paper on trauma patients for EMS mags (definitely NSR)

[Max Gosey]

If you're bored... wanted some feedback on how this jives with your experience as EMS. Just glad to be done with 2/3 of my writing class. Whew! (Sorry for no paragraph breaks, but there are too many to go through and fix...)

Introduction
In the field of emergency medicine, EMTs and Paramedics must very frequently make difficult decisions in very little time, especially when treating patients of significant trauma. Often one of the most critical decisions the EMT must make is to which facility the critically injured patient should be transported.
Picture yourself in this scenario: You are dispatched on a very rainy day to the scene of a three-car MVA. You arrive to find the cars in such bad shape that the Jaws are an absolute necessity. After the fire department arrives and performs its extrications, you begin to assess an unrestrained 15 year-old girl. You find she has multiple lacerations and a possible flail chest. You notice bilateral open femur fractures that will definitely require surgery. You also notice she has a severely broken hip and is losing blood from the fracture. She has experienced a frontal impact with the windshield, mangling her jaw and severely obstructing her airway; this will likely need surgical attention also.
Your heart is racing, your adrenaline is pumping, and your hands are moving nearly as quickly as your mind, considering exactly what needs to be done to keep this girl alive. The rain precludes the possibility of an airlift to the regional trauma center. The Jaws of Life have cost 20 minutes of prehospital time, but this girl needs life-saving surgical attention quickly. The nearest hospital is 12 minutes away but is only a level III facility inadequately equipped for definitive care of this patient. The regional trauma center, a level I facility, is 35 minutes away. Where do you take this dying girl?
The truth is that EMTs never really have a “right” answer unless protocols are extremely specific; however, in most cases, far too many variables exist to rely solely on protocols and medical direction, so the EMT must use his best judgment with split-second timing to provide the best care for the trauma patient as quickly as possible. As in the recent outline of New York’s Department of Health protocols for major trauma (Wronski, 2004), protocols instruct providers to request ALS and air transport and transport without delay to “the appropriate hospital,” which again implies reliance on judgment. However, the protocols (Wronski, 2004) do specifically define “major trauma” to include all of the findings listed in the above scenario, “systolic blood pressure less than 90 mmHg, two or more suspected proximal long bone fractures, suspected pelvic fracture,” and eight other fairly clear stipulations of physical findings. In the above scenario, the “appropriate hospital” is a regional level I trauma center, which by designation by the American College of Surgeons is prepared to provide emergency surgery almost immediately. But one must consider as an alternative stabilizing the patient at the nearest facility, sometimes referred to as a “noncenter” if it has not received trauma center designation.
The following analysis presents studies of patients of specified injury severity indices: Injury Severity Scores, Revised Trauma Scores, and Glasgow Coma Scale scores. In Principles and Practice of Emergency Medicine, George Schwartz (1992) defines the Injury Severity Score (ISS) as an index ranging from 1 to 75 that is the “sum of the squares of the highest [Abbreviated Injury Score] value in each of the three most severely injured regions of the body.” The Abbreviated Injury Score ranges from 1 to 6, 1 being minor and 5 being fatal, and is compiled for each of the six anatomic regions of the body, presumably the head, torso, and four extremities (Schwartz, 1992).
The Revised Trauma Score (RTS) is essentially based on a combination of factors that predict mortality: systolic blood pressure, respiratory rate, respiratory effort, and Glasgow Coma Scale Score, which is a 15-point assessment of level of consciousness based on eye opening, motor response, and verbal response (Schwartz, 1992). The Revised Trauma Score is applicable to roughly 80% of patients of major trauma; the other 20% compensate physiologically and die despite a promising RTS (Schwartz, 1992). Researchers have compiled multiple surveys involving these criteria to study the effects of transporting directly versus interfacility transfer.
The last issue one must address is the importance of not only survival but also decreased morbidity, which involves the shortest possible length of stay, the least possible ICU days, the shortest possible recovery time, the least emotional loss, and the least possible disability as a result of severe injury (Smith et al, 1990). Where a patient receives treatment and how soon may strongly influence all of these factors.
In essence, when the difference in transport time is reasonable to consider direct transport to a designated trauma center, the quicker access to definitive care results in a higher chance of survival and lower morbidity.
The following numerical data, expert opinions, and interview responses are evidence that both ALS and BLS providers should strongly consider this claim in deciding where to take major trauma patients.

[Max Gosey]

Body
Schwartz (1992) agrees that in urban areas the loss of time to initial stabilization in bypassing the nearest facility is “more than compensated for by the continuous readiness of a trauma center to care for severely injured patients,” and he states that trauma experts strongly agree with this premise (Schwartz, 1992). In addition, he addresses a study that documents delays of definitive care between one and two hours in the preparation of transport (Schwartz, 1992), which are highly detrimental to the “golden hour” referring to the ideal time of one hour from time of injury to operating room. Schwartz also illustrates that survival rates have improved with direct admission to operative intervention over primary treatment in hospitals’ emergency departments (1992).
James Gosey, MD states that in his experience patients are often subject to sometimes superfluous procedures—especially CT scans and X-rays—that could be conducted at the receiving facility, ultimately delaying access to definitive care (J. Gosey Jr., personal communication, October 26, 2005). Gosey supports to concept of the “golden hour,” saying that the least possible time between injury time and operative intervention will ultimately result in greater chance of survival, despite the risk of morbidity or mortality associated with increase in transport time (J. Gosey Jr., personal communication, October 26, 2005).
Sampalis et al (1997) state that regionalized trauma systems reduce deaths linked to trauma because “the time interval between injury and definitive care is minimized and because patients are treated at highly specialized trauma centers.” Their study performed in Quebec between April of 1993 and December of 1995 involves 1,608 patients transferred from lower level facilities—437 from a level II center and 1,171 from a level III center—and 2,756 patients transported directly to a level I trauma center (Sampalis et al, 1997). In this group, the average Injury Severity Score (ISS) is 14, and the average Revised Trauma Score (RTS) is 7, with similar distribution of these scores for each group (Sampalis et al, 1997).
The study illustrates that transfer patients in this area are 1.96 times as likely to die from trauma as those transported directly to the level I facility (Sampalis et al, 1997). The mortality rate of the transfer group is 8.9%; the mortality rate of the direct group is only 4.8% (Sampalis et al, 1997). A more salient difference is apparent in comparing deaths in the emergency room: The study reflects the death of 3.4% of transfer patients and only 1.2% of direct patients (Sampalis et al, 1997). This odds ratio is equal to 2.96 (Sampalis et al, 1997).
In addition, mortality rates in this study vary with type and severity of injury (Sampalis et al, 1997). In the transfer group, patients with head injury and ISS scores of 1-12, 12-24, and 25 or greater reflect mortality rates of 3.5%, 11.1%, and 23.2%, respectively (Sampalis et al, 1997). Direct patients of these criteria reflect equivalent or considerably lower rates of 1.6%, 7.3%, and 23.2%, respectively (Sampalis et al, 1997). Transfer patients without head injury in the same respective categories are subject to death rates of 2.2%, 12.5%, and 20.0%; direct patients are again subject to lower rates: 1.5%, 4.4%, and 8.8% (Sampalis et al, 1997). The average odds ratio of death due to transfer with respect to all these figures is approximately 2.02. The authors summarize these figures by stating that the transferred patients “had a 57% adjusted increase in the odds of dying” over those transported directly to a level I center (Sampalis et al, 1997).
Hannan et al (2005) conclude from the following evidence that “in New York, regional trauma centers exhibit considerably lower mortality than area [level II] trauma centers or noncenters for adult patients meeting specific physiologic criteria.” Their study involves treatment of 3,791 adult patients who had a GCS score less than 14, systolic blood pressure less than 90, respirations greater than 29 or less than 10, and/or heart rate above 120 or below 50 and arrived alive at the emergency department where they received initial treatment; of these patients, 1,852 went to one of nine regional trauma centers, 1,219 went to one of 21 area trauma centers, and 720 went to one of 119 noncenters in New York (Hannan et al, 2005). In this study, the authors offer two comparisons: odds ratios between centers and noncenters and odds ratios between level I centers and centers of lower or no designation (Hannan et al, 2005).
The greatest differences are apparent in the latter category; the odds ratio of death in a level I center to death in a level II center or noncenter is below one in all but one category. The study classifies patients separately by physiologic criteria and then anatomic criteria (Hannan et al, 2005). The mortality odds ratios in comparison between level I centers and level II centers or noncenters for patients with critical GCS scores, blood pressure, respirations, and pulse are 0.72, 0.63, 0.58, and 0.70 respectively; the ratio of the union of the above criteria is 0.75 (Hannan et al, 2005). In the same comparison, patients with head, chest, internal, pelvic, and femoral/tibial injuries show odds ratios of 0.67, 0.89, 0.62, 1.07, and 0.67, respectively; the ratio of the union is again significantly lower than one at 0.74 (Hannan et al, 2005).
In the other comparison Hannan et al offer—centers versus noncenters—, differences are more subtle but are again consistent with the first comparison in that the mortality odds ratios of centers to noncenters are less than one in all but the pelvic fracture anatomic category (Hannan et al, 2005).. In the order listed above, odds ratios for physiologic criteria are 0.85, 0.89, 0.95, and 0.99; the odds ratio of the union of these criteria is 0.95 (Hannan et al, 2005). The same follows for anatomic criteria, for which the odds ratios, again in the order listed above, are 0.88, 0.90, 0.67, 1.32, and 0.71; the ratio of the union is 0.97.
In addition to survival and death, one must also address the issue of morbidity as a function of specialization of treatment. Smith et al (1990) show in a study of 1,332 patients treated with open reduction and internal fixation of femoral fractures that patients experience a shorter average time to operative intervention—0.4 days as opposed to 0.9—at trauma centers than at other acute care facilities (Smith et al, 1990). This leads to a significant reduction in average rate of complication; complications including “acute myocardial infarction, pancreatitis, pulmonary emboli, renal failure, respiratory failure, electrolyte imbalance, and disseminated intravascular coagulation” are apparent among 32% of patients treated early at noncenters (64 of 201 patients) with additional injuries, whereas only 18% of comparable patients (68 of 376) experience complications at trauma centers (Smith et al, 1990). Also, a much higher percentage of patients with multiple injuries—68%—receive treatment “early” at trauma centers than the 51% of multiply injured patients at noncenters (Smith et al, 1990).
Smith et al (1990) also show clinically significant (albeit only nearly statistically significant) reductions in mortality of these patients. This study reflects the death of only 1.0% of patients who received treatment at trauma centers (6 total) and the death of 2.2% of patients at noncenters (16 total) (Smith et al, 1990). The authors of this study conclude from this data that “patients treated in trauma centers suffered fewer complications, and this is especially true in the older age group [patients over the age of 55]” (Smith et al, 1990). The authors also conclude that patients who receive open reduction and internal fixation at trauma centers will receive treatment sooner and will consequently have reduced complications (Smith et al, 1990).
In a recent interview, Mike Schroeder BSN and RN of emergency medicine (personal communication, October 24, 2005) testifies that the “ultimate goal is to get the patient to the trauma center by the quickest means possible.” He states that trauma patients at his facility, a level II facility, often arrive prior to transfer to Charity Hospital, a center of level I designation, for intubation and airway stabilization. Schroeder says patients must have a secure airway in order to be transported directly to a level I facility, which is not always possible. Physicians on helicopters and other modes of air transport can perform certain surgical airway procedures that facilitate direct transport, but again, air transport is not always possible (M. Schroeder, personal communication, October 24, 2005).
According to Donnie DuVall Jr., NREMTP, NYS statewide BLS protocol provides that “a patient with significant MOI (based on established criteria consistent with BTLS, etc.), will be transported to a regional trauma facility if one can be reached in less than 1 hour” (D. Duvall Jr., personal communication, October 19, 2005). Duvall also states that “The only ex[c]eptions would be if the crew were unable to secure and/or manage the airway, or if the patient arrests. Many local hospitals in our area do not have radiology, anesthetists, specialty surgeons, and OR teams in the facility during second and third shifts (and may not have some services available at all). The time necessary to gather appropriate staff at 2 AM will far exceed the time needed to transport the patient an extra half [h]our to the regional trauma center” (D. Duvall Jr., personal communication, October 19, 2005). Duvall’s experience and opinion show that, if at all possible, patients should be transported directly to a regional trauma center, based on sound professional judgment.

[Max Gosey]

Conclusion
The testimonies of three experienced professionals, the opinions of experts, and a significant collection of raw data reflect that trauma patient survival rates and morbidity rates are lower when the patients go directly to a level I trauma center under the circumstances imposed in these studies
The numerical statistics in this argument reflect under only one condition better results at a non-specialized facility than at a trauma center—pelvic fractures, the treatment of which is not always a critical emergency procedure (Smith et al, 1990). Every other statistic shows a lower mortality rate lower for patients of the same condition who received the same treatment at trauma centers as opposed to lowe.r-level facilities. Thus there must be a positive connection between specialization of care, promptness in receiving that specialized care, and chance of survival.
Essentially, one may conclude that all trauma patients—regardless of severity—should receive appropriate care at the appropriate facility as quickly as possible. In the case of severely injured patients who risk death, this appropriate facility is very often a highly specialized location such as a level I trauma center, although level II designation is sometimes appropriate if care is not absolutely immediately critical. As Gosey (2005) states, the quickest means possible is most often direct transport due to frequent significant delays at the facility of initial stabilization. The idea of a “golden hour” between time of injury and time of operative intervention is especially critical for severely injured multi-trauma patients, and initial stabilization may compromise this timeframe, resulting in detriment to overall patient care particularly if initial stabilization is not an absolute necessity (as it is for patients of severe hypovolemia).
This positive connection between specialization of care and outcome success applicable to critically injured patients who must receive emergent care also says something about specialization of health care overall. Provided that costs are similar, though they rarely are, patients should always seek the highest level of care offered since more specialized care reflects better results. This is something to consider for treatment in all disciplines of healthcare, not just emergency medicine.
. However, evidence does exist to support the null hypothesis that there is no advantage to direct transport over initial stabilization. Also, some believe that direct transport is in some cases detrimental to survival.
The evidence presented in this argument thus far has concerned studies conducted mainly in urban environments, where bypassing the “nearest facility” may not always result in a significant delay in definitive care. Rural environments may present a different scenario in which delays may be hours to reach regionalized trauma care. Rogers et al (1999) conclude in a study of 2,674 trauma patients in Vermont and upstate New York, where “major geographic obstacles… impede transport” that transferred patients on the whole have more severe and acute injuries than those transported directly to regional trauma centers in their area. Many times this scenario involves absolutely necessary stabilization at the nearest facility (Rogers et al, 1999), due to severe hypovolemia or other life-threatening condition that cannot be stabilized en route to a trauma facility. The ultimate conclusion in this study is that “trauma care in rural areas that involves initial stabilization at outlying hospitals does not adversely affect mortality.” Sihler et al (2002) testify this same premise, stating, “It has been shown that, in rural [emphasis added] communities, initial stabilization before transfer to a higher-level facility does not adversely affect mortality.”
In addition to the null hypothesis, the converse hypothesis exists that stabilization can be beneficial (M. Schroeder, personal communication, October 24, 2005). This again is true only under very specific circumstances, in which every second of transport time is absolutely critical, especially hypovolemia and other conditions that can lead to multi-system organ failure. Schroeder (2005) says that patients who have lost significant blood must arrive at the nearest facility for transfusion, citing the premise that “if they arrive dead, they’re gonna stay dead”. However, Gosey (2005) argues that this scenario is extremely rare, saying that most patients subject to these conditions die before they can be extricated (in the case of a severe MVA) or die before the arrival of EMS to the scene of injury. He states that most patients at risk for multi-system organ failure can support a blood pressure by means of Ringer’s lactate for “a while” (J. Gosey Jr., personal communication, October 26, 2005). Thus, only when a patient is already decompensating for shock and when time of transport to the trauma center is significantly greater than that of the nearest facility should EMS not bypass.


Works Cited
Hannan, EL, Farrell, LS, Cooper, A, Henry, M, Simon, B, Simon, R. (2005). Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers? Journal of the American College of Surgeons, 200(4), 584-592. Retrieved October 21, 2005, from Medline database.
Wronski, EG. (2004). Protocol of Adult Major Trauma (Including Traumatic Cardiac Arrest) [Electronic Version]. State of New York Department of Health. Retrieved October 23, 2005, from http://www.health.state.ny.us/nysdoh...ajortrauma.pdf
Sihler, KC, Hansen, AR, Torner, JC, Kealey, GP, Morgan, LJ, Zwerling, C. (2002). Chracteristics of twice-transferred, rural trauma patients. Prehospital Emergency Care, 6(3), 330-335. Retrieved October 21, 2005, from Medline database.
Smith, JS Jr, Martin, LF, Young, WW, Macioce, DP. (1990). Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories. Journal of Trauma, 30(12), 1533-1538. Retrieved October 21, 2005, from Medline database.
Schwartz, G. R., (Ed.). (1992). Pricinciples and Practice of Emergency Medicine. Philadelphia: Lea & Febiger.
Rogers, FB, Osler, TM, Shackford, SR, Cohen, M, Camp, L, Lesage, M. (1999). Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting. Journal of Trauma, 46(2), 328-333. Retrieved October 21, 2005, from Medline database.
Sampalis, JS, Denis, R, Frechette, P, Brown, R, Fleiszer, D, Mulder, D. (1997). Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. Journal of Trauma, 43(2), 288-295. Retrieved October 21, 2005, from Medline database.