An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

Incarceration is associated with higher mortality after trauma: An unreported health care disparity

BACKGROUND

While the United States has the highest incarceration rate worldwide, at nearly 1% of the adult population (more than 2 million people), insights regarding health disparities in this population remain limited. This retrospective cohort study represents the largest national database analysis of incarcerated trauma patients to date and investigates whether incarceration status is an independent risk factor for poor outcomes after trauma for US adults.

METHODS

We analyzed data from the National Trauma Data Bank from 2017 to 2018. Using multilevel logistic regression, we measured risk-adjusted associations between incarceration status (assessed by International Classification of Diseases, Tenth Revision , location codes) and trauma outcomes: mortality, any in-hospital complications, aggregate major complications, and failure to rescue. We report odds ratios and 95% confidence intervals, adjusting for demographics, transfer status, insurance, comorbidities, injury mechanism, injury severity, and presenting vitals. A secondary analysis was performed using nearest neighbor matching with a 2:1 ratio of nonincarcerated to incarcerated patients, followed by multilevel logistic regression.

RESULTS

There were 12,888 incarcerated patients and 1,654,254 nonincarcerated patients. Incarcerated patients were younger (median, 36 vs. 55 years), more likely to be male (94.9% vs. 60.5%), Black (27.9% vs. 13.9%), and Hispanic (15.7% vs. 11.5%) and presented more frequently with minor injuries (Injury Severity Score, <9; 65.4% vs. 48.9%) and with stabbings and other blunt events as mechanisms of injury. Although unadjusted mortality was lower for incarcerated patients, after adjustment, they were significantly more likely to die (adjusted odds ratio (AOR), 1.42 [1.19-1.68]), which was consistent in the matched analysis (AOR, 1.19 [1.03-1.36]). Incarcerated patients were, conversely, less likely to suffer any in-hospital complication (AOR, 0.76 [0.68-0.85]; matched AOR, 0.88 [0.81-0.97]).

CONCLUSION

Our study redemonstrated that incarcerated trauma patients' demographics and injuries differ significantly from nonincarcerated patients. Furthermore, incarceration was an independent risk factor for mortality, a previously unreported disparity. This highlights the need for improved data collection regarding incarceration status and national prospective investigations.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest

Importance

Traumatic cardiac arrest (TCA) presents a critical challenge in trauma care, often occurring rapidly after injury before effective interventions are available.

Objective

To evaluate the association of prehospital resuscitative thoracotomy with survival outcomes for TCA.

Design, Setting, and Participants

This retrospective cohort study examined all cases of prehospital resuscitative thoracotomy for TCA in London from January 1999 to December 2019. Data were analyzed from July 2022 to July 2023.

Exposure

Prehospital resuscitative thoracotomy for TCA.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Secondary outcomes included survival to hospital admission and neurological status at discharge.

Results

Prehospital resuscitative thoracotomy was undertaken in 601 patients with out-of-hospital TCA. The median (IQR) age was 25 (20-37) years; 538 (89.5%) were male and 63 (10.5%) female. A total of 529 patients (88.0%) had a penetrating mechanism of injury. TCA occurred at a median (IQR) of 12 (6-22) minutes after the emergency call, with 491 arrests (81.7%) before the advanced trauma team's arrival. TCA was the result of cardiac tamponade (105 patients, 17.5%), exsanguination (418 patients, 69.6%), and exsanguination combined with cardiac tamponade (72 patients, 12.0%). Thirty patients (5.0%) survived to hospital discharge, with a favorable neurological outcome observed in 23 survivors (76.6%). Survival varied significantly with the cause of TCA: 22 of 105 patients (21%) with cardiac tamponade, 8 of 418 patients (1.9%) with exsanguination, and none of the 72 patients with combined or other pathologies survived. There were no survivors beyond 15 minutes of TCA for cardiac tamponade and 5 minutes after exsanguination. Multivariable analysis revealed that the cause of TCA (adjusted odds ratio [aOR], 21.1; 95% CI, 8.1-54.7; P < .001), duration of TCA (aOR, 20.9; 95% CI, 4.4-100.6, P < .001), and absence of the need for internal cardiac massage (AOR, 0.2; 95% CI, 0.06-0.5; P = .001) were independently associated with survival.

Conclusions and Relevance

TCA occurs soon after injury, with only a brief window available for effective intervention. This study found that resuscitative thoracotomy is feasible in a mature, physician-led, urban prehospital system and is associated with improved survival for patients with out-of-hospital TCA, particularly when caused by cardiac tamponade, in situations where other treatment options are limited.

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

An Analysis of 24-Hour Survival Based on Arrival by Atypical Ground Transport Versus Ground Emergency Medical Services

OBJECTIVES

Studies comparing police, privately owned vehicle (POV), and ground Emergency Medical Services (GEMS) trauma transports reveal mixed results. It remains unclear whether using nonstandard transport methods may be beneficial in the setting of certain injuries. We sought to determine 24-h survival after transport by police or POV when compared to GEMS.

METHODS

We analyzed data from the Trauma Quality Improvement Program datasets from 2020 to 2022 for patients arriving from scene by POV, police, or GEMS. The primary outcome was 24-h survival. Multivariable logistic regression models were used to adjust for confounders. Further stratification was performed by mechanism. We used abbreviated Injury Severity Score (ISS) by body region to assess those with and without penetrating torso trauma.

RESULTS

Patients arriving by POV had a lower median age than those arriving by GEMS and a higher proportion of pediatric patients. This group exhibited a lower incidence of blunt trauma but a higher incidence of penetrating trauma, along with fewer serious injuries across all body regions. Across all adjusted models, arrival by POV was associated with higher odds of 24-h survival, except for cases of penetrating torso trauma among pediatric patients. Patients arriving by police also had a lower median age but a reduced proportion of pediatric patients. This group showed a higher proportion of penetrating trauma and serious injuries to the thorax and abdomen. Police arrivals with blunt trauma had higher odds of 24-h survival, while those with penetrating trauma had lower odds of 24-h survival, a pattern consistent when stratifying by ISS greater than 15.

CONCLUSIONS

This study highlights a survival advantage for trauma patients transported by POV compared to GEMS. Limitations include a lack of prehospital transport time and intervention data. While police transport showed improved survival for blunt trauma, it was associated with worse outcomes for penetrating trauma. These findings suggest that nontraditional transport methods may be beneficial in certain scenarios. Future research should aim to refine transport protocols, investigate the impact of nontraditional methods on transport time, and better understand the impact of prehospital interventions on patient outcomes.

Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business?

INTRODUCTION

Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome.

METHOD

This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality.

RESULT

A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS.

CONCLUSION

Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.