SAN DIEGO-Trauma care in the United States is on or heading toward life support. Although this may sound hyperbolic, it points to a need, seen by many otolaryngologists and other surgeons, to raise awareness of the growing gap between the numbers of people in need of trauma services and the accessibility of getting those services. Reimbursement issues, time requirements, and geographical constraints are all challenging issues that otolaryngologists and other surgeons face in providing head and neck trauma services. To continue to provide these services, otolaryngologists need to address these challenges and continually update their skills to provide the best care possible.
The need to enhance trauma systems nationwide, in every state, is illuminated by data that show that fewer than 10% of hospitals have a trauma center, only eight states have fully developed trauma systems, and up to 38% of the population may not be covered by a statewide trauma center.
There is concern that we’re not training otolaryngologists to handle trauma and that translates not only onto the battlefield but to hospitals across America.-Marion Couch, MD, PhD
The lack of infrastructure support for trauma services comes at a time, ironically, when the nation is building a homeland security effort to be ready for mass casualties that may result from a natural disaster or terrorist attack.
To address issues related to developing optimal trauma care of head and neck injuries, a panel of experts convened during a miniseminar held at the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 2009 annual meeting to discuss both technical and socioeconomic issues otolaryngologists face to remain central players in trauma systems. Called Comprehensive Contemporary Management of Otolaryngologic Trauma, the miniseminar drew on the experiences gained during military and civilian trauma care to highlight essential components of a good trauma system.
Lessons from the Battlefield
G. Richard Holt, MD, of the Department of Otolaryngology-Head and Neck Surgery at the University of Texas Health Science Center at San Antonio-who, as a flight surgeon in Operation Iraqi Freedom, helped evacuate soldiers at the site of the injury, often under hostile conditions-emphasized that all physicians who treat patients with severe injuries are duty bound by their profession to step forward in time of need, such as in the face of a natural disaster or terrorist attack.
We are physicians first and can manage multiple traumas due to our training and experience, he said. Most of us are certainly trained in maintenance of the airway and trauma to the head and neck, so we all, as otolaryngologists, should be capable of stepping into the fray as needed.
Penetrating Neck Wounds
One lesson in a treatment approach to head and neck injuries drawn from the battlefield is management of penetrating neck wounds. Although Dr. Holt said that the current trend toward selective neck exploration via new imaging and other technological advances is feasible to diagnose these injuries, he cautioned that this approach should not result in anunduly nonaggressive approach to these injuries because of the risk of death from missing an injury.
We cannot be lulled into relying totally on imaging studies that might jeopardize the patient’s well-being, he emphasized, but rather still consider penetrating injuries of the neck to be a surgical condition.
He emphasized situations in which mandatory surgical exploration may be safer for patients, including geographically isolated facilities, insufficient diagnostic imaging capabilities, inadequately trained radiologists, unreliable or outdated equipment, poor transportation capability to a higher-level treatment center, patient or family transportation refusal, and local or regional military or paramilitary conflicts where transporting a patient to a higher-level facility would be dangerous.
Opening the Airway
Another lesson drawn from the battlefield is the critical role otolaryngologists play as first responders to a trauma injury in establishing the airway. According to Manuel Lopez, MD, of the Facial Plastic and Reconstructive Surgery Service in the Department of Otolaryngology-Head and Neck Surgery at Lackland Air Force Base in San Antonio, TX, establishing the airway in a trauma injury is the essential first role that otolaryngologists play in a triage situation, such as a mass casualty situation such as Hurrican Katrina or 9-11. Only after the airway is secure should the otolaryngologist do a secondary examination of the entire head and neck for injuries.
Speaking on the different techniques currently available to open the airway, Robert M. Kellman, MD, Professor and Chair of Otolaryngology and Communication Sciences at SUNY-Upstate Medical University in Syracuse, NY, emphasized that otolaryngologists are the specialists, bar none, who are called in as the backup specialists for any difficulties opening the airway. There is no other specialty that competes with us as the backup person to handle the airway, he said.
As an otolaryngologist with many years of experience managing airway problems in trauma patients off the battlefield, Dr. Kellman emphasized that otolaryngologists need to be familiar with available techniques to permit expedient use of the least morbid technique. Among the techniques that are becoming more widely used are techniques for nasotracheal intubation (eg, using flexible fiberoptic incubation using a fiberoptic bronchoscope) and orotracheal intubation (eg, using a lighted stylet or rigid fiberoptic laryngoscope).
These newer technologies are designed primarily as techniques that allow you to avoid having to get to the final step in the pathway, said Dr. Kellman, which is the need to open the airway by performing either a cricothyroidotomy or tracheotomy.
According to Dr. Kellman, the most important issue in a trauma injury is to avoid injury to the cervical spine. He said that intubation approaches using the fiberoptic instruments or lighted stylet probably are the least likely to result in neck movement that may lead to spinal cord injury.
For patients who cannot be intubated, he said that use of the laryngeal mask airway (LMA) saves the most lives. However, he cautioned about safety concerns with these masks, given that they may not prevent aspiration or reflux.
Acute Management of Facial Fractures
Another lesson learned from the battlefield is that high-velocity facial wounds can be treated immediately, versus the traditional delayed approach.
According to Dr. Lopez, he and his colleagues who have deployed to Iraq and Afghanistan have treated thousands of soldiers with this approach. The assumption that the soft tissue in a high-velocity facial wound had to heal for about a week prior to closing it is not borne out by the good results they have seen in patients in whom their facial wounds are closed immediately.
Fortunately, we don’t see a lot of high-velocity facial wounds in civilian life, he said, adding that he would treat these types of wounds immediately in a civilian setting as well should it arise.
Socioeconomic Issues
Providing trauma care is not easy, and the challenges are great. There is concern that we’re not training otolaryngologists to handle trauma and that translates not only onto the battlefield but to hospitals across America, said Marion Couch, MD, PhD, of the Department of Otolaryngology-Head and Neck Surgery at University of North Carolina School of Medicine in Chapel Hill.
Of the several socioeconomic issues that make trauma care challenging, Dr. Couch emphasized that the large number of people without health insurance is a key factor.
The issue of uninsured patients is intimately associated with the sustainability of trauma, she said, adding that it is becoming more difficult for surgeons, as well as institutions and hospitals, to handle trauma injuries because the reimbursement rate is so low. To take on these cases, she said, you often have to take a financial hit.
One solution proposed to address these challenges is for otolaryngologists to use a standardized daily progress note to increase coding accuracy and associated billing. Data show a 394% average revenue increase when standardizing documentation.
Given the difficulties of providing trauma services, Dr. Couch said that efforts are under way to provide education and support for otolaryngologists and to advocate within the specialty, with the American College of Surgeons, and with local and federal government to improve ways to deliver trauma services. To this end, a Head and Neck Trauma Study Group is working toward becoming a full committee within the AAO-HNS.
©2009 The Triological Society