When someone suffers severe injury, a few hours, several minutes - sometimes mere seconds - are all that separate life from death. And that depends on how long paramedics take to arrive on scene, assess the extent of injury and take the victim to the nearest medical facility.
When the injury is too serious for a standard emergency room, patients are treated at one of several hundred trauma centers in the United States - centers with advanced medical and surgical capabilities.
If such an incident occurs in or near south Florida, the victim is taken to the Ryder Trauma Center at the University of Miami/Jackson Memorial Medical Center. Certified as a Level I trauma center - the highest ranking - Ryder is the first, and often last, chance for addressing catastrophic wounds before it's too late.
Not only do the Ryder Trauma Center's doctors and surgeons save lives day in and day out, but they also perform scientific research and test technology that could lead to dramatically increased efficiency during triage in a mass casualty incident - preserving time, resources and lives.
The Ryder Trauma Center's doors are open 24/7, and it houses a top-notch team of surgeons ready to care for those rushed in by ambulance or helicopter. Having served the public since 1992, Ryder physicians see about 4,000 admissions annually. Thirty percent are victims of gunshots, stabbings or falls; and 70 percent are victims of blunt trauma, vehicular accidents and various other causes. In addition, doctors at the facility train Army forward surgical teams for deployment in Iraq and Afghanistan.
When it comes to administering patient care, Ryder has a whole different set of technologies in play, many of which could influence how triage is conducted.
The word "triage" is derived from the French verb "trier," which means "to sort." In the medical world, triage refers to how medical professionals decide who gets treated and in what order.
"There's a whole list of items we look for," said Hugo Rodriguez, chief of emergency medical services for Miami, about triage criteria that first responders use at trauma scenes. "Let's say they have no radial pulse - that's an automatic trauma center [criterion]. And we're dealing with injuries, obviously, as opposed to just medical problems. So if you have a penetrating injury to the head, neck or torso, that's enough to take you to the trauma center."
Other criteria include paralysis, a heart rate higher than 120, amputation, second- or third-degree burns to more than 15 percent of the body and long bone fractures, Rodriguez said.
Ryder doctors study how heart-rate variability - the measure of beat-to-beat variations in the heart - affects triage in the field and diagnostic care in the operating room. Dr. Kenneth Proctor, Ryder's scientific director of research and a professor of surgery, anesthesiology and biomedical engineering at the University of Miami, leads this area of investigation.
"When the helicopter lands at the site of injury, [paramedics] slap leads on the patient and start measuring heart-rate variability," he said.
Leads are insulated electrical conductors connected to heart-rate monitoring devices. One end of a lead has a pad that's placed on a person's chest to measure the heartbeat, and the readings travel through the wiring to the monitor.
"We're asking the question, ‘Can heart-rate variability be used to assess the severity of [trauma]? Can it be used as a triage tool?'" Proctor said. "Then once the patient arrives at the hospital, we're asking a separate question of whether heart-rate variability can be used to assess the severity of traumatic brain injury."
Heart-rate variability has the potential to save time, money and manpower if used to triage accident victims: A paramedic on the ground could read a victim's heart rate to assess an injury's severity. If the injury warranted immediate care, a helicopter would be called to fly the victim in; otherwise ground ambulance transport would suffice. The heart-rate measurements would prevent hospitals from dispatching helicopters and extra personnel unnecessarily.
Proctor's team is studying if it's possible for this scenario to become commonplace via heart-rate variability.
Telemedicine in a Crisis
Doctors communicating with patients, each other or first responders through voice and visual communication devices - better known as telemedicine - can help tremendously during a crisis. Imagine an earthquake has devastated a major downtown area: Hundreds of civilians are buried beneath rubble, and nearly 100 more are wandering around suffering from various injuries. Paramedics arrive and begin questioning and examining as many people as possible to assess who needs care. But they're overtaxed. They need more help; they wish they could make quicker assessments.
What if surgeons at trauma centers could see the wounded through cameras and help first responders make triage decisions? What if they could assess who needs immediate care and who can wait a bit longer so the severely injured can be stabilized until they reach a trauma center?
In the near future, Ryder's work with telemedicine and combat mass casualty could help civilian first responders communicate with physicians at accident and disaster scenes.
"Most major advances in civilian trauma care have arisen because of different necessities that were the result of battlefield problems," Proctor said. Many military injuries are similar to civilian ones, as are the thought processes behind their treatment, so the medical field's work to improve military care can influence domestic care or vice versa.
Dr. Jeffrey Augenstein, the Ryder Trauma Center's co-director, chief of research and IT, and a surgery professor, leads the facility's military-funded projects in remote care. He said Ryder conducts mock combat casualty exercises that lets doctors see patients right along with first responders, thanks to a camera.
The first responder is at the scene, usually with a live person playing the victim, and is accompanied by someone else with a high-definition camera. Teleconferencing technology lets a doctor elsewhere see and communicate with the first responder.
"Our study [questions], is there any improvement or deteriorations if you're remote versus physical? They're talking to the person, obviously, who's in the trauma center remotely doing the triage," Augenstein said of responders in these exercises. "So they're answering questions in certain cases, but we're trying to get virtually all of the information from the cameras rather than relying too heavily on the person. We're trying to use them in kind of a robot-like way."
Augenstein said Ryder began conducting these exercises nearly two years ago. Though mock combat-setting exercises are designed for remote triage, mock civilian-setting exercises are designed for doctors to guide others in administering care in the hospital setting. But Augenstein said it's possible the types of exercises in both settings could be modified as Ryder further develops the remote-triage process.
One method of differentiating major wounds from minor ones is with a technology that sounds like it should be on a science fiction TV program. This method - near-infrared spectroscopy - places a device on the head or torso that shines a light into the body, allowing doctors to probe for injury without breaking the skin.
"This light will penetrate skin, muscle [and] bone to underlying tissues and allow a readout that estimates continuous tissue oxygenation," Proctor said.
In theory, this technology that Ryder has studied should be useful to the trauma world because it gives doctors a unique view into the circulatory system.
"Basically the whole goal of the circulatory system is to maintain oxygenation to the brain, heart and vital organs," Proctor said, adding that when a person is injured and their system is breaking down, oxygenation isn't maintained to vital tissue.
It's a noninvasive way to discover patient problems. There are no needles, no blood samples - just light. Proctor said Ryder has gone as far as it can with near-infrared spectroscopy research, having discovered the technology offers value-added benefits to traditional means of diagnostic analysis, but doesn't surpass them.
Ryder stopped testing near-infrared spectroscopy in the first quarter of 2008, but may resume testing at a later date.
Proctor said he and colleagues would like for both near-infrared spectroscopy and heart-rate variability tools to be placed in ambulances so paramedics could use them for triage in the field. He describes them both as novel monitoring strategies, but there are other Ryder innovations that he said are novel therapeutic or resuscitative strategies.
One strategy is using blood substitutes to treat patients who've lost their own blood. According to Proctor, doctors typically administer a saline solution intravenously to patients who've lost too much blood, but it doesn't beat the real thing. They use saline because real blood can't be stored for long periods of time, nor can it be easily transported without refrigeration. This makes real blood hard for paramedics to carry in ambulances for long periods of time. It would help if medical professionals had an alternative.
To solve this problem, companies are developing blood substitutes that can be stored longer at room temperature. Ryder uses a compound called Hemopure by Biopure Corp. of Cambridge, Mass., for preclinical experiments in animals. So far, the Food and Drug Administration (FDA) hasn't approved the compound for use by Americans and won't until successful preclinical results are achieved. Proctor said, consequently, the Navy asked Ryder to perform the preclinical trials. The Navy plans to use the data as evidence to gain FDA approval for the Naval Medical Research Center to perform clinical trials with people. According to Biopure, Hemopure is compatible with all blood types.
Ryder's work with life-saving solutions doesn't stop with blood substitutes. Another compound is recombinant factor VIIa, also known as NovoSeven, which was created to treat hemophiliacs, induces coagulation to clot flowing blood. It was first used as a therapeutic tool in trauma care in 1999 to treat a wounded Israeli soldier in Tel Aviv. The doctors turned to NovoSeven after all other therapy methods failed. Ryder is also experimenting with another substance to combat the opposite extreme - when the body clots too much. It accelerates bleeding to reverse hypercoagulation.
The Ryder Trauma Center's ultimate goal for the new medical technologies is to put them in place and then improve them, Augenstein said.
"It's all based on identifying a problem first," he said, "and then trying to solve it."