Who, What, Where?
Go into your community and map the Level 1 Trauma Centers within a 45 min land transportation time (35 to 50 miles) of your home or place of employment. Interrogate the internet, and plot the total number of beds, operating rooms (formal and outpatient if so noted), and ICU beds in those institutions. Do the same for other hospitals in your designated zone. Now locate the Walk-In clinics, urgicenters, family or primary care clinics and Outpatient-surgical centers (including plastic surgery and ENT) and plot their capacity. Behavioral health, though not part of this assignment, should also be considered. ( I have done this part)
1- You are to submit a spreadsheet of your findings and a map plot of your area. Think about how this may help a community plan for a MASCAL. Color code “halos” for Immediate, Delayed, and Minimal physical care (and behavioral, should you choose). Further consideration: The assignment specifies a ground transport window. You may choose to extend the ‘Immediate’ category receivers to account for adequate flight conditions. In accommodation for lift-off (5-10 min), and an immediate hot load of a helicopter (5-10 min), you should consider your actual in-flight time as <30-40 min. (60-80 mile radius)
2- As a healthcare worker studying the clinical medical management in disaster, you should be aware of the near-immediate facilities and resources available to you in the event of need. Trauma (physical) is primarily a hemorrhage control game before you run out of blood. The most recent literature confirms a circulating blood volume (in the “pipes” of about 5 liters, with a “flow” (cardiac output in health) of about 5 liters per minute. Prevalent Ultrasound Doppler Flow estimates about 2.5 lpm in the femoral vessel (the groin). Five liters lost at 2.5 liters per minute for a torn femoral artery could represent a complete loss of circulation in two minutes or less. At least one author wants to redefine the Platinum Ten minutes to the Platinum Two minutes of bleeding control (maybe it should be the Palladium two Minutes?
If you live through those first minutes (are not DRT, or Dead Right There) and survive the time for First Responders to arrive, there is a good chance of recovery, if we don’t dawdle, apply the few Basic and Advanced Trauma skills that make a significant difference, and get you on the trajectory to a definitive treatment area.
We’ve worked diligently to study accessible bleeding points, mostly extremity or the related “junctions”; a bit of effort at the consideration to slow blood loss in the pelvis and perhaps the abdomen. Even these methods, though are temporizing techniques to buy the time to get to Definitive Hemostasis (internal bleeding control) which has emerged as the concept of Damage Control Surgery.
While some EMS systems, especially Air Medical EMS, have enhanced their response with the ratio of components to 1:1:1 in the effort to reconstitute whole blood for volume replacement, this is still somewhat a limited effort to stave off the irreversible shock and the “Lethal Triad” of acidemia (metabolic failure from poor perfusion, not just “flow”)/hypothermia (exothermic failure from altered metabolism) , and coagulopathy (from platelet consumption or loss). This was R Adams Cowley (no period after “R”) hypothesis when he spoke about the irreversible nature of the course to death from shock not addressed within the “Golden Hour”. We do have better technology to support failing organ systems now, and although there may bot be a 60-minute cliff, there is still the need for expeditious care, with stopping the blood loss a critical consideration.
Many of you recognized the ITLS “Platinum ten minutes” as our mantra, in the absence of an unavoidable delay due to extrication, to expedite movement to an OPERATING ROOM with SURGEONS, and the best way to assure that is transport to a Level I or II trauma center. Your review of the “geographic effect” of the movement of the masses of lightly injured, self mobile, victims resulting in hospital surge can and will eventually degrade the Level I or II surgical capability. Thus, destination decisions (by the casualty transportation officer in the ICS, ideally with real-time intel via the health care coalitions or dispatch center) is an important aspect of a maximally effective response.