There are over 1,675 trauma centers in the United States. Although there are still gaps in coverage, particularly in rural areas, 82% of the U.S. population has rapid access to a trauma center. And, there is a 25% reduction in mortality after injury with trauma center care compared to treatment at a nontrauma center. The rapid development of trauma centers and systems across the United States is one of the most important developments in the history of surgery.1
Despite this success, injuries are still the fifth leading cause of death. This figure actually understates their impact. Years of Potential Life Lost (YPLL), which subtracts the age a person dies from their life expectancy, is a better measure of burden of disease. When a man in the United States dies from an injury at the age of 20, the YPLL is 58 because the average life expectancy for a man in the United States is 78. If he dies of heart disease at the age of 77, there is only one YPLL.
Heart disease causes five times the number of deaths as injuries, but injuries account for one and one half times as many years of life lost, and more than the amount attributable to all malignant neoplasms.2 Thus, the task of reducing injury-related mortality is far from complete.
In a 12-year longitudinal study that tested the impact of a rigorous emphasis on continuous quality improvements, the center involved was unable to reduce major complications or mortality during the entire study period, despite implementation of numerous protocols.3 The authors concluded that mature trauma centers have already reached the limits of their effectiveness at reducing injury-related deaths. Further reductions in trauma mortality will require new strategies.
The reasons for this were demonstrated in a study that looked at 753 consecutive deaths in a trauma center.4 Over 40% of those who died received cardiopulmonary resuscitation in the field and had nonsurvivable injuries. The leading cause of death was severe traumatic brain injuries. Roughly 90% of patients who died had such severe organ damage and destruction that no current or conceivable future treatments would ever be able to prevent their death.
Late deaths due to multiple organ failure, secondary brain injury, sepsis, and pulmonary emboli accounted for only 6% of deaths. The preventable death rate was 2.6%. Thus, a research breakthrough that prevents all deaths due to complications and eliminates all medical errors would have only a marginal effect on survival rates in trauma centers. The actual reductions would be much less than that. Up to 75% of injury-related deaths occur in the field. Autopsy reports suggest that most field deaths probably occur within minutes of injury before help has a chance to arrive. These patients will not benefit from improvements in care.
The most promising way to reduce trauma mortality is to implement evidence-based injury prevention programs. Numerous ...