ORIGINAL CONTRIBUTION advanced trauma life support; prehospital care; scene time
The Impact of Injury Severity and Prehospital Procedures on Scene Time in Victims of Major Trauma Study objective: To evaluate the relationship among injury severity, prehospital procedures, and time spent at the scene by paramedics for victims of major trauma. Design: Retrospective s t u d y of 98 consecutive patients with an Injury Severity Score of more than 15 who were brought to a trauma center by fire department paramedics. Setting: A m e d i u m - s i z e d m e t r o p o l i t a n e m e r g e n c y m e d i c a l services (EMS) system and a Level I trauma center. Results: There were 66 male and 32 female patients with a m e a n age of 34 years. Thirty-two patients (32.6%) died. Blunt and penetrating trauma accounted for 68.4% and 31.6% of cases, respectively. Thirty-three patients (33. 7%) had successful advanced airway procedures, and 81 (82. 7%) had at least one IV line started in the field. Analysis of scene time, prehospital procedures, and injury severity parameters revealed that more procedures were performed in the field on the more severely injured cases; that despite this, there was a trend toward shorter scene time for more severely injured patients; and that there was a m e a n scene time of 8.1 minutes. This is the shortest scene time reported to date for prehospital trauma care in an EMS system. Conclusion: Extremely short scene times can be attained without foregoing potentially life-saving advanced life support interventions in an urban EMS system with strong medical control. In such a system, the m o s t severely injured victims m a y spend less time at the scene although more procedures are performed on them. [Spaite DW, Tse DJ, Valenzuela TD, Criss EA, Meislin HW, Mahoney M, Ross l. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. A n n Emerg Med D e c e m b e r 1991;20:1299-1305.]
Daniel W Spaite, ME), FACEP* David J Tse, MD* Terence D Valenzuela, MD, FACEP*t Elizabeth A Criss, RN* Harvey W Meislin, MD, FACEP* Mark Mahoney, MD* John Rosst Tucson, Arizona From the Arizona Emergency Medicine Research Center, University of Arizona College of Medicine;* and Medical Division, Tucson Fire Department, Tucson, Arizona.t Received for publication February 21, 1991. Revision received June 10, 1991. Accepted for publication July 3, 1991. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, California, May 1989. Address for reprints: Daniel W Spaite, MD, FACER Arizona Emergency Medicine Research Center, 1501 North Campbell, Tucson, Arizona 85724.
INTRODUCTION Debate continues over the use of advanced life support (ALS) in the prehospital management of victims of major trauma.l-35 Central to this debate has been the assumption that benefits from various procedures must be weighed against the potential detrimental impact of prolonged prehospital time that delays definitive care. To determine the amount of time spent in on-scene treatment for severely injured patients by ALS personnel in our metropolitan emergency medical services (EMS) system and to determine the association between prehospital procedures and scene time in this group, we evaluated patients with an Injury Severity Score (ISS) of more than 15 who were brought to a Level I trauma center by fire department paramedics. We were specifically interested in evaluating whether procedure- or severity-associated delays exist in the care of critically injured trauma victims in our EMS system. MATERIALS A N D M E T H O D S We retrospectively studied 98 consecutive trauma patients with an ISS of more than 15 who were brought to a Level I trauma center by Tucson Fire Department ALS personnel during the 16-month period of May 1, 1987, through August 31, 1988. Tucson, Arizona, has a population of approximately 400,000 and encompasses an area of 149 square miles within the city limits. EMS personnel from the Tucson Fire Department respond
20:12 December 1991
Annals of Emergency Medicine
1299/45
TRAUMA SCENE TIME Spaite et al
Gunshotwound _ _ (23.5%~
Motorvehicle",..../ crash (28.6%) -J
Pedestrian ~ s M (18.4%) struck otorcycle crash (12.27o) tabwound (8.2%) ~/ yclecrash
MeanISS:26.4 Range:16-75 30-
(5.1%)
Fall (3.1%) Assault(1%)
~-
20-
1
FIGURE 1. Mechanism of injury.
10-
FIGURE 2. Injury severity. FIGURE 3. Scene times.
to all 911 m e d i c a l e m e r g e n c y calls w i t h i n t h e city. T h e r e are 17 basic life support (BLS) units and eight ALS units, with mean response times ( t i m e f r o m a l a r m to a r r i v a l at t h e scene) of 3.0 and 5.0 minutes, respectively. Extensive prehospital data on e a c h v i c t i m are a c c e s s i b l e t h r o u g h the fire d e p a r t m e n t ' s m a i n f r a m e data base. This data collection s y s t e m is based on a modification of the Unif o r m Fire I n c i d e n t R e p o r t i n g Syst e m 36 and has been described in det a i l e l s e w h e r e . 37 C o m p l e t e e m e r gency department, operative, and inp a t i e n t r e c o r d s w e r e a v a i l a b l e for each patient, and autopsy reports were obtained for all fatalities. The prehospital procedures that were e v a l u a t e d were oral and nasal i n t u b a t i o n , c r i c o t h y r o t o m y , IV line placement, and military antishock trousers (MAST) placement. The data were entered into a DBASE III+ prog r a m for a n a l y s i s . For c o m p a r a t i v e evaluations, patients were grouped into " h i g h " ISS (more t h a n 20) and " l o w " ISS (16 to 20) cohorts. Statistical analysis was performed using the ×2 t e s t w i t h Y a t e s ' c o r r e c t i o n (EPISTAT statistical package) for nonparametric comparisons and the twot a i l e d S t u d e n t ' s t test (KWIKSTAT s t a t i s t i c a l package) for a n a l y s i s of c o n t i n u o u s v a r i a b l e s . P < .05 w a s considered significant.
RESULTS A t o t a l of 98 p a t i e n t s m e t s t u d y criteria. Sixty-six (67.3%) were male, and 32 (32.7%) were female. M e a n age was 34 years w i t h a range of 4 to 87 years. 46/1300
15 20 25 30 35 40 45 50 55 60 ISS The m o s t c o m m o n m e c h a n i s m of injury was motor vehicle crashes (28.6%). G u n s h o t w o u n d s and pedestrian injuries were the next most c o m m o n group (Figure 1). T h e median ISS was 25, w i t h a m e a n of 26.4 and a range of 16 to 75 (Figure 2). T h i r t y - t w o patients (32.7%)died. The prehospital intervals from the t i m e t h e call was i n i t i a l l y received u n t i l a r r i v a l of t h e p a t i e n t at t h e t r a u m a c e n t e r are s h o w n (Table 1). Scene t i m e is d e f i n e d as t h e t i m e e l a p s e d f r o m w h e n u n i t r e p o r t s to t h e c o m m u n i c a t i o n s c e n t e r t h a t it has arrived on-scene u n t i l it reports l e a v i n g t h e scene. T h e s e r e p r e s e n t exact recorded t i m e s and are not dep e n d e n t on an e s t i m a t e m a d e by preh o s p i t a l personnel. Scene t i m e data are s h o w n (Figure 3). S e v e n t y cases (71.4%) had a scene t i m e of ten m i n utes or less. O n l y two patients had a scene t i m e of m o r e t h a n 15 minutes; in each of these cases, heavy extrication was involved. T h e longest scene t i m e was 17 minutes. A d v a n c e d a i r w a y p r o c e d u r e s were a t t e m p t e d in 36 patients (36.7%) and w e r e s u c c e s s f u l i n 33 of t h e 36 (91.7%). IV l i n e p l a c e m e n t was att e m p t e d in 90 patients (91.8%), and at least one IV line was started succ e s s f u l l y i n 81 of t h e 90 (90.0%). Scene times and prehospital proc e d u r e s p e r f o r m e d in p a t i e n t s are c o m p a r e d based on five p a r a m e t e r s a s s o c i a t e d w i t h i n j u r y s e v e r i t y (Figure 4). By all five criteria (Trauma Score, Annals of Emergency Medicine
65 70 75
501 40 ~_ 30 ~- 2O I0 O 3
5 10 Minutes
15
20
G l a s g o w C o m a Scale, ISS, fatal injury, and p r e h o s p i t a l cardiac arrest), the more severely injured patients had m o r e prehospital procedures performed on t h e m t h a n did the less sev e r e l y i n j u r e d cohort. D e s p i t e this, there was no significant difference in the a m o u n t of t i m e s p e n t on scene for the m o s t severely injured patients compared w i t h those w h o were less severely injured. In fact, the trend in all five categories was toward a shorter scene t i m e for m o r e severely injured t r a u m a v i c t i m s (Figure 4). Sixteen v i c t i m s suffered t r a u m a t i c cardiac arrest in the field. M e a n ISS was m u c h h i g h e r for t h e s e p a t i e n t s than for nonarrested patients (24.0 vs 38.9, P < .0001). Despite the fact that m o r e p r o c e d u r e s w e r e p e r f o r m e d in t h e s e p a t i e n t s , no m o r e t i m e w a s spent at the scene for arrested than for nonarrested patients (Figure 4). S p l i n t i n g of e x t r e m i t i e s w a s analyzed separately. Twelve patients
20:12 Oecember 1991
T R A U M A S C E N E TIME Spaite et al
haumaScore
GCS~
ISS
0-12
13-16
3-12
13-15
21-75
46
51
60
37
71
Fatality 16-20 27
F I G U R E 4. S c e n e t i m e a n d procedures for various i n j u r y s e v e r i t y parameters.
PCAt
Yes
No
Yes
No
32
66
16
81 (No. of oatients)
h o s p i t a l f r o m p h y s i o l o g i c a l abnorm a l i t i e s t h a t could be i m p r o v e d b y prehospital ALS care (ie, intubation, IV fluids), giving v i c t i m s the chance to benefit from "definitive" care. ,~-7, l 2,15,18,19,21,23-26,35,47,50,51,65,81-83 (t test)
(t test) A-
~Meannumberor orohospgal procedores. GCS,prehospilalGlasgowComaScale;PGA,traomabeprebespitalcardiacarrest.
4
TABLE 1. Means for time variables Variable
Mean (min)
SD
Response time
47
2.2
Range (min) 0 - 14
Scene time
8.1
3.5
1 - 17
Transport time
8.5
4.4
1 - 23
21.3
7.3
2 - 38
Total prehospita] time
(12.2%) h a d s p l i n t i n g p e r f o r m e d at the scene. Despite the fact that ALS procedttres were a t t e m p t e d in all 12 s p l i n t e d p a t i e n t s , s c e n e t i m e s for splinted and n o n s p l i n t e d t r a u m a victims were similar {7.9 and 8.2 m i n utes, respectively; P -- .811). DISCUSSION There is little doubt that the develo p m e n t of t r a u m a systems has profoundly i m p a c t e d the l i k e l i h o o d of survival after m a j o r trauma.4,7,1a, 23, 35-51 T h e l i t e r a t u r e has also s h o w n clearly that this i m p a c t on o u t c o m e is s u b s t a n t i a l l y t i m e dependent. 8-~1, 4o,43,52-55 As sophisticated EMS systems have developed, the risk of inordinate a m o u n t s of t i m e being spent at the scene in a t t e m p t s to "stabilize" t r a u m a p a t i e n t s has been disc u s s e d e x t e n s i v e l y . 1,8-tl,13,t4,t7,56 The m a j o r c o n c e r n v o i c e d by n u merous a u t h o r s is t h a t a " s t a y and p l a y " a p p r o a c h to t r a u m a m a n a g e m e n t in the field w i l l use p r e c i o u s time that is m o s t appropriately spent rapidly evacuating the v i c t i m to definitive care.l,8-]l,]4,]7,2o,57, 58 S o m e authors believe tl~at the only appropriate on-scene i n t e r v e n t i o n s in severely i n j u r e d p a t i e n t s are e x t r i c a tion, spinal i m m o b i l i z a t i o n , external 20:12 D e cem be r t991
hemorrhage control, and airway management.S-11,1z,5s,59
Previous Studies T h e a m o u n t of t i m e s p e n t o n scene by prehospital personnel in the setting of t r a u m a has been reported by n u m e r o u s a u t h o r s (Table 2). `3,5,9, 12,13,15, 17, 19, 22-24, 26,28,29,31,33, 56, 60-68
Of p a r t i c u l a r c o n c e r n has been the association between prehospital procedures, p a r t i c u l a r l y the p l a c e m e n t of IV lines, and i n c r e a s e d o n - s c e n e time.9-11,13,20,58,69-72 A l t h o u g h recent s t u d i e s h a v e s h o w n t h a t IV l i n e p l a c e m e n t can be done m u c h m o r e rapidly than reported in early investig a t i o n s , 12,24,27,59,65,73,74 m a n y a u thors believe that the clear priority of rapid evacuation to a t r a u m a center r e m a i n s p a r a m o u n t . 1,8-11,17,31,33,57,58 The major concern raised regarding ALS care in the field has, in general, n o t been the care itself but rather the t i m e delays a s s o c i a t e d w i t h rendering such care o n s c e n e . 8,9,17,20,22,27,58 E x c e p t for c o n c e r n t h a t IV f l u i d s given before hemorrhage control m i g h t be d e t r i m e n t a l , 6 2 , 75-80 f e w w o u l d argue that ALS care per se is undesirable. In fact, some authors believe that a significant n u m b e r of patients die or deteriorate en route to a Annals of Emergency Medicine
Thus, if ALS care c o u l d be rend e r e d to s e v e r e l y i n j u r e d p a t i e n t s without delaying transport, little controversy would exist regarding the d e s i r a b i l i t y of its use. 58,59 Alt h o u g h m u c h d i s c u s s i o n a n d editorializing has occurred regarding this controversy, the actual objective data that exist detailing ALS-associated t i m e delays in EMS systems are r e l a t i v e l y scant. Some a u t h o r s have reported significant t i m e delays assoc i a t e d w i t h ALS care, 9,13,17,23,64,68, 72,84,85 whereas others have found little or no delay. 4,7,12,22,24,26,32 In fact, s o m e a u t h o r s have r e p o r t e d s h o r t e r t i m e s associated w i t h ALS care compared w i t h BLS care.~5, 66 The objective of this investigation was to identify w h e t h e r procedure-associated delays are a p r o b l e m a m o n g s e v e r e l y injured patients in our m e d i u m - s i z e d urban EMS system.
Scene Time, Injury Severity, and Prehospital Procedures It has been s h o w n t h a t an ISS of m o r e t h a n 15 is s t r o n g l y a s s o c i a t e d w i t h a s i g n i f i c a n t r i s k of m o r t a l ity. 86-9° It is t h i s s e v e r e l y i n j u r e d group that benefits m o s t from rapid evacuation to definitive care. Because this group is also the m o s t l i k e l y to s u s t a i n a d e t r i m e n t a l o u t c o m e if p r o m p t transport to a t r a u m a center does not occur, we chose to specific a l l y e v a l u a t e t h i s group to determ i n e the a m o u n t of t i m e spent at the scene. Our data revealed the shortest scene t i m e reported for severely traum a t i z e d v i c t i m s in a n y s y s t e m to date (Table 2). The only patients who h a d a s c e n e t i m e of m o r e t h a n 15 m i n u t e s (2.0%) were those requiring prolonged extrication, and nearly t h r e e f o u r t h s of t h e p a t i e n t s h a d scene t i m e s of ten m i n u t e s or less. P a t i e n t s w h o were m o r e severely injured had m o r e procedures carried out on t h e m than their counterparts (Figure 4). Despite this, no m o r e t i m e was spent at the scene in this group. In fact, by all five criteria used to evaluate injury severity, there was a 1301/47
T R A U M A S C E N E TIME Spaite et al
TABLE 2. Reported scene time for victims of major trauma in various systems Mean Scene Time (min)
Reference
Year
System
Hedges et al3 Aprahamian et al5
1982 1983
Thurston County, Washington
24.9
Milwaukee
21
Intra-abdominal vascular injuries
Aprahamian et al5
1983
Cayten et a113 Cayten et aU3
1984 1984
Milwaukee New York New York
tl 17.3 25.4
BLS, "minor" trauma All mechanisms, BLS All mechanisms
Pons et a112 Pons et a112
1985 1985
Denver Denver
10.1 9.5
Gunshot wounds Stab wounds
Aprahamian et a119
1985
Aprahamian et a119 Aprahamian et al ~9
1985 1985
Milwaukee Milwaukee Milwaukee
18 21 30
Blunt, cardiac arrest Penetrating, cardiac arrest "Other" mechanisms, cardiac arrest
Smith et a19 Smith et al9
1985 1985
Sacramento
16.2
All mechanisms, no obtainable blood pressure
Sacramento
17.3
Smith et al9 Mattox et al6~
1985 1986 1986
14.5 17.8 14.9
All mechanisms, blood pressure of 1 to 69 mm Hg All mechanisms, blood pressure of 70 to 100 mm Hg
Mattox et a161
Sacramento Houston Houston
Ivatury et al lz Bickell et a163
1987 1987
New York
12.2
Houston
17.3
Penetrating, MAST
Bicketl et a163
1987
Houston
13.1
Penetrating, no MAST
Cwinn et a124 Werman et a129
1987 1987
Denver Chattanooga, Tennessee
13.9 19
Blunt trauma Paramedics before basic trauma life support training
Werman et a129
I987 1987 1987
Chattanooga, Tennessee Mobile, Alabama
12.5 11.2
After basic trauma life support training
Jurkovich et a128 Lilja et a167 Lilja et a167
1987
Minneapolis Minneapolis
10.4 8.2
Blunt, hypotensive Penetrating, hypotensive
Comment* Blunt
MAST, all mechanisms No MAST, all mechanisms Penetrating thoracic wounds
Trauma (major and minor) and medical
Potter et aP5
1988 1988 1988
Brisbane, Australia Sydney, Australia
17 13
All mechanisms, BLS
Potter et aP5 Hedges et a122
Thurston County, Washington
26.0
Reines et a123 Reines et a123
1988 1988
South Carolina South Carolina
24.8 18.9
Blunt Motor vehicle crashes
Clevenger et al3~ Clevenger et a131
1988 1988
Charleston, South Carolina Charleston, South Carolina
37 9.5
Before "scoop and run" rule, ED thoracotomy patients After "scoop and run" rule
Mattox et a162 Mattox et a162
1989 1989
Houston
16.4
MAST, all mechanisms
Houston
12.6
Jones et a165
1989 1989 1989
17 16.5
No MAST, all mechanisms Major and minor trauma
Cayten et a166 Cayten et a166
Los Angeles County New York New York
11.8
BLS, penetrating Penetrating
Cayten et a166
1989
Cayten et a166
1989
New York New York
19.7 17.7
BLS, motor vehicle crashes Motor vehicle crashes
Tortella et al6° Tortella et alSO
1990 1990
11.5
All mechanisms, standing orders All mechanisms, OLMCt
Honigman et a126 SIovis et a133
1990 1990
Present study
1991
10.8 Denver Atlanta Tucson
_
All mechanisms
Motor vehicle crashes, BLS
10.7
Penetrating cardiac wounds
11.6 8.1
Hypotensive trauma patients All mechanisms
*Enlries not specified as BLS are ALS. tOLMC, on-line medical conlrol.
trend toward shorter scene times in the m o r e severely injured cohorts (Figure 4). This is an important finding because the need to rapidly t r a n s 48/1302
port injured patients to definitive care becomes greater with increasing severity. A t e n d e n c y for ALS personnel in Annals of Emergency Medicine
some EMS systems to " w a s t e " c i o u s t i m e p e r f o r m i n g ALS cedures has been discussed in v i o u s reports.9-tl, 17 H o w e v e r ,
preproprenu-
20:12 D e c e m b e r 1991
TRAUMA SCENE TIME Spaite et al
merous authors have noted that such problems need not be intrinsic to ALS care itself but rather reflect poor medical direction and failure of physicians to e n s u r e p r o p e r priorit i e s. 1,4-6,8,10~12,16,1 7,24,26-28,67, 74,91-93 Since 1985, a physician medical director has been involved extensively in system supervision and alteration, development of quality assurance programs, paramedic skills evaluations, and a research program that has involved the fire department. It is reassuring that the ALS personnel in our system have clearly followed the strong emphasis that the medical control authority has placed on rapid evacuation of severely injured patients. It is also quite striking that this priority has not been at the expense of potentially life-saving ALS interventions in the prehospital setting. Our data reveal that the two concepts are not mutually exclusive and that the "all-or-none" and "black or white" arguments that have filled much of the literature may be moot. Statements such as "... the simple fact is that paramedic field and scene times generally are excessive ''94 may be descriptive of some systems; however, this clearly is a system-specific problem and is not intrinsic to prehospital care in general. The ALS units in this system have two paramedics on board at all times. In addition, fire engines with four firefighter-emer~ency medical technicians are on scene for all injured patients. Thus, the interpretation of the "portability" of our findings (and those of o t h e r i n v e s t i g a t i o n s ) to other systems must be viewed with this in mind. It is certainly possible that s y s t e m s w i t h a single ALStrained individual on the responding units or with no additional BLS personnel on scene might experience greater delays with any given number of ALS (or BLS) p r o c e d u r e s performed. This parameter m a y ultimately impact on whether it is most appropriate to "scoop and run" or "stay and play" in different EMS systems. 26 In our system, it appears that multiple BLS and ALS procedures are occurring simultaneously on scene during the "packaging" and evacuation of the patient, leading to little or no delay resulting from on-scene interventions. C l e a r l y , t h e r e is a m i n i m u m amount of time that must be spent on scene to p a c k a g e p a t i e n t s . 12, 20:12 December 1991
23,26,28 However, the optimum minim u m is u n k n o w n and has been a subject of heated debate. From this and previous investigations, it appears that in an urban setting, highly trained p a r a m e d i c s w i t h i n t e n s e medical direction can perform a significant n u m b e r of ALS interventions in the prehospital setting while spending only eight to 12 minutes at the scene. 12,26,60 A well-run ALS system can yield comparable or shorter scene times compared with systems t h a t use o n l y BLS care at the s c e n e . 15,23,31
O ' G o r m a n and associates stated strongly that a n y delay for IV line placement is inappropriate because IV line placement success rates were at least as high when attempted en r o u t e as w h e n a t t e m p t e d at the scene. 59 They stated, "Protocols for IV administration in nontrapped patients should initiate IV access o n l y e n r o u t e to the hospital while the ambulance is moving. Even if delay at the scene is minimal, it is not possible to justify any delay, since IVs can be successfully i n s t i t u t e d en r o u t e . " T h e y c o n c l u d e that o n l y " z e r o - t i m e " p r e h o s p i t a l IV line p l a c e m e n t is justifiable in major trauma victims and state that this can only happen en route to the hospital. Our data raise the strong possibility that, at least in an urban system with numerous ALS and BLS personnel at each incident, zero-time IV line placement may be possible at the scene when performed concomitantly with other activities that must be done regardless of whether ALS interventions are attempted simultaneously.
Limitations This investigation had several limitations. First, as with any retrospective evaluation, the existence of unk n o w n or u n c o n t r o l l e d variables could have had an impact on the findings. However, the impact of this limitation should be minimized by the fact that the actual time data were collected prospectively on all patients in this system. Second, the investigation may not be relevant to nonurban systems that have longer transport times and fewer resources. CONCLUSION An analysis of the time spent by paramedics on scene with victims of major trauma revealed a mean of 8.1 Annals of Emergency Medicine
minutes. To our knowledge, this is the shortest reported scene time of any trauma system. The most severely injured patients spent no more time on scene than those in the less severely injured cohort. Despite this, nearly twice as m a n y prehospital procedures were carried out on these patients. These data reveal that with proper training and supervision, ALS personnel can rapidly remove critically injured patients from the scene without foregoing potentially lifesaving interventions. Future investigations will be required to determine the proper priorities for ALS interventions performed in the field in v i c t i m s of major trauma. In addition, the impact of the number of available ALS and BLS personnel on procedures, scene time, and outcome remains unknown and warrants further study. The authors thank Glenda King and Stephanie Higie, RN, MSN, for their invaluable help with this project.
REFERENCES 1. Gold CR: Prehospital advanced life support vs "scoop and r u n " in trauma management. A n n Emerg M e d 1987;16:797-801. 2. Brill J, Geiderman J: A rationale for scoop and run: Identifying a subset of time-critical patients. Topics Emerg Med 1981;3:37-43. 3. Hedges J, Sacco WJ, Champion HR, et al: An analysis of prehospital care of blunt trauma. J Trauma 1982~22: 989-993. 4. Jacobs L, Sinclair A, Beiser A, et al: Prehospital advanced life support: Benefits in trauma. [ Trauma 1984~24: 8-13. 5. Aprahamian C, Thompson B, Towne J, et al: The effect of a paramedic system on mortality of major open intraabdominal vascular trauma. ] Trauma 1983;2,3:687-690. 6. Copass MK, Oreskovich MR, Bladegroen MR, et al: Prehospital cardiopulmonary resuscitation of the critically injured patient. A m ] Surg 1984;148:20-26. 7. Former GS, Oreskovich MR, Copass MK, et al: The effects of prehospital trauma care on survival from a 50meter fall. J Trauma 1983;2,3:976 980. 8. Trunkey D: Is ALS necessary for prehospital trauma care? J Trauma 1984;24:86-87. 9. Smith P, Bodai B, Hill A, et al: Prehospital stabilization of critically injured patients: A failed concept. J Trauma 1985;25:65-70. 10. Border JR, Lewis FR, Aprahamian C, et al: Panel: Prehospital trauma care-Stabilize or scoop and run. J Trauma 198,3;2,3:708-711. 11. Gervin AS, Fischer RP: The importance of prompt transport in salvage of patients with penetrating heart wounds. J Traltma 1982;22:443-448. 12. Pons PT, Honigman B, Moore EE, et al: Prehospital advanced trauma life support for critical penetrating wounds to the thorax and abdomen. J Traiuna 1985;25: 828-8,32. 13. Cayten CG, Longmore W, Kuehl A, et al: Basic life support vs advanced life support for urban trauma [abstract}. J Treuma 1984;24:651. 14. Ramenofsky ML, Luterman A, Curreri PW, et al: EMS for pediatrics: Optimum treatment or unnecessary delay? ] Pediatr Surg 1983; 18:498-503.
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TRAUMA SCENE TIME Spaite et al
15. Potter 19, Goldstein G, Fung SC, et al: A controlled trial of prehospitM advanced life support in trauma. Ann Emerg Med 1988~17:582-588. 16. Cales RM: Advanced life support in prehospital trauma care: An intervention in search of an indication? leditorialJ. Ann Emerg Med 1988;17:651-653. 17. Ivatury RR, Nallathambi MN, Roberge RJ, et ah Penetrating thoracic injuries: In-field stabilization vs prompt transport. ] Trauma 1987~27:1066-1073. 18. Messick J, Rutledge R, Meyer AA: Advanced life support training is associated with decreased trauma death rates: An analysis of 12,417 trauma deaths (abstract). f Trauma 1990;30:1621. 19. Aprahamian CA, Dann JC, Thompson BM, et al: Traumatic cardiac arrest: Scope of paramedic services. Ann Emerg Med 1985;14:583-586. 20. Lewis FR: Prehospital iutravenous fluid therapy: Physiologic computer modelling. J Trauma 1986~26: 804-811. 21. Cou~ton J, Little JM: Role of the intensive care ambulance in the transport of accident victims. Aust N Z J Surg 1983;53:435-438. 22. Hedges JR, Ferro S, Moore B, et al: Factors contributing to paramedic on-scene time during evaluation and management of blunt trauma. A m J Emerg Med 1988;6: 443-448. 23. Reines FED, Bartlett RL, Chudy NE, et al: Is advanced life support appropriate for victims of motor vehicle accidents: The South Carolina Highway Trauma Project. J Trauma 1988;28:563-570.
1985;13:861-863. 40. Eastman AB, Lewis FR, Champion HR, et al: Regional trauma system design: Critical concepts. A m ] Surg 1987;154:79-87. 41. Shackford SR, Mackersie RC, Hoyt DB, et al: Impact of a trauma system on outcome of severely injured patients. Arch Surg 1987;122:523-527. 42. West JG, Cales RH, Gazzaniga AB: Impact of regionalization: The Orange County experience. Arch Surg 1983;118:740-744. 43. West JG, Trtmkey DD, Lira RC: Systems of trauma care: A study of two counties. Arch Surg 1979;144: 455-460. 44. Smith JS, Martin LF, Young WW, et al: Do trauma centers improve outcome over non-trauma centers? The evaluation of regional t r a u m a care u s i n g discharge abstract data and patient m a n a g e m e n t categories. ] Trauma 1990;30:1533-1538. 45. Cales RH: Trauma mortality in Orange County: The effect of implementation of a regional trsuma system. Ann Emarg IVied 1984;13:1-10. 46. Kreis DL Plasencia G, Augenstein D, et al: Preventable trauma deaths: Dade County, Florida. J Trauma 1986;26:649-653. 47. Oruato JP, Craren El, Nelson NM, et al: Impact of inproved emergency medical services and emergency trauma care on the reduction in mortality from trauma. ] Trauma 1985;25:575-579.
of scene time by advanced life support (ALS) in an urban setting, f Trauma 1985;25:679. 65. Jones SE, Nesper TP, Alcouloumre E: Prehospital intravenous line placement: A prospective study. Ann Emarg Ivied 1989;18:244-246. 66. Cayten CG, Stahl W, Murphy J: Severity index/outcome assessment of prehospital trauma. Prehosp Disaster IVied 1989~4:79. 67. Lilja GP, Robinson R, Dannewitz S: Rapid treatment of patients in shock by paramedics with medically directed protocols (abstract}. Ann Emerg Meal 1987;16:512. 68. Cayten CG, Longmore W, Kuebl A, et al: BLS versus ALS for trauma in an urban setting (abstract). Ann Emerg Med 1986;15:626-627. 69. Diamond NI, Schoffelman J, Elliott ]W: Factors in successful resuscitation by paramedics. J A m Coll Emerg Phys 1977;6:42-46. 70. Mattox KL, Feliciano DV: Role of external cardiac compression in truncal trauma, f Trauma 1982;22: 934-936. 71. Smith JP, Bodai BI: The urban paramedic's scope of practice. JAMA 1985;253:544-548. 72. McSwain NR, Garrison WB, Artz CP: Evaluation of resuscitation f r o m cardiopulmonary arrest by paramedics. Ann Emarg Med 1980;9:341-345. 73. Feldman R: IV line placement: A time study for prehospital providers. [EMS 1986;11:43-45. 74. McSwain NE, Timberlake GA: Controversial issues in prehospital care. Topics Emerg Med 1987;9:1-11.
48. Mullner R, Goldberg J: Toward an outcome-oriented medical geography: An evaluation of the Illinois trauma/ e m e r g e n c y medical services system. Soc Sci M e d 1978;12D:103-110.
75. McSwain NE: Pneumatic anti-shock garment: State of the art-1988. Ann Emerg Med 1988;17:506-525.
49. Waters JM, Wells CH: The effects of a modern emergency medical care system in reducing automobile crash deaths. J Trauma 1973;13:645-647.
76. McSwam NE: Discussion of Mattox, et al: Prospective randomized evaluation of MAST. ] Trauma 1986; 26:786.
50. Brodsky H, Hakkert AS: Highway fatal accidents and accessibility of emergency medical selvices. Soc Sci Med 1983;17:731-740.
77. Bickell WH, Shaftan GW, Mattox KL: Intravenous fluid administration and uncontrolled hemorrhage (editorial). J Trauma 1989;29:409.
51. Rivara FP, Maier RV, Muellar BA, et al: Evaluation of potentially preventable deaths among pedestrian and bicyclist fatalities. JAMA 1989;261:566-570.
78. Wangensteen SL, Eddy DiM, Ludewig RM: The hydrod y n a m i c s of arterial hemorrhage. Surgery 1968;64: 913-921.
28. lurkovich GJ, Campbell D, Padrta J, et al: Paramedic perception of elapsed field time. J Trauma 1987;27: 892-897.
52. Cowley RA, Hudson F, Scanlan E, et al: An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. ] Trauma 1973;13:1029-1038.
79. Mines B, Koucky CJ, Zacheis HG: Experimental uncontrolled arterial hemorrhage. Surgery 1966;60:434-438.
29. Welman HA, Nelson RN, Campbell JE, et al: Basic trauma life support. Ann Emerg Med 1987; 16:1240-1243.
53. Eiseman B: Combat casualty management in Vietnam. ] Trauma 1967;7:53-63.
30. Lloyd S: MAST and IV infusion: Do they help in prehospital t r a u m a m a n a g e m e n t ? A n n Emerg M e d 1987;16:565-567.
54. McNabney WK: Vietnam in context. Ann Emerg Med 1981;10:659-661.
24. Cwinn AA, Pons PT, Moore EE, et al: Prehospital advanced trat~ma life support for critical blunt trauma victims. Ann Emerg Meal 1987;16:399-403. 25. Wears RL, Winton CN: Load and go versus stay and play: Analysis of prehospital IV fluid therapy by computer simulation. Ann Emarg Med 1990;19:163-168. 26. Honigman B, Rohweder K, Moore EE, et al: Prehospital advanced trauma life support for penetrating cardiac wounds. Ann Emerg Med 1990;19:145-150. 27. Pons PT, Moore EE, Cusick JM, et al: Prehospital venous access in an urban paramedic s y s t e m - A prospective on-scene analysis. ] Trauma 1988;28:1460-1463.
31. Clevenger FW, Yarbrough DR, Reines HD: Resuscitative thoracotomy: The effect of field time on outcome. J Trauma 1988;28:441-445.
55. Seelig lM, Becker DP, Miller JD, et al: Traumatic acute subdural hematoma: Major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981;304:1511-1518.
32. Kaweski SM, Sise MJ, Virgilio RW: The effect of prehospital fluids on survival in trauma patients. J Trauma 1990;30:1215-1219.
56. Luterman A, Ramenofsky M, Berlyman C, et al: Evaluation of prehospital emergency medical service: Defining areas for improvement. J Trauma 1983;23: 702-707.
33. Slovis CM, Herr EW, Londorf D, et al: Success rates for initiation of intravenous therapy en route by prehospital care providers. A m J Emerg Med 1990;8:305-307.
57. Frazier WH, Brand DA: Emergency d e p a r t m e n t trauma care: Priorities and documentation. Surg Ciin North A m 1980;60:1009-1020.
34. Rottman SJ, Larmon B, Manix T: Rapid volume infusion in prehospital care. Prehosp Disaster Ivied 1990;5: 225-230.
58. Blaisdell FW: Trauma: Myths and magic: The 1984 Fitts Lecture. J Trauma !985;25:856-863.
35. Guisto JA, Iserson KV: The feasibility of 12-gange intravenous catheter use in the prehospital setting. J Emerg Med 1990;8:173-176. 36. National Fire Protection Association (NFPA): Uniform Fire Incident Reporting System (UFIRS) Coding Manual. Boston, NFPA, 1977, vol 4. 37. Valenzuela TD, Keeley KT, Criss EA, et al: Implementation of a computerized management information syst e m in an urban fire department. A n n Emerg M e d 1989;18:573-578. 38. Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: The TRISS method. J Trauma 1987;27:370-378. 39. Clemmer TP, Orme ~, Thomas FO, et ah Outcome of critically injured patients treated at level 1 trauma centers versus full-service community hospitals. Crit Care Med
50/1304
59. O'GolmanM, Trabulsy P, Pilcher DB: Zero-time piehospital IV. ] Trauma 1989;29:84-86. 60. TortellaBJ, Salant M, Lavery RF, etal: Standing orders for field intravenous lines does not shorten prehospital time in trauma patients {abstract). ] Trauma 1990~30:1624. 61. Mattox KL, Bickell WH, Pepe PE, et al: Prospective randomized evaluation of antishock MAST in post-traumatic hypotension. J Trauma 1986;26:779-786.
80. Harris BH, Shaftan GW, Chin CJ, et al: An experimental study of venous hemostasis. Surgery 1967;61:891-896. 81. Fray CF, Huelke DF, Gikas PW: Resuscitation and survival in motor vehicle accidents. ] Trauma 1969;9: 292-310. 82. Bull JP: The ISS of road traffic casualties in relation to mortality, time of death, hospital treatment time and disability. Accident Anal Prevent 1975~7:249-255. 83. Spaite DW, Joseph M: Prehospital cricothyrotomy: An investigation of indications, technique, complications, and patient outcome. Ann Emerg Med 1990;19: 279-285. 84. Donovan Pl, Cline DM, Whitley TW, et al: Prehospital care by EMTs and EMT-Is in a rural setting: Prolongation of scene times by ALS procedures. Ann Emarg ivied 1989;18:495-500. 85. Schon¢eld NA, Park K, Lev R, et al: Paramedic physical assessment and intervention in children {abstract). Arm Emarg IVied 1989;18:437. 86. Lowe DK, Oh GR, Neely KW, et al: Evaluation of injury mechanism as a criterion in trauma triage. A m J Surg 1986~152:6-10. 87. LongWB, Bachulis BL, Hynes GD: Accuracy and relationship of mechanisms of injury, Trauma Score, and Injury Severity Score in identifying major trauma. A m ] Surg 1986;151:581-584.
62. Mattox KL, Bickell W, Pepe PE, et al: Prospective MAST study in 911 patients. J Trauraa 1989;29:1104-1112.
88. Spaite DW, Criss E, Valenzuela T, et al: Railroad accidents: A metropolitan experience of death and injury. Ann Emerg Med 1988;17:620-625.
63. Bickell WH, Pepe PE, Bailey ML, et al: Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. A n n Emerg Med 1987;16:653-658.
89. West JG, Murdock NIA, Baldwin LC, et al: A method for evaluating field triage criteria. J Trauma 1986; 26: 655-659.
64. Cayten G, Longmore W, Kuehl A, et al: Prolongation
90. Smith JS, Bartholomew MJ: Trauma index revisited: A better triage tool. Crit Care Med 1990;18:174-179.
Annals of Emergency Medicine
20:12 December 1991
TRAUMA SCENE TIME Spaite et al
91. McSwain NE: Discussion of Lewis, et al: Prehospital fluid therapy: Physiologic computer modelling. J Trauma 1986~26:809.
improved emergency medical services and emergency trauma care on the reduction in mortality from trauma. J Tramna 1985;25:577.
92. McSwain NE: Discussion of Ornato, et al: Impact of
93. Trunkey DD: Discussion of Copass, et al: Prehospital
20:12 December 1991
Annals of Emergency Medicine
cardiopulmonary resuscitation of the critically injured patient. A m J Surg 1984r148:20-26. 94. Lewis FR: Ineffective therapy and delayed transport. Prehosp Disas Med 1989;4:129-130.
1305/51
The Impact of Injury Severity and Prehospital Procedures on Scene Time in Victims of Major Trauma Study objective: To evaluate the relationship among injury severity, prehospital procedures, and time spent at the scene by paramedics for victims of major trauma. Design: Retrospective s t u d y of 98 consecutive patients with an Injury Severity Score of more than 15 who were brought to a trauma center by fire department paramedics. Setting: A m e d i u m - s i z e d m e t r o p o l i t a n e m e r g e n c y m e d i c a l services (EMS) system and a Level I trauma center. Results: There were 66 male and 32 female patients with a m e a n age of 34 years. Thirty-two patients (32.6%) died. Blunt and penetrating trauma accounted for 68.4% and 31.6% of cases, respectively. Thirty-three patients (33. 7%) had successful advanced airway procedures, and 81 (82. 7%) had at least one IV line started in the field. Analysis of scene time, prehospital procedures, and injury severity parameters revealed that more procedures were performed in the field on the more severely injured cases; that despite this, there was a trend toward shorter scene time for more severely injured patients; and that there was a m e a n scene time of 8.1 minutes. This is the shortest scene time reported to date for prehospital trauma care in an EMS system. Conclusion: Extremely short scene times can be attained without foregoing potentially life-saving advanced life support interventions in an urban EMS system with strong medical control. In such a system, the m o s t severely injured victims m a y spend less time at the scene although more procedures are performed on them. [Spaite DW, Tse DJ, Valenzuela TD, Criss EA, Meislin HW, Mahoney M, Ross l. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. A n n Emerg Med D e c e m b e r 1991;20:1299-1305.]
Daniel W Spaite, ME), FACEP* David J Tse, MD* Terence D Valenzuela, MD, FACEP*t Elizabeth A Criss, RN* Harvey W Meislin, MD, FACEP* Mark Mahoney, MD* John Rosst Tucson, Arizona From the Arizona Emergency Medicine Research Center, University of Arizona College of Medicine;* and Medical Division, Tucson Fire Department, Tucson, Arizona.t Received for publication February 21, 1991. Revision received June 10, 1991. Accepted for publication July 3, 1991. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, California, May 1989. Address for reprints: Daniel W Spaite, MD, FACER Arizona Emergency Medicine Research Center, 1501 North Campbell, Tucson, Arizona 85724.
INTRODUCTION Debate continues over the use of advanced life support (ALS) in the prehospital management of victims of major trauma.l-35 Central to this debate has been the assumption that benefits from various procedures must be weighed against the potential detrimental impact of prolonged prehospital time that delays definitive care. To determine the amount of time spent in on-scene treatment for severely injured patients by ALS personnel in our metropolitan emergency medical services (EMS) system and to determine the association between prehospital procedures and scene time in this group, we evaluated patients with an Injury Severity Score (ISS) of more than 15 who were brought to a Level I trauma center by fire department paramedics. We were specifically interested in evaluating whether procedure- or severity-associated delays exist in the care of critically injured trauma victims in our EMS system. MATERIALS A N D M E T H O D S We retrospectively studied 98 consecutive trauma patients with an ISS of more than 15 who were brought to a Level I trauma center by Tucson Fire Department ALS personnel during the 16-month period of May 1, 1987, through August 31, 1988. Tucson, Arizona, has a population of approximately 400,000 and encompasses an area of 149 square miles within the city limits. EMS personnel from the Tucson Fire Department respond
20:12 December 1991
Annals of Emergency Medicine
1299/45
TRAUMA SCENE TIME Spaite et al
Gunshotwound _ _ (23.5%~
Motorvehicle",..../ crash (28.6%) -J
Pedestrian ~ s M (18.4%) struck otorcycle crash (12.27o) tabwound (8.2%) ~/ yclecrash
MeanISS:26.4 Range:16-75 30-
(5.1%)
Fall (3.1%) Assault(1%)
~-
20-
1
FIGURE 1. Mechanism of injury.
10-
FIGURE 2. Injury severity. FIGURE 3. Scene times.
to all 911 m e d i c a l e m e r g e n c y calls w i t h i n t h e city. T h e r e are 17 basic life support (BLS) units and eight ALS units, with mean response times ( t i m e f r o m a l a r m to a r r i v a l at t h e scene) of 3.0 and 5.0 minutes, respectively. Extensive prehospital data on e a c h v i c t i m are a c c e s s i b l e t h r o u g h the fire d e p a r t m e n t ' s m a i n f r a m e data base. This data collection s y s t e m is based on a modification of the Unif o r m Fire I n c i d e n t R e p o r t i n g Syst e m 36 and has been described in det a i l e l s e w h e r e . 37 C o m p l e t e e m e r gency department, operative, and inp a t i e n t r e c o r d s w e r e a v a i l a b l e for each patient, and autopsy reports were obtained for all fatalities. The prehospital procedures that were e v a l u a t e d were oral and nasal i n t u b a t i o n , c r i c o t h y r o t o m y , IV line placement, and military antishock trousers (MAST) placement. The data were entered into a DBASE III+ prog r a m for a n a l y s i s . For c o m p a r a t i v e evaluations, patients were grouped into " h i g h " ISS (more t h a n 20) and " l o w " ISS (16 to 20) cohorts. Statistical analysis was performed using the ×2 t e s t w i t h Y a t e s ' c o r r e c t i o n (EPISTAT statistical package) for nonparametric comparisons and the twot a i l e d S t u d e n t ' s t test (KWIKSTAT s t a t i s t i c a l package) for a n a l y s i s of c o n t i n u o u s v a r i a b l e s . P < .05 w a s considered significant.
RESULTS A t o t a l of 98 p a t i e n t s m e t s t u d y criteria. Sixty-six (67.3%) were male, and 32 (32.7%) were female. M e a n age was 34 years w i t h a range of 4 to 87 years. 46/1300
15 20 25 30 35 40 45 50 55 60 ISS The m o s t c o m m o n m e c h a n i s m of injury was motor vehicle crashes (28.6%). G u n s h o t w o u n d s and pedestrian injuries were the next most c o m m o n group (Figure 1). T h e median ISS was 25, w i t h a m e a n of 26.4 and a range of 16 to 75 (Figure 2). T h i r t y - t w o patients (32.7%)died. The prehospital intervals from the t i m e t h e call was i n i t i a l l y received u n t i l a r r i v a l of t h e p a t i e n t at t h e t r a u m a c e n t e r are s h o w n (Table 1). Scene t i m e is d e f i n e d as t h e t i m e e l a p s e d f r o m w h e n u n i t r e p o r t s to t h e c o m m u n i c a t i o n s c e n t e r t h a t it has arrived on-scene u n t i l it reports l e a v i n g t h e scene. T h e s e r e p r e s e n t exact recorded t i m e s and are not dep e n d e n t on an e s t i m a t e m a d e by preh o s p i t a l personnel. Scene t i m e data are s h o w n (Figure 3). S e v e n t y cases (71.4%) had a scene t i m e of ten m i n utes or less. O n l y two patients had a scene t i m e of m o r e t h a n 15 minutes; in each of these cases, heavy extrication was involved. T h e longest scene t i m e was 17 minutes. A d v a n c e d a i r w a y p r o c e d u r e s were a t t e m p t e d in 36 patients (36.7%) and w e r e s u c c e s s f u l i n 33 of t h e 36 (91.7%). IV l i n e p l a c e m e n t was att e m p t e d in 90 patients (91.8%), and at least one IV line was started succ e s s f u l l y i n 81 of t h e 90 (90.0%). Scene times and prehospital proc e d u r e s p e r f o r m e d in p a t i e n t s are c o m p a r e d based on five p a r a m e t e r s a s s o c i a t e d w i t h i n j u r y s e v e r i t y (Figure 4). By all five criteria (Trauma Score, Annals of Emergency Medicine
65 70 75
501 40 ~_ 30 ~- 2O I0 O 3
5 10 Minutes
15
20
G l a s g o w C o m a Scale, ISS, fatal injury, and p r e h o s p i t a l cardiac arrest), the more severely injured patients had m o r e prehospital procedures performed on t h e m t h a n did the less sev e r e l y i n j u r e d cohort. D e s p i t e this, there was no significant difference in the a m o u n t of t i m e s p e n t on scene for the m o s t severely injured patients compared w i t h those w h o were less severely injured. In fact, the trend in all five categories was toward a shorter scene t i m e for m o r e severely injured t r a u m a v i c t i m s (Figure 4). Sixteen v i c t i m s suffered t r a u m a t i c cardiac arrest in the field. M e a n ISS was m u c h h i g h e r for t h e s e p a t i e n t s than for nonarrested patients (24.0 vs 38.9, P < .0001). Despite the fact that m o r e p r o c e d u r e s w e r e p e r f o r m e d in t h e s e p a t i e n t s , no m o r e t i m e w a s spent at the scene for arrested than for nonarrested patients (Figure 4). S p l i n t i n g of e x t r e m i t i e s w a s analyzed separately. Twelve patients
20:12 Oecember 1991
T R A U M A S C E N E TIME Spaite et al
haumaScore
GCS~
ISS
0-12
13-16
3-12
13-15
21-75
46
51
60
37
71
Fatality 16-20 27
F I G U R E 4. S c e n e t i m e a n d procedures for various i n j u r y s e v e r i t y parameters.
PCAt
Yes
No
Yes
No
32
66
16
81 (No. of oatients)
h o s p i t a l f r o m p h y s i o l o g i c a l abnorm a l i t i e s t h a t could be i m p r o v e d b y prehospital ALS care (ie, intubation, IV fluids), giving v i c t i m s the chance to benefit from "definitive" care. ,~-7, l 2,15,18,19,21,23-26,35,47,50,51,65,81-83 (t test)
(t test) A-
~Meannumberor orohospgal procedores. GCS,prehospilalGlasgowComaScale;PGA,traomabeprebespitalcardiacarrest.
4
TABLE 1. Means for time variables Variable
Mean (min)
SD
Response time
47
2.2
Range (min) 0 - 14
Scene time
8.1
3.5
1 - 17
Transport time
8.5
4.4
1 - 23
21.3
7.3
2 - 38
Total prehospita] time
(12.2%) h a d s p l i n t i n g p e r f o r m e d at the scene. Despite the fact that ALS procedttres were a t t e m p t e d in all 12 s p l i n t e d p a t i e n t s , s c e n e t i m e s for splinted and n o n s p l i n t e d t r a u m a victims were similar {7.9 and 8.2 m i n utes, respectively; P -- .811). DISCUSSION There is little doubt that the develo p m e n t of t r a u m a systems has profoundly i m p a c t e d the l i k e l i h o o d of survival after m a j o r trauma.4,7,1a, 23, 35-51 T h e l i t e r a t u r e has also s h o w n clearly that this i m p a c t on o u t c o m e is s u b s t a n t i a l l y t i m e dependent. 8-~1, 4o,43,52-55 As sophisticated EMS systems have developed, the risk of inordinate a m o u n t s of t i m e being spent at the scene in a t t e m p t s to "stabilize" t r a u m a p a t i e n t s has been disc u s s e d e x t e n s i v e l y . 1,8-tl,13,t4,t7,56 The m a j o r c o n c e r n v o i c e d by n u merous a u t h o r s is t h a t a " s t a y and p l a y " a p p r o a c h to t r a u m a m a n a g e m e n t in the field w i l l use p r e c i o u s time that is m o s t appropriately spent rapidly evacuating the v i c t i m to definitive care.l,8-]l,]4,]7,2o,57, 58 S o m e authors believe tl~at the only appropriate on-scene i n t e r v e n t i o n s in severely i n j u r e d p a t i e n t s are e x t r i c a tion, spinal i m m o b i l i z a t i o n , external 20:12 D e cem be r t991
hemorrhage control, and airway management.S-11,1z,5s,59
Previous Studies T h e a m o u n t of t i m e s p e n t o n scene by prehospital personnel in the setting of t r a u m a has been reported by n u m e r o u s a u t h o r s (Table 2). `3,5,9, 12,13,15, 17, 19, 22-24, 26,28,29,31,33, 56, 60-68
Of p a r t i c u l a r c o n c e r n has been the association between prehospital procedures, p a r t i c u l a r l y the p l a c e m e n t of IV lines, and i n c r e a s e d o n - s c e n e time.9-11,13,20,58,69-72 A l t h o u g h recent s t u d i e s h a v e s h o w n t h a t IV l i n e p l a c e m e n t can be done m u c h m o r e rapidly than reported in early investig a t i o n s , 12,24,27,59,65,73,74 m a n y a u thors believe that the clear priority of rapid evacuation to a t r a u m a center r e m a i n s p a r a m o u n t . 1,8-11,17,31,33,57,58 The major concern raised regarding ALS care in the field has, in general, n o t been the care itself but rather the t i m e delays a s s o c i a t e d w i t h rendering such care o n s c e n e . 8,9,17,20,22,27,58 E x c e p t for c o n c e r n t h a t IV f l u i d s given before hemorrhage control m i g h t be d e t r i m e n t a l , 6 2 , 75-80 f e w w o u l d argue that ALS care per se is undesirable. In fact, some authors believe that a significant n u m b e r of patients die or deteriorate en route to a Annals of Emergency Medicine
Thus, if ALS care c o u l d be rend e r e d to s e v e r e l y i n j u r e d p a t i e n t s without delaying transport, little controversy would exist regarding the d e s i r a b i l i t y of its use. 58,59 Alt h o u g h m u c h d i s c u s s i o n a n d editorializing has occurred regarding this controversy, the actual objective data that exist detailing ALS-associated t i m e delays in EMS systems are r e l a t i v e l y scant. Some a u t h o r s have reported significant t i m e delays assoc i a t e d w i t h ALS care, 9,13,17,23,64,68, 72,84,85 whereas others have found little or no delay. 4,7,12,22,24,26,32 In fact, s o m e a u t h o r s have r e p o r t e d s h o r t e r t i m e s associated w i t h ALS care compared w i t h BLS care.~5, 66 The objective of this investigation was to identify w h e t h e r procedure-associated delays are a p r o b l e m a m o n g s e v e r e l y injured patients in our m e d i u m - s i z e d urban EMS system.
Scene Time, Injury Severity, and Prehospital Procedures It has been s h o w n t h a t an ISS of m o r e t h a n 15 is s t r o n g l y a s s o c i a t e d w i t h a s i g n i f i c a n t r i s k of m o r t a l ity. 86-9° It is t h i s s e v e r e l y i n j u r e d group that benefits m o s t from rapid evacuation to definitive care. Because this group is also the m o s t l i k e l y to s u s t a i n a d e t r i m e n t a l o u t c o m e if p r o m p t transport to a t r a u m a center does not occur, we chose to specific a l l y e v a l u a t e t h i s group to determ i n e the a m o u n t of t i m e spent at the scene. Our data revealed the shortest scene t i m e reported for severely traum a t i z e d v i c t i m s in a n y s y s t e m to date (Table 2). The only patients who h a d a s c e n e t i m e of m o r e t h a n 15 m i n u t e s (2.0%) were those requiring prolonged extrication, and nearly t h r e e f o u r t h s of t h e p a t i e n t s h a d scene t i m e s of ten m i n u t e s or less. P a t i e n t s w h o were m o r e severely injured had m o r e procedures carried out on t h e m than their counterparts (Figure 4). Despite this, no m o r e t i m e was spent at the scene in this group. In fact, by all five criteria used to evaluate injury severity, there was a 1301/47
T R A U M A S C E N E TIME Spaite et al
TABLE 2. Reported scene time for victims of major trauma in various systems Mean Scene Time (min)
Reference
Year
System
Hedges et al3 Aprahamian et al5
1982 1983
Thurston County, Washington
24.9
Milwaukee
21
Intra-abdominal vascular injuries
Aprahamian et al5
1983
Cayten et a113 Cayten et aU3
1984 1984
Milwaukee New York New York
tl 17.3 25.4
BLS, "minor" trauma All mechanisms, BLS All mechanisms
Pons et a112 Pons et a112
1985 1985
Denver Denver
10.1 9.5
Gunshot wounds Stab wounds
Aprahamian et a119
1985
Aprahamian et a119 Aprahamian et al ~9
1985 1985
Milwaukee Milwaukee Milwaukee
18 21 30
Blunt, cardiac arrest Penetrating, cardiac arrest "Other" mechanisms, cardiac arrest
Smith et a19 Smith et al9
1985 1985
Sacramento
16.2
All mechanisms, no obtainable blood pressure
Sacramento
17.3
Smith et al9 Mattox et al6~
1985 1986 1986
14.5 17.8 14.9
All mechanisms, blood pressure of 1 to 69 mm Hg All mechanisms, blood pressure of 70 to 100 mm Hg
Mattox et a161
Sacramento Houston Houston
Ivatury et al lz Bickell et a163
1987 1987
New York
12.2
Houston
17.3
Penetrating, MAST
Bicketl et a163
1987
Houston
13.1
Penetrating, no MAST
Cwinn et a124 Werman et a129
1987 1987
Denver Chattanooga, Tennessee
13.9 19
Blunt trauma Paramedics before basic trauma life support training
Werman et a129
I987 1987 1987
Chattanooga, Tennessee Mobile, Alabama
12.5 11.2
After basic trauma life support training
Jurkovich et a128 Lilja et a167 Lilja et a167
1987
Minneapolis Minneapolis
10.4 8.2
Blunt, hypotensive Penetrating, hypotensive
Comment* Blunt
MAST, all mechanisms No MAST, all mechanisms Penetrating thoracic wounds
Trauma (major and minor) and medical
Potter et aP5
1988 1988 1988
Brisbane, Australia Sydney, Australia
17 13
All mechanisms, BLS
Potter et aP5 Hedges et a122
Thurston County, Washington
26.0
Reines et a123 Reines et a123
1988 1988
South Carolina South Carolina
24.8 18.9
Blunt Motor vehicle crashes
Clevenger et al3~ Clevenger et a131
1988 1988
Charleston, South Carolina Charleston, South Carolina
37 9.5
Before "scoop and run" rule, ED thoracotomy patients After "scoop and run" rule
Mattox et a162 Mattox et a162
1989 1989
Houston
16.4
MAST, all mechanisms
Houston
12.6
Jones et a165
1989 1989 1989
17 16.5
No MAST, all mechanisms Major and minor trauma
Cayten et a166 Cayten et a166
Los Angeles County New York New York
11.8
BLS, penetrating Penetrating
Cayten et a166
1989
Cayten et a166
1989
New York New York
19.7 17.7
BLS, motor vehicle crashes Motor vehicle crashes
Tortella et al6° Tortella et alSO
1990 1990
11.5
All mechanisms, standing orders All mechanisms, OLMCt
Honigman et a126 SIovis et a133
1990 1990
Present study
1991
10.8 Denver Atlanta Tucson
_
All mechanisms
Motor vehicle crashes, BLS
10.7
Penetrating cardiac wounds
11.6 8.1
Hypotensive trauma patients All mechanisms
*Enlries not specified as BLS are ALS. tOLMC, on-line medical conlrol.
trend toward shorter scene times in the m o r e severely injured cohorts (Figure 4). This is an important finding because the need to rapidly t r a n s 48/1302
port injured patients to definitive care becomes greater with increasing severity. A t e n d e n c y for ALS personnel in Annals of Emergency Medicine
some EMS systems to " w a s t e " c i o u s t i m e p e r f o r m i n g ALS cedures has been discussed in v i o u s reports.9-tl, 17 H o w e v e r ,
preproprenu-
20:12 D e c e m b e r 1991
TRAUMA SCENE TIME Spaite et al
merous authors have noted that such problems need not be intrinsic to ALS care itself but rather reflect poor medical direction and failure of physicians to e n s u r e p r o p e r priorit i e s. 1,4-6,8,10~12,16,1 7,24,26-28,67, 74,91-93 Since 1985, a physician medical director has been involved extensively in system supervision and alteration, development of quality assurance programs, paramedic skills evaluations, and a research program that has involved the fire department. It is reassuring that the ALS personnel in our system have clearly followed the strong emphasis that the medical control authority has placed on rapid evacuation of severely injured patients. It is also quite striking that this priority has not been at the expense of potentially life-saving ALS interventions in the prehospital setting. Our data reveal that the two concepts are not mutually exclusive and that the "all-or-none" and "black or white" arguments that have filled much of the literature may be moot. Statements such as "... the simple fact is that paramedic field and scene times generally are excessive ''94 may be descriptive of some systems; however, this clearly is a system-specific problem and is not intrinsic to prehospital care in general. The ALS units in this system have two paramedics on board at all times. In addition, fire engines with four firefighter-emer~ency medical technicians are on scene for all injured patients. Thus, the interpretation of the "portability" of our findings (and those of o t h e r i n v e s t i g a t i o n s ) to other systems must be viewed with this in mind. It is certainly possible that s y s t e m s w i t h a single ALStrained individual on the responding units or with no additional BLS personnel on scene might experience greater delays with any given number of ALS (or BLS) p r o c e d u r e s performed. This parameter m a y ultimately impact on whether it is most appropriate to "scoop and run" or "stay and play" in different EMS systems. 26 In our system, it appears that multiple BLS and ALS procedures are occurring simultaneously on scene during the "packaging" and evacuation of the patient, leading to little or no delay resulting from on-scene interventions. C l e a r l y , t h e r e is a m i n i m u m amount of time that must be spent on scene to p a c k a g e p a t i e n t s . 12, 20:12 December 1991
23,26,28 However, the optimum minim u m is u n k n o w n and has been a subject of heated debate. From this and previous investigations, it appears that in an urban setting, highly trained p a r a m e d i c s w i t h i n t e n s e medical direction can perform a significant n u m b e r of ALS interventions in the prehospital setting while spending only eight to 12 minutes at the scene. 12,26,60 A well-run ALS system can yield comparable or shorter scene times compared with systems t h a t use o n l y BLS care at the s c e n e . 15,23,31
O ' G o r m a n and associates stated strongly that a n y delay for IV line placement is inappropriate because IV line placement success rates were at least as high when attempted en r o u t e as w h e n a t t e m p t e d at the scene. 59 They stated, "Protocols for IV administration in nontrapped patients should initiate IV access o n l y e n r o u t e to the hospital while the ambulance is moving. Even if delay at the scene is minimal, it is not possible to justify any delay, since IVs can be successfully i n s t i t u t e d en r o u t e . " T h e y c o n c l u d e that o n l y " z e r o - t i m e " p r e h o s p i t a l IV line p l a c e m e n t is justifiable in major trauma victims and state that this can only happen en route to the hospital. Our data raise the strong possibility that, at least in an urban system with numerous ALS and BLS personnel at each incident, zero-time IV line placement may be possible at the scene when performed concomitantly with other activities that must be done regardless of whether ALS interventions are attempted simultaneously.
Limitations This investigation had several limitations. First, as with any retrospective evaluation, the existence of unk n o w n or u n c o n t r o l l e d variables could have had an impact on the findings. However, the impact of this limitation should be minimized by the fact that the actual time data were collected prospectively on all patients in this system. Second, the investigation may not be relevant to nonurban systems that have longer transport times and fewer resources. CONCLUSION An analysis of the time spent by paramedics on scene with victims of major trauma revealed a mean of 8.1 Annals of Emergency Medicine
minutes. To our knowledge, this is the shortest reported scene time of any trauma system. The most severely injured patients spent no more time on scene than those in the less severely injured cohort. Despite this, nearly twice as m a n y prehospital procedures were carried out on these patients. These data reveal that with proper training and supervision, ALS personnel can rapidly remove critically injured patients from the scene without foregoing potentially lifesaving interventions. Future investigations will be required to determine the proper priorities for ALS interventions performed in the field in v i c t i m s of major trauma. In addition, the impact of the number of available ALS and BLS personnel on procedures, scene time, and outcome remains unknown and warrants further study. The authors thank Glenda King and Stephanie Higie, RN, MSN, for their invaluable help with this project.
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Annals of Emergency Medicine
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