On March 30, three seriously injured patients were admitted to the emergency room at The George Washington University Medical Center. They were successfully resuscitated, each underwent a surgical procedure, and today they are doing well. Press coverage of this near tragedy concentrated on its successful outcome and the personalities of its very public participants. What guaranteed a favorable conclusion was a systems approach to the care of acute trauma patients -- those patients whose lives are threatened because of serious multiple internal injuries.
Five percent of people injured in motor vehicle accidents in the United States suffer acute trauma and would benefit from the techniques that this organized approach to trauma care provides. But has this country organized the existing technology to provide this kind of critical care?
In 1966, the National Research Council published a paper that documented the woefully inadequate emergency service for accident and trauma victims in this country.
At about the same time, U.S. military physicians in the Vietnam conflict were discovering improved techniques for the treatment of trauma victims. Rapid helicopter evacuation by paramedics to hospitals with a team of medical personnel trained and equipped to care for trauma patients was achieving excellent results. The mortality rate for injured personnel arriving at the hospital was 2 percent in the Vietnam conflict compared with 8 percent in World War I.
In many respects, the problems in the management of civilian accident victims in the 1950s and 1960s were similar in kind but different in magnitude and scope from the problems encountered by the military prior to the Vietnam conflict. Untrained personnel with inadequate transportation and communication systems were taking accident victims to facilities that often were not appropriately prepared to treat the patient.
Much has changed for the better in this country since the 1960s. The 1966 NRC paper, physicians returning from Vietnam and the Emergency Medical Service Act of 1973, which provided federal funds for the development of emergency medical care and model programs in Maryland and Illinois, have all helped to improve management of trauma victims. But much remains to be done.
What constitutes a good trauma system? The process begins with the notification of the authorities of an injury and a prompt response by an ambulance team consisting of at least one trained paramedic. The training of paramedics varies, but usually includes a minimum of 200 hours of advanced life-support training. The paramedic is capable of assessing the patient's medical problems, starting intravenous line for fluid and drug administration and establishing an adequate airway and other measures designed to stabilize the patient. The paramedics then establish communication with a trauma center to seek instruction and notify the facility of the estimated time of arrival.
In response to the communication, a trauma team assembles before the arrival of the patient in the resuscitation area of the hospital. The team consists of a surgeon, an anesthesiologist, an emergency medicine physician and nurses. Ideally, these people are trained in their specialties. pExperienced senior residents are adequate, provided fully trained personnel are available within a short period of time. These personnel function as a team whose initial purpose is to stabilize the cardio-respiratory function of the patient. The efforts are governed by a written protocol agreed upon and familiar to team members. All necessary equipment is available. Once the patient is stabilized, the trauma team leader establishes priorities for definitive treatment. Subsequent care depends on the type and severity of the patient's injury and may include surgery, intensive care or long-term rehabilitation. All the specialists who participate in a patient's care should be familiar with the problems peculiar to the trauma patient.
The institution that serves as the trauma center has additional responsibilities. Conferences discussing each trauma case are standard. All personnel involved in a trauma case participate in these conferences, and the team discusses how the case was managed and how the case could have been handled better. The institution also should develop continuing education and training programs for all levels of medical care. And trauma center personnel should work with community officials to see that all components of emergency medical services are developed.
A regional trauma center is only one component of an emergency medical service system's approach to trauma victims, but it deserves special discussion. It is the practice throughout the country for ambulance services to take the injured patient to the nearest hospital. This is no longer appropriate. The reasons are compelling to accept the concept of regional trauma centers. Medical personnel interested in trauma care, trained in the management of trauma victims and organized specifically to provide that care, will produce better results than an institution that views the management of trauma victims as another of its services.
President Reagan was brought to the resuscitation area of our institution having sustained a gunshot wound to the left chest. He had a low blood pressure because he had lost about 30 percent of his blood volume. Any further blood loss within a short period of time and the president would have been in shock, which might have become irreversible. He would have "crashed." Instead, he had four intravenous lines inserted, received fluid and four units of blood, an amount equal to 50 percent of his intravascular volume, had a chest tube inserted and underwent diagnostic tests including x-rays, electrocardiograms and blood tests. He was in the resuscitative area 35 minutes; he came into the area with a blood pressure of 80 and left the area with a blood pressure of 160. More good work was done in the operative and post-operative period, but a major victory had been won. The president's vital signs were stabilized.
This incident emphasizes the importance of an aggressive, organized approach to the care of acute trauma patients and should provide the impetus for localities and institutions to review their own emergency care systems.