Prehospital management of trauma: A tale of three cities

The controversies that have surrounded the prehospital management of trauma stem not only from a lack of appropriate evaluation data, but also from a lack of medical accountability and "street-wise," academic physician involvement within emergency medical services (EMS) systems. As a result, the approach to EMS trauma care has often been over-generalized and debated in terms of simplistic, unidimensional concepts, such as "scoop and run" versus "field stabilization," without any regard for the type and anatomic location of injury involved, the efficiency and skill of rescuers, the proximity and actual capabilities of definitive care resources, and the logistics of the prehospital setting. The failure to understand and delineate these variables has led to conflicting studies and has confused the analysis of potential therapeutic modalities and management strategies. In view of this, a survey is provided of three major cities, each with intensive, academic physician involvement in their EMS systems, and the approach and rationale for their prehospital care strategies are summarized. In all three systems, patients generally are categorized according to three major injury types (penetrating, blunt, and thermal) and then further subcategorized with regard to anatomical involvement, specifically those involving potential (or known) internal truncal injuries versus those with isolated head trauma or isolated extremity injury. For all three, high-flow O₂ delivery and aggressive, advanced airway management (by endotracheal intubation whenever feasible) are keystones of management. In cases of potential or known internal truncal injury, the priority is also expeditious transport to facilities with definitive surgical care with the establishment of IV access and rapid fluid infusions en route. However, in the majority of cases encountered by EMS personnel, careful and meticulous splinting, extrication, and cervical spine immobilization are indicated prior to patient movement. Therefore, rapid evacuation is not always recommended, particularly in those victims of low-velocity vehicular accidents, beatings, or falls who are alert, unintoxicated, and free of any symptoms or findings suggestive of truncal injury. IV fluid resuscitation can also be initiated on-scene in the majority of patients with controlled or self-limited non-truncal hemorrhage. The unconscious patient with blunt head trauma is perhaps the most challenging in prehospital care. While emphasis must be placed primarily on the provision of adequate lung inflation (tidal volume of 15 mL/kg) with high O₂ flows, the maintenance of adequate blood pressure, and cervical immobilization, followed by attempts at mild hyperventilation (usually rates of 15 to 18 breaths/min), these critical interventions must be balanced with the need for rapid evacuation as the noncommunicative patient must always be assumed to have potential internal truncal injuries and/or hemorrhage. The decision to transport to a trauma center should not be based solely on injury scoring indices, but must also take into consideration the mechanism of injury. Rural EMS care must be recognized as unique and deserving of special study. Interpretations of studies evaluating the efficacy of aeromedical programs must take into account multiple variables, including injury types, speed of evacuation to trauma centers, level of care provided by air and ground crews, and other medical elements of the system. Outcome data should be collected and analyzed in terms of the patient's return to previous employment and social status, as well as in-hospital morbidity and costs of medical care. The intense involvement of "street-wise" physicians who are familiar with the prehospital environment appears to enhance the efficacy of prehospital system design and medical care. Emergency medical curricula should reflect the growing need to provide role models and train physicians to assume leadership roles in prehospital medical management and research. Responsible EMS research will be crucial in answering the many questions and uncertainties sorrounding prehospital trauma care.