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Home , Emergency medicine, Trauma center, Trauma surgery

AS REAL the evolution of trauma care and emergency AS IT GETS

By Barbara Ravage

14 THE SAFETY NET SPRING 2006 Born on the battlefi eld, trauma care came of age during the turbulent 1960s, when the lessons learned in the Korean and Vietnam confl icts were brought back to the United States to treat trauma on the home front. To be sure, there were emergency rooms long before that time, but they would hardly be recognizable compared to today’s high-tech emergency departments and Level I trauma centers.

Specialty and trauma specifi cally trained in emergency medicine.” care developed in response to the unique In 1910, the Flexner report, Medical Educa- dangers and needs of the urban environment, tion in the United States and Canada, spurred driven by the demand for better care on the the evolution of medicine into a specialty- part of both providers and , and by driven fi eld. But it took the National Re- technological advances ranging from CT scans search Council’s 1966 report, Accidental Death to remote fi eld telemedicine. Three public and Disability: The Neglected of Modern — Los Angeles County+USC, San Society, to provide the impetus for specialty OPPOSITE: Rancho Los Amigos Francisco General, and Cook County — were training of in emergency medicine. National Rehabilitation Center. on the front lines of developing trauma care. At the time, Anderson was professor of ob- BELOW: Doctors work on stetrics and gynecology at the University of injured at General Hospital, The Birth of Emergency Medicine Southern California School of Medicine and Los Angeles, after the series of earthquakes that rocked Southern California, 1933. In the late sixties, the emergency room at CONTINUED ON NEXT PAGE LAC+USC Medical Center was no different from that in most municipal hospitals in the country, except it was bigger and busier. Patients by the hundreds walked or were car- ried through its portals every day. From bullet to heart attacks, spinal cord to severe , drug overdoses to miscarriages, patients in need of immediate care were tended to by a handful of residents on rotation, with the support of nurses and . According to Gail V. Anderson, MD, under whose stew- ardship the LAC+USC Medical Center ER became a world-class , “Before the advent of emergency medicine as a specialty, emergency rooms were staffed by part-time, itinerant physicians who were essentially moonlighting. groups formed and were practicing emergency medi- cine on a full-time basis, but no one had been chief of the and gynecology service Modeled after the mobile army surgical at LAC+USC Medical Center, its main teach- hospital (M.A.S.H.) units, the nation’s fi rst ing hospital. In 1971, he was asked to chair a hospital-based civilian trauma units were new department of emergency established in 1966 at San Francisco General medicine at USC, the fi rst in Hospital and Chicago’s Cook County hospi- Inner-city public hospitals the nation. In 1976, Anderson tals. Both had long served the poorest residents helped found the American of their cities and had reputations for providing remain the last, best training Board of Emergency Medicine. a broad range of quality emergency care. Emergency medicine was The modern facility at San Francisco General grounds for trauma . accepted as the twenty-third stands on the site of the old Mission Emer- board-certifi ed medical gency Hospital, built in 1909. In 2002, the specialty in 1979 and administered its fi rst sprawling, nearly century-old Cook County certifi cation exams in 1980. Hospital was replaced by The John H. Stroger, As a pioneer of emergency medical Jr. Hospital of Cook County, with a high-tech, education, Anderson asserts that the training self-contained . programs in public hospitals offer “the best Although these two trauma units served way of assuring quality emergency care for as models in the sixties, it was a decade later this large mass of people.” that formal guidelines were established for the systematic delivery of trauma care. The 1976 From M.A.S.H. to the Home Front report from the American College of Committee on Trauma (ACSCOT), Optimal Every trauma is an emergency, but not every Hospital Resources for Care of the Seriously Injured, emergency involves trauma. Indeed, trauma is specifi ed the requirements for effective trauma a complex event requiring a team of physicians, systems. Out of that report came the now- nurses, and technicians specially trained to do familiar trauma center levels, as well as the the right thing at top speed. Much is made of organization of multidisciplinary trauma teams the “,” the window of opportunity and the trauma center verifi cation process. for saving the life of a severely injured , San Francisco General, LA County+USC, but in the most severe cases, the and Stroger hospitals are sites of Level i trauma measures its opportunities in minutes. centers. As anchors for large inner-city popu- lations, they see more than their share of trauma cases, and as public hospitals, they are EARLY CIVILIAN TRAUMA CARE committed to offering the best possible care to all patients, regardless of ability to pay. That commitment is well expressed by Stroger’s The nation’s fi rst specialized civilian trauma units were established just four chief of trauma, Roxanne Roberts, MD, who decades ago at San Francisco General says, “We’re all here because we fell in love and Chicago’s Cook County hospitals. with the patients that we take care of and we But urgent care has been an aspect of believe in the mission of the hospital. We’re hospital services throughout their history. certainly not here for the salaries or the glory.” Here, doctors at Central Emergency Hospital in San Francisco provide emer- Or as William Schecter, MD, chief of surgery gency care in 1935. at San Francisco General, put it: “The thing about working in a place like this is that when you go home at the end of the day you at least know that you tried to do the right thing.”

The Training Challenge

“Trauma care is undergoing a sea change,” says Schecter. Thanks to huge advances in the fi eld, innumerable lives have been saved. Today, the

16 THE SAFETY NET SPRING 2006 odds are that a trauma patient who reaches the Trauma Care Evolves hospital alive will live to be discharged. Diag- nostic technologies such as CT scanners have The classic picture of the dramatically reduced the need for exploratory trauma team in a life-and- surgery that was previously standard in cases of death race against time is only . Non-invasive techniques to stop part of a larger view. Today, also mean “the number of injured trauma care encompasses patients that actually need surgery is much what happens to patients lower than it used to be,” Schecter maintains. before they even get to the But those advances have had unintended hospital and long after they consequences in the training of surgeons and leave. often other trauma team members. In most hospi- begins in fi tted tals, blunt trauma resulting from car accidents, out with advanced life-saving for example, makes up the majority of cases. equipment and highly It is in the area of blunt trauma that non-sur- trained EMTs in constant gical techniques have had the greatest utility. telecommunication with the “It’s becoming increasingly diffi cult to hospital-based trauma team. maintain the interest of young surgeons be- Rehabilitation for disabled cause the number of operations they do is trauma patients is also part much lower than before,” Schecter observes. of the mission. Inner-city public hospitals like San Francisco End-of-life care and sup- General, however, continue to see a dispro- port for families are often portionate number of penetrating traumas, neglected in a place where for which surgery is a life-saving necessity. sudden and unexpected death “I happen to work in a hospital where, unfor- is a daily reality, but not at tunately, we still treat numerous shootings and Stroger Hospital in Chicago. stabbings, so from a surgical point of view, it’s In what is a new model for still quite interesting.” Thus, inner-city public the hospice concept, Stroger hospitals remain the last, best training grounds was awarded a grant by the for . “We have a saying here Foundation in 2005 at San Francisco General Hospital: ‘This is to develop a hospice program as real as it gets,’” says Schecter. for its trauma unit. “As sur- If was the driving force geons we’re trained not to behind the development of trauma care, give up,” says Kimberly Joseph, LAC+USC Hospital is among a select group MD, director of the Trauma that is returning the favor. Taking advantage ICU at Stroger. “Perhaps we of the expertise at this , the wait too long before talking Department of Defense initiated a coopera- about death and asking the patient and their PHOTOS Page 14: Submitted; Page 15: Corbis; Page 16: San Francisco History Center, San Francisco Public Library; Page 17: Pennsylvania tive program to train medical corps personnel family what they would like.” The Aetna Hospital Historic Collections, Philadelphia for conditions no one in the military had grant, she believes, “will help us identify seen since Vietnam. In a partnership between specifi c needs of patients and their families LAC+USC and the San Diego-based Navy during this time and how we can make the Trauma Training Center, Navy fl eet and dying process easier.” forward resuscitative surgical teams gain Increasingly, trauma centers are including hands-on experience in the LAC+USC Level prevention in their mandate. and 1 trauma center. Jackson Memorial Hospital violence prevention programs at LAC+USC, in Miami, another NAPH member, provides Stroger, and San Francisco General employ a similar service to the Army at its Ryder public education, community outreach, and Trauma Center, while the Air Force trains at counseling in this effort. As Schecter puts the R. Adams Cowley Trauma Center it, “What we would ideally like to do is put in Baltimore. ourselves out of business.”

SPRING 2006 THE SAFETY NET 17