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Trauma: The Paradigm for Medical Care in the 21st Century

2003; Lippincott Williams & Wilkins; Volume: 54; Issue: 5 Linguagem: Inglês

10.1097/01.ta.0000033769.65011.31

1529-8809

Ronald V. Maier,

Pelvic and Acetabular Injuries

It has been one of my greatest honors to serve as your President for the last two years. However, I also remain greatly saddened by the devastating events that caused the cancellation of our meeting last year. The resilience and determination of our country was indeed tested, but we have demonstrated our strength of will and our drive to go forward; and that we will, I am sure. For those of you who missed the opportunity to visit Seattle, I begin with a view of Harborview Medical Center, located in a landscape quite different from our current surroundings. Much of what I will present is based on my experiences at this Level I Trauma Center, not because it is better than the other excellent centers at which you work, but because I know trauma care most completely as it is practiced at this institution. In addition, I must recognize a role model whom has meant so much to me and to so many others in the field of trauma. Dr. C. James Carrico was an early and critical mentor who influenced every aspect of my career, from the selection of trauma as a career to his prodding me into a postdoctoral fellowship in inflammatory cell biology to guidance as a budding academic trauma surgeon and intensivist in his role as Chief of Surgery at Harborview Medical Center and, forever, my “Chief”. He was the most dedicated, thoughtful, compassionate, and caring academician with whom I have had the privilege to work. I thank him for all he so willingly gave to me, and I dedicate this presentation to his memory (Fig. 2). Fig. 2: Dr. C. James Carrico.Is trauma the paradigm for medical care in the 21st Century and, if it is, how did we get here? What have we accomplished? Where have we failed, and where should we go? Trauma care has come far in this country, arising from a scattering of isolated “county hospitals” left over when these large urban institutions became too expensive to maintain as societal safety nets for the “poor people.” However, while direct societal support disappeared, the people kept coming and the hospitals stayed full. Many had severe injuries and many had no money; both required care that was not available elsewhere, so the institutions persisted, primarily in the large urban settings. These institutions, in large part by default, became increasingly dedicated to the care of the injured. As these institutions grew in stature as leaders in the care of the critically injured, they became more and more alienated from the developing mainstream of modern elective surgical specialty care. Although the elective “insured” patient increasingly avoided these institutions, their place in the health care system has always been recognized, although never fully appreciated, unless they have threatened to close. As with previous armed conflicts, the Vietnam War in the late 1960s contributed major advances in the care of the severely injured, including demonstration of the benefit of well-organized prehospital care and rapid delivery to definitive care. In Miami, for cardiac disease, and a year later in Seattle, for cardiac and, for the first time, trauma, citywide organized EMS systems were created. While Dr. David Boyd, in Illinois, attempted to create the first statewide trauma system, Dr. R. Adams Cowley in Baltimore achieved a unique political success in centralizing trauma care in the state of Maryland with a dedicated Shock Trauma Institute at its core, supported by line item funding. Later, in the 1970s, on the West Coast, the seminal studies published by West and Trunkey, comparing trauma outcomes between San Francisco and Orange County, demonstrated a reduction in unnecessary deaths from >30% to 15. On average, we have had a 4% per-year risk adjusted decrease in mortality along with a significant decrease in intensive care unit (ICU) length of stay. 7 Since 1985 there has been a >50% reduction in mortality in patients with adult respiratory distress syndrome. In a similar analysis, Dr. Peitzman in Pittsburgh demonstrated a similar improvement in outcomes in their injured patient population as their institution and system of trauma care achieved increasing maturity. 8 Thus, the trauma community recognized the necessity for a systems-based practice 20 years before it became a general competency for practice proposed by the American Board of Medical Specialties (ABMS). Presently, there continues to be a healthy debate as to which of the many components in this empiric, nonevidence-based system are truly necessary for optimal outcome in the critically injured patient. Our egos demand that it must be me, the individual macho trauma person. Even I have implied that optimal care in Seattle would require me to work 24/7. Fortunately, our Chief of Trauma, Dr. Jurkovich, and other colleagues have pointed out that my presence 24 hours a day may not be quite that imperative for survival of the injured patient. Many leaders in the field have argued that the presence of the attending in the hospital, awaiting the arrival of the patient, is critical for an optimal outcome. Dr. Demetriades and colleagues have shown that restructuring and committing to a dedicated trauma service, including in-house trauma surgeons, produces a marked improvement in patient survival. 9 But, I would ask, is it dependent on being in-house or on being committed? Our senior surgical resident colleagues are really quite good at recognizing and resuscitating a severely injured patient. Recently, Dr. Cryer confirmed a prior analysis by Dr. Richardson and others showing a lack of correlation between number of patients treated per surgeon per year and patient outcome, implying that the benefit in outcome may be due to factors other than the individual surgeon. 10 Using the University Hospital Consortium (UHC) database, we demonstrated that the presence of an in-house attending did not influence outcome, however existence of a trauma training fellowship had a positive impact on survival and showed a decrease in resource consumption as measured by ICU length of stay. 11 Now, I do not believe that the presence of a fellow is better than an attending, however I do believe that commitment to training the next generation of trauma surgeons functions as an excellent surrogate to identify those institutions with the volume of patients and dedication to trauma necessary to optimize outcome. “Playing the game” to meet the in-house requirement is not the answer. Forcing the endovascular fellow to take call or enticing physicians with money to stay in-house when they have no real interest or commitment to trauma should not be expected to produce an optimal outcome. In fact, specialty surgeons, in addition, are currently extorting hospital administrators to pay for being on call. As Jack Wilberger, MD, Past Chair of the American Association of Neurosurgeons/Critical Neurosurgery (AANS/CNS) Section on Neurotrauma points out, the average $1200 per day reimbursement produces a neurosurgical commitment to the individual patient that is substantially less than those centers without reimbursement. There is little commitment to develop the overall infrastructure needed for optimal outcomes. Not to mention that in today’s fiscal environment, trauma centers are operating on such a limited margin they cannot hope to sustain this approach to trauma care. We must address these issues based in reality. Dr. Lucas, through his efforts on the Verification Committee, demonstrated that previous Neurosurgical coverage availability standards, while laudable, were not reality- or patient outcome-based and need to be changed. Recent Emergency Medicine Treatment and Labor Act (EMTALA) regulation changes concur, however our work from Seattle does not imply, as has been misinterpreted, that the attending surgeon is not critical to the outcome. The attending must be involved in the care of the critically ill. The trauma attending must be the “captain of the ship” in the emergency department (ED), operating room, or ICU as required. Most importantly, whether you are doing a Whipple procedure for cancer or a major trauma resuscitation, the data repeatedly document that the outcome will be better if a system is in place, the resources committed, and manpower appropriately trained. 12 Commitment is the key. Are we achieving our goal of regionalized trauma care? Assessment pre- and post-implementation of trauma systems, such as that by Drs. Shackford, Eastman, and Hoyt in San Diego, demonstrated a dramatic early impact on patient outcome. 13 However, a necessary process in the maturation of the trauma system is ongoing refinement of regionalized trauma care. During our update of trauma systems throughout America in 1995, Drs. Bazzoli, MacKenzie, and I were impressed that the most frequent and significant failing of regional trauma systems was the inability to limit the number of Level I and II trauma facilities to match the needs of the community. 14 The legislatively defined lead organization, while frequently empowered to limit the number of facilities, is often unable to muster the political courage or clout necessary to achieve this requirement. Unfortunately, without these controls in place, too many institutions meet the requirements for high-level trauma designation. The presence of these competing institutions, similar to medicine in general, does not follow traditional marketplace principals. There is not only not an enhancement in overall level of care, but also a significant increase in the cost of trauma care as expensive resources and manpower are unnecessarily duplicated. The trauma community must respond to this challenge. An even greater potential negative impact is the detrimental effect produced by dilution of experience. 15 In our recent evaluation of academic Level I trauma centers contributing to the UHC database, Dr. Nathens evaluated the relationship between trauma center volume and outcome in patients with penetrating abdominal trauma and patients with blunt, multi-system injury. This study was unique in that these two cohorts were defined prospectively and the centers participating were predominantly academic Level I trauma centers from across the country—they were not restricted to one geographic locale. The impact of trauma center volume on outcome was significant only for patients with high severity of injury. There was no measurable outcome benefit in patients with penetrating trauma without shock or blunt trauma patients without coma. This explains why many studies have failed to show a difference in outcome based on volume. In a recent analysis of trauma centers in New York State by Cooper and others, there was no outcome difference between the various centers. 16 Unfortunately, the largest volume center in that study admitted approximately 350 patients per year with ISS >15. Dilution with large numbers of low risk injuries that do well regardless of expertise do not adequately answer the question of outcome for low-volume high-risk groups that should maximally benefit from regionalized care. In our analysis, the cohorts of patients with shock or coma (as surrogates for severity of injury) treated in trauma centers with major trauma volumes greater than approximately 650 cases per annum demonstrated significantly improved survival and shorter length of stay than centers below this threshold (Fig. 6). 17 Simply stated, as in every other aspect of highly specialized surgery, “practice makes perfect.”18Fig. 6: Reprinted with permission of the Journal of the American Medical Association. (Line graph entitled “Trauma Center Experience & Outcome”).Many regional Level I trauma centers currently do not admit this level of severe trauma. Does this mean that they should not be a Level I trauma center? An arbitrary number should not drive the designation process. The focus should be on commitment and outcome. Currently, we are fixated on numbers and process rather than outcomes and quality. How many minutes until the surgeon shows up? How many cases? How long is the patient in the ED? Since we do not have good outcome assessment tools, we are left with process surrogates, but this is not our ultimate goal. We continue to be overly consumed by the assessment of process. Meeting process standards, while laudable, should be guidelines, not critical failures. Level I trauma centers should be the best regional resource available, and they should be based on community needs and institutional resources, not politics and finances. As Dr. Gene Moore stated in his Presidential Address to the American Association for the Surgery of Trauma (AAST) in 1994, that we need to strive for bigger and better Level I trauma centers, not an increasing number of smaller, expensive, competing Level I trauma centers. 19 The Level I trauma center should maximize volume to generate optimal research, education, and practical experience to produce optimal patient outcome. The questions should be: does the lead institution have the resources to care for the patients? Do geographic and other logistics, such as traffic patterns, prevent regionalization of care? Trauma center designation must be divorced from the concept: all we need to do is spend enough money and we can meet the requirements of verification to become a Level I trauma center. The great opportunity provided by regional trauma systems elevates injury care above the rest of medicine. If we do not protect this concept, society will treat us similar to others, whether it be publication of outcomes such as cardiac surgery in New York or direct linkage of reimbursement to volumes and outcomes, such as the national liver transplant program. With constant leverage from corporate payers such as the LeapFrog Group, do not doubt, expensive, high-risk care will be regionalized. The newly developed Consultation for Trauma Systems program of the ACS Committee on Trauma under the direction of Dr. Eastman is a major attempt to provide regional trauma systems with reasoned input into the overall planning and design of their systems. 20 Hopefully, efforts such as these will help overcome individual egos and institutional financial pressures that are impeding rational system implementation. Regional trauma care is fiscally prudent, and being fiscally prudent greatly augments the argument that the trauma system should be financially underwritten by society, which if you have not noticed, is what we will ultimately need to survive. RESEARCH AND EDUCATION A major shortcoming of the AAST and the injury field in general has been our inability to generate the legislative support to provide adequate funding for trauma research. However, although funding remains a significant challenge, research and education remain the foundation of the AAST and the major underpinning of the success of trauma care in America. The efforts of AAST and those of the American College of Surgeons’ Committee on Trauma, the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) continue to elucidate the response of the injured host from the molecular to the physiologic level. Analyses of our delivery of care and the results of new technology and techniques have highlighted our meetings. We have developed and tested our own guidelines for care rather than default to those less knowledgeable. The care guidelines developed by EAST are recognized around the world as models of evidence-based medicine. The clinical trials conducted by WTA have tested our empiric approaches to confirm their validity. Recently, the Board of Regents of the ACS with support from NHTSA have committed significant resources to the National Trauma Data Bank as the national injury repository. 21 This database is rapidly maturing into an excellent national resource. Through this effort, the epidemiology and outcomes of injury can be tracked to direct research efforts, intervention trials, and educational efforts based on individual institutional comparisons to the national averages. In addition, medicine is becoming a global community, and we must reach out to create an increasing world view for trauma care. Members of the AAST, such as Drs. Mock, Deane, and Boffard, have become leaders in this daunting effort. As stated by Dr. Meyer in his Presidential Address, by 2020 trauma will be the number one cause of death in the young world-wide and the fourth leading cause of death overall. 22 Industrialization and increasing access to motorized transportation and firearms are producing a lethal evolution for survival among the world’s youth (Fig. 7). 23 However even with limited resources, a significant impact can be made. Dr. Mock in Mexico and Ghana and Drs. Deane and Boffard in India, along with others, have developed educational courses for first responders in these resource-challenged countries. In the more advanced countries, the COT has been the leader through propagation of ATLS training to 39 different countries that have standardized the initial approach to the injured patient worldwide. As recently advocated by the IOM, standardization and reduction in variations in care are crucial for improvement in outcomes. Interestingly, this approach to improved care was developed by the trauma community nearly three decades ago following the initial stimulus by Dr. Skip Collicott, following an airliner crash in Nebraska. Fig. 7: Reprinted with permission of the American Public Health Association. (Table entitled “Leading Causes of Death For Both Sexes...”)Recently, the International Association for the Surgery of Trauma and Surgical Intensive Care (IATSIC) of the International Society of Surgery (ISS), of which the AAST is an Integrated Society, has developed a Definitive Surgical Trauma Care Course (DSTC). This course has already been presented in multiple countries around the world and is increasingly requested, particularly in countries where penetrating trauma is a primary means of communication. The course is focused on the practicing surgeon to provide additional training in surgical techniques and approaches for the operative care of the severely injured patient. Currently, the IATSIC, in conjunction with the World Health Organization, is also developing an Essential Trauma Care guide of minimal standards for optimal care of the injured patient for resource challenged countries based upon the concepts of the highly successful Verification Program of the COT. The input and support of members of the AAST is critical for this worldwide effort. I encourage all members of the AAST interested in becoming closer linked to trauma activities around the world to become members of IATSIC and participate in these ongoing global efforts. Lastly, while the validity of applying public health control approaches to injury is rapidly evolving for these preventable, non-random events susceptible to intervention, we have succeeded poorly in educating the American public, including our elected officials. In Seattle, 70% of the public has been trained in CPR, which makes Seattle the safest place to have a cardiac arrest but one of the worst places in which to faint, however the societal support systems for cardiac disease, cancer, diabetes, stroke, and other neural diseases are extensive and grounded in broad-based, grass roots networks. In trauma, we continue to struggle. Amazingly, most surgeons, even trauma surgeons, speak of “accidents.” The implication is that the injury is an act of God, over which one has no control and certainly no responsibility. This nihilistic attitude has been the greatest obstacle to injury prevention. 24 I would argue that running a red light while intoxicated with a blood alcohol content of 220 mg/dl is not an accident but a planned disaster, and it is imminently preventable. We must use every opportunity to educate ourselves and to join with Public Health initiatives such as the National Center for Injury Prevention and Control of the Centers for Disease Control (CDC) to address the injury epidemic. 24 In Seattle, the Harborview Injury Prevention and Research Center undertook a massive citywide campaign to increase bicycle helmet use among children. A previous study demonstrated that a correctly fitted bicycle helmet decreased head injury by 85% in children. The resultant campaign increased helmet use from 2% to >60%, and simultaneously, admissions for children with head injuries sustained in bicycle crashes decreased by >50%. 25 Similarly, the Buckle Up America campaign of the Department of Transportation has documented the impact of both risk prevention education and legislation on trauma. While adult seat belt use has not reached the goal of 85%, the increase in child seat use has been dramatic and is now >90%. Concomitantly, fatalities in children under age 5 have dropped 12%, and fatalities in children under age 1 have decreased 21%. Similarly, many other programs developed by members of the AAST have had major impacts on the incidence of injury from head trauma to gang violence. Surgeon leadership in injury-related public health activities is a crucial opportunity to showcase the value of trauma systems for society. The association of alcohol abuse and acute trauma has long been recognized with intoxication involved in >50% of injuries. Similar to other chronic diseases, the frequent failures in the treatment of alcoholism have produced a nihilistic attitude in the medical community, however over the last two decades, an increasing body of data has confirmed the ability of intervention to significantly reduce the recidivism and devastating impact of alcohol-related trauma in our society. 26 Dr. Gentilello, through a dogged determination, has educated the appropriate legislative bodies to implement significant legislation to deal with reimbursement for alcohol-related injury. Commitment, determination, and valid data using the public health model can prevail. Not only have our patients benefited greatly, and a major source of lost revenues been regained, but also trauma surgeons become recognized as advocates for our patients. By “taking the high road” on behalf of the injured, we help not only our patients but also ourselves. ADVOCACY AND COALITIONS In the field of trauma, we are blessed with dedicated and committed organizations working to lessen the impact of trauma on society. While these groups remain poorly coordinated, interactions and collaborations are improving and the potential is immense. The AAST and all organizations interested in the improvement of care for the injured must reach out as active patient advocates and assist in whatever way possible in the development of these coalitions. In representing you as the President of the AAST, I have worked with numerous coalitions and policy makers. While being President of the prestigious AAST helps, being a concerned active clinical trauma surgeon carries a significant impact, particularly when functioning as a spokesperson for the injured patient. Legislators, lobbyists, coalitions, and patients have thanked me for providing data and insights regarding the needs of the injured patient and the system that cares for them. The personal rewards of having any impact that will potentially improve survival or benefit the outcome of the injured are truly exceptional, and the successes of the coalitions have been significant, but we have a long way to go. For example, the 106th congress appropriated $3 million to the Health Resources and Services Administration to improve the nation’s trauma system through Public Health Service (PHS) Title XII appropriations. Currently, the President has requested zero reappropriation, and reauthorization has not been implemented. What have you done to educate your legislative leaders regarding this critical funding? While our opportunities are extensive, our organizational efforts remain limited. The American College of Surgeons has only recently changed their IRS status to permit formal lobbying on behalf of the surgical patient. However, trauma is only a small part of the overall scope of the College. We need to enhance our access through our liaison with the Committee on Trauma. In addition, we need to increase the lobbying potential of the Coalition for American Trauma Care, of which AAST is a major sponsor. The Coalition for American Trauma Care was created by Dr. Champion out of frustration over lack of access to the key policy makers in Congress. It has become a recognized voice on the hill and a valid resource for congressional staff. Recently, the American Foundation for Trauma evolved from the Trauma Resource Network, a national network of over 160 sponsoring trauma centers working to improve their fiscal stability. I