Mass enlistment: the future of trauma care

In a few moments, Dr Lewis Kaplan will be telling Practical Patient Care about how a visit to a dojo, a conversation with a former US surgeon-general and the memory of John Glenn convinced him to moonlight as a SWAT team medic. But first, he has to negotiate heavy traffic. “We are all on holiday this week, and we were trapped behind a lot of construction vehicles, which added about an hour to the drive,” Kaplan explains after pulling over, family in tow. “I had anticipated being home, but clearly we are still on the road.”

An associate professor at the Perelman School of Medicine, University of Pennsylvania, in addition to his post as the interim chief of surgery at the Veterans Affairs Medical Center in Philadelphia, Kaplan is one of the US’s leading traumatologists. At its core, Kaplan believes, the future of the field lies in expanding the number of people who can enhance patient survivability in cases of serious injury. That means not only relying on the contributions of paramedics and doctors in the ICU, but also police officers and even the general public.

It was in a bid to observe just how far this contribution could be stretched that Kaplan volunteered his own expertise in traumatology to the New Haven Police Department, shortly after assuming a previous academic posting at Yale University. “I had always been involved with martial arts in one way or another, and I found a dojo that was appropriate for the form that I was most comfortable with,” he recalls. “One of the guys who attended was a sniper for one of the local SWAT teams. We got talking, and, at the same time, my now older son – he was nine years old at the time – was reading a book about John Glenn, who was a very civic-minded person. He asked me, ‘What do you do that’s civic-minded?’ And I thought, ‘Wow. I give all this free care to people who can’t pay, and I spend my nights in the hospital taking care of people who are sick and injured.’ And I realised, really, it wasn’t quite enough.”

Tactical care

By volunteering at his local SWAT team, Kaplan was consciously following the example of the former US surgeon-general Richard Carmona, whom he had met briefly a few years before. Carmona had a swashbuckling reputation.

A former special forces operative in Vietnam, he earned his medical degree in 1979 before forging a career as a leading traumatologist in Tucson, Arizona. Having witnessed enhanced survival rates arising from the practice of embedding medics in special forces squads, he applied the same principles with some success in civilian medicine by joining his local SWAT team. Never one to shy away from a challenge – according to the Chicago Tribune, Carmona “rappelled down a rope dangling from a helicopter to rescue a person stranded on a cliff”, inadvertently inspiring the creation of a made-for-TV movie – the former surgeon-general was a vocal advocate of the principles of Tactical Emergency Medical Services (TEMS) being extended to SWAT teams across the US.

“It took me about three cups of coffee and two doughnuts to convince the police department that it was a really good plan,” Kaplan recalls. “[The team] never anticipated being trained to put on a tourniquet or decompress a chest. It was absolutely relevant to them and they embraced it as if it was the most serious thing that they had ever done.”

For Kaplan, the whole experience opened his eyes to a range of treatments for trauma casualties that could take place on the scene with various degrees of training, not only by members of a SWAT team but the far larger number of patrol officers, who are often the first emergency responders to reach the scene of an incident. Yet the gap in adequate training among law enforcement officers is clear. In a report co-authored by Kaplan in the Journal of Trauma and Acute Care Surgery in 2016, 100 US police departments – half of them located in state capitals, the rest in randomly selected jurisdictions – were surveyed on their officers’ ability to perform simple trauma care techniques in the field.

“Most officers are trained in CPR and to use an automatic extro-defibrillator device,” he explains. “Many of them carry tourniquets too, but their departments often haven’t specifically trained them in their use, or in that of pro-coagulant dressings. Many of the officers are going out on their own and equipping themselves in ways that make sense, but perhaps not in as organised and carefully crafted fashion as one might like. There are growing pains.”

Blind spots

Yet Kaplan is among a cohort of traumatologists who believe that the future of US trauma care does not solely lie in closing the gap in training for simple procedures. He believes that there is room for the deployment of more advanced devices among law enforcement officers and EMS networks. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one such treatment.

“REBOA is a balloon occlusion catheter that gets fed up the femoral artery into the aorta,” explains Kaplan. “If you have someone with a massive liver injury, you can close off the blood flow from the inside. Right now, they are doing that in the military sphere, and there seems to be very good results with it. It is just starting to be deployed in the civilian world, and there are mixed reviews about whether or not this is good, but the notion of even earlier haemorrhage control with additional devices that are now not external, but internal, is a bit of a paradigm shift.”

Ultrasound constitutes another blind spot in front-line civilian trauma care, according to Kaplan. “We use it liberally in the emergency department and quite a bit in the ICU, but it is not at all used anywhere on EMS rigs,” he says. “The ambulance is devoid of ultrasound for the most part. There are always some hospitals that protest, ‘Oh no, we are trialling it’, but it is not standard and medics are not expected to be competent at ultrasound.

But it would make sense. In determinations of cardiac arrest, you can use it to look at whether someone’s chest should be decompressed or look at blood volume in the heart.”

There is even room for simple but effective changes to be made in the ICU, according to Kaplan. The professor is a vigorous proponent of airway pressure release ventilation (APRV), wherein the attempt is made to mechanically ventilate as much of the lung in the trauma patient as possible by maintaining a constant pressure rate and relieving it in short bursts during exhalation. This technique is not the norm, but Kaplan believes that APRV is, in fact, more appropriate for patients with lung injury. “Their lungs become leaky from inflammation,” he explains. “Sometimes, they have direct injury as well, but those lungs are often recruitable.”

Kaplan concedes that it does take longer to wean patients off APRV than other methods of mechanical ventilation, a factor aggravated by the competing responsibilities of doctors in the ICU. APRV also requires more monitoring and small changes in application to be made over time, something that can be difficult to accomplish during long nights on the emergency ward.

Yet Kaplan is unequivocal. “It makes, for me, much more physiological sense,” he says. “But most places do not use
this as a primary mode. They use it as a salvage mode and, so, since I have students and fellows whom I need to train to be able to function in an environment that does not principally use the APRV as an initial mode of ventilation, they do not get used to ventilating people upfront with that either.”

National medicine

These are important ideas, but also emblematic of a field that has not sustained fundamental change since the formation of the first EMS systems in the 1960s. There is, after all, no organisation along the lines of the National Cancer Institute to promote further research in how best to enhance the organisation of the ICU, or funding equivalent to that thrown at diseases that are unlikely to match the $670 billion that traumatic injury was estimated to have cost in medical expenses and lost productivity in 2013.

“There are millions of dollars devoted all of a sudden to Zika virus, and if you walk through West Philadelphia and around the University of Pennsylvania, there’s no Zika virus but you find bloodstains on the cement,” Kaplan reasons. “It all depends upon your perspective, and all of them are somewhat local in many ways.”

Yet there are signs that trauma care in the US may be reaching beyond its established model, thanks to its priorities dovetailing with the national response to terrorist incidents. “The notion of having a culture of competence in response to disasters of any kind has taken a toehold, and there are programmes that have been developed jointly simply to educate the public – laypeople, not medical professionals – about disaster response: how to participate, how to recognise when it is safe and then what you can and cannot reasonably do for people,” says Kaplan.

It is a compelling narrative, and one reinforced by rising instances of gun violence and the potential of ‘lone wolf’ terrorists to wreak bloody havoc upon crowded areas. “Just look at what happened with the Boston Marathon bombings,” Kaplan says, citing the case of dozens of medical professionals on the rope line rushing into the smoke to help. “Just look at all the people that are taking one course or another from the American Heart Institute, or the American Red Cross, for CPR and other related kinds of support services.”

Embedded at the heart of American trauma care, Kaplan is proud of what he sees. On top of the range of innovations he has seen even in recent years, the trauma fellowships at Perelman are full. “While trauma care is demanding – it is a high-stress environment, it often involves long hours, people can be absolutely weary, and you do get to see the seedy underbelly of society – you have unique rewards,” the professor says, rather wistfully. “And in that way, you serve the rest of your community in a unique way.”