Scoop-and-run or stay-and-play? The question has been asked countless times in the prehospital setting. While there is no disputing the fact that the hospital represents the ultimate destination for definitive care, there is always some question as to whether precious transport time should be compromised for prehospital interventions. In some instances, immediate therapy appears to be justified. In cases of trauma, however, a growing body of evidence supports the rapid transport of patients to a trauma-referral center.

One of the more interesting articles that I’ve read regarding this topic was published in 2003 in the Annals of Surgery.

The beauty of the study was that it was able to look at three very different pre-hospital trauma care systems in action.

All patients were treated at Level I trauma hospitals, and the main outcome measure was death during hospitalization secondary to their injuries. Most of the patients (57%) were injured in motor vehicle collisions, and 28% were injured in falls. Firearm injuries represented 3% of the total injuries.

The study was an observational study based on these three cohorts, and included 9,405 patients (54% Montreal, 27% Toronto, 19% Quebec City).

At first glance, these numbers appear impressive — it would appear that BLS is superior to ALS provided by both paramedics and physicians in terms of trauma mortality. In fact, the mortality rate for Quebec City was found to be significantly lower compared to Montreal and Toronto (P < .001). However, there were a generous number of  statistically significant differences between the patient populations and their treatments between the systems. For example, the mean ISS was significantly higher for the patients treated by a physician at the scene compared to the other two groups (P = .001).

To help adjust for these differences, several logistic regression models were tested. In one, the analysis showed that the adjusted odds of dying in Quebec City (BLS-only) were 20% lower compared to Montreal (MD-ALS) (P = .01). In a second model, treatment by an MD at the scene compared to BLS-only was associated with a 36% increased risk of dying (P = .001). The third analysis found that when any type of ALS was on the scene, the adjusted odds of dying were increased by 21% (P = .01).

MD-ALS crews were found to have a significantly longer mean scene time (24.9 minutes) compared to BLS crews (21.9 minutes) and PMD-ALS crews (19.3 minutes) (P = .01).

Despite significant shortcomings in the data as a consequence of population and system differences and the use of an observational design, the data are compelling and thought-provoking. The authors offer several hypotheses to explain the apparent increase in mortality by ALS providers:

• Increased time spent in the performance of ALS procedures on-scene delays transport to definitive care.
• Certain ALS procedures, such as IV fluid replacement, may actually be harmful for patients with major trauma.
• The increased risk of mortality associated with MD-ALS is probably due to lack of standardized protocols and lack of specific training.

The authors conclude that for trauma in urban settings, optimal care would emphasize minimization of on-site care and restriction to BLS procedures to facilitate rapid transport of major trauma patients to trauma hospitals.

Do you agree with this contention?