It was early in my professional experience when I realized that trauma treatment isn’t just about the surgical process inside the OR. The way I have experienced this was during the early 2000’s at Parkland Memorial Hospital in Dallas. I repeatedly observed that many patients arrived with injuries that could be treated and survived. The procedures that followed were correct. The surgical staff involved in these procedures were highly qualified. However, the end result was too frequently death. A consistent element was time. Too much time had elapsed before the patient reached the hospital.
A time gap existed between the moment of injury and the time the patient received hospital care. This time gap became difficult for me to ignore. I called it “the time gap.” The time gap was not a result of failure in medical treatment; however, the failure was in accessibility. These patients were hemorrhaging, suffocating, or experiencing cerebral dysfunction while waiting for the medical attention that only began when they entered the hospital. By the time the patient had reached the hospital, the critical time that mattered had elapsed.
The Unconventional Proposal
In 2004, I proposed an unconventional method for treating trauma that was initially met with skepticism. I suggested that surgeons in the field accompany the Dallas SWAT Team. My concept was simple. Death occurs prior to the patient reaching the hospital. Therefore, if medical care is going to save the patient, then the medical care should follow the patient (not the other way around). The care did not need to be faster. The care did not need to have improved communication through radios. The care simply needed to involve actual medical decision-making and action taken at the location of the injury.
My proposal raised concerns. Surgeons belong in a hospital setting, not in an armored vehicle. The environment is unpredictable. The risk to the surgeons and the police personnel accompanying them was very real. However, the deaths we were observing were very real as well. Law enforcement officers were suffering injuries as a result of active shooter events. Civilian victims of crimes were dying from massive bleeding before emergency medical technicians (EMTs) could safely arrive at the crime scene. Waiting for clearance to enter the crime scene meant waiting too long.
The plan moved forward cautiously. Adjustments were made to the training of both the police and the surgeons. Equipment was modified to meet the unique demands of a mobile medical setting. Safety and communication protocols were developed. The goal of the project was never to replace EMTs. The goal was to provide a bridge between the initial injury and the time the patient receives traditional medical care.
Validating the Concept
The implementation of the program led to immediate and unmistakable results. Lives were saved on the scene of the incident that would have otherwise been lost in transit. Bleeding was controlled in mere minutes in some cases. In multiple incidents, airways were managed prior to oxygen deprivation occurring and leading to permanent neurological damage. Some chest injuries were treated with a procedure known as decompression before the patient suffered a cardiac arrest.
Early medical intervention often reduced the trauma activation treatment patients needed. The early intervention dramatically altered the course of treatment and ultimately allowed some officers to return to their homes and civilians to reunite with their loved ones, who would have died as a result of the injuries sustained in previous incidents.
Each of the individual successes validated the same fundamental principle. The earlier you initiate quality medical care at the injury site, the less heroic the subsequent surgery will be.
Transition of Patient Care
Providing medical care to a patient at the site of the injury fundamentally changes your view of healthcare. In the operating room (OR), you work in a controlled yet chaotic environment. Bright lights illuminate the operative area. Medical equipment is readily available. The medical team moves in a well-coordinated and efficient manner. At the scene of an injury, none of these elements exist. The noise level is high. Stress levels are high. Danger exists. In addition, you have to make medical judgments based on limited information and limited resources.
As a surgeon, this type of environment requires a significant mental adjustment. Unlike striving for perfection, you must focus on prioritizing.
- Stop the bleeding.
- Protect the brain.
- Save the life.
In this environment, there is little time for extensive diagnostic testing. There is only time for decision-making.
This mental paradigm change also influenced the way I approached trauma care after returning to the hospital. I began approaching trauma care from a different perspective regarding trauma timelines. I began working more closely with pre-hospital teams. I advocated for education programs that placed an emphasis on early decision-making rather than delayed interventions.
Since its inception, the tactical medic model has evolved significantly. Initially perceived as an unconventional approach, modern trauma systems now recognize the tactical medic model as a legitimate and viable component. The underlying lesson remains the same. The critical time that matters most is the time that elapses before the patient arrives at the hospital. If one truly wishes to preserve lives, then medical care must begin at the site of the injury.
