title: From 9-1-1 call to death: evaluating traumatic deaths in seven regions for early recognition of high-risk patients.
abstract: BACKGROUND
  This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations.
  
  
  METHODS
  This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (<48 hours) versus late (>48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter.
  
  
  RESULTS
  During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries.
  
  
  CONCLUSIONS
  Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients.
  
  
  METHODS
  Epidemiologic study, level III.
authors.affiliation: From the Center for Policy and Research in Emergency Medicine (D.D., B.W., C.D.N.), Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Division of Emergency Medicine (N.W.), Department of Medicine, University of Washington, Seattle, Washington; Department of Emergency Medicine (N.K.), University of California at Davis, Sacramento; Department of Emergency Medicine (N.E.W.), Stanford University, Palo Alto; and Department of Emergency Medicine (R.Y.H.), University of California San Francisco, San Francisco General Hospital, San Francisco, California; Department of Emergency Medicine (J.S.H.), Denver Health Medical Center, Denver; and Department of Epidemiology (J.S.H.), Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado; and Intermountain Injury Control Research Center (N.C.M.), Department of Pediatrics, and Division of Emergency Medicine (E.D.B.), Department of Surgery, University of Utah, Salt Lake City, Utah.
authors.forename: Dylan
authors.initials: D
authors.lastname: Dean
authors.forename: Brian
authors.initials: B
authors.lastname: Wetzel
authors.forename: Nathan
authors.initials: N
authors.lastname: White
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
authors.forename: Nancy Ewen
authors.initials: NE
authors.lastname: Wang
authors.forename: Jason S
authors.initials: JS
authors.lastname: Haukoos
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
authors.forename: N Clay
authors.initials: NC
authors.lastname: Mann
authors.forename: Erik D
authors.initials: ED
authors.lastname: Barton
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D019601:Pacific States / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D015206:Southwestern United States / Q000453:epidemiology; D013060:Speech; D013997:Time Factors; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality*