Prehospital management of trauma: a tale of three cities

The controversies that have surrounded the prehospital management of trauma stem not only from a lack of appropriate evaluation data, but also from a lack of medical accountability and "street-wise," academic physician involvement within emergency medical services (EMS) systems. As a result, the approach to EMS trauma care has often been over-generalized and debated in terms of simplistic, unidimensional concepts, such as "scoop and run" versus "field stabilization," without any regard for the type and anatomic location of injury involved, the efficiency and skill of rescuers, the proximity and actual capabilities of definitive care resources, and the logistics of the prehospital setting. The failure to understand and delineate these variables has led to conflicting studies and has confused the analysis of potential therapeutic modalities and management strategies. In view of this, a survey is provided of three major cities, each with intensive, academic physician involvement in their EMS systems, and the approach and rationale for their prehospital care strategies are summarized. In all three systems, patients generally are categorized according to three major injury types (penetrating, blunt, and thermal) and then further subcategorized with regard to anatomical involvement, specifically those involving potential (or known) internal truncal injuries versus those with isolated head trauma or isolated extremity injury. For all three, high-flow O2 delivery and aggressive, advanced airway management (by endotracheal intubation whenever feasible) are keystones of management. In cases of potential or known internal truncal injury, the priority is also expeditious transport to facilities with definitive surgical care with the establishment of IV access and rapid fluid infusions en route.(ABSTRACT TRUNCATED AT 250 WORDS)