Scoop & Run
	Date: Sun, 29 Sep 1996 15:45:39 From: Karim Brohi [karim@trauma.org] I used to be a true blue scoop & run sort of surgeon/anaesthetist. For the past month I have been working in the field, on HEMS, and I have to say I'm no longer convinced. In many situations I'm sure it is the right thing to do, but I and my colleagues have seen several patients in whom I am absolutely convinced that prehospital intervention saved life. How quick is scoop & run? Our ambulance service is unable to provide such data accurately. The scoop & run time is made up of : Incident being discovered Incident put through to ambulance control Ambulance crew activated Ambulance arrival 10 minutes? EMS crew provides (as minimum): Assessment Extrication (variable) Oxygen C-Spine control & hard collar Manual placement onto spine board/scoop stretcher Patient to ambulance 10 minutes? (if you're lucky & no other interventions such as IV) Ambulance to trauma centre (variable) 5 minutes. >From personal experince I would say these values are more like 'whip & sprint' than scoop & run, but they still make incident to trauma centre time of around 25 minutes. Much work has been done on the futility of resuscitating blunt trauma once a patient is in full arrest. There must be a proportion of patients who are in extremis on arrival at the trauma centre because at some point during that 25 minutes or so they have - lost their airway tension pneumothorax cardiac tamponade etc and more patients whose morbidity is increasing because they have for example an intracerebral haematoma and hypoventilation/poor oxygenation. For example this past week we had : - man with petrol burns to face neck & chest with obstructed airway from swelling who was unintubatable and needed surgical cricothyroidotomy. Nearest hospital (not trauma/burns) was ~9 minutes by ground ambulance. - 15 year old MVA with head injury, fixed & dilated L pupil, dilated right pupil with O2sat 85% GCS 6 E1V2M3 who was jaw clenching with a gag replex and so unintubatable by EMS crews but was anaesthetised & intubated on scene. Pupils came down following intubation & mannitol. Nearest hospital (no neurosurgery) 14 minutes by ambulance. - 48yr old crushed by forklift truck with anterior flail chest, bilateral tension pneumothorax and BP 60/-, pulse 32/min who had bilateral chest drains & intubation/ventilation following anaesthesia. Nearest hospital 6 minutes. - 2yr old unattended child fell 2 floors from window. GCS 4 on scene with pulse 48, o2sats 89%, (later subdural/sah on CT) who was anaesthetised/intubated -> pulse 120/min, O2sat 100%. Nearest hospital 7 minutes. - Motorcyclist vs Lorry with GCS 15 but maxillofacial injuries (LeFort 2 bilateral & communuted mandible) bleeding profusely from oropharynx, mouth & nose and whom EMS crews were neither able to maintain his airway nor spinal stabilisation who was anaesthetised, intubated & ventilated. Nearest hospital (no maxillofacial unit) 9 minutes. Some of these may have had vitals on arrival in hospital. Some may not. A recent study in the Journal of Trauma shows physicians spend more time on scene than EMS crews. This was held to be a bad thing. 1. Physicians are not trained in pre-hospital care, and without such training are worse at decision making & action in the field than paramedics. There was no indication given in this paper than the physicians had recieved appropriate training. An appropriately trained physician however, working with an experienced paramedic, can do much more in the field than an EMS crew alone. 2. The philosophy of scoop & run is based on 'time to definitive care'. If you can provide some of that definitive care in the streets, when 10 minutes has elapsed rather than 25 minutes, you have improved your response time, not lengthened it, even though your on-scene time may be increased. 3. Physicians can triage to appropriate hospitals (paramedics have to take to the nearest hospital in England). My views then in summary : Scoop & run is not the definitive answer to everything. Some interventions in the field are lifesaving and/or morbidity reducing and cannot/should not have to wait to be done in the hospital 15+ minutes later More work needs to be done into pre-hospital care. However systems are so disparate that comparing them is very difficult. A hospital based physician in the field is potentially dangerous. A physician with adequate training in pre-hospital medicine is potentially life saving. Hope I haven't upset the applecart.
	Date: Sun, 29 Sep 1996 21:49:43 From: Chris Taylor [chris@knakee.demon.co.uk] >3. Physicians can triage to appropriate hospitals >(paramedics have to take to the nearest hospital in England) in England being the operative term. IMHO, in the debate over Major Trauma the differences in geography between the US and the UK has largely been ignored. >My views then in summary : [snip first part of summary] >A hospital based physician in the field is potentially >dangerous. let me rephrase this in my own words: a hospital physician used to examining and treating patients in the clear, brightly lit, organized world of a well run resuscitation room is potentially lifethreating to patients in the field as well as in danger of seriously injurying himself due to lack of awareness of adequate safety precautions. > >A physician with adequate training in pre-hospital medicine >is potentially life saving. > >Hope I haven't upset the applecart. you did :) it was about time someone did, too
	Date: Sun, 29 Sep 1996 16:53:02 From: TMcGuire@lanminds.com (Thomas J. McGuire) Dr. Brohi cites pleural decompression, paralytics, pericardicentesis and cricothyrotomy as key on-scene interventions to consider. In my local, short-transport time, urban EMS system some of these interventions are under fire due to miniscule utilization rates and high mortality rates (cric) or strenuous opposition from trauma service (paralytics). Prehospital MD involvement, in instances other than disasters (e.g., Loma Prieta earthquake) would probably be considered unrealistic given difficulty in predicting the rare occasions when MD expertise would be useful on-scene. Does more work need to be done in this area? Probably. Given the rare circumstances when these interventions are truly life-saving, statistical poweris hard to achieve. Lacking any useful outcome studies regarding these interventions, their prehospital use seems threatened. In the meantime, we are pounded with studies suggesting the "yellow cab" may suffice (1,2). 1) Title Paramedic vs private transportation of trauma patients. Effect on outcome. Author Demetriades D; Chan L; Cornwell E; Belzberg H; Berne TV; Asensio J; Chan D; Eckstein M; Alo K Source Arch Surg, 131: 2, 1996 Feb, 133-8 Abstract 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. 2) Title Urban trauma transport of assaulted patients using nonmedical personnel [see comments] Author Branas CC; Sing RF; Davidson SJ Source Acad Emerg Med, 2: 6, 1995 Jun, 486-93 Abstract 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.
	Date: Sun, 29 Sep 1996 19:28:43 From: Jose A. Acosta [miguel@mwr.is] I just finished reviewing autopsy data at a major Level I Trauma center in the US and found that over 70% of trauma deaths occur within the first 24 hrs after admission to the hospital. In addition close to 1/3 of deaths occur within 15 minutes of arrival. We need to address this issue instead of spending millions on sepsis which may be intersting but is not the number 1 killer of trauma patients. New more aggressive schemes may be necessary to impact early deaths in trauma. This may mean aggressive treatment at the scene by trained trauma surgeons. Reports of treatment at the scene by nontrauma surgeons should not be used to say that scoop and run is the best alterenative we have.
	Date: Mon, 30 Sep 1996 14:28:04 From: Arnaud Derossi [aderossi@pratique.fr] I'm pleased to discover that the "Field stabilization" is slowly but surely convincing those involved in prehospital cares that is has a huge interest; our opinion in France is that the only place for "scoop and run" is for some open trauma such as knife or gunshoot, where the only treatment can be done in the the OR... The usual ATLS team in France is composed by an emergency physician or an anesthaesiologist (trained in prehospital care, disaster medicine, and medical dispatching), and a registered nurse specialized in anesthaesiology. ... the prehospital medicine "philosophy" is to take the intensive care unit out of the hospital, to the patient.
	Date: Mon, 30 Sep 1996 07:54:34 From: Dr. Jay Smith [SSMITH4@surg.hmc.psu.edu] You should address the cause of these deaths. Is it something preventable or a nonsurvivable injury? Most of our early deaths come from hemorrhage from major structures such as the heart, aorta, or hepatic veins. Others are from nonsurvivable head injuries. What is the breakdown of the deaths you reviewed? Were any of these deaths preventable and from what causes as ascertained by the autopsies?
	Date: Mon, 30 Sep 1996 23:13:26 From: Jose A. Acosta [miguel@mwr.is] The preventable death rate as evaluated by a group of Level 1 trauma center directors was approximately 1%. The problem is that if we continue to describe deaths as preventable and nonpreventable little will be done to reach that next step with innovative therapies.
	Date: Tue, 1 Oct 1996 20:18:54 From: Ken Mattox [KMATTOX@aol.com] I have been reluctant to get into this argument. I have been following the posts with interest. Most of them contain a lot of emotion and very little data. The real truth of the matter is that the golden hour NEVER has been proven to exist or not and here is a great deal of research for all of us. For those who have participated in this debate for the last two weeks, there is definitely a blind bias at work. Each of you have made some incorrect assumptions based on preconceived notions; the world is obviously flat, diet pills cause one to loose weight, the sun revolves around the earth, the golden hour is sacred, blood letting cures disease, aggressive fluid resuscitation improves outcome, wrinkle removing cream makes one look younger, and helicopters and ALS ambulances have made a difference over and above the advances in trauma centers. Sherlock Holmes said to Dr. Watson: "....you see, but you do not perceive." More than 70% of the EMS, emergency medicine, and trauma care dogma of the 1960s is now considered to be bogus. MOST of the EMS dogma of today has NEVER been subjected to scientific scrutany. I debated against Dr. Demetrides last year on this subject. He has some very convencing data. Do not be to quick to jump on a dying horse. We have over the last 30 years attempted super aggressive resuscitation in the field and in the emergency center, including cardiopulmonary bypass very soon after arrival in the ec. Dr. Acosta's data regarding early trauma deaths is repeatable across the US and indeed the world. Furthermore, even laboratory studies show that 1/3 of shocked animals (like people) from hemorragic shock die. Perhaps what is needed is to determine how to recognize when our efforts are futle and even if someone with a non-reversible injury were shot in the operating room and an operation was performed at time zero, I suspect that the figures of 2% of the total trauma population (33% of the shocked population) will still die.........Aggressive resuscitation in the field, use of helicopters, aggressive EC resuscitation, etc. will only delay and make more expensive, painful to the family and patient, the ultimate death..........When God puts her/his hands on, take yours off....
	Date: Tue, 8 Oct 1996 01:29:40 From: Keith A Zuspan [keithz1@usa.pipeline.com] At the risk of coming in the middle of a discussion, I would like to ask for some information. I have been reading about scoop and run, and early trauma deaths etc. I would like to know what the percentage of non-preventable trauma deaths there are in the pre-hospital setting. Seems like I have read through ACS that approxl 50% of deaths occur in the field and 50% die in the hospital setting. Also the trimodal distribution describes that 1/3 die immediately from their injuries, 1/3 within a short period, and another 1/3 of sepsis and complications. The implication seems to be that so many patients die so quickly after the trauma that few changes in the pre hospital setting would make an impact. Is this really accurate? Do such large numbers really die "immediately" after injury of massive CNS trauma? I am wondering if we in trauma truly expect that so many deaths occur so rapidly and are really non preventable from the clinical standpoint. I am preparing to evaluate trauma deaths in Ohio and want to know if the 50% prehospital death is what actually occurs in the best trauma systems. It seems to me that I have read these numbers for years...maybe from earlier studies from areas without organized trauma systems. Does the pre-hospital death rate change much statistically when a trauma system is in place? I have looked at urban county data to find that less than 50% of deaths occur in pre hospital setting. I realize I have very limited data, but want to know whether I should be satisfied or not with what I have always considered to be accepted numbers. I want to know what some of the more organized trauma systems show in terms of pre-hospital death.
	Date: Mon, 30 Sep 1996 18:10:32 From: Ronald M. Stewart [stewartr@uthscsa.edu] You can quote me on this: 95% of these patients are like Humpty Dumpty. They have fatal irreparable mechanical injuries....and "all the kings horses and all the kings men......cannot (and will not) put humpty back together again." The only solution is PRE-INJURY prevention efforts....not prehospital care or hospital care. We must do something to reduce the liklihood that these patients will be injured, otherwise we will not see a dent in the civilian mortality following injury. You can spend billions of dollars on prehospital care and you will save only a very small percentage of these patients. Our autopsy data scream out for effective injury prevention programs. It is time for us to do more than talk about injury prevention.
	Date: Thu, 03 Oct 1996 09:01:55 From: Robert F. Smith [rfsmith@interaccess.com] I'm really pleased to hear you say this. I'm also excited that among the hard core trauma providers there is such strong consensus on the need for all of us to work actively in prevention as part of our jobs.
	Date: Thu, 3 Oct 1996 09:47:01 From: Barry Pless [BARRYP@EPID.Lan.McGill.CA] As Editor of Injury Prevention, I can only add "bravo" to your comments on the need for prevention.
	Date: Wed, 02 Oct 1996 11:46:20 From: Robert F. Smith [rfsmith@interaccess.com] I am fascinated by the two articles mentioned which purport to show that Civilian transport of patients is not harmful and may be better than EMS transport. I promise I will rush out and read them today, but could I make a couple of uniformed comments beforehand? On the surface I am concerned with the methodological limitations of these retrospective studies. To compare the effect of two different transport methods on patient outcome one must assure that the two patient populations are the same before transport, and that all of the things occurring in the pre hospital setting in both groups which are going to be lumped into "transport" are the same or are accounted for: i.e. pre hospital interventions and length of transport time. In the study by Demetriades et al there is a self selection bias that is not addressed ( in the abstract). PATIENTS are defined as all patients meeting the criteria for major trauma. This is not the case. For the EMS group someone makes a decision that 911 should be called. The paramedics are then obligated to treat and transport each of these patients. For the civilian group, someone makes a decision that the patient is salvageable, and that they have the means of rapid transport to an ER. It seems that both the time from injury to ED and the patients' initial presentation at the scene might be different. Patients who would have met criteria for major trauma in the civilian group but were not felt to be appropriate candidates for rapid transport to the ED by their friends are not included in the study. They might have gone on to be DOAs, crime scene to morgue transports or even subsequent EMS transports. The authors apparently attempt to control for this potential bias by comparing ISS in the two groups. ISS is not that great a way to describe severity of injury in trauma patients and is a terrible way to describe the severity of injury in penetrating trauma patients. It has no physiologic component and does not account for the negative synergy of multiple injuries in one body area which is increasingly common with high velocity semiautomatic GSWs. As it was, the ISS apparently accounted for close to 1/2 of the difference in relative risk in the two groups. Their are more evolved scoring systems such as TRISS or ASCOT ( and newer ones such as Neural Networks as I learned at AAST) that might do a little better job at describing the severity of injury in the two groups. The fact that we have so many scoring systems is testament to the fact that none are that good. The second study from Johns Hopkins suffers from the same problem of describing the severity of injury in the two groups. TRISS does have a physiologic component which rely most heavily on the GCS. As we learn about bad things that happen in the shock state involving various mediators, it is clear that these things are not being accounted for in current Injury Severity Scoring systems. The second study acknowledges the problem of scene selection bias. Lastly, this probably is in the text, but it would be interesting to see a comparison of the deaths in each group in each study.
	Date: Fri, 4 Oct 1996 19:06:39 From: Fabio H. Carvalho, MD [fhcarvalho@sul.com.br] I agree that prevention should problably be the best and most cost-effective way to reduce mortality from trauma and more money and efforts should be spent on this. It's also clear that timely intervention in trauma patients is crucial if good outcomes are to be obtained. One point of discussion is WHERE that intervention could or should be done. In patients with head or thoracic trauma some times the most important procedures- to mantain airway and ventilation- can be safelly performed in the field, even if that means some delay in transportation time to the trauma center. However, one situation that cannot be handled with adequately in the pre-hospital setting is haemorrhagic shock. In this situation one must assume that there is ongoing haemorrhage and transport with no delay. At our Pre-Hosp. Trauma Service(SIATE) a physician is always sent to severe trauma events because we only have EMT-B in our sistem, so, the decision whether more time can be spent in field with a patient or not is most of the time taken by a trained physician. It avoids two situations: 1) Under-resuscitation of victims who would benefit from a more agressive in-field approach. 2) Transport delays due to futile attempts to stabilaze patients who need operative in-hospital resuscitation.
	Date: Sun, 6 Oct 1996 18:19:32 From: Aviel Roy-Shapira [avir@bgumail.bgu.ac.il] First of all note that almost all of your examples have to do with airway management. It is clear to even the hard core scoop and run person that the airway sould be secured. This does not mean intubation necesserily, but it does mean that some method of airway protection is necessary, before you load the patient intot the ambulance. Intubation can be done en route. Similarly, decompression of tension peumothorax can be done enroute. After all, it only takes a needle in the 2nd interspace. PHTLS teaches that for ciritical patients, scene time should be limited to 10 min or less. Pure scoop and run is not advocated by any authority anymore. For me, anything that can be treated definitively at the scene or en route should be done. Airway problems? YES Tension pneumothorax? YES Pressure or tourniquet for external bleeding YES (despite all the bad press for tourniquets, they can be life saving, particularly in mass casualties) Shock from anyother source NO. Including tamponade. I have yet to see a successful Rx of tamponade with a needle. Can anyone on this list provide a first hand experience of a successful Rx of tamponade with a needle?