Coming in hot: Police transport and prehospital time after firearm injury

Abstract

BACKGROUND:In Philadelphia, PA, police and emergency medical services (EMS) transport patients with firearm injuries. Prior studies evaluating this system have lacked reliable prehospital times. By linking police and hospital data sets, we established a complete timeline from firearm injury to outcome. We hypothesized that police-transported patients have shorter prehospital times that, in turn, are associated with improved survival and increased unexpected survivorship at 6 and 24 hours. METHODS:This retrospective study linked patient-level data from OpenDataPhilly Shooting Victims and the Pennsylvania Trauma Systems Foundation. All adults transported to a Level I or II trauma center after firearm injury in Philadelphia from 2015 to 2018 were included. Patient-level characteristics were compared between cohorts; unexpected survivors were identified using Trauma Score-Injury Severity Score. Multiple regression estimated risk-adjusted associations between transport method, prehospital time, and outcomes. RESULTS:Police-transported patients (n = 977) had significantly shorter prehospital times than EMS-transported patients (n = 320) (median, 9 minutes [interquartile range, 7-12 minutes] vs. 21 minutes [interquartile range, 16-29 minutes], respectively; p < 0.001).Police-transported patients were more often severely injured than those transported by EMS (60% vs. 50%, p = 0.002). After adjusting for confounders, police-transported patients had improved survival relative to EMS on hospital arrival (87% vs. 84%, respectively, p = 0.035), but not at 6 hours (79% vs. 78%, respectively, p = 0.126) or 24 hours after arrival (76% vs. 76%, respectively, p = 0.224). Compared with EMS, police-transported patients were significantly more likely to be unexpected survivors at 6 hours (6% vs. 2%, respectively, p < 0.001) and 24 hours (3% vs. 1%, respectively, p = 0.021). CONCLUSION:Police-transported patients had more severe injuries, shorter prehospital times, and increased likelihood of unexpected survival compared with EMS-transported patients. After controlling for confounders, patient physiology and injury severity represent meaningful determinants of mortality in our mature trauma system, indicating an ongoing opportunity to optimize in-hospital care. Future studies should investigate causes of death among unexpected early survivors to mitigate preventable mortality.

Is Faster Transport Time Really Associated With Decreased Firearm Injury Mortality?

“…We have serious reservations about this, given that several major data are unknown: time between injury and arrival of the rescue team, type of transport (police or ambulance), severity of patients' condition, actual transport time for the cohort studied, and any actions performed during management, even though a recent study stressed the value of prehospital de-compression of patients with traumatic pneumothorax in terms of survival. 3 We are also blind to the place of death of the individual (is it at the scene of the attack, during transport or in hospital?). In this study of 1015 patients, only 24 of them were more than 15 minutes from the predicted transport time and 7 died.…”

Is Faster Transport Time Really Associated With Decreased Firearm Injury Mortality?—Reply

“…However, as we discuss in the article, there are several ways to improve access, one of which is minimizing time in the field. The balance of evidence supports that for people with gunshot wounds, scoop and run is the preferred approach in urban trauma systems . Prehospital interventions may benefit some.…”

“…The balance of evidence supports that for people with gunshot wounds, scoop and run is the preferred approach in urban trauma systems. 2,3 Prehospital interventions may benefit some. However, the cited studies of prehospital transfusion and needle decompression 4,5 include predominantly blunt injury (50%-82%) with long prehospital times (40-90 minutes) and are therefore not informative for optimizing urban trauma systems to reduce deaths from gun violence.…”

Intubation of bleeding patients in the emergency department or the operating room: A medical decision to be justified—reply

“…While this is a tangent to the purpose of our study, we do agree that select prehospital interventions such as tourniquet application, TXA, and transfusion are important strategies that may benefit some patients. However, the balance of evidence supports that “scoop and run” is the preferred system-level approach among bleeding patients treated at urban centers in the United States 3,4 . Our study cohort were primarily hemodynamically unstable patients with penetrating injuries (firearm injury, 51%; stab injury, 21%).…”