Dear Editor,
We thank the reader for taking the time to submit this letter to the editor in response to our submission, “Characterizing emergency department surgical airway placement in the setting of trauma” [1]. In this letter they lay out several comments and feedback that we would be happy to address regarding the data on the application of emergency surgical airway (ESA) in the setting of trauma.
Their feedback focuses on the details regarding the airway attempts that are not fully detailed within our manuscript. The data from which this study was derived was obtained from the Trauma Quality Improvement Program data registry. This database comes from the American College of Surgeons and is required for all verified level 1 trauma centers and optional, though strongly encouraged, but other verified trauma centers. The purpose of the database is to provide performance improvement feedback to participating centers and standardize trauma care. The performance metrics, such as the development of venous thromboembolic events, are captured within the database, but unfortunately there are no metrics that focus on airway interventions [2]. As such, we must rely on diagnostic and procedural codes which confer limited details regarding the interventions, such as devices used, attempts, and complications. Thus, this database provides large volumes of data which supports data mining but lacks granularity. Other datasets that focus on the details of airway management are better utilized for more granular analyses, though they offer comparatively low volumes of rare events, such as emergency surgical airway access [3,4]. Moreover, vital signs are limited to arrival vital signs without further details on trends in vital signs to assess. Perhaps, this highlights the need for emergency medicine-focused performance improvement databases that can improve and standardize care across the specialty.
The readers also raise questions regarding the presentation of the data. In the tables, we do present associated 95 % confidence intervals, though no t-test was applied. It is our standard practice to assess the continuous variables for normal versus skewed distribution, and where applicable, we will apply the t-test for normally distributed variables. In this case, due to the skewing, we opted to apply the more conservative Wilcoxon rank sum test. The footer of the table should have better reflected this.
Lastly, data on time to extubation is not captured. While data such as ventilator length of stay is provided, this does not account for more granular details such as extubation attempts, re-intubations, and conversion to tracheostomy with possible decannulation. Thus, without such details, we felt that presenting that variable carried excessive confounding. To that end, we can share that the total hospital length of stay among survivors was 13 days (interquartile range [IQR] 5–23) among ESA recipients compared to 9 days (IQR 3–19, p < 0.001) among intubation-only recipients.
Again, we thank the reader for taking the time to submit this letter to the editor. The feedback we have received has highlighted the importance of advanced of airway science in the setting of trauma.
Footnotes
IRB approval
Only de-identified data was obtained and therefore our study met criteria for research not involving human subjects and therefore IRB approval was not required.
Disclaimer
The views and information presented are those of the authors and do not reflect the official position of the US Army Medical Center of Excellence, the US Army Training and Doctrine Command, or the Departments of the Army, Departments of Defense, or the US Government.
CRediT authorship contribution statement
Steven G. Schauer: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft. Amy R. Krepps: Methodology, Writing – review & editing. Julie M. Winkle: Methodology, Writing – review & editing. Franklin L. Wright: Methodology, Writing – review & editing. Andrew D. Fisher: Methodology, Writing – review & editing. Michael D. April: Methodology, Writing – review & editing. David J. Douin: Methodology, Writing – review & editing.
Declaration of competing interest
DJD has received funding from the National Institute of Health and the Department of Defense. JMW has received honorariums from the Society of Critical Care Medicine for committee duties. DJD, FLW, MDA, and SGS have all received funding from the Department of Defense.
Contributor Information
Steven G. Schauer, Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO, USA.
Amy R. Krepps, Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA.
Julie M. Winkle, Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
Franklin L. Wright, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
Andrew D. Fisher, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA.
Michael D. April, 14th Field Hospital, Fort Stewart, GA, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
David J. Douin, Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA.
References
- [1].Krepps AR, Douin DJ, Winkle JM, et al. Characterizing emergency department surgical airway placement in the setting of trauma. Am J Emerg Med. Aug 24 2024;85:48–51. 10.1016/j.ajem.2024.08.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
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