In the aftermath of the Boston Marathon bombing on April 15, Level I trauma centers at six area teaching hospitals treated hundreds of patients, many with serious injuries. The coordinated response was successful: Everyone who made it to the hospital that day survived.
Before the Boston bombing, the AAMC had scheduled a May Capitol Hill briefing to emphasize the role academic medicine plays in trauma care. Speakers at the briefing noted that the large number of Level I trauma centers in Boston was one of the key reasons for the successful response. At the same time, they expressed concerns about the impact of federal budget cuts on trauma centers, including potential closures and reduced access to trauma services.
According to experts at the briefing, if a similar disaster were to strike in a locale without immediate access to Level I trauma care, more casualties would be likely because most areas are not as well equipped as Boston.
Mary Devine, emergency management coordinator with the Conference of Boston Teaching Hospitals, who spoke at the briefing, described the response that day in Boston.“Within minutes, the trauma centers cleared out their emergency departments, opened up the operating rooms, and said, ‘We are ready. Send us whoever you have.’”
Some states have only one or two Level I trauma centers, according to the American Trauma Society. Of the 4,985 hospitals in the United States, only 112 are verified by the American College of Surgeons (ACS) as adult Level I trauma centers. More than 80 percent of these trauma centers are operated by AAMC-member teaching hospitals.
Experts at the briefing noted that high costs have forced some existing Level I trauma centers to close. A 2009 Medical Care study showed that 339 trauma centers, including Level I centers, shut their doors between 1990 and 2005 because of inadequate funding. Trauma centers nationwide also are at risk from sequestration’s 2 percent cut to Medicare reimbursements, which could force more closures because Medicare is the main funding source for trauma centers.
“Boston-area hospitals’ coordinated response to the marathon bombings and the ongoing research and education initiatives at all Level I centers demonstrate the important role academic medicine plays in trauma care,” said Atul Grover, M.D., Ph.D., AAMC’s chief public policy officer, who moderated the event.
Level I trauma centers provide the highest level of trauma care. To receive a Level I verification from the ACS, these centers must be ready at a moment’s notice to respond to large-scale disasters. At the same time, they are responsible for a steady stream of patients with injuries caused by everyday accidents or gun violence. Level I trauma centers also play a major role in training future physicians.
The resources and mission of academic medicine make teaching hospitals an ideal location for trauma centers, according to Patrick Kim, M.D., trauma program director and assistant professor of surgery at the University of Pennsylvania Health System.
“Trauma centers are busy enough for residents to get exposure to major trauma regardless of what they end up doing in their careers,” Kim said. “If a teaching hospital does not have a trauma center, it’s very likely residents in some specialties will have to go to a Level I trauma center to get that exposure.”
In Tennessee, there are only a few Level I trauma centers. The trauma center at the University of Tennessee Medical Center often receives patients who require enhanced services that local hospitals cannot provide.
“Nobody calls up to say they are going to have a car crash or a terrorist event. You have to have the resources available when the trauma happens,” said Brian Daley, M.D., residency program director and chief of the Division of Trauma and Critical Care at the University of Tennessee Graduate School of Medicine.
Level I trauma centers are stocked with medical supplies and equipment to treat high volumes of patients. They have helicopters to transport the injured. In addition, all have surgeons who are board-certified in trauma-related specialties. To qualify as a Level I facility, a center must have surgeons and other specialists who are available around the clock.
To ensure staff are prepared for any event, Level I trauma centers also participate in regular drills. Many of the Boston centers used emergency procedures developed in war zones, such as Iraq and Afghanistan. This amped-up preparation saves lives. According to the Centers for Disease Control and Prevention, the survival rate is 25 percent higher for patients treated at Level I centers.
Daley pointed out that the teaching environment also lends itself to performance improvement. “The nice thing about the teaching environment is it allows us to constantly evaluate and re-evaluate what’s going on in the trauma center and try to apply new therapies.”
This, he said, has led to advances such as the adaptation of “damage control surgery.”
“Rather than doing a long operation that takes hours, we are doing the operation in bits and pieces to make sure a patient’s physiology is restored. We then take them back [to the operating room] when they are more suitable and complete the operations.”
Another example of performance improvement came about in the aftermath of the marathon bombings. According to Jerry Berger, director of media relations at Beth Israel Deaconess Medical Center, in the midst of receiving 24 patients, one of the trauma surgeons at Beth Israel devised a disaster trauma service with a multidisciplinary team to attend to the complex recovery needs of victims. The team continues to hold weekly clinics that include not only trauma, orthopedic, and vascular care but also pastoral care, social work, and physical therapy.
“It’s much easier for patients to bring all of the services together,” Berger said. “Once discharged, they don’t have to do all of the running around. They just sit in one exam room and the team comes to them.”
In Tennessee, Daley said the response from Boston’s trauma centers underscores the importance of trauma care and the need for continued funding.
“Every day there are millions of Americans injured, and everyone pretty much takes trauma care for granted,” Daley said. “With our current financial constraints, there may not always be access, especially in places where services and resources are limited.”