Elsevier

The Lancet

Volume 363, Issue 9423, 29 May 2004, Pages 1794-1801
The Lancet

Series
Development of trauma systems and effect on outcomes after injury

https://doi.org/10.1016/S0140-6736(04)16307-1Get rights and content

Summary

The ideal system for management of trauma remains controversial, especially in respect of prehospital care and regionalisation of trauma-care delivery. To explore these issues, we compare two differing trauma systems—in the USA the focus is on the trauma centre, with a lesser emphasis on prehospital care, whereas in France there is more emphasis on prehospital care coordinated by the Service d'Aide Médicale Urgente. We describe the historical developments, current structure, and major controversies with regard to trauma-care delivery in the two countries. Comparative evidence on the effectiveness of the two systems was obtained through a structured review of databases, but very little evidence permits direct comparison of outcomes across the two systems. Crude injury mortality rates and fatality rates from motor-vehicle accidents (crashes in US usage) are higher in France than in the USA, although adjustment for potential confounders is difficult. Adjusted mortality rates suggest equivalent outcomes among patients who survive to hospital, although these data are confounded by the lack of a contemporaneous comparator population. There are differences in the American and French trauma systems that might translate into measurable differences in trauma-related mortality. However, the lack of data to allow comparison of outcomes between countries significantly impedes the identification and implementation of components of a trauma system that are effective and the discarding of those that offer little benefit.

Section snippets

History

The American experience during the war in Korea laid the earliest foundation for the current system of trauma care in the USA. Evacuation of the wounded along the traditional chain from the front lines to surgical care, as had been possible during the world wars of 1914–18 and 1939–45, was made difficult by challenging terrain.2 A further difference was the availability of helicopters, which were used to move the wounded rapidly from combat zones to mobile army surgical hospitals. Additional

History

Until World War II, the French and American experience of trauma care was derived from combat. The concept of haemorrhagic shock was described in the 19th century, with the observation that the longer the delay between the wounding of a soldier and his receiving definitive surgical care to stop bleeding, the greater his chances of dying. The importance of blood loss in the evolution of shock was not recognised until later. The convergence of these two notions—to limit blood loss rapidly while

Can we compare outcomes between countries?

The ambivalence towards advanced prehospital care in the USA contrasts strikingly with the emphasis on the value of physician-directed prehospital care in France. These two countries represent diametrically opposing views of the importance of prehospital care to the outcome for the patient. The extent of regionalisation of trauma care also differs, with the French only recently deciding not to increase the number of centres devoted to trauma care.

To compare outcomes between different systems of

Conclusion

The delivery of effective trauma care requires a complex system needing trained practitioners with specific expertise and skills, availability of diagnostic and therapeutic resources, and readily available specialty care. The trauma system of a given region or country represents a local solution to a complex organisational problem involving coordination of resources and services provided by many players, and is largely dependent on tradition rather than outcome-driven data. In the absence of

Search strategy

Our intention was to compare the effectiveness of the two systems; however, we found that a valid comparison of effectiveness was not possible with existing data. A thorough search of the MEDLINE database (January, 1966, to December, 2003) for reports with the medical subject headings or keywords “American,” “French”, “United States”, “France”, “trauma”, “wounds and injuries”, in various combinations and in concert with a manual search of references cited in published original and review

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