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Better care born on the front lines

September 22, 2008|Mary Engel | Times Staff Writer

Like ambulances and blood transfusions, trauma centers -- hospital units on standby to treat the most severe injuries -- were born in the battlefield.

The Korean War's MASH units, or mobile army surgical hospitals, were set up close to the action to treat wounded soldiers delivered by helicopter. During the Vietnam War, rapid transport of the wounded to crack teams of surgeons and nurses was credited with a drop in deaths from war injuries, from 30% of those wounded in World War II to 24%, according to Department of Defense figures.

Hospitals began opening civilian trauma centers after a 1966 report by a group of prominent physicians pointed out that people in the U.S. had a better chance of surviving a war wound than a car crash.

Around 1989, the medical industry began to focus on knitting together various centers to form trauma systems, said Dr. David Hoyt, chairman of trauma surgery at UC Irvine Medical Center and School of Medicine and a founder of the San Diego trauma system.

A system includes first responders and paramedics who provide initial aid and quickly assess which injuries need the most urgent care. The motto of trauma systems is to get the right patient to the right hospital in the right amount of time, especially in cases with multiple patients such as the Metrolink crash.

"The trauma system is the foundation for responding to a disaster," Hoyt said. "When you have a multi-casualty event, then you have a system in place to triage many patients to several different hospitals."

That, too, developed in step with military medicine. In Iraq and Afghanistan today -- where fewer than 10% of wounded service members die of their injuries -- the concept of "triage and transport" has been honed to an art, said Dr. Chet Morrison, a 14-year veteran of the Army Medical Corps who was in Iraq in 2004.

Wounded soldiers are treated near the front lines before being transported to nearby field hospitals for "damage control" surgery, then flown in the Air Force equivalent of flying critical care units to hospitals in Germany or the United States.

"In Los Angeles, it's less of a problem because you don't have to go the thousands of miles," said Morrison, now director of surgical critical care and attending trauma surgeon at Michigan State University.

"There are very high-level hospitals that are right there. But you sort these people out, and the sickest people go to the higher level of care, and the less injured to other hospitals," he said.

Having a well-honed triage system in place is one of the keys to saving lives in traumatic injuries, Morrison said. The other is to stop the patient from bleeding to death.

In severe trauma, the blood can ooze from so many places and from so many tiny vessels that it is impossible to staunch, and it can become so thin that it doesn't clot. Quickly infusing blood and chemical products that restore clotting is critical.

"If you can get them to stop bleeding, they will rapidly get better," Morrison said. "If you can't get them to stop bleeding, nothing you can do will help them."


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