Organization of trauma care.

Abstract

The organization of trauma care and the study of trauma systems is an evolving and dynamic endeavor. Historically, trauma has centered on the clinical care of specific injuries and wounds. In ancient times, for those who survived the initial insult, treatment would have centered on superficial soft tissue injuries and fractures. Prayers, incantations, topical salves and dressings would have been the primary modalities of treatment. Careful observation and trial and error would lead to improved treatments and increased capabilities to care for more extensive injuries. As early as 6000 B. C., the Egyptians are reported to have performed amputations, extraction of foreign bodies and lithotomies (1). The opportunity for such learning has almost always been provided by conflict and war. Military surgeons have led the way in both the clinical and the systematic care of the injured patient. Dominique Larrey, during the Napoleonic Wars, developed the concepts of rapid evacuation and early treatment of the injured. Towards this goal he created the ambulance volante or “flying hospital” to evacuate soldiers from the battlefield to the hospital for treatment. Moreover, he established hospitals near the battlefield to decrease the distance and time for evacuation. Prior to these simple concepts, the injured soldiers would often lay on the battlefield for hours to days before any treatment was given (2). A further development in the creation of trauma systems came during the American Civil War. The military recognized that for both issues of mobility and economics, it was not feasible to provide definitive care at every battle being fought. Instead, military hospitals were established along the same Army organization as line units and progression up the hierarchy led to hospitals with increasing levels of care (3). By World War I, the systematic treatment of the wounded through progressive echelons of care was standard protocol (4). Army medics and Navy corpsmen had the dangerous task of evacuating the wounded from the battlefield to the Battalion Aid Station where the injured were treated and returned to combat or quickly stabilized and triaged to a higher level of care at hospitals in the rear. In World War II, motorized ambulances had decreased the evacuation time to 4–6 hours (3). Research in shock and the extensive use of blood transfusions to treat it decreased mortality and morbidity due to acute renal failure from under-resuscitation. Antisepsis and the advent of antibiotics further contributed to the decreased mortality. The U.S. Army had been keeping detailed medical reports of the wounded since the Civil War and these precursors to present day trauma registries allowed development of protocols regarding the best treatment of specific wounds. As an example, during WW II, it was a court martial offense not to treat a colon injury with a colostomy (5). With the advent of helicopters by the Korean War and the Vietnam Conflict, evacuation times were now less than one hour from the battlefield to a fully equipped hospital. Wounded soldiers were expeditiously triaged and cared for by well-trained personnel in a system that provided for definitive care in the shortest time possible. This led to a 97.5 % survival among those soldiers who arrived to a surgical hospital alive (6). These principles were adopted in West Germany in 1970 with the establishment of trauma centers along the autobahns. Helicopters and ambulances ensured rapid prehospital transport of injured persons to definitive care. This contributed, in part, to a 25 percent reduction in motor vehicle crash mortality after system implementation (2).