Trauma care in Arkansas: A medical symphony 

That's how a long-time nurse describes the way the state's new system is working.

MANNING THE COMMUNICATIONS CENTER: MEMS Brandi Johnson at the controls image
  • Brian Chilson
  • MANNING THE COMMUNICATIONS CENTER: MEMS Brandi Johnson at the controls.

The most important numbers — those that show definitively how well the state's new trauma system is saving lives and sparing patients disabling injuries — are not yet in. The state's Trauma Registry, a measure of hundreds of data points implemented in 2010, is being analyzed now to determine what deaths and injuries were preventable.

But medical personnel — including Dr. Todd Maxson, the trauma medical director at Arkansas Children's Hospital and the trauma consultant to the Arkansas Department of Health's trauma section — say the change has been "tremendous."

And there's a significant number the trauma care community does know: 7. That's the average of how many minutes it takes the Arkansas Trauma Communications Center to arrange transport for a seriously injured person to the most appropriate hospital to care for them. Before the creation of the call center, it took up to six hours or more for emergency departments caring for the injured to make arrangements to get patients to the most appropriate hospital for care; meanwhile, the patient languished. Now, thanks to information relayed by the call center from emergency medical technicians and paramedics, emergency departments can have a trauma team ready and waiting when the patient arrives.

It means that Brittany Redding, now 21, survived a broken neck (she'd fractured two vertebra at the top of her neck, called a "hangman's fracture"), skull fracture, brain hemorrhage, ruptured spleen and uncontrolled bleeding, broken ribs, multiple pelvis fractures and other injuries she sustained when her car was T-boned by another car in Fort Smith in June 2013.

Just two weeks earlier, Mercy Hospital at Fort Smith had devised a new procedure to handle patients with major injuries who needed to be stabilized before transport to a hospital that could take care of them. When Redding arrived at Mercy at 3:36 p.m., the ambulance personnel had already radioed the emergency room the extent of her injuries and her trauma team had been activated. In the ER, she got a chest tube; in the OR she had a splenectomy and her bleeding was stabilized. When she came out of surgery, an Air Evac helicopter was waiting to take her to the University of Arkansas for Medical Sciences. She was flown out at 5:30 p.m. It's been a tough year for her, but she's recovered.

"Under the old regime, she most likely would not have survived," said Linda Nelson, the trauma coordinator at Mercy Hospital and an emergency department nurse for 28 years. In the past, Redding would have been brought to the emergency room and a doctor would have done a diagnostic workup. Then the surgeon would have been contacted. The surgeon would then pull his medical team together based on the injuries he was seeing.

Under the old system, had Redding been injured in a rural area, an ambulance would have been required to transport her to the nearest hospital, whether that hospital was equipped to treat her or not. Then, the ambulance would have left. "We were done. I did my duty," said Tim Tackett, a paramedic for 27 years and member of the Governor's Trauma Advisory Council, said about the old system. The rural hospital's doctors and nurses would have had to take it from there — trying to reach doctors at other hospitals by phone and getting approval to send the patient on and arranging for transport. Hours could pass before arrangements were complete. Meanwhile, Redding would have waited.

"In the past, we all acted in silos, not necessarily speaking the same language. We were not necessarily coordinating our efforts," Nelson said. Treatment "was sequential." Today, treatment is "like a symphony."

Redding believes the trauma team's efforts at Mercy are the reason she is alive. "I had a C-1 and C-2 vertebrae fracture. I shouldn't even be walking, I shouldn't be breathing, I should be on a ventilator. It's a miracle. It has to do with how you are handled from beginning to end. Honestly, I believe that UAMS did an amazing job, but it was the first people to put hands on me, it was Mercy."

The Arkansas legislature approved bills creating a trauma system and a tobacco tax to fund it in 2009.

At the time, Arkansas was one of only three states in the nation without a trauma system.

The system, with a budget of $22.7 million for 2015, has many parts: participating hospitals, designated as Levels I (the University of Arkansas for Medical Sciences and Arkansas Children's Hospital) through Level IV depending on the services they offer; the Arkansas Trauma Communications Center, which coordinates emergency transport statewide; and continuing education for emergency medical personnel, from technicians to physicians. As those involved note, the system is only as strong as its weakest link. "If any part of the trauma system breaks down, lives don't get saved," surgeon Maxson said.

One of the trauma system's best tools is the live dashboard operated at the ATCC by MEMS, which got the state's business to be the Grand Central Terminal of the system because it already had a dashboard in place for Pulaski County. Two employees dedicated to trauma are on duty around the clock, taking calls from ambulance EMTs and medics and manning computer displays that show what hospitals are available to provide which procedures, data that is updated in real time by the hospitals. Availability in each specialty — such as neurosurgery — is color-coded: Alpha (green) means the hospital has capability and availability. Bravo (yellow) means the hospital has capability but is operating at capacity. Charlie Temp (red) means the service is temporarily not offered. Charlie (orange) means that the service is never available at the hospital. "Arkansas has a lot of orange," ATCC director Jeff Tabor said during a tour of the center.

To make the call center work as it should, Tabor said, "we had to offer a no diversion guarantee." That means if a hospital says it has an orthopedic surgeon available, it has to accept a patient in need of one. No longer do ambulances make "round robin" trips to ERs in Little Rock to find a department willing to accept their patients.

The dashboard, which also indicates helicopters in service, requires hospitals to stay on top of the information they put into the system and medics and other medical professionals to accurately describe the injuries of their patients so operators know what hospital is most appropriate to treat the injuries. Every ambulance in Arkansas now has a trauma radio, which allows EMTs and paramedics to communicate with the dashboard over the AWIN digital channel used by the State Police.

Part of the trauma system is making use of technology that some hospitals did not know they had: the ability to read CT scans and send them electronically to doctors at the receiving hospital. No longer must hospitals download scans of brain injuries to a disc — discs that may or may not open at the receiving hospital — to transfer along with the patient. No longer do patients have to undergo repeat CT scans. The system uses technology already provided to hospitals some time back for disaster preparedness (on computers sometimes forgotten and stuffed away into a corner of the ER) to upload scans to an image repository accessible to hospitals. "A dozen kids are alive because we've been able to get [the doctors] these," Maxson said. He gave as an example a patient of his who'd been struck by a car while on a bicycle and "had an epidural hematoma and was changing neurologically." Films of the injury taken at a Level III hospital were uploaded to the repository, Children's downloaded them (a transfer that took a minute) and had the trauma crew with neurosurgeons available when the patient arrived. "She spent 13 minutes in the trauma room and went up to the OR where she had her epidural evacuated safely and she is doing very well," Maxson said.

The trauma system has also changed the way persons with serious hand injuries are treated. With only one hand surgeon capable of doing replants at one time and only a few other trained hand surgeons that took calls, patients were sent to hospitals out of state via helicopter, at great expense. Sometimes, their injuries either couldn't be helped by surgery or weren't serious enough.

As part of the trauma system, Arkansas now has the Hand Trauma Telemed Program, and Tabor has seven hand surgeons he can call on to determine the severity of the injury.

The Health Department's records on trauma fatalities showed a drop from 2009 to 2011 of 90 deaths. The number of fatalities rose again in 2012. Those figures are not adjusted for population, so it's not known as a percentage what the change in outcomes was. A more important statistic, perhaps, is the number of times a trauma team was activated. In 2010, a trauma team was activated for 11 percent of all trauma patients. In 2014 so far, that has risen to 22 percent — higher than the national average.

So is the system paying off? For legislators, "ultimately, all you want to know is am I less likely to die before you gave me the money," said Bill Temple, branch chief for injury prevention and control at the Health Department. So what is a saved life worth? Economists say between $2 million and $6 million. As a trauma surgeon, Maxson sees those cases. Part of his job is to "take family into a very small room [and give them bad news]. I'm moved greatly by the impact of 90 people being alive. It's an incredible gift."

There are challenges ahead for the trauma system: Its budget has declined over the years and carry-over funds that helped created unanticipated but highly valuable parts of the system are disappearing as more of the system goes online. One of the trauma system's best tools — and one which was not in the original trauma budget — is the ATCC call center operated by MEMS. The Governor's Trauma Advisory Council has begun looking at changes in the way it allocates its dollars in the future.

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