Emergency medicine (EM) and the development of trauma systems have substantial overlap in their recent histories. Although many medical advances occurred during the Korean War (1950 to 1953), the evolution of medical care delivery during the Vietnam War (1965 to 1973) spurred the development of trauma systems and contributed substantially to the development of the specialty of EM. Dr. Carl Bartecchi recognized the disparities in care provided to victims of trauma at war and in civilian life. He explained that “…chances of survival were greater if you were wounded on a battlefield in Vietnam than if you were in a crash on an American highway.¹” In fact, in 1965, more people died in motor vehicle crashes than in 8 years of fighting in Vietnam. This point was not lost on the medical community, and in 1966 the National Academy of Sciences (NAS) released a report titled Accidental Death and Disability: The Neglected Disease of Modern Society.² This report highlighted the shortcomings of the management of injuries in the United States and spurred the development of trauma systems, trauma centers, and catalyzed the formalization of trauma surgery and EM.

Following the NAS report, the federal government passed the National Highway Safety Act (NHSA) of 1966, mandating establishment of minimum standards for provision of care for crash victims. The NHSA essentially created emergency medical services (EMS) in the United States, and in 1968 the FCC and AT&T established the 9-1-1 system. The first US paramedic program was started in Miami in 1969, and in 1970 Ronald Reagan (as Governor) passed law allowing California paramedics to administer advanced medical care without approval from a supervising physician. In 1973, the federal government passed the EMS Act providing funds for 300 state and regional EMS systems.

With the backdrop of an EMS system being created, there was an increasing need for receiving physicians competent in emergency diagnostics and invasive procedures required for stabilization. The first EM residency program was established in Cincinnati in 1970. Residency programs in EM continued to develop and EM was granted conjoined (modified) board status in 1979 and full board status in 1989. As of 2005, there were 135 EM residency programs graduating approximately 1,300 physicians annually.³,⁴

During the same period, the surgical community took the lead in developing standards, systems, and training for the care of the injured. In 1976, orthopaedic surgeon Dr. J. Styner crashed his private plane and was left to care for his severely injured passengers (family) under suboptimal circumstances. He highlighted the shortcomings of the existing system stating “… when I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed.⁵”

This tragedy sparked a renewed interest in organizing national systems to train physicians in emergency trauma stabilization and care, and the first Advanced Trauma Life Support (ATLS) course was developed in 1978. The
American College of Surgeons Committee on Trauma (ACSCOT) in 1976 published Optimal Care for the Injured Patient, a document establishing the standards for the organization, structure, support, and care at Level I and II trauma centers. In 1985, the Institute of Medicine again brought attention to the issue of trauma care with Injury in America: A Continuing Public Health Problem. The American College of Emergency Physicians published their Guidelines for Trauma Care Systems in 1987, and in 1990 congress passed the Trauma Care Systems Planning and Development Act to foster the development of trauma systems within individual states. The intertwined history of EM and trauma care in the United States is essential in understanding the involvement of emergency physicians (EPs) in trauma care.

At the core of the trauma system is the injured patient. EPs are bedside clinicians with a history of patient advocacy. Although the trauma system in the United States is extensive with 84% of the population able to reach a level I or II trauma center within 60 minutes,⁶ most injuries are minor and do not require transport to a regional trauma center. These patients are largely cared for by EPs. Core components of EM training include understanding prehospital systems and protocols, recognizing patterns and mechanisms of injury, and understanding the acute management of injuries. As such, the EP has two discrete roles in trauma care: within the tertiary trauma center and outside of the tertiary trauma center.

Within the trauma center, EPs function as part of the multidisciplinary trauma team. They work in a coordinated manner with trauma surgeons, EM and surgical trainees, trauma nurses, and support staff. They are experts in emergent airway management, emergency procedures, and resuscitation. They may function as trauma team leaders (TTLs) and facilitate diagnostics and interventions.

A number of trends in trauma and emergency care are changing the role of EPs within trauma centers. As trauma surgeons broaden their scope and become acute care surgeons,⁷,⁸ surgical staff may not be immediately available upon arrival of the trauma patient as they tend to other surgical or critical care emergencies. This may extend the typical emergency physician’s involvement in the resuscitation and diagnostics of the injured patient within the trauma center and facilitate the surgeon’s role simultaneously. In addition, the growing trend toward overtriage within regions has resulted in increasing trauma center volume and frequent discharges after emergency department (ED) evaluation.⁹ As a result, many trauma centers employ secondary triage upon arrival to the trauma center. In secondary triage, when patients arrive at the trauma center and are found to be less injured, or less at risk for injury than initially expected, a lower tier of trauma resuscitation is activated.¹⁰ In these situations, the EP is invaluable, and surgical presence may not be necessary.

One example of the role EPs can have in a large urban trauma setting is the TTL model used in the Canadian trauma system. The TTL group is made up of a multidisciplinay collection of physicians and surgeons who have an interest, dedication, and expanded competencies in the early management and resuscitation of major trauma. In the McGill University Health Centre in Montreal, the TTL team consists of five EPs, four surgeons, two anesthetists, and one nonsurgical intensivist. The TTL responds to all major trauma cases (activations) within 20 minutes and replaces the in-house ED physician as leader of the in-house surgery resident-led trauma team. In the case of a nonsurgeon TTL, a trauma surgeon is on call to respond to surgical emergencies.

There are practical clinical benefits of working with a motivated multidisciplinary team of physicians interested in trauma using their skills to the collective benefit of the team and of the patient. The surgeons and surgical housestaff feel more supported in their role managing major trauma (especially the nonoperative cases) and have been more able to expand their role to cover more emergency general surgical coverage. The EPs feel that they have a more clearly defined role in the trauma program. The integration of EPs, surgeons, intensivists, and anesthetists into one team has dramatically harmonized the interactions between the departments in managing major trauma.

These collaborative working relationships have permitted surgical groups to absorb significantly more emergency surgical responsibility with the same staffing and with minimal impact on the overall call burden. When a surgeon is on call as TTL, he is also on as the trauma surgical call; however, when a nonsurgeon is on duty as TTL, the surgeon is on duty for trauma and general surgery emergencies. When the surgical team is operating on a surgical emergency, trauma patients are received with minimal interruption of the surgical team, as the ED-TTL functions independently but in close communication with the surgical team.