CLINICALORTHOPAEDICSANDRELATEDRESEARCHNumber422,pp.17–22
©2004LippincottWilliams&Wilkins
TraumaSystemDevelopmentinNorthAmerica
WilliamS.Hoff,MD,FACS*;andC.WilliamSchwab,MD,FACS
Theconceptsoforganizedtraumacare,manyofwhichorig-inatedinmilitarymedicine,havebeenproveneffectiveintheciviliansector.Aformaltraumasystemincludesallphasesofcarefromprehospitalthroughrehabilitation.Althoughtraumacentersassumetheleadershiprole,inatrulyinclu-sivesystem,allhealthcareproviders(prehospitalproviders,communityhospitals,andtraumacenters)haveadefinedroleinprovidingcaretopatientswithtrauma.Asaresult,patientsreceivetreatmentattheappropriateinstitution,re-sourcesareallocatedappropriately,andtheclinicaloutcomeisoptimized.Suchasystemideallyissuitedtotheuniqueneedsofthemasscasualtyscenario.
Initsmostbasicform,traumareferstophysicalinjurywhich,becauseofitsseverity,posesapotentialthreattolifeorlimb.Traumasystemshaveevolvedasanorganizedapproachtoprovideseverelyinjuredpatientsrapidinitialtreatment.Inkeepingwiththeaforementioneddefinition,traumasystemsaredesignedtopromoteoptimumcarealongacontinuumfromprehospitalcarethroughrehabili-tationtoprovidepatientswiththebestoutcomepossible.Theadvantagesofsuchanorganizedapproachseemlogi-calandideallysuitedtothemultiplecasualtysituation.However,althoughtheconceptoftraumasystemshasbeenreasonablywelldeveloped,http://www.77cn.com.cnrgeareasofthecountry,es-peciallymoreruralareas,lackrefinedsystemsoftraumacare.
Thissectionwillbeginwithabriefreviewofthees-sentialmedicalhistorypertinenttotraumasystemdevel-opment.WethenwilldescribetheconceptofthemoderntraumasystemandelaborateontheexperienceintheUnitedStatesandCanada.Finally,inthecontextofourcurrentnationalchallenge,wewilloffersomesummarypointsandsuggestionsonfuturedirectionsfortraumasys-temdevelopment.
From*St.Luke’sHospital,Bethlehem,PA;andthe UniversityofPenn-sylvaniaMedicalCenter,Philadelphia,PA.
Correspondenceto:WilliamS.Hoff,MD,FACS,St.Luke’sHospital,Dept.ofTrauma&SurgicalCriticalCare,801OstrumStreet,Bethlehem,PA18015.Phone:610-954-2200;Fax:610-954-6459;E-mail:hoffw@http://www.77cn.com.cn.DOI:10.1097/01.blo.0000128292.43913.83
BriefHistoryofTrauma
Majoradvancementsinclinicalcareandtraumasystemsdevelopmenthaveparalleledmilitaryhistory.AlthougheachwarthroughoutthehistoryofWesterncivilizationhashadsomecontributiontotraumasystemdevelopment,thefirstsignificantadvancemaybeattributabletoDom-iniqueLarreyduringtheNapoleanicWars.Inthelate1700s,Larreydevelopedthe“flyingambulance”totrans-portwoundedsoldierstodefinitivecare.Beforethisinno-vation,woundedsoldierssimplywereleftonthebattle-fielduntil,sometimesdaysaftercompletionofthebattle,theycouldberetrievedsafely.Inaddition,Larreyestab-lishedfieldhospitalsclosetotheactivecombat.7,22
Larrey’scontributionsrepresentthecornerstoneonwhichmoderntraumacareandtraumasystemshavebeenbuilt.Patientoutcomeafterinjuryisoptimizedbyrapidprovisionofdefinitivecare.
Significantdevelopmentsinciviliantraumamedicinelargelyhavebeentheresultofourtwentiethcenturymili-tarycampaigns.22DuringWorldWarI,anorganizedsys-temofcasualtytriagethroughprogressivelevelsofcarewasestablished.WoundedsoldierswereevacuatedviamotorizedambulancetoBattalionAidStationswheretheywereevaluated,treated,andreturnedtocombatortrans-portedtoahigherlevelofcare.22,25PhysiciansreturningfromWWIputtheBattalionAidStationconceptintoci-vilianpracticewiththedevelopmentofaccidentroomsdesignedtoevaluateinjuredandcriticallyillpatients.4IncreaseduseofthemotorizedambulanceinWorldWarIIalsoreducedtimetotreatmentforwoundedsoldiers(Table1).
Improvedradiocommunications,theuseofhelicopterstotransportinjuredsoldiers,andfront-linesurgicalhospi-talswereinnovationsoftheKoreanconflict.MobileArmySurgicalHospitals(MASHUnits)werecapableofprovid-inginitialsurgicalcareclosetothefrontlinesasopposedtosimplyservingastriagestations.Increaseduseofaero-medicaltransportalsoreducedtransportationtimeduringtheVietnamWar(Table1).22,25TheVietnamWaralsomarkedthebeginningoforganizedfieldcarewithspe-ciallytrainedmedics.Theseindividualslaterwouldbe-cometheparamedicsincivilianmedicine.4
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