Intensive Care Paramedic Skills in the Management of Major Trauma – Effect on Mortality in an Informal, Two-Tiered, Decentralised State-Wide Trauma System

Background: A number of studies have attempted to determine the value of pre-hospital Advanced Life Support (ALS) interventions in trauma patients. Few of these studies provide enough detail of the scope of advanced skills performed, the education/training arrangements in which these skills have been learned, the pre-ALS educational platform training, or the organizational arrangements in which paramedics respond to enable comparison of like with like services. Combined, these factors provide a significant challenge to interpretation of the findings and the utility of extrapolating the results to other operational settings. In many published reports, survival to discharge is the outcome of interest and rarely are there analyses of the effectiveness of ALS interventions on survival benefit across the patients entire care pathway. We sought to examine whether or not the training of Intensive Care Paramedics in Queensland had resulted in improved survival, at any point in the care trajectory, for major trauma patients. Method: Retrospective linked analysis of routinely collected emergency prehospital clinical records, inpatient records and death registry data was conducted for all-age, all-cause major trauma for the four-year period 1998-2001. The key outcomes of interest were survival to hospital, survival to discharge or 30 days post discharge; and survival overall. Binomial logistic regression, controlled for GCS less than 9, age, sex and the presence or absence of co-morbidities, was employed to determine the relationship between advanced life support interventions performed by Intensive Care Paramedics and survival from major trauma. Results: Between 1998 and 2001, Intensive Care Paramedics in Queensland attended approximately one quarter (24.4%; n=5, 481) of major trauma cases (N= 22, 463). Patients experiencing a major trauma and who are attended by Intensive Care Paramedics had a statistically significant higher prehospital survival probability at all times (OR 1.16; 95%CI 1.02-1.39) but were more likely to die in hospital (OR 0.69; 95% CI 0.58-0.80). Overall mortality however, when controlled for GCS <9, age, sex and co-morbidities, was not significantly reduced by the presence of Intensive Care Paramedics (OR 1.05; 95%CI 0.95-1.16). Conclusion: The standard of advanced skill training in Queensland provides a pre-hospital survival benefit to major trauma patients in the State; however this effect is not sustained across the care continuum. We were not able to determine from this data whether this was a consequence of the resuscitation of patients who would inevitably die from catastrophic injuries or who succumbed later in their patient career as a result of end-organ damage and/or systemic infection.