Elsevier

Injury

Volume 34, Issue 9, September 2003, Pages 735-739
Injury

Trauma care systems in the United States

https://doi.org/10.1016/S0020-1383(03)00152-9Get rights and content

Abstract

The trauma system in the United Sates is in the process of evolution. Although it is recognised that a systems approach to trauma care is ideal, this concept has yet to be realised fully due to political, financial and geographic considerations. The pre-hospital controversies of in-the-field care, resuscitation, and transport are still debated. In-hospital care is governed by a trauma service using the guidelines of the American College of Surgeons (ACS). Speciality care is usually delivered as a consultative service at the request of the trauma service. Co-ordination by the trauma surgeon assures appropriate timing and amount of care by the specialities. Problems facing the delivery of trauma care are malpractice, reimbursement for speciality trauma care call and the need to extend the system to all trauma patients.

Section snippets

The trauma system in the USA

Although no national system for trauma care exists in the USA, the American College of Surgeons Committee on Trauma (ACSCOT) [2] and the American College of Emergency Physicians (ACEP) are dedicated to improving the care of the injured patient. ACEP [1] published a new policy statement in August 1999 entitled “Trauma care systems development, evaluation, and funding” which states that “… Patients with time critical injuries should have their needs matched to an appropriate trauma care facility

Introduction to pre-hospital care

Based on rapid evacuation of injured soldiers from the battlefield to proximate surgical care, [4], [6], [8] the Commercial Hospital in Cincinnati, OH established the first civilian, hospital-based ambulance service in 1865. Four years later, the first city service was developed by New York City’s Bellevue Hospital [4].

During the first half of the 20th century, few, if any, standards or regulations for service provision were available or mandated. With the development of the interstate system

Emergency response systems

Various EMS system designs exist and are typically based on the needs of a jurisdiction, or community. Rural community EMS may be private and volunteer, whereas suburban, or urban, systems are typically paid and usually under municipal government (fire department), private company, or set up as a public utility with a governing board charged with developing specifications for performance. Designs may include multiple levels of provider (basic to advanced life support), or the addition of first

Pre-hospital: medical direction

An EMS medical director is a physician with specialised interest in, and knowledge of, patient care activities unique to the pre-hospital environment. System overview extends from the communications centre through to all components of field care, interacting with all clinical, educational, competence teaching activities and quality improvement aspects of the system. Medical direction is categorised as off-line (indirect) and on-line (direct).

Medical accountability for patient care activities is

Pre-hospital: material resources

Prior to the 1960s, ambulances were crude in design and ill-equipped to address basic medical conditions. During the period of federal EMS development, guidelines for emergency vehicle specifications were adopted and equipment lists were proposed. Today, both the ACS and ACEP continue to publish documents that recommend design, equipment, and medications for ambulances [1].

Central to the entire pre-hospital care system is the communications system. This involves multiple components, all

Pre-hospital care: trauma emergencies

Physicians typically agree that early pre-hospital intervention and stabilisation are critical for patients with medical complaints. Equally, emergency physicians and trauma surgeons typically agree that rapid transport with definitive airway control, if necessary, by endotracheal intubation, to the hospital, without spending an inordinate amount of time at the scene, is the most important priority for injured patients. Data on the importance of ALS procedures in trauma patients may appear

Hospital care

The ultimate goal of a trauma system is for the most seriously injured to receive care in an appropriate, designated trauma centre that is well-prepared to deal with their particular injuries. Victims transported initially to the nearest community hospital should be assessed rapidly, stabilised and prepared for transfer to a trauma centre. The Advanced Trauma Life Support (ATLS) course teaches a common framework to expedite this process, directing that only life-saving interventions be

Relationships of specialities

Depending on local arrangements, variable levels of collaboration occur between the acute trauma team and the specialities in the acute resuscitation of the trauma patient. This ranges from complete involvement in all trauma cases to select involvement as deemed necessary on a consultant basis by the trauma team leader. Usually, the specialist orthopaedic surgeon, neurosurgeon or plastic surgeon, unless especially interested in the acute resuscitation phase. maintains a position as a consultant

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