist or pedestrian during the act?
It’s one thing to train the layperson to perform CPR, or control bleeding. Can the same concept be applied to a more complex process of identifying a critical injury, mapping a route to a trauma center, and maintaining control of a motor vehicle while operating at high speed?
The real patient transport solution
While the study is interesting, what isn’t addressed is the availability of EMS resources at the time of the injury. We can’t know who was transported with activating EMS, and who was transported by private vehicle because the ambulance was delayed. The system works when it’s applied appropriately. The challenge is the ability to fund, staff and manage a system that can be there reliably when called for. That’s a policy issue worth exploring.
