Philosophy of PHTLS
PHTLS teaches knowledge that includes an understanding of anatomy and physiology, patient care skills and the limitations of time and blood loss, and the need to get the patient to the operating room as quickly as possible. This philosophy allows, nay requires, the provider to use critical thinking to make and carry out decisions that will enhance the survival of the trauma patient. PHTLS does not train providers to use protocols for patient care. Protocols are a robotic approach that does not allow better alternatives to be considered. Rather PHTLS provides and teaches understanding of medical care and critical thinking to achieve these goals . Each provider/ patient contact involves a unique set of circumstances. If the provider understands the basis of medical care and the specific needs of this individual patient, then unique patient decisions can be made that provide the particular patient being treated with the greatest chance of survival. It is the belief of the PHTLS educational process that providers are not medical technicians carrying out instructions sent down from “on high,” but rather that they have a good fund of knowledge, are critical thinkers, and have appropriate care skills to make and carry out excellent patient care. PHTLS does not “tell” the provider what to do but supplies the provider with the appropriate knowledge and skills to use critical thinking to arrive that the best management of the specific trauma patient( s) at hand. The opportunity for a prehospital care provider to help another person is greater in the management of trauma patients than in any other patient encounter. The number of trauma patients encountered is higher than most other patient populations, and the chance for survival of the trauma patient who receives excellent trauma care, both in the prehospital and the hospital setting, is probably greater than that of any other critically ill patient. The prehospital care provider can lengthen the life span and productive years of the trauma patient and benefit society by virtue of the care provided. The prehospital care provider, through effective management of the trauma patient, has a significant influence on society. Understanding, learning, and practicing the principles of PHTLS is more beneficial to patients than any other educational program. 1 The following facts have led to the revised and expanded Chapter 2 on injury prevention in this edition of Prehospital Trauma Life Support.
The Problem
Trauma is the leading cause of death in persons between 1 and 44 years of age. 2 Approximately 80% of teenage deaths and 60% of childhood deaths are secondary to trauma. Trauma continues to be the seventh leading cause of death in elderly persons. Almost three times more Americans die of trauma each year than died in the entire Vietnam War and in the Iraq war through 2008. 3 Every 10 years, more Americans die of trauma than have died in all US military conflicts combined. Only in the fifth decade of life do cancer and heart disease compete with trauma as a leading cause of death. About 70 times as many Americans die yearly from blunt and penetrating trauma in the United States as died yearly in the Iraqi conflict through 2008. Prehospital care providers can do little to increase the survival of a cancer patient. For the trauma patient, however, prehospital care providers can often make the difference between life and death; between temporary disablement and serious or permanent disability; or between a life of productivity and a life of destitution and welfare. In the United States, about 60 million injuries occur each year; 40 million will require emergency department care; 2.5 million will be hospitalized; and 9 million of these are disabling . About 8.7 million trauma patients will be temporarily disabled, and 300,000 will be permanently disabled. 4 , 5 The cost for care of trauma patients is staggering. Billions of dollars are spent on the management of trauma patients, not including the dollars lost in wages, insurance administration costs, property damage, and employer costs. The National Safety Council estimates that the economic impact in 2007 from both fatal and non-fatal trauma is approximately $ 684 billion. 6 Lost productivity from disabled trauma patients is the equivalent of 5.1 million years at a cost of more than $ 65 billion annually. For patients who die, 5.3 million years of life are lost (34 years per person) at a cost of more than $ 50 billion. Comparatively, the costs per patient (measured in dollars and in years lost) for cancer and heart disease are much less, as illustrated in Figure 1-1 . For example, proper protection of the fractured cervical spine by a prehospital care provider may make the difference between lifelong quadriplegia and a productive healthy life of unrestricted activity. Prehospital care providers encounter many more such examples almost every day.
FIGURE 1-1 A: Comparative costs in thousands of dollars to US victims of trauma, cancer, and cardiovascular disease each year. B: Comparative number of years lost as a result of trauma, cancer, and cardiovascular disease.
The following data come from WHO Global Burden of Disease project, 2004:
Road traffic injuries are a huge public health and development problem— Road traffic crashes kill 1.3 million people a year or an average of 3242 people every day. Road traffic crashes injure or disable between 20 million and 50 million people a year. Road traffic crashes rank as the ninth leading cause of death and account for 2.2% of all deaths globally.
The majority of road traffic injuries affect people in low-income and middle-income countries, especially young males and vulnerable road users—90% of road traffic deaths occur in low-income and middle-income countries 7 ( Figure 1-2 ).
The impact of preventable injuries is worldwide. Although the events that produce injuries and deaths may be of a differing etiologies from country to country, the consequences are not. Trauma is a worldwide problem . We who work in the trauma community have an obligation to our patients to prevent injuries, not just be able to treat them after they occur. The often told story about EMS illustrates this point. On a long winding mountain road, there was one turn where cars would often slide off and land at the bottom, 100 feet below. It was the decision of the community to station an ambulance at the bottom of the dangerous area to care for the patients that were involved. The better alternative would have been to place guard rails along the road on the curve to PREVENT the incident from occurring in the first place. Trauma care is divided into three phases: pre-event, event, and postevent. The prehospital care provider has responsibilities in each phase.
Pre-event Phase
Trauma is no accident, even though it is often referred to as such. An accident is defined as either “an event occurring by chance or arising from unknown causes” or “an unfortunate occurrence resulting from carelessness , unawareness , ignorance.” Most trauma deaths and injuries fit the second definition but not the first and are preventable. Traumatic incidents fall into two categories: intentional and unintentional. The pre-event phase involves the circumstances leading up to an injury. Efforts in this phase are primarily focused on injury prevention. In working toward prevention of injuries, the public must be educated to increase the use of vehicle occupant restraint systems, promote methods to reduce the use of weapons in criminal activities, and promote nonviolent conflict resolution. In addition to caring for the trauma patient, all members of the health-care delivery team have a responsibility to reduce the number of victims. Currently, violence and unintentional trauma cause more deaths annually in the United States than all diseases combined. Violence accounts for more than one third of these deaths ( Figure 1-3 ). Motor vehicles and firearms are involved in more than one half of all trauma deaths, most of which are preventable ( Figure 1-4 ). FIGURE 1-2 Worldwide distribution of road traffic deaths per 100,000 population.
FIGURE 1-3 Unintentional trauma accounts for more deaths than all other causes of trauma death combined. (Data from the National Center for Injury Prevention and Control: Wisqars leading causes of death reports, 1999– 2006. Centers for Disease Control and Prevention.) Motorcycle-helmet– usage laws are one example of legislation that has affected injury prevention. In 1966, the US Congress gave the Department of Transportation the authority to mandate that states pass legislation requiring the use of motorcycle helmets. The use of helmets subsequently increased to almost 100 %, and the fatality rate from motorcycle crashes decreased dramatically. Congress rescinded this authority in 1975. More than half the states repealed or modified the existing legislation. As states reinstate or repeal these laws, mortality rates change. Recently, more states have repealed, rather than instituted, such laws, resulting in increased death rates in 2006 and 2007. 9 Motorcycle deaths are on the rise while deaths from automobiles are decreasing. The increase in motorcycle deaths was 11% in 2006. 10 The most likely cause for this dramatic increase in mortality is the decreased use of helmets while riding. Only 20 states have universal helmet laws. In states with such laws helmet usage is 74% whereas in states without such laws the usage rate is 42%. 11 The decreased number of states with such laws is the major factor from the drop in overall helmet usage from 71% in 2000 to 51% in 2006. As an example in one state (Florida), the change in the law in 2002 produced an increased death rate 24% greater than the increase in registrations would have predicted. In August 2008, US Secretary of Transportation, Mary Peters, reported a drop in highway fatalities in automobiles while at the same time there was an increase in motorcycle fatalities. There has been major improvement in all aspects of vehicular safety except motorcycles.
FIGURE 1-4 Motor vehicle trauma and firearms account for almost half of the deaths that result from traumatic injury. (Data from the National Center for Injury Prevention and Control: Wisqars leading causes of death reports, 1999– 2006. Centers for Disease Control and Prevention.) Another example of preventable trauma deaths involves drunk driving. 13 As a result of pressure to change state laws for the level of intoxication while driving and through the educational activities of such organizations as Mothers Against Drunk Drivers (MADD), the number of drunk drivers involved in fatal crashes has been consistently decreasing since 1989. Another way to prevent trauma is through the use of child safety seats. Many trauma centers, law enforcement organizations, and emergency medical services (EMS) conduct programs to educate parents in the correct installation and use of child safety seats. The other component of the pre-event phase is preparation by trauma care providers for the events that are not prevented. Preparation includes proper and complete education with updated information to the current medical care. It is just as important to update your knowledge with current medical practices and knowledge as it is to update your home computer or handheld device with the latest software. In addition, it is necessary to review the equipment on the response unit at the beginning of every shift and to review with your partner the individual responsibilities and expectations of who will carry out what duties. It is just as important to review the conduct of the care when you arrive on the scene as it is to decide who will drive and who will be in the back with the patient.
Event Phase
This phase is the moment of the actual trauma. Steps performed in the pre-event phase can influence the outcome of the event phase. This applies not only to our patients, but also to ourselves. Whether driving a personal vehicle or an emergency vehicle, prehospital care providers need to protect themselves and teach by example. It is important to always drive safely, follow traffic laws, not engage in distracting activities such as cell phone use or texting, and use the protective devices available, such as vehicle restraints, in the driving compartment and in the passenger or patient-care compartment.
Postevent Phase
Obviously, the worst possible outcome after a traumatic event is death of the patient. Donald Trunkey, MD, has described a trimodal categorization of trauma deaths. 14 The first phase of deaths occurs within the first few minutes and up to an hour after an incident. These deaths would likely occur even with prompt medical attention . The best way to combat these deaths is through injury prevention and safety strategies. The second phase of deaths occurs within the first few hours of an incident. These deaths can be prevented by good prehospital care and good hospital care. The third phase of deaths occurs several days to several weeks after the incident. These deaths are generally caused by multiple organ failure. Much more needs to be learned about managing and preventing multiple organ failure; however, early and aggressive management of shock in the prehospital setting can prevent some of these deaths ( Figure 1-5 ). R Adams Cowley, MD, founder of the Maryland Institute of Emergency Medical Services (MIEMS), one of the first trauma centers in the United States, described and defined what he called the “Golden Hour.” 15 Based on his research, Cowley believed that patients who received definitive care soon after an injury had a much higher survival rate than those whose care was delayed. One reason for this improvement in survival is preservation of the body’s ability to produce energy to maintain organ function. For the prehospital care provider, this translates into maintaining oxygenation and perfusion and providing rapid transportation to a facility that is prepared to continue the process of resuscitation using blood and plasma (Damage Control Resuscitation) and to not artificially elevate the blood pressure (< 90 mmHg) using large volumes of crystalloid. An average urban EMS system, in the United States, has a response time (from the time of notification that the incident occurred until arrival on the scene) of 6– 8 minutes. A typical transport time to the receiving facility is another 8– 10 minutes. Between 15 and 20 minutes of the magic “Golden Hour” are used just to arrive at the scene and transport the patient. If prehospital care at the scene is not efficient and well organized , an additional 30– 40 minutes can be spent on the scene. With this time on the scene added to the transport time, the “Golden Hour” has already passed before the patient arrives at the hospital where the better resources of a well-prepared emergency department are available for the benefit of the patient. Research data are starting to support this concept. 16 , 17 One of these studies showed that critically injured patients had a significantly lower mortality rate (17.9% vs. 28.2%) when transported by a private vehicle rather than an ambulance. 16 This unexpected finding was most likely the result of prehospital care providers spending too much time on the scene. In the 1980s and 1990s , a trauma center documented that EMS scene times averaged 20– 30 minutes for patients injured in motor vehicle crashes (MVCs) and for victims of penetrating trauma. This situation raises the questions that all prehospital providers need to ask: “Is what I am doing going to benefit the patient? Does that benefit outweigh the risk of delaying transport?” One of the most important responsibilities of a prehospital care provider is to spend as little time on the scene as possible. In the first precious minutes after arrival to a scene, a prehospital care provider rapidly assesses the patient, performs lifesaving maneuvers, and prepares the patient for transportation. In the 2000s, following the tenets of PHTLS prehospital, times have decreased and survival has increased.
FIGURE 1-5 Immediate deaths can be prevented only by injury-prevention education because some patients’ only chance for survival is for the incident not to have occurred. Early deaths can be prevented through timely, appropriate prehospital care to reduce mortality and morbidity. Late deaths can be prevented only through prompt transport to a hospital appropriately staffed for trauma care. A second responsibility is actually transporting the patient to an appropriate facility. The factor that is most critical to any patient’s survival is the length of time that elapses between the incident and definitive care. For a cardiac arrest patient, definitive care is the restoration of a normal heart rhythm and adequate perfusion. Cardiopulmonary resuscitation (CPR) is merely a holding pattern. For a patient whose airway is compromised, definitive care is the management of the airway and restoration of adequate ventilation. The reestablishment of either ventilation or normal cardiac rhythm by defibrillation is usually easily achieved in the field. However, as critical care hospitals develop STEMI programs, the amount of time until balloon dilatation of the involved cardiac vessels is becoming more important. 18 , 19 , 20 , 21 The management of trauma patients is different but time is just as critical, perhaps more so. Definitive care is usually hemorrhage control and restoration of adequate perfusion by replacement of fluids as near to whole blood as possible. Administration of packed red blood cells to plasma, in a ratio of 1: 1 to replace lost blood, has produced impressive results by the military in Iraq and Afghanistan and now in the civilian community. These fluids are not available for use in the field and are another reason for rapid transport to the hospital. En route to the hospital balanced resuscitation (see Shock chapter) has proven to be important. Hemostasis (hemorrhage control) cannot always be achieved in the field or in the emergency department (ED); it must often be achieved in the operating room (OR). Therefore, in determining an appropriate facility to which a patient should be transported, it is important that the prehospital care provider consider the transport time to a given facility and the capabilities of that facility in the critical thinking process.
FIGURE 1-6 In locations in which trauma centers are available, bypassing hospitals not committed to the care of trauma patients can significantly improve patient care. In severely injured trauma patients, definitive patient care generally occurs in the operating room (OR). An extra 10 to 20 minutes spent en route to a hospital with an in-house surgeon and in-house OR staff will significantly reduce the time to definitive care in the OR. (Blue, EMS response time. Purple, on-scene time. Red, EMS transport time. Orange, surgical response from out of hospital. Yellow, OR team response from out of hospital.) A trauma center that has a surgeon available either before or shortly after the arrival of the patient, a well-trained and trauma-experienced emergency medicine team, and an OR team immediately available can often have a trauma patient with life-threatening hemorrhage in the OR within 10– 15 minutes of the patient’s arrival and make the difference between life and death. On the other hand, a hospital without such in-house surgical capabilities must await the arrival of the surgeon and the surgical team before transporting the patient from the ED to the OR. Additional time may then elapse before the hemorrhage can be controlled, resulting in an associated increase in mortality rate ( Figure 1-6 ). There is a significant increase in survival if non-trauma centers are bypassed and all severely injured patients are taken to the trauma center. 22 - 29 Experience, in addition to the initial training in surgery and trauma, is important. Studies have demonstrated that the more experienced surgeons in a busy trauma center had a better outcome than the less experienced trauma surgeons. 30 , 31
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