AS RE AL

the evolution of trauma care and emergency medicine

AS IT GE TS By Barbara Ravage

14 THE SAFETY NET SPRING 2006

Born on the battlefield, trauma care came of age during the
turbulent 1960s, when the lessons learned in the Korean and
Vietnam conflicts were brought back to the United States to
treat trauma on the home front. To be sure, there were hospital
emergency rooms long before that time, but they would hardly
be recognizable compared to today’s high-tech emergency
departments and Level I trauma centers.

Specialty emergency medicine and trauma specifically trained in emergency medicine.”

care developed in response to the unique In 1910, the Flexner report, Medical Educa-
dangers and needs of the urban environment, tion in the United States and Canada, spurred
driven by the demand for better care on the the evolution of medicine into a specialty-
part of both providers and patients, and by driven field. But it took the National Re-
technological advances ranging from CT scans search Council’s 1966 report, Accidental Death
to remote field telemedicine. Three public and Disability:The Neglected Disease of Modern
hospitals — Los Angeles County+USC, San Society, to provide the impetus for specialty OPPOSITE: Rancho Los Amigos
Francisco General, and Cook County — were training of physicians in emergency medicine. National Rehabilitation Center.
on the front lines of developing trauma care. At the time, Anderson was professor of ob- BELOW: Doctors work on
stetrics and gynecology at the University of injured at General Hospital,
Los Angeles, after the series
The Birth of Emergency Medicine Southern California School of Medicine and
of earthquakes that rocked
Southern California, 1933.
In the late sixties, the emergency room at CONTINUED ON NEXT PAGE

LAC+USC Medical Center was no different

from that in most municipal hospitals in
the country, except it was bigger and busier.
Patients by the hundreds walked or were car-
ried through its portals every day. From bullet
wounds to heart attacks, spinal cord injuries
to severe burns, drug overdoses to miscarriages,
patients in need of immediate care were tended
to by a handful of residents on rotation, with
the support of nurses and orderlies. According
to Gail V. Anderson, MD, under whose stew-
ardship the LAC+USC Medical Center ER
became a world-class emergency department,
“Before the advent of emergency medicine
as a specialty, emergency rooms were staffed
by part-time, itinerant physicians who were
essentially moonlighting. Physician groups
formed and were practicing emergency medi-
cine on a full-time basis, but no one had been
 chief of the obstetrics and gynecology service Modeled after the mobile army surgical
at LAC+USC Medical Center, its main teach- hospital (M.A.S.H.) units, the nation’s first
ing hospital. In 1971, he was asked to chair a hospital-based civilian trauma units were
new department of emergency established in 1966 at San Francisco General
Inner-city public hospitals medicine at USC, the first in
the nation. In 1976, Anderson
Hospital and Chicago’s Cook County hospi-
tals. Both had long served the poorest residents
remain the last, best training helped found the American
Board of Emergency Medicine.
of their cities and had reputations for providing
a broad range of quality emergency care.
grounds for trauma surgery. Emergency medicine was
accepted as the twenty-third
The modern facility at San Francisco General
stands on the site of the old Mission Emer-
board-certified medical gency Hospital, built in 1909. In 2002, the
specialty in 1979 and administered its first sprawling, nearly century-old Cook County
certification exams in 1980. Hospital was replaced by The John H. Stroger,
As a pioneer of emergency medical Jr. Hospital of Cook County, with a high-tech,
education, Anderson asserts that the training self-contained trauma center.
programs in public hospitals offer “the best Although these two trauma units served
way of assuring quality emergency care for as models in the sixties, it was a decade later
this large mass of people.” that formal guidelines were established for the
systematic delivery of trauma care. The 1976
From M.A.S.H. to the Home Front report from the American College of Surgeons
Committee on Trauma (ACSCOT), Optimal
Every trauma is an emergency, but not every Hospital Resources for Care of the Seriously Injured,
emergency involves trauma. Indeed, trauma is specified the requirements for effective trauma
a complex event requiring a team of physicians, systems. Out of that report came the now-
nurses, and technicians specially trained to do familiar trauma center levels, as well as the
the right thing at top speed. Much is made of organization of multidisciplinary trauma teams
the “golden hour,” the window of opportunity and the trauma center verification process.
for saving the life of a severely injured patient, San Francisco General, LA County+USC,
but in the most severe cases, the trauma team and Stroger hospitals are sites of Level i trauma
measures its opportunities in minutes. centers. As anchors for large inner-city popu-
lations, they see more than their share of
trauma cases, and as public hospitals, they are
EARLY CIVILIAN TRAUMA CARE committed to offering the best possible care
to all patients, regardless of ability to pay. That
commitment is well expressed by Stroger’s
The nation’s first specialized civilian
trauma units were established just four chief of trauma, Roxanne Roberts, MD, who
decades ago at San Francisco General says, “We’re all here because we fell in love
and Chicago’s Cook County hospitals. with the patients that we take care of and we
But urgent care has been an aspect of believe in the mission of the hospital. We’re
hospital services throughout their history.
certainly not here for the salaries or the glory.”
Here, doctors at Central Emergency
Hospital in San Francisco provide emer- Or as William Schecter, MD, chief of surgery
gency care in 1935. at San Francisco General, put it: “The thing
about working in a place like this is that when
you go home at the end of the day you at least
know that you tried to do the right thing.”

The Training Challenge

“Trauma care is undergoing a sea change,” says

Schecter. Thanks to huge advances in the field,
innumerable lives have been saved. Today, the

16 THE SAFETY NET SPRING 2006

 odds are that a trauma patient who reaches the Trauma Care Evolves
hospital alive will live to be discharged. Diag-
nostic technologies such as CT scanners have The classic picture of the
dramatically reduced the need for exploratory trauma team in a life-and-
surgery that was previously standard in cases of death race against time is only
blunt trauma. Non-invasive techniques to stop part of a larger view. Today,
bleeding also mean “the number of injured trauma care encompasses
patients that actually need surgery is much what happens to patients
lower than it used to be,” Schecter maintains. before they even get to the
But those advances have had unintended hospital and long after they
consequences in the training of surgeons and leave. Resuscitation often
other trauma team members. In most hospi- begins in ambulances fitted
tals, blunt trauma resulting from car accidents, out with advanced life-saving
for example, makes up the majority of cases. equipment and highly
It is in the area of blunt trauma that non-sur- trained EMTs in constant
gical techniques have had the greatest utility. telecommunication with the
“It’s becoming increasingly difficult to hospital-based trauma team.
maintain the interest of young surgeons be- Rehabilitation for disabled
cause the number of operations they do is trauma patients is also part
much lower than before,” Schecter observes. of the mission.
Inner-city public hospitals like San Francisco End-of-life care and sup-
General, however, continue to see a dispro- port for families are often
portionate number of penetrating traumas, neglected in a place where
for which surgery is a life-saving necessity. sudden and unexpected death
“I happen to work in a hospital where, unfor- is a daily reality, but not at
tunately, we still treat numerous shootings and Stroger Hospital in Chicago.
stabbings, so from a surgical point of view, it’s In what is a new model for
still quite interesting.” Thus, inner-city public the hospice concept, Stroger
hospitals remain the last, best training grounds was awarded a grant by the
for trauma surgery. “We have a saying here Aetna Foundation in 2005
at San Francisco General Hospital: ‘This is to develop a hospice program
as real as it gets,’” says Schecter. for its trauma unit. “As sur-
If military medicine was the driving force geons we’re trained not to
behind the development of trauma care, give up,” says Kimberly Joseph,
LAC+USC Hospital is among a select group MD, director of the Trauma
that is returning the favor. Taking advantage ICU at Stroger. “Perhaps we
of the expertise at this public hospital, the wait too long before talking
Department of Defense initiated a coopera- about death and asking the patient and their PHOTOS Page 14: Submitted; Page 15: Corbis; Page 16: San Francisco
History Center, San Francisco Public Library; Page 17: Pennsylvania
tive program to train medical corps personnel family what they would like.” The Aetna Hospital Historic Collections, Philadelphia
for conditions no one in the military had grant, she believes, “will help us identify
seen since Vietnam. In a partnership between specific needs of patients and their families
LAC+USC and the San Diego-based Navy during this time and how we can make the
Trauma Training Center, Navy fleet and dying process easier.”
forward resuscitative surgical teams gain Increasingly, trauma centers are including
hands-on experience in the LAC+USC Level prevention in their mandate. Injury and
1 trauma center. Jackson Memorial Hospital violence prevention programs at LAC+USC,
in Miami, another NAPH member, provides Stroger, and San Francisco General employ
a similar service to the Army at its Ryder public education, community outreach, and
Trauma Center, while the Air Force trains at counseling in this effort. As Schecter puts
the R. Adams Cowley Shock Trauma Center it, “What we would ideally like to do is put
in Baltimore. ourselves out of business.”

SPRING 2006 THE SAFETY NET 17