Okay, now everything in trauma is officially in question!

[Guest guest]

Maybe leeches and bloodletting will make a comeback!

DP

Scene Time May Not Affect Mortality in Trauma Patients

Vicki Gerson

October 29, 2008 (Chicago, Illinois) — Time on the scene of an

accident or assault does not predict mortality in trauma patients

taken to a level 1 trauma center, according to a retrospective

observational cohort study. However, the results need to be validated,

the researchers say.

The study was presented here at the American College of Emergency

Physicians (ACEP) 2008 Scientific Assembly.

Emergency medicine physicians have always believed that the " golden

hour " of care was the most important factor for trauma-patient

outcomes. " However, there are no real data to support this theory, "

lead author T. Cudnik, MD, associate professor in the

Department of Emergency Medicine, Ohio State University Medical

Center, in Columbus, told Medscape Emergency Medicine. " The data for

this study was collected from the institution's trauma registry. "

Dr. Cudnik and colleagues wanted to determine whether scene time had

an effect on mortality in injured patients who were transported

directly from the accident scene by ground or by air to a level 1

trauma center. This study took place between January 2001 and December

2006 in a large metropolitan area and included all patients aged 15

years or older who were admitted for at least 2 days or who died

before 2 days. A total of 4461 patients were included in the analysis.

These patients had injuries from auto accidents, penetrating injuries,

falls, or assaults. They were injured in their homes or in public

places. Dr. Cudnik noted that the location of the injury was not

accounted for in the analysis. Furthermore, although some of these

patients might have had a myocardial infarction, such information was

not obtained nor included in the analysis. The researchers did not

include transferred trauma patients or patients arriving by private

transportation.

A multivariate logistic regression analysis was developed for scene

time and mortality to see if there was any association, and it

adjusted for factors such as age, mode of transportation, and severity

of injury. Injury severity score (ISS) and revised trauma score were

obtained. Of the total patient group, 59% were transported by air.

According to the study abstract, " the median ISS was 10, and overall

mortality was 5.2%. Mean scene time did not differ between survivors

(14.4 minutes) and nonsurvivors (15.3 minutes). "

In the final analysis, scene time was the only factor that had no

association with mortality (odds ratio [OR], 0.98; 95% confidence

interval [CI], 0.96 - 1.01; P = .17). This lack of association

remained when patients were stratified by those who had been intubated

before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and

those who had not (OR, 0.99; 95% CI, 0.95 - 1.02).

Even for patients with a scene time longer than the mean, there was no

" observable " increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P =

..25). In addition, no increase in mortality was seen when patients

were stratified by ground transport vs air transport, blunt vs

penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or

higher, and by those with an out-of-hospital systolic blood pressure

of less than 90 mm Hg vs 90 mm Hg or more.

The researchers also looked to see whether scene time interval (in

10-minute increments) was found to be associated with an increase in

mortality; it was not. The area under the receiver operating

characteristic curve was 89.4.

" We can't take the study on its face value [to determine whether]

scene time is a predictor or not a predictor of mortality, "

O'Neil, MD, course director of the Research Forum at the meeting and

associate chair of the Department of Emergency Medicine at Wayne State

University School of Medicine in Detroit, Michigan, told Medscape

Emergency Medicine.

" There are many factors that go into scene time that the study did not

look at, " Dr. O'Neil pointed out. " Was the scene secure? Did the

patient have to be extracted from the car? When it is possible to

'scoop and run' with patients, they do a little bit better. "

Nolan McMullin, MD, FACEP, a staff emergency physician at the

Cleveland Clinic, in Ohio, who heard the presentation, said, " I find

it a little surprising that scene time was not associated with a

higher mortality. Throughout emergency medicine, we are taught how

important it is to reach the medical center quickly. "

Dr. Cudnik did say that he would like to see future studies validate

his findings. " It is important to identify which patients need to be

transported quicker than others in order to save more lives. "

The study did not receive commercial support. Dr. Cudnik has disclosed

no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2008 Scientific

Assembly: Abstract 171. Presented October 27, 2008.

[Guest guest]

I have been talking and writing about this since Boyd, MD told me the

story about Cowley, Boyd and others sitting in a bar in Baltimore when

Cowley came up with the idea of the Golden Hour. There are several other

articles that show that out-of-hospital time is not a factor in trauma

mortality. But, the purveyors of helicopters, lights and sirens, and similar

endeavors would rather spin this as a " biased study " or otherwise a priori.

BEB

From: texasems-l [mailto:texasems-l ] On

Behalf Of

Sent: Thursday, October 30, 2008 2:22 PM

To: texasems-l

Subject: Okay, now everything in trauma is officially in

question!

Maybe leeches and bloodletting will make a comeback!

DP

Scene Time May Not Affect Mortality in Trauma Patients

Vicki Gerson

October 29, 2008 (Chicago, Illinois) - Time on the scene of an

accident or assault does not predict mortality in trauma patients

taken to a level 1 trauma center, according to a retrospective

observational cohort study. However, the results need to be validated,

the researchers say.

The study was presented here at the American College of Emergency

Physicians (ACEP) 2008 Scientific Assembly.

Emergency medicine physicians have always believed that the " golden

hour " of care was the most important factor for trauma-patient

outcomes. " However, there are no real data to support this theory, "

lead author T. Cudnik, MD, associate professor in the

Department of Emergency Medicine, Ohio State University Medical

Center, in Columbus, told Medscape Emergency Medicine. " The data for

this study was collected from the institution's trauma registry. "

Dr. Cudnik and colleagues wanted to determine whether scene time had

an effect on mortality in injured patients who were transported

directly from the accident scene by ground or by air to a level 1

trauma center. This study took place between January 2001 and December

2006 in a large metropolitan area and included all patients aged 15

years or older who were admitted for at least 2 days or who died

before 2 days. A total of 4461 patients were included in the analysis.

These patients had injuries from auto accidents, penetrating injuries,

falls, or assaults. They were injured in their homes or in public

places. Dr. Cudnik noted that the location of the injury was not

accounted for in the analysis. Furthermore, although some of these

patients might have had a myocardial infarction, such information was

not obtained nor included in the analysis. The researchers did not

include transferred trauma patients or patients arriving by private

transportation.

A multivariate logistic regression analysis was developed for scene

time and mortality to see if there was any association, and it

adjusted for factors such as age, mode of transportation, and severity

of injury. Injury severity score (ISS) and revised trauma score were

obtained. Of the total patient group, 59% were transported by air.

According to the study abstract, " the median ISS was 10, and overall

mortality was 5.2%. Mean scene time did not differ between survivors

(14.4 minutes) and nonsurvivors (15.3 minutes). "

In the final analysis, scene time was the only factor that had no

association with mortality (odds ratio [OR], 0.98; 95% confidence

interval [CI], 0.96 - 1.01; P = .17). This lack of association

remained when patients were stratified by those who had been intubated

before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and

those who had not (OR, 0.99; 95% CI, 0.95 - 1.02).

Even for patients with a scene time longer than the mean, there was no

" observable " increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P =

..25). In addition, no increase in mortality was seen when patients

were stratified by ground transport vs air transport, blunt vs

penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or

higher, and by those with an out-of-hospital systolic blood pressure

of less than 90 mm Hg vs 90 mm Hg or more.

The researchers also looked to see whether scene time interval (in

10-minute increments) was found to be associated with an increase in

mortality; it was not. The area under the receiver operating

characteristic curve was 89.4.

" We can't take the study on its face value [to determine whether]

scene time is a predictor or not a predictor of mortality, "

O'Neil, MD, course director of the Research Forum at the meeting and

associate chair of the Department of Emergency Medicine at Wayne State

University School of Medicine in Detroit, Michigan, told Medscape

Emergency Medicine.

" There are many factors that go into scene time that the study did not

look at, " Dr. O'Neil pointed out. " Was the scene secure? Did the

patient have to be extracted from the car? When it is possible to

'scoop and run' with patients, they do a little bit better. "

Nolan McMullin, MD, FACEP, a staff emergency physician at the

Cleveland Clinic, in Ohio, who heard the presentation, said, " I find

it a little surprising that scene time was not associated with a

higher mortality. Throughout emergency medicine, we are taught how

important it is to reach the medical center quickly. "

Dr. Cudnik did say that he would like to see future studies validate

his findings. " It is important to identify which patients need to be

transported quicker than others in order to save more lives. "

The study did not receive commercial support. Dr. Cudnik has disclosed

no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2008 Scientific

Assembly: Abstract 171. Presented October 27, 2008.

[Guest guest]

Well, maggots and leeches are, in fact, already back. Maggots are used for

wound debridement, and leeches are used to enhance circulation in reattached

body parts.

GG

>

> Maybe leeches and bloodletting will make a comeback!

> DP

>

> Scene Time May Not Affect Mortality in Trauma Patients

>

> Vicki Gerson

>

> October 29, 2008 (Chicago, Illinois) — Time on the scene of an

> accident or assault does not predict mortality in trauma patients

> taken to a level 1 trauma center, according to a retrospective

> observational cohort study. However, the results need to be validated,

> the researchers say.

>

> The study was presented here at the American College of Emergency

> Physicians (ACEP) 2008 Scientific Assembly.

>

> Emergency medicine physicians have always believed that the " golden

> hour " of care was the most important factor for trauma-patient

> outcomes. " However, there are no real data to support this theory, "

> lead author T. Cudnik, MD, associate professor in the

> Department of Emergency Medicine, Ohio State University Medical

> Center, in Columbus, told Medscape Emergency Medicine. " The data for

> this study was collected from the institution' this study was col

>

> Dr. Cudnik and colleagues wanted to determine whether scene time had

> an effect on mortality in injured patients who were transported

> directly from the accident scene by ground or by air to a level 1

> trauma center. This study took place between January 2001 and December

> 2006 in a large metropolitan area and included all patients aged 15

> years or older who were admitted for at least 2 days or who died

> before 2 days. A total of 4461 patients were included in the analysis.

>

> These patients had injuries from auto accidents, penetrating injuries,

> falls, or assaults. They were injured in their homes or in public

> places. Dr. Cudnik noted that the location of the injury was not

> accounted for in the analysis. Furthermore, although some of these

> patients might have had a myocardial infarction, such information was

> not obtained nor included in the analysis. The researchers did not

> include transferred trauma patients or patients arriving by private

> transportation.

>

> A multivariate logistic regression analysis was developed for scene

> time and mortality to see if there was any association, and it

> adjusted for factors such as age, mode of transportation, and severity

> of injury. Injury severity score (ISS) and revised trauma score were

> obtained. Of the total patient group, 59% were transported by air.

> According to the study abstract, " the median ISS was 10, and overall

> mortality was 5.2%. Mean scene time did not differ between survivors

> (14.4 minutes) and nonsurvivors (15.3 minutes). "

>

> In the final analysis, scene time was the only factor that had no

> association with mortality (odds ratio [OR], 0.98; 95% confidence

> interval [CI], 0.96 - 1.01; P = .17). This lack of association

> remained when patients were stratified by those who had been intubated

> before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and

> those who had not (OR, 0.99; 95% CI, 0.95 - 1.02).

>

> Even for patients with a scene time longer than the mean, there was no

> " observable " increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P =

> .25). In addition, no increase in mortality was seen when patients

> were stratified by ground transport vs air transport, blunt vs

> penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or

> higher, and by those with an out-of-hospital systolic blood pressure

> of less than 90 mm Hg vs 90 mm Hg or more.

>

> The researchers also looked to see whether scene time interval (in

> 10-minute increments) was found to be associated with an increase in

> mortality; it was not. The area under the receiver operating

> characteristic curve was 89.4.

>

> " We can't take the study on its face value [to determine whether]

> scene time is a predictor or not a predictor of mortality, "

> O'Neil, MD, course director of the Research Forum at the meeting and

> associate chair of the Department of Emergency Medicine at Wayne State

> University School of Medicine in Detroit, Michigan, told Medscape

> Emergency Medicine.

>

> " There are many factors that go into scene time that the study did not

> look at, " Dr. O'Neil pointed out. " Was the scene secure? Did the

> patient have to be extracted from the car? When it is possible to

> 'scoop and run' with patients, they do a little bit better. "

>

> Nolan McMullin, MD, FACEP, a staff emergency physician at the

> Cleveland Clinic, in Ohio, who heard the presentation, said, " I find

> it a little surprising that scene time was not associated with a

> higher mortality. Throughout emergency medicine, we are taught how

> important it is to reach the medical center quickly. "

>

> Dr. Cudnik did say that he would like to see future studies validate

> his findings. " It is important to identify which patients need to be

> transported quicker than others in order to save more lives. "

>

> The study did not receive commercial support. Dr. Cudnik has disclosed

> no relevant financial relationships.

>

> American College of Emergency Physicians (ACEP) 2008 Scientific

> Assembly: Abstract 171. Presented October 27, 2008.

>

>

**************

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[Guest guest]

It's not just the purveyors of helicopters, L & S, and so forth. It's trauma

surgeons, ER physicians, nurses, and administrators who cling to fantasies

that drive this stuff, along with the medics who have to work under them and get

along.

Here in Tucson, in the Great State of Arizona where we are " blessed " with a

system of statewide protocols and rules that requires every service to be

connected to a base hospital, and the base hospital systems are basically run by

nurses, and the trauma centers call the shots, it is still a rule that anybody

involved in a MVC at >40 mph must be transported to the Level 1, even if

there's nothing apparently wrong with them. (Can you spell " r-e-v-e-n-u-e

e-n-h-a-n-c-e-m-e-n-t? " ). They still collar folks standing who were up walking

around and waving their arms about when the arrived, based upon MOI. I could

go

on and on.

Oh, yes, BTW, the " system " has installed video cameras (at a cost of

several hundered thousand dollars) in the ambulances so that the trauma surgeons

who, the system assumes, generally are just sitting around at the desk drinking

their coffee and eating peanut brittle while they await the arrival of the next

ambulance, can watch the care being given enroute and actively participate.

Toto, we're not in Kansas anymore. Of course, the medics hate that, and

they keep the cameras turned off. So much for that system. Since it was

launched with great media attention, nothing else has been heard about it.

Seems

that nobody asked whether or not it would really make any difference in patient

care. The guy who bought it is convinced it will. He's a trauma surgeon.

So far nothing has been heard about great saves brought about by his video

medics receiving instructions from the learned surgeons. That's because they

already knew what to do and don't need somebody looking over their shoulder

to interrupt their care and read the protocol to them. Although, since time

on scene doesn't make any difference, maybe they can sit there and the trauma

doc can conduct a complete assessment from his perch at the telemetry counter.

Even worse, Tucson still transports coded patients Code 3 to the hospital,

and just recently I heard them transporting a patient " postical, vitals within

normal limits, 10 minutes out " Code 3 to---you guessed it----the Level 1,

because it's the Base Hospital. Why, we'll never know. Oops. Yes, we do

know.

They're siren crazy, and they've drunk the Kool-Aid. And they're doing

what they're told.

As one of my favorite (NOT) ER docs in Abilene used to say, " Don't do

anything to them, just bring them to me! "

So, before we pillory the poor paramedics for some of the stuff they do,

let's take a look at who really runs things---the doctors and the administrators

and, here, the nurses. As long as we have " trauma doctors " who are drunk with

Cowley Kool-Aid and administrators who make medics run everybody Code 3 going

and coming because they won't provide enough trucks for coverage, EMS mythology

is safe.

As a " profession " EMS folks just came to town on the turnip truck when it

comes to science. We were always pragmatically trained (skills over education)

and we assumed lots of stuff because the guys who started EMS assumed it

themselves.

At the time, Cowley was a hero, and he still is to many. He did a lot of

good, but he also was quite wrong about some things, and those he taught

continue to sell those ideas to those he trained today, and I'm talking about

doctors

here. The thing he was NOT wrong about was the value of a catchy slogan.

THE GOLDEN HOUR! Puts shivers up my spine.

And last, we're humans. We love adrenalin. That's why we do this. Take

away the adrenalin and where would we be? Since we don't teach our people to

get excited about real medicine and its possibilities, we have to rely on

external stimuli like loud sounds and pretty lights and the power trip that

comes

with being able to blast through stop signs and red lights and drive 100

miles an hour for no reason.

Got to go. The next turnip truck's due any minute.

Gene Gandy, JD, LP

My opinions are my own.

>

> I have been talking and writing about this since Boyd, MD told me the

> story about Cowley, Boyd and others sitting in a bar in Baltimore when

> Cowley came up with the idea of the Golden Hour. There are several other

> articles that show that out-of-hospital time is not a factor in trauma

> mortality. But, the purveyors of helicopters, lights and sirens, and similar

> endeavors would rather spin this as a " biased study " or otherwise a priori.

>

> BEB

>

> From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On

> Behalf Of

> Sent: Thursday, October 30, 2008 2:22 PM

> To: texasems-l@yahoogrotexasem

> Subject: Okay, now everything in trauma is officially in

> question!

>

> Maybe leeches and bloodletting will make a comeback!

> DP

>

> Scene Time May Not Affect Mortality in Trauma Patients

>

> Vicki Gerson

>

> October 29, 2008 (Chicago, Illinois) - Time on the scene of an

> accident or assault does not predict mortality in trauma patients

> taken to a level 1 trauma center, according to a retrospective

> observational cohort study. However, the results need to be validated,

> the researchers say.

>

> The study was presented here at the American College of Emergency

> Physicians (ACEP) 2008 Scientific Assembly.

>

> Emergency medicine physicians have always believed that the " golden

> hour " of care was the most important factor for trauma-patient

> outcomes. " However, there are no real data to support this theory, "

> lead author T. Cudnik, MD, associate professor in the

> Department of Emergency Medicine, Ohio State University Medical

> Center, in Columbus, told Medscape Emergency Medicine. " The data for

> this study was collected from the institution' this study was col

>

> Dr. Cudnik and colleagues wanted to determine whether scene time had

> an effect on mortality in injured patients who were transported

> directly from the accident scene by ground or by air to a level 1

> trauma center. This study took place between January 2001 and December

> 2006 in a large metropolitan area and included all patients aged 15

> years or older who were admitted for at least 2 days or who died

> before 2 days. A total of 4461 patients were included in the analysis.

>

> These patients had injuries from auto accidents, penetrating injuries,

> falls, or assaults. They were injured in their homes or in public

> places. Dr. Cudnik noted that the location of the injury was not

> accounted for in the analysis. Furthermore, although some of these

> patients might have had a myocardial infarction, such information was

> not obtained nor included in the analysis. The researchers did not

> include transferred trauma patients or patients arriving by private

> transportation.

>

> A multivariate logistic regression analysis was developed for scene

> time and mortality to see if there was any association, and it

> adjusted for factors such as age, mode of transportation, and severity

> of injury. Injury severity score (ISS) and revised trauma score were

> obtained. Of the total patient group, 59% were transported by air.

> According to the study abstract, " the median ISS was 10, and overall

> mortality was 5.2%. Mean scene time did not differ between survivors

> (14.4 minutes) and nonsurvivors (15.3 minutes). "

>

> In the final analysis, scene time was the only factor that had no

> association with mortality (odds ratio [OR], 0.98; 95% confidence

> interval [CI], 0.96 - 1.01; P = .17). This lack of association

> remained when patients were stratified by those who had been intubated

> before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and

> those who had not (OR, 0.99; 95% CI, 0.95 - 1.02).

>

> Even for patients with a scene time longer than the mean, there was no

> " observable " increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P =

> .25). In addition, no increase in mortality was seen when patients

> were stratified by ground transport vs air transport, blunt vs

> penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or

> higher, and by those with an out-of-hospital systolic blood pressure

> of less than 90 mm Hg vs 90 mm Hg or more.

>

> The researchers also looked to see whether scene time interval (in

> 10-minute increments) was found to be associated with an increase in

> mortality; it was not. The area under the receiver operating

> characteristic curve was 89.4.

>

> " We can't take the study on its face value [to determine whether]

> scene time is a predictor or not a predictor of mortality, "

> O'Neil, MD, course director of the Research Forum at the meeting and

> associate chair of the Department of Emergency Medicine at Wayne State

> University School of Medicine in Detroit, Michigan, told Medscape

> Emergency Medicine.

>

> " There are many factors that go into scene time that the study did not

> look at, " Dr. O'Neil pointed out. " Was the scene secure? Did the

> patient have to be extracted from the car? When it is possible to

> 'scoop and run' with patients, they do a little bit better. "

>

> Nolan McMullin, MD, FACEP, a staff emergency physician at the

> Cleveland Clinic, in Ohio, who heard the presentation, said, " I find

> it a little surprising that scene time was not associated with a

> higher mortality. Throughout emergency medicine, we are taught how

> important it is to reach the medical center quickly. "

>

> Dr. Cudnik did say that he would like to see future studies validate

> his findings. " It is important to identify which patients need to be

> transported quicker than others in order to save more lives. "

>

> The study did not receive commercial support. Dr. Cudnik has disclosed

> no relevant financial relationships.

>

> American College of Emergency Physicians (ACEP) 2008 Scientific

> Assembly: Abstract 171. Presented October 27, 2008.

>

>

[Guest guest]

I realize everything you are saying. I think the evidence is

beginning to be too much to ignore, and eventually they all will have

to admit that the earth is round! Oooops, I mean that the sun is

really at the center...ooops. That the golden hour is a myth.

It is really true; a fact is something that the majority believes at

any time, but a truth never changes.

>

> I have been talking and writing about this since Boyd, MD told

me the

> story about Cowley, Boyd and others sitting in a bar in Baltimore when

> Cowley came up with the idea of the Golden Hour. There are several

other

> articles that show that out-of-hospital time is not a factor in trauma

> mortality. But, the purveyors of helicopters, lights and sirens, and

similar

> endeavors would rather spin this as a " biased study " or otherwise a

priori.

>

>

>

> BEB

>

>

>

> From: texasems-l [mailto:texasems-l ] On

> Behalf Of

> Sent: Thursday, October 30, 2008 2:22 PM

> To: texasems-l

> Subject: Okay, now everything in trauma is officially in

> question!

>

>

>

> Maybe leeches and bloodletting will make a comeback!

> DP

>

> Scene Time May Not Affect Mortality in Trauma Patients

>

> Vicki Gerson

>

> October 29, 2008 (Chicago, Illinois) - Time on the scene of an

> accident or assault does not predict mortality in trauma patients

> taken to a level 1 trauma center, according to a retrospective

> observational cohort study. However, the results need to be validated,

> the researchers say.

>

> The study was presented here at the American College of Emergency

> Physicians (ACEP) 2008 Scientific Assembly.

>

> Emergency medicine physicians have always believed that the " golden

> hour " of care was the most important factor for trauma-patient

> outcomes. " However, there are no real data to support this theory, "

> lead author T. Cudnik, MD, associate professor in the

> Department of Emergency Medicine, Ohio State University Medical

> Center, in Columbus, told Medscape Emergency Medicine. " The data for

> this study was collected from the institution's trauma registry. "

>

> Dr. Cudnik and colleagues wanted to determine whether scene time had

> an effect on mortality in injured patients who were transported

> directly from the accident scene by ground or by air to a level 1

> trauma center. This study took place between January 2001 and December

> 2006 in a large metropolitan area and included all patients aged 15

> years or older who were admitted for at least 2 days or who died

> before 2 days. A total of 4461 patients were included in the analysis.

>

> These patients had injuries from auto accidents, penetrating injuries,

> falls, or assaults. They were injured in their homes or in public

> places. Dr. Cudnik noted that the location of the injury was not

> accounted for in the analysis. Furthermore, although some of these

> patients might have had a myocardial infarction, such information was

> not obtained nor included in the analysis. The researchers did not

> include transferred trauma patients or patients arriving by private

> transportation.

>

> A multivariate logistic regression analysis was developed for scene

> time and mortality to see if there was any association, and it

> adjusted for factors such as age, mode of transportation, and severity

> of injury. Injury severity score (ISS) and revised trauma score were

> obtained. Of the total patient group, 59% were transported by air.

> According to the study abstract, " the median ISS was 10, and overall

> mortality was 5.2%. Mean scene time did not differ between survivors

> (14.4 minutes) and nonsurvivors (15.3 minutes). "

>

> In the final analysis, scene time was the only factor that had no

> association with mortality (odds ratio [OR], 0.98; 95% confidence

> interval [CI], 0.96 - 1.01; P = .17). This lack of association

> remained when patients were stratified by those who had been intubated

> before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and

> those who had not (OR, 0.99; 95% CI, 0.95 - 1.02).

>

> Even for patients with a scene time longer than the mean, there was no

> " observable " increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P =

> .25). In addition, no increase in mortality was seen when patients

> were stratified by ground transport vs air transport, blunt vs

> penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or

> higher, and by those with an out-of-hospital systolic blood pressure

> of less than 90 mm Hg vs 90 mm Hg or more.

>

> The researchers also looked to see whether scene time interval (in

> 10-minute increments) was found to be associated with an increase in

> mortality; it was not. The area under the receiver operating

> characteristic curve was 89.4.

>

> " We can't take the study on its face value [to determine whether]

> scene time is a predictor or not a predictor of mortality, "

> O'Neil, MD, course director of the Research Forum at the meeting and

> associate chair of the Department of Emergency Medicine at Wayne State

> University School of Medicine in Detroit, Michigan, told Medscape

> Emergency Medicine.

>

> " There are many factors that go into scene time that the study did not

> look at, " Dr. O'Neil pointed out. " Was the scene secure? Did the

> patient have to be extracted from the car? When it is possible to

> 'scoop and run' with patients, they do a little bit better. "

>

> Nolan McMullin, MD, FACEP, a staff emergency physician at the

> Cleveland Clinic, in Ohio, who heard the presentation, said, " I find

> it a little surprising that scene time was not associated with a

> higher mortality. Throughout emergency medicine, we are taught how

> important it is to reach the medical center quickly. "

>

> Dr. Cudnik did say that he would like to see future studies validate

> his findings. " It is important to identify which patients need to be

> transported quicker than others in order to save more lives. "

>

> The study did not receive commercial support. Dr. Cudnik has disclosed

> no relevant financial relationships.

>

> American College of Emergency Physicians (ACEP) 2008 Scientific

> Assembly: Abstract 171. Presented October 27, 2008.

>

>

>

>

>

>

[Guest guest]

When do I get a barber pole for the bloodletting?!

>

> Well, maggots and leeches are, in fact, already back. Maggots are

used for

> wound debridement, and leeches are used to enhance circulation in

reattached

> body parts.

>

> GG

[Guest guest]

Seriously, folks, a basic principle of science: Everything we think we

know is constantly subject to question; all corrections are temporary and

subject to further inquiry. This is one of the things that always renders

algorithmic intervention a problematic approach. Done at its best,

clinical reasoning, like scientific reasoning, involves querying of the

algorithm rather than its reification--to wit, you lay the algorithm over

the observed presentation like a template and look for its deviations

(there are always deviations). The specificity of diagnosis and treatment

develops as the deviations are addressed and rectified. This is also how

the science that underlies diagnosis and treatment evolves--tenets are

questioned, systematic observations made, and deviations addressed and

rectified.

Anyone who tells you their pet contention, whatever it may be, has been

" scientifically proven " is certainly not a scientist . . . odds are that he

or she is a salesman, a lawyer, or a con artist,. The principle lesson of

science is this: " Trust all who seek the truth; doubt all who claim to

find it. "

Gist, Ph.D.

Principal Assistant to the Director

Kansas City, Missouri Fire Department

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