Douglas J.E. Schuerer, M.D.
Associate Professor of Surgery
Washington University School of Medicine
May 7, 2014
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In 2008, legislation passed in Missouri
creating the “Time Critical Diagnosis” system.
Created a statewide system for emergency
medical care for trauma, stroke, or STEMI.
Idea was to build on the trauma framework
for the other two diagnoses.
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Goal:
Quick assessment, diagnosis and treatment
by a facility that can provide timely, definitive
care to minimize risk for preventable
complications and death.
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Trauma Task Force
Review entire trauma system including
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Need for level IV trauma centers
Develop statewide trauma classification system
Develop triage/ transfer protocols
Develop disease specific protocols (burns,
amputations, etc.)
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Written regulations for Level IV centers
Final Trauma classification and Triage
Protocols
Recognized the importance and need for
regional EMS committees.
Based planning on rapid disposition to
appropriate centers.
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What is the Golden Hour?
Developed as a theoretical concept initially in
the care of the traumatically injured patient
by Dr. Crowley in Baltimore.
Important as we realized when trauma deaths
occur and from what causes.
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Some studies have suggested that the
concept is faulty and there is no specific
benefit to getting to a trauma center quickly
However many have shown that rapid
transport to a trauma center improves
survival
Trauma mortality is higher in rural areas,
often due to delayed transport.
Air ambulances improve survival in rural
areas as well.
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No definitive studies exist in trauma, but
stroke and STEMI have well developed time
targets
Trauma likely different because of variability
of the disease.
Why would the Golden Hour make a
difference?
Treatment
Problem
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Loss of airway
Tension pneumothorax
Pericardial tamponade
Acute blood loss
Epidural hematoma
Aortic rupture
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Intubation
Chest tube
Pericardiocentesis
Transfusion /
Operating Room (OR)
OR
OR / Blood Pressure
control
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Have facilities always ready to care for the
acute injuries
Surgeon available for immediate Operating
Room (except Level IVs)
Multidisciplinary team ready
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Trauma centers improve survival over nontrauma centers.
Patients transferred to higher level trauma
centers do better than if not transferred from
lower level trauma centers.
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State verification as highest level of
preparedness.
American College of Surgeons verification an
even more stringent review process. Fewer
hospitals in the region have achieved this
higher benchmark.
None have held in continuously as BarnesJewish as for 17 years.
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Able to treat all types of trauma at a
moments notice.
Regional resource for the care of the injured
patient.
Research and education an important part of
the mission.
Injury prevention initiatives a required
element.
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Developed Triage and Transfer Protocols to
guide initial placement of patients with
injuries.
In general, the plan calls for more injured
patients to be taken to higher level centers.
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Add Level 4 centers for the lowest level
patients.
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March 16, 2009, Richardson sustained a head
injury when she fell skiing.
No helmet, not required in Quebec
Skiing lesson at the Mont Tremblant Resort in
Quebec, Canada about 80 miles (130 km)
from Montreal.
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Was initially lucid
Ski Patrol called ambulance, who were waiting
at bottom of the mountain
They skied by and told them they were not
needed.
She refused treatment at least twice, but was
eventually taken by ambulance from the hotel
3 hours after the injury to a local hospital.
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She was transferred to
a trauma center in
Montreal by ground,
and arrived 7 hours
after her injury.
There were no air
ambulance services in
Quebec at the time
She died the next day,
and was an organ
donor, from a epidural
hematoma.
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What about TCD?
Debate over who can refuse care
Early launch of helicopters can improve
survival
Patients like this will need to go directly to a
higher level of care, reducing double
transfers and time to definitive care
With early transfer, this was survivable
And then there was the helmet issue…
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Had watched the Mike Tyson fight the night
of September 7, 1996
He decided not to wear his normal bullet
proof vest.
At about 11:15 pm, he was a passenger in a
car riding on the Las Vegas strip.
A car pulled next to them and emptied
multiple rounds into the car.
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The driver, Suge Night was also superficially
hit in the head
Tupac could talk and breathe at the time.
He floored it, did a spin out and drove about
1 mile away in a few minutes
This was impressive as the strip was crowded
and three wheels were shot out.
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Ambulance met them at 1130pm
He was at UMC at 12 MN
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He reportedly said, “ I can’t breathe.”
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A chest tube was placed with 1500 mL out
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He underwent an immediate operation
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Unclear what happened when, but at next
operation the next day he likely had a
pmeumonectomy.
Originally he improved, but he died 6 days
after the shooting after several rounds of
bleeding and CPR.
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He unfortunately was on such a crowded
road, it was almost like a rural location
EMS did meet him at a location, but it was
still 30 minute transport time
Unclear if a balanced resuscitation was used,
but he did develop coagulopathy
Even more rapid transport unlikely to help
given need for pulmonectomy.
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The events of Sunday, August 31, 1997:
◦ 12:20 am: Princess Di and Dodi Fayed leave in car
with bodyguard Trevor Rees-Jones and driver Henri
Paul.
◦ There is still much debate over whether Paul was
intoxicated – he probably was.
◦ 12:23: The car reaches the Place de l’Alma tunnel.
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Estimates are the car was going 90 – 120
mph – it is zoned 30 mph.
For unknown reasons, the car veered, braked
and lost control.
It then struck the 13th concrete pillar, rolled
over and rebounded off the right wall.
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Paul and Fayed were killed instantly.
12:27 : Firefighters get the first call for help.
Dr. Frederic Mailez, a bystander ER physician,
said Diana “was unconscious, moaning, and
gesturing.”
12:40 : Police and firefighters arrive.
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Trevor-Jones and Diana are still alive.
First reports were they had to cut Diana out,
but later this was not the case.
52 minutes later, Diana was placed in the
ambulance.
The ambulance started on the journey to the
hospital – 3.7 miles away.
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2:05 : 43 minutes later she arrives at the
hospital. There was one stop in route to
administer adrenaline. Travel rate was 25
mph. Total ambulance arrival to hospital time
was 1 hour 35 minutes (3.7 miles)
Resuscitation including thoracotomy is tried
for 2 hours.
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4:05 : Princess Diana declared dead.
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Ambulance
◦ The French developed the first ambulances in 1797.
◦ Developed to rapidly evacuate casualties from the
battlefield during the Italian campaign (The French
always seem to have a lot of casualties when they
don’t surrender first.)
◦ Horse- drawn wagons.
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SAMU (Service d’Aide Medicale Urgente)
◦ French ambulance system
◦ Physician on board at all times, traveling MICU
◦ They believe in treating the patient at the scene
 “Stay and Play”
 In US “ Scoop and Run”
◦ Driving slower is better, “So the patient is not
rocked around.”
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Diana was found
to have a torn
left pulmonary
vein.
Normally, this
would present as a
left hemothorax
and require a left
thoracotomy.
Hemothorax
Wide Mediastinum
CT
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By report, she actually had a right
hemothorax secondary to a torn pericardium.
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The initial incision was on the wrong side,
thus delaying time until the repair of the
pulmonary vein.
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My thoughts:
◦ The delayed time until the patient got to the O.R.
probably changed her outcome.
 Apparently “The Golden Hour” is not important in
France.
◦ TCD principles would likely have saved her,
including balanced resuscitation.
◦ Pulmonary vein bleeding can still be fatal, even with
rapid hospital transport.
◦ The unfortunate wrong initial side of surgery
compounded the time until repair was effected.
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I think in the United States she would have
lived if not in a rural area.
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March 30, 1981: Only 70 days after taking
office, at 1425, Reagan exited the Hilton
Hotel and approached his limo.
As he waved to the crowd, he and three
others were shot by John Hinkley, who was
apparently trying to impress Jodi Foster.
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Watched “Taxi Driver” with DeNiro playing a
man who protected Foster’s character in the
movie by killing her pimps.
Wanted to do a grand gesture to impress
Foster.
Bought a $25 gun and waited outside the
Washington Hilton.
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Hinkley fired six times in three seconds.
He used Devastator bullets, designed to
expand on impact.
Four of the six hit someone, the last hit
Reagan.
SS Agent McCarthy also was hit.
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McCarthy dove in
front of the
President to stop a
bullet.
He was hit in the
chest, but
survived.
He received the
NCAA Award of
Valor.
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Reagan was hit by a bullet that ricocheted off
his armor plated limo. (He did not know it at
the time.)
Also shot were Press Secretary James Brady,
Secret Service Agent Timothy McCarthy, and a
D.C. police officer, Thomas Delahanty.
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He was pushed into the limo by the secret
service and he felt pain in his rib.
He said, “Get the … off, I think you’ve broken
a rib.”
Then he coughed up blood.
The agent ordered the limo driver to go to
George Washington Medical Center – 9 blocks
away.
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He reported difficulty breathing.
1435: Arrival to ED – “I can’t catch my
breath.”
◦ He fell to his knees and was carried to a trauma
room.
◦ Extreme pain.
◦ Initial BP – 80/palp
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Blood noted at face and mouth.
O2 by mask, Fluid, 2 Units PRBCs started.
President able to make jokes.
Wound at 4th intercostal space, posterior
axillary line.
No breath sounds over left chest.
Hct from 40 to 30 in 30 minutes.
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Chest tube yielded 1200 ml of blood and
continued at 200 – 300/ 15 minutes. – Total
of 2275 in the E.D.
There is some discrepancy here, with other
reports of only 1200 to 1300 total.
Most trauma texts now advise thoracotomy
if more than 1500 ml at first and more than
200 an hour of bleeding.
BP – 160/100 in 15 minutes.
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There are some who say a left subclavian line
was attempted which led to the increased
bleeding from the chest tube – so a trip to the
O.R.
In fact, most low velocity GSW’s to the chest
do not require thoracotomy (90%)
Did he really need the O.R?
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Likely yes, but not from the lung injury but
potentially from a subclavian vein injury – we
will never know.
It turns out it was a devastator bullet with
lead azide-filled centers that wold have
required an operation to remove anyway.
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1458 CXR:
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President to the surgeon Dr. Benjamin Aaron,
“Please tell me you’re a Republican.”
Dr. Aaron, a liberal Democrat, “Today, Mr.
President, we’re all Republicans.”
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Bullet finally found and bleeding controlled.
Operation
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2 hours and 40 minutes
EBL 3000 to 3500
Transfused 8 units PRBC, 3 units FFP, 1 pack plts
HCT 33 in the recovery room
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Recovery delayed by atelectasis, mucous
plugging, and possible pneumonia
He was never reintubated, but was bronched
twice.
He was discharged on 4/11/81, POD #12
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What would be different with TCD?
◦ Ambulance vs. limo.
◦ Chest CT with angio would rule-out concern for
cardiac wound.
◦ Abdominal CT would replace DPL.
◦ Likely would have avoided emergent O.R.
◦ Would not have looked so long for the bullet during
the case (avoid coagulopathy).
Questions?