To the Editor, We read with great interest the article by Kleber et al. [1] about trauma management and trauma-related deaths. We agree with the authors about the necessity to re-evaluate and improve trauma care policies. However, the shifting of traumatic death distribution (trito bi-modal, as suggested) should be, in our opinion, considered to be a regional phenomenon. Not all trauma-care systems are equal, and not all countries have reached the same high level of implementation in trauma care. The first goal of trauma care is the regionalization of the patients. This leads to improved outcomes and optimization of resources [2]. However, not all European countries are organized into national trauma systems. The diversity in organization determines differences in the timing of assistance to patients. This could have a strong impact on mortality. Several regions in southern Europe still have quite old hospital buildings. The delivery of care in old buildings may make management of the internal organization difficult, leading to crucial delays in delivery of key clinical services, such as blood distribution, biochemistry, and radiology. Sometimes trauma patients in these institutions may have need to short intrahospital ambulance transfers and this may be cause of definitive treatment delays and developing of hypothermia. The Italian experience is a clear demonstration of the difficulty in organizing resources to optimize trauma care. Even in a developed country, few regions are making a concerted effort to start a national trauma system. EmiliaRomagna and Lombardy are among the most advanced regions in Italy in trauma management. The authors’ three centers, Bologna, Bergamo, and Parma, treat an average of 600, 200, and 100 trauma patients per year, respectively, while the general population in these areas is 2,950,000. Even with good experience in managing trauma patients, we don’t agree with the statement of the authors. The second critical period of trauma management, the time from the hospital admission to entry into the intensive care unit (ICU), remains crucial. On the one hand, a failure in centralization of patients, and on the other hand the absence of definitive national protocols for treating them, allow each individual center to decide arbitrarily the best treatment strategy. This policy—or lack of policy—ultimately leads to waste and to poorer outcomes in terms of morbidity and mortality, because the quality of trauma management is aleatory. Moreover, the heterogeneous formation of the personnel involved in the care of traumatized patients also has a negative effect on outcomes [3]. Our German colleagues have clearly demonstrated the necessity to elaborate national protocols and guidelines. Such national systems might lead to a European common formative program for surgeons and trauma teams that P. Brambillasca (&) Department of Anesthesiology & Critical Care, USC1, Ospedali Riuniti, Largo Barozzi 1, 24128 Bergamo, Italy e-mail: pbrambillasca@ospedaliriuniti.bergamo.it