NASEM Releases Video Illustrating Need for a National Trauma Care System

November 18th, 2016

To accompany its June 2016 report calling for improved trauma care in the U.S., the National Academies of Science, Engineering and Medicine created a video that briefly illustrates the report’s main messages. Advances in military  trauma care achieved during the Afghanistan and Iraq wars can be translated to the civilian sector to improve trauma care for all Americans, say the report’s authors. Sustaining these military advances, and closing the gap between the military and civilian sectors, can help to improve trauma care—to protect those the nation sends into harm’s way, and to benefit every American.

View the video HERE.

En Route Care and Training for Immediate Responders Explored in November JOT Supplement Covering 2015 MHSRS Proceedings

November 10th, 2016

Supplement 1 of the Journal of Trauma, Volume 81, No.5, carries multiple papers emanating from the 2015 Military Health System Research Symposium. Below are synopses of several. To read the entire supplement, click here.

Machine learning and new vital signs monitoring in civilian en route care: A systematic review of the literature and future implications for the military  

Researchers Nehmiah Liu and Jose Salinas, PhD, reviewed the existing literature related to machine learning (ML) algorithms (MLA) and new vital signs monitoring (NVSM) in civilian en route care in order to determine their potential to fill combat medicine capability gaps. Recent machine learning technologies include those that monitor novel vital signs such as heart rate variability (HRV) and heart rate complexity (HRC). In addition, the photopletysmograph wave form and data quality indices offer potential ways to evaluate the need for lifesaving interventions during en route care.

There continues to be limited means of monitoring and recording data in-flight–such as vital signs, waveforms or interventions made by in-flight personnel—and an imperative to leverage such data to improve care and reduce mortality. Thus, the researchers are optimistic that new innovations could be of benefit in combat scenarios, but caution that further validation is warranted before widespread use. “Almost all studies required further validation in prospective and/or randomized controlled trials,” they determined.

 

Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes

A 2009 change in military combat medicine policy led to the integration of Air Force Pararescuemen with paramedic training into MEDEVAC missions in a bid to decrease mortality. Paramedic level training was thus incorporated into the initial flight medic training of DUSTOFF medics in 2012, and a new program course at Fort Sam Houston provided additional paramedic and critical care training to promote all skill competencies at the EMT–intermediate/paramedic level as well as CCFP certification.

Vikhyat Bebarta, MD, and other researchers at Fort Sam Houston sought to analyze the resulting reallocation of resources in order to determine whether the intended benefit had been attained. In this study, the researchers identified and described medical providers and their specific roles on MEDEVAC missions, and identified associations between provider type, procedures performed, medications administered, survival, and 30-day outcomes.

In a review of more than 1,200 records of US casualties between 2011 and 2014, they determined that 76% of MEDEVAC personnel were medics, 21% paramedics, and 4% were advanced-level providers (ADVs) including nurses, physicians, and physician assistants. Providers with higher-level training were more likely to perform more advanced procedures during en route care; however, there was no significant association between provider type and in-theater or 30-day mortality rates. “More evidence is needed to determine the appropriate level of MEDEVAC personnel training and skill maintenance necessary to minimize combat mortality,” the researchers concluded.

Liu and Salinas argue for research that advances these technologies for en route care. “Importantly, these innovations could not only enhance trauma casualty care for our nation’s war fighters in a complex global environment but also close gaps–specifically, monitoring and the early detection and treatment of various injuries,” say the researchers.

 

Improving national preparedness for mass casualty events: A seamless system of evidence-based care

Researchers Alexander Eastman, MD, William Fabbri, MD, Kathryn Brinsfield, MD, and Lenworth Jacobs, MD, argue in a special report that the U.S. lacks “a unified, coordinated national system to respond to intentional mass casualty attacks….”

The researchers note that our national preparedness goal is thwarted by segmented, compartmentalized, or simply unobtainable investigative, clinical, and medical examiner data following mass casualty events. The distributed nature of the ownership of various segments of the civilian health care system is to blame, they say, and the consequence is that “conjecture, bias, and anecdote inform the civilian section of our national response rather than scientific evidence.”

The Hartford Consensus, they contend, is one attempt to evaluate evidence-based approaches to the problem. The authors review recommendations from successive Hartford Consensus meetings and conclude that immediate responders to mass casualty events, employing bleeding control techniques, hold the key to national resilience. Immediate responders, as defined, include law enforcement officers, bystanders, and even victims.

“Our military colleagues have demonstrated that a robust data collection system, organized scientific study of the problem, and system-wide implementation of evidence-based solutions can significantly improve survival from intentional traumatic injury,” Eastman et al. conclude. “Our duty now is to build the foundations of an analogous civilian system in order to begin to answer the remaining questions and to truly improve our national preparedness.”

New Book Celebrates the Progress of Trauma Care in America

November 7th, 2016

Dr. Catherine Musemeche is a student of medical history and a former pediatric surgeon who weaves vivid personal anecdotes throughout her comprehensive telling of the evolution of trauma care in America—from the Civil War through the conflicts in Iraq and Afghanistan.

Recently published by University Press of New England, HURT—The Inspiring, Untold Story of Trauma Care reads like an adventure story, complete with compelling prose and action-packed portraits of real-life heroes like R Adams Cowley, James Styner, Deke Farrington, Sue Baker, John Paul Stapp and plenty of others. HURT is both a celebration of how far the trauma care system has traveled in an astonishingly short amount of time and a reminder of what is left to accomplish.

A board-certified Fellow of the American College of Surgeons, Dr. Musemeche and has flown on rescue helicopters, trained and practiced in trauma centers in Houston and Chicago and operated on hundreds of trauma victims of all ages. Her work is meticulously cited and includes references to articles by Thomas Scalea, Martin Croce, David Livingston, Brent Eastman and many others with whom the trauma care community is very familiar.

This is a great book for ER residents, aspiring trauma surgeons, nurses or anyone in the medical field who is interested in knowing about the history of the U.S. trauma system and standards. Order a copy today, or catch Dr. Musemeche’s next book reading at BookWoman in Austin, TX on Saturday, November 26 at 1:00 p.m. Check the BookWoman calendar for updates.

NIH For Trauma Necessary to Support Civilian Acute Care Needs

October 20th, 2016

In an article published in The New England Journal of Medicine, Todd Rasmussen, MD (DoD Combat Casualty Research Program) and Arthur Kellerman, MD (Uniformed Services University of the Health Sciences) propose the establishment of an NIH institute dedicated to trauma and emergency care research.

DoD funding represents more than 80 percent of the federal government’s annual investment in trauma care research, the authors point out. “Although this arrangement ensures the military relevance of federal research on trauma care, it provides little support for civilian priorities and leaves the field overly dependent on DoD funding.”

Rasmussen and Kellerman reference the June 2016 report from the National Academies of Science, Engineering and Medicine, which calls for a National Trauma Action Plan that integrates civilian and military trauma care capabilities. Establishing an NIH for trauma, they contend, will help to “drive the number of preventable deaths after injury down to zero.”

Read the article.

Stop the Bleed Initiative Plugged by CBS’s “Code Black” Cast Members

October 11th, 2016

Stop the Bleed, a nationwide campaign to educate bystanders on how to control bleeding related to traumatic injuries, just released a video featuring actors from “Code Black” in an effort to raise awareness about the campaign. Launched by the White House a year ago, the initiative is similar to longstanding efforts to engage citizens in first aid like administering CPR and using AED machines in emergency situations. By following the protocol, bystanders can act to staunch bleeding while waiting for help to arrive.

“Uncontrolled bleeding injuries can result from natural and manmade disasters and from everyday accidents,” explained the White House when announcing the initiative in October, 2015. “If this bleeding is severe, it can kill within minutes, potentially before trained responders can arrive. Providing bystanders with basic tools and information on the simple steps they can take in an emergency situation to stop life threatening bleeding can save lives.” For more information, visit the Department of Homeland Security: HERE.

Watch the PSA on Youtube: HERE

 

NTI Past Chair Jenkins and Colleague Grabo Share Lessons from War

September 21st, 2016

In a Scranton Journal story about how military surgeons rediscover and refine treatments from the past while saving lives on the battlefield, Donald Jenkins, MD, and Daniel Grabo, MD, talk about the concept of “damage-control surgery” conducted in austere environments.

While deployed in Oman and treating severely injured soldiers who needed blood transfusions, Dr. Jenkins had to tap the only immediate source–fresh whole blood from other soldiers–instead of stored blood components, as has been used for decades. “Trauma victims given two units of whole blood, as opposed to the typical 12 of processed blood, gained their health back more quickly,” he discovered. When Jenkins returned to practice in civilian trauma centers, he brought this lesson home to share with his fellow surgeons.

The resurgent use of whole blood and tourniquets are examples of how wartime necessities bring past wisdom to light. Thanks to Jenkins’ work, the younger Grabo and his colleagues reach for these treatments as standard protocols.

Jenkins and Grabo are both alumni of the University of Scranton and both are recipients of medical service awards: Jenkins received the American Legion’s Distinguished Service Medal and Grabo received the Romanian Medal of Honor for his efforts to save the lives of Romanian soldiers injured in Afghanistan.

Read the full story.

New Jersey Trauma Surgeon Provides a Dose of Reality in Star-Ledger Op-Ed

September 20th, 2016

Dr. Terrence Curran, a trauma and critical care surgeon at Morristown Memorial Hospital, wrote an op-ed for the New Jersey Star-Ledger in support of introduced legislation to raise awareness about the dangers of distracted driving. He suggests that widespread public education campaigns are needed to change behaviors and lower the toll of traumatic injury on our highways.

“The word ‘accident’ is not part of the vocabulary because trauma is a very preventable disease,” Curran says. He shares some of the realities of traumatic injury that he sees on a daily basis–for those lucky enough to live–damaged bodies, agonizing months in rehabilitation, permanent disabilities and suffering.

“I applaud Assemblyman John Wisniewski (D-Middlesex), Nicholas Chiaravalloti (D-Hudson) and Patrick Diegnan (D-Middlesex) for introducing legislation to raise awareness about the dangers of distracted driving,” Curran says, “but we should not wait for that bill to pass to increase the fight against dangerous driving behaviors.”

“While both the National Institute of Health and the Congressionally Directed Medical Research Program of the Department of Defense fund trauma research, the level of spending does not equal the magnitude of the problem,” he adds.

Read the full op-ed.

 

NTI Shares Lessons Learned Over a Decade of Study Management

September 8th, 2016

Just published in the Journal of Trauma and Acute Care Surgery (Vol 81, No 3), “The National Trauma Institute: Lessons learned in the funding and conduct of sixteen trauma research studies” analyzes and discusses how funded researchers approached obtaining regulatory approval, enrolling patients, navigating the Exception from Informed Consent process, coordinating multiple study sites and more.

The article offers some solutions for reducing challenges and lag times inherent in the study completion timeline. Among the insights, 40 percent of the funded investigators reported delays in obtaining regulatory approval at one or more institutional levels, which had serious impacts on study management. “The time required to obtain approvals delayed the funding awards considerably and resulted in the loss of study sites, turnover in research trainees, and the need to use alternate sources of funds for research staff salaries, protocol review, and community consultation costs,” NTI found.

NTI’s insights about navigating the regulatory environment square with the findings of the National Academies of Sciences, Engineering and Medicine (NASEM) in its June 2016 report: A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. “To accelerate progress toward the aim of zero preventable deaths after injury and minimizing disability, regulatory agencies should revise research regulations and reduce misinterpretation of the regulations through policy statements” is one of the recommendations of the NASEM Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector. [Read a summary of the NASEM report HERE].

In all, NTI reports lessons that are instructive for trauma researchers in four key areas: regulatory processes, multisite coordination, adequate funding, and research infrastructure.

Needs Based Assessment of Trauma Systems Tool Unveiled in ACS Bulletin

September 6th, 2016

Controversy surrounding the number and location of designated trauma centers in the U.S. has led to much discussion and the emergency of two camps: one in favor of restraining the proliferation of centers and one in favor of allowing individual institutions to decide for themselves whether to pursue designation.

Following the convening of a consensus conference that reviewed the principles for trauma center designation and arrived at a set of practical methods and metrics for use in a needs based assessment, the American College of Surgeons Committee on Trauma this month released the ACS Needs Based Assessment of Trauma Systems (NBATS) tool. The tool is designed “to evaluate the need within a particular geographic area, termed a trauma service area (TSA)…[and] the number of centers needed within the TSA,” say the authors of an article about the tool in the ACS Bulletin (V101 No 9).

Incorporating critical data elements used in other system benchmarking efforts, the ACS NBATS assigns points based on population, transport time, community support and the number of severely injured patients discharged. While there is no clear evidence supporting the use of any of the specific measures proposed, “all the recommendations reflect the expert opinion of the convened group, as derived through a deliberative process,” according the Bulletin article.

The ACS COT is now circulating the tool to stakeholder groups for testing and validation. To participate in the process of review and refinement, contact Maria Alvi, Manager of Trauma Systems and Quality Programs at malvi@facs.org.

Research Sponsored by NTI Yields Insights on VTE

September 6th, 2016

This month, Martin A. Schreiber, MD, and his team published an article in JAMA Surgery online, following the completion of a study funded by the Department of Defense through the National Trauma Institute (NTI). The randomized clinical study compared patient outcomes for those administered standard vs. TEG-adjusted prophylactic enoxaparin dosing.  The researchers found that the time to enoxaparin initiation was more rapid than prior studies and the incidence of VTE was low and similar in both groups.

The data suggest that a difference in reaction time of more than 1 minute to initial fibrin formation comparing standard kaolin and heparinase TEGs may be associated with a decreased risk of venous thromboembolism (VTE); however, the study population may have been too limited to reveal significant results. “Low VTE incidence may be due to an early time to enoxaparin initiation and an overall healthier and less severely injured study population than previously reported,” note the researchers. Of the 185 trial participants, only 22 achieved a difference in reaction time greater than 1 minute despite increased enoxaparin dosing in the treatment group.

Risk factors for VTE were identified as older age, higher body mass index, increased Acute Physiology and Chronic Health Evaluation II score and more missed doses per patient.

As VTE is a major cause of potentially preventable death in trauma patients, related studies are important. One recommendation arising from this work is to improve compliance with dosing protocols (almost all the subjects missed at least one dose). Because the results were inconclusive, follow-on research focusing on patients with more severe injuries and prolonged hospital stays—during which there would be additional follow-up over time—is recommended. “These data demonstrate that many trauma and surgical patients are hypercoagulable at baseline and that further investigations into the effects of platelet activation, obesity, time to enoxaparin administration, and AT-III deficiency are needed.”