A velvet revolution in Maine’s trauma system

Until several years ago if I got a call as the doc in a rural Maine emergency department that a couple of severely injured car-crash victims were probably coming our way from the highway, I tightened my sphincters, lost some more hair, and hoped the staff of that small hospital could handle what was coming because we were largely on our own.

In the last decade, however, Maine’s trauma system has evolved into a sophisticated system that swings into action from the roadsides of rural Maine to the bedsides of trauma centers, with small hospitals in between, all linked in a chain of survival that previously did not exist in this largely rural state.

What a difference years of dedicated work at trauma system development has made. In the old system, hospitals and local ambulance crews jealously protected their turf and their autonomy, sometimes insisting on local care of trauma patients who, in a more developed trauma system, would have gone straight to trauma centers. Few realized that sometimes the best care for the patient was care given by someone else, somewhere else; we all thought we were the answer to the patient’s problem because we were smart, talented, dedicated and passionate about taking care of “our patients.”

Some physicians at large Maine hospitals, however, were often reluctant to accept complex trauma patients that small hospital doctors wanted to send to them. On more than one occasion during those dark years of trauma care in Maine, I spent precious time on the phone trying to convince one specialist after another at a big medical center to accept my injured patient, only to be told to find another specialist to accept the patient.

That physicians were not cheering every time I called them about a trauma patient was no surprise, however. They did not have dedicated trauma teams and operating rooms backing them up, and there were few trauma surgeons in Maine who were trained and happy to accept trauma patients sent from all over the state to their hospital. Care of trauma patients was, and remains, time consuming, difficult and fraught with malpractice risk and poor reimbursement rates for physicians.

We have kissed that problem goodbye. Where there were no trauma centers in the state, now there are three, and these trauma centers accept all trauma patients without question. In each trauma center, one phone call from a rural doc gets the patient approved for rapid transfer and assistance with transfer decisions.

There was no helicopter system back then either, so critically injured patients always had to be transported by emergency medical technicians by ground ambulance. While dedicated and skilled, those EMTs could not offer the same level of care in transfer offered by LifeFlight of Maine. LOM has critical care paramedics and nurses on board who can provide advanced trauma care, transfuse blood during flight if necessary, and fly at 150 miles per hour.

As an emergency room doc, I can now call the LifeFlight helicopter to come even before the patient arrives at my hospital, just based on the crash and injury description from EMTs and police at the roadside. If I call the helicopter while the patient is being extricated by EMTs at the scene, the air ambulance can often be at my hospital within minutes after the ground ambulance arrives with the patient. The trauma center doctor or trauma surgeon has given me advice on initial patient care to maximize the patient’s chance of survival from my link in the chain to their link. In other cases, state police and EMTs can call the helicopter right to the scene of the injury and the patient can be flown directly to the nearest smaller hospital or trauma center.

The system is not all about trauma centers and helicopters. It is about all levels of the chain of survival – from small hospitals to large, from local EMS crews to LOM crews, all doing what they do best and functioning as a system of caregivers rather than a collection of isolated heroes.

This has come about because a group of dedicated people – EMTs, state government emergency medical system leaders, nurses, hospital leaders and physicians, etc. – put their parochial interests aside and did the grinding work of building a trauma system for the people who live in, and visit, Maine. They have brought about an extraordinary, quiet revolution in trauma care in this rural state, and while Maine does not have injury death risk data available, such systems have been proven time and again elsewhere to reduce the risk of death from injury in rural states.

The success of this sustained effort in the development of a better model for cooperative care of patients suggests other opportunities for similar efforts to change and improve patient care in Maine. A small state on the economic and geographic margins needs such solutions to be able to continue to afford the health care system needed to be an attractive place to live and work. The model should be examined by state policymakers and others for its applicability to other health care needs.

With luck and common sense, you will never find out how much those who developed Maine’s trauma system have done for you and yours, but you should give thanks for what they have done just the same.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.