Anna Shaw
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
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
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
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
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
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
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
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
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
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
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
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 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
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
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
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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