This talk at the 2012 Essentials of Emergency Medicine Conference was to make a point: the philosophy of ‘Scoop & Run’ is based on dogma rather than science, which I challenge with some examples from the literature and from actual cases.
While for the sake of argument I opposed Scoop & Run, my take home point was that ‘Stay & Play’ can be equally pointless: the right balance depends on the case, and one approach is not applicable to all of prehospital care.
Here are the main points and references from the talk:
Scoop & Run is for A-Holes
What’s Scoop & Run?
The dogma of ‘Scoop & Run’ – prioritizing the rapid transport of a trauma patient to hospital over providing on scene resuscitation – needs to be challenged.
What’s an A-Hole? Google can help with this one
Why do some people, including some A-holes, fervently believe in Scoop & Run?
They believe in and perpetuate the following misconceptions:
(1) Trauma is a ‘surgical disease’ – and therefore trauma patients’ lives can only be saved in hospital by teams that include surgeons
Nonsense! At one American major trauma centre for example, emergency operation by a trauma surgeon for blunt trauma averages once every 7 weeks for adults and less than once every 3 years for children (1)
(2) Advanced medical intervention at the scene slows things down
Poppycock! Giving the right care early does not delay definitive care (2,3). In fact it has been shown to speed it up (4)
(3) Advanced medical intervention at the scene (like RSI) causes harm
Drivel! Only when it’s badly done (5,6), not when the right training and QA is in place (7)
This becomes self-fulfilling – if you don’t train people properly it’s bad; with proper supervision and governance, it’s good.
(4) Decreasing scene times save lives
Bollocks! The data do NOT support this assertion! (8,9)
What do patients die from?
All kinds of things, but often a combination of insults. The earlier these are minimized with good resuscitation, the better. The ‘trimodal distribution of trauma death’ model is outdated; most deaths occur in the first hour, often from treatable injury (10). This hour in many systems is a prehospital event!
When else shouldn’t you Scoop & Run?
When you can’t… the trapped patient!
When you fix the surgical problem: 13 of 71 (18%) patients undergoing prehospital thoracotomy in London survived to discharge (11)
What’s the right answer? Scoop and run or stay and play?
Only an A-hole falsely dichotomises life into two absolute choices. Some patients with life-threatening non-compressible hemorrhage clearly DO need emergent surgical rescue. Most trauma patients do NOT fit this description. Scene time should be minimized, and on scene care limited to what is needed, but only a A-hole with no medical skill or knowledge would try to ‘scoop and run’ with patients who could benefit from on scene resuscitation.
References
1. Steele R, Green SM, Gill M, et al. Clinical decision rules for secondary trauma triage: predictors of emergency operative management.
Ann Emerg Med. 2006 Feb;47(2):135
2. TP D Dissmann and S Le Clerc. The experience of Teesside helicopter emergency services: doctors do not prolong prehospital on‐scene times
Emerg Med J. 2007 January; 24(1): 59–62
3. Spaite DW, Tse DJ, Valenzuela TD, et al. The impact of injury severity and prehospital procedures on scene time in victims of major trauma.
Ann Emerg Med. 1991 Dec;20(12):1299-30
4. Henderson KI, Coats TJ, Hassan TB, et al. Audit of time to emergency trauma laparotomy. Br J Surg. 2000 Apr;87(4):472-6
Despite having longer scene times with a physician based system, ED times were significantly shortened and time from injury to laparotomy was significantly decreased.
5. Davis DP, Stern J, Ochs M, Sise MJ, Hoyt DB. A follow-up analysis of factors associated with head-injury mortality following paramedic rapid sequence intubation. J Trauma 2005;59:486—90
6. Gausche M, Lewis RJ, Stratton SJ, Haynes BF, Gunter CS, Goodrich, SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90
7.Bernard, S. A., Nguyen, V., Cameron, P., Masci, K., Fitzgerald, M., Cooper, D. J., Walker, T., et al. (2010). Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury. Annals of Surgery, 252(6), 959–965
8. Newgard CD, Schmicker RH, Hedges JR, et alEmergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort.
Ann Emerg Med. 2010 Mar;55(3):235-246. Full text here
9. Petri RW, Dyer A, Lumpkin J. The effect of prehospital transport time on the mortality from traumatic injury
Prehosp Disaster Med. 1995 Jan-Mar;10(1):24-9
10. Demetriades, D., Kimbrell, B., Salim, A., Velmahos, G., Rhee, P., Preston, C., Gruzinski, G., et al. (2005). Trauma Deaths in a Mature Urban Trauma System: Is “Trimodal” Distribution a Valid Concept? Journal of the American College of Surgeons, 201(3), 343–348
11. Davies, G. E., & Lockey, D. J. (2011). Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results. The Journal of Trauma: Injury, Infection, and Critical Care, 70(5), E75–E78