Are we doing Emergency Medicine wrong?
An observation and thought experiment.
In June of 1859, a battle in Solferino, Italy, inspired the formation of the Red Cross society.
Like many observations of disasters from people not involved, the problem and solution was obvious.
Soldiers wounded on the battlefield need(ed) medical care. So doctors (surgeons are included in this because I am not listing them separately every time) and nurses would volunteer to provide care. (paramedic, army medics, and corpsmen, were not a thing yet.)
The “medics” who would provide this care noticed something very important… It is really dangerous to be on a battlefield…
As such, protective symbols were developed and “rules” enacted in order to “protect” these battlefield providers. To this day, it works so well (dripping sarcasm here) that on both historical and modern battlefields, wearing these “protected” symbols might as well have been like painting a giant target in high-visibility colors on yourself with a flashing neon sign that says “shoot me!”
During my time on a military base that came under constant attack during a war, nobody wore these “protected” symbols, when necessary, they were as small and subdued as possible. I was even instructed by the military police officer who did my safety briefing that medical providers were #4 on the sniper target list, with officers, radio operators, and heavy weapons taking the #1, 2, and 3 spots respectively.
During that war and in conflicts since, I have read countless news articles about members of the International Red Cross in warzones coming under fire and being killed despite wearing “protected symbols.”
So much so, that in the typical dark humor of my siblings in arms, we refer to people who purposefully wear and display these symbols as “The Knights of the Concentric Circles.” (That is a target if you didn’t get the reference.)
Some very intellectual person then decided that it is probably better if the highly educated and limited numbers of doctors and nurses were moved further away from combat and some easier to replace people would provide first aid and transport the wounded away from the battle to these “valuable” providers.
The result was that the serious injured would be moved away from the front towards the highly trained providers.
The results could be best described as “better than not.” But it left a lot to be desired.
As warfare progressed into the 20th century, every effort was made to move doctors as close to the front as reasonably safe, in order to reduce the time and distance for advanced medical and surgical care.
In the Late 1960s and Early 1970s, during the US war in Vietnam, with the availability of capable helicopters, the modern trauma system as we know it was developed. It is often referred to as “the spoke and wheel model.”
At the center of the wheel are placed hospitals, usually academic (university) hospitals, staffed with the most capable people and the most advanced equipment.
At the periphery of the wheel, are the “aid stations” or "community hospitals. Staffed with the most basic of still capable providers and minimal equipment.
The spokes of the wheel are identified as the various modes of transportation between the periphery and the center. Ambulances, helicopters, boats, et al.
Every imaginable (and some not imaginable) efforts were made to improve and refine the care and transport of patients in need. From medical and surgical procedures, efficient dispatch of transport, and provider training to get the most out of the least. The results have been good. But they obviously peaked.
There were a lot of inefficiencies that could not be removed using this system. First, lesser educated and experienced providers could only do so much. Almost none of them were capable of surgical intervention. Traumatic injury is a surgical disease, some 90% orthopedic, and with the single exception of central compartment syndrome, none of it life-threatening.
The majority of life-threatening trauma, even including burns, is vascular in nature. Blood or parts of blood are not going where they need to and usually going where they cause the most harm, like onto the ground, or in a closed body compartment like the skull or thorax. It' only accounts for roughly 10% of traumatic injury, but it is the 10% where life and limb are saved.
As humans, we are unique. We are the only creatures on the planet that will risk any number of lives in order to help just 1 individual. In our instinct and cultures, we spare no amount of resources in order to do it. Billions of dollars a day, entire industries are set up around it.
The “trauma system” was designed for the wars of the 20th century. With the technology, knowledge, and practices available.
This spoke and wheel system was then adopted to other types of life-threatening diseases, such as myocardial infarction (heart attack,) stroke, et al. Resulting in Percutaneous Coronary Intervention (PCI) centers, stroke centers, etc.
Then came the wars of the 21st century…
Having mastered the systems of the 20th century, the patient outcomes from war made apparent that more advanced care was needed closer to the battle. As close as possible. Specially trained doctors and nurses were developed and equipped in order to bring the most advanced capabilities, which were not practical before. Like using blood products at the point of care, surgical control of bleeding, or temporary vascular grafts to name just a few. (I am writing at the system level today, not detailing modern trauma treatments.)
Civilian systems started to mirror the modern military once more. Advanced providers and treatments would move towards the point of injury and illness. To provide advanced care and eliminate redundant movement before treatment.
Under the 20th century system, when a person was injured, often times, callers would notify the authorities, an ambulance would be dispatched, in many cases, non-ambulance responders such as fire apparatus, etc. would move towards the patient. Basic treatments would be rendered, perhaps more advanced (read expensive) transport would be arranged, respond to the scene of the injury directly or to a hospital near by. At best, this resulted in 2 movements to bring a patient to the center of the wheel. In extreme conditions, 4 or 5 movements would be needed. All of which add time, monetary cost, and personnel; effectively delaying the treatment patients needed for the best outcomes.
Train like you fight; fight like you train.
Disaster medicine and response is a subdivision of emergency response. In general, it is considered “abnormal” or periodic. It is usually considered stressful to the people responding.
When people are under stress (and doctors and nurses are people) they generally perform habitually or comfortably. This has been the downfall of many a disaster plan for medical providers both in an out of the hospital. Plans that call for special, seldom used equipment, procedures, and treatments are doomed to fail. Equipment which cannot be located or used effectively, is worse than no equipment at all. It inhibits patient care and adds stress to providers, resulting in synergistic degradation of global effectiveness.
The more providers who are participating in disaster response, the more diluted skills and experience become. This problem is compounded when these very providers have other “normal” responsibilities, building habits, requiring alternative thought processes, and priorities.
When you look at military special forces units, they basically have 2 functions. Perform high risk missions and train for high risk missions. Simply, they are either doing their job or training to do that exact job.
You don’t see US Navy SEALS, British SAS, et al. practicing tier 1 special forces missions 1 week, how to be a line infantryman the next week, an administrator the week after, and so on…
Yet around the world, every day, we see emergency doctors primarily functioning as primary care providers. They functionally train to be a jack-of-all trades, and succeed at being a master of none.
Their ongoing education and training is as diluted as their experience doing actual emergency care. Even worse, many emergency physicians around the world do not even receive initial training, much less ongoing training, on medical care specific to life-threatening illnesses.
I maintain my position, most emergency physicians provide no better care to any patients with life-threatening conditions than a US paramedic.
For patients with life threatening illness and injury, these “emergency” providers are reliant on surgeons, anesthesiologists, cardiologists, and essentially everyone other than themselves!
By contrast, you see paramedics and emergency nurses required to have ongoing training and experience in intensive care, emergency department care, and prehospital care and transport.
Now I know there are some emergency physicians who are an exception to this rule, but they are the minority, not the average.
They can hardly be blamed, they are simply a product of the system they were designed and trained for.
”Surgeons are not technicians, they are doctors who also know how to operate.” - A cardiac surgeon I met whose name I cannot spell
In the USA, but not in Europe, despite my best efforts, exists the specialty of critical care surgery, formerly trauma surgery. For brevity, it is a surgeon trained to operate on and subsequently provide intensive care to the critically ill and injured. They provide comprehensive care to both daily and in extreme circumstances, to the critically ill and injured.
Their major drawback, is in almost every non-military system, they are at the center of the wheel. As far away from the point of impact as possible. Which means the best providers for emergency patients don’t even exist in most countries and even when they do, they are completely out of position to immediately provide their specialized care.
Thus we find ourselves in the position
Where “emergency” specialists are not actually capable at providing the best care to emergency patients. (often while simultaneously decrying people without emergencies are a waste of their time, oddly enough…) Despite their name, emergency is quite simply not their job!
What if..?
What if there was an entire medical specialty, world-wide, that focused on providing comprehensive care to patients with life threatening conditions?
What if there were a multidisciplinary team of providers tasked with the care of such patients over an entire region on a daily basis?
What if equipment and other resources were prepositioned in the periphery of the wheel and the providers would go to the patient or the nearest resources or both as appropriate? Just like a military special forces unit or…Your local fire department already does in case of disaster?
What if this team of providers only did 2 things. 1. Provide care to the critically ill and injured with the most advanced and up to date skills, knowledge, and capability and 2. Train to do it when they were not?
What if these teams were able to provide care in any environment? From a car accident on the side of the road, a ship at sea, a community hospital, a natural or man-made disaster, or the ivory tower hospital in the center of down town?
What stops us from doing this? Tradition? Political opposition? Allocated funds?
If what we are doing today has already peaked, isn’t it time to change to do better?