Re: The role of timely emergency care for hypotensive trauma patients—the three Rs

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In Reply:
We agree with Chidambaram and Goh1 regarding general limitations of any retrospective cohort study, and that includes our recent study.2 Indeed, even though we dedicated almost one fifth of the discussion to underscore these and every other limitation we could think of, perhaps we should have said more. Nevertheless, it is unlikely that we, or anyone else, will ever definitively resolve such issues in a controlled clinical trial because it would be unethical to randomize hypotensive patients with torso gunshot wounds to urgent or delayed surgery.
We respectfully disagree with Chidambaram and Goh's assertion that our study adds no new insights to trauma care. The time to definitive surgery for patients in extremis is not established. Within the context of the limitations outlined in the manuscript, we are confident in our conclusion that a greater than 10-minute time to the operating room (OR) increases the risk of mortality almost threefold in hypotensive patients with gunshot wound and that protocols should be designed to shorten time in the emergency department.
Unfortunately, we apparently did not effectively communicate this message to at least some readers because Chidambaram and Goh stated that “we have chosen an arbitrary duration of 10 minutes to the OR as the cut-off with no justification for this value.” In fact, the 10-minute mark was by no means arbitrary—it was derived directly from the actual time to OR in 309 patients. Patients who arrived to the OR in <10 minutes had 20% overall mortality. After 10 minutes, overall mortality peaked at 45%. Cumulative mortality was also plotted as a function of time to OR, and survival analysis was performed using multivariate Cox regression models to investigate the effect in patients with hypotension or injuries of the lungs, liver, and abdominal vascular structures.
Chidambaram and Goh stated that our strategy is not possible in their emergency department with the current constraint of resources at their center. We feel that the approach of expediting the time to operation utilizes less resources than the usual approach. We have coined a variation on the phrase describing the “basics,” “reading, 'riting, and 'rithemetic.” It is simply “red top (type and cross), 'rist band (can't do anything without the identifier), and run!” Time spent on radiographs, urinary catheters, and laboratory studies is time stolen from stopping the bleeding.
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