Trauma, are we doing it backwards?


It has been a rather busy week for me, meeting with the high council of scientific affairs, lunch with the masterminds, yet another study manuscript to edit (Maybe I should actually start charging money for that…), and a few shifts in the ED. Parenting duty this week has also had a few extra hours this week.

In all of the madness, I forgot to copy all of the trauma files I have for an ortho colleague who is interested in trauma, I also have to follow up on the trauma research project that really needs attention.

As I was copying files, and thinking about damage control surgery as it relates to trauma, I couldn’t help but observe, the original doctors of the Red Cross went out into the field, this was also the case for surgeons in the US civil war. There is even a saying by an author whose name escapes me, because I read a lot and often remember what I read and not who wrote it, but the saying is, “If you want to be a surgeon, you must follow the army.” In the 1950s the idea of the MASH was introduced into military field practice, and has evolved in modern wars to becoming the forward surgical area.

Despite this obvious and apparently effective attempt at moving surgery closer to the site of injury, civilian medicine uses the idea of the regional trauma center, in an attempt to conserve resources and bring everyone to expert care. Let’s also not pretend that there are not considerable economic implications.

In order to justify this “trauma center” idea, considerable resources are put into transporting people to the trauma center. Not only in the form of air medical transport, but also in over-triage guidelines for pre-hospital providers. Another issue is when the injured patient is transported to an “outlying” facility, presumably for stabilization, but patients who require stabilization are not usually served by the outlying facility. Sure there may be an emergency doctor there, perhaps even an intensivist, anesthesiologist, or even a surgeon staffing the ED. The ED is often woefully under equipped, and the staff not trained nor willing to provide emergent stabilization procedures, such as hemicraniectomies, temporary vascular shunts and repairs, massive transfusion, and a host of other surgical and intensive therapies. What is done is “stabilization” circa 1970s medicine by pouring crystalloid fluids into the patient, perhaps some hemostatic agents, and maybe if the patient is lucky some compression dressings, all while waiting for the transport to the trauma center. Forget endovascular repairs, fluid balance, temperature regulation, and the like.

Now there is no doubt in my mind, and probably a few others, that trauma centers are actually really good at taking care of trauma patients. By virtue of being regional, they see the most, they are staffed with experts who are passionate about trauma care. Often have the latest and greatest devices, a cadre of subspecialist experts, and all manner of post injury care and rehab. What could possibly be wrong with this?

Well, one of the things I have witnessed working and visiting a number of these fine centers around the world is that the patients delivered to them are often after a considerable delay, ineffective or harmful treatment, and in many cases past the window of cutting edge care (no pun intended to the fine folks in the UK doing field thoracotomies with great success), or they are simply not injured severely enough to actually need or benefit from the trauma center.

Now whenever I bring up that the military way is the exact opposite as the civilian way, never once does anyone question the treatments or treatment modalities. The counter arguments are things such as “Do you know how much ICU space that would take?” “We don’t have enough doctors.” “How are we going to pay for this?” “This isn’t the military.”

But when you think about it, whether it is blunt trauma or penetrating trauma, you cannot possibly stabilize a patient who is actively bleeding without physically stopping that bleeding. It has been the dream of non-surgeon medics for ages unknown to have a medicine that stops bleeding. Currently, we don’t have that, and likely never will have that. But still they try all manner of techniques to normalize numbers in patients, while ignoring the obviousness of the truth. If you want to stop a leaky pipe in your house you have to dig up that pipe and plug the hole. Bleeding humans are no different. (Unless of course we accept that we were not built with easy access panels, but given various surgical approaches, I would say that is quite debatable.)

Another thing I absolutely adore to see in the civilian trauma world (Pay no attention to the sarcasm…) is the region with multiple high level specialized trauma centers operating within miles or even blocks of each other. This of course dilutes the patient pool, and as such the experience of the staff, it doesn’t meaningfully decrease time from place of injury to treatment, and it spawns an extraordinarily expensive and unsafe practice of sending air medical ambulances all over hell and gone trying to snatch up trauma patients from the outlying areas. Greater minds than me have talked about the inefficient and expensive use of air med, I won’t get into it today.

I have seen rural EDs staffed by surgeons on numerous occasions. On every opportunity, I asked the surgeon why they did not even have tools in the ED for emergent surgery. In one of those rare instances where different doctors actually agree on something, the unanimous answers were: 1. We are not comfortable doing those types of procedures in uncontrolled patients. 2. We are afraid we will do something that will make it worse for the trauma center. And 3. We are really not paid for that.

In other words, these facilities just help increase the time and cost of getting a patient to a trauma center while simultaneously doing nothing, or ineffective/harmful things they are comfortable with. Then to make up for it, they cause the need for extraordinarily expensive air evacuation.

Perhaps the solution is to move trauma experts closer to the injury locations on a rotating basis? After all, the urban centers will not see a decrease in their need for local trauma resources. But it seems cheaper and more cost effective in the long run to put specialists closer to the rural or industrial areas to stop over triage and use of air med as a way to efficiently spend money? It also seems these experts could be equipped and comfortable performing damage control procedures and concurrent intensive therapies which would stabilize patients for transport to the dedicated centers?

Maybe by doing things “the civilian way” we are creating a system of lesser care that costs more? Since the disease of trauma primarily affects people between the ages of 2-44, (some people say 1-44 years, but I have my reasons for going with 2) who have the most productive or potential capabilities in life, the system is set up to fail on many levels, and spending some money and time to change it would be more beneficial in all respects in the long run?

Why is nobody willing to change? For their comfort or the interest of the patient?


2 thoughts on “Trauma, are we doing it backwards?

  1. Mike, I think that that’s primarily money and patient density. Sure, you could put a trauma team in Weatherford, OK or Southeastern Nowheresville Regional, but the patient density isn’t going to support it absent the occasional MCI. After the third week of the “Level-One Trauma” EMS is being in being a simple isolated fracture or a hand lac, the team’s going to get pulled back to the Mothership.

    The military model works because it’s going into an area of virtually-certain patient contacts -and- it STILL preserves the over-reliance on HEMS. If you put every COP and FOB battalion aid station on the level of a community Level-III hospital with larger ones having more capability, you wouldn’t be wrong, but we still have definite levels and orders. When my buddy’s legs were blown off, he wasn’t flown back to his patrol base’s battalion aid station, he was flown directly to Bastion (ER/OR) and then on to Germany, which is more of an ICU analogue than anything, with Walter Reed being the rehab center.

    I think the civilian model is the best possible trauma care model for most economies due to the costs involved. I hate to say it, but if people want really excellent care close to their injury site, no matter where they live, they need to either have a very involved and targeted investment in that care -or- be in the city. That’s true in Krakow, London, Beijing or Oklahoma City.

    • I wasn’t thinking of a trauma team, I was thinking of a surgeon or special training for EMs who are already there. Once you stop bleeding, you no longer need an immediate helicopter ride. ATLS is a perfect example. But it is rather a dated class without a lot of focus on skills that were perfected from 10 years of war.

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