The PreHospital Trauma System From 20,000 Feet

While the title takes a metaphorical stance on the viewpoint below, it is safe to say that prehospital providers should have an understanding of how everything works. The adage that “trauma is easy” is long overdue for removal from our vocabulary. image

According to the CDC accidents (unintentional injuries) are the fourth cause of death in the United States (CDC, 2016). In 2015, 146,571 deaths occurred due to trauma. This statistic is a pretty staggering number from any viewpoint. With that, we have seen little in the ways we manage trauma from a prehospital perspective. I will say there have been some massive changes, mostly for the better. Now these changes such as shifts in assessment models and newer treatment strategies, have had an impact on outcomes and survivability. So, let’s look at what we’re doing and then understand why, as well as take the blinders off and look at the whole picture.

It wouldn’t make sense to look at what we’re doing now, or what the future holds without looking a little at the past. Historically, trauma has been a series of algorithms and understatements that honestly undermine what effect we have on someone’s life. Referring to the statement above “trauma is easy” and adding “load and go” or “it’ll buff out,” it’s safe to say that these terms have been used synonymously with the response to and management of trauma patients. These statements in my earlier personal practice have to lead to a sense of complacency that could have ultimately lead to apathy towards continuing my education to serve patients better. It is safe to say there were a fair amount of assumptions made in trauma management past. Everyone was placed on a long backboard, large bore IVs, rapid transport with attempts to resuscitate patients to “normal blood pressure” of 120/80 with no real information dictating these treatment modalities. What we have learned from this, that probably seems common sense now; not everyone needs a backboard, IV fluids do not replace blood, there is no such thing as over-resuscitating patients and 120/80 is not “normal” for everyone. We were getting patients to the trauma center, and then they were passing two to three weeks later, and the understanding of why has not been well understood until recently.

What Has Changed?

That brings us to the now, what’s changed? One of the most evident changes that are present across all first responder disciplines is the ever decreasing uses of long backboards for trauma patients. While this change may be occurring slower some places than others, it is still progress! Another shift has been the integration of tourniquets earlier rather than later. This once voodoo practice has become initial treatment in extremity hemorrhage. This shift is primarily based on the overwhelming amount of data that has been analyzed from our past 16 years at war. The data has been instrumental in genuinely pushing prehospital trauma management to evidence-based practice. Our ability to now look at information and definitively say if treatments are or are not working is a huge milestone in our field. However, the translation of this information to actionable changes in protocol has taken some time.

So what can we do to shorten the timeline of better patient care? I most certainly do not have that answer, but do have some thoughts on the matter. Proactivity and advocating to crush complacency is a good starting point. Medicine is known as a practice because it is precisely that, application of the scientific method to care for humans that are sick or injured. If we as providers continue to do the same thing to patients given changes that would improve outcomes, we are causing a detriment to our society.

One of the most frustrating statements to hear is “I’m only an EMT or first-responder.” The continued use of this statement is one of the worst psychological weapons against the growth and progression of our discipline. There is no member of the team that is less or more valuable. Arguably, the first responder has the most significant impact on the survivability of trauma patients. If you look at the raw numbers (there are variations), it can take only three to five minutes for an individual to bleed out from a major vessel interruption. Plainly said, the first person to make contact with that patient, is the one that has the most impact on their survival. This is not in the medic’s hands, nor should it be in anyone’s minds that it is the case.

The three most preventable causes of death from trauma are extremity hemorrhage, tension pneumothorax and airway obstruction. This is from combat data but also applies domestically. Each of those components also has a basic skill set that can be implemented by an EMT or even a trained layperson. Tourniquets, chest seals, and airway positioning are all basic skills that greatly increase survivability. There is a caveat, however, and it needs to be very clear. Regardless of the provider skill level. Nothing we do in the field “fixes” the injuries sustained in a traumatic event. We merely slow the clock, but the importance of our care should not be underemphasized. Our interventions are an attempt to minimize the worsening of whatever injury has occurred, as well as get them to a surgeon quickly.

Training Programs

Looking at care provided in the field for trauma can be pretty closely related to that of the AHA’s tiered training programs. There is something everyone can do. You go to any public place these days, and there is a good chance that you find an AED (automated external defibrillator) on a wall. This is due to a push as well as legislation supporting the need for access to equipment and training for sudden cardiac arrest. It has been proven that this program is saving lives. Is it not fair to say though that the same could be assumed for trauma? More trained people and access to equipment could be directly tied to a decrease in mortality from traumatic events.

The evidence supports this, but it also must be said that there has been a direct correlation between bleeding control training, etc. as it is associated only with active shooter events or mass casualty incidents. This belief is an unfortunate misconception. Trauma is trauma regardless of the means in which it occurred. It is non-selective to only acts of violence, which leads us to the national shift occurring.

Standardizing Improvements

All of this new-found insight into mortality related to trauma, and the availability of data has to lead to an increasing interest in the topic. There has also been an increase in standardizing and improving care outside of the hospital. This starts with the citizen or layperson. The Bleeding Control (B-Con) program through the American College of Surgeons is a testament to this interest. Again, relating to the AHA model loosely, it has been found that the first person trained to intervene has the most impact.

So, as responders we must increase awareness within our communities, as well as direct organizations and individuals to vetted and accurate training that could help them save lives. From a first responder role, we also need to equip ourselves mentally as well as with the correct tools to intervene appropriately. Mentally means to step outside of our comfort zone and be a proactive member of the prehospital community to educate yourself and advocate for the departments to do the same. Then we must be more comfortable in interacting with trauma centers and build the relationships when working together to create a truly seamless transition of care from the citizen first responder all the way to the trauma surgeon.

While this is a very generalized overview, there is so much more that could be said on this topic. I challenge you to investigate more into the recognition and treatment of traumatic injuries, as well as understand it is not isolated to the “tactical environment.”

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Andrew Rowley began his career as a firefighter/EMT at a volunteer fire department. He joined the Army as a medic and is now teaching combat medicine and sustainment at the unit level. He worked in Charlotte, North Carolina for Mecklenburg EMS Agency, as a paramedic. Rowley’s current position is flight paramedic with Wake Forest Baptist Health in Winston-Salem, North Carolina. He is the president of Special Operations Aid and Rescue, LLC.

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