Not a Second to Spare
UAMS Leads New Statewide Trauma System as a Level One Trauma Center
Ashley Machado drifted off to sleep in the back seat of her car as a friend drove it on icy Highway 70 east of North Little Rock the evening of Jan. 11, 2011. She awoke to screams, a crash – and then nothing.
With broken bones and life-threatening internal injuries, there was not a second to spare in getting Machado to a hospital. Not just any hospital, but one with the surgical specialties needed to save the 20-year-old’s life – including repairing a tear in the main artery coming from her heart.
Paramedics at the accident scene sent Machado directly to UAMS Medical Center about 15 miles away, the closest hospital with the care she needed.
Immediate routing to the nearest appropriate hospital will become increasingly faster for emergency responders anywhere in the state with the implementation of a new statewide trauma system which was approved by the state Legislature and signed into law by Gov. Mike Beebe in 2009.
“We have to make sure the patient has as straight a line as possible to the facility best able to provide the care they need,” said Dr. J. Michael Gruenwald, an orthopedic surgeon and professor in the UAMS College of Medicine. “If you get the patient to the correct hospital, a life can be saved.
“I think it’s totally realistic that this system could save hundreds of lives a year,” he said. Gruenwald was an early and vocal advocate for the system which went online at 8 a.m. on Jan. 3 when the Arkansas Trauma Communications Center began taking calls from hospitals across the state. Based at Metropolitan Emergency Medical Services (MEMS) in Little Rock, the trauma system call center – staffed by a paramedic or registered nurse – streamlines the process for directing trauma patients to hospitals within the system. “In the past, there could be six- to eight-hour delays in getting trauma patients referred to the appropriate hospital,” said Jeff Tabor, program director for the trauma call center, citing logistics and other problems that could slow a transfer. “Now the average time is about 10 minutes. The new system has already made that much of an impact.”
Hospitals participating in the trauma system are designated by the Arkansas Department of Health at one of four levels depending on the capability of treating traumatic injuries and resources available for trauma education and research.
UAMS Medical Center was the first in the state to be designated Level I by providing the highest level of trauma care with specialized surgeons on duty at all times for treating the most serious and urgent cases.
UAMS trauma services got a boost with the January 2009 opening of a hospital expansion that included a larger, more comprehensive Emergency Department featuring a general X-ray room and a computed tomography (CT) scanner, eliminating the need to transport trauma patients out of the department for imaging.
“Our designation as a Level I center and participation in the statewide system assures that we are prepared to effectively care for the most severely injured patients – whether they arrive directly from the accident scene or they are transferred from another facility,” said R.T. Fendley, UAMS Medical Center senior associate hospital director.
The designation is not based only on medical services. Terry Collins, UAMS director of trauma services, noted UAMS also had to demonstrate to the trauma system survey team from the Arkansas Department of Health that UAMS had injury prevention education and outreach programs as well as a program of trauma research.
“This is truly an institution-wide commitment to trauma care,” Collins said.
UAMS worked toward its Level I designation for about a year and a half before being named the state’s first Level I center in September 2010. Even before that, UAMS had been verified as a Level I trauma center by the American College of Surgeons in 1994, Collins said.
At the Scene
In its first two months, Tabor said the trauma call center had already received more than 465 calls from hospitals all over Arkansas. Of those, 112 have been routed to UAMS.
This number of calls is expected to increase dramatically in the near future when all the state’s ambulance services can connect directly to the call center.
From an accident scene, emergency responders will classify injuries and then coordinate care with the call center. The call center will be able to direct the ambulance to the closest trauma center with the services needed for a particular patient.
Previously, patients may have been sent to the closest facility regardless of the type of injuries sustained.
Now, depending on condition and the extent of injuries, the trauma system may route a patient past other facilities that could treat some – but not all – of the injuries.
“Within the state there are very few institutions set up to handle a complex, multi-system case requiring manpower and many specialty services,” said Dr. John Eidt, a vascular surgeon and professor in the UAMS College of Medicine. “Survival is related to time.”
Getting the proper treatment can be the difference between a full recovery and long-term disability. “I think it’s totally realistic that this system could save hundreds of lives a year.”
Traumatic injuries remain the leading cause of death in Arkansas for adults and children one to 44 years old. A 2008 report by the American College of Surgeons said the overall injury fatality rate in Arkansas is nearly 50 percent higher than the national average, and the injury fatality rate for motor vehicle crashes (the second most common injury mechanism in the state) is 60 percent higher than the national average. In 2005, Arkansas ranked 50th in the nation for timely trauma center accessibility.
The U.S. Centers for Disease Control said getting to a Level I trauma center can lower the risk of death by 25 percent for patients with severe injuries.
“With a system that gets patients appropriate care as quickly as possible, there is less pain and suffering, less disability, fewer family problems that long-term injury can sometimes cause and less risk of addiction to pain killers,” Gruenwald said. “It’s much bigger than just the lives saved.”
“I know that I’m lucky to be alive,” said Machado, whose next memory was waking up at UAMS three days after the accident.
The one-vehicle accident left her with a long list of injuries including two broken ribs, a broken elbow and a shattered pelvic bone where the hip socket forms. Internal injuries included a ruptured bladder, a bruised lung and a tear in the aorta – the large artery running down the spine that pumps blood from the heart.
Machado’s injuries are precisely the type the trauma system was created to address – a multi-system trauma with a combination of injuries beyond the resources of most local hospitals.
Timing is critical for an aortic injury such as the one Machado suffered, Eidt said. Blood was leaking through a tear in the inner lining of the aorta into the outer tissue. If the outer tissue bursts, the patient will likely bleed to death.
Eidt inserted a stent to close off the leak in Machado’s aorta using a procedure that did not require major surgical incisions.
Rods were inserted in her arm to stabilize it while the bones healed, and Gruenwald performed reconstructive surgery to repair her pelvic bone and hip socket.
After a couple weeks in the hospital, Machado was able to return home to Danville. A month after the accident, she said she was feeling better but still sore. Sitting in a wheel chair, she said she will talk to anyone she meets about the importance of wearing a seat belt – which she was not.
Machado is determined not to get down about what could have been. She will begin physical therapy after her injuries heal and says she is ready and grateful for the chance.