Synthesis Paper Final Draft

Anna Shaw

April 23, 2019

Emergency Transportation: Are We Doing it Right?

Abstract:

Urban violent crime in the United States presents a major public health concern, and is

primarily associated with penetrating trauma, such as gunshot (GSW) or stab wounds. These

injuries are severe and require fast, efficient, and immediate medical attention. In 2018, they

were the leading cause of homicides in Baltimore, Maryland. Typically, when a person

experiences penetrating trauma, an ambulance arrives on-scene to provide basic or advanced life

support before transporting them to the nearest trauma center. However, due to the urgency of

penetrating wounds, private transport via a police officer or a bystander may yield faster

transport times for the patient, thus increasing their chance of survival. The aim of this study was

to determine and compare the timeliness of EMS and private transport times in Baltimore, MD.

In order to do so, EMS and private transport times were calculated for 290 homicides in 2018 in

Baltimore. From the data, it was concluded that private transport times were lower than EMS

transport times, however there was no indication of whether or not private transport would result

in lower patient mortality rates. Therefore, further research is required to determine the effect of

faster private transport times on patient outcome.

Introduction:

Urban violent crime is a dire problem that plagues cities every year and presents a major

public health concern in the United States. In 2018 alone, there were 6,010 murders in 72 cities

[1] ​
The care a patient needs from initial evaluation through to final discharge from the hospital.
in the United States (Murders in 72 US cities for 2018). A myriad of solutions have been

proposed by health experts and and policy makers to mitigate this crisis.

One potential solution is to decrease transport times of trauma patients and victims of

violent crime to trauma centers. Emergency Medical Services (EMS) transportation via

ambulance is designed to be among the most efficient methods of transport to definitive care​[1]

for a patient. It is also intended to minimize patient mortality rates (What is EMS: A Definition

2011). However, recent studies suggest that private vehicle transport (PT) may have better

outcomes than EMS transportation. Both work on the principle of scoop and run and stay and

play, but it is unclear why private transport may be more beneficial (Huber, S., et. al 2016).

Timely access is a key component in the transportation of trauma patients. Medical health

professionals suggest that there is a “golden hour” in which care must be given to a patient

within one hour of the injury for the optimal patient outcome (​The Golden Hour - Journal of

Emergency Medical Services. 2008​). So far, there has been little data conducted to explore and

quantify the differences between EMS and PT in relation to response and transport times

(Hashmi, Z. G, 2019). Existing data suggests that faster transport times results in fewer

prehospital deaths, and PT may be faster and more efficient at transporting trauma patients.

Therefore, the objective of this study was to quantify and compare EMS transport times and PT

times in Baltimore, Maryland, in order to achieve a better understanding of the methods used to

transport victims of penetrating trauma. Because the study found that private transport is more

timely than EMS transport, the EMS transport system in Baltimore, Maryland, should be

improved to reduce EMS response and transport times.

Literature Review:
 In most penetrating trauma cases, it is vital for the victim to have timely access to a

trauma center. A study concerning mortality rates in patients with different levels of access to

definitive care showed that those victims in states with more timely access to a trauma center had

a lower age-adjusted mortality rate (AAMR) and fewer prehospital deaths than those who did not

have the same access. For example, 96.4%-100% of New York’s population has access to a level

I/II trauma center (highest level of trauma centers with the highest level of care; there are 3

levels of trauma centers) within one hour and the AAMR per 100,000 people is 25.2%-41.3%.

On the contrary, only 31.7%-59.0% of Louisiana’s population has access to a level I/II trauma

center within one hour and a 60.2%-71.3% AAMR per 100,000 people (​Hashmi, Z. G., et. al

2019). Ultimately, this study revolved around the importance ​of timely access to a trauma center

in achieving the goal of “zero preventable deaths after injury.” The study concluded that

“approximately 7,600 deaths per year may be averted through improved access to definitive

care” (​Hashmi, Z. G., et. al 2019). ​The more quickly patients are transported to a trauma center,

the more likely it is that they will survive, which is why it is imperative that patients receive the

most efficient transportation possible.

Primary transfer is defined as the transport of the patient from the scene of the accident to

the hospital where they will receive definitive care​. While this method is thought to decrease

mortality rates, it comes with various risks. In the UK, one of the consequences of primary

transfer is increased transport times from the scene to a major trauma center, which puts the

patient at risk for further injury ​(​Davies, G., & Chesters, A., 2015). The other option for patient

transfer is secondary transfer. This involves initial transport to the nearest hospital for initial

treatment followed by later movement to a different hospital for more comprehensive care.
Though secondary transfer decreases transport times, it has been shown to increase mortality and

morbidity rates among patients (Gray, A. et. al 2004). This is due to a combination of factors.

For example, a patient with penetrating trauma can develop a pneumothorax, or a collapsed lung,

while being transported from one hospital to another, further worsening their condition. In

addition, moving a patient with ventilators, I.V.s, and other advanced life support (ALS)

equipment could increase the risk for equipment failure, putting the patient at more risk than they

would be if they had initially been transferred to an adequate hospital ​(​Davies, G., & Chesters,

A., 2015). It is clear that primary transfer is the safer mode of transfer for the patient, however

time is still an extremely important factor. If patients are transported via primary transport and

the transport times were dramatically decreased, patient mortality would likely decrease as well.

Penetrating trauma was the leading cause of homicides in Baltimore, Maryland in 2018.

According to the Baltimore Sun Homicides Map, there were 309 homicides in 2018. The

majority, or ​88.67% (274/309) of all homicides in Baltimore in 2018 were caused by shooting

and 5.5% (17/309) were caused by stabbing. This data presents itself as a suitable focus for the

study because penetrating trauma in particular necessitates timely transport. Penetrating

abdominal trauma affects 35% of patients admitted to urban trauma centers in the United States.

Because penetrating trauma to the abdomen is especially life-threatening due to the countless

complications that can arise, time is of the essence for these patients in particular (​Waheed A,

Burns B., 2019​). It is therefore vital to get them to definitive care as quickly and as efficiently as

possible. Even modest delays in emergency transport can be life threatening to the patient in

emergency situations (​Mell, H. K. et al., 2017​).

 Patients can be transported using two primary methods: private vehicle or EMS transport.

EMS transportation is transportation by a ground ambulance or helicopter and is intended to

provide basic or advanced prehospital life support to a patient with the aim of decreasing patient

mortality (What is EMS: A Definition. 2011). Ground EMS systems are enhanced with lights

and sirens (L&S) with the goal of decreasing the response and transport times of the ambulance.

Ground transport with L&S saves from ​1.7 to 3.6 minutes in EMS response time and ​0.7-3.8

minutes in transport time (Neulander MJ et. al. 2018). When they arrive on-scene, EMTs are

trained to provide basic life support (BLS) to a patient, such as using bag-valve-mask ventilation.

Paramedics receive more training and are able to use ALS techniques, including endotracheal

intubation and inserting IVs. The training that the first-responders receive is intended to decrease

the patient’s likelihood of death (Barbara Haas, & Avery B Nathens 2008). However, because it

takes time for a bystander to call 911, for 911 to dispatch an ambulance, and for the ambulance

to arrive on scene and provide life support, EMS transport systems are generally associated with

slower transport times.

Private transport is the transportation of a patient to definitive care by a bystander, police

officer, or another available person on the scene. A study by Dimitriades and colleagues ​showed

that among patients, whose injuries were corrected for injury severity, transported to a large,

urban, level I trauma center that while there was a 28.8% mortality rate for patients transported

by EMS transport, there was a 14.1% mortality rate for those transported via private transport.

These results suggest that private transport is ultimately safer for the patient (1996). Another

study based in Germany reflected the results of the aforementioned study, also indicating that PT

led to a slightly decreased mortality rate than EMS transport (Huber, S., et. al 2016). An
additional study focused specifically on the mortality rates of trauma victims with penetrating

trauma in urban U.S. trauma systems and found that PT leads to a lower likelihood of death

when compared with ground EMS transport. Overall, private transport has been shown to

contribute to lower mortality rates even though it lacks the basic or advanced life support

systems of EMS transport. This, therefore, provides cause to look into the reasons for the

decreased mortality rates.

In addition to the methods in which a patient can be transferred, there are different

mechanisms that can be used to transport a patient. These are commonly known as “stay and

play” and “scoop and run.” Stay and play entails providing ALS on the scene of an accident

before transporting the patient to a trauma center (Barbara Haas, & Avery B Nathens 2008 ). It is

more commonly associated with EMS transport and, although created with good intentions, it

has been shown to do more harm than good in some studies. A review of the two mechanisms by

Barbara Haas and Avery B. Nathens referenced several studies that supported the case for stay

and play, however they detected multiple inconsistencies and inaccuracies within them that made

them less reliable. In order to completely and accurately analyze ALS, the definition for ALS

must be uniform across the area that is being studied. In most studies surrounding mortality rates

with ALS, the definition of ALS varied among the different environments that were studied, thus

rendering the studies less reliable. When further studied, it was revealed that some ALS methods,

including endotracheal intubation, could cause unexpected harmful effects on patients with

traumatic brain injury, thereby increasing patient mortality (Barbara Haas, & Avery B Nathens

2008 ). Many prehospital interventions, like intubation, do not provide the patient with definitive

care and further delay the time it takes to transport that patient to a hospital or trauma center.
 Scoop and run is the mechanism by which a patient is transported from the scene of an

accident to definitive care via ambulance or a mode of private transport with BLS. Because there

is little to no on-scene resuscitation, scoop and run is more timely than stay and play. According

to Dr. Zain Hashmi, MBBS, “in the United States and in much of North America, we have done

scoop and run, and in Europe, they have primarily done stay and play.” Hashmi added that this

may be the case because the scoop and run strategy is likely more beneficial for patients with

penetrating trauma, of which there are more in the United States than in Europe. As the scoop

and run strategy is primarily used in the United States, it is also likely the main strategy used in

Baltimore in order to reduce EMS transport times.

If the patient is being transported via ambulance, there will be an inevitable span of time

in which the ambulance will be responding to the scene that adds to the time for which the

patient will not receive any care (​Mell, H. K. et. al. 2017). ​This period of time is one of the risks

associated with EMS transportation that leads to increased patient mortality. However the

likelihood of death can be reduced with bystander intervention. According to a study based in

Norway, bystanders were present on the scene of an accident in 97% of trauma cases. These

bystanders have the potential to step in and perform life-saving procedures for the patient

(Bakke, H. K. et. al. 2015). Bystander intervention depends on the type of emergency; traumatic

urban injuries were most common for bystander intervention. This can be easily applied to

GSWs and stab wounds in Baltimore, Maryland.

According to a report from Baltimore Citistat, the average EMS response time in

Baltimore, Maryland from FY2013 to FY2016 was 12.75 minutes (Baltimore FireStat Briefing

Memo). This is significantly slower than average urban and suburban response times across the
United States (7.0 and 7.7 minutes, respectively), and is just short of two minutes more than the

average rural EMS response time (14.50 minutes) (​Mell, H. K. et. al. 2017​). The shear difference

between the average urban EMS response time and the average Baltimore EMS response time

indicates that the overall EMS response and transport times in Baltimore are likely slower than

private transport times and that there are areas that can be improved within the Baltimore EMS

system.

Data Collection:

Rationale:

This method of data collection was appropriate because all other methods would not have

worked well and the information that was sought was readily available online. This data

collection method is closest to meta analysis, though the bulk of the data did not come from

studies; it came from various online resources. This data collection method was decided with the

help of an advisor because there were many available online resources that provided the data

needed. The data was compiled and transferred from online into a spreadsheet. It was then

synthesized, and conclusions were drawn from it.

The data was collected from the Baltimore Sun Homicide Map, which contained 290

homicides that resulted from penetrating trauma across Baltimore, excluding those homicides

that resulted from blunt force, asphyxiation, or unknown injuries. After compiling the

information the addresses of the homicides were entered into Google Maps and the hypothetical

transport times were observed, ensuring that the time of day in which they were observed was

consistent with the time of day in which the homicides occurred. The time it would take for the

victim to be driven from the scene to the nearest trauma center was recorded in the spreadsheet;
there were four trauma centers incorporated into the data collection: Johns Hopkins Hospital

(Level I), Johns Hopkins Bayview Medical Center (Level II), Sinai Hospital (Level II), and

Maryland Shock Trauma Center (Primary Adult Resource Center (PARC)). After the

hypothetical private transport times were collected and recorded, the hypothetical EMS transport

times were found. They were found using a type of variable, as there was no available data from

the actual EMS response and transport times from the homicides. In order to do this, the EMS

response times in Baltimore from FY2013 to FY2016 were averaged (12.75 minutes) and added

to the hypothetical private vehicle transport times. After that, the potential time ambulance lights

and sirens saves (0.7-3.8 minutes) during transport were deducted, providing the hypothetical

EMS transport times (from 911 call definitive care). The data showed that private transport times

are lower than EMS transport times in Baltimore, MD when EMS response times and L&S are

incorporated into the overall transport time. The data from the private and EMS transport times

were then averaged and condensed into a smaller, simplified data table shown below.

Data:

Hypothetical Private and EMS Transport Times for Homicides with Penetrating Trauma

in Baltimore, Maryland

District Average Private Transport Average EMS Transport

Time (min) Time (min)

Central 8.45 17.40-20.50

Eastern 6.00 15.14-18.05

Northern 11.55 20.66-23.60

Northeastern 11.63 20.58-23.68

Northwestern 7.37 16.42-19.42

Southern 10.40 19.35-22.36

Southeastern 6.10 15.98-18.15

Southwestern 10.43 19.38-22.40

Western 8.96 17.91-21.01

Analysis:

According to the data collection, private transport was ultimately more timely than EMS

transport, though that does not mean that private transport leads to improved patient outcome.

More research is needed to determine which mode of transport would yield the lowest mortality

rate. The next step in this process would be to analyze studies surrounding the urgency of

penetrating trauma and the optimal time for transport that would yield the lowest mortality rates.

The question would be, “In victims with penetrating trauma, is it more beneficial to wait a

shorter period of time until definitive care but have no prehospital care or wait a longer period of

time for prehospital and definitive care?” If that question was answered, a threshold could be

created from which 911 dispatchers could advise a person to wait for EMS or get the victim to

the nearest trauma center via private transport.

The results of the data collection were not surprising. They were especially not surprising

due to the average EMS response times in Baltimore. The average EMS response time in

Baltimore is fairly slow- 12.75 minutes from 911 call to arrival on scene- so the EMS transport

times were not expected to be faster than the private transport times, even with the benefit of

L&S. These results mean that the research question has yet to be completely answered; as

mentioned before, further research is required to fully determine what method of transportation

yields the lowest mortality rates.

 The research would have been greatly improved by obtaining the actual transport times of

those homicide victims who were successfully transported to a trauma center, however this data

was not available or does not exist. If the data were available, There would be more accurate

EMS transport times to compare with the hypothetical private transport times, thereby yielding

more reliable results. The data also does not include specifics on the actual injuries the victims

received. Because determining optimal transport times is highly dependent upon the severity of

the injury, having more clear data regarding the victim’s injury would be highly beneficial to the

research. Further studies could focus less on homicides and more on those patients with

penetrating trauma that were successfully transported to definitive care, recovered, and were

discharged from the hospital, observing which mode of transportation is more timely, but which

ones lead to lower mortality rates and improved long-term results.

Conclusion:

This data could be used to potentially form a threshold for transportation times in

Baltimore from which 911 dispatchers could advise a patient suffering from penetrating trauma

what mode of transportation to use based on their location, level of trauma, and access to a

private vehicle and competent driver. If this could be determined, mortality rates in victims of

penetrating trauma in Baltimore could be reduced. It is important to note that this threshold

would only apply to Baltimore and not to all urban areas, as EMS response times and levels and

availability of definitive care differ from city to city. It is also important to note that this data

should not stand alone; further research needs to be done in order to determine which mode of

patient transport would yield the lowest mortality rates in Baltimore, as this study focused only

on transportation times.
Conclusion:

Private transport is overall more timely than EMS transport for penetrating trauma

injuries in Baltimore, MD. Though there is a need for additional studies regarding the urgency of

penetrating trauma in patient transport, it is clear that the EMS transport system currently in

place should be improved in order to minimize transport times, thus potentially decreasing

patient mortality rates. One way in which the system can be improved is by encouraging

bystander intervention through educating the citizens of Baltimore on what to do in an

emergency. While bystander intervention may not decrease the time it takes for the patient to

receive definitive care, it has the potential to greatly reduce prehospital mortality. An additional

way in which the transport system could be improved is to create a threshold by which 911

dispatchers could determine whether or not to advise the person calling to use private transport

or to wait for EMS care based on their location in relation to nearby trauma centers.

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