Many people believe that if they were injured their local hospital could provide all the care they need.  Given the dire nature of some injuries, this is not the case.  Over the last several decades, steps have been taken to assure that patients, especially those with critical or multiple injuries, seamlessly receive the proper care, in the proper locations, with proper interventions, and if necessary, transfer to a hospital able to provide the best and most appropriate care.  There are four major components to this system:  Pre-hospital care, Acute Care Facility care, Post-Hospital care, and Injury Prevention Education.  This is best illustrated by the following story: 

A 16 year old male was involved in a car crash at 50 miles an hour.  He struck a tree, but unfortunately, was not wearing a seatbelt.  His chest struck the steering wheel and he blacked out.  Witnesses immediately called 911.  Welcome to the Trauma System.  The ambulance personnel arrived within 15 minutes, and gently and carefully extracted this young man from his car.  They took great pains to protect his neck and back, and place IV lines to give fluids.  Because he was in a rural location, they took him to the closest hospital.  On the way, they called ahead, so the emergency department could be ready for his arrival. 

Prehospital Component:  911, Emergency ambulance crews, and education

Upon arrival at the local hospital, the emergency room doctor quickly examined the patient, performed some key tests, and two life-saving maneuvers: a breathing tube and a tube into his chest cavity for a collapsed lung.  After evaluation the emergency physician identifies several things:  The large vessel coming from his heart looked abnormal on chest x-ray, and a large amount of blood came from the chest tube.  She also noted a swollen belly, concerning for internal injury, and swelling of his left thigh and wrist.  Being a very small hospital, it became clear that she did not have the resources (a chest surgeon, a general/trauma surgeon, and a limited blood bank) to care for this badly injured patient.  She called the regional trauma center, activated the helicopter system, and had a direct doctor-to-doctor discussion, quickly arranging transfer.  

Acute Care Facility Component: Inter-facility transfer protocols, experienced transport teams and plans, and education

The trauma center, upon receiving the call, activated a multitude of resources.  Trauma Centers, particularly Level I and II centers, maintain a host of resources at the ready:  trauma bays for resuscitation, operating rooms and teams on standby, trained trauma resuscitation teams, intensive care units, well-stocked blood banks, advanced x-ray capabilities, and a cadre of specialists to care for all sorts of injuries (neurosurgeons, trauma surgeons, orthopedic, chest, and facial surgeons, to name a few).  Clearly, this young man would need that cadre and those resources.  Even before patient arrival to the trauma center, the operating room team was on standby, the chest surgeon notified of a potential life-threatening injury, and the blood bank alerted. The trauma team was assembled and present when the patient arrived. 

2 AM: The patient arrived, quickly examined, internal bleeding verified, and the need for additional blood confirmed with the blood bank.

2:15 AM: Arrival in the operating room.  His abdomen is explored quickly and a damaged spleen removed.  The doctors taking care of anesthesia place additional IV lines and perform an ultrasound of his heart and aorta, and document an injury to the aorta, the large vessel leaving the heart.  

2:50 AM: The heart surgeon, on standby, scrubs in, and the patient is carefully positioned to approach the damaged vessel.  Upon entering the chest, the vessel blows.  Quick thinking, excellent help, and having the resources available, all serve to save this young man’s life.

4:05 AM: The chest is closed, and the patient taken to the ICU to begin the post-operative vigil and to complete the evaluation for other non-life-threatening injuries.  

Acute Care Facility Component: Trauma hospitals committed to the highest level of care: trauma specialists, physician subspecialists (e.g. neuro-, cardiac, and orthopedic surgery), specialized teams, operating rooms on standby, advanced x-ray capabilities, and education

Hospital Course:

Fortunately, although an additional wrist and leg fracture were noted, the patient had no head injury.  He undergoes further surgery for these injuries and was kept in the intensive care unit for 4 days on a ventilator.  Once off the ventilator, he was transferred to a regular room to begin the process of healing and initial rehabilitation.

Acute Care Facility Component: Specialized trauma nurses, physical and occupational therapy, nutrition and pharmacy resources, and education

Post-Hospital Care:

This patient remained weak from his injuries and operations.  His parents, who both had full time jobs, did not feel comfortable caring for him at home initially.  Specialized therapy to his arm and leg were needed.  Thus, he was discharged to a Rehabilitation Hospital until his strength and function returned. 

Post-Hospital Care Component: Expert Rehabilitation Services, family support, and patient education

The trauma hospital where this patient received his care has gathered data regarding injury in teenagers.  They launch a program on Teen Driving and High Risk Behaviors.  Over the next year, they bring these educational programs to local schools to highlight the importance of safe driving habits. The graduating class at the local high school make a promise to each other to wear their seatbelts every day.

Injury Prevention Component: Research - Learning how and why people get injured, and providing education to the general public to decrease injury rates

The Trauma System: By Design

J Dunn

April 30, 2012