Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Background and objective The efficiency of intraoperative autotransfusion in scoliosis surgery is poorly known but needs to be evaluated, not least because of the large blood losses in these patients. This is a retrospective analysis of transfusion requirements of 43 such patients.

Methods Records from 43 patients were studied. During surgery, the shed blood was salvaged and washed in an autotransfusion device (AT1000 Autotransfusion Unit®) and a suspension of red cells was reinfused.

Results Fifty-eight per cent of the intraoperative blood loss was salvaged. The total blood loss during the patients' hospital stay was calculated from the haemoglobin balance; 24% of this loss was salvaged by the device. Moreover, 36 of the patients needed allogeneic blood transfusion.

Conclusion The efficiency of the autotransfusion device was relatively low in relation to the total extravasation, mainly because the postoperative blood loss is substantial.

Background and objective The main objective of this study was to assess mortality and morbidity after thoracic surgery in a medical centre, without resident chest surgeons and anaesthesiologists, and to determine specific risk factors.

Methods A prospective cohort study using a local database which includes patients’ clinical characteristics, results of preoperative investigations, surgical and anaesthesia data and all postoperative complications was undertaken. Two hundred and seventy-three consecutive patients undergoing thoracic surgery from 1992 to 1999 were studied. The referral chest medical centre was without resident thoracic surgeons or anaesthesiologists; postoperative care was led by local chest physicians according to standardized protocols and in close collaboration with university-based surgeons and anaesthesiologists.

Results The majority of patients had lung cancer (71%) and underwent resection of at least one lobe (62%). Thirty-day mortality rate was 2.2% and one or more complications occurred in 74 patients (27%). Three patients had to be transferred to a university hospital for further treatment. Univariate predictors of complications included age (> 70 years), history of smoking, body mass index, as well as the extent and duration of surgery. After multiple logistic regression analysis, smoking (current or past), prolonged surgery (>120 min) and major lung resection (pneumonectomy or bilobectomy) remained the only independent risk factors.

Conclusions Overall perioperative mortality and morbidity rates did not exceed those reported from large teaching hospitals. In selected patients, thoracic surgery can be safely performed in a specialized chest medical centre without on-site surgeons and anaesthesiologists.

The efficacy of an integrated autotransfusion regimen, including pre-donation and perioperative salvage of autologous blood, was prospectively evaluated in 2884 patients undergoing total hip (n=2016) or knee arthroplasty (n = 480), and hip revision (n = 388) with either balanced general, regional, or integrated epidural/general anaesthesia. Allogenic concentrated red blood cells were transfused in the presence of symptomatic anaemia or when haemoglobin concentration was < 6gdL−1 (10gdL−1 in patients affected by cerebrovascular or coronary artery disease) after all salvaged and pre-donated autologous blood had been transfused. A total of 278 patients (9.6%) received allogenic blood. Risk factors for allogenic blood transfusion were: preoperative haemoglobin concentration < 10gdL−1 (after autologous blood pre-donations) (Odds ratio: 8.7; 95% CI: 6.5–16.8; P=0.004), hip revision versus hip or knee arthroplasty (Odds ratio: 5.8; 95% CI: 3.9–8.5; P=0.0001) and inability in obtaining the number of predonations required by the Maximum Surgery Blood Order on Schedule (Odds ratio: 3.4; 95% CI: 2.7–4.1; P=0.0001). The incidence of perioperative complications, including wound infection and haematoma, as well as myocardial ischaemia, respiratory failure and thromboembolic complications, was higher in those patients requiring allogenic blood transfusion (29.8%) than that observed in patients receiving only autologous blood (6.6%) (P=0.0005); while the mean time duration from surgical procedure to patient discharge from the orthopaedic ward was shorter in those patients not receiving allogenic blood transfusion (12 days; 25–75th percentiles: 8–14 days) than in those patients who required perioperative transfusion with allogenic blood (15 days; 25–75th percentiles: 10–17 days) (P=0.0005). In conclusion, this prospective study highlighted the clinical relevance of applying an extensive and integrated autotransfusion regimen in order to reduce allogenic blood transfusion and associated complications in patients undergoing major joint replacement.