A 2011 study in the Journal of Trauma concluded, after a retrospective study of deaths due to mechanical trauma, that the overall preventable death rate in trauma was 7%, and of those patients who survived to be treated at a hospital, the preventable death rate was 11%. The study found “opportunities for improvement” in care in those cases at a rate of 67% in those patients treated in the emergency department. In fact, most opportunities for improvement exist in the emergency department setting. Those areas in which care could be significantly improved with decreased mortality include airway problems, fluid resuscitation, and the diagnosis and management of chest injury.
The study concluded with the recommendation that primary care providers in the emergency department be educated in basic stabilization and treatment principles. In fact, in those emergency department setting without a trained emergency medicine specialist, it is shocking to find a number of providers have not taken advantage of certification in Advanced Trauma Life Support. This course is offered to physicians only, and is a short but effective hands-on course in the basic principles of recognition and management of trauma. It is often required for both emergency-medicine and non-emergency medicine trained providers who cover emergency departments, and although board certification in Emergency Medicine makes the necessity for the course in this group less critical, there cannot be a more important certification for any other provider likely to encounter victims of trauma in their practice setting.
Trauma costs exceed 400 billion dollars annually in the United States, and trauma is the leading cause of death in the group aged 1 through 44 years old. Long-term disability resulting from mechanical trauma is also exceptionally costly in both economic terms and in terms of lives ruined.
The Advanced Trauma Life Support (ATLS) course was developed in 1980, by an orthopedic surgeon whose small plane crashed, and who saw his family members receive disorganized medical care. He developed an algorithm-based course to ensure that systematic care would become routine and as a result, potentially mortal injuries would not go unrecognized and untreated while less important injuries, i.e., a broken arm or a superficial bleed, were attended to.
Recognition of the three peaks of death after a trauma resulted in a strong focus on the first hour after a trauma, known as “The Golden Hour.” After immediate death, a disproportionate number of post-traumatic deaths occur during this first hour, and are primarily due to failure to rapidly and accurately assess the patient and promptly initiate the appropriate resuscitative measures. (The third peak consists of late deaths that may occur several weeks after the initial injury, in an ICU setting due to infection or multi-organ failure.)
The key principles taught in the ATLS certification course lead practitioners who do not normally encounter trauma in their practice to approach a traumatically injured patient in a way that may be counter-intuitive to their normal clinical routine. These principles include primary and immediate treatment of the GREATEST THREAT TO LIFE, treatment without a definitive diagnosis and despite lack of a complete history.
The algorithm begins with the easily remembered “ABCDE,” which stands for Airway and management of the Cervical Spine, Breathing, Circulation (stop the bleeding), Disability (neurologic status) and Exposure/Environment.I included that mnemonic not for you to learn, but as a jump-off point for a discussion of airway problems that, if not recognized and treated immediately, may result in death. Airway problem recognition is one common source of preventable traumatic mortality.
The airway refers to the passage from the nostrils and oropharynx through the larynx to the lungs, which inhale oxygen rich (21% FiO2) air from the environment and exhale carbon dioxide, a waste product of our metabolism, into the environment. The lungs are both ventilated – which refers to oxygenation and exhalation of carbon dioxide – and “perfused.” Perfusion refers to the flow of blood through the pulmonary veins from the right side of the heart. This is blood that is returning carbon dioxide from the body to be exhaled. After this occurs, the hemoglobin in the red blood cells is ideally saturated with oxygen in the lung and it the oxygen-rich blood carries the vital gas to the body’s cells and tissues. Without oxygen, our cells die very quickly. So, although I will discuss what happens in the lungs themselves in more detail later, for now, airway refers to the passage for oxygen from the environment into the lungs, where it can enter the blood stream bound for your brain, heart and other vital organs.
If that airway is interrupted, then your lungs will continue to receive blood that returns from the periphery to release carbon dioxide, but without oxygen, the blood will only return to the tissues unable to provide that essential environmental ingredient. After 5 or 6 minutes without oxygen, your tissues die. If your heart muscle dies, it doesn’t regenerate. If your brain tissue dies, you have death or permanent neurologic deficits.
Some reasons that the airway may be interrupted include laceration or transection of the trachea as a result of penetrating neck trauma, swelling in the tissues of the airway that subsequently occludes the opening, or lumen; or trauma to the maxillofacial region, including the mandible or jaw, or even dislodged teeth or massive oral bleeding. Massive hemorrhage in the neck or swelling of the tissues in that region can cause the trachea to deviate, crushing and obstructing your breathing tube. Loss of consciousness can cause the airway tissues to collapse upon them, blocking the passage of oxygen to the lungs.
Reading a death certificate after a traumatic death of a loved one is difficult on many levels. One important consideration is that in an emergency, documentation is structured but limited and without medical knowledge, and the ability to review the record of treatment interventions after the event, the death certificate may shed no real light on the cause of death, and certainly will not give an opinion about whether or not that death was preventable.
Airway problems are only one topic when discussing preventable traumatic death, and I will write again, on topics of preventable deaths due to failure to diagnose or treat breathing and then circulatory problems.
If you have a loved one who has suffered death or extreme disability as the result of a trauma, you should consult with one of Passen & Powell’s top-rated Chicago medical malpractice lawyers. Call us today at 312-527-4500 for a Free Consultation.