Dear Editor,We are very happy to have received such a greatresponse since the publication of our article about trau-matic deaths in Berlin 2010 [1]. Furthermore, we expectmore controversy and scientific discussion after publicationof the second part, preventable trauma deaths (article inreview, World Journal of Surgery).In our opinion, the major finding of our first study is theunderestimation of the importance of preclinical trauma man-agement. The results of our second study will clarify that thequalityofpreclinicaltraumamanagementisoverestimated,andtherefore the significance and potential to reduce traumaticdeaths is not recognized. With the primary focus on advance-ments in critical care, one of the two ‘‘hot spots’’ of traumamanagement, the main problem, preclinical trauma manage-ment,isdisregarded[2].Inarecentstudy,werevealedtheneedfor individualized preclinical treatment of trauma patients withinvasive preclinical measures, e .g., intubation and chest tubing[3]. Therefore, we conclude that the education of paramedicsand emergency physicians, and the active contribution oftrauma surgeons to preclinical trauma management are crucialfactors for improving the quality of national trauma manage-ment, and that adding these components has the potential tosignificantly lower mortality after severe trauma. All organi-zational, structural, and management efforts (national traumanetwork, trauma registry, national interdisciplinary guideline)rely on effective preclinical trauma management. Thus, wehave to secure the preclinical treatment of trauma patients andadvocate for their needs.Referring to the letter from Brambillasca et al. [4]wetotally agree with their striving for structures and nationalprotocols necessary for a modern trauma system, but thebasis of all is an intact chain of survival. The weakest link isalways crucial, and in our study, preclinical trauma care wasthe weakest link. Therefore, we recommend advancingpreclinical trauma management further by educating para-medics and emergency physicians in the administration ofsafe and effective preclinical treatment of patients aftersevere trauma. Self-evidently there are regional or nationaldifferencesdemandingananalysisoflocaltraumasystemstoreveal their weakest link(s). To our minds, the new bimodaltemporal distribution of traumatic deaths is not only aregional phenomenon but also the logical consequence ofcontinuous advancement in the treatment and logistics oftraumapatientsrevealingthetwohotspots,orweakest links:preclinicaltraumamanagementandintensivecaremedicine.References