title: Paramedics' and pre-hospital physicians' assessments of anatomic injury in trauma patients: a cohort study.
abstract: BACKGROUND
  The pre-hospital assessment of a blunt trauma is difficult. Common triage tools are the mechanism of injury (MOI), vital signs, and anatomic injury (AI). Compared to the other tools, the clinical assessment of anatomic injury is more subjective than the others, and, hence, more dependent on the skills of the personnel.The aim of the study was to estimate whether the training and qualifications of the personnel are associated with the accuracy of prediction of anatomic injury and the completion of pre-hospital procedures indicated by local guidelines.
  
  
  METHODS
  Adult trauma patients met by a trauma team at Helsinki University Trauma Centre during a 12-month period (n = 422) were retrospectively analysed. To evaluate the accuracy of prediction of anatomic injury, clinically assessed pre-hospital injuries in six body regions were compared to injuries assessed at hospital in two patient groups, the patients treated by pre-hospital physicians (group 1, n = 230) and those treated by paramedics (group 2, n = 190).
  
  
  RESULTS
  The groups were comparable in respect to age, sex, and MOI, but the patients treated by physicians were more severely injured than those treated by paramedics [ISS median (interquartile range) 16 (6-26) vs. 6 (2-10)], thus rendering direct comparison of the groups ineligible. The positive predictive values (95% confidence interval) of assessed injury were highest in head injury [0,91 (0,84-0,95) in group 1 and 0,86 (0,77-0,92) in group 2]. The negative predictive values were highest in abdominal injury [0,85 (0,79-0,89) in group 1 and 0,90 (0,84-0,93) in group 2]. The measurements of agreement between injuries assessed pre- and in-hospitally were moderate in thoracic and extremity injuries. Substantial kappa values (95% confidence interval) were achieved in head injury, 0,67 (0,57-0,77) in group 1 and 0,63 (0,52-0,74) in group 2. The rate of performing the pre-hospital procedures as indicated by the local instructions was 95-99%, except for decompression of tension pneumothorax.
  
  
  CONCLUSIONS
  Accurate prediction of anatomic injury is challenging. No conclusive differences were seen in the ability of pre-hospital physicians and paramedics to predict anatomic injury in the respective patient populations.
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland. hetti.kirves@hus.fi
authors.forename: Hetti
authors.initials: H
authors.lastname: Kirves
authors.forename: Lauri
authors.initials: L
authors.lastname: Handolin
authors.forename: Mika
authors.initials: M
authors.lastname: Niemelä
authors.forename: Janne
authors.initials: J
authors.lastname: Pitkäniemi
authors.forename: Tarja
authors.initials: T
authors.lastname: Randell
mesh_terms: D000328:Adult; D004632:Emergency Medical Services / Q000458:organization & administration*; D004634:Emergency Medical Technicians / Q000193:education / Q000592:standards* / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000193:education; D005260:Female; D005387:Finland; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D010820:Physicians / Q000592:standards* / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014218:Triage / Q000379:methods; D000078329:Workforce; D014949:Wounds, Nonpenetrating / Q000175:diagnosis*