Part 1: A Brief History of Trauma Systems

The history of trauma care in America parallels our history of caring for injured military personnel during war.

Systems of care for injured service members were first implemented during the Civil War from 1861-1865. Triage, aid stations, and rapid transport to field hospitals or general hospitals would be rudimentary by today’s standards, but this system was a significant achievement of the time and set the stage for injury management during World Wars I and II and the Korean War.⁷

During the Civil War, President Abraham Lincoln drove creation of the first trauma manual, which was the first time processes to care for injured patients were formally documented. Later, the concept of taking researchers into the battlefield to study outcomes (or how they fare after their treatment) began during World War II. Many of these wartime advances served as models for the modern trauma system.⁸

After World War II, medical specialization in America increased and the first hospital emergency departments opened.⁹ They were staffed by hospital physicians who volunteered for emergency medicine training, since emergency medicine was not yet a formalized specialty. The Hill-Burton Act of 1946 helped accelerate this movement by providing grants to states to build hospitals and requiring those hospitals to have emergency departments.¹⁰ This requirement continues to apply to the majority of non-profit hospitals today. At the time, however, ambulance services were nonexistent, or if present, typically run by funeral homes. Lessons learned from WW II set the stage for modern, professional emergency medical services (EMS) systems.

Further advances in medical transportation, including use of helicopters during Korean and Vietnam Wars, demonstrated that rapid evacuation to definitive care (a trauma center or facility that provides a spectrum of care for all injured patients), saves lives.¹¹

“Collaboration between civilian and military health systems started at least 100 years ago,” said David B. Hoyt, MD, FACS, Executive Director of the American College of Surgeons. “These partnerships helped advance care both during peacetime and during times of conflict.”

Further advances in medical transportation, including use of helicopters during Korean and Vietnam Wars, demonstrated that rapid evacuation to definitive care (a trauma center or facility that provides a spectrum of care for all injured patients), saves lives.

“Collaboration between civilian and military health systems started at least 100 years ago,” said David B. Hoyt, MD, FACS, Executive Director of the American College of Surgeons. “These partnerships helped advance care both during peacetime and during times of conflict.”

On the homefront, ACS recognized injury as an important national issue and created its Committee on Fractures in 1922 to focus on improving patient care.¹² It was renamed the Committee on Trauma in the 1950s.

More attention was drawn to trauma or injury in the U.S. because of the development of the nation’s interstate highway system in the 1950s. A landmark report by the National Academy of Sciences in 1966, “Accidental Death and Disability: The Neglected Disease of Modern Society,” described traumatic injury as a national epidemic.¹³

“The 1966 report was a turning point for trauma,” said Dr. Hoyt. “The report helped spur new efforts to create regional EMS and 911 systems and establish paramedic training programs. The ACS Committee on Trauma then began its work to develop trauma center standards and create the National Trauma Data Base, which collects data on care and outcomes to this day.”

In addition, two pieces of legislation helped further advance pre-hospital care. In 1966, the Highway Safety Act created the National Highway Traffic Safety Administration (NHTSA) and required all states to develop EMS systems.¹⁴ Then in 1973, the Emergency Medical Services Systems Act established a grant program to support regional EMS systems, emergency medical technician (EMT) training and development of air transport services.¹⁵

Injury prevention was also a key focus during this time. The U.S. began requiring seat belts in all cars in 1968, though it took until 1984 for states to begin passing laws requiring their use.^16,17The first airbags for cars were released in 196918 and the first bike helmet was developed in 1975.19 The trauma community, including surgeons, nurses, and emergency medicine physicians strongly advocated for these advances.

It was also during this time that ACS released its Optimal Hospital Resources for the Injured Patient manual in 1976, outlining the criteria for an ideal trauma center. This publication set the stage for the components of an optimal trauma system from prevention to pre-hospital care to acute care, to rehabilitation, and research.

“The Optimal Resources manual became the guidebook for trauma centers and trauma systems,” said Ronald Stewart, MD, FACS, Chair, ACS Committee on Trauma. “It set the standards for care across pre-hospital and acute-care settings and defined the skills and equipment trauma teams and centers needed. It continues to evolve and is now used by trauma leaders in the United States, Canada, and Latin America.”

In addition, in its Optimal Resources manual, ACS established the process for categorizing hospitals as Levels I, II, III or IV based on minimum standards at each level of care. In the 1980s, the ACS Verification Review Committee began conducting on-site reviews of hospitals seeking trauma designation, as well as consultations with hospitals, communities, and states that were establishing a trauma center or system.²⁰

And it worked. Studies have shown trauma standards and verification saves lives. A 2006 study in The New England Journal of Medicine found that after adjusting for differences in injury severity, patients treated at a verified trauma center had a 25 percent lower chance of dying than patients treated at a non-trauma center.²¹

ACS also created a series of education programs including Advanced Trauma Life Support (ATLS), which was introduced in 1980. It teaches methods for immediate management of injured patients including resuscitation and stabilization, as well as triage and transfer. Since its introduction, the course has been taken by more than one million medical providers globally.²² Other ACS-developed courses, including Basic Endovascular Skills for Trauma (BEST), Advanced Surgical Skills for Exposure in Trauma (ASSET), Trauma Evaluation and Management (TEAM) and Advanced Trauma Operative Management (ATOM) are among the most important trauma education and training programs globally.  Rural Trauma Team Development (RTTD) emphasizes a team approach to the initial evaluation and resuscitation of the trauma patient at a rural facility, and the Disaster Management and Emergency Preparedness (DMEP) teaches planning methods, preparedness, and medical management of trauma patients in mass casualty disaster situations.

The ACS Stop the Bleed course is the newest offering aimed at turning civilian bystanders into immediate responders.

All of that work saved millions of lives, but important gaps in care remained.

“The nation’s developing trauma system became a patchwork of care, with limited Federal ownership. While care was advancing quickly in some parts of the country, other areas lagged far behind. As a result, thousands of lives per year continued to be lost,” said Dr. Hoyt.

• A series of reports in the 1980s and 1990s reiterated the need for coordinated national attention on trauma. In 1985, the National Academy of Sciences report “Injury in America: A Continuing Health Problem,” called for a greater focus on emergency care.²³ The report led to development of the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control in 1992. It also spurred passage of the Trauma Care Systems Planning and Development Act in 1990 which supported development of trauma systems nationwide.²⁴ However, the programs were eliminated in 1995, leaving a gap in Federal leadership.

• In 2001, the Healthcare Resources and Service Administration (HRSA) Division of Healthcare Preparedness created the Trauma/EMS Systems Program,²⁵ but it too was eliminated from the Federal budget in 2006.

• Two reports by the Institute of Medicine in 1999, “Reducing the Burden of Injury: Advancing Prevention and Treatment,” and in 2007, “Hospital-Based Emergency Care: At the Breaking Point,” emphasized the nation’s spotty trauma system and ongoing need for a greater focus on reducing lives lost to traumatic injury.

• And, finally, a 2016 report by the National Academies of Science, Engineering and Medicine (NASEM), “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths,” became the sixth report in the past 50 years to address the need for a national trauma system.

“Over 50 years ago experts first called for a national trauma system. Since that time we’ve tried many times to bring understanding of the problem and potential solutions to the forefront,” said Dr. Hoyt.

“We now need to ask, ‘What can we do that’s different as we go forward?’ We’ve been repeating this message over and over for the past 35 years. Now is the time to make this happen,” said Dr. Stewart.

Today there is new urgency to the issue as mass casualty attacks threaten homeland security. At the same time the country continues to unwind from the conflicts in Iraq and Afghanistan. These wars saw the lowest combat case-fatality rate in the history of armed conflict,

“There has been a rich relationship between civilian and military surgeons for a long time. Now we need to determine how to sustain that,” said Dr. Hoyt.

The 2016 NASEM report, mentioned earlier, outlines 11 recommendations for completing the nation’s trauma system, including Federal leadership, coordination between military and civilian health leaders, stronger collaboration between states, steps to address gaps in trauma care, and a national trauma research plan with dedicated funding for clinical trials.

In April 2017, ACS and partner organizations NHTSA, the U.S. Department of Defense (DOD), NASEM and the National Institutes of Health (NIH) brought together trauma leaders from government agencies, the military, and the private sector at the NIH in Bethesda, MD, to develop an action plan to implement the NASEM report’s recommendations. While participants acknowledge the issue has been discussed for 50 years, leaders resoundingly agreed that now is the time to act to save lives.

“This is a health crisis we can no longer ignore,” said Dr. Stewart “At least one-third of Americans today live in an area without a complete trauma system, and tens of thousands of lives are lost unnecessarily each year. This is the most important health problem facing our children and our military service members during times of conflict. We must act now.”

“A national trauma system is the backbone for disaster preparedness and national security in our country,” said Robert J. Winchell, MD, FACS, Chair, ACS Trauma Systems Evaluation and Planning Committee. “As a nation, we must address this vital need.”

In our next story, we’ll take a deeper look at innovations shared between military and civilian trauma systems that have saved lives on the battlefield and on the homefront. These lessons are serving as a model for one national trauma system inclusive of military and civilian care.

References

1. https://www.nigms.nih.gov/education/pages/Factsheet_Trauma.aspx
2. https://www.nigms.nih.gov/education/pages/Factsheet_Trauma.aspx
3. Florence, C., T. Simon, T. Haegerich, F. Luo, and C. Zhou. 2015. Estimated lifetime medical and work-loss costs of fatal injuries—United States, 2013. Morbidity and Mortality Weekly Report 64(38):1074-1082.
4. https://www.nap.edu/catalog/23511/a-national-trauma-care-system-integrating-military-and-civilian-trauma
5. Branas, C. C., E. J. MacKenzie, J. C. Williams, C. W. Schwab, H. M. Teter, M. C. Flanigan, A. J. Blatt, and C. S. ReVelle. 2005. Access to trauma centers in the United States. Journal of the American Medical Association 293(21):2626-2633.
6. https://www.nap.edu/catalog/23511/a-national-trauma-care-system-integrating-military-and-civilian-trauma
7. https://www.ncbi.nlm.nih.gov/pubmed/3046560
8. http://www.nbcnews.com/id/42490904/ns/technology_and_science-science/t/how-civil-war-changed-modern-medicine/#.WRm_8JIrLIU
9. https://www.nap.edu/read/11621/chapter/16
10. https://www.nap.edu/read/11621/chapter/16
11. https://www.nap.edu/read/11621/chapter/16
12. https://www.facs.org/quality-programs/trauma
13. https://www.nap.edu/read/11621/chapter/16
14. https://www.nap.edu/read/11621/chapter/16
15. https://www.nap.edu/read/11621/chapter/16
16. http://www.autonews.com/article/19960626/ANA/606260818/1964-brought-seat-belts-for-every-buyer
17. http://www.ghsa.org/state-laws/issues/Seat-Belts
18. https://www.consumeraffairs.com/news04/2006/airbags/airbags_invented.html
19. http://www.davison.com/blog/2013/05/14/history-tuesday-the-bicycle-helmet
20. https://www.nap.edu/read/11621/chapter/16#358
21. https://www.ncbi.nlm.nih.gov/pubmed/16436768
22. https://www.facs.org/quality-programs/trauma/education
23. https://www.nap.edu/read/11621/chapter/16
24. https://www.nap.edu/read/11621/chapter/16#357
25. https://www.nap.edu/read/11621/chapter/16#357