Stabilization and Transfer to Definitive Care
When a trauma patient is en route or has already arrived at a small hospital with limited resources, one of the most critical decisions to be made is whether the patient can be treated locally or whether transfer is necessary. Trauma outcome is directly related to time to definitive care. If it is clear from the field report that the victim’s injuries will exceed local resources, that is the time to begin making transfer arrangements in order to eliminate the principal rate-limiting step (i.e., dispatch and arrival of the transport team and conveyance).84 Hospitals that need to transfer patients frequently know in advance which trauma centers will receive them and should have transfer agreements in effect.
Once the patient is in the emergency department, it is the responsibility of the surgeon or physician leading the team to recognize the need for transfer and initiate arrangements as soon as possible. From that point onward, all efforts should be directed at optimizing the patient’s physiology. ATLS should be the guide to the resuscitation, and testing and interventions should be limited to essentials and should not delay the departure.85 Unfortunately, inappropriate imaging particularly with CT has been shown to delay some transfers. Compounding the problem is the fact that, because of unavailability of images or reports from the referring hospital, many of these studies are repeated at the receiving Level I or II center, creating further delay, expense, and risk to the patient. One institution reported that 53% of 410 patients required repeat imaging at an average cost of $2,985 per patient.86 Referring physicians appear to obtain such studies out of liability concerns or because the trauma center may not accept the patient without confirmation of the severity of injury. A potential solution, beyond education and outreach, could be the establishment of regional Picture Achieving and Communication System (PACS) networks that are connected by broadband technology between referring and receiving hospitals.
The team leader should speak directly with the receiving trauma surgeon and should avoid transferring care directly to a subspecialist (orthopedic surgeon, neurosurgeon, plastic surgeon). If the receiving hospital is on diversion, its representatives should help the referring hospital find an alternate destination.
Federal law now governs transfer of patients from an emergency department to another hospital, to another area within the same hospital, or to home. Violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations can lead to draconian penalties for hospitals and individuals. Punishments include denial of the ability to care for Medicare and Medicaid patients, as well as civil liability. This set of rules, originally enacted in 1985 to prevent patient “dumping” (inappropriate transfer of unstable indigent patients from private to public emergency rooms), has been expanded to what is essentially a federal right to emergency care and a federal malpractice act. The receiving hospital is obligated to report whenever a patient was “unstable” or inappropriately transferred. A complaint by any concerned party must be investigated by the Office of the Inspector General (OIG).87
Most traumatic events will be viewed by the patient, although not necessarily by health care workers, as an emergency. Any patient has a right to request a medical screening exam (MSE) for a perceived emergency medical condition (EMC). The hospital or clinic is required to determine by this exam whether or not an EMC in fact exists. If the patient has an EMC, “the hospital must stabilize the emergency condition, or, if it is unable to stabilize the patient, the hospital must transfer the patient to a hospital that is capable of stabilizing the emergency condition. Hospitals with specialized capabilities or facilities are required to accept transfers of patients who require such specialized services ….”87 What constitutes an EMC, and the details of the MSE, is open to interpretation.
How are hospitals and physicians to respond (Table 8-2)? One strategy already being employed is for surgeons to refuse to take trauma calls and for hospitals to close their doors to injured patients. The ethical and legal ramifications of this approach are debatable and will undoubtedly be subjected to close scrutiny. The proactive response is for health care workers and facilities to familiarize themselves with the provisions of the law and to establish, in cooperation with each other, a trauma program that will be in compliance. Properly executed transfer agreements should, in most cases, streamline the process. It is likely that the strongest defense in any given instance will be the ability to demonstrate that actions were directed toward the patient’s best interest. For the trauma patient, the following would be appropriate:
Prehospital triage protocols for identification of critically injured patients
A mechanism for ensuring early evaluation at the bedside by the appropriate surgeon or emergency medicine physician
Prompt initiation of resuscitation and stabilization measures
Early decision regarding the medical need for transfer
Consultation with the receiving hospital (ideally with the trauma surgeon)
Documentation of indications for, and acceptance of, transfer
Arrangement of the appropriate transfer team, conveyance, and equipment
Before transfer, stabilization of the patient’s condition to the degree possible given the resource imitations of the transferring hospital
Managed care may also interfere with the orderly transfer of patients as established by a regional trauma system. Several types of problems have arisen. Payments for emergency and after-hours transfers have been denied for lack of prior authorization, even though such authorization was impossible to obtain at the time. Triage to a hospital within the managed care system may be mandated, even though that facility may not be an authorized trauma center. The American College of Surgeons has issued a statement condemning such practices and encouraging cooperation of managed care and trauma systems.88
Operative Stabilization and Transfer
Most patients respond to standard resuscitative measures and, once stabilized, can be admitted locally, discharged home, or transferred to a higher level of care. A small proportion, probably less than 10%, will be either transient or nonresponders and will remain hemodynamically abnormal despite continued skilled resuscitation. If the patient has multiple injuries, suffers from significant medical comorbidity, is at the extremes of age, or has injuries requiring subspecialty (i.e., neurosurgical) or complex intensive care, transfer will likely be necessary. The more remote the primary facility is, the greater the risk that the patient will deteriorate during transfer unless something is done to address the underlying problem, generally hemorrhage. In this circumstance, the local general or subspecialty surgeon should be prepared to operate and stabilize the patient before transfer.89 With a properly equipped transport vehicle, usually a fixed-wing aircraft or helicopter, the patient may often be transferred immediately thereafter into the hands of the flight team without any compromise of care.67,90 Operative stabilization of this sort falls into the following two categories: definitive surgery and damage control surgery.
Under most circumstances a stabilizing procedure can be conducted and completed in conventional fashion, such that no further treatment will be required for that particular problem. Examples would include, but are not limited to, the following:
Establishment of a surgical airway
Splenorrhaphy or splenectomy, hepatorrhaphy, resection and debridement, or insertion of perihepatic packs
Closure of evisceration
Closure of injuries to the gastrointestinal tract
Repair or shunting of truncal and extremity vascular injuries
Reduction of dislocations
Debridement and control of hemorrhage from open fractures in an extremity or mangled extremities
Damage control operations followed by temporary closure of the abdomen have been described for a variety of truncal injuries with an emphasis on limiting time in the operating room and avoiding the triad of acidosis, hypothermia, and coagulopathy.91–93 Candidates for these desperate measures typically have an overwhelming constellation of injuries. Most reports on damage control surgery and temporary closure techniques have come from urban trauma centers. Following a period of rewarming and correction of hypothermia, acidosis, and a coagulopathy in the intensive care unit, the patient is then returned to surgery for definitive repair of the remaining injuries. Rural surgeons can apply the same principles. Occasional patients will have such complex injuries that definitive management exceeds the technical abilities or resources of the local surgeon and hospital, but may be amenable to temporizing maneuvers, followed by rapid transfer in an aircraft equipped as an airborne intensive care unit.94 Examples include packing of the liver for complex hepatic injuries; peritoneal cleansing, hemorrhage control, and stapling or rapid suture of multiple bowel perforations; temporary abdominal closure; and abbreviated thoracotomy, hemorrhage control, and temporary chest closure for patients with extensive pulmonary and thoracic vascular injuries.95 If interventional radiology is not available locally, patients with unstable pelvic fractures may benefit from application of external fixators prior to transfer.
Surgeons in Alberta compared outcomes in patients referred to a Level I center from Level III and IV hospitals in the region, focusing on those patients arriving in unstable condition and requiring emergency laparotomy. Most had multisystem injuries and required operations by surgical subspecialists, as well. Despite the presence of serious concurrent injuries, however, they concluded that while the community surgeons in the Level III hospitals were triaging patients appropriately, some patients might have benefited from a damage control operation prior to transfer.96
Injury to the brain remains the single greatest source of morbidity and mortality for trauma victims.18 Many patients sustain their closed head injuries far from the nearest neurosurgeon, and time becomes the enemy. Under most circumstances, the only option is to minimize secondary brain injury with appropriate ventilatory and pharmacologic maneuvers and expedite transfer.97,98 A small proportion of these patients, however, will have lesions amenable to surgical drainage. While rural hospitals generally lack neurosurgical services, most hospitals in the United States now have CT scanners. General surgeons can be trained to perform burr holes and/or limited craniotomy for decompression and hemorrhage control in patients with epidural or subdural hematomas noted on a CT scan.99,100 When a patient with an injury to the brain shows signs of rapid deterioration and a delay of more than 90 minutes to definitive neurosurgical care is anticipated, consideration should be given to emergency decompression of the hematoma.98,101 The necessary components are as follows:
A general surgeon trained in indications for and technique of burr holes with limited craniotomy
Traumatic brain injury with lateralizing signs and threatened herniation
Surgical lesion present on CT scan
Consultation with, and approval of, neurosurgeon at receiving trauma center
Limited craniotomy for decompression and hemorrhage control
Immediate transfer to definitive care97
Most trauma patients can be cared for at a local community hospital capable of offering continuous surgical care. “The mindset that a well-trained general surgeon is not able to care for many trauma patients must be corrected.”72 Although triage and transfer guidelines address anatomic, physiologic, and mechanism of injury parameters, there are few publications that describe specifically which patients might reasonably be cared for in small hospitals. Currently accepted examples are patients with isolated extremity fractures, minor burns, lacerations, a hemothorax and/or pneumothorax, multiple rib fractures, traumatic brain injury with GCS of 14–15, and a variety of organ and vessel injuries within the ability and comfort range of the attending surgeon. It is important for surgeons to remember that colleagues, nursing staff, and ancillary services must also be able to provide the necessary adjunctive care. Patients at the extremes of age, with multiple organ system involvement, the need for prolonged ventilator support and/or intensive care, and serious underlying illnesses, will probably benefit from care in a trauma center under most circumstances. Patients should always be advised of the option to be transferred. It is important to be aware of pertinent state statutes or transfer guidelines used by the regional trauma system and to realize that in the event of misadventures, the burden of proof will rest with the doctor who chooses not to transfer a patient.
The management of patients with blunt injury to solid abdominal viscera (particularly spleen and liver) presents some difficult logistical problems for the rural surgeon. Most patients with injuries to the spleen or liver and normal hemodynamics can be managed without an operation. When an operation is necessary, the well-trained general surgeon is certainly fully capable of performing a splenectomy or splenorrhaphy. Major hepatic injuries have the potential for overwhelming the technical ability of the surgeon or the resources of a small blood bank, but may be amenable to simple suture repair, resectional debridement, or packing and immediate transfer. It is to the patient’s advantage to be managed in the local hospital rather than be transferred to a distant Level I or II center, if it can be done safely. The problem lies with the patient who deteriorates unexpectedly, becomes hypotensive, and requires urgent surgery. In a hospital lacking house staff, immediate availability of the surgeon, and a plan for rapid preparation of the operating room, there is a small but real potential for death from exsanguinating hemorrhage. In these circumstances, a lower threshold for early operation or transfer is appropriate.102
When patients are selected properly for local treatment, a number of advantages accrue. It is generally more convenient for patient and family as friends, clergy, and support groups in the area provide moral support and can hasten recovery and reintegration into the community. Risks inherent in emergency transfers are eliminated. Use of local services keeps money in the community. Because most rural trauma is motor vehicle related, insurance coverage is better than average and supports the financial stability of the hospital. Finally, appropriate local care reduces the burden on busy regional trauma centers.72,103
A downside for many surgeons is that trauma of this sort, particularly in the era of observation of injuries to solid organs, is not very exciting and produces relatively few operations. Overseeing care for patients while subspecialists perform a variety of operative procedures does not appeal to many general surgeons. Hours are inconvenient, and trauma emergencies can wreak havoc with elective schedules. The high incidence of substance abuse in association with traumatic events is well documented and may make evaluation and management of injured patients difficult or unpleasant. Surveys of surgeons’ attitudes toward trauma reflect many of these concerns and yet, interestingly, demonstrate that rural surgeons are significantly more willing to accept these burdens than are their urban colleagues.50,104 In fact, the opportunity to provide potentially lifesaving treatment to friends, neighbors, or acquaintances and to see its long-term effects is one of the benefits of a general surgery practice in a small town.72
Population shifts in the coming years will have an impact on the problems of rural trauma. Although many parts of the Great Plains are becoming progressively depopulated, rural areas of the coastal regions, Rocky Mountains, Southwest, and Sunbelt states are experiencing an influx of young, active people who are tired of city life and eager for what small town America has to offer. Equipped with cell phones, modems, GPS-based equipment, and sport utility vehicles, these members of generations X and Y (and their baby boom parents) are very much into hiking, camping, climbing, skiing, and other activities that are best pursued in rural and frontier settings. They are affluent and well educated and accustomed to getting what they want. It is likely that, in order to support their desired lifestyles, they will expect or demand a trauma infrastructure that is sophisticated, efficient, effective, and comparable to what is available in a resource-rich environment. Whether they will be willing to pay for it through taxes or user fees is another matter. An important mission for rural systems will be convincing constituents of the importance of financial support for trauma activities.