An organized approach to trauma care: legacy of R Adams Cowley

The organized approach to caring for trauma patients was introduced into the civilian setting by the innovative pioneer, R Adams Cowley. His system in Maryland has the following 11 components: (1) a State Police Aviation Division that transports patients throughout the State; (2) trained paramedics at the scene of the accident as well as on the helicopter, who will stabilize the patients en route to the Shock Trauma Center; (3) one central dispatch communication center in Baltimore that coordinates information between paramedics and the Trauma Center; (4) a Shock Trauma Center with a helicopter landing zone near the building; (5) trained trauma nurses and trauma technicians to transfer the patient from the helicopter by stretcher to the resuscitation area; if there is a special complication, such as an airway problem, the anesthesiologist and or trauma surgeon may meet the helicopter on the roof as well; (6) trauma surgeons, board-certified in surgery, with a certificate of added qualification in surgical critical care, to treat the critically ill trauma patients in the resuscitation area; (7) a CT scan and portable X-ray units in the admission area that aid in the diagnosis of the injury; (8) operating rooms adjacent to the admission area for repair of trauma injuries; (9) a surgical intensive unit to care for the trauma patient; (10) a team of specialty physicians trained in a wide variety of specialties who work as a multidisciplinary unit caring for the hospitalized patient; and (11) an ambulatory outpatient unit that allows the patient to be followed in the center after discharge. Dr. R Adams Cowley incorporated each of these 11 components for an organized trauma center into Maryland. In recognition of his landmark contributions to trauma, the eight-story Shock Trauma Center was named the R Adams Cowley Shock Trauma Center. There is growing evidence that this organized system in trauma care seen in Maryland must be replicated in every state in our nation. The results of the Health Resources and Services Administration Report in 2002 show serious limitations in our nation's organized approach to emergency and trauma care. This report indicates that many Americans do not have access to well-trained pre-hospital emergency personnel. Between 10 and 15% of the US population does not have access to basic emergency medical and communication services. Moreover, the presence of key trauma system components continues to vary throughout the country, most likely because of growing economic constraints. Emergency communication systems remain fragmented, and adequate training programs and protective equipment for health personnel remains notably absent. The threat of inadequate funding for the state manifests itself in the consistent uneasiness regarding the recruitment and continued retention of trauma care providers. Federal authorities must devise national emergency medical and organized trauma programs to save the lives of injured Americans.     

A Tribute to William B. Long, Jr., and William B. Long, III: A Celebration of Their Revolutionary Contributions to Trauma Care

An emergency medical system for trauma care has been conceived in our nation in an effort to improve delivery of emergency care to the accidentally injured patient. There are an estimated 20 million disabling injuries in our nation that should be cared for in trauma centers each year. This report has been written to acknowledge Dr. William Long, Jr., as well as Dr. William B. Long, III, for their unique contributions in establishing the Maryland Statewide Trauma System. Dr. William Long, Jr., played an instrumental role in working with Dr. R Adams Cowley to verify the life-saving value of the Maryland State Police helicopter system. In addition, Dr. Long, Jr., crafted a plan with Dr. R Adams Cowley that allowed Dr. Cowley the autonomy from the University of Maryland Medical School to develop a separate and distinct trauma facility, which is recognized throughout the world. It is indeed fortuitous that Dr. William B Long, III, experienced these landmark changes in trauma care in Maryland, which provided a catalyst for his future career that included extensive training in general surgery in Edinburgh as well as training in trauma surgery with Dr R Adams Cowley. These unique experiences convinced him to expand his training into cardiothoracic surgery. During these academic adventures, he became an international authority on the mathematics of trauma scores, cardiothoracic trauma resuscitation, and the components of a Level I trauma center.These empowering experiences became a catalyst for Dr. William Long, III, to undertake the scientific and clinical studies that would allow him to develop the only American College of Surgeons Committee on Trauma (ACSCOT) Verified Level I Trauma Center in the Pacific Northwest. This report describes in considerable detail Dr. William B. Long, III,'s Trauma Center at Legacy Emanuel Trauma Center (Portland, Oregon) as well as to outline his plans to further improve trauma care in the state of Oregon so that it remains a legacy for his academic career. His dreams for having a comprehensive trauma system in the Pacific Northwest are described in detail so that it an be replicated in our nation and our world.Dr. Long became the Trauma Medical Director for Emanuel Hospital in the Fall of 1983. He began building Emanuel's trauma program by establishing an infrastructure that would support technically advanced ways of restoring life and function. His trauma center consisted of the following components: trauma registry, trauma resuscitation nurse program, direct to operating room policy with unstable trauma patients, anesthesia as part of the trauma resuscitation team, massive transfusion protocol, mobile surgical transport team, outreach to rural communities, recruitment of specialists with interest in trauma care, development of a new trauma physical facility, and the Physician Assistant educational program.     

Blunt trauma: combined anterior urethral and bladder ruptures in one patient

The combined injuries of bladder rupture and anterior urethral tear without evidence of pelvic fracture or perineal injury are described. The injuries, the result of blunt trauma, were successfully repaired surgically. This combination has not previously been noted at the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems (MIEMSS), a major regional center for blunt trauma.     

Developing Australia's first statewide trauma registry: what are the lessons?

Trauma registries, like disease registries, provide an important analysis tool to assess the management of patient care. Trauma registries are well established and relatively common in the USA and have been used to change legislation, promote trauma prevention and to evaluate trauma system effectiveness. In Australia, the first truly statewide trauma registry was established in Victoria in 2001 with an estimated capture of 1700 major trauma cases annually. The Victorian State Trauma Registry, managed by the Victorian State Trauma Outcomes Registry and Monitoring (VSTORM) group, was established in response to a ministerial review of trauma and emergency services undertaken in 1997 to advise the Victorian Government on a best practice model of trauma service provision that was responsive to the particular needs of critically ill trauma patients. This taskforce recommended the establishment of a new system of care for major trauma patients in Victoria and a statewide trauma registry to monitor this new system. The development of the Victorian state trauma registry has shown that there are certain issues that must be resolved for successful implementation of any system-wide registry. This paper describes the issues faced by VSTORM in developing, implementing and maintaining a statewide trauma registry.     

Effectiveness of implementing a trauma triage system on outcome: a prospective evaluation

A 9-month prospective study was conducted in Salt Lake County to evaluate the efficacy of a field trauma triage system using the CRAMS score. Before the triage system was implemented trauma victims were taken to the nearest appropriate hospital. Post-implementation, trauma victims with field CRAMS scores of 1 through 6 were triaged to the Level I Trauma Center. Of the 113 study patients, 53 were in the pre-implementation phase and 60 in the post-implementation phase. The study patients with CRAMS scores of 4 or less had lower mortality when cared for at the Level I Trauma Center (p = 0.013). We conclude that trauma patients who are severely injured (CRAMS less than or equal to 4) have a significantly higher rate of survival if taken to the Level I Trauma Center. The use of the CRAMS triage system appears to be an effective approach toward improving trauma care in Salt Lake County.     

Medizinische Leitungsfunktionen im deutschen Rettungsdienst

The chief emergency physician in the field and the medical director of emergency medical services (EMS) are both managerial positions in the German system of prehospital emergency medicine. The chief emergency physician in the field is the medical supervisor in the field to manage major accidents and medical mass casualties. The director of emergency medical services is the medical expert for emergency medicine in the governmental organization responsible for EMS and public healthcare. Both functions are important cornerstones of a high quality prehospital emergency system. Based on different State laws in the Federal Republic of Germany, there are no uniform requirements. This review compares and evaluates the requirements and performance profiles of these management functions between the different German State laws and describes the recommendations of the professional societies.     

Der Rettungshubschrauber im organisierten Rettungsdienst

Report about the scope and the further developments of the organized emergency service in the Federal Republic of Germany; special emphasis is laid upon the system of rescue helicopters. In the light of statistics the efficiency of the helicopter system is shown, which was developed over the last eight years and comprises at present 24 stations. It is discussed how rescue helicopters can be used in severe accidents with a great number of injured persons. In cases of disaster several helicopter stations from different regions should cooperate. Primary operations with immediate medical help on the spot and the quick, gentle transport of the seriously ill patient to a specialized hospital are of great advantage. The rescue helicopter is also gaining more and more importance for secondary transports.     

Locally applied hypothermia and microvascular muscle flap transfers.

The success rate for wound closure of grade III open tibia-fibula fractures with free muscle flaps is approximately 90%. Complications and loss of free flaps are due mainly to anastomotic problems, local anatomical considerations, or recipient vessel injuries, which prolong the ischemic time of the transferred free muscle tissue. We present the techniques used at the Shock Trauma Center of The Maryland Institute for Emergency Medical Services Systems (MIEMSS), which has allowed us a 100% success rate for the last 80 free muscle transfers performed. This surgical technique involves the use of locally applied hypothermia to decrease muscle metabolism and no-reflow phenomena. Representative cases are illustrated, which could have been failures because of increased ischemic time.     

Einsatzkonzepte in der Luft- und Bergrettung

Preclinical emergency care in Germany is becoming increasingly important. Demographic as well as structural factors influence the need for differentiation and flexibility of rescue services. Air rescue plays an important role here. In these conditions, rescue helicopters undergo an extension of their range of use, regardless of the original assignment defined for a location. The example of the intensive care helicopter at the Trauma Centre Murnau in Bavaria, Germany, demonstrates the successful implementation and adaptation of this multiuse concept.     

Air Zermatt

Zermatt, the third largest Swiss municipality, numbers just under 5500 inhabitants, but because of brisk tourism the population can swell up to 35,000 in peak seasons. Air Zermatt has been a private helicopter company for 36 years in this region of the High Alps and constitutes an important part of the emergency rescue service. Close cooperation between registered emergency medical technicians, emergency physician, and pilot on the one hand and rescue specialists of the Swiss Alpine Club on the other ensures proper care for emergency patients even in difficult terrain. Not all emergencies require surgical management: skiers, mountaineers, and hikers not infrequently also suffer medical complications such as acute coronary syndrome or metabolic decompensation. To guarantee the services of an emergency physician in the region, Air Zermatt maintains several helicopters and ambulances. The “Alpine Rescue Center by Air Zermatt” circulates information on medical and technical aspects of air rescue; moreover, its own flying school trains pilots to further safeguard the future of alpine rescue services.     

On-scene helicopter transport at night

Air medical rescue services at night are associated with an increased risk for life and health of the helicopter crew. They are not allowed in all federal states of Germany and only a few bases provide this service. The advantage of short transportation times by air cannot be achieved at night due to a flight preparation phase of at least 30 minutes until lift-off. Two case reports demonstrate that requests for helicopters at night may even lead to a transportation associated delay of treatment because of the time until the helicopter arrives on-scene. Thus emergency physicians have to know the possibilities and limitations of helicopter emergency medical services at night.     

Trauma mortality and trauma center designation: an international comparison

In order to compare trauma mortality of a designated Level I Trauma Center in the United States with a major metropolitan hospital in New Zealand, patients presenting to these institutions were reviewed. Over a 1 year period 824 patients (62 deaths) presented to the Southern New Jersey Regional Trauma Center (SNJRTC) and 602 (60 deaths) to the Resuscitation room at Auckland Hospital (AH). There were no differences between age or severity of injury in those patients dying at the two institutions but brain injury was significantly more common a cause of death at Auckland Hospital (P less than 0.001). At SNJRTC exsanguination was significantly more common (P less than 0.05) and patients were more likely to die in the admitting area (P less than 0.01). The results confirm the similarity of the trauma mortality between a major metropolitan hospital in New Zealand and a United States Level I Trauma Center dealing primarily with blunt trauma. Effectiveness of trauma care in the two locations as judged by the average Injury Severity Score of CNS and non-CNS related deaths, is comparable. This suggests that despite not being completely equipped as a Level I Trauma Center the commitment to caring for patients at the New Zealand hospital is an important factor affecting the outcome.     

Erhebliche Unterschiede bei der Ausstattung von notarzt-besetzten Rettungsmitteln

Laws regulating emergency medical systems in the federal state of Baden-Wuerttemberg call for equipment of physician-staffed ambulances that is based on current knowledge in emergency medicine. Using single issues, the grade of implementation is determined. Therefore, 127 emergency physician bases received a questionnaire regarding the equipment of the physician-staffed ambulances and helicopters, deadline June 30, 2001. 116 stations (91,3%) participated. A 12-lead ECG is available in 52,6%, out-of-hospital fibrinolysis is possible in 15 systems (12,9%). Alternatives to endotracheal intubation are carried in 53,3% (cricothyroidotomy: 83,3%). 31 bases provide capnometry or other devices for verifying correct tube placement. A mobile phone is available in 88 systems (75,9%). In conclusion, comparing equipment of physician-staffed ambulances statewide, striking differences can be found.     

Statewide tracking of crash victims' medical system utilization and outcomes

BACKGROUND: For the study year, the state of Massachusetts had the lowest fatal motor vehicle crash rate in the nation. The state was interested in exploring new approaches to save additional lives. The study goal was to determine the potential for Massachusetts's medical system to reduce fatalities through alternative utilization of existing transport methods, treatment hospital types, and victim pathways. METHODS: This was a 1-year retrospective statewide population-based study of all persons involved in a trafficway motor vehicle crash in which at least one person died within 30 days. Database linkage was used to track the pathway and outcome of every involved victim from the crash scene, including air medical and ground ambulance utilization, community or trauma center treatment, and interhospital transfers; air and trauma center (TC) scene triage levels were computed retrospectively. All crash and hospital locations were geomapped and confounding factors were included. RESULTS: Air and ground scene transports to TCs were underutilized by 7:1 and 4.5:1, respectively. No request was the major reason for air underutilization. Underutilization was associated with reduced lived-to-died ratio (L/D) by pathway of up to 10:1. Statewide, air transport to Level I trauma centers had both the highest (1.0, scene) and lowest L/Ds (0.6, interfacility). A 4.5:1 difference in L/D was associated with fulfilled versus unfulfilled air requests. By emergency medical service region, L/D varied by nearly 3:1 and utilization of scene air and TC transports by 5:1 and 4:1. Victim helicopter emergency medical services transport to a TC with an Injury Severity Score > or =19 was identified as critical and was associated with L/D differences of 3.7:1. The paradox of lower L/D for scene air transports to TCs occurring simultaneously with higher overall system L/D was observed and explained. System-based L/D differences of 1.8:1 were observed associated with increases in appropriate triage. Results that explain the "golden hour" effect are shown and discussed. CONCLUSION: Appropriate scene triage decision-making and the resulting victim pathways are associated with systemwide L/D increases of 1.8:1. On that basis, potentially 53 to 90 lives in this study (13% to 22% of the statewide total) could have been saved.     

Urban helicopter response to the scene of injury

Metropolitan Houston with a population of four million has the nation's poorest freeway system. Its two Level I trauma centers are adjacent within a centrally located freeway loop, therefore the city is ideally suited for a trauma scene helicopter transport service. During 1981 there were 577 flights to the scene of injury (blunt, 466; penetrating, 111). Flights were requested by 60 agencies (EMS, law enforcement, etc.). All flights were manned by a surgical resident and flight nurse. The flight distances ranged from 2 to 57 miles (average, 14.4). Three hundred six flights (53%) were within the city, including 59 (10.2%) within the freeway loop. In approximately one half of the flights, the initial responding EMS unit was a paramedic unit. The average time at the scene was 28 minutes. The overall mortality for trauma scene flights was 35.7% (206/577). Eighty-nine patients (15.1%) died at the scene and were not transported (initial median scene Trauma Score, 2). The mortality among transported patients was 24.0% (117/488). Twenty-nine patients died during attempted emergency-center resuscitation (initial median scene Trauma Score, 5). Eight-eight patients died after hospital admission (initial median scene Trauma Score, 10). Only 27 patients (5.5%) did not require hospitalization. Scene treatment (intubation, hyperventilation and, when appropriate, mannitol administration) was routinely initiated for patients with severe head injuries. Two hundred seventy-nine patients required cardiopulmonary resuscitation, tracheal intubation, chest-tube placement, or other invasive procedures. Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medically desirable for one half of the flights.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prehospital care of the injured: what's new

Emergency medical services (EMS) play a critical role in the trauma system as the point of initial patient care and stabilization and in determining the regional flow of patients and the commitment of resources to the critically injured. Trauma surgeons and emergency physicians need to be involved in the organizational planning of EMS systems to ensure that uniform patient care protocols are developed for triage and treatment. Ongoing efforts should focus on addressing national variability in care provided after injury to ensure optimal outcome for patients in all regions. Through additional research, the best practice and optimal EMS system design will continue to be defined.     

Impact of helicopters on trauma care and clinical results.

This report reviews the history of the development of civilian helicopter ambulance program as a component of a total emergency medical services (EMS) system. Current literature demonstrates significant reduction in trauma mortality for those patients transported by air either from the scene of the accident or from an outlying hospital to a trauma center. The primary factor is not the speed of the transport but administration of life-saving care by the helicopter medical crew at the scene of the accident or at the outlying hospital. Regulations have been developed to assure proper patient selection, quality care, safety, and minimization of misuse of this expensive resource.     

Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary?

BACKGROUND: Previous studies have suggested that patients transported by emergency medical services (EMS) following major trauma had a longer injury-to-treatment interval and a higher mortality rate than their non-EMS-transported counterparts. HYPOTHESIS: There is little actual benefit of thoracolumbar immobilization for patients with torso gunshot wounds (GSW). DESIGN: Retrospective analysis of prospectively gathered data from the Maryland Institute for Emergency Medical Service Systems State Trauma Registry from July 1, 1995, through June 30, 1998. SETTINGS: All designated trauma centers in Maryland. PATIENTS: All patients with torso GSW. MAIN OUTCOME MEASURES: (1) A patient was considered to have benefited from immobilization if he or she had less than complete neurologic deficits in the presence of an unstable vertebral column, as shown by the need for operative stabilization of the vertebral column; (2) mortality. RESULTS: There were 1000 patients with torso GSW. Among them, 141 patients (14.1%) had vertebral column and/or spinal cord injuries. Two patients (0.2%) (95% confidence interval, -0.077% to 0.48%) required operative vertebral column stabilization, while 6 others required other spinal operations for decompression and/or foreign body removal. The presence of vertebral column injury was actually associated with lower mortality (7.1% vs 14.8%, P<.02). CONCLUSIONS: This study suggests that thoracolumbar immobilization is almost never beneficial in patients with torso GSW, and that a higher mortality rate existed among those GSW patients without vertebral column injury vs those with such injuries. The role of formal thoracolumbar immobilization for patients with torso GSW should be reexamined.