Police Transport for Penetrating Trauma—Lessons From Patients in Philadelphia

The so-called golden hour in trauma care remains a standard thesis in that the best mortality outcome is obtained with the shortest time from injury to definitive hemorrhage and damage control. This premise has prompted many adjuncts to trauma care, ranging from the Stop the Bleed campaign¹ to the widespread proliferation of resuscitative endovascular balloon occlusion of the aorta technique. The challenge in prehospital care has always been the balance between minimizing field time and rapid transport to definitive care, specifically to the operating room to stop bleeding and contamination, and scene care encompassing advanced life support skills of intravenous access, external tamponade, and in some systems, definitive airway management.^2-4

This study by Winter et al⁵ using the Pennsylvania Trauma Outcomes Study registry analyzed the association of transport by traditional emergency medical services (EMS) vs law enforcement for adult patients who had sustained penetrating trauma in Philadelphia, Pennsylvania. The premise was that direct transport by police was likely to bring the patient to the hospital, and hopefully to definitive care, more quickly than EMS. Like the data that have been previously published on this topic, such as a 2016 study by Wandling et al,⁶ Winter et al⁵ found that there was no overall advantage to EMS transportation, but also no improvement in 24-hour mortality in patients transported by police. In subset analysis of patients with severe injuries (Injury Severity Score, >25), patients were less likely to be dead on arrival if they were transported by the police, but no difference in outcome at 24 hours was observed.

There are very few studies examining this issue, likely owing in large part to the fact that there are very few police departments with policies in place that support this practice. Philadelphia is a nearly unique exception, in that during the course of the study by Winter et al,⁵ police transport increased from 328 patients in 2014 to 489 patients in 2018, while the number of patients transported by EMS remained relatively stable. It is important to note that in the unmatched analysis, patients transported by the police had higher mortality in all subgroups. And while the matching technique used by the authors was statistically sound, the issue of equipoise and unmeasured differences in the 2 groups remains. It seems clear that patients transported by the police were more severely injured and physiologically distressed.

Similar to previous work in this area, several critical data points were not available for analysis. One such data point was the time from injury to police or EMS arrival, which is nearly impossible to collect. Also, the time from police or EMS arrival to hospital arrival was missing, but these data should be included in the dispatch and scene time logs of the EMS. Granular data on life-saving interventions performed at the scene or during transport were also not included in the analysis. Additionally, for patients who died, potential interventions that were not performed but may have been associated with better outcomes were also not available. Matching was used in an attempt to neutralize confounders, but with so many potential variables that went into decisions made by police to transport rather than wait for EMS, capturing and accounting for these differences was simply not possible using registry data.

Despite these limitations, the question being addressed by the study by Winter et al⁵ is a critically important area of research with important ramifications for the future role of policing. There are tangible barriers to the widespread implementation of law enforcement–based transportation of patients. Ongoing budget cuts across the country could make expansion of the scope of practice for law enforcement a struggle, when many departments are having difficulty just coping with the standard law enforcement needs within their jurisdictions.⁷ There are liability concerns, training and equipment needs, and even practical hurdles, such as the hard molded plastic rear passenger compartments of the ubiquitous Explorer Police Interceptor vehicles (Ford Motor Company) that make transporting a patient safely in anything but an upright belted position impossible. A clear, evidence-based outcome benefit will be required before universal acceptance of this practice. The optimal patient population that should be transported by the police, what magnitude of delay until EMS arrives is acceptable to wait, and what, if any, life-saving interventions should be implemented during transport all need to be delineated.

Further study is warranted. For patients who are critically ill or injured and for whom minutes count, having a policy that allows a law enforcement officer who is already at the scene to extract a patient directly from the hot zone where EMS cannot safely enter and to initiate transportation immediately, decreasing the time to definitive trauma care, may save both officer and civilian lives.

Published: January 25, 2021. doi:10.1001/jamanetworkopen.2020.35122

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Inaba K et al. JAMA Network Open.

Corresponding Author: Gregory J. Jurkovich, MD, Department of Surgery, UC Davis Health, Sacramento, CA 95817 (gjjurkovich@ucdavis.edu).

Conflict of Interest Disclosures: None reported.