LETTER TO THE EDITOR Is Field Resuscitation by Nonsurgeons Equivalent to In-hospital Resuscitation by Trauma Surgeons? To the Editor: o address unbridled health care expenditure in the United States, it is important to examine how medical care is delivered in other regions of the world, particularly where it seems to be more cost-effective. Dr Haider and associates1 offer a provocative analysis of trauma outcomes comparing the French versus US trauma systems. In France, emergency medicine physicians and anesthesiologists evaluate and resuscitate critically injured patients at the scene, and the role of the surgeon is limited to organ-specific operative procedures when indicated by further evaluation of the patient after hospital arrival. In contrast, the US trauma system is designed to rapidly transport seriously injured patients to trauma centers where trauma surgeons coordinate resuscitation and triage patients requiring operative care to the operating suite as soon as possible. Minimizing time from injury to definitive hemostasis is the overriding objective. In the systematic analysis conducted by Haider et al, the conclusion was that outcome

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was equivalent. Although a commendable effort to match patients, critical physiologic indices of injury, for example, admission base deficit, lactate, and international normalized ratio, were understandably lacking. I was fortunate to hear Dr Haider’s superb presentation of this study in Lyon at the European Association for the Surgery of Trauma and Emergency Surgery (ESTES), where it was graciously accepted by the European attendees. But before we contemplate modifying the US trauma system, we must carefully consider the inherent limitations in the study design. Given the study population described, it is clear that the overall mortality rate per capita for trauma is higher in France. A conspicuous issue of this study is the likely survival bias favoring the Lyon database because it represents hospitalized patients who survived their initial 45 minutes of trauma care at the scene. The highest rate of in-hospital mortality in US trauma centers is within the first 30 minutes, and death during this timeframe is often used to define likely unsalvageable. There were no data indicating how many patients were declared dead at the scene in Lyon. Perhaps the authors should reanalyze their data excluding those in the National Trauma Data Base who succumbed within the first 30 minutes in the hospital, or, optimally, within the first 45 minutes after first responder arrival at the scene. Furthermore, a description of the specific cause and time of death would facilitate interpreting the comparison. Gunshot wounds

are uncommon in France, and it is difficult to envision how an obligatory 45-minute delay in achieving torso hemostasis would result in equivalent outcomes. It is interesting to observe the evolution of “emergency surgery” in Europe, where there is even greater fragmentation of surgery than in the United States. In the United Kingdom, there are literally hospitals divided into upper versus lower digestive disease as well as specific facilities designated for thoracic, vascular, neurosurgical, and orthopedic care. Surgeons in Europe are not involved in surgical critical care. Although outstanding results have been achieved in elective surgery, this environment is now being questioned for its capacity to deliver optimal acute care surgery. The meeting in Lyon was the 14th annual of ESTES; we will soon hold the 75th annual meeting of the American Association of the Surgery of Trauma. Ernest E. Moore, MD Hunter B. Moore, MD Department of Surgery Denver Health Denver, CO [email protected]

REFERENCE 1. Haider AH, David JS, Zafar SN, et al. Comparative effectiveness of in-hospital trauma resuscitation at a French trauma center and matched patients treated in the United States. Ann Surg. 2013;258: 178–183.

Disclosure: All authors have seen and approved of this manuscript. No funding and no conflicts of interest. C 2015 Wolters Kluwer Health, Inc. All Copyright  rights reserved. ISSN: 0003-4932/15/26201-e0029 DOI: 10.1097/SLA.0000000000000618

Annals of Surgery r Volume 262, Number 1, July 2015

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Is Field Resuscitation by Nonsurgeons Equivalent to In-hospital Resuscitation by Trauma Surgeons?

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