Multicenter Canadian Study of Prehospital Trauma Care

Moishe Liberman, MD, David Mulder, MD, André Lavoie, PhD, Ronald Denis, MD, John S. Sampalis, PhD

Disclosures

Annals of Surgery. 2003;237(2) 

In This Article

Discussion

This observational study evaluated the association between three different types of prehospital care and mortality in patients with severe injuries. The study took advantage of the existing variations in prehospital trauma care between different regions of Canada. This variation reflects differences in local policies that result in inequality of care provided to trauma victims in Canada. The policies governing the type of prehospital care are determined at government and local health board levels and reflect an existing disagreement with respect to the prehospital management of patients with severe injuries.

The current study compared the mortality of patients with severe trauma who were ultimately treated for injuries at four level I, tertiary trauma centers in Montreal, Quebec City, and Toronto. The prehospital trauma care in these cities varies significantly, with physician-provided ALS in Montreal, paramedic-provided ALS in Toronto, and BLS only, provided by EMTs in Quebec City. The study was restricted to patients treated in designated tertiary, level I trauma centers to remove potential confounding factors related to differences in the level of hospital care provided to these patients.

The results of the study show that the use of on-site ALS, in general, does not provide any benefits in reducing mortality in patients with major trauma. This result is generalizable to patients injured in urban centers served by highly organized trauma care systems with access to a level I trauma center. The data from this study show that when physicians provide on-site ALS to trauma patients, the risk of mortality is significantly increased when compared to both EMT-provided BLS and paramedic-provided ALS. On-site ALS provided by paramedics was not associated with a reduction in mortality when compared to EMTs.

The results of this study are compatible with others in the literature that support the "scoop and run" approach for the prehospital management of trauma patients in an urban setting. The lack of effectiveness of ALS in general has often been attributed to the increased time required to perform ALS procedures at the scene. However, there is now a considerable body of evidence to suggest that certain ALS procedures, such as IV fluid replacement, may be harmful for patients with major trauma.24, 29, 42, 43 The increased risk of mortality associated with MD-ALS is probably due to the lack of standardized protocols and lack of specific training. The results of this study, in combination with the already existing evidence in the current literature, fail to support the use of ALS in the prehospital management of urban trauma patients. These conclusions may or may not apply to rural trauma patients. These results would suggest policy changes that minimize on-site care and restrict it to BLS procedures only. Resources should be allocated for the establishment of trauma care systems and networks that ensure rapid transport of major trauma patients to highly specialized trauma hospitals. In these systems, emphasis should be placed on minimizing on-scene time and establishing patient transfer corridors to decrease time to definitive in-hospital care and maximize efficiency of the healthcare resources.

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