“Death lab” evolves into modern trauma system

Status Check! is a new series that explores the history of pre-hospital emergency medicine, common misconceptions, misunderstanding, hot topics in EMS and public perception.

BY TODD BOWMAN

HAGERSTOWN, Maryland – Possibly one of the most well known hospitals for the treatment of trauma patients is the R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore…a facility that accepts severely injured trauma patients from Washington County.

Dr. R Adams Cowley, of which the shock trauma center is named, once called shock “a momentary pause in the act of death,” a process that once set in motion was irreversible…Cowley’s goal was to make it reversible.

With an Army award grant of $100,000 to study shock in people, Cowley developed the first clinical shock trauma unit in the nation, consisting of two beds and later adding two additional beds.

By 1960, staff was trained and equipment was in place. Patients began to “trickle in” referred by other physicians…but they came in dying. In fact, many people called the four bed unit the “death lab,” according to the university website. Cowley and his staff were able to save some of these patients, getting them through the critical phase and then returning them to their own physicians.

As Cowley’s program advanced a theory that many EMS providers still reference today known as the “Golden Hour” emerged.

Cowley explained in an early interview, “there is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might die right then; it may be three days or two weeks later, but something has happened in your body that is irreparable.”

“Dr. Cowley’s research was an integral part of developing the current trauma system. In Maryland, that resulted in partnering with the Maryland State Police to provide aeromedical transportation from accident scenes to definitive care facilities,” Washington County Division of Emergency Services Assistant Director of EMS Operations David Chisholm said. “This means that no matter where the patient is, we can get them to a trauma center or other specialty care facility quickly and still able to provide effective and efficient care during transport.”

In 1968, Cowley negotiated to have patients transported by military helicopter to get patients to the shock trauma unit more quickly. After discussion with the Maryland State Police, the first medevac helicopter transport occurred in 1968 after the opening of the five-story, 32-bed center for the study of trauma.

Maryland established the first statewide EMS system and has become a model worldwide. The years from 1973 to present were filled with revolution and evolution.

According to the university website, prior to 1973 patients were transported to the closest hospital in vehicles that were not appropriately equipped or staffed for the patient’s injuries.

Today, there are more than 600 well-equipped emergency ambulances, 11 public service medevac helicopters, and more than 27,000 volunteer and career pre-hospital providers. These pre-hospital providers follow state protocols in treating and transporting patients in the field…protocols in the early 1970s traditionally reserved for physicians only.

Paramedics and emergency medical technicians in Maryland are trained to triage patients and select an appropriate facility for their injuries and needs. For example, a pediatric trauma patient will be transported to a recognized pediatric trauma center.

Chisholm said there are several factors to consider when choosing a facility including the severity of the injuries, stability of the patient, age, and type of injuries.

“For instance, a pediatric patient with traumatic injuries will more than likely be referred to either the Baltimore or Washington D.C. pediatric center.” Chisholm said. “Burn patients that have severe burns over a large part of their body will go to a burn center located in either Baltimore or Washington D.C.”

Chisholm added that patients with severe injuries could be taken (locally) to Meritus Medical Center, if the patient is critically injured and (in) need of stabilization. The patient could also be flown directly from the scene to a level 1 trauma center, cutting down on the time delay to definitive care…a concept that took Cowley years to implement and perfect.

In 1989, Cowley opened and combined the highest level of patient care and teaching with research, leading to advances in therapy for the critically injured. This institute also focuses on trauma presentation, injury control and public policy as a way of saving lives. Most importantly, thousands of trauma victims are alive today and are a living testimony to his dedicated work.

Cowley demanded loyalty, dedication, skill and hard work. He demanded it of those who worked for him and he demanded it of himself. He never gave up the vision that he believed in. Northing was impossible to him. He wanted the critically ill and injured to survive and he moved mountains to make it possible…Cowley wanted the very best of the citizens of Maryland.

The Maryland Institute for Emergency medical Services Systems lists R. Adams Cowley Shock Trauma Center at the University of Maryland Medical System as the primary adult resource center.

MIEMSS lists the pediatric trauma centers at The Johns Hopkins Children’s Hospital, Baltimore, and Children’s National Medical Center, Washington D.C.

Locally, Meritus Medical Center is a classified as a Level 3 trauma center, Chisholm said.

“It means that they have highly skilled healthcare providers, surgeons and allied healthcare staff that are capable of taking care of trauma patients,” Chisholm said. “The surgeons are not necessarily in the facility all of the time. They can provide initial stabilization to complex injuries but will often refer (the patient) to a level 1 trauma center for further care.”

Chisholm added that this designation is only for adult patients and they are not a pediatric trauma center or a burn center.

“It is impossible for every hospital to be capable of taking care of every patient type,” Chisholm said.

Chisholm, like Cowley, has seen many changes over his years of service to the community.

Chisholm, with 36 years of experience, both career and volunteer, has seen the changes in the Maryland EMS system. Beginning in a small rural, Allegany County community in 1981, he later moved to Frederick County and continued his career for Frederick County Fire and Rescue. He retired in 2011 after 22 years with the department. Additionally, Chisholm has been a registered nurse since 2005 working in the emergency department, ICU, endoscopy and nursing administration.

“Our expanding protocols and beginning to base our treatments on evidenced based practice has been the biggest advance of recent years,” Chisholm said. “The use of research will carry our profession into the future…”

Todd Bowman is a senior writer for Shock-Advised.com and can be followed on Twitter @todd_bowman87. For live and up-to-the-minute coverage follow @ShockAdviseNEWS on Twitter and Facebook.

Photo by S-A photographer CJ Rinehart.

Information on the timeline of Shock Trauma was obtained from the University of Maryland website.

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