Trauma System Faces the Painful Problem of Unnecessary Use

The young woman had smashed her speeding car into a tree, flipping the auto onto its roof, ramming the engine into the passenger compartment and leaving the driver dangling upside down, suspended by her seat belt.

Based on the accident’s reported severity, paramedics alerted the Life Flight helicopter for a major trauma victim even before arriving at the scene. Immediately upon arrival, the paramedics, based on their gut reaction to the East County accident, radioed for Life Flight even though the woman did not exhibit the severe circulatory, breathing and mental problems normally associated with a major trauma.

The woman was flown to Sharp Memorial Hospital--the nearest of the county’s six designated trauma centers--where she continued to show normal physiological signs. She was released from the hospital the following day.

The incident is listed as over-triage, one of many cases where a patient was transported to a trauma center but turned out not to need the specialized care that the six hospitals provide for people with serious injuries.

Trauma system officials estimate that 45% of the 3,200 persons initially judged as major trauma victims during 1984-85 were cases of over-triage.

All trauma systems nationwide confront the problem of how to accommodate everyone who needs immediate, comprehensive surgical care without, at the same time, taking in those who don’t. The 2-year-old San Diego system missed 7% of potential trauma patients, first-year figures showed.

The issue, one of long standing in the medical community, broke into public consciousness last month with a crash on Interstate 5 of one of Life Flight’s three helicopters, shortly after it delivered a North County accident victim to Scripps Memorial Hospital. The patient did not require major trauma care, and several Life Flight doctors later complained that the helicopter was being used too often in such cases, increasing the risk to flight crews.

Others then alleged that Life Flight was being overused deliberately to justify its existence and that the entire aeromedical program should be reexamined.

Life Flight is a critical component of the county trauma system. It enables officials to limit the number of centers to six in the 4,300-square-mile county service region. The system sets a 20-minute guideline from scene to hospital. If a ground ambulance cannot make that time limit, Life Flight should then be used, the regulations say. Without the helicopters, many additional trauma centers would be needed to meet the 20-minute test.

Program statistics and interviews with a wide range of trauma authorities reveal no major, deliberate misuse of Life Flight. Life Flight transports about 35% of all patients labeled as trauma victims at the accident scene (ground ambulances take the rest), and those figures have remained fairly constant during the two years of the program. Only in a relatively few cases is Life Flight called when a ground ambulance could reach a trauma center within 20 minutes.

But officials do believe too many victims are categorized in the field as trauma cases, necessitating needless Life Flight trips.

“We have more over-triage than we would like, so the helicopter ends up being used often for patients with lesser injuries,” said Dr. Paul Haydu, an emergency room physician at Palomar Memorial Hospital in Escondido, the trauma center for inland North County. “The less over-triage we have, the less times the helicopter will go out on non-essential runs.”

Dr. Tom Ruben, director of emergency services at Scripps Encinitas Hospital, a non-trauma center, added: “The feeling of all doctors is that the number of accidents is proportional to the number of miles flown, so let’s make every mile flown count.”

“Life Flight gets caught in the middle,” Ruben said. “It must respond to requests from the field” based on present trauma judgment criteria. Ruben chairs the Trauma Task Force, established by the county two years ago to review and recommend changes in the trauma system.

The main concern, he said, is over-triage, where too many victims in the field are categorized as needing special care.

How to determine who is a major trauma victim is central to the way the system operates. There are basically three sets of criteria used by paramedics, emergency medical technicians and others who respond.

One set--known as CRAMS--measures physiological data such as blood pressure, circulation, breathing, speech, abdominal tenderness and responsiveness to stimuli. These are tallied on a point basis, from zero to 10. If the total is seven or below, the patient automatically goes to a trauma center.

Use of the CRAMS scale results in little over-triage, doctors says. A person who scores seven or lower usually turns out to be in need of fast, life-saving care. However, many doctors believe that the scale can miss trauma patients, resulting in under-triage.

“We know that, occasionally, young, healthy victims--which many trauma victims tend to be--will compensate physiologically at first for their injuries and will still show normal blood pressure or adequate motor response because we get to them so fast in the field,” said Dr. Steve Shackford, chief trauma surgeon at the UC San Diego Medical Center. Such patients, if then taken only to the nearest emergency room and not a trauma center, could later deteriorate physiologically without the necessary surgical expertise to treat them.

In an effort to compensate for possible under-triage, the county system also allows for patients to be labeled trauma victims based on two other sets of criteria. One is anatomical injuries and the other is on the nature of the particular accident.

A gunshot or stab wound to the abdomen, for example, is almost always judged as life-threatening, and therefore justifying a trauma response, no matter the physiological score, Shackford said. Anatomical judgments result in little over-triage, Ruben said, particularly because penetrating injuries such as knife or gunshot wounds to the upper torso are always serious.

But judgment based on accident criteria, commonly called mechanism of injury, has proven controversial and is at the heart of the over-triage problem. Those mechanisms include: rolling of a car with the victim thrown from the vehicle, survivors of a traffic accident in which another occupant of a car was killed, or a fall of more than 15 feet. If any of those or other mechanisms take place, an injured person is considered a trauma patient.

“Some of these are in a gray area,” Shackford said. “Based on my professional career (as a trauma surgeon), ejection with an auto rollover usually results in a great deal of injury. But with a passenger death, does that mean the others in the car should go to a trauma facility? I’m not certain that is correct, but that is what we do now.”

Dr. Bill Baxt, Life Flight medical director at UCSD Medical Center and an early proponent of the trauma system, said that “even if only one in 10 cases (of using mechanism) results in a trauma patient, it’s emotionally difficult to say then the next patient doesn’t qualify.

“There’s a user bias in medicine; better safe than sorry. To no one’s fault, I think perhaps we’ve been led down the garden path to mechanism (in terms of prediction).”

San Diego Fire Department Engineer Chris Brainard, a certified paramedic who teaches first responders to emergencies, recalled several cases where fire personnel did not feel patients needed trauma care but nevertheless sent them to centers because they fit the mechanism criteria.

Palomar’s Haydu said that all participants were anxious at the start of the trauma system two years ago not to miss potential victims by being too strict with guidelines. “If we made any minor miscalculations, we wanted to make them in favor of taking more people to the hospital than fewer.

“Usually when I miss (in judging trauma or non-trauma), it usually involves cases where I have put more stress on mechanism.”

Trauma systems nationwide continue to experience over-triage. Shackford noted preliminary figures from Maryland, where all trauma victims statewide funnel into a single hospital, that show over-triage near 65%. Orange County has a 60% over-triage rate, according to a paper presented last week by University of California, Irvine, Medical School Prof. John West at a trauma symposium in Anaheim. Orange County places stronger emphasis on mechanism than does San Diego, West said in his paper, and therefore has greater over-triage.

A consensus seems to be building in San Diego County to alter, if not eliminate, many of the injury mechanism criteria so that they are not automatically used to send people to trauma centers. Ruben’s task force hopes to recommend changes this summer.

“I think the major problem comes from using mechanism as an automatic,” Ruben said. “I’d like to see it used instead as an educational tool, to tell both paramedics and doctors, ‘Hey, if the accident happened this way, pay close attention’ but use the information in conjunction with physiological and other data.”

Haydu suggested that paramedics, often the first responders--particularly in urban areas such as the City of San Diego--be given more responsibility in such decisions. Shackford agreed, saying that paramedics have shown excellent field judgments. “When they say, ‘Hey, I don’t think this guy is injured sufficiently’ despite other criteria, I would tend to believe them, that’s my visceral feeling.”

And Ruben said that an occasional trauma victim taken to a non-trauma emergency room still would get good care in “one of America’s most medically competent places; we’re not abandoning such people as if this were the Serengeti Plain (of Africa).”

Baxt said that Life Flight itself is doing more re-evaluations on the scene, deciding that a patient is not a trauma candidate despite the criteria which the first responders used in calling for the helicopter.

“But you’ve got to remember that up until now, there just hasn’t been enough research nationwide with trauma as a disease to know precisely how to determine what is major trauma and what is not,” Baxt said. He said that, up until now, over-triage could only be dropped to around 30% of all cases by accepting under-triage of 30%; that is, missing three out of every 10 trauma patients.

“And that would be absolutely unacceptable to the public and the medical community,” Baxt said.

Shackford believes that over-triage can be reduced gradually to 30% without missing large numbers of seriously injured, given the experience that San Diego has been accumulating. The county has been praised nationwide for the voluminous statistical reviews that have been compiled on every patient who enters the trauma system. “The 30% over-triage would be acceptable and achievable,” Shackford said.

Another trauma surgeon, Dr. Brent Eastman of Scripps Memorial, cautioned that as much as over-triage should be minimized, he still worries more about under-triage.

Eastman noted that the 3,200 patients brought to trauma centers involve only 4.2% of all patients--about 76,000--taken to county emergency rooms last year by ground and air ambulance, and less than 1% of all persons who showed up at emergency rooms. “Forty-five percent sounds like a lot of over-triage but the actual numbers of people are very small,” he said.

“There’s no easy answer and I don’t think a simple triage criterion would solve the problem,” Eastman said, adding that he prefers to err on the side of the patient rather than the economics of the system.

“Over-triage is political and economic, under-triage is a medical problem. I recently had a case of a boy with a bad liver injury who would not have been brought in except under the mechanism of injury.”

Nevertheless, the economics of over-triage are a concern, especially because Life Flight costs upward of $1,500 per flight, half of which the participating trauma centers must pay. Only $1.25 million of the helicopter’s $3.3 million yearly budget is covered through patient and insurance payments.

In a few cases, ground emergency units apparently are calling Life Flight to transport potential trauma patients even though the units are within 20 minutes of a trauma center. Such use of Life Flight as a convenient taxi service has taken place on numerous occasions in suburban areas on the edge of the 20-minute limit, such as Lemon Grove and Santee.

“It probably happens, it sounds logical,” Chief Bill Wright of the Lemon Grove Fire Department said. Wright pointed out that if the city’s one ground paramedic unit--which serves Spring Valley and La Mesa in addition to Lemon Grove--takes a trauma victim to Mercy Hospital, the area’s trauma center, it will be out of service effectively for about 90 minutes on a round-trip.

“We really don’t like to go by ground to Sharp Memorial,” added Santee Fire Department Division Chief John Terry. “It’s not good for all the other patients out here needing our (paramedic) help around the clock.”

Life Flight’s Baxt said the helicopter is the perfect solution for such jurisdictions, no matter what specific protocols say. “Where only 5% of their medical emergency patients may be trauma victims, they can argue that you should not deprive their other 95% of the few paramedic units available, and instead use Life Flight.

“But when over-triage is 40%-50%, then you’ve got a problem. But the bottom line is going to be that if we can cut the over-triage, we will cut the overuse of Life Flight.”