Jack Stout

JEMS Magazine

December 1983

TRAUMA CENTER – ABC STYLE

I must first confess that I have seen only one episode of ABC’s “Trauma Center”. Alan Jameson, Patrick Smith, and I were spending one of our typically lonely nights on the road, this time in Fort Worth, Texas, when we decided to watch an episode just to see what sorts of new images the average viewer might be learning from the new series. What we saw was truly amazing – so amazing that I decided to postpone an important article concerning first responder systems in favor of this probably futile attempt to prepare you, in some small way, for dealing with the almost certain impact of this new series upon the way the general public and elected officials think about prehospital care systems.

Public Expectations Do Matter

The private ALS providers, particularly those dedicated to clinical excellence and high performance, faced an uphill, practically vertical, public relations battle long before “Trauma Center” hit the screen. In the old days, good private operators had to somehow distinguish themselves from the widespread negative images created by the less-well motivated participants within the industry. We have all seen the film clips of two funeral home ambulance crews slugging it our over a body while the injured patient was left unattended. In “Mother, Jugs, and Speed”, Raquel Welch helped show the world how multiple private companies compete in hilarious yet deadly ways to swipe each other’s business, and how they team up with winos to rip off the welfare program. Between the entertainment industry and the actual performance of a whole lot of really rotten ambulance providers, the really reputable ambulance provider had one hellva time surviving at all, much less being appreciated.

For a long time, the general public, and therefore elected officials, thought very little about the situation, since it was generally understood that the main purpose of an ambulance is to provide a quick ride to the hospital. In that narrow context, the public was willing to view the deadly performance of many private providers as zany antics- kind of funny. The reputable private provider could try to distinguish himself from the rest, but no one really cared.

By the early 1970’s, the federal government was deciding to apply lessons learned in Vietnam to EMS delivery systems back home. Several hundred million dollars were spent, and the part of it that went into prehospital care heavily favored those increasingly publicized socialized ambulance services. Captain Waters hit the road with his sound slide show about Jacksonville, Florida’s fire department-based service. I had to follow Captain Waters on a speaking program in front of 800 people, and believe me he had them rolling in the aisles. Before long there were dozens of such slide shows and even professionally made films circulating throughout America working a hard sell in favor of socialized ambulance systems. They didn’t call them “socialized”, but the clear message was that fire departments or third city departments do the job best. And if the reputable private provider had trouble surviving before, imagine how he felt when governmentally financed showmanship and outright salesmanship entered the arena along with the continuing guilt by association which was the inevitable result of sharing an industry with cream-skimmers and body-snatchers.

And then came the really big blow. Jack Webb decided that the combination of Johnny Gage and Julie London couldn’t miss. The non-transporting fire department based ALS rescue service hit the TV screen, and just about everybody in America learned how a real EMS system should work. Local elected officials throughout America took note and forked over the local tax dollars. A handful of private ambulance providers got lucky by signing exclusive transport contracts with non-transporting socialized rescue services. But the opportunity to demonstrate high quality private ALS service was continuing to diminish. And in cities that chose to let Johnny Gage transport patients as well, the private providers were reduced to squabbling over the non-emergency transfer work. Some didn’t mind, but the private owner who dreamed of operating a superb and efficient community ALS service was often cut off from the chance.

Johnny Gage did us all a tremendous service by teaching the public that a good ambulance service does more than provide rapid transport. People learned more about what to expect from an ambulance service system by watching Johnny Gage than as a result of all the “consumer information and education” programs combined. But the unintentional and subtle message included with that valuable lesson was that good ambulance services are run by agencies of local government. Unintentional or not, the private sector took another beating.

Sometime later, the Department of Transportation did its own study of ambulance services and tentatively concluded that, while fire department based systems might be okay, a third city department might be even better. So in the minds of a great many Americans, particularly those elected to local public office, the only decision left was whether to put it in the fire department or to create a third emergency department of local government. I know because I spent almost a decade of my life trying to convince these same local officials that, under a restructured competitive opportunity, the private sector could deliver the good and do it more effectively than anyone else.

The private sector of the ambulance industry did plenty on its own to destroy public confidence in both the motivation and capability of private ambulance providers. To survive the last decade, the reputable private ALS provider had to hold off the cream-skimmers, avoid anti-trust difficulties, somehow distinguish his operation from the rest of the industry, and roll with the punches unintentionally delivered by the entertainment media. If it hadn’t been for Howard Jarvis, (Proposition 13) and the recession, it could have been curtains for the surviving private ALS providers.

Sharing the Public Relations Nightmare

Probably the one really nice things about ABC’s new “Trauma Center” is that it doesn’t just single out private ambulance operators for irritation and humiliation. No, the episode I saw made fools out of just about everybody. Maybe that’s why we were doubled up in laughter throughout much of the show. I just can’t resist telling the highlights and watching the reactions. Here goes.

Lesson 1: What’s a Trauma Center?

In opening scenes, the medical director escorts the world’s most ignorant architect through the center and explains that patients with non life-threatening conditions go to emergency rooms, while patients with more serious problems go to the trauma center. Now I know it’s hard to explain bona fide triage to the general viewing audience, but I couldn’t help wondering about all those board certified emergentologists who work in emergency departments which were not blessed with trauma center designation. Imagine trying to explain to your eight-year-old daughter who has just seen “Trauma Center” that you really do save lives on occasion, and not just by accident.

Lesson 2: When It’s Serious, Send a Helicopter

Some guy is fooling around with poisonous snakes, gets bit in what is obviously an inner-city urban setting. Somehow the trauma center gets the call. It’s not explained how the trauma center got the call, but we can only imagine that someone dialed 911, and that some diagnosis-specific dispatch protocol indicates that if it’s a deadly poisonous snake bite, you dispatch the trauma center- not the fire department’s first responders and not the local ambulance system. In fact, throughout the entire program, there is no evidence that there is a local ambulance system or that one is ever needed. Talking it over at the trauma center, it’s pretty serious stuff, and therefore doctors in a helicopter must go-not paramedics. Apparently there’s isn’t much a paramedic can do in such a situation. We have already learned that trauma centers handle all the life-threatening emergencies and now we are learning that if it’s really serious, such as an unknown snake bite, send a doctor…in a helicopter.

Lesson 3: Paramedics Make Good Snake Catchers

When the helicopter arrives at the scene of the snake bite, there is an ambulance of unknown origin parked outside, but when the physicians arrive at the site of the patient, the only folks on the scene are police officers. No EMTs or paramedics. I still wonder who drove the ambulance that was parked outside, and why weren’t they attending the patient? Maybe the police relieved them so they could grab a burger.

Anyway, after the patient was hustled back to the hospital, the two paramedics on duty are told that a snake was still missing, and maybe they should go help the police hunt it down. While the paramedics were clearly unqualified to handle a patient in such a serious condition, they were sent to work standby and to assist the police in capturing the missing snake. Naturally, about 100 policemen couldn’t find the snake, but the two paramedics could, and by ripping off the plexiglass cover from a game machine, Lou Ferrigno (the big paramedic) captured the snake.

It was mildly interesting to note that the patient was treated with a special anti-venom, selected, after the snake was identified. One wonders how this treatment would have been different had the patient been inadvertently delivered to an “ordinary” emergency department.

Lesson 4: It’s Serious, Send a Doctor

We have already learned that doctors and helicopters – not paramedics- are necessary to save some kinds of patients. Next we see a male nursing student, also a part-time male stripper, take a close-range bullet in the chest. Again, by way of some exotic but unknown system of telephone access and triaged dispatching, the trauma center is alerted. This time the helicopter isn’t necessary, so the two paramedics and the van-type ambulance are sent. But wait! This, too, is a pretty serious case, so a doctor accompanies the paramedics. Apparently, paramedics can handle snakes but not critically hurt patients, at least not all by themselves.

The two paramedics and the doctor arrive on the scene. The doctor-not the paramedics- accesses the patient, and the doctor orders the application of a MAST suit. There is nothing to indicate that either paramedic had a inkling that a MAST suit might be in order, so I guess it was a good thing the doctor was there. So far, we have learned that paramedics can catch snakes, and put some kind of special clothing on a patient if a doctor says so. We aren’t told what a MAST suit is or what it’s for, although later we will learn all about a McSwain Dart.

Lesson 5: If It’s a Plane Wreck, Send a Doctor

While the doctor was telling the paramedics how to handle a gun shot wound, the helicopter was flying over to the repair shop to have its radio fixed. Enroute, the helicopter spots a twin-engine private plane in trouble, and directs the pilot to an open field about a mile away. Now pay attention. This is the most amazing EMS system response ever conceived. A twin-engine aircraft traveling well over 100 miles an hour is headed directly at a field less than a mile away. The helicopter radios the trauma center which dispatches the two paramedics on the ambulance to the scene of the impending crash. But because it might be serious, the paramedics can not be sent out alone. No, a doctor is sent to supervise them.

This very same ambulance dispatched from a urban trauma center somehow travels through the city, to the outskirts of town, across a dirt road and though an open field, and manages to arrive at the scene of the crash before the pilot can crawl out of the plane. That’s what I meant earlier when I suggested that perhaps no other ambulance system is necessary in a community whose trauma center has one helicopter and one ambulance.

Lesson 6: Always Have One Big Paramedic And One Little Paramedic

When we first developed system status management, we went to some pretty complicated lengths to develop really flexible staffing patterns and shift schedules. But I guess we blew it, because we completely overlooked the most obvious staffing requirements-one big paramedic and one little paramedic.

When the two paramedics and the doctor got to the scene of the airplane crash, the pilot’s wife was trapped in the wreckage and experiencing tension pneumothorax. They don’t actually tell you that it’s tension pneumothorax, but you learn that a rib had punctured the lung and that the chest cavity is filling with air making it impossible for the victim to breathe. Now, here comes the big/little paramedic staffing plan. They can’t get the patient out of the plane, and the doctor is a medium-sized doctor. Luckily, one of the paramedics is a little paramedic, and so is able to crawl into the wreckage to be the eyes and hands of the physician performing the patient assessment. Under the direct on-site supervision of the physician, the little paramedic feels around, listens to some breath sounds, and conveys what he has learned to the doctor. The doctor explains the meaning of these signs and symptoms to the paramedic who is obviously qualified to feel around and listen, but not qualified to interpret what he has discovered. But thank God he’s little.

A little later, fuel was about to ignite, and so it is necessary to pick up the fuselage of the plane and hold it so the victim can be removed. Again, the big/little staffing plan comes into play as paramedic Lou Ferrigno (formerly the Hulk) holds the entire fuselage in the air long enough for the victim and the little paramedic to escape. Notice the capital equipment cost savings of such a system. No expensive jaws-of-life, no complicated cutting tools, and expensive air bags for lifting heavy objects. Just one little paramedic and one big paramedic. That probably explains how they could perform all-out ALS out of a Type II van.

Lesson 7: What’s a McSwain Dart

For some reason, it wasn’t necessary to explain to millions of viewers what MAST pants are or what they do. Probably an oversight. But the mistake was only made once, since when the little paramedic learned that air in the chest cavity was making the victim’s breathing impossible, the doctor asked the paramedic if he knew what the “McSwain Dart” was. I think the paramedic had heard of such a device, but just to be certain, the doctor explained the dart and its function to the paramedic who, being little, was able to find the spot and insert the dart as per the doctor’s instructions. I wondered if the paramedic really knew what the dart was for, because when the dart went in, the paramedic asked the doctor if it was good that a big puff of air came out upon insertion. But even if the paramedic was unclear as to the purpose of a McSwain Dart, millions of Americans watching the show do understand. And they understand correctly, because Dr. Norman McSwain himself as one of the four medical advisors listed in the credits.

Lesson 8: Paramedics are Egomaniacs

Throughout the entire program, the writers maintained a little separate running plot. One of the paramedics, the little one, had a high school reunion coming up, and was embarrassed to attend, since most of his classmates were successful doctors, lawyers, architects, and he was just a paramedic.

This was a problem throughout the show, and nearly created a crisis when the little paramedic announced his intention to go to work in a relative’s auto parts store. I wondered if the little paramedic thought there was more prestige in becoming an owner of an auto parts store than being a paramedic.

Fortunately, the problem was resolved at the end of the show when the little paramedic’s picture appeared in the local paper along with an article declaring him a hero for his role in the aircraft rescue event. Dressed in his three-piece suit and ready to leave for the reunion, the little paramedic stopped by the hospital to pick up his date. One of the doctor’s handed him a copy of the newspaper article with his picture, suggesting that he might enjoy showing it off at the reunion. Not necessary, in this case. The little paramedic had his pockets stuffed full of xerox copies of the article, and announced his intentions to pass them out en masse. And to top things off, the elevator door opened to reveal the little paramedic’s incredibly beautiful and voluptuous date.

We have learned that while paramedics can perhaps not be trusted to handle really serious cases alone, they do catch snakes, little ones can get into small spaces, and big ones can lift airplanes and tear off plexiglass pieces for snake-catching purposes. These are handy features indeed. But we also learned that paramedic career crisis can be cured with a picture in the newspaper and a gorgeous blonde to show off. Paramedics are simple folks at that.

The Ultimate System

As I watched the show, it looked to me as though professional paramedics took the worst image beating, followed closely by non-trauma center emergency departments. But sometimes the most subtle messages are the most powerful. In this case, I am absolutely certain that I will spend much of my time over the next few years explaining to elected officials why one ambulance and one helicopter, one little paramedic and one big paramedic, and some doctors to handle the serious cases doesn’t constitute the ultimate system.

Maybe the “Trauma Center” episode I saw was unusual. Maybe future episodes will be more responsibly thought out. But doesn’t it seem like a show entitled “Trauma Center” should focus at least some of its attention upon the really important benefits of true regionalization of acute care for that small percentage of critically injured trauma patients.

In the single episode I happened to see, the only in-hospital acute care dealt with at all had to do with identifying the snake. Absolutely every other clinical event involved trauma center physicians being rushed out of the trauma center by way of helicopter and instant-response ambulance to instruct paramedics in the obvious.

Perhaps the writers can’t figure out how to make what actually happens in a real trauma center seem dramatic enough. And maybe it’s unreasonable or at least unrealistic, to hope that the program could run interference for those folks who have struggled and continued to struggle for the true regionalization of critical trauma care.

Instead of teaching the public that trauma centers handle life-threatening conditions while regular emergency departments handle less serious cases, would it really be any more difficult to show that the acute care of the critical trauma patient presents different problems than the acute care of equally critical but non-trauma patients, such as snake bite victims? Instead of teaching the public that paramedics need at-scene physician leadership when the case is serious, would it really be that much harder to show the value of a high-performance prehospital care system and its true relationship to trauma center work? And what about those states where the bureaucrats have folded under the pressure of medical politics, and have allowed practically every hospital that applied to receive trauma center designation? Would it really be that difficult to show the public that proper care of the critical trauma patient is more team-performance sensitive than the care of other kinds of critical cases, and that trauma care must be somewhat centralized in order to give any institution a sufficient volume of critical trauma patients to evolve a precision team performance under pressure?

One might argue that such messages are too complicated and too technical for consideration as underlying messages in an entertainment program. But if its not too difficult to work into the script a fairly complete and accurate discussion of the use and function of a McSwain Dart, then its not to difficult to deal more responsibly with the really difficult and complex organizational issues.

Like I said, practically everyone took an image beating in that episode of “Trauma Center”. But the reputable private provider of ALS prehospital care services has grown accustomed to such treatment. Maybe I’m just dreaming, but wouldn’t it have been nice if the ambulance based at the trauma center was part of a privately operated high performance prehospital care system? Did the big/little paramedic team really have to be on the payroll of the hospital? Hospitals, including trauma centers, are often used as ambulance post locations in privately operated ALS systems. A script writer would have had more-not less-dramatic opportunity if the ambulance crew based at the trauma center worked for a superb private ALS provider. It would have been more interesting- not less interesting- to demonstrate the sophisticated technology of fully centralized dispatching, system status management, and computer-aided dispatching than to simply omit the entire issue of access and dispatch methodology.

With a few simple changes in the basic format, the program could have been helpful rather than misleading. And none of these format changes would have prevented the writers from continuing to demonstrate instantaneous response times, the value of the big/little paramedic staffing plan, the snake catching prowess of medics, or the constant need for at-scene physician supervision of prehospital care. These idiotic messages could have been retained, for whatever reason, even in the context of a more realistic structural format. I guess you can’t win them all, but at least this time the private ALS provider can enjoy the company of nearly everyone else working in this industry as we all take another subtle and unintentional image beating.