Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

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Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma


ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

The current issue of Academic Emergency Medicine has a paper comparing trauma transports by police and by EMS. It was a bit of a surprise to see that one of the authors is Dr. John Pryor.

*Dr. Pryor was killed in action in Iraq while serving in the United States Army on December 25, 2008. He was instrumental in the development of this idea, the acquisition of the data, and the early versions of the manuscript. He was an extraordinary clinician, researcher, teacher, mentor, and friend and is greatly missed at the University of Pennsylvania and beyond, by his many collaborators, patients, and friends.[1]

The study compares the outcomes of proximal penetrating injury patients transported by PFD EMS (Philadelphia Fire Department EMS), which is notoriously understaffed due to political and administrative problems, with patients transported by PPD (Philadelphia Police Department). Proximal penetrating injury is generally a GSW (Gun Shot Wound) or SW (Stab Wound) to the head, neck, torso, or to the upper arm or upper leg. If I cut myself while shaving, I have a proximal penetrating injury, but it is not something that requires any more treatment than provide by my own clotting factors in my blood.

Rapid transport of trauma victims to definitive care within the ‘‘golden hour’’ has been the goal for decades, 3 but the validity of this time benchmark has been questioned. 4,5 There has been substantial debate about whether injured adults should receive advanced interventions in the prehospital setting (‘‘stay and stabilize’’) or simply be rapidly transported to definitive care (‘‘scoop and run’’).[1]

This study does not look at any particular intervention, but solely at transporting agency. PFD EMS = probably some treatment. PPD = probably no treatment.

If questioning whether the Golden Hour is anything more than a sales pitch concocted by R Adams Cowley on the back of a napkin in a bar, we might expect some review of the transport times, but that is not included in this study.

Therefore, would any result of this study provide any strong evidence about on scene treatment or about the authenticity of unicorns the Golden Hour?

No.

What this study does examine is the policy of having PPD transport patients rather than wait for PDF EMS. Since the staffing problems seem to have continued to deteriorate after the completion of the study, the policy probably leads to a significantly higher percentage of PPD transports now.

Nearly two decades ago, the city of Philadelphia implemented a policy allowing for police department (PD) transport of victims of penetrating trauma. Short-term outcomes were demonstrated to be equivalent for PD-transported patients. 18[1]

How do patients fare now that we do so much more for penetrating trauma patients.

Then – IV, intubation, fluids, maybe pain management.

Now – IV, intubation (possibly drug facilitated, which is definitely not comparable with RSI), fluids, maybe pain management (more likely, but not by much). In Pennsylvania, the use of drug facilitated intubation (etomidate up to 30 mg) has become common in some places, but probably not in Philadelphia. The same is true of prehospital pain management. In Philadelphia, neither treatment is likely to have changed from the treatment available 20 years ago.

We sought to determine the relation between prehospital mode of transport (PD vs. EMS) and survival in victims of proximal penetrating trauma. Based on previous work, 18 we hypothesized that severity adjusted mortality among penetrating trauma patients would be similar for individuals transported to the ED by police and by EMS.[1]

When we consider the kinds of treatment available only from EMS, IV, fluids, intubation, suction, pain management – are any of these expected to make a difference in survival?

No formal policy outlines how care should be provided to injured patients transported by police, and in practice (based on our observations) individuals transported by police are typically rendered no care, including even direct pressure on bleeding extremity wounds.[1]

Essentially, transport without any treatment vs transport with bleeding control.

If there is a penetrating injury to the torso, how effective is bleeding control?

If someone is stabbed/shot, how effective is applying pressure to the ribs at delivering that pressure to the blood vessels that are severed?

Is applying pressure to the ribs going to do more to impair respirations than to control bleeding?

Annually, there are nearly 250,000 calls for emergency service in Philadelphia, and all are answered by the Philadelphia Fire Department (PFD)-EMS ambulances that are part of the multitiered service provided by the PFD. During the study period, there were between 40 and 50 ambulances operating in the city. Most of the ambulances are staffed by crews that consist of either two paramedics or one paramedic and a firefighter⁄emergency medical technician. Near the end of the study period, a small number of basic life support ambulances were added to the response structure to augment existing service.[1]

The unadjusted results are in Table 1.

The police transported much more seriously injured patients. These patients were more likely to be male, more likely to be younger, and more likely to be shot. It is no surprise that these patients were more likely to die.

The question is –

When adjusted for severity of injury and other relevant variables other than mode of transport, did transport by PPD lead to a higher death rate?

Did transport by PFD EMS lead to a higher death rate?

Table 2 shows the answer to those questions.

Overall, the difference between survival when transported by PPD and when transported by PFD EMS is not detectable.

When looking at the subsets of those shot and those with an ISS above 15, then there is a difference, but it is not statistically significant.

In other words, the policy of having police transport patients, when EMS is not already on scene and not expected to show up right away, does not seem to lead to any worse outcomes.

While it is not something that could be measured by this study, it may be that this policy is lowering the fatality rate from these penetrating injuries, since we do not know how much longer it would have taken for EMS to arrive. 5 minutes more. 15 minutes more. 30 minutes more. We can only guess.

What treatment is provided by PFD EMS that might make a difference in survival? Bleeding control seems to be the extent of treatment that might affect survival, whether we look at 20 years ago or today.

Although we demonstrated an overall higher mortality rate among patients transported by police, we found no difference between transport groups in subgroup analyses examining patients by mechanism of injury (GSW or SW). Similarly, we also found that adjustment for injury severity removed the effect of mode of transport on outcomes. Both of these analyses suggest that although police transported patients may appear to be associated with a greater risk of dying, this observed difference is largely attributable to case mix. We are left with the conclusion that police transport of patients with proximal penetrating injuries is not associated with lower survival when compared to EMS-transported patients.[1]

This works. This should continue.

But what about spinal precautions?

We should not be immobilizing penetrating injury patients.[2]

There are a few policy implications associated with our findings. We believe that these findings suggest that implementation of police transport for this patient population is safe and may help to decompress overwhelmed EMS systems or those without any significant EMS structure either in rural areas or in resource-poor countries. There are implications for dispatch policy, as well, in that proximity of the prehospital provider to the injury scene should outweigh the level of training when making decisions about dispatch for penetrating injury.[1]

Police transport of seriously injured patients should not just continue in Philadelphia, but should be considered in other places that have similar concerns about the immediate availability of EMS to transport proximal penetrating injury patients.

Late entry 3/15/2011 12:30 – At The EMT Spot, this is covered in Should We Let the Cops Transport Our Patients?

Footnotes:

[1] Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma.
Band RA, Pryor JP, Gaieski DF, Dickinson ET, Cummings D, Carr BG.
Acad Emerg Med. 2010 Dec 16. doi: 10.1111/j.1553-2712.2010.00948.x. [Epub ahead of print]
PMID: 21166730 [PubMed – as supplied by publisher]

[2] Spine Immobilization in Penetrating Trauma: More Harm Than Good?
Rogue Medic
Research Review

Band RA, Pryor JP, Gaieski DF, Dickinson ET, Cummings D, & Carr BG (2010). Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine PMID: 21166730

.

Comments

  1. Put the matter of this study aside and ask yourself if you’d permit 40 unlicenced ambulances running around with scanners and stealing your patients? Also, you need to address the fact that in phila 911 calls are routed through police first leading to a delay in ems getting these calls. Or police flooding ems with mva with no known injuries, assault with no known injuries calls because they can. Or police not advising there dispatchers they have a founded shooting til there transporting. Or police who frequently crash and risk the lives of the patient and themselves driving like fools. Or police driving around ems units that arrive on scene. There is alot of background not addressed within the scope of the study.

    • Anonymous,

      Put the matter of this study aside and ask yourself if you’d permit 40 unlicenced ambulances running around with scanners and stealing your patients?

      Stealing?

      As they point out in the study, this policy was started 20 years ago to help when there is no ambulance immediately available.

      Also, you need to address the fact that in phila 911 calls are routed through police first leading to a delay in ems getting these calls.

      Dispatch is not affected by this policy.

      Or police flooding ems with mva with no known injuries, assault with no known injuries calls because they can.

      Please provide some evidence that a policy of having police transport patients with penetrating injuries would in any way permit this?

      Or are you suggesting that police dispatch would make up calls, so that police can transport patients?

      Why would they do this?

      What kind of dispatch/street cop conspiracy are you suggesting?

      Where is the incentive to transport these patients?

      These are patients who are some of the least likely to be insured.

      Even if they were insured, what insurance company is going to pay the police for transport?

      Or police not advising there dispatchers they have a founded shooting til there transporting.

      That is a possibility. since police would probably not be providing any attempts at stabilization prior to transport, the delay in notifying dispatch would not matter. The ambulance is not going to be there instantly. that is the reason for the policy – the delay in response of an understaffed EMS system.

      Or police who frequently crash and risk the lives of the patient and themselves driving like fools.

      Please provide some evidence that the accident record of the police is any worse than the accident record of EMS.

      Or police driving around ems units that arrive on scene.

      If EMS is on scene, this should not apply.

      There is alot of background not addressed within the scope of the study.

      The study addressed the outcome of patients transported to one level one trauma center by PFD EMS and by PPD. That was it.

      There is a lot of misinformation in your comment.

      Why the scare tactics of the police are out to kidnap EMS patients?

      Why are you suggesting that the police want to go out of their way to transport patients and end up with blood all over their vehicles?

      What would be the benefit of having the patient wait another 5 minutes, 15 minutes, 30 minutes, et cetera for an ambulance to arrive?

      The authors stated –

      We believe that these findings suggest that implementation of police transport for this patient population is safe and may help to decompress overwhelmed EMS systems or those without any significant EMS structure either in rural areas or in resource-poor countries.

      That statement seem to be well supported by this study and by the earlier study done when the policy was implemented a couple of decades ago.

    • Started 20 years ago around the time PPD stopped transporting non-ill persons that wanted a ride to an ER. I am suggesting by police radio giving out jobs with no know injuries we are bogged down doing there job while they do ours. The simple fact is its not a cops job! I dont write tickets or do there job so stop doing mine! Medics are often on the street as much as the police so who know if there would be a delay in care, we never have the chance to even make it on scene. Oh, and police make more OT and other related shift extensions by doing this…

      • Anonymous,

        Started 20 years ago around the time PPD stopped transporting non-ill persons that wanted a ride to an ER.

        How is this different from all of the other places that don’t have police transport non-ill patients to the ED?

        I am suggesting by police radio giving out jobs with no know injuries we are bogged down doing there job while they do ours.

        Who should decide which agency should transport non-ill patients?

        The simple fact is its not a cops job! I dont write tickets or do there job so stop doing mine!

        You want police to transport patients to the ED, but only the patients you don’t want to transport?

        Medics are often on the street as much as the police so who know if there would be a delay in care, we never have the chance to even make it on scene.

        That pretty much answers the question.

        You are not on scene.

        You are not available to transport the patient.

        So, how would there not be a delay?

        Oh, and police make more OT and other related shift extensions by doing this…

        That is something I had not thought of. That is one reason that could encourage police to transport, rather than waiting for EMS.

        I still do not see any incentive for 911 to not dispatch EMS.

        There should be more ambulances on the street in Philadelphia.

        I keep hearing that EMS has 28 ambulances, but an assessment of the system determined that there should be at least 70 ambulances. This is, in part, a response to the understaffing of EMS.

  2. I think that the bigger lessons here are that for trauma response times and transport times matter. It’s not, as Anonymous seems to think whether PFD or PPD does the transport. It’s how fast the transport takes place. Nor are the internal politics of how the calls get routed to the FD important. Someone has to answer the 9-1-1 calls, and the majority of those calls are for the police. If the calls were routed to the FD first, it’s likely that on balance more people would be harmed.

    The latest data from the war zones shows that intubation should be delayed as long as possible. The introduction of drugs to induce anesthesia, whether in the field or even in the trauma room, has serious negative effects. To the point that in Iraq and Afghanistan induction and intubation were delayed until the patient was in the OR, the surgeons were assembled, and the patient had been prepped for surgery. Once induced and intubated, the surgeons immediately start cutting because the likelihood of cardiac arrest is high.

    I know it’s all sexy and hip to deride the “Golden Hour” but the truth is that the underlying concept, get the patient to definitive care (surgery) as quickly as possible is valid. Time counts and for trauma the cure for the most part is still surgery. Part of that is transport as rapidly and safely as possible. In Philadelphia, that seems to entail letting the police transport. In my system, it entails educating the BLS crews to transport as soon as they can and not wait on scene for ALS to arrive. In other systems, the answer is going to be different.

    • Too Old To Work,

      I think that the bigger lessons here are that for trauma response times and transport times matter.

      I would say that for some patients time is very important. That probably includes some penetrating trauma.

      The latest data from the war zones shows that intubation should be delayed as long as possible. The introduction of drugs to induce anesthesia, whether in the field or even in the trauma room, has serious negative effects.

      I missed that. What is it from?

      I know it’s all sexy and hip to deride the “Golden Hour”

      Too Old To Work called me sexy. 🙂

      the truth is that the underlying concept, get the patient to definitive care (surgery) as quickly as possible is valid.

      The underlying concept, get the patient who needs surgery right away to definitive care (surgery) as quickly as possible is valid.

      How many of the trauma alerts actually end up in surgery within an hour of arrival at the trauma center? Probably less than 5%.

      Better assessment and better judgment could eliminate a lot of the burden on the trauma system caused by calling trauma alerts for minor injuries based on poor protocols.

      Time counts and for trauma the cure for the most part is still surgery.

      That does not seem to be the case. Very little of trauma requires rapid surgical intervention.

      In Philadelphia, that seems to entail letting the police transport. In my system, it entails educating the BLS crews to transport as soon as they can and not wait on scene for ALS to arrive. In other systems, the answer is going to be different.

      In Philadelphia, due to understaffing there are sometimes significant delays.

      We do not know how much longer penetrating injury patients would have to wait, but we do know that they are being transported by police because EMS is not there.

      It could be 5 minutes, 15 minutes, 30 minutes, we don’t know.

      This study does not examine the times, only the outcomes.

      There is no difference in outcomes whether transport is by PFD EMS or by PPD.

  3. Ok so maybe the non-ill person was a bad example but agree with me that the study supports rapid transport and in this case it just happens to be police. Now follow this by police doing this is it part of the reason there are not more units on the street? A few people bleeding out in the street in front of the block makes a strong point.

    • Anonymous,

      The study does support rapid transport of unstable patients with penetrating injuries.

      There are more reasons for understaffing in Philadelphia than the small number of patients transported by police. This covers about 114 patients per year. Philadelphia is stated to be about 200 medics short of being fully staffed. This makes very little difference in the overall almost 250,000 calls for EMS in Philadelphia each year.

      114 out of 250,000 is 0.05% of calls. Not 5%. Not half of one percent. Half of one tenth of one percent.

      The reason staffing in Philadelphia is so poor is that politics is more important than patients. If the overworked medics realize that the overtime is not worth it and stop taking the extra shifts, there might be a much more noticeable lack of service that the politicians would have to explain.

      The politicians created the problems in the Philadelphia system, but they blame everyone else for the problems created by their ignorance.

      .

  4. This study also doesn’t address police transporting patient’s to the wrong type of hospitals. By them transporting patient to non-trauma centers, they only add to the complex nature of the injury and create secondary “calls” because of it. Generally the pratice of police transporting medical or trauma patient’s shouldn’t be taking place.

    • cs,

      This study also doesn’t address police transporting patient’s to the wrong type of hospitals. By them transporting patient to non-trauma centers, they only add to the complex nature of the injury and create secondary “calls” because of it.

      This is true, but the study only looked at patients arriving at the Hospital of the University of Pennsylvania, which is a level 1 trauma center.

      A different study should look at the rate of police transporting trauma patients to community hospitals.

      A further different study should look at Philadelphia Fire Department EMS transporting trauma patients to community hospitals.

      Generally the pratice of police transporting medical or trauma patient’s shouldn’t be taking place.

      Generally, that is true, but in Philadelphia there is a severe shortage of EMS and the administration does not seem to be interested in making EMS a desirable job.

      It is not unusual for medics to choose to demote to fire fighter, because there is no opportunity for promotion on the EMS side of the house.

      The recent move by the government to get the medics thrown out of the fire fighters’ union is not doing anything to decrease the shortage of medics.

      The city residency requirement also discourages anyone who does not already live in the city.

      Medics can go to Philadelphia to get some high volume experience, then go to the suburbs and some, but only some, of the suburban departments will actually treat them as people who do not need to be treated like children.

      Philadelphia has many problems. This policy does not solve them, but it does decrease the impact on a system that is dangerously understaffed to satisfy political pressures. From the little I have read about Detroit, they also seem to put the patients and the employees dead last. The solution is to throw the vermin out, but the electorate does not appear to understand EMS any more than the politicians do.

      .

  5. I had literally a 4 min response time a few days to a shooting, and the patient was already gone. No ambulance is on scene instantly, and there is just so much wrong with the relationship between police and fire that this is an example of it.

  6. I have been a medic for the phila fire dept for 13 years at a medic unit doing 8000 runs a year. There are many things that are not factored into this study .
    1. Zero care being done during the transport in police vehicle
    2.police have no bsi issued and use none during transport of bloody pt
    3.delay of dispatch of EMS and lack of direct communication between police and EMS
    4.it is frequent practice for police to pull around an arriving medic unit
    5. Police do get more OT transporting a trauma pt
    6. Transport of pt’s that should be left DOA to preserve a crime scene
    7. Unsafe,reckless driving by police often leaves the pt wedged between the seats of the car upon arrival at the ED.
    8. ED staff being exposed due to trying extricate a bleeding mess that is wedged in the rear of a patrol car. ( the police aren’t getting the pt out once at the ED)
    9. Delay of care and lack of treatment while trying to remove the pt from a patrol car
    10.Improper sanitation of the transporting police vehicle after the bloody transport
    Medic units are often times available with good response times and the practice is still being done. It is a poor, unsafe standard of care and should be stopped. Believe me we do get our fair share of penetrating trauma but allowing this in any fashion is an insult to our profession.

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