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Emergency physician presence’s impact in prehospital major trauma care

It was with great interest that we read the article by Hirano and col- leagues [1]. The question of the presence of an emergency physician in the prehospital setting is a very important issue from both a strictly medical point of view and from an economic point of view. Neverthe- less, we have some concerns about the trial.

First, the populations studied are definitively not comparable both in terms of gravity and because they were included from different centers. Indeed, if the ISS, RTS and TRISS scores predict a greater severity for pa- tients in the physician group, the analysis of the characteristics of study subjects confirms the prediction with more serious lesions of thorax, ab- domen and pelvis which are statistically significant. The fact that pa- tients treated by a physician-staffed EMS system go to medical centers that are different from those supported by paramedics implies a selec- tion bias with a major center effect, as the authors say in their discus- sion. To put it bluntly, this study is equivalent to comparing more seriously injured patients treated by emergency physicians with less-in- jured patients treated by paramedics.

Second, we note that patients treated by a prehospital medical team arrive at the ED 9 min later and to the CT scan 15 min later than those belonging to paramedic group. We wonder about the additional 6-min- ute delay to arrive at a CT scan in the physician group. Indeed, we would expect that these patients, already perfused in prehospital, would go faster to the CT scan, which is not the case. Could this be explained by a center effect–are CT scans in these centers systematically farther from the ED–or by the fact that some of the incoming patients go di- rectly to the operating room for Damage control surgery and then have a CT scan much later? Patients taken care of by a prehospital med- ical team are transfused on average 35 min earlier and are at the oper- ating room 21 min earlier than those supported by paramedics. As a reminder, European guidelines recommend that unstable bleeding trauma patients should receive a transfusion as soon as possible and be taken to emergency surgery without performing a CT scan [2]. So, treatment of patients from the physician group is more in agreement with the guidelines than the treatment supported by paramedics.

Third, the authors describe the achievement of intravenous fluid ad- ministration. It is almost non-existent in the paramedics’ group while 31.7% of patients in the physician group arrived at the ED with an IV drip. This point raises several questions. We would have liked to know what the item “intravenous fluid” covered. Was the simple act of setting up Peripheral venous access with a crystalloid solution enough, or did it indicate a certain minimum infused volume? It would also have been interesting to know what volume was infused on average in each group when we know the importance of restricted fluid therapy.

Finally, we noted that the abstract indicates data were collected be-

tween 2004 and 2013, while the manuscript seems to say that data were collected until 2015. Given that paramedics have been permitted to per- form intravenous administration since 2014, we are inclined to think that dates in the manuscript are more accurate.

In total, we are very skeptical about the conclusion of this study that “failed to show a difference in mortality between non-physician staffed ambulances and physician-staffed ambulances.” Rather, we believe that this study shows that more seriously injured patients who are managed earlier by a medical team do not die more. We, therefore, believe that

the presence of an emergency physician in the prehospital setting for these patients will remain beneficial in terms of mortality, except that it is necessary not to waste time on scene. In other words, after the con- cepts such as “scoop and run” or “stay and play,” we think that emer- gency physicians in the prehospital setting need to “play and run.” [3].

Nicolas Cazes* Pascal Menot Daniel Meyran

Bataillon de Marins-Pompiers de Marseille, Groupement Sante, Service Medical d‘Urgence, 9 boulevard de Strasbourg, 13233 Marseille

cedex 20, France

* Corresponding author.

E-mail address: [email protected] (N. Cazes) https://doi.org/10.1016/j.ajem.2019.10.047

References

1. Hirano Y, Abe T, Tanaka H. American journal of emergency medicine efficacy of the presence of an emergency physician in prehospital major trauma care: a nationwide cohort study in Japan. Am J Emerg Med 2019;37(9):1605-10.
2. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ. The European guide- line on management of major bleeding and coagulopathy following trauma: fifth edi- tion. Crit Care 2019;23(98):1-74.
3. Gauss T, Ageron F-X, Devaud M-L, Debaty G, Travers S, Garrigue D, et al. Association of prehospital time to in-hospital trauma mortality in a physician-staffed emergency medicine system. JAMA Surg 2019 [Epub ahead of print].

The authors respond: ”Emergency physician in prehospital major trauma care: It is still up to date”

We thank for your interest in our study which assessed the efficacy of the presence of an emergency physician in prehospital major trauma care on survival outcome to discharge by retrospectively analyzing na- tionwide Japanese Trauma Data Bank (JTDB) between 2004 and 2015 [1]. We are willing to provide our answers to some concerns.

As indicated in the letter, our study demonstrated that patients with more severe trauma (higher ISS, RTS and TRISS) were generally transported to hospital accompanied by an emergency physician rather than paramedics only in Japan. This difference of severity might be the reason why fewer patients treated by physicians in prehospital settings survived to hospital discharge than those treated by paramedics. Be- cause time to hospital arrival, CT scan, blood transfusion, and surgery are also affected by severity of trauma as well as center effects, the re- sults that time to hospital arrival or CT scan were delayed when trauma patients were treated by a physician on scene also might be partially due to the difference of severity. However, we carefully controlled the severity of pre-existing trauma by including ISS and Prehospital vital signs as confounders in the adjustment for the multivariable logistic re- gression and cox-proportional-hazard regression analysis, which re- sulted in no significant difference on survival to discharge and revealed the significant delay of time to hospital arrival or CT scan in the physician-stuffed group. It is notable that recent meta-analysis showed the opposite result that mortality was significantly lower in the EMS-physician-treated group of patients. However, the statistical difference diminished when analysis was limited to the studies that were adjusted or matched for injury severity [2]. Moreover, we should refer to our study inclusion criteria of only Severe trauma patients

with ISS?16 to compare survival outcome. In real world, a number of less severe patients who are not fatal are also accompanied by an emer-

gency physician because we sometimes cannot predict the severity of trauma patients only by the first limited information.

It is sure that there are still several limitations in our study, as was mentioned in the discussion. We could not control the institutional