***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: To determine whether the presence of a physician in the prehospital setting influences patient outcome , the predicted mortality of 258 patients with blunt trauma treated and transported by a medical helicopter staffed by a flight nurse and flight paramedic  was compared with that of 316 similar patients with blunt trauma treated and transported by a medical helicopter staffed by a flight nurse and flight physician . All patients were r and omized between the two treatment teams . The mortality of the patients treated by the flight nurse/flight paramedic team was that predicted by the methodology . The mortality of the patients treated by the flight nurse/flight physician team was 35 % lower than that predicted , and significantly lower than that of the flight nurse/flight paramedic-staffed helicopter Objective To evaluate whether the type of on-site care a trauma patient receives affects outcome . Summary Background Data The controversy regarding the prehospital care of trauma patients between Advanced Life Support ( ALS ) and Basic Life Support ( BLS )  is ongoing . Due to this unresolved controversy , as well as historical , cultural , and political factors , there are significant variations with respect to the type of prehospital care available for trauma patients . Methods This prospect i ve cohort study compared three types of prehospital trauma care systems : Montreal , where physicians provide ALS ( MD-ALS ) ; Toronto , where paramedics provide ALS ( PMD-ALS ) ; and Quebec City , where emergency medical technicians provide BLS only ( EMT-BLS ) . The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries . All patients were treated at highly specialized tertiary ( level I ) trauma hospitals . The main outcome measure was death as a result of injury . Follow-up was to hospital discharge . Results The overall mortality rates by type of on-site personnel were physicians 35 % , paramedics 24 % , and EMTs 18 % . For patients with major but survivable trauma , the overall mortality rates were physicians 32 % , paramedics 28 % , and EMTs 26 % . The overall mortality rate of patients receiving only BLS at the scene was 18 % compared to 29 % for patients receiving ALS . For the subgroup of patients with major but survivable injuries , the mortality rates were 30 % for ALS and 26 % for BLS . The adjusted increased risk for mortality in patients receiving ALS at the scene was 21 % . Conclusions In urban centers with highly specialized level I trauma centers , there is no benefit in having on-site ALS for the prehospital management of trauma patients BACKGROUND The role of prehospital basic life support as opposed to prehospital advanced life support and the best qualifications for emergency personnel are controversial . Our objective was to establish whether the prehospital deployment of emergency physicians ( EPs ) rather than emergency medical technicians ( EMTs ) decreased mortality in blunt polytrauma patients . METHODS In a prospect i ve , observational cohort study conducted between 1990 and 1996 , we used the A Severity Characterization of Trauma score to compare the actual mortality with the predicted mortality in 71 blunt polytrauma patients , 63 treated by EMTs alone and 8 treated also by anesthetic nurses .  The same comparison was conducted in 196 blunt polytrauma patients treated by EPs together with EMTs or paramedics .  Multivariate logistic regression analysis was conducted to test for any confounding factors and bias , and for the identification of factors associated with mortality . Inclusion criteria were blunt trauma at a minimum of two body sites , an Injury Severity Score of 8 or more , and direct admission to our trauma center . RESULTS The mortality in patients treated by EPs was 11.2 % ( 22 of 196 ) and was statistically not significantly lower than the 14.1 % calculated for the patients treated without EP involvement ( 10 of 71 ) . In the group treated by EPs , there were 1.3 ( 95 % confidence interval [ CI ] , -5.9 - 8.5 ) , or 6 % , fewer deaths than would have been expected on the basis of the results of the Major Trauma Outcome Study ( p = 0.734 ) . In contrast , in the group treated without EP involvement , there were 3.4 ( 95 % CI , -0.2 - 7 ) , or 34 % , more deaths than predicted ( p = 0.066 ) . This trend was confirmed by multivariate logistic regression , which showed a significant mortality odds ratio of 37 ( 95 % CI , 2 - 749 ) for the EMT group as compared with the EP group . CONCLUSION In contrast with the deployment of EPs , care of blunt polytrauma patients by EMTs showed a statistical trend to a higher mortality than predicted and also a significantly higher risk of mortality . It is likely that the consistent deployment of EPs for moderate to severe blunt polytrauma in our catchment area might prevent between 0 % and 23 % of all deaths from blunt polytrauma or , in absolute terms , up to 1 death per year or 0 to 9.9 per 100 patients treated by an EP instead of an EMT Objective . To assess whether a top-level type of prehospital care , made of helicopter , physician , and advanced life support ( ALS ) procedures , improves the outcome of blunt trauma victims found in cardiac arrest ( CA ) as compared with a simpler type , composed of ground ambulance , nurse , and exp and ed basic life support ( BLS ) . Methods . This was a cohort study from the data set of a prospect i ve , population -based , 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia . Results . Fifty-six victims received the higher level of care ( helicopter emergency medical services [ HEMS ] group ) and 73 received the lower one ( ground-BLS group ) . The two groups were homogeneous for mechanism of injury , gender , and time interval before cardiopulmonary resuscitation ( CPR ) . Age was lower in the ground-BLS group . The percentage of patients in which CPR was attempted was significantly higher in the HEMS group ( 43 % vs. 20 % ; CI 0.061 to 0.379 ) . On-scene return of spontaneous circulation ( ROSC ) was also more likely in the HEMS group ( 37.5 % of attempted CPRs vs. 6.6 % ; CI 0.027 to 0.591 ) . None of the patients evacuated from the scene without ROSC ever attained it in hospital . This policy was virtually exclusive to the ground-BLS group . Survival to hospital discharge was 3.5 % ( severely disabled ) in the HEMS group and 0 % in the ground-BLS group ( CI −0.008 to 0.078 ) . Conclusion . A top-level type of prehospital care had significantly more chances to resuscitate blunt trauma victims found in CA as compared with a simpler level . No significant benefit on long-term outcome was found , but more cases might be needed in future studies because of the inevitably low number of survivors HYPOTHESIS A pattern of prehospital care combining advanced life support , physician staffing , and helicopter transport improves the outcome of patients with severe brain injuries , compared with combined exp and ed basic life support , nurse staffing , and ground transport . DESIGN Inception cohort from the data set of a population -based , prospect i ve study on major trauma . SETTING Prehospital and hospital trauma systems of an Italian region . PATIENTS All patients with major trauma ( Injury Severity Score , > or=16 ) and severe head injury ( Abbreviated Injury Scale score for the head , > or=4 ) rescued alive from March 1 , 1998 , to February 28 , 1999 , who received either form of care . Patients with self-inflicted injuries were excluded . The 184 patients who met the entry criteria were divided equally between care groups . INTERVENTIONS None . MAIN OUTCOME MEASURES Mortality at 30 days and Glasgow Outcome Scale score of survivors . RESULTS After verifying the comparability of the cohorts , no survival or disability benefit could be demonstrated ( 95 % confidence interval [ CI ] of the odds ratio for mortality [ helicopter/ambulance ] [ 95 % CI 1 ] , 0.72 to 2.67 ; 95 % CI of the difference in Glasgow Outcome Scale score medians between helicopter and ambulance groups [ 95 % CI 2 ] , 0.0 to 0.0 ) . Similar results were derived from analyses restricted to the subgroups identified by low ( < or=90 mm Hg ) roadside systolic blood pressure ( 95 % CI 1 , 0.58 to 7.17 ; 95 % CI 2 , -1 to 2 ) and by need for urgent neurosurgical intervention ( 95 % CI 1 , 0.16 to 2.60 ; 95 % CI 2 , 0 to 2 ) . Exclusion from the ambulance group of victims rescued in urban areas did not change the results ( 95 % CI 1 , 0.80 to 3.24 ; 95 % CI 2 , 0.0 to 0.0 ) . Stratification by age , Injury Severity Score , and Glasgow Coma Scale score demonstrated a small survival benefit ( 95 % CI 1 , 1.12 to 2.12 ) in the ambulance subgroup with Glasgow Coma Scale score from 10 to 12 . Multiple logistic regression analysis confirmed that the group did not affect mortality . CONCLUSION This study was conceived to emphasize the supposed advantages of the combined helicopter , physician , and advanced life-support rescue . No increased benefit compared with the simpler rescue group could be demonstrated BACKGROUND In Europe and Switzerl and , hardly any studies have been performed on regional trauma systems . We therefore decided to conduct a prospect i ve study in our region to establish whether an organized trauma system derived from the American model would have a beneficial effect on the survival of blunt polytrauma patients . METHODS In a prospect i ve observational cohort study conducted between 1990 and 1996 , we compared the actual mortality in 280 blunt polytrauma patients admitted directly to our trauma center with the predicted mortality using the A Severity Characterization of Trauma score . The same comparison was made for 190 transferred polytrauma admissions from regional hospitals . Our hypothesis was that for the transferred admissions , the actual mortality would be significantly higher than predicted , but that there would be no difference for the directly admitted patients . Inclusion criteria were blunt trauma of at least two body sites and an Injury Severity Score of 8 or more . RESULTS Mortality in the patients admitted directly to the trauma center was 11.8 % ( 33 of 280 ) , which was not significantly lower than that for the transferred admissions at 14.2 % ( 27 of 190 ) . There were 10 % ( 3 of 30 ) more deaths than predicted among the direct admissions ( i.e. , 3 more deaths ; 95 % confidence interval , -5.2 - 11.1 ; p = NS ) . Among the transferred admissions , there were 46 % ( 8.6 of 18.4 ) more deaths than predicted ( i.e. , 8.6 more deaths ; 95 % confidence interval , 2.5 - 14.7 ; p < 0.05 ) . CONCLUSION It is likely that a regional trauma system in eastern Switzerl and for polytrauma patients with an ISS of 8 or more would have a moderately positive effect on mortality . During the period of observation , transferred admissions from regional hospitals to our trauma center had a 46 % higher mortality than predicted . In absolute terms , therefore , with a regional trauma system , it might have been possible to avoid between one death every 2 to 3 years and two to three deaths every year Background : To date , the benefit of prehospital advanced life-support programs on  trauma-related mortality and morbidity has not been established Methods : The Ontario Prehospital Advanced Life Support ( OPALS ) Major Trauma Study was a before – after systemwide controlled clinical trial conducted in 17 cities . We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase ( during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously ) . The primary outcome was survival to hospital discharge . Results : Among the 2867 patients enrolled in the basic life-support ( n = 1373 ) and advanced life-support ( n = 1494 ) phases , characteristics were similar , including mean age ( 44.8 v. 47.5 years ) , frequency of blunt injury ( 92.0 % v. 91.4 % ) , median injury severity score ( 24 v. 22 ) and percentage of patients with Glasgow Coma Scale score less than 9 ( 27.2 % v. 22.1 % ) . Survival did not differ overall ( 81.1 % among patients in the advanced life-support phase v. 81.8 % among those in the basic life-support phase ; p = 0.65 ) . Among patients with Glasgow Coma Scale score less than 9 , survival was lower among those in the advanced life-support phase ( 50.9 % v. 60.0 % ; p = 0.02 ) . The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant ( 1.2 , 95 % confidence interval 0.9–1.7 ; p = 0.16 ) . Interpretation : The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients . We also found that during the advanced life-support phase , mortality was greater among patients with Glasgow Coma Scale scores less than 9 . We believe that emergency medical services should carefully re-evaluate the indications for 
    Output:
    
Conclusion Our systematic review revealed only few controlled studies of variable quality and strength examining survival with prehospital physician treatment .
Increased survival with physician treatment was found in trauma and , based on more limited evidence , cardiac arrest .
Indications of increased survival were found in respiratory diseases and acute myocardial infa rct ion .