How Close Are You to a Trauma Center?

Access to a Level I trauma center lowers the risk of death by 25% but not all trauma victims have immediate access to this highest level of trauma care. Nearly 45 million Americans are still not within an hour of a Level I or II trauma center. The lack of emergency care and trauma centers has a disparate impact on the poor, those in rural areas and those who are geographically distant from trauma centers. 

These disturbing facts were confirmed most recently in the December 2016 issue of The Journal of the American College of Surgeons in an article entitled, "Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need? (Vol. 223, 764-773)." Unfortuately, the simple answer to this highly relevant question is "no." In the authors' analysis of over 1.3 million trauma admissions at 1,987 trauma centers spread across the country they found that there is no association between the density of trauma admissions and the location of Level I and Level II trauma centers. States with higher trauma burdens tend to have lower per-capita income and increased mortality rates. However, there is no association between trauma admissions and availablity of trauma centers. 

This marked regional variation between clinical need and availability of trauma services across the United States is something we should all be concerned about no matter where we live because it could affect our friends and loved ones and even us if we find ourselves traveling into these underserved areas. What can be done about this life-threatening discrepancy in trauma services? The authors of this timely study admit that there is no easy solution although a centrally organized national trauma system, something that does not exist now, might have the insight and authority to help balance resources and urge a more equitable distribution. The authors also suggest that perhaps the trauma center verification process might be altered to include an assessment of local need. 

This is one more issue that a National Insitute of Trauma Medicine would be able to address but there isn't one in the United States. Trauma, the fourth leading cause of death and the number one cause of death between the ages of 1 and 44 doesn't merit one . . . . yet.

More about trauma centers and how they save lives in Chapter 6 of my book Hurt: The Inspiring, Untold Story of Trauma Care. 

The Dutch Reach: Safety Tip to Avoid Injuring Cyclists

Riding a bicycle is great exercise and a plus for the environment but the fact remains that cyclists are vulnerable to injury, especially riding in congested urban areas. One of the lurking dangers includes the potential to get "doored," that is for a cyclist to run into a driver's car door as she is opening it after parking. Getting doored can result in severe injuries and even death but there is a way for drivers to safely avoid dooring cyclists. The Dutch Reach, as reported in this article from Public Radio International, is a safety maneuver taught in driver's ed in the Netherlands where there are a large number of cyclists on city streets.

The concept is simple: instead of opening your car door with your left hand you reach around with your right hand to open the door. This forces you, the driver, to turn your upper body and look behind you before opening the door and hopefully to be able to detect not only a cyclist but also a jogger or a stroller or anyone else coming up quickly behind your parked vehicle.

I tried this today in my MINI Clubman and it was easier than I imagined and it worked. By reaching around with my right hand I was forced to turn and see what was behind me before opening my car door. I'm not suggesting that using the Dutch Reach will avoid all injuries to cyclists or that it will work for every vehicle and driver but it's the cultural norm in the Netherlands, testimony to it's effectiveness. There are a lot of bicyclists in Austin and in my neighborhood so I'm going to make the Dutch Reach a part of my routine. More on injury prevention in Chapter 3 The Weakest Link of my book HURT: the inspiring, untold story of trauma care. 

Stop the Bleeding

Of the approximately 5 milion people who die around the world from trauma every year, at least a third bleed to death. Massive hemorrhage is second only to traumatic brain injury as the cause of death from injury. Not recognizing and failing to respond to hemorrhage is the major preventable cause of death from trauma. Why can't we live without blood? Blood carries oxygen to all our tissues and organs and they cannot function without it. Without an adequate supply of red blood cells we'll quickly die.

Trauma surgeons are starting to reshuffle the deck on priorities in resuscitating trauma patients. For the better part of a half century, stopping bleeding has been the third priority behind airway and breathing problems. Stopping the bleeding is climbing the ranks of priorities particularly in combat where most casualties die within ten minutes of being wounded and usually from exsanguination. 

The military has instituted the MARCH protocol (Massive Hemorrhage, Airway, Respirations, Circulation and Hypethermia) that instructs medics to stop external bleeding before doing anything else. Direct pressure is applied first and if bleeding continues from an extremity a tourniquet is applied above the site of bleeding. The Combat Application Tourniquet (CAT) can be applied by a wounded soldier using just one hand. Applying a tourniquet before a patient goes into shock can improve survival by ninety percent. Tourniquets are becoming part of standard civilian EMS procedure once again and some are suggesting that police carry them also. 

Military surgeons have become experts on stopping the bleeding and lucky for us they have passed that expertise on to the civilian world. More on new ways to stop internal bleeding in Chapter 7 The Color of Blood in Hurt: The Inspiring, Untold Story of Trauma Care. 

Expanding the Golden Hour

R Adams Cowley of Maryland Shock Trauma was the first to describe "the golden hour," the critical hour after injury during which action must be taken to save a patient's life. Treatment of injury is time-sensitive. Patients must be treated in that first hour after injury, before they bleed out and before the body's predetermined biological processes set the scene for shock to take hold. 

But getting a patient to a hospital within that first hour is not always possible and when it's not we need to think of ways to expand the golden hour, to give our patients their best chances of survival in the field. Nowhere has this been better demonstrated than on the battlefield, particularly in the last decade of war. 

One of the best ways to expand the golden hour and buy time for a patient in the field is to stop the bleeding. Military doctors found that most combat casualties die within ten minutes of being wounded and usually from exsanguination. Tourniquets had fallen out of favor during World War II and Vietnam over concerns about choking off the blood supply to a damaged limb but they have made a comeback because of concerns over fatal hemorrhage. 

The Combat Application Tourniquet (CAT) is a simple tourniquet that can be applied by a wounded soldier using only one hand. Applying a tourniquet before a patient goes into shock can improve survival by 90 percent. Tourniquets have been so effective in combat that the CAT is becoming part of standard civilian EMS procedure again and even some police are carrying them.

Other ways to expand the golden hour include using hemostatic bandages like QuikClot Combat Gauze, bandages impregnated with kaolin, an agent that accelerates the body's own clotting mechanisms. There is even a way to stem suspected internal bleeding. The XStat, the "medical version of Fix-a-Flat," is a syringe filled with small spongelike discs impregnated with a clotting agent. The syringe can be deployed into an open wound like a bullet hole in the abdomen to help tamponade internal bleeding. 

These hemorrhage control measures will only buy so much time for the injured. When effective, however, they might just delay the onset of shock and expand the golden hour sufficiently to save the patient. 

More on bleeding and R Adams Cowley in Chapters 6 & 7 of HURT: the inspiring, untold story of trauma care.

The Lessons of War

Every war is a trauma lesson. Along with devastating injuries comes an opportunity to improve the care of the wounded because there is no better incubator for studying trauma than war with its large number of casualties. From the American Revolution up through Desert Storm (1775-1991) approximately 1.5 million soldiers were killed. While all of these wars were fought with rifles of various kinds, each one produced it's own unique pattern of injury due to weapon type and battle tactics.

The musket was used during the Revolutionary War. Because the musket had to be loaded with gunpowder, paper and a metal ball, men fought in shoulder-to-shoulder formation, lined up three rows deep. The low-powered round ball bullets traveled like a bad knuckleball and were accurate to a distance of only fifty yards. The balls produced a lot of fractures and soft tissue injuries but the wounds were survivable. 

By the time the Civil War erupted the Springfiled .58-caliber rifle, a more powerful and more accurate weapon, had been invented. Upon firing, the half-inch minie ball would spin, increasing its velocity to 950 feet per second. Overnight the rifle's accuracy increased to six hundred yards, the length of six football fields leaving soldiers still fighting in formation vulnerable to being easily picked off by the new weapon.

The minie balls flattened out when they hit the skin and ripped apart the body causing large wounds with vastly more tissue destruction. At a time that predated antiseptic techniques and antibiotics, severely damaged limbs posed the danger of life-saving infection. Surgeons were forced to default to the only life-saving operation they knew--limb amputations. Of the 174,000 gunshot wounds to the extremities in Union soliders amost 30,000 required amputation. 

In World War I men fought in trenches exposing their head and necks to the new automatic weaonry of machine guns. As a result, there were a record number of gunshot wounds to the face that forced the development of surgical techniques that layed the groundwork for plastic surgery. Vietnam brought "bouncing Bettys," underground grenades that lopped off feet and legs. The wars in Iraq and Afghanistan were beleagured by improvised explosive devices (IEDs), remote controlled bombs that blew off every part of a soldier that wasn't armored and rattled his brains. 

Through every iteration of warfare our military surgeons have improvised and innovated, devising new techniques and devices to treat the next generation of war wounds. Fortunate for the civilian trauma population, many of those techniques have trickled down to modern-day trauma centers.

More on weaponry and the changing patterns of injury in chapters 2 & 10 of Hurt, The Inspiring Untold Story of Trauma Care.