When trauma expert A. Brent Eastman MD, chairman of the American College of Surgeons Board of Regents, describes his inspiration to take up medicine, he often starts with a tale from his childhood in Evanston, in rural southwestern Wyoming.
He tells how in the early 1950s, his uncle Gilbert was basically the region's entire trauma system. Gilbert was not only the county coroner, he also owned the area's funeral home and taught first aid on the side.
"Whenever there were injuries on the roads or ranches, he and his mortuary helper could slip out the coffin rollers in his 1951 Cadillac combination hearse and ambulance, slip in a gurney, stick on the flashing red light, and be on their way," Eastman wrote in a recent issue of the Journal of the American College of Surgeons. The article, part of the Scudder Oration on Trauma, is entitled "Wherever the Dart Lands: Toward the Ideal Trauma System."
Sometimes, a funeral had to be postponed for a medical emergency. "It was a somewhat delicate maneuver to offload the casket and take off for the scene of the trauma, not to mention disconcerting to bystanders, when the hearse arrived. No doubt some of them wondered about a conflict of interest; would they turn left to the mortuary, or right to the hospital."
Gilbert also organized the town's response to "The Great Train Wreck of 1951," when a train carrying surgeons from San Francisco to Chicago ran a red light covered by snow in Evanston, and hit the back of another train. Several of the surgeons were killed and several others wounded.
"As an 11-year-old boy I was taken by my father, a locomotive engineer running the great steam engines and my hero, to see this crash because the engineer was a next-door-neighbor and friend. This was my first exposure to mass casualty and it awakened my interest in trauma," Eastman says.
This week, Eastman was back in Wyoming, where he and his wife, fellow Scripps Memorial physician Sarita Eastman, own a vacation home.
Spending quiet time there beneath the majesty of the Grand Tetons, he spoke with me about the discovery of the Golden Hour by Maryland Shock Trauma's R. Adams Cowley MD, and the fact that most cities in the country now have major certified trauma centers. And he spoke of the challenges that remain in bringing those life-saving, rapid fire systems to the reach of small town America.
It's now closer than ever, with trauma care funding and demonstration projects for rural America embedded in 10 of the 974 pages of the Patient Protection and Affordable Care Act. The landmark legislation included mentions of various grants for rural trauma spending, many in the tens of millions dedicated for trauma system improvement. But unfortunately, that money was not appropriated, Eastman says, something he hopes will change with the rural support of Sen. Max Baucus of Montana and Nevada Sen. Harry Reid.
"It would be a big start," Eastman says hopefully.
Eastman himself helped create one of nation's first trauma systems. In San Diego County in the early 1980s, he and several emergency room doctors from area hospitals persuaded reluctant county health officials that though such a system might hurt some hospitals in some political districts, (those hospitals would no longer receive patients via ambulance,) it would lower the preventable trauma death rate. And that it did, from 22% to between 1% and 2%, figures that have been maintained for the last quarter century.
Patients might be stabilized in smaller, non trauma hospitals initially. But if they can be transported—through a preferably government-regulated, monitored system—to a verified trauma center, ready specialty board-certified providers such as neurosurgeons, anesthesiologists, plastic surgery experts and others could save most of these otherwise doomed patients.
There, patients critically injured by vehicle collisions, violence, falls, or in the case of the Wyoming wilderness, bear maulings and lightning strikes, could survive with plenty of quality years to enjoy.
With so much success throughout the state, California trauma experts are aggressively working to create a system that would merge all five trauma regions throughout the state so those who might have an unintentional injury in an area without a nearby hospital, or without one with teams and equipment ready to go in 10 minutes, Eastman tells me.
To prove his point on how trauma systems save lives, Eastman recently superimposed three maps to show comparative death rates from motor vehicle and bicycle accidents across the country. A large swath of the non-coastal West, Montana, Wyoming, New Mexico and Arizona, Oklahoma, Kansas, Nebraska, and major portions of states straddling the Mississippi Delta, Louisiana, Mississippi, Alabama and Arkansas are colored in red, which indicates highest death rates per 100,000 of 28 to 87 or orange, with death rates or 23 to 28.
"The areas where it took longer than 60 minutes to get to a trauma center, the death rate was significantly higher," he says.
Areas in blue had the lowest vehicle death rates of 4.89 to 13.66, such as Southern and San Francisco Bay Area in California, virtually all of New England and the states along the coast of Lake Michigan. Those are the areas with interlocking trauma systems and transfer agreements with smaller hospitals that may be the first to receive critically injured patients.
With a second map, Eastman superimposed long travel times to get to a trauma center with death rates per 100,000. That too showed a correlation between longer times and more death.
And in the third map he superimposed again the number of surgeons by county.
The counties with longer distances to a trauma center, fewer surgeons and higher death rates match with amazing accuracy, Eastman showed.
Eastman isn't suggesting that every small town in America turn its local 25-bed critical access facility into a trauma center. That's extremely impractical.
But what he is suggesting is that local health and political leaders agree to create systems to parlay patients from those smaller hospitals to regional centers as soon as those patients can be safely transported, sometimes by helicopter, sometimes by ground. But transported, he says.
"What I feel—I and others with the same passion for the care of injured patients—is that you, could throw a dart at a map of the U.S. And wherever it lands, in 10 years, if you were injured there you'd be assured that you'd be expeditiously transported to the level of care you needed. That doesn't mean you'd be in a trauma center in an hour. But there'd be a system that got you there as soon as possible."
Creation of such a system will take recognition from leaders in rural areas "that they can't do it all on their own," Eastman says. "And I know from talking with some of them, these rural areas really want these agreements as much as anybody."
"One of the surgeons said to me recently, 'Brent, you know the definition of rural trauma? It's when you get called at 3 in the morning with a big crash on the interstate and multiple badly injured and you drive to the hospital and your truck is the only one in the parking lot.'"
With systems pre-arranged, that one surgeon can get on the phone and call a regional trauma center, even if it's several hundred miles away. "We can say, 'I've got 10 people, but we can take care of two.' And boom, it happens. The helicopter or ground transport comes where appropriate."
That's Eastman's dream for the future, with support from politicians, the healthcare system, and of course, funding specifically called for in the nation's new health reform bill.
Someday, Eastman says, he may move back to Wyoming and retire. And when that day comes, he hopes, the nation's trauma system will be seamless.