Trauma Care Systems in the US
While injury has been known to be a common cause of death since statistics were first being gathered about 150 years ago, the role of injury as a leading killer of children and young adults is a more recent phenomenon. There have been decreases in the rate of death due to infectious diseases along with an increase in death due to trauma-related events, such as motor vehicle accidents. This is all due to the industrialization of today’s society.
Deaths from motor vehicle accidents increased markedly between 1910 through 1929 to peak at 30 deaths per 100,000 population in the 1930s and 1940s. This was the time in which trauma gained its current status as a major cause of death between those between the ages of 1 and 34. It became the fifth leading cause of death overall. This has resulted in trauma becoming the number one cause of years of life lost in the US today.
Most unintentional injuries are caused from motor vehicle accidents, including drivers, occupants, motorcyclists, and pedestrians. Falls, usually occurring in the elderly population, were the second leading cause of death among unintentional injuries. Poisoning-related deaths follow falls and after that, there is burns and drowning as a cause of death. Intentional injuries make up about 50,000 deaths per year with about 60 percent being from suicides and 40 percent being from homicides.
The overall mortality rate from trauma has gradually decreased in the last two decades. This is due to a decrease in the number of workers involved in dangerous occupations and to improvements in roads, motor vehicles, and building safety. There is also improved trauma treatment and injury prevention efforts. Major research studies have been done, indicating the importance of trauma as a public health issue—just as important as heart disease and cancer. This has resulted in the formation of the National Center for Injury Prevention and Control, a part of the CDC. The healthcare community has assumed a greater role in the control of injuries. This has become a collaboration of epidemiologists, surgical/medical specialists, economists, biomechanical engineers and public health practitioners.
Prevention has become a major goal in the management of automobile injuries. Motor vehicle injuries have declined to their lowest rate since the 1920s. Deaths per mile traveled have decreased to the lowest level ever recorded. This has been because of increased safety of motor vehicles, better roads, and a decrease in alcohol-related motor vehicle accidents. Some of these decreased deaths have been offset, however, by an increase in deaths from firearms, which outweigh deaths from traffic accidents in some states.
The most significant advances in the care of injured patients within the last fifty years has been in surgical advances, better imaging technology, a better understanding of basic cellular response to shock, and better anesthesiology techniques. As it relates to trauma, one of the best efforts has been in the coordination of care that spans from the occurrence of injury, notification of an accident, emergency care, critical care and rehabilitation. The establishment of better prehospital care, hospital care and rehabilitation care is also important to better survival.
History of Trauma and EMS Services
There have been technological advances in hospital trauma care as well as the organization of the delivery of trauma treatment. Some of these improvements are as follows:
- Better prehospital transport to the emergency department.
- Increased training and capabilities of prehospital care providers.
- Growth of EMS as a specialty.
- The creation of trauma surgery as a subspecialty within surgery.
- The advancement of courses such as ATLS.
- The development of trauma centers with different classifications.
- Improved regional and state legislative authority over trauma management.
One of the more significant advances is the more efficient transportation of injured patients by a better organized EMS system. There are EMS systems in just about every community in the US. More people appreciate the value of the “golden hour” in trauma management and communication between the EMS providers and the hospitals has improved. More rapid notification of a possible injury through the 911 system has improved trauma care. The use of prehospital helicopters has improved the transportation of patients living at further distances from high level trauma centers.
The system is supported by community fire departments, personnel trained at the EMT level, and paramedics. The increased training of prehospital personnel has improved the treatment of things like airway obstruction and heavy bleeding. There has been a greater understanding of where to take critically injured patients.
Physician staffing of emergency departments have changed over the years. Half a century ago, emergency rooms were minimally equipped and were often staffed by a nurse and/or an intern who would evaluate every patient before calling the patient’s physician. This standard of care has changed in all but the most remote of hospitals. There has been the advent of the specialty of emergency medicine, who staff most community hospitals as well as almost all teaching hospitals. Trauma training has increased among emergency medical specialists. There has even been an increase in training of surgeons in trauma care so that there are surgical specialties trained in trauma on call or physically at major urban hospitals and teaching hospitals.
There has been the development of hospitals especially trained to treat adults and children with trauma. There are more than 1200 adult and pediatric trauma centers in the US with more than 200 designated as level 1 trauma centers. Some states, however, have been slower than others to adopt these kinds of hospitals. Much still needs to be done in some areas of the country to improve trauma care in more rural areas and in states where much of the state is rural.
There have been many contributions to trauma care by the Committee on Trauma of the American College of Surgeons. They have been instrumental in developing trauma and trauma-related surgical specialties throughout the US. The College of Surgeons was instrumental in the development of the Advanced Trauma Life Support (ATLS) course, which has educated many surgeons, emergency medicine specialists, and prehospital caregivers.
The Committee on Trauma has also been instrumental in developing a verification process for identifying those hospitals that have the capabilities of providing trauma care, although the actual designation of trauma centers still rests with local and state healthcare authorities.
Trauma centers are just part of a larger trauma system that includes prehospital care, inter-hospital transfer, acute hospital care and rehabilitative care. Outcomes for trauma centers have been found to be consistently better than those of community hospitals. Those areas that have a complete trauma care system show an even better improvement in outcome when compared to those areas of the country that do not have these types of systems.
Military models have helped improve the status of trauma care systems in the US. Physician’s experiences in the Korean War and the Vietnam War have been invaluable when it comes to trauma care in non-military settings. While there are other trauma care protocols in other countries, the trauma care model in the US is one that emphasizes the role of the trauma surgeon as leader of the trauma team. Other parts of the trauma team have also been deemed important, including emergency doctors, orthopedists, anesthesiologists, and neurosurgeons.
Current Status of Trauma Care
The best trauma systems in the US involve the following: prevention of trauma, good prehospital care, good acute hospital care, and proper rehabilitation. Things like helmet promotion are invaluable and have increased helmet use among children over a short period of time. Seat belt promotion, pedestrian safety, decreasing drunk driving, burn prevention, and handgun storage also have improved trauma care in those areas that have begun to incorporate them as part of injury prevention.
Access to the 911 system is necessary for good prehospital care. Things like identifying the address of the caller to 911 operators have improved the rate at which ambulances have been able to get to people who have been injured. Those communities that employ EMTs as first responders also have better trauma care. The identification of the various levels of trauma centers helps EMTs better know where to transport the more critical patients.
The volume of critically-injured patients a level 1 trauma center receives directly enhances their performance. The sickest patients tend to do better when taken to a level 1 trauma center that has a high volume of trauma patients. It is suggested that, to be a level one trauma center, the center must care for at least 1200 trauma patients per year. Twenty percent of these patients should have an Injury Severity Score of at least 15 or higher. Each trauma surgeon should manage at least 35 trauma patients per year with an Injury Severity Score of more than 15. These recommendations ensure that the trauma center is capable of managing high level traumas.
Challenges and Opportunities Facing Trauma Care
Despite the above mentioned advances in science, technology, and trauma system organization, there are still serious problems facing trauma care in the US. The major cause of these problems is a lack of recognition of the importance of trauma on the population as a whole and the funding priorities of the government.
While there have been advances in the recognition of trauma as a serious problem, funding for trauma-related research studies is still far below that given for diseases like cancer and heart disease. Even after the terrorist attacks of September 11, 2001, funding for terrorism preparedness has largely ignored trauma systems and trauma centers, in spite of the fact that there is an intact and prepared network of hospitals that are skilled in providing the type of injuries seen in terrorist attacks.
Adding to the institutional difficulties is the lack of many surgeons willing to take on trauma patients. In one survey, 43 percent of all general and neurosurgeons preferred not to take care of trauma patients. Reasons cited were lack of adequate reimbursement for care and the fact that many trauma patients are uninsured. The after-hours nature of trauma care and the disruption of elective surgeries along with a perception of increased liability risk were also cited as factors why these types of surgeons didn’t want to care for trauma patients.