CHAPTER 1 THE DEVELOPMENT OF TRAUMA SYSTEMS

Modern trauma care consists of three primary components: prehospital care, acute surgical care or hospital care, and rehabilitation. Ideally, a society, through state (department, province, regional, etc.) government, should provide a trauma system that ensures all three components. The purpose of this chapter is to show how trauma systems have evolved, whether or not they work, and to define current problems.

From an historical viewpoint, it is an accepted concept that trauma care and trauma systems are inextricably linked to war. What is not appreciated is that trauma systems are not recent concepts. They date back to centuries before the Common Era. It is not known for certain whether the wounds of prehistoric humans were due primarily to violence or to accident. The first solid evidence of war wounds came from a mass grave found in Egypt and date to approximately 2000 BC. The bodies of 60 soldiers were found in a sufficiently well-preserved state to show mace injuries, gaping wounds, and arrows still in the body. The Smith Papyrus records the clinical treatment of 48 cases of war wounds, and is primarily a textbook on how to treat wounds, most of which were penetrating. According to Majno, there were 147 recorded wounds in Homer’s Iliad, with an overall mortality of 77.6%. Thirty-one soldiers sustained wounds to the head, all of which were lethal. The surgical care for a wounded Greek soldier was crude at best. However, the Greeks did recognize the need for a system of combat care. The wounded were given care in special barracks (klisiai) or in nearby ships. Wound care was primitive. Barbed arrowheads were removed by enlarging the wound with a knife or pushing the arrowhead through the wound. Drugs, usually derived from plants, were applied to wounds. Wounds were bound, but according to Homer, hemostasis was treated by an “epaoide,” that is, someone sang a song or recited a charm over the wound.

The Romans perfected the delivery of combat care and set up a system of trauma centers throughout the Empire. These trauma centers were called valetudinaria and were built during the 1st and 2nd centuries ACE. The remains of 25 such centers have been found, but significantly, none were found in Rome or other large cities. Of some interest, there were 11 trauma centers in Roman Britannia, more than exist in this area today. Some of the valetudinaria were designed to handle a combat casualty rate of up to 10%. There was a regular medical corps within the Roman legions, and at least 85 army physicians are recorded, mainly because they died and earned an epitaph.

From elsewhere in the world came other evidence that trauma systems were provided for the military. India may well have had a system of trauma care that rivaled that of the Romans. The Artasastra, a book written during the reign of Ashoka (269–232 BC) documented that the Indian army had an ambulance service, with well-equipped surgeons and women to prepare food and beverages. Indian medicine was specialized, and it was the shalyarara (surgeon) who would be called upon to treat wounds. Shalyarara literally means “arrow remover,” as the bow and arrow was the traditional weapon for Indians.

Over the next millennium, military trauma care did not make any major advances until just before the Renaissance. Two French military surgeons, who lived 250 years apart, brought trauma care into the Age of Enlightenment.

Ambrose Paré (1510–1590) served four French kings during the time of the French-Spanish civil and religious wars. His major contributions to treating penetrating trauma included his treatment of gunshot wounds, his use of ligature instead of cautery, and the use of nutrition during the postinjury period. Paré was also much interested in prosthetic devices, and designed a number of them for amputees.

It was Dominique Larrey, Napoleon’s surgeon, who addressed trauma from a systematic and organizational standpoint. Larrey introduced the concept of the “flying ambulance,” the sole purpose of which was to provide rapid removal of the wounded from the battlefield. Larrey also introduced the concept of putting the hospital as close to the front lines as feasible in order to permit wound surgery as soon as possible. His primary intent was to operate during the period of “wound shock,” when there was an element of analgesia, but also to reduce infection in the postamputation period.

Larrey had an understanding of problems that were unique to military surgery. Some of his contributions can best be appreciated by his efforts before Napoleon’s Russian campaign. Larrey did not know which country Napoleon was planning to attack, and there was even conjecture about an invasion of England. He left Paris on February 24, 1812, and was ordered to Mentz, Germany. Shortly thereafter, he went to Magdeburg and then on to Berlin, where he began preparations for the campaign, still not knowing precisely where the French army was headed. In his own words, “Previous to my departure from the capital, I organized six divisions of flying ambulances, each one consisting of eight surgeons. The surgeons-major exercised their divisions daily, according to my instructions, in the performance of operations, and the application of bandages. The greatest degree of emulation, and the strictest discipline, were prevalent among all the surgeons.”

The 19th century may well be described as the century of enlightenment for surgical care in combat. This was partly because of better statistical reporting, but also because of major contributions of patient care, including the introduction of anesthesia. During the Crimean War (1853–1856), the English reported a mortality rate of 92.7% in cases of penetrating wounds of the abdomen, and the French had a rate of 91.7%. During the American War Between the States, there were 3031 deaths among the 3717 cases of abdominal penetrating wounds and a mortality rate of 87.2%.

The Crimean War was noteworthy in having been the conflict in which the French tested a number of local antiseptic agents. Ferrous chloride was found to be very effective against hospital-related gangrene, but the English avoided the use of antiseptics in wounds. It was also during the Crimean War that two further major contributions to combat medicine were introduced when Florence Nightingale emphasized sanitation and humane nursing care for combat casualties.

The use of antiseptics was continued into the American War Between the States. Bromine reduced the mortality from hospital gangrene to 2.6% in a reported series of 308 patients. This contrasted with a mortality of 43.3% among patients for whom bromine was not used. Strong nitric acid was also used as an antiseptic in hospital gangrene, with a mortality rate of 6.6%. Anesthetics were used by federal military surgeons in 80,000 patients. Tragically, mortality from gunshot wounds to the extremities remained high, paralleling that reported by Paré in the 16th century. The mortality from gunshot fractures of the humerus and upper arm was 30.7%; those of the forearm, 21.9%; of the femur, 31.7%; and of the leg, 14.4%. The overall mortality rate from amputation in 29,980 patients was 26.3%.

The Franco-Prussian War (1870–1874) was marked by terrible mortality and the reluctance of some surgeons to use the wound antiseptics advocated by Lister. The mortality rate for femur fractures was 65.8% in one series, and ranged from 54.2% to 91.7% in other series. Late in the conflict, surgeons finally accepted Lister’s recommendations, and the mortality rate fell dramatically.

During the Boer War (1899–1902), the British advised celiotomy in all cases of penetrating abdominal wounds. However, early results were abysmal, and a subsequent British military order called for conservative or expectant treatment.

During the early months of World War I, abdominal injuries had an unacceptable 85% mortality rate. As the war progressed, patients were brought to clearing stations and underwent surgery near the front, with a subsequent decrease in mortality to 56%. When the Americans entered the conflict, their overall mortality from penetrating abdominal wounds was 45%. One of the major contributions to trauma care during World War I was blood transfusion.

Since World War II, many contributions to combat surgical care have led to reductions in mortality and morbidity. Comparative mortality rates for various conflicts are listed in Table 1. Surgical mortality is shown in Table 2. The introduction of antibiotics and improvements in anesthesia, surgical techniques, and rapid prehospital transport are just a few of the innovations that have led to better outcomes.

MODERN TRAUMA SYSTEM DEVELOPMENT

Between the two world wars, some significant advances were made in civilian trauma care. Böhler formed the first civilian trauma system in Austria in 1925. Although initially directed at work-related injuries, it eventually expanded to include all accidents. At the onset of World War II, the Birmingham Accident Hospital was founded. It continued to provide regional trauma care until recently. By 1975, Germany had established a nationwide trauma system, so that no patient was more than 15–20 minutes from one of these regional centers. Due to the work of Tscherne and colleagues, this system has continued into the present, and mortality has decreased by over 60% (Figure 1).

Figure 1 Trauma deaths have a trimodal distribution. The first death peak (approximately 50%) is within minutes of the injury. The second death peak (approximately 30%) occurs within a few hours to 48 hours. The third death peak occurs within 1 to 4 weeks (approximately 15%) and represents those patients who die from the complications of their injury or treatment. From a public health perspective, the first death peak can only be addressed by prevention, which is difficult, since part of this strategy means dealing with human behavior. The second death peak is best addressed by having a trauma system, and the third death peak by critical care and research.

In North America, foundations for modern trauma systems were being undertaken. In 1912, at a meeting of the American Surgical Association in Montreal, a committee of five was appointed to prepare a statement on the management of fractures. This led to a standing committee. One year later, the American College of Surgeons was founded, and in May 1922, the Board of Regents of the American College of Surgeons started the first Committee on Fractures with Charles Scudder, MD, as chair. This eventually became the Committee on Trauma. Another function begun by the college in 1918 was the Hospital Standardization Program, which evolved into the Joint Commission on Accreditation of Hospitals. One function of this standardization program was an embryonic start of a trauma registry with acquisition of records of patients who were treated for fractures. In 1926, the Board of Industrial Medicine and Traumatic Surgery was formed. Thus, it was the standardization program by the American College of Surgeons, the Fracture Committee appointed by the American College of Surgeons, the availability of patient records from the Hospital Standardization Program, and the new Board of Industrial Medicine in Traumatic Surgery that provided the seeds of the trauma system.

In 1966 the first two trauma centers were established in the United States: William F. Blaisdell at San Francisco General Hospital and Robert Freeark at Cook County Hospital in Chicago. Three years later, a statewide trauma system was established in Maryland by R. A. Cowley. In 1976, the American College of Surgeons Committee on Trauma developed a formal outline of injury care called Optimal Criteria for Care of the Injured Patient. Subsequently, the task force of the American College of Surgeons Committee on Trauma met approximately every 4 years and updated their optimal criteria, which are now used extensively, in establishing regional and state trauma systems, and have recently been exported to Australia. Other contributions by the American College of Surgeons Committee on Trauma include introduction of the Advanced Trauma Life Support courses, establishment of a national trauma registry (National Trauma Data Bank), and a national verification program. The latter is analogous to the old hospital standardization program, and “verifies” by a peer review process whether a hospital’s trauma center meets American College of Surgeons guidelines.