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Leading surgeon urges civilian trauma healthcare to follow military's lead

Immediate treatment and swift transportation to a well-equipped hospital have slashed death rates from Iraq and Afghanistan. Rural areas in particular could benefit from such a system.

September 12, 2010|By Tony Perry, Los Angeles Times

Reporting from San Diego — War has often spurred medical advances: immunization against tetanus during World War I, the perfection of penicillin during World War II, and more.

Now a leading San Diego physician wants the medical and political establishments in the United States to improve trauma care for civilians by adopting a system akin to that developed by the U.S. military to treat battlefield casualties from Iraq and Afghanistan.

Trauma continues to be "a disease for which we have a cure," said Dr. A. Brent Eastman.

Still, for people under age 45, trauma-related injuries are the leading cause of death in the United States. Death rates are highest in rural areas with a paucity of trauma surgeons and inadequate air transportation, Eastman said.

In a detailed speech last year to a convention of surgeons, and in an article in the August edition of the Journal of the American College of Surgeons, Eastman suggests that the U.S. look to the military's success in reducing the death rate from wounds inflicted in battle.

The same can be done for trauma patients in the United States, Eastman said, but not if the nation's patchwork system for trauma care remains "fragmented, overwhelmed and underfunded."

Eastman — a general, vascular and trauma surgeon — is chief medical officer and corporate senior vice president of Scripps Health in San Diego, which runs five blue-chip hospitals, two of which are trauma centers.

He also is chairman of the Board of Regents of the American College of Surgeons and in the 1980s helped create the San Diego County trauma system, which has been credited with greatly reducing the percentage of "preventable" deaths in the region.

According to one study, the percentage of wounded personnel in Iraq and Afghanistan who die is in the low single-digits, compared to nearly 25% in Vietnam.

The military system starts with emergency treatment on the battlefield by Army medics and Navy corpsmen — often at risk of their own lives.

That treatment is followed by swift transportation by helicopter or land vehicle to a field hospital, then to a larger, better equipped hospital "in-country" and finally evacuation to a military hospital in the United States or Germany.

In 2007, Eastman was a visiting physician at Landstuhl Regional Medical Center, the U.S. military hospital next to the air base at Ramstein, Germany. Since 2004, nearly 13,000 U.S. service personnel wounded in Afghanistan and Iraq have been evacuated to Landstuhl.

Eastman continues to be impressed with the surgical skills of military physicians and the speed with which injured personnel are brought to Landstuhl. "It's all about getting the right patient to the right place at the right time and [Landstuhl] does it as good as anyone," he said.

In one case, Eastman said, he was the third surgeon within 24 hours to operate on a Marine who had lost a leg in Iraq to a roadside bomb. Without the immediate surgery done in Iraq, Eastman said, the Marine would probably have lost his other leg and might have died of shock or bled to death.

One key to reducing death rates from trauma in the United States, Eastman said, is a transportation system that can get an injured person to the right hospital. There is a direct correlation between high death rates in an area and a lack of trauma surgeons, he said.

A British newspaper recently suggested that a British soldier hurt on an obscure battlefield has a better chance of getting timely and expert medical care than someone hurt in downtown London.

Dr. Atul Gawande, a surgeon and associate professor at the Harvard School of Public Health, lauds the military system for reducing casualty rates.

Although there have been advances in trauma medicine because of the wars in Iraq and Afghanistan — notably new blood-clotting materials and better use of tourniquets —the military's success in reducing casualties was not dependent on those innovations, Gawande noted in his book, "Better: A Surgeon's Notes on Performance.

"They did so through a commitment to making a science of performance, rather than waiting for new discoveries," Gawande wrote.

Eastman said one military strategy that he would like to see copied is the use of videoconferencing so that professionals can compare notes. A hospital improving its care in isolation from the rest of the region is not sufficient, he said.

"It has to be a trauma system," he said.

A third of states have no statewide trauma system, Eastman said. And of states that do have such systems, nearly two-thirds report that funding to sustain them is in jeopardy.

The healthcare legislation passed by Congress and signed by President Obama calls for an overhaul of the nation's trauma care system, but does not provide any funding.

Eastman believes that failing to fund a better system is only delaying the public's costs of care and rehabilitation for people left incapacitated by trauma.

"The people who are injured from trauma are our youth, our children, our future," he said.

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