- Email: [email protected]
Our responsibility to trauma
SPECIAL CONTRIBUTION
Our Responsibility to Trauma Curtis P. Artz, MD, FACS* Charleston, South Carolina
INTRODUCTION
It is a t r e m e n d o u s thrill to participate in the portion of the UA/EMS program associated with Robert H. Kennedy, MD. He really is "the f a t h e r of t r a u m a care" as we know it in North America today. Bob K e n n e d y b e c a m e c h a i r m a n of the Committee on T r a u m a of the A m e r i c a n College of S u r g e o n s (ACS) ==4 the year I completed medical Curtis P. Artz, MD school and he occupied t h a t post for 13 years. D u r i n g this period, he was chief of t r a u m a service at New York City's Beckman-Downtown Hospital - - a model for t r a u m a services for m a n y years. The original work he did as the result of a n a t i o n a l survey of fracture s p l i n t i n g i n a m b u l a n c e s first recognized the problem of t r a n s p o r t i n g the injured in this country. His life has been dedicated to t h a t and other aspects of t r a u m a care. The publication of the A m e r i c a n College of Surgeons'
Emergency Care of the Sick and Injured, which he edited, stands as a m o n u m e n t to his dedication to care of the injured. For m a n y years he directed the Field P r o g r a m of the Committee on T r a u m a . It was d u r i n g this period t h a t the c u r r e n t wave of i m p r o v e m e n t in emergency medical services (EMS) came to fruition. Bob K e n n e d y had a d r e a m for America - - to provide the injured with the privilege of high q u a l i t y care. He dedicated his life to this dream and the fruits of his labors are evident to all of us who work *Professor of Surgery and Chairman of the Department, Medical University of South Carolina College of Medicine. Robert H. Kennedy Lecture - - Presented at the Fifth Annual Meeting of UA/EMS in Vancouver, British Columbia, Canada, May 1975. Address for reprints: Curtis P. Artz, MD, Medical University of South Carolina College of Medicine, Charleston, South Carolina 29401.
Page 520 Volume 4 Number 6
in the field of t r a u m a . My d r e a m today is t h a t you will catch the light of his s h i n i n g star and, with enthusiasm, amplify his efforts and accomplishments_
Development The t r e a t m e n t of t r a u m a in this country has always been u n i q u e . Our e x i s t i n g competence is more poorly applied to the m a n a g e m e n t of the injured t h a n to the treaLm e n t of a n y disease. At the end of the Korean conflict the mortality rate in a Mobile A r m y Surgical Hospital was reduced to 2.2%. Then few cities, and certainly no rural areas, could match this low m o r t a l i t y for civilian injuries. The t u r n i n g point in the care of t r a u m a occurred more t h a n ten years later with the 1966 publication of the National Research Council's white paper,AccidentaIDeath
and Disability, the Neglected Disease of Modern Society. This p a m p h l e t s t i m u l a t e d a n a t i o n a l effort to. improve the care of the injured. About the same time, Congress passed the National H i g h w a y Safety Act which offered some m e a n s of i m p l e m e n t i n g better emergency care and t r a n s p o r t a t i o n of the injured. E v e r y :state now has an executive council on emergency medical services. In addition, there has been a great increase in the n u m b e r ofEMS~ systems with r e g i o n a l a n d local advisory councils. S i g n i f i c a n t progress h a s b e e n m a d e in developing improved a m b u l a n c e services. C o m m u n i t i e s have bought new ambulances; a host of emergency medical technicians (EMTs) have been trained. In 1968, the Guidelines for Training of Ambulance Personnel, p u b l i s h e d by the National Research Council, became the curriculum for the basic course of i n s t r u c t i o n in emergency medical care. This was f o l l o w e d by Dr. K e n n e d y l s pocket manual:. entitled, Emergency Care of the Sick and Injured, published by the A m e r i c a n College of Surgeons. In 1971, a textbook entitled, Emergency Care and TranS portation of the Sick and Injured, edited by C. A. Rock wood, MD, was published by the A m e r i c a n Academy 0( Orthopedic Surgeons. This volume is now recognized ~s the n a t i o n a l text for the EMT basic course. Sirhaltase" ously, t h e N a t i o n a l R e s e a r c h C o u n c i l published A/~
Advanced Training Program for Emergency Medical Tec~"
November/December 1975 . J ~
rlicians, which provided the guidelines for an advanced ~MT course of 480 hours. In 1970, under the auspices of ~theAmerican Medical Association's Commission on Emerge~cy M e d i c i n e Services, the N a t i o n a l R e g i s t r y for ~mergency Technicians was begun. These are only a few of ,tiae highlights of progress in the field of t r a u m a d u r i n g the last two decades.
Modern Trauma Care - - T h e EMSS Act A new period in the history of t r a u m a care in the United States began with the passage of the Emergency Medical Services Systems Act of 1973. This act became Public Law ~3-154 on November 6, 1973. It amended the Public Health ~ervice Act to assist and encourage the development of :0rnprehensive area emergency medical services systems. It provides for grants and contracts for feasibility studies 0nd planning, e s t a b l i s h m e n t and i n i t i a l operation, expansion and improvement, research and support of t r a i n i n g 'in emergency medical services. The Act is administered ~mder the Secretary of the D e p a r t m e n t of Health, EducaILi0nand Welfare. The Director of the Emergency Medical ~ervice program is David Boyd, MD. The guidelines for applications u n d e r this Act were published in Program Guidelines of Emergency Medical ervices Systems and are available from the United States Department of Health, Education and Welfare, Public Health Service, Health Services A d m i n i s t r a t i o n , Box 911, R0ckville, Maryland. A n u m b e r of s e m i n a r s are being held t h r o u g h o u t the 'country in an a t t e m p t to provide information about the gct and the essentials of a good application for funding. rhroughout these meetings there has been one predominant theme: a good application will spell out specifically theleadership role of physicians. Emergency medical serw ices in this country need to be developed by physicians. gany highly competent p l a n n e r s and public health officials are necessary for staffing and organizing but there mustbe an identifiable role for physicians knowledgeable in emergency medicine. Undoubtedly, m a n y UA/EMS ~ernbers are i n t i m a t e l y involved in their communities in ious facets of emergency medical care. You are the up that will make the Emergency Medical Services stems Act of 1973 work. Those who are drafting appliations need your support and assistance. Your expertise ~d your contacts with other capable physicians in the tea are necessary for a workable system.
l
mortality, effective medical care had to be given in the forward area. Emergency medical care faces a s i m i l a r situation in civilian life today. Once a p a t i e n t arrives at a modern emergency facility the care is excellent. However, the construction of an efficient way for t r a u m a patients to enter the EMS system and receive expert m a n a g e m e n t at the scene of the accident w a r r a n t s our best organizational and t r a i n i n g efforts. The N a t i o n a l Registry of EMTs has now certified more t h a n 22,000 basic EMTs, produced a standardized kit tbr a practical e x a m i n a t i o n and is in the process of developing a new advanced EMT curriculum. C o m m u n i c a t i o n between the physician and the EMT in the field is absolutely essential. Various types of technological a d v a n c e s have allowed for some very h i g h l y sophisticated c o m m u n i c a t i o n systems. For example, a 47 lb kit has been developed for the Houston Fire D e p a r t m e n t by the N a t i o n a l Aeronautic Space Agency. Chief L. O. M a r t i n states t h a t these u n i t s allow easy and excellent c o m m u n i c a t i o n between the EMT at scene of the accident and the physician in the emergency department. This lightweight package also t r a n s m i t s a n electrocardiogram. If we are to improve the effectiveness of the EMT at the scene, it seems imperative t h a t some competent m e a n s of communication be provided.
Emergency Physicians are Needed Obviously, this means t h a t there is somebody in the emergency d e p a r t m e n t with the skills to answer the questions and the ability to care for the p a t i e n t immediately upon his arrival. Last year your K e n n e d y lecturer, Oscar P. Hampton, MD, talked about the emergency physician. Certainly, physicians are needed in the emergency departm e n t with the expertise to cope with any problem t h a t m a y arise. The best system would be a group of the traditional specialists available i n the emergency d e p a r t m e n t 24 hours a day. It is doubtful t h a t such an a r r a n g e m e n t could ever be achieved except in very large u n i v e r s i t y programs where senior residents would serve in this capacity. Our problem t h e n is to t r a i n a physician who is competent to perform the necessary diagnostic and therapeutic m a n e u v e r s to care for the injured and acutely ill u n t i l the traditional specialist arrives.
The basic r e q u i r e m e n t of any emergency system is the ~MT. A wealth of t r a i n i n g materials is now available for ~,~ITeducation Many communities still need individuals [rained in the basic course but a n increasing n u m b e r of ~MTswho have completed one of the more highly sophistitared, advanced courses are working in the field. The Vanced courses p e r m i t EMTs to c o n s t a n t l y improve ir ability and upgrade their position.
The d i l e m m a in t r a i n i n g such an i n d i v i d u a l is that cm'rently there is no way of recognizing his expertise. M a n y feel t h a t there should not be a n y additional so-called "specialty boards." Some have suggested t h a t the specialty of a n emergency physician be recognized by the Board of F a m i l y Practice. This group m i g h t issue a special certificate of competence in emergency medicine if the applicant, after completion of his family practice board, completed two additional years in emergency medicine. Two years in emergency medicine in addition to the three years curr e n t l y required for family practice residents would make this a five year stint and few medical students would opt for such a t r a i n i n g program.
[The need for medical care of t r a u m a or any other emer~ncy problem is p a r a m o u n t at the scene of the accident. ['~is has" b e n very evident in our recent wars. The mor!/ity rate, once the 'victim reached a Mobile A r m y Surgi~/Hospital, was m i n i m a l . To s i g n i f i c a n t l y decrease
Undoubtedly, m a n y c o m m u n i t y hospitals need emergency physicians. It is obvious t h a t more p r i m a r y physicians are required and this is another form of a p r i m a r y physician. At the present time, m a n y medical students would like to enter the field of emergency medicine but,
~he Crucial EMT
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November/December 1975
Volume 4 Number 6 Page 521
without some recognition, they fear for their status and the future of their career. Most of us interested in improving emergency medical services recognize the need for such a physician. Although perhaps not necessary in the large metropolitan u n i v e r s i t y centers, someone with such skills and t r a i n i n g is needed in the hundreds of c o m m u n i t y hospitals t h r o u g h o u t the country if we expect to have round-the-clock capabilities for true emergency care. The i m p o r t a n t point concerning emergency physicians is t h a t at the present time there is profound need for them. The demands are great and therefore the salary is handsome. Positions are being filled by contract physicians and moonlighting residents. If the service is to be upgraded, a first career p r i m a r y physician, skilled in emergency medicine, m u s t be provided. The facilities to care tbr the injury victim lag far behind our knowledge. The old emergency room has developed into a n emergency d e p a r t m e n t and the e q u i p m e n t and staffing have improved i m m e n s e l y in the past several years. As prehospital and emergency d e p a r t m e n t care improves, the need for s u p p o r t i n g facilities increases. The facility m u s t have radiological, surgical and intensive care capabilities. It is not enough to have a good emergency d e p a r t m e n t and a. highly competent surgeon. The seriously injured p a t i e n t m a y develop p u l m o n a r y complications and require a special respiratory team.
Specialized Centers for Handling Trauma
As hospitals expand, special centers will develop for certain key problems. These include t r a u m a centers with good diagnostic facilities, 24 hour laboratory and radiological capabilities, a renal team for dialysis and managem e n t of acute r e n a l failure, and a staff of surgical specialists. Other centers t h a t must be developed are b u r n centers, hand centers, head i n j u r y centers, spinal cord injury centers, r e h a b i l i t a t i o n centers and, in certain areas, pediatric b u r n centers. Plus, in every section there should be one facility skilled in t r a n s p l a n t a t i o n . Obviously, o p t i m u m care is rendered when the p a t i e n t is t a k e n to the facility best equipped for his type of injury. This m e a n s t h a t emergency facilities m u s t be categorized. The A m e r i c a n Medical Association's Commission on Emergency Medical Services, with m u l t i d i s c i p l i n a r y n a t i o n a l organizations represented, established guidelines for the categorization of hospital emergency services. As you know, four categories were established: (1) comprehensive emergency services (2) major emergency services (3) general e m e r g e n c y services (4) basic e m e r g e n c y services. F u l f i l l m e n t of these guidelines has been very difficult and r e q u i r e s your finest leadership and t h a t of m a n y other organizations_ The i m p l e m e n t a t i o n of hospital categorization will require hospital boards of trustees and staff to plan together and determine the financial aspects necessary to obviate the possible loss of r e v e n u e if one hospital is to be upgraded and receive most of the patients. Somehow, physicians m u s t be the leaders i n organizing the hospitals of t h e i r c o m m u n i t y to accept categorization of emergency services. W h e n Robert Kennedy, MD, took over as director of the Field P r o g r a m for the A m e r i c a n College of Surgeons he made his famous statement, "Emergency d e p a r t m e n t s are
Page 522 Volume 4 Number 6
the weakest link in the care of the injured." Eventually, his work c u l m i n a t e d in a set of hospital emergency depart, merit standards t h a t were adopted by the Committee 0a T r a u m a . Shortly t h e r e a f t e r he developed a pamphlet entitled, A Model of the Hospital Emergency Department, which w e n t t h r o u g h three p r i n t i n g s . Subsequently, ih 1970, a final brochure, The Design and Function of a Hospital Emergency Department was published by the Sub, committee on Emergency Services - - Hospital and these guidelines have served for the basis of upgrading many of the emergency d e p a r t m e n t s in this country.
UA/EMS and Education So far most of the discussion has centered around organi. zation for better t r a u m a care. Now let us enter a field in which the m e m b e r s of this organization have served as real leaders. It is the field of education - - the training of the t r a u m a team. This includes physicians, nurses, physicians' assistants and EMTs. In addition to the need for emergency physicians, there is a need for surgeons t r a i n e d especially for dealing with t r a u m a . Although the I n s t i t u t e of Surgical Research at the Brooke Army Medical Center now has almost 100 of its a l u m n i in academic i n s t i t u t e s in the United States, more b u r n surgeons are required. W h e n the Committee on Development of B u r n C e n t e r s m e t at The Interna. tional Society for B u r n Injuries in Buenos Aires, Septem. ber 1974, they stated t h a t the p r i m a r y requisite for a good b u r n center was a competent and dedicated b u r n surgeon as its leader. Similarly if we are to develop t r a u m a cen. ters, there m u s t be fellowships i n t r a u m a for surgeons who have completed their residency in general surgery'. and would like to specialize in the care of the traumatically injured. Some are available b u t more are needed. The AT8, following the p a t t e r n of the A m e r i c a n Cancer Society, is now a t t e m p t i n g to develop so-called % r a u m a professorships." This is a n endowed chair in a medical sch001~ financed by a gracious donor to the ATS and occupied by an i n d i v i d u a l who has demonstrated competence in the field of t r a u m a . Such professorships should improve the teaching of t r a u m a at the medical s t u d e n t and residency levels. It should s t i m u l a t e y o u n g people to dedicate their lives to the care of t r a u m a . At the present time many d e p a r t m e n t s of surgery are looking for a faculty member to provide capable leadership i n the teaching and managem e n t of t r a u m a . Most of you occupy positions like this in your universities. You need to devise a program of education, residency t r a i n i n g and fellowship for the medical s t u d e n t who wants to foilow your lead. It is our responsibility as leaders of the t r a u m a team to take a specific interest in the t r a i n i n g and continuing education of all who help us. Those in n u r s i n g should see t h a t n u r s e specialists are developed for the intensive m a n a g e m e n t of various types of injuries such as head and s p i n a l C o r d injuries, chest injuries, fractures and b u r n s . You m u s t accept the leadership for inservice education in your i n s t i t u t i o n and intensify your efforts in c o n t i n u i n g education for emergency physicians, emer" gency d e p a r t m e n t nurses, critical care nurses, b u r n nurseS, physicians' assistants, and EMTs. For m a n y years, research in t r a u m a has suffered because of the emphasis on i n v e s t i g a t i o n of h e a r t disease, ca~cer
November/December 1975 ~ P
'¢d stroke. Undoubtedly, the National Cancer I n s t i t u t e '[1Ua the N a t i o n a l H e a r t and Lung Institute have received ~ • hich percentage of the federal dollar. The a m o u n t of I~10'~e=ybeing spent o n r e s e a r c h in t r a u m a by the N a t i o n a l ~!j,~-titutes of H e a l t h (NIH) has increased only slightly ~"'[,ringthe past years. The I n s t i t u t e for General Medical sciences has money; it probably could obtain more b u t research proposals have not been forthcoming. At #e present time, the great need in research in t r a u m a is ~0t money b u t ideas from competent investigators_ The enacted Public Law 93-498 - - The Federal Fire prevention and Control Act of 1974 - - directs the NIH to isLablish a n expanded program of research on b u r n s , treatment of b u r n injuries and r e h a b i l i t a t i o n of fire vicli~s- For this purpose, $13,000,000 has been authorized tver the next two years. It would be wonderful to be able 10stimulate an i n t e r e s t in t r a u m a in some of the more Ikillful medical s t u d e n t s so t h a t they would pursue a areer where research i n this field is a p a r t of t h e i r ctivities.
'¢ood
recently
There are m a n y areas that deserve further attention. uch information has come to light d u r i n g the last two tecades in the field of shock through the study of some trilliant surgeons and physiologists b u t much r e m a i n s to lelearned. One of the great killers of the injured p a t i e n t s infection. Little is k n o w n about the response of the ~riously injured to infection. For m a n y years, researchers lave produced new drugs to kill micro-organisms. How 'iceit would be if someone could devise a way of enhanc~gthe host's defense mechanisms. The changes that occur 1a seriously injured p a t i e n t cause t r e m e n d o u s losses of nergy. The role of h y p e r a l i m e n t a t i o n in m a i n t a i n i n g a etter balance in the t r a u m a victim w a r r a n t s f u r t h e r ~ploration. The transfer of various parts of the body with Leirown blood supplies, such as muscle bundles and skin ~ps, needs f u r t h e r d e v e l o p m e n t . C e r t a i n l y , t r a u m a gistries m u s t be developed to categorize the causes of ~uma as we seek m e a n s of prevention and t r e a t m e n t .
M a n y more problems a w a i t the p r o b i n g investigator. Finally, the problem of t r a u m a m u s t be t a k e n to the public. There is a great need for public education. The ATS has accepted this as one of its major objectives. First we m u s t teach the public the m e a n i n g of t r a u m a . More t h a n half a century ago when the A m e r i c a n Cancer Society started, few people understood the m e a n i n g of cancer and if they did they were too scared to m e n t i o n it. Now the organization is very productive and much is being done about cancer. The public needs to become more interested in trauma_ We must upgrade first aid t r a i n i n g in schools so t h a t every American citizen will receive at least the basic course. Our citizens m u s t know what to do in case of a n emergency. They m u s t be t a u g h t certain basic steps in life support and how to e n t e r our emergency medical system. The ATS has made great progress in the last two years. The founding membership increased from 400 to more t h a n 3000. This type of membership will close December 1975 and similarly dedicated individuals will become a n n u a l patron members. Crusades for r e g u l a r members have been conducted in several states d u r i n g the m o n t h of May. The ATS is another vehicle t h r o u g h which we can reach our common goals. A l r e a d y t h a t o r g a n i z a t i o n has two 30 second films being shown on television t h r o u g h o u t the country to emphasize the importance of trauma. Other short movies are needed to emphasize the use of pressure to arrest hemorrhage, ways of m a i n t a i n i n g an airway, the Heimlich m a n e u v e r for large food particles caught in the trachea, use of cold in the immediate t r e a t m e n t of b u r n s and e x t i n g u i s h i n g fire. Our responsibility to t r a u m a is a major one. There is much to be done collectively and individually. Members of UA/EMS are now providing leadership for improved care of the injured victim. For this you receive my heartiest c o n g r a t u l a t i o n s . May your e n e r g i e s be s u s t a i n e d and your efforts intensified.
I
~P November/December 1975
Volume 4 Number 6 Page 523
Our Responsibility to Trauma Curtis P. Artz, MD, FACS* Charleston, South Carolina
INTRODUCTION
It is a t r e m e n d o u s thrill to participate in the portion of the UA/EMS program associated with Robert H. Kennedy, MD. He really is "the f a t h e r of t r a u m a care" as we know it in North America today. Bob K e n n e d y b e c a m e c h a i r m a n of the Committee on T r a u m a of the A m e r i c a n College of S u r g e o n s (ACS) ==4 the year I completed medical Curtis P. Artz, MD school and he occupied t h a t post for 13 years. D u r i n g this period, he was chief of t r a u m a service at New York City's Beckman-Downtown Hospital - - a model for t r a u m a services for m a n y years. The original work he did as the result of a n a t i o n a l survey of fracture s p l i n t i n g i n a m b u l a n c e s first recognized the problem of t r a n s p o r t i n g the injured in this country. His life has been dedicated to t h a t and other aspects of t r a u m a care. The publication of the A m e r i c a n College of Surgeons'
Emergency Care of the Sick and Injured, which he edited, stands as a m o n u m e n t to his dedication to care of the injured. For m a n y years he directed the Field P r o g r a m of the Committee on T r a u m a . It was d u r i n g this period t h a t the c u r r e n t wave of i m p r o v e m e n t in emergency medical services (EMS) came to fruition. Bob K e n n e d y had a d r e a m for America - - to provide the injured with the privilege of high q u a l i t y care. He dedicated his life to this dream and the fruits of his labors are evident to all of us who work *Professor of Surgery and Chairman of the Department, Medical University of South Carolina College of Medicine. Robert H. Kennedy Lecture - - Presented at the Fifth Annual Meeting of UA/EMS in Vancouver, British Columbia, Canada, May 1975. Address for reprints: Curtis P. Artz, MD, Medical University of South Carolina College of Medicine, Charleston, South Carolina 29401.
Page 520 Volume 4 Number 6
in the field of t r a u m a . My d r e a m today is t h a t you will catch the light of his s h i n i n g star and, with enthusiasm, amplify his efforts and accomplishments_
Development The t r e a t m e n t of t r a u m a in this country has always been u n i q u e . Our e x i s t i n g competence is more poorly applied to the m a n a g e m e n t of the injured t h a n to the treaLm e n t of a n y disease. At the end of the Korean conflict the mortality rate in a Mobile A r m y Surgical Hospital was reduced to 2.2%. Then few cities, and certainly no rural areas, could match this low m o r t a l i t y for civilian injuries. The t u r n i n g point in the care of t r a u m a occurred more t h a n ten years later with the 1966 publication of the National Research Council's white paper,AccidentaIDeath
and Disability, the Neglected Disease of Modern Society. This p a m p h l e t s t i m u l a t e d a n a t i o n a l effort to. improve the care of the injured. About the same time, Congress passed the National H i g h w a y Safety Act which offered some m e a n s of i m p l e m e n t i n g better emergency care and t r a n s p o r t a t i o n of the injured. E v e r y :state now has an executive council on emergency medical services. In addition, there has been a great increase in the n u m b e r ofEMS~ systems with r e g i o n a l a n d local advisory councils. S i g n i f i c a n t progress h a s b e e n m a d e in developing improved a m b u l a n c e services. C o m m u n i t i e s have bought new ambulances; a host of emergency medical technicians (EMTs) have been trained. In 1968, the Guidelines for Training of Ambulance Personnel, p u b l i s h e d by the National Research Council, became the curriculum for the basic course of i n s t r u c t i o n in emergency medical care. This was f o l l o w e d by Dr. K e n n e d y l s pocket manual:. entitled, Emergency Care of the Sick and Injured, published by the A m e r i c a n College of Surgeons. In 1971, a textbook entitled, Emergency Care and TranS portation of the Sick and Injured, edited by C. A. Rock wood, MD, was published by the A m e r i c a n Academy 0( Orthopedic Surgeons. This volume is now recognized ~s the n a t i o n a l text for the EMT basic course. Sirhaltase" ously, t h e N a t i o n a l R e s e a r c h C o u n c i l published A/~
Advanced Training Program for Emergency Medical Tec~"
November/December 1975 . J ~
rlicians, which provided the guidelines for an advanced ~MT course of 480 hours. In 1970, under the auspices of ~theAmerican Medical Association's Commission on Emerge~cy M e d i c i n e Services, the N a t i o n a l R e g i s t r y for ~mergency Technicians was begun. These are only a few of ,tiae highlights of progress in the field of t r a u m a d u r i n g the last two decades.
Modern Trauma Care - - T h e EMSS Act A new period in the history of t r a u m a care in the United States began with the passage of the Emergency Medical Services Systems Act of 1973. This act became Public Law ~3-154 on November 6, 1973. It amended the Public Health ~ervice Act to assist and encourage the development of :0rnprehensive area emergency medical services systems. It provides for grants and contracts for feasibility studies 0nd planning, e s t a b l i s h m e n t and i n i t i a l operation, expansion and improvement, research and support of t r a i n i n g 'in emergency medical services. The Act is administered ~mder the Secretary of the D e p a r t m e n t of Health, EducaILi0nand Welfare. The Director of the Emergency Medical ~ervice program is David Boyd, MD. The guidelines for applications u n d e r this Act were published in Program Guidelines of Emergency Medical ervices Systems and are available from the United States Department of Health, Education and Welfare, Public Health Service, Health Services A d m i n i s t r a t i o n , Box 911, R0ckville, Maryland. A n u m b e r of s e m i n a r s are being held t h r o u g h o u t the 'country in an a t t e m p t to provide information about the gct and the essentials of a good application for funding. rhroughout these meetings there has been one predominant theme: a good application will spell out specifically theleadership role of physicians. Emergency medical serw ices in this country need to be developed by physicians. gany highly competent p l a n n e r s and public health officials are necessary for staffing and organizing but there mustbe an identifiable role for physicians knowledgeable in emergency medicine. Undoubtedly, m a n y UA/EMS ~ernbers are i n t i m a t e l y involved in their communities in ious facets of emergency medical care. You are the up that will make the Emergency Medical Services stems Act of 1973 work. Those who are drafting appliations need your support and assistance. Your expertise ~d your contacts with other capable physicians in the tea are necessary for a workable system.
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mortality, effective medical care had to be given in the forward area. Emergency medical care faces a s i m i l a r situation in civilian life today. Once a p a t i e n t arrives at a modern emergency facility the care is excellent. However, the construction of an efficient way for t r a u m a patients to enter the EMS system and receive expert m a n a g e m e n t at the scene of the accident w a r r a n t s our best organizational and t r a i n i n g efforts. The N a t i o n a l Registry of EMTs has now certified more t h a n 22,000 basic EMTs, produced a standardized kit tbr a practical e x a m i n a t i o n and is in the process of developing a new advanced EMT curriculum. C o m m u n i c a t i o n between the physician and the EMT in the field is absolutely essential. Various types of technological a d v a n c e s have allowed for some very h i g h l y sophisticated c o m m u n i c a t i o n systems. For example, a 47 lb kit has been developed for the Houston Fire D e p a r t m e n t by the N a t i o n a l Aeronautic Space Agency. Chief L. O. M a r t i n states t h a t these u n i t s allow easy and excellent c o m m u n i c a t i o n between the EMT at scene of the accident and the physician in the emergency department. This lightweight package also t r a n s m i t s a n electrocardiogram. If we are to improve the effectiveness of the EMT at the scene, it seems imperative t h a t some competent m e a n s of communication be provided.
Emergency Physicians are Needed Obviously, this means t h a t there is somebody in the emergency d e p a r t m e n t with the skills to answer the questions and the ability to care for the p a t i e n t immediately upon his arrival. Last year your K e n n e d y lecturer, Oscar P. Hampton, MD, talked about the emergency physician. Certainly, physicians are needed in the emergency departm e n t with the expertise to cope with any problem t h a t m a y arise. The best system would be a group of the traditional specialists available i n the emergency d e p a r t m e n t 24 hours a day. It is doubtful t h a t such an a r r a n g e m e n t could ever be achieved except in very large u n i v e r s i t y programs where senior residents would serve in this capacity. Our problem t h e n is to t r a i n a physician who is competent to perform the necessary diagnostic and therapeutic m a n e u v e r s to care for the injured and acutely ill u n t i l the traditional specialist arrives.
The basic r e q u i r e m e n t of any emergency system is the ~MT. A wealth of t r a i n i n g materials is now available for ~,~ITeducation Many communities still need individuals [rained in the basic course but a n increasing n u m b e r of ~MTswho have completed one of the more highly sophistitared, advanced courses are working in the field. The Vanced courses p e r m i t EMTs to c o n s t a n t l y improve ir ability and upgrade their position.
The d i l e m m a in t r a i n i n g such an i n d i v i d u a l is that cm'rently there is no way of recognizing his expertise. M a n y feel t h a t there should not be a n y additional so-called "specialty boards." Some have suggested t h a t the specialty of a n emergency physician be recognized by the Board of F a m i l y Practice. This group m i g h t issue a special certificate of competence in emergency medicine if the applicant, after completion of his family practice board, completed two additional years in emergency medicine. Two years in emergency medicine in addition to the three years curr e n t l y required for family practice residents would make this a five year stint and few medical students would opt for such a t r a i n i n g program.
[The need for medical care of t r a u m a or any other emer~ncy problem is p a r a m o u n t at the scene of the accident. ['~is has" b e n very evident in our recent wars. The mor!/ity rate, once the 'victim reached a Mobile A r m y Surgi~/Hospital, was m i n i m a l . To s i g n i f i c a n t l y decrease
Undoubtedly, m a n y c o m m u n i t y hospitals need emergency physicians. It is obvious t h a t more p r i m a r y physicians are required and this is another form of a p r i m a r y physician. At the present time, m a n y medical students would like to enter the field of emergency medicine but,
~he Crucial EMT
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without some recognition, they fear for their status and the future of their career. Most of us interested in improving emergency medical services recognize the need for such a physician. Although perhaps not necessary in the large metropolitan u n i v e r s i t y centers, someone with such skills and t r a i n i n g is needed in the hundreds of c o m m u n i t y hospitals t h r o u g h o u t the country if we expect to have round-the-clock capabilities for true emergency care. The i m p o r t a n t point concerning emergency physicians is t h a t at the present time there is profound need for them. The demands are great and therefore the salary is handsome. Positions are being filled by contract physicians and moonlighting residents. If the service is to be upgraded, a first career p r i m a r y physician, skilled in emergency medicine, m u s t be provided. The facilities to care tbr the injury victim lag far behind our knowledge. The old emergency room has developed into a n emergency d e p a r t m e n t and the e q u i p m e n t and staffing have improved i m m e n s e l y in the past several years. As prehospital and emergency d e p a r t m e n t care improves, the need for s u p p o r t i n g facilities increases. The facility m u s t have radiological, surgical and intensive care capabilities. It is not enough to have a good emergency d e p a r t m e n t and a. highly competent surgeon. The seriously injured p a t i e n t m a y develop p u l m o n a r y complications and require a special respiratory team.
Specialized Centers for Handling Trauma
As hospitals expand, special centers will develop for certain key problems. These include t r a u m a centers with good diagnostic facilities, 24 hour laboratory and radiological capabilities, a renal team for dialysis and managem e n t of acute r e n a l failure, and a staff of surgical specialists. Other centers t h a t must be developed are b u r n centers, hand centers, head i n j u r y centers, spinal cord injury centers, r e h a b i l i t a t i o n centers and, in certain areas, pediatric b u r n centers. Plus, in every section there should be one facility skilled in t r a n s p l a n t a t i o n . Obviously, o p t i m u m care is rendered when the p a t i e n t is t a k e n to the facility best equipped for his type of injury. This m e a n s t h a t emergency facilities m u s t be categorized. The A m e r i c a n Medical Association's Commission on Emergency Medical Services, with m u l t i d i s c i p l i n a r y n a t i o n a l organizations represented, established guidelines for the categorization of hospital emergency services. As you know, four categories were established: (1) comprehensive emergency services (2) major emergency services (3) general e m e r g e n c y services (4) basic e m e r g e n c y services. F u l f i l l m e n t of these guidelines has been very difficult and r e q u i r e s your finest leadership and t h a t of m a n y other organizations_ The i m p l e m e n t a t i o n of hospital categorization will require hospital boards of trustees and staff to plan together and determine the financial aspects necessary to obviate the possible loss of r e v e n u e if one hospital is to be upgraded and receive most of the patients. Somehow, physicians m u s t be the leaders i n organizing the hospitals of t h e i r c o m m u n i t y to accept categorization of emergency services. W h e n Robert Kennedy, MD, took over as director of the Field P r o g r a m for the A m e r i c a n College of Surgeons he made his famous statement, "Emergency d e p a r t m e n t s are
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the weakest link in the care of the injured." Eventually, his work c u l m i n a t e d in a set of hospital emergency depart, merit standards t h a t were adopted by the Committee 0a T r a u m a . Shortly t h e r e a f t e r he developed a pamphlet entitled, A Model of the Hospital Emergency Department, which w e n t t h r o u g h three p r i n t i n g s . Subsequently, ih 1970, a final brochure, The Design and Function of a Hospital Emergency Department was published by the Sub, committee on Emergency Services - - Hospital and these guidelines have served for the basis of upgrading many of the emergency d e p a r t m e n t s in this country.
UA/EMS and Education So far most of the discussion has centered around organi. zation for better t r a u m a care. Now let us enter a field in which the m e m b e r s of this organization have served as real leaders. It is the field of education - - the training of the t r a u m a team. This includes physicians, nurses, physicians' assistants and EMTs. In addition to the need for emergency physicians, there is a need for surgeons t r a i n e d especially for dealing with t r a u m a . Although the I n s t i t u t e of Surgical Research at the Brooke Army Medical Center now has almost 100 of its a l u m n i in academic i n s t i t u t e s in the United States, more b u r n surgeons are required. W h e n the Committee on Development of B u r n C e n t e r s m e t at The Interna. tional Society for B u r n Injuries in Buenos Aires, Septem. ber 1974, they stated t h a t the p r i m a r y requisite for a good b u r n center was a competent and dedicated b u r n surgeon as its leader. Similarly if we are to develop t r a u m a cen. ters, there m u s t be fellowships i n t r a u m a for surgeons who have completed their residency in general surgery'. and would like to specialize in the care of the traumatically injured. Some are available b u t more are needed. The AT8, following the p a t t e r n of the A m e r i c a n Cancer Society, is now a t t e m p t i n g to develop so-called % r a u m a professorships." This is a n endowed chair in a medical sch001~ financed by a gracious donor to the ATS and occupied by an i n d i v i d u a l who has demonstrated competence in the field of t r a u m a . Such professorships should improve the teaching of t r a u m a at the medical s t u d e n t and residency levels. It should s t i m u l a t e y o u n g people to dedicate their lives to the care of t r a u m a . At the present time many d e p a r t m e n t s of surgery are looking for a faculty member to provide capable leadership i n the teaching and managem e n t of t r a u m a . Most of you occupy positions like this in your universities. You need to devise a program of education, residency t r a i n i n g and fellowship for the medical s t u d e n t who wants to foilow your lead. It is our responsibility as leaders of the t r a u m a team to take a specific interest in the t r a i n i n g and continuing education of all who help us. Those in n u r s i n g should see t h a t n u r s e specialists are developed for the intensive m a n a g e m e n t of various types of injuries such as head and s p i n a l C o r d injuries, chest injuries, fractures and b u r n s . You m u s t accept the leadership for inservice education in your i n s t i t u t i o n and intensify your efforts in c o n t i n u i n g education for emergency physicians, emer" gency d e p a r t m e n t nurses, critical care nurses, b u r n nurseS, physicians' assistants, and EMTs. For m a n y years, research in t r a u m a has suffered because of the emphasis on i n v e s t i g a t i o n of h e a r t disease, ca~cer
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'¢d stroke. Undoubtedly, the National Cancer I n s t i t u t e '[1Ua the N a t i o n a l H e a r t and Lung Institute have received ~ • hich percentage of the federal dollar. The a m o u n t of I~10'~e=ybeing spent o n r e s e a r c h in t r a u m a by the N a t i o n a l ~!j,~-titutes of H e a l t h (NIH) has increased only slightly ~"'[,ringthe past years. The I n s t i t u t e for General Medical sciences has money; it probably could obtain more b u t research proposals have not been forthcoming. At #e present time, the great need in research in t r a u m a is ~0t money b u t ideas from competent investigators_ The enacted Public Law 93-498 - - The Federal Fire prevention and Control Act of 1974 - - directs the NIH to isLablish a n expanded program of research on b u r n s , treatment of b u r n injuries and r e h a b i l i t a t i o n of fire vicli~s- For this purpose, $13,000,000 has been authorized tver the next two years. It would be wonderful to be able 10stimulate an i n t e r e s t in t r a u m a in some of the more Ikillful medical s t u d e n t s so t h a t they would pursue a areer where research i n this field is a p a r t of t h e i r ctivities.
'¢ood
recently
There are m a n y areas that deserve further attention. uch information has come to light d u r i n g the last two tecades in the field of shock through the study of some trilliant surgeons and physiologists b u t much r e m a i n s to lelearned. One of the great killers of the injured p a t i e n t s infection. Little is k n o w n about the response of the ~riously injured to infection. For m a n y years, researchers lave produced new drugs to kill micro-organisms. How 'iceit would be if someone could devise a way of enhanc~gthe host's defense mechanisms. The changes that occur 1a seriously injured p a t i e n t cause t r e m e n d o u s losses of nergy. The role of h y p e r a l i m e n t a t i o n in m a i n t a i n i n g a etter balance in the t r a u m a victim w a r r a n t s f u r t h e r ~ploration. The transfer of various parts of the body with Leirown blood supplies, such as muscle bundles and skin ~ps, needs f u r t h e r d e v e l o p m e n t . C e r t a i n l y , t r a u m a gistries m u s t be developed to categorize the causes of ~uma as we seek m e a n s of prevention and t r e a t m e n t .
M a n y more problems a w a i t the p r o b i n g investigator. Finally, the problem of t r a u m a m u s t be t a k e n to the public. There is a great need for public education. The ATS has accepted this as one of its major objectives. First we m u s t teach the public the m e a n i n g of t r a u m a . More t h a n half a century ago when the A m e r i c a n Cancer Society started, few people understood the m e a n i n g of cancer and if they did they were too scared to m e n t i o n it. Now the organization is very productive and much is being done about cancer. The public needs to become more interested in trauma_ We must upgrade first aid t r a i n i n g in schools so t h a t every American citizen will receive at least the basic course. Our citizens m u s t know what to do in case of a n emergency. They m u s t be t a u g h t certain basic steps in life support and how to e n t e r our emergency medical system. The ATS has made great progress in the last two years. The founding membership increased from 400 to more t h a n 3000. This type of membership will close December 1975 and similarly dedicated individuals will become a n n u a l patron members. Crusades for r e g u l a r members have been conducted in several states d u r i n g the m o n t h of May. The ATS is another vehicle t h r o u g h which we can reach our common goals. A l r e a d y t h a t o r g a n i z a t i o n has two 30 second films being shown on television t h r o u g h o u t the country to emphasize the importance of trauma. Other short movies are needed to emphasize the use of pressure to arrest hemorrhage, ways of m a i n t a i n i n g an airway, the Heimlich m a n e u v e r for large food particles caught in the trachea, use of cold in the immediate t r e a t m e n t of b u r n s and e x t i n g u i s h i n g fire. Our responsibility to t r a u m a is a major one. There is much to be done collectively and individually. Members of UA/EMS are now providing leadership for improved care of the injured victim. For this you receive my heartiest c o n g r a t u l a t i o n s . May your e n e r g i e s be s u s t a i n e d and your efforts intensified.
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Volume 4 Number 6 Page 523