MEDICAL SPECIAL REPORT 2The origins of trauma care delivery are deeply rooted in the major military conflicts of the lastcentury. During the Napoleonic Wars, Dominique Larrey established the concepts of field hospitals,
the use of the “flying ambulances” and the principles of triage. In the World War I, rapid and timely
evacuation of the injured from the battlefield through echelons of treatment facilities, each withincreasing surgical capabilities, became the standard of care. During the World War II, in addition to
reducing the time from evacuation to treatment, the principle of “resuscitation” or treatment of
shock prior to transport evolved. When combined with the other advances in transfusiontechnology, surgical technique, antibiotics, and so on, this systematic approach to trauma careresulted in a significant decrease in mortality. This approach was further refined in the Koreanconflict and the Vietnam War, when wounded soldiers were rapidly transported within minutes byhelicopter to fully capable hospitals, where the entire spectrum of trauma care from initialresuscitation to definitive surgical management was delivered. Experience gained in the battlefieldof trauma
care for victims of “urban warfare.” However, in spite of extensive training, these same
trauma surgeons were unable to provide the same level of care outside these urban hospitals.Therefore, it became clear that the system, and not the individuals, were responsible for theobserved successes, and the need for trauma systems, not just trauma surgeons, becamerecognized.The publication of seminal report
, Accidental Death and Disability: The Neglected Disease of ModernSociety
, in 1966 became the catalyst in changing the delivery of trauma care. This report highlightedthe magnitude of the problem in both human and economic terms and lack of an organized public orgovernmental response to the problem. As this became a major political issue, Congress respondedby enacting the National Highway Safety Act of 1966. The resultant funding spurred thedevelopment of trauma systems in the states of Maryland, Florida, and Illinois. Additional federalfunding followed passage of Titles 18 and 10 of the Medicare and Medicaid Act, the EmergencyMedical Services System Act of 1973, and the Emergency Medical Services Amendments of 1976.
Prompted by perceived financial gains, a large number of hospitals sought designation as “traumacenters.” With the sharp decline in fund
ing following the Omnibus Budget Reconciliation Act of 1981, the exodus of participating institutions was as rapid as their entry into the system. Thespecialty care of trauma then became the purview of centers that retained an interest in caring forvictims of traumatic injury in spite of the disadvantages that are associated with doing so.Over the ensuring years, trauma systems have matured with the trauma center as theircornerstone. Adequately addressing the issue of traumatic injury is recognized to include a spectrumbeginning the injury prevention and education, throughout the immediate acute care phase, andextending into the rehabilitation. The success of these systems is recognized in the ability of traumacenters, in the context of trauma systems, to reduce mortality and morbidity. Further, lessonslearned are being applied in the theatre of war. Medical teams on the front lines of battle in Iraq andAfghanistan are receiving training prior to deployment at select trauma centers and employingprinciples refined in the civilian sector (Figure 1).
PREHOSPITAL TRAUMA CARE