Ch 1 - PHTLS: Past, Present, & Future - History of Trauma Care in Emergency Medical Services

History of Trauma Care in Emergency Medical Services

The stages and development of the management of the trauma patient can be divided roughly into four time periods as described by McSwain in the Scudder Oration of the American College of Surgeons in 1999. 32 This text, the PHTLS course, and care of the trauma patient are based on the principles developed and taught by the early pioneers of prehospital care. The list of these innovators is long; however, a few especially deserve recognition.

Ancient Period

All of the medical care that was accomplished in Egypt, Greece, and Rome, by the Israelites, and up to the time of Napoleon is classified as premodern EMS. There is much to be learned here, but most of the medical care was accomplished within some type of medical facility. Little was done by prehospital providers in the field.

 Larrey Period

 In the late 1700s, Baron Dominick Jean Larrey, Napoleon’s chief military physician, recognized the need for prompt prehospital care. In 1797, he noted that “the remoteness of our ambulances deprive the wounded of the requisite attention. I was authorized to construct a carriage which I call flying ambulances.” 33 He developed these horse-drawn “flying ambulances” for timely retrieval of warriors injured on the battlefield and introduced the premise that individuals working in these “flying ambulances” should be trained in medical care to provide on-scene and en route care for patients. By the early 1800s, he had established the theory of prehospital care that we continue to use to this day: the “flying” ambulance proper training of medical personnel move into the field during battle for patient care and retrieval field control of hemorrhage transport to a nearby hospital provide care en route develop frontline hospitals He also developed hospitals that were close to the front lines (much like the military of today) and stressed the rapid movement of patients from the field to medical care. Baron Larrey is now recognized as the father of EMS in the modern era. Unfortunately, the type of care developed by Larrey was not used 60 years later at the beginning of the War Between the States by the Union Army in the United States. At the First Battle of Bull Run in August 1861, the wounded laid in the field— 3000 for three days, 600 up to a week. 33 , 34 Jonathan Letterman was appointed Surgeon General and created a separate medical corps with better organized medical care . At the Second Battle of Bull Run a year later, there were 300 ambulances and attendants collected 10,000 wounded in 24 hours. 34 In August 1864, the International Red Cross was created at the First Geneva Convention. 29 The convention recognized the neutrality of hospitals, of the sick and wounded, of all involved personnel, and of ambulances and guaranteed safe passage for ambulances and medical personnel to move the wounded. This was the first step in what we utilize today within the military as our Code of Conduct. This is an important component of the Tactical Combat Casualty Care Course, which is now an integral part of the PHTLS program.

Hospitals, Military, and Mortuaries

In 1865, the first private ambulance in the United States was created in Cincinnati, Ohio, at Cincinnati General Hospital. 34 Several EMS systems soon developed in the United States: Bellevue Hospital Ambulance 34 followed in New York in 1867; Grady Hospital Ambulance Service (the oldest continuously operating hospital-based ambulance) in Atlanta in the 1880s; Charity Hospital Ambulance Services created in 1885 by a surgeon, Dr. A. B. Miles in New Orleans; and many other facilities in the United States. These ambulance services were run basically by hospitals, by the military, or by mortuaries up until 1950. 32 Some changes in medical care occurred during the various wars up until the end of World War II, but generally the system and the type of care rendered prior to arrival in the Battalion Aid station (Echelon II) or at the back door of the civilian hospital remained unchanged until the mid 1950s. Many ambulances in the major cities with teaching hospitals were staffed by interns beginning their first year of training. The last ambulance service to require physicians on the ambulance runs was Charity Hospital in New Orleans in the 1960s. Despite the fact that physicians were present, most of the trauma care was primitive. The equipment and supplies were not changed from that used during the War Between the States. 32

Farrington Era

The era of J.D. “Deke” Farrington, MD, began in 1950. Dr. Farrington, the father of EMS in the United States, stimulated the development of improved prehospital care with his landmark article, “Death in a Ditch.” 35 In the late 1960s, Farrington and other early leaders, such as Oscar Hampton, MD, and Curtis Arts, MD, brought the United States into the modern era of EMS and prehospital care. 41 Dr. Farrington was actively involved in all aspects of ambulance care. His work as chairman of the committees that produced three of the initial documents establishing the basis of EMS— the essential equipment list for ambulances of the American College of Surgeons (ACS), 36 the KKK 1822 ambulance design specifications of the US Department of Transportation, 37 and the first emergency medical technician (EMT) basic training program— also propelled the idea and development of prehospital care. In addition to the efforts of Dr. Farrington, others actively helped promote the importance of prehospital care for the trauma victim. Robert Kennedy, MD, was the author of “Early Care of the Sick and Injured Patient.” 38 Sam Banks, MD, with Dr. Farrington, taught the first prehospital training course to the Chicago Fire Department in 1957, which initiated proper care of the trauma patient. A 1965 text edited and compiled by George J. Curry, MD, a leader of the ACS and its Committee on Trauma, stated: “Injuries sustained in accidents affect every part of the human body. They range from simple abrasions and contusions to multiple complex injuries involving many body tissues. This demands efficient and intelligent primary appraisal and care, on an individual basis, before transport. It is obvious that the services of trained ambulance attendants are essential. If we are to expect maximum efficiency from ambulance attendants, a special training program must be arranged.” 38 Although prehospital care was rudimentary when Curry wrote this passage, the words still hold true as prehospital care providers address the specific needs of the trauma patient in the field. The landmark white paper, “Accidental Death and Disability: the Neglected Disease of Modern Society,” further accelerated the process in 1967. 39 The National Academy of Sciences/ National Research Council issued this paper just one year after Curry’s call.

Modern Era of Prehospital Care

The modern era of prehospital care began with the Dunlap and Associates report to the EMS Department of Transportation in 1968 defining the curriculum for EMT Ambulance Training. This training is now known as EMT-Basic. The National Registry of EMTs was established in 1970 and developed the standards for testing and registration of trained EMS personal as advocated in the NSF/ ACS white paper. Rocco Morando was the leader of the NREMT for many years and was associated with Drs. Farrington, Hampton, and Artz. Curry’s call for specialized training of ambulance attendants for trauma was initially answered by using the educational program developed by Drs. Farrington and Banks, by the publication of the “orange book” by the American Academy of Orthopedic Surgeons (first edited by Dr. Walter Hoyt), by the EMT training programs from NHTSA, and by the PHTLS training program during the past 25 years. The first training efforts were primitive but have progressed significantly in a relatively brief time. The first textbook of this era was Emergency Care and Transportation of the Sick and Injured. This was the brainchild of Walter A. Hoyt Jr., MD, and was published in 1971 by the American Association of Orthopedic Surgeons. 32 This text is now in its 9th edition. During this same period , the Glasgow Coma Scale was developed in Glasgow, Scotland, by Dr. Graham Teasdale and Dr. Bryan Jennett for research purposes. Dr. Howard Champion (the author of the Blast chapter in the military version of this textbook) brought it into the United States and incorporated it into the care of the trauma patient for assessment of the continued neurological status of the patient. 40 The Glasgow Coma Scale is a very sensitive indicator of improvement or deterioration of such patients. In 1973, federal EMS legislation was created. Dr. David Boyd was in charge of this system. He divided the components of trauma care into 15 segments. One of these segments was education. This became the basis for the development of EMT-Basic, EMT-Intermediate, and EMT-Paramedic care throughout the United States. The curriculum was initially defined by the US Department of Transportation in the National Highway Traffic Safety Administration and became known as the National Standard Curriculum or the DOT curriculum. Dr. Nancy Caroline defined the standards and the curriculum for the first EMT-Paramedic program and wrote the initial textbook used in the training of EMT paramedics. The Blue Star of Life was designed by the American Medical Association as the symbol of the “Medic Alert” indication that a patient had an important medical condition the EMS should note. It was given to the National Registry of EMTs (NREMT) by the AMA as the logo of that registration and testing organization. Because the American Red Cross would not allow the “Red Cross” logo to be used on ambulances as an emergency symbol, Lew Schwartz (chief of NHTSA’s EMS branch) asked Dr. Farrington, who at the time was the chairman of the NREMT board, to allow NHTSA to use the emblem for ambulances . Permission was granted by Dr. Farrington and Rocco Morando (executive director of NREMT). It has since become an international symbol of Emergency Medical Services. 32 The National Association of EMTs was developed in 1975 by Jeffrey Harris with the financial support of NREMT.  The accomplishments of these great physicians, EMS providers, and organizations stand out; however, there are many more, too numerous to mention, who contributed to the development of EMS. To all of them, we owe a great debt of gratitude. The modern era of EMS in the United States can essentially be divided into four periods 32 : Grab and run No care— either in the field or en route, with rapid transportation to the hospital, frequently without anyone in the patient-care compartment— was the system prior to the 1950s. Field management and care This period began with the publication of the national standard curriculum in 1969 continued until approximately 1975. Stay and play From 1975 until mid-1980s, the trauma patient and the cardiac patient were treated exactly alike; that is, attempts to stabilize the patient in the field, often for prolonged amounts of time, were provided. No delay trauma care In the mid-1980s it became apparent that the trauma patient was different from the cardiac patient. Trauma surgeons such as Frank Lewis, MD, and Donald Trunkey, MD, realized that, unlike the cardiac patient for whom all or most of the tools needed for re-establishment of cardiac output— CPR, external defibrillation , and supportive medications— were available to the properly trained EMT in the field, for the trauma patient, the most important tools— surgical control of internal hemorrhage and replacement of blood— were not available in the field. The importance of moving the patient rapidly to the correct hospital became apparent to both the field providers and the medical directors. This includes a facility with a well -trained trauma team comprised of emergency physicians, surgeons, trained nurses, O.R. staff, blood bank, registration and quality assurance processes, and all of the steps necessary for the management of the trauma patient. All of these resources are awaiting the arrival of the patient with the surgical team standing by to take the patient directly into the operating room. Over time, these standards have been modified to include such concepts as permissive hypotension (Dr. Ken Mattox) and Red Blood Cell: plasma transfusion (1: 1) (Dr. John Holcomb). However, the bottom line of rapid availability of a well-equipped OR has not changed. Rapid treatment of the trauma patient depends on a prehospital care system that offers easy access to the system. This access is aided by a single emergency phone number (e.g., 9-1-1 in the United States, other numbers in other countries), a good communication system to dispatch the emergency medical unit , and well-prepared and well-trained prehospital care providers. Many people have been taught that early access and early CPR save the lives of those experiencing cardiac arrest. Trauma can be approached the same way. The principles just listed are the basis for good patient care; to these basic principles has been added the importance of internal hemorrhage control, which cannot be accomplished outside of the trauma center and operating room. Thus, rapid assessment, proper packaging, and rapid delivery of the patient to a facility with OR resources immediately available has become the additional principle that was not understood until the mid-1980s.