Archive for August, 2009

NTI Annual Symposium Report: Global Disaster Medicine Triage System Proposed

Monday, August 31st, 2009

Dr. Richard Schwartz, director of the Emergency Medical Support Program at the Medical College of Georgia, reported on the development of a set of proposed national guidelines for mass casualty triage.

“We’ve had the concept of triage for over 200 years,” Schwartz said, “This idea of doing the greatest good for the greatest number of people.” But considering that there are today some 120 versions of mass casualty triage, the development of a single, easily understood system could relieve some of the confusion in an already chaotic situation.

Schwartz was a member of the Terrorism Injury Information Dissemination and Exchange (TIDE) project, which looked at the practical information doctors have gleaned from disasters and conducted a structured literature review of existing triage systems. The end result, he said, is that no one system is strongly supported by the evidence, but several specific strategies seen across different systems rose to the top.

The group came to a consensus on the following attributes of triage, and combined them into a recommended global system, called SALT (Sort, Assess, Lifesaving Interventions, Triage):
-Global sorting
-Focus on life saving interventions
-Best evidence supports use of mental status and systolic BP as criteria
-Simple
-Rapid
-Inexpensive
-Use NATO triage categories (Immediate, Delayed, Minimal, Expectant, Dead (IDMED))

Attendees asked about whether the system took into account language barriers and the deafening effects of explosions–in both cases, patients would not be able to follow commands (for the purposes of sorting). Schwartz noted that SALT did not factor in language.

NTI Trauma Symposium Report: Using Portable Ultrasound in Pre-hospital Settings

Monday, August 31st, 2009

In this session that explored the use of ultrasound machines in far-forward care, LTC John McManus and Maj Seth Lotterman took opposite sides of the debate, with McManus arguing that portable ultrasound machines can aide in the evaluation and, therefore, treatment of patients.

Ultrasound is not invasive, does not take much training to use, and can help medics make some basic decisions about care and get them to the right care providers more quickly. “How can an early diagnosis be bad?” he asked. The biggest issue is whether it’s better to “stay and play” or “load and go.” He said common wisdom is that the quicker you can get patients to the hospital, the better. “But that isn’t always true.”

McManus also pointed out that ultrasound monitors are becoming more advanced and cheaper.

Lotterman argued that ultrasound may play a role in far-forward operations, but it is limited. Aside from the issues of outdoor glare affecting the readability of the monitor, how easily the machine can be damaged, and its battery life, Lotterman asked, “Who will conduct QA and oversight? Is this another job for the medical director?”

Medical literature from Europe shows that pre-hospital use of ultrasound has some utility, but Lotterman pointed out that in the U.S., medical researchers are still evaluating utility, effect on transport times, impact on patient outcomes, issues with reimbursement and maintaining skills.

An audience participant noted that while in an urban setting, patients can make it to a well-staffed trauma center in a very short amount of time, in rural settings where hospitals are farther apart and take longer to reach, portable ultrasounds may have more efficacy.

NTI Annual Symposium Report: Rigorous Scientific Study Needed to Determine Optimal DCR

Monday, August 31st, 2009

Dr. John Holcomb and Dr. Ronald Stewart, both members of the NTI Board of Directors, debated whether damage control resuscitation (DCR) is the best therapy for massively bleeding patients.

Citing current medical research in the Annals of Surgery and Journal of Trauma, and the weight of widespread clinical practice, Holcomb contended that DCR is, indeed, the best option for the sickest trauma patients. Stewart argued that DCR provides unknown benefit and may be harmful, and cited various studies that contradicted Dr. Holcomb’s assertions. “Papers in support of DCR use retrospective data with no controls,” Stewart said.

While taking opposite sides for the purpose of debate, both doctors are actually in agreement that DCR is the treatment of choice, but more study is needed. Both Stewart and Holcomb are participating in a prospective study of DCR over the next year and hope to be able to definitively determine the very best therapy.

Stewart said rigorously scientific, randomized control trials are what’s needed in order to determine the most effective treatments—the type of large, multicenter trials that the National Trauma Institute is beginning to fund.

Holcomb recommended that junior doctors actually read the literature cited as the source of common protocols to understand the underlying physiology and to avoid over-generalizing. Some ideas tend to get carried to an extreme, said Stewart. “We should be self-critical and aware of our biases.”

NTI Annual Symposium Report: Coverage on Texas Public Radio

Monday, August 31st, 2009

National Trauma Institute Board Chair Ronald M. Stewart and Executive Director Sharon Smith were interviewed for this Texas Public Radio news report, which aired this morning. As the story notes, this year’s Symposium focus on mass casualty response, as well as its sessions on a range of trauma-related topics, is designed to motivate research as well as provide trauma caregivers with the latest information from both military and civilian trauma care arenas.

NTI Annual Symposium Report: Disaster Planning for Ophthalmology in Houston

Monday, August 31st, 2009

In this session, Dr. Amy Coburn talked about the disaster plan developed for Houston in addressing ophthalmology issues. Her first question was why do we need an eye plan in a disaster –- she noted that it’s important because the eye is a particularly vulnerable part of the body, and because eye injuries adversely affect disaster response. The first step in determining a disaster response plan for an area is to assess its risk. The Houston region, for example, encompasses 10 counties and includes 5.5 million people, about 30 percent of whom are uninsured. Its jurisdiction includes Galveston, which experienced a recent natural disaster in Hurricane Ike.

The Houston plan applies to mass casualty incidents, including terrorist attacks, as well as natural disasters, such as Hurricane Katrina, which inspired the push for a disaster plan. It utilizes a number of existing entities, including hospitals and other eye-related organizations, and anticipates the various logistical and transportation challenges that could arise in such a situation.

NTI Annual Symposium Report: Orthopedic Trauma

Monday, August 31st, 2009

This session featured LtCol James Keeney and COL James Ficke, debating the pros and cons of ORIF in combat zones, as well as on LTC Kevin Kirk and Maj Michael Charlton on Mangled Hind Foot/Pilon: Limb Salvage/Early Amputation, moderated by Drs. David Teague and Mark Richardson.

The first half of the session explored the question put forth at the start of Ficke’s presentation: “Would you fix your son’s or daughter’s talus in Iraq?” Keeney pointed to the complexity of support services and cleanliness of Balab Air Base in Iraq as an indication that theater hospital conditions are improving, and looked at the higher risks of infection related to delays in wound coverage. Ficke argued that combat conditions, infection risks, and requirements for accelerated fixation still make ORIF in the theater a riskier prospect. In certain types of ORIF cases, Ficke noted infection rates haven’t significantly improved from the Vietnam War era. Given that these patients have to be evacuated to higher-level care eventually, that ORIF should be reserved for those environments.

The second half of the session explored the question of limb salvage vs. early amputation in mangled hind foot and pilon injuries. Kirk advocates for limb salvage in most cases, except for life over limb and non-reconstructable soft tissue cases. Kirk cited SIP (sickness impact profile) scores showing no difference early amputation and limb salvage patients, and comparable return to work rates. Charlton advocated for early amputation, noting a number of studies showing increased numbers of hospitalizations ad higher infection rates for limb salvage patients, plus complications specifically related to the talus and the calcaneus. He also noted that late amputation in a limb salvage case is often seen as a failed treatment by the patient, whereas early amputation is not perceived the same way.

NTI Annual Symposium Report: Innovations in Mass Casualty Response

Monday, August 31st, 2009

Military doctors–including Dr. Peter Rhee (recently separated), COL Lorne Blackbourne, COL Brian Eastridge and LtCol Todd Rasmussen–opened the Mass Casualty Innovations session with graphic depictions of injuries sustained by soldiers in Iraq and some live footage of far-forward medical operations there to illustrate some of the lessons learned from Operation Iraqi Freedom.

Dr. Rhee described his experience caring for hundreds of injured civilians and soldiers at a time during a suicide bombing attack. Among his recommendations were:
-Keep triage simple, using quick, seasoned judgement to separate the wounded into immediate, delayed, walking and expectant categories
-Initiate a “walking blood bank” in order to get fresh, whole blood into the severely injured
-Prepare three plan levels to deal with small, medium and large numbers of wounded

COL Eastridge talked about the difficulty of categorizing a patient as “expectant,” or too injured to save. That decision is frought with both professional and emotional angst, he said.

With the experience that has come with our military involvement in the Middle East, Eastridge noted that the U.S. now has significant knowledge of how to deal with mass casualty situations, and has been quick to adopt new strategies as they come to light. “The mortality rate compared to that in Vietnam is way down,” he said.

Innovations that have been put into practice in the last few years include the combat application tourniquet (CAT), a combat pill pack, and vascular shunts. Eastridge noted that, as evidence from field hospitals mounts, there is indication that more advanced vital signs may be better indicators of patients’ conditions, thus leading to more effective categorization and treatment and better outcomes.

On the civilian side, Dr. Dror Soffer of the Tel-Aviv Medical Center in Israel, discussed how terror activities in his country affect the operations of the trauma center. As terrorism spreads throughout the world, he warned U.S. doctors to be prepared to deal with such trauma. In particular, he said, terrorism results in:
-Young, unprotected civilians being wounded
-Patients having more than one major trauma
-Blast lung injuries
-Amputations
-Burns

Soffer stressed the need for joint efforts among law enforcement, national agencies, medical facilities, and others to effectively deal with the trauma that results from terrorist activities.

NTI Annual Symposium Report: LTG Schoomaker Delivers Keynote Address

Monday, August 31st, 2009

The National Trauma Institute’s 15th Annual Symposium began with a keynote address from LTG Eric B. Schoomaker, the U.S. Army Surgeon General, whose discussion included a review of the ongoing, innovative collaborations happening between civilian and military trauma care centers. Noting that it is neither ethical nor practical to carry out clinical trials in combat zones, Schoomaker discussed four consortia in which amazing breakthroughs are happening in trauma care as a result of civilian and military collaboration. These include:

* The Orthopedic Extremity Trauma Research Program, with a goal of returning injured soldiers to function, including the recent, remarkable case of a soldier who survived amputation of all four extremities;
* The Armed Forces Institute for Regenerative Medicine, doing what Schoomaker termed, “amazing, science fiction type work” in cranio-facial reconstruction, compartment syndrome, burn repair, healing without scarring, and limb and digit salvage and reconstruction;
* The Prospective Observational Multicenter Massive Transfusion Study; and
* The Burn Multi-Center Clinical Trials, investigating a correlation between the intensity of PT and OT sessions and recovery.

LTG Schoomaker emphasized that rather than relying on anecdotal evidence and engaging in passionate debate, what is most needed to move medicine forward is the dispassionate, sound evidence that comes from quality science. Quality care, he said, can only come from quality science.

NTI Featured In U.S. Medicine

Thursday, August 27th, 2009

Sharon Basu, a reporter with U.S. Medicine, a magazine reaching more than 35,000 healthcare professionals working in the Department of Veterans Affairs, Department of Defense, and U.S. Public Health Service, recently wrote about the National Trauma Institute — specifically, about our advocacy for increasing trauma research. The article looks at the need to raise awareness of the impact of trauma and to increase funding for trauma care and recovery.

As NTI Executive Director Sharon Smith noted in the article, there’s not the sort of grassroots network for trauma survivors you’d expect of a category as prevalent as trauma — in large part because many people don’t think of trauma as a category. “People don’t think of car wrecks and falling from ladders and senior citizens falling down and breaking their hips,” Smith said in the article. “That is trauma, but people don’t think of all of that.”

As a number of U.S. Medicine readers are literally on the front lines of trauma care, we’re honored to be featured by the magazine, and are grateful to them for helping spread the word about the need for more trauma research and education. Next Monday and Tuesday, of course, we’ll be hosting our 15th Annual Trauma Symposium — this year’s version of the yearly event in which we highlight the work and discoveries of trauma care researchers and practitioners. We’ll be submitting updates to the blog, highlighting a number of the presentations and exchanges now in their final stages of preparation.

NTI Attends Military Meeting

Thursday, August 13th, 2009

NTI Executive Director Sharon Smith and Research Director Vivienne Marshall attended the 2009 ATACCC (Advanced Technology Applications for Combat Casualty Care) conference, held August 10-12 in St. Petersburg, FL. This is an annual meeting where military doctors present the latest statistics and research results related to military casualties in an effort to help the Department of Defense (DOD) establish priorities and areas of operational need.

ATACCC presented a great opportunity for NTI to meet with DOD staff to discuss funding and to connect with trauma researchers. Sharon and Vivienne shared information with researchers about NTI’s upcoming funding announcements.

They urged interested investigators to sign up on NTI’s website to receive announcements of the RFPs as they become available beginning this fall.

Sharon and Vivienne also met with key staff from TATRC, the DOD agency that manages NTI’s Congressional awards and contracts to discuss incoming Congressional appropriations.

The next meeting on everyone’s schedule is NTI’s own Annual Trauma Symposium, coming up August 31 and September 1. Register now!