How would you deal with this situation? It is New Year’s Eve, and the driver of a stolen vehicle is traveling 80 miles per hour on an interstate highway. He loses control and hits multiple cars, finally crashing into a car that, in turn, rolls over several times before coming to rest on the driver’s side on an adjacent road.
The innocent driver, whose car was crashed into by the stolen car, remains conscious and is extricated by bystanders and placed by first responders into an ambulance.
What should be done for the patient in the ambulance—a 6´6˝, 290-pound, middle-aged man in good health with no underlying comorbidities? Should the first responders:
- Take him to the nearest community hospital?
- Take him to a certified Level II trauma center that is six miles away?
- Take him to a certified Level I trauma center that is nine miles away?
Jamie Coleman, MD, FACS, describes just such a situation in the article that accompanies this month’s “A look at The Joint Commission.” In the article, Dr. Coleman describes how the patient was taken by ambulance to a Level II trauma center for evaluation. The physician performs a visual physical exam revealing scattered abrasions but no other external signs of trauma.
Given the mechanism of injury and the high likelihood of injuries, what would you expect to be done next?
- Follow the standard Advanced Trauma Life Support® (ATLS®) protocol, which applies to all patients involved in a high-impact event—even if injuries are not apparent. These would include hematologic, ultrasound, and radiographic evaluations.
- Attenuate the evaluation to only a physical exam because it is New Year’s Eve and the trauma center is busy; the patient is alert and communicative.
Take into consideration that the patient lives hundred of miles from this trauma center. He was on his way to the airport at the time of the collision. Upon discharge, the patient would either proceed directly to the airport or to a hotel for overnight accommodations. The potential of a chest injury, which could result in an indolent pneumothorax and could be exacerbated in a pressurized aircraft, is significant.
Would this change your approach or expectations? Would you do any of the following?
- Take extra precautions in evaluating the patient, as he was alone and wanted to get home?
- Extend your observation time to ensure the patient was safe to travel alone?
- Call the family and develop a joint discharge decision?
In this case, the physician called the patient’s spouse—who is a trauma surgeon—and informed her that the patient was alert, awake, and ready for discharge within 45 minutes of the patient’s arrival in the emergency department. But no hematologic, ultrasound, or radiographic evaluations had been performed.
The patient’s spouse, however, requested a complete ATLS workup to evaluate her husband for injuries that might not immediately be apparent.
- Was it appropriate for the trauma surgeon spouse to advocate that strongly for her husband?
- Should the physician acquiesce to the wishes of the trauma surgeon spouse or continue with the original discharge plan?
- Who should be held accountable if the patient had an adverse event on the way home after discharge?
- Should the patient’s profession as a lawyer influence the decision-making of the physician or the trauma center’s administration?
- Should the fact that it was New Year’s Eve and there was a reasonable expectation more patients would present to the trauma center influence the decision-making of the physician or the administrative policies of the trauma center?
The physician at the trauma center acquiesced to the suggestions made by the patient’s trauma surgeon spouse. The hematologic, ultrasound, and radiographic evaluation revealed non-life-threatening injuries, and the patient was ultimately discharged.
Now, let’s look at this situation from a different angle.
The trauma surgeon spouse is white, and the injured lawyer patient is Black. Did race impact the decision-making in this case? How could implicit racial bias be identified in this situation, as it is by definition an unconscious bias? Do you think the racial reality of the situation impacted the decision-making in this case?
This trauma center is certified by a state authority as a Level II trauma center, which leads the prehospital ambulance personnel and the public to assume that the trauma center would follow the same standards of care for injured patients as a Level I center.
What strategies should the trauma surgeon spouse pursue to prevent this situation from happening to another patient who experiences a similar event? Would you:
- Advocate for personally requesting an interview with the clinical and administrative leadership of the trauma center?
- Ask the leadership of the center to perform a full evaluation of the event?
- Push for the center to institute policies or training to avoid a similar occurrence in the future?
And do you think there are two standards of care at play here because the patient is Black? If the trauma center is certified by the state and not by a national evaluating organization such as the American College of Surgeons (ACS), what should be done to influence the state to evaluate its verification requirements and adopt a national standard?
The College’s and The Joint Commission’s involvement in improving trauma care
In 1913, the ACS was established in response to extensive variations in surgical care across hospitals in the U.S. In 1951, The Joint Commission was established as a collaborative association with the mission and goal of developing uniform, high standards of care for all patients across the country.
In the mid-1970s, a surgeon and his family were involved in a plane crash. The surgeon was distressed by the care his family received at a rural hospital in Nebraska, and ATLS was born. The ACS Committee on Trauma (ACS COT) developed the ATLS educational program with the mission of educating physicians and standardizing quality of care for all injured patients. Since then, the ACS COT has stratified and verified trauma centers nationally by level to demonstrate to the public and prehospital personnel that verified centers provide uniform, high-quality care to injured patients.
It appears this work is incomplete, as some geographic locations and states use their own verification, designation, and evaluation of trauma systems and trauma centers. The public and all patients should expect to receive high-quality care independent of geographic location, mechanism of injury, patient volume, gender, race, or socioeconomic status. Variation in care contributes to the disparities in health care that are challenging the nation. Developing national standards, implementing them, and monitoring their performance will assure excellent care for all patients.
The irony of this story is not only that it is true, but also that it occurred in the Chicago area and not far from the headquarters of the ACS and The Joint Commission. The State of Illinois does not use the national ACS trauma center verification standard process. Each state should carefully evaluate its own verification process, and if it is at variance with the highest ACS trauma center verification standards, the state should either evaluate its performance or adopt the nationally accepted standards promulgated by the ACS, The Joint Commission, and other professional accreditation bodies.
I’m grateful to Dr. Coleman for sharing the distressing event that spurred me to write this article. I have profound respect for her willingness to work to enhance care for all injured patients.
Disclaimer
The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
