Review of: Seamon MJ, Fisher CA, Gaughan J: "Prehospital Procedures Before Emergency Department Thoracotomy: 'Scoop and Run' Saves Lives." Journal of Trauma. 63(1):113-120, 2007.
This study comes to us from Temple University Hospital, a level 1 trauma center located within in the inner city of Philadelphia. The authors reviewed the charts of all patients who underwent emergency department thoracotomy (EDT) from 2000 to 2005. The decision to perform EDT was made primarily based on perceived "down time" and not on mechanism of injury or the presence/absence of signs of life (SOL). All patients suffered penetrating wounds from either gun shot or stabbing.
Overall, 180 consecutive patient records were reviewed. They were separated into two groups. Group one arrived by EMS, and group two by police and private vehicle (P/PV). Out of those, 88 arrived by EMS and 92 by P/PV (77 by police and 15 by private vehicle). Seven of the 88 (8.0%) EMS patients survived to hospital discharge compared to 16 or 92 (17.4%) of those that arrived by P/PV.
Time to injury and arrival at the hospital was not because it was unavailable or unreliable from the P/PV group. The mean EMS pre-hospital time was 19.0 +/- 9.0 (range, 5-54) minutes. The EMS patients more often exhibited signs of life in the field and had a lower injury severity scored in comparison to the P/PV group. Moreover, EMS patients were more likely to lose SOL prior to ED arrival despite more aggressive attempts at CPR.
Other than CPR in 7.95%, the P/PV group received no other prehospital treatments. Of the seven survivors from EMS transport, three didn t undergo any prehospital procedures.
Most patients transported by EMS underwent prehospital procedures (78 of 88 [88.6%]) They included 17 c-collars, 59 IV lines and 61 intubations. For each procedure performed, patients were 2.63 time LESS likely to survive.
The authors conclude that we should seriously consider reducing the number of prehospital procedures and adopt a Scoop and Run approach to these patients.
This paper is consistent with the rising tide of data supporting the "less is more" approach to patient care, particularly in the urban EMS arena. I can't find fault with the analysis of the authors, though I wish there had been an attempt to determine the cause for some patients to be transported by P/PV and some by EMS. Was it because law enforcement made the decision that they could get the patient to the hospital quicker than waiting for EMS? Were the EMS patients further away from the hospital? Were there scene safety issues that prevented EMS from gaining access to the patient?
Despite these shortcomings the paper provides us useful information regarding the changing role of prehospital procedures, such as IV lines and intubation, as well as CPR when signs of life are lost.
It's questionable whether sufficient volume can be replaced with crystalloids for these injuries, and there may be benefit from permissive hypotension. Intubation may carry with it the same drawbacks in penetrating trauma as it does in cardiac arrest, by impeding venous blood return to the hear not to mention increasing the risk of tension pneumothorax.
I would encourage the authors to examine the EMS records more closely or preferably perform a prospective study to determine if there are indeed significant differences in the two groups that would account for the decrease in survival. Once that's done, perhaps we can have greater faith in adopting the "Scoop and Run" philosophy.