Trauma Center Density In Urban Areas

The focus of this post is going to be a little different. I’ll be coming up out of the trenches of clinical care, and focusing on trauma systems for a bit. Specifically, I’m going to look at the density of high-level trauma centers in bigger cities. For my non-US readers, this paper is based on data from the States, but is most likely applicable in your countries as well.

Why look at trauma center distribution? More than 80% of the population lives in an urban area of the US. And over the next thirty years, that number will approach 90%. As more people move to the big cities, there are concentrations of homelessness, poverty, mental illness, and violence. This last factor is one of the reasons for trauma center existence, and their distribution is ostensibly one of the reasons to have a trauma system in the first place.

In theory, there should be an optimal number of trauma centers for a given population base. The American College of Surgeons (ACS) created a needs-based assessment tool to predict the optimal number of centers given the population size, trauma volume, EMS transport times, and more. If you are interested, you can download it here.

But has it been followed? Trauma leaders from some of the most established Level I centers in the country performed an analysis of the density of Level I and II centers in 15 of the largest cities in the US. They tried to test what social and economic conditions in an area determined the number of centers available in it, if any.

The cities were determined using information from 2015 census information. The trauma centers in each were identified from ACS or state system information.

Here are the factoids:

  • 14 of 15 cities had multiple Level I or II centers
  • There was a large variation of centers per geographic area covered, ranging from 1 per 150 km sq (Philadelphia) to 1 per 596 km sq (San Antonio)
  • Population density (the population divided by the number of trauma centers) varied from 1:285,000 people in Columbus to 1:870,000 in San Francisco
  • The median minimum distance between centers was 8 km, and varied from 1 km in Houston to 43 km in San Antonio
  • Poverty and unemployment rates were highly correlated to violence rates
  • There was no correlation with trauma center density and social determinants of health or violence rates

Bottom line: What does all this mean? It appears that the number and geographic distribution of trauma centers in larger cities has nothing to do with need as measured by the social and economic conditions of the area. More likely, it is related to financial considerations. Trauma center closures in urban areas have disproportionately occurred in the lowest income areas. And it is less likely that new centers will open in these areas.

Obviously, hospitals need to make money to survive. Insurance coverage has become more available to people with lower incomes over the past 10 years. Unfortunately, the reimbursement rates for hospital stays continue to decline slowly. This combination makes it more difficult for a hospital to eke out an existence in one of these areas.

What can be done? Unfortunately, this is one of those many-headed hydra type issues. There are so many competing interests, and the people affected have little representation in the process. Our trauma systems should play a larger part in this, as they are supposed to have some say over the structure and distribution of their centers. Unfortunately, many of them do not have the financial support or the political wherewithal to do this.

Ultimately, I believe that we are working for something that should be considered a common good. Which means that it is up to state and ultimately the federal government to work with all the stakeholders to better control the distribution of this valuable resource. Which means that it is up to the trauma center administrators and trauma leaders to make sure the call is heard by their government leaders who can make things happen.

This is likely to remain a sticky problem during the age of COVID. Resources are needed for more pressing matters right now. But when the time comes, all trauma professionals need to speak up and help work this problem. Get involved with your regional trauma advisory committee. Make sure your state trauma advisory council makes it a priority. And don’t shy away from letting your legislators know about the problem. Otherwise, they will remain blithely unaware and our patients may continue to suffer.

Reference: Describing the density of high-level trauma centers in
the 15 largest US cities. Trauma Surgery & Acute Care Open 2020;5:e000562.

The “Double-Barrel” IO: Can It Work?

Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours.

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids:

  • Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
  • Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
  • The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
  • Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
  • Multiple fluid + drug infusion combinations were tested without incident
  • There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. Don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury 46(11):2239-42, 2015.

The September 2020 Trauma MedEd Newsletter: Sleep Loss & Fatigue

This issue is devoted to one of the most undervalued aspects of maintaining your health and career: sleep. This issue covers the basics of sleep, how it impacts trauma professionals, and what to do about sleep problems.

Topics covered include:

  • Facts On Fatigue And Sleep Loss
  • Impact on EMS Providers
  • Impact on Nurses
  • Impact on Physicians And APPs
  • What To Do About Fatigue And Sleep Loss

To download the current issue, just click here! Or copy this link into your browser:

This newsletter was released to subscribers over a week ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!

VIP Syndrome In Healthcare (Very Important Person)

Current events are making this classic post even more poignant!

The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

Who is a VIP? It may be a celebrity. A family member. Or even a colleague. Or the President of the United States. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

Does Time To Interventional Radiography Make a Difference In Solid Organ Injury?

Solid organ injury is one of the more common manifestations of blunt abdominal trauma. Most trauma centers have some sort of practice guideline for managing these injuries. Frequently, interventional radiology (IR) and angioembolization (AE) are part of this algorithm, especially when active bleeding is noted on CT scan.

So it makes sense that getting to IR in a timely manner would serve to stop the bleeding sooner and help the patient. But in most hospitals, interventional radiology is not in-house 24/7. Calls after hours require mobilization of a call team, which may be costly and take time.

For this reason, it is important to know if rapid access to angioembolization makes sense. Couldn’t the patient just wait until the start of business the next morning when the IR team normally arrives?

The group at the University of Arizona at Tucson tackled this problem. They performed a 4-year retrospective review of the TQIP database. They included all adult patients who underwent AE within four hours of admission. Outcome measures were 24-hour mortality, blood product usage, and in-hospital mortality.

Here are the factoids:

  • Out of over a million records in the database, only 924 met the inclusion criteria
  • Mean time to AE was 2 hours and 22 minutes, with 92% of patients getting this procedure more than an hour after arrival
  • Average 24-hour mortality was 5%. Mortality by hours to AE was as follows:
    • Within 1 hour: 2.6%
    • Within 2 hours: 3.6%
    • Within 3 hours: 4.0%
    • Within 4 hours: 8.8%
  • There was no difference in the use of blood products

The authors concluded that delayed angioembolization for solid organ injury is associated with increased mortality but no increase in blood product usage. They recommend that improving time to AE is a worthy performance improvement project.

Bottom line: This study has the usual limitations of a retrospective database review. But it is really the only way to obtain the range of data needed for the analysis. 

The results seem straightforward: early angioembolization saves lives. What puzzles me is that these patients should be bleeding from their solid organ injury. Yet longer delays did not result in the use of more blood products.

There are two possibilities for this: there are other important factors that were not accounted for, or the sample size was too small to identify a difference. As we know, there are huge variations in how clinicians choose to administer blood products. This could easily account for the apparent similarities between products given at various time intervals to AE.

My advice? Act like your patient is bleeding to death. If the CT scan indicates that they have active extravasation, they actually are. If a parenchymal pseudoaneurysm is present, they are about to. So call in your IR team immediately! Minutes count!

Reference: Angioembolization in intra-abdominal solid organ injury:
Does delay in angioembolization affect outcomes?  J Trauma 89(4):723-729, 2020.

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