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Sun Apr 23 13:30:10 BST 2006

In a message dated 23-Apr-06 05:44:21 Central Daylight Time,  
Rgross at harthosp.org writes:

How  right you are - my own state of CT is the perfect example; this is
the  richest per capita state in the Union and yet we have 2 corners of
the  state that are woefully underserved from the trauma viewpoint - so
much so  that we joke abouyt driving extra-slowly so as never to get into
a wreck  there!  And then there is the city where up to just recently,
there  were 2 Level I centers just over a mile apart.  Tactical reasons?
Hell  NO - purely political.  And that is, in my mind, far "worse" than
the  tactical resourse maldistribution.  So Chuck, I guess what I am
saying  is that what I was saying yesterday is that there are
generalities that one  needs to look at - without needing to look at the
specifics in each  case.  Simple, really.  'Cauase you and I are on the
same line  here!

Take care,
Ron

Thank you...and thank you, Ken, Rick, Claudia,  Ceasar, Tim and the rest of 
the heavy trauma types on the list for  providing me with a 'post graduate 
course' in truly advanced Trauma  management.

Here's what I have come to understand over the  last 10 years of reading and 
debating on this list:

1: Trauma IS a surgical disorder...if you can't  control the bleeding, clean 
out and repair the wound, you can't save the  patient. This can come at many 
levels, from a simple cut with ground in dirt  that can be handled by an intern 
on up to a 'crash' splenectomy or epidural  hematoma that will kill the 
patient in minutes if not treated by a surgical  specialist with good hands, great 
nurses and aggressive anesthesia  support.

2: True heavy trauma IS a SMALL minority of the  patients seen in all but the 
most centralized, Trauma specialized  Centers.

3: The odds are that very few of the folks who  need care for heavy trauma 
carry anywhere near the level of insurance (even in a  state supported system) 
to pay for all of their needs as they wend their way  through the system.

4: As a result of 2 and 3, Trauma care is  woefully underfunded and can not 
support itself alone. This results in the idea  of fewer, larger 'regional' 
trauma centers rather than many smaller 'local'  ones, as there is a need for a 
large enough volume of patients to maintain the  skills of both the docs and 
the nurses involved. This also results in the  problem that there are MANY areas 
of world, even the more populous Northeast and  Southwest US coasts and some 
of the developed areas of Europe, where physical  transport times *by the best 
available method* can result in delays of up to 5  hours or more between the 
time of trauma and arrival at the full service trauma  center. Some European 
models attempt to bring that time down by providing  a surgeon and a mobile 
trauma center direct to the patient. To the best of  my knowledge, neither method 
has proven more successful at reducing mortality or  morbidity at the end of 
the patient's stay.

5. Most of the patients seen in (and thereby  financially supporting) our 
Emergency Departments are more properly given care  by generalist physicians, 
either EM or FM trained (since those two are really  the only 'generalist' 
specialties left). Despite the aura of Kelly Brackett, MD,  FACS and Joe Early, MD 
FACS, and the ideals preached at facilities such as the  Louisiana State 
University Medical Center, Shreveport, most surgeons do not want  to be involved in 
the treatment of simple splinters, runny noses or even  evolving myocardial 
infarctions.Some larger EDs are busy enough to support a  separate 'Peds' area, 
so that they can break down the patient load into "under  17" and "over 17" 
blocks, and allow for 'more specialization' of the physician  and nursing staff. 

6. (personal observation) In the smaller, more  local facilities, INCLUDING 
some purported Level II (ACS/COT standard), many of  the EM trained docs who 
learned at 'heavy trauma centers' tend to burn out at a  rate high enough to 
make one blink. I believe that this is because they feel  that their hard won 
skills are being underutilized due to the patient mix....and  not enough 
'adrenalin' surge from treating 'real' emergencies (both medical and  trauma). It's 
quite hard to keep that edge when you know that the next 20  patients you see 
probably could have waited 12 hours to see their primary care  provider in the 
am...it's even harder to handle when you realize that your ED  has become THE 
Primary Care source for a certain subset of the  population. (and that's 
speaking as a former Primary Care specialist!) 

    a: Even at these Level  II centers, it is often tough to find a surgeon 
when you need one, simply  because there can be times (especially if the Level 
II  center accepts transfers) there are more patients than on call surgeons- 
an  advantage of a larger teaching hospital where you not only have senior 
level  house staff (PGV or higher surgical residents and surgical fellows) but 
also the  attendings. 

    b: Frequently, those  same facilities suffer from a lack of (nursing) 
staffed inpatient beds as well,  tying up the ED with patients waiting to be 
admitted to the ICU, CCU or floor.  This only exacerbates the problem of moving a 
patient from a local facility to a  regional one.

7. The recognition that all physicians, mid  levels, nurses and facilities 
NEED some sort of comprehensive framework to  provide a rational basis for 
Trauma Care was first codified in the Advanced  Trauma Life Support Course as 
developed in Nebraska and later promoted by the  American College of Surgeons. This 
was later extended to a rational basis  for *all major emergency* care by the 
Minnesota Academy of Family  Physicians in cooperation with the Minnesota 
Academy of Surgeons and the large  medical centers and medical school in 
Minneapolis into the Comprehensive  Advanced Life Support course which combined *all* 
of the various 'merit  badge courses' into one overarching course that saves 
time (by only having one  set of anatomy, physiology and pharmacology classes) 
and provides the basics  (including a nice 'wet' lab) in a way to encourage 
the use of TEAMWORK (as a  matter of fact, hospitals and ambulance companies are 
encouraged to send TEAMS  of physicians, mid levels, nurses and or paramedics 
to attend the class  *together*) to improve patient care and reduce the time 
needed to recognized,  treat, stabilize and prepare to ship those patients who 
exceed the capacity  of the local facility.

All this being said, it is my considered opinion  that the College of 
Surgeons, the College of Emergency Physicians, the College  of Family Physicians 
(from where MANY of the small town EDs draw their docs),  and the Association of 
EMS Physicians (you might note that I didn't  specify ANY nationality in these) 
need to get together and figure out  a way to:

a: Describe, design and develop a more rational  system of general emergency 
care, starting from the time of first contact with  the EMS system (often 911 
here in the US and 999 elsewhere in the world) through  discharge home after 
rehabilitation.

b: Address solutions to the real world  problem of maldistribution of 
facilities, staff and specialists, including time  standards for transferring 
patients and acceptance by the receiving facility.  (probably need to get the 
Cardiologists in here to cover the problems  transferring 'hot' cardiac patients as 
well!)

c: Set standards according to modern Patient  Oriented Evidence that are 
*MINIMUMS* of expected performance, including  standards of review and quality 
improvement to insure that procedures are  properly performed at the proper time 
on the proper patients, including, but not  limited to, advanced airway 
procedures, placement of assorted tubes and drains,  acute reduction of several 
types of dislocations, etc. These items should be  viewed as life or limb saving 
solutions to assist in the proper treatment  and stabilization prior to the 
arrival of the specialist to the patient or the  patient to the specialist. Too 
often we see such standards in the EMS field as  'ceilings' not as 
'floors'...and just as often, we see outdated standards being  still held by either 
sending or receiving facilities as 'standard of care.' I  would suggest that the 
standards set by Cochrane Reviews would be a good  place to start.

d: Provide teaching solutions that are  practical, portable, persuasive, and 
cost effective to get those standards  out to the medical community in 
specific, the politicians and beaurocrats in  general, and even the population at 
large so as to develop more support for  the efforts of the providers in the 
field.

e: Personally (as in all of us teaching, not  just preaching) provide support 
for the efforts of local and regional EMS and ED  facilities to upgrade their 
standards of care to meet the new, more patient  oriented standards.

I hope that this proposal generates more light  than heat on this forum. A 
true paradigm shift is needed to promote the  improvement of EMS, Emergency Care 
and Trauma Care in the world, not just the  US.

ck

Charles S. Krin, DO  FAAFP

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a paradigm shift