- Email: [email protected]
The differential survival of trauma patients
82 wishing to improve their grasp of these issues: (1) Human wants are unlimited but resources are finite. (2) Economics is as much about benefits as it is about costs. (3) The costs of health care are not restricted to the health care sector. (4) Choices in health care inescapably involve value judgments. (5) Simple rules of market operation do not apply in the case of health care. (6) Consideration of costs is not necessarily unethical. (7) Choices in health care relate to changes in the level or extent of a given activity; the relevant evaluation concerns these marginal changes, not the total activity. (8) The provision of health care is but one way of improving the health of the population. (9) We prefer to postpone costs and bring forward benefits. (10) Although equity is desirable, reduction in inequality has a price. [Robert L. Wears, MD, FACEP] Editor’s Note: A distressingly large proportion of papers in the current literature reflect serious misconceptions about health economics. An understanding of the principles outlined in this paper may protect readers from nonsense,and authors from embarrassment.
0 THE DIFFERENTIAL SURVIVAL OF TRAUMA PATIENTS. Baxt WG, Moody l? J Trauma. 1987; 27:602-606. This prospective observational study was designed to determine if major blunt trauma victims without severe brain injury (as defined by a Glasgow Coma Score of 29) treated in an organized trauma care system have significantly lower mortality. A total of 545 patients treated and transported by a helicopter emergency care serviceand admitted to the trauma servicewere studied over a period of 5 years. A total of 104 patients suffered severe brain injury; the mortality in this group was 30.8% The mortality rate in the non-brain-injured group was 0.9%. After adjusting for the effect of brain injury on trauma and injury severity scores, the brain-injured patients had a slightly greater predicted probability of survival than did the non-brain-injured, indicating that the observed increase in mortality was not due to the presence of more severe extracranial injuries. There appears to be a marked difference in mortality between patients who have sustained major blunt trauma with and without brain injury. These results could have important implications in developing triage criteria and patient care priorities. [Robert L. Wears, MD, FACEP] Editor’s Note: An interesting incidental finding in this paper was that the average Trauma Score of the non-braininjured patients transported by helicopter to a level 1 trauma center was 14.8.
Cl THE IMPACT OF A PHYSICIAN AS PART OF THE AEROMEDICAL PREHOSPITAL TEAM IN PATIENTS WITH BLUNT TRAUMA. Baxt WG, Moody P. JAMA. 1987; 257:3246-3250. To determine whether the presence of a physician in the prehospital setting influences patient outcome, the predict-
The Journal
of Emergency
Medune
ed mortality of 258 patients with blunt trauma treated and transported by a helicopter staffed by a flight nurse and flight paramedic was compared with that of 316 similar patients transported by a helicopter staffed with a flight nurse and flight physician. The mortality in each group was compared with mortality predicted by the TRISS methodology. There was no significant difference between observed and expected deaths in the nurse/paramedic group, but there was a significant decrease in mortality (5.3% to 3.5%) in the physician group. Analysis of these casesrevealed that the difference was attributable to increased survival of patients whose predicted survival was less than 50%. [Robert L. Wears, MD, FACEP] Editor’s Note: Although this study was not truly randomized, it does raise important questions. Only one patient in 56 benefited from the presence of a physician. Should a physician go on every flight, or just on the 6% to 7% with patients who have lessthan 50% predicted surv,ival? Many are currently questioning the effectiveness of field advanced life support measures in trauma patients. Could this be an indication that more on-scene physician involvement in prehospital care is needed, and not just in the glamourous helicopter runs, either?
0 PATIENTS’ AND PHYSICIANS’ ATTITUDES REGARDING THE PHYSICIAN’S PROFESSIONAL APPEARANCE. Gjerdingen DK, Simpson DE, Titus SL. Arch Intern Med. 1987; 147:1209-1212. Physicians’ appearance has been a topic of interest for more than two centuries; however, little objective work has been done on patients’ or physicians’ attitudes toward dress. A total of 404 patients, residents, and attending staff physicians in the north central United States were surveyed regarding their reaction to a variety of items of appearance for male and female physicians. Results were scored simply as desirable, neutral, or undesirable. For all participants, positive responses were associated with traditional items, such as shirt and tie, white coat, dress or skirt and blouse, and name tags. Negative responses were associated with casual items such as blue jeans, scrub suits, athletic shoes, or clogs. Overly feminine items such as prominent ruffles or dangling earrings, and faddish items such as long hair or earrings for men were also rated negatively. Demographic analysis revealed the response to be relatively uniform regardless of age, income, or educational status. Patients were generally more tolerant in their attitude toward physician appearance than were physicians. [Robert L. Wears, MD, FACEP] Editor’s Note: These results need to be interpreted cautiously, since a person’s response to an isolated item on a questionnaire might not accurately reflect his response to the physician in the flesh. Unfortunately for many emergency physicians, scrub suits ranked near the bottom of the list.
0 THE DIFFERENTIAL SURVIVAL OF TRAUMA PATIENTS. Baxt WG, Moody l? J Trauma. 1987; 27:602-606. This prospective observational study was designed to determine if major blunt trauma victims without severe brain injury (as defined by a Glasgow Coma Score of 29) treated in an organized trauma care system have significantly lower mortality. A total of 545 patients treated and transported by a helicopter emergency care serviceand admitted to the trauma servicewere studied over a period of 5 years. A total of 104 patients suffered severe brain injury; the mortality in this group was 30.8% The mortality rate in the non-brain-injured group was 0.9%. After adjusting for the effect of brain injury on trauma and injury severity scores, the brain-injured patients had a slightly greater predicted probability of survival than did the non-brain-injured, indicating that the observed increase in mortality was not due to the presence of more severe extracranial injuries. There appears to be a marked difference in mortality between patients who have sustained major blunt trauma with and without brain injury. These results could have important implications in developing triage criteria and patient care priorities. [Robert L. Wears, MD, FACEP] Editor’s Note: An interesting incidental finding in this paper was that the average Trauma Score of the non-braininjured patients transported by helicopter to a level 1 trauma center was 14.8.
Cl THE IMPACT OF A PHYSICIAN AS PART OF THE AEROMEDICAL PREHOSPITAL TEAM IN PATIENTS WITH BLUNT TRAUMA. Baxt WG, Moody P. JAMA. 1987; 257:3246-3250. To determine whether the presence of a physician in the prehospital setting influences patient outcome, the predict-
The Journal
of Emergency
Medune
ed mortality of 258 patients with blunt trauma treated and transported by a helicopter staffed by a flight nurse and flight paramedic was compared with that of 316 similar patients transported by a helicopter staffed with a flight nurse and flight physician. The mortality in each group was compared with mortality predicted by the TRISS methodology. There was no significant difference between observed and expected deaths in the nurse/paramedic group, but there was a significant decrease in mortality (5.3% to 3.5%) in the physician group. Analysis of these casesrevealed that the difference was attributable to increased survival of patients whose predicted survival was less than 50%. [Robert L. Wears, MD, FACEP] Editor’s Note: Although this study was not truly randomized, it does raise important questions. Only one patient in 56 benefited from the presence of a physician. Should a physician go on every flight, or just on the 6% to 7% with patients who have lessthan 50% predicted surv,ival? Many are currently questioning the effectiveness of field advanced life support measures in trauma patients. Could this be an indication that more on-scene physician involvement in prehospital care is needed, and not just in the glamourous helicopter runs, either?
0 PATIENTS’ AND PHYSICIANS’ ATTITUDES REGARDING THE PHYSICIAN’S PROFESSIONAL APPEARANCE. Gjerdingen DK, Simpson DE, Titus SL. Arch Intern Med. 1987; 147:1209-1212. Physicians’ appearance has been a topic of interest for more than two centuries; however, little objective work has been done on patients’ or physicians’ attitudes toward dress. A total of 404 patients, residents, and attending staff physicians in the north central United States were surveyed regarding their reaction to a variety of items of appearance for male and female physicians. Results were scored simply as desirable, neutral, or undesirable. For all participants, positive responses were associated with traditional items, such as shirt and tie, white coat, dress or skirt and blouse, and name tags. Negative responses were associated with casual items such as blue jeans, scrub suits, athletic shoes, or clogs. Overly feminine items such as prominent ruffles or dangling earrings, and faddish items such as long hair or earrings for men were also rated negatively. Demographic analysis revealed the response to be relatively uniform regardless of age, income, or educational status. Patients were generally more tolerant in their attitude toward physician appearance than were physicians. [Robert L. Wears, MD, FACEP] Editor’s Note: These results need to be interpreted cautiously, since a person’s response to an isolated item on a questionnaire might not accurately reflect his response to the physician in the flesh. Unfortunately for many emergency physicians, scrub suits ranked near the bottom of the list.