On August 31, 1997 at 12:25am a Mercedes crashed into a concrete pillar at 100km/h in Paris. There were four people in the car. The driver and a passenger in the back seat, were killed instantly. The front seat passenger suffered facial injuries and a broken wrist but survived thanks to his seat belt and the airbag. The fourth passenger who was in the back seat did not wear a seat belt but survived the initial crash. However, she suffered major thoracic trauma, several cuts on the forehand, arm and thigh as well as a dislocated shoulder.
Coincidentally, an off-duty doctor, as well as a firefighter arrived at the scene just one minute after the crash. Over the course of the next hour they tried to save the passengers life by treating her falling blood pressure. They were joined by the physician staffed SAMU mobile hospital unit.
At 1:30am, over an hour after the impact, the ambulance drove her slowly to Piete-Salpetriere hospital, 6.15 kilometers away. At that time of the night, it would normally take five to ten minutes for that drive. However, it took the ambulance 40 minutes. The driver applied standard French emergency procedures. He drove very slowly to not subject the patient to shocks and bumps.
Within 10 minutes of her arrival, the patient suffered a cardiac arrest, prompting the doctors to inject large doses of epinephrine directly into her heart, and to perform an emergency thoracotomy. The operation revealed that the source of the hemorrhaging was a single lesion, a partial rupture of the left pulmonary vein at the point of contact with the left atrium. The tear was sutured, and the hemorrhaging was stopped. But despite nearly two hours of manual internal massage, and the application of electroshocks, it was impossible to reestablish a heartbeat. The patient was declared dead at 4 a.m. That patient was Diana, the Princess of Wales. 1
Going back two decades in time, we want to tell you another story. In February 1976 the American surgeon J. K. Styner was flying his wife and three kids from Los Angeles to Lincoln, Nebraska in his six-seat Beech Baron airplane when he crashed into a row of trees. Although his wife didn’t survive the impact, all of his kids as well as himself managed to escape the aircraft. After several hours they were able to get to a road and stop a car that would take them to the local hospital.
To their surprise, they found the door to the emergency department locked. Later, two doctors arrived. However, it was evident that they were not prepared for this kind of situation. There was an obvious lack of training for proper triage and treatment. After organizing transport to the next larger facility, 117km away, they finally received proper trauma treatment. Mr Styner was so upset by the events that he started crafting a training format that would teach an evidence-based approach of trauma care to hospitals around the world. The format prioritized treatment principles (‘Treat first what kills first – the ABCDE approach’) over patient assessment strategies (called the ‘Primary Survey’). This was the birth of what is now widely known as “Advanced Trauma Life Support – ATLS”. 2
The Advanced Trauma Life Support© (ATLS) program has changed in-hospital management of major trauma patients and is now the accepted standard of care in over 50 countries worldwide and has been taught to over 1 million physicians3-6. Several studies in the rural United States – where Mr Styner stood before closed doors two decades before, confirmed an improvement in the care of trauma patients. The new process was linked with a lower mortality in patients with serious, but survivable injuries7-9. Furthermore, there is evidence that educational initiatives like the ATLS course format improve knowledge of hospital staff on available emergency interventions10.
Continuous education and standardization in Emergency Medicine is not limited to traumatology. The modern Emergency Department physician is also trained in Advanced Cardiac Life Support© (a similar course format teaching emergency interventions in cardiovascular emergencies) or Pediatric Advanced Life Support©. Furthermore, there are dozens of additional courses and classes available to surgeons, emergency physicians, emergency department nursing staff, paramedics or EMTs ranging from Hazardous Material (HAZMAT) Life Support over opioid emergency training to psychological trauma education in emergency patients.
One of ATLS key concepts is the so called “golden hour”. The underlying idea is that an injured patient has 60 minutes from the time of injury to receive surgical care, after which morbidity and mortality increase significantly11. In several studies significant correlation between reduced out-of hospital times and mortality rates could have been found and were linked to injuries that would usually lead to death within one to two hours after the injury, such as severe head injuries and intra-abdominal bleeds12-16. Severe thoracic injuries such as a rupture of a pulmonary vein, which in contrast to a traumatic rupture of the aorta will not kill someone instantly but do so over time fall into this category17-19.
Coming back to our first patient, Princess Diana, both the coroner’s report and the testimony of the chief surgeon that night confirmed a partial tear of one of the left pulmonary veins to be the only mortal injury sustained. The question that never will be answered remains: Would the Princess have survived today?
If you would like to know more about how Nodus Medical can help you in emergency medicine, feel free to reach out to us.
- T Sancton. Death Of A Princess, Did Princess Diana Have To Die?: A Case Study In French Emergency Medicine. The Internet Journal of Rescue and Disaster Medicine. 1999 Volume 1 Number 2. Available from: http://ispub.com/IJRDM/1/2/12892#sthash.KYqfK099.dpbs
- Styner JK. The birth of Advanced Trauma Life Support (ATLS). The Surgeon [Internet]. 2006 Jun;4(3):163–5. Available from: http://dx.doi.org/10.1016/S1479-666X(06)80087-9.
- van Vugt AB: [‘Advanced trauma life support’ in Netherlands]. Ned Tijdschr Geneeskd. 2000, 144 (44): 2093-2097
- Scharplatz D, Sutter PM, Ummenhofer W: [ATLS (advanced trauma life support) in Switzerland]. Swiss Surg. 2000, 6 (6): 343-346. 10.1024/1023-93220.127.116.113
- Rastad J, Lindebert T: [“Advanced trauma life support” in Sweden. A flying start for trauma education]. Lakartidningen. 1996, 93 (30–31): 2660-2661.
- Skinner DV: Advanced trauma life support. Injury. 1993, 24 (3): 147-148. 10.1016/0020-1383(93)90277-D
- Olson CJ, Arthur M, Mullins RJ, Rowland D, Hedges JR, Mann NC. Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers. Surgery [Internet]. 2001 Aug;130(2):273–9. Available from: http://dx.doi.org/10.1067/msy.2001.115898.
- van Olden GDJ, Dik Meeuwis J, Bolhuis HW, Boxma H, Goris RJA. Clinical impact of advanced trauma life support. The American Journal of Emergency Medicine [Internet]. 2004 Nov;22(7):522–5. Available from: http://dx.doi.org/10.1016/j.ajem.2004.08.013.
- van Olden GDJ, Dik Meeuwis J, Bolhuis HW, Boxma H, Goris RJA. Advanced Trauma Life Support Study: Quality of diagnostic and therapeutic procedures. The Journal of Trauma: Injury, Infection, and Critical Care [Internet]. 2004 Aug;57(2):381–4. Available from: http://dx.doi.org/10.1097/01.TA.0000096645.13484.E6.
- Jayaraman S, Sethi D, Chinnock P, Wong R. Advanced trauma life support training for hospital staff. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD004173. DOI: 10.1002/14651858.CD004173.pub4
- Rogers FB, Rittenhouse KJ, Gross BW. The golden hour in trauma: dogma or medical folklore?. Injury. 2015 Apr 1;46(4):525-7.
- Samplais JS, Lavoie A, Williams JI, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993;34:252-261.
- Sampalis JS, Denis R, Lavoie A, et al. Trauma care regionalization: a process-outcome evaluation. J Trauma 1999;46:565-581.
- Dinh MM, Bein K, Roncal S. Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes. Int J Care Injured 2013;44:606-610.
- Tien HCN, Jung V, Pinto R, et al. Reducing time to treatment decreases mortality of trauma patients with acute subdural haematoma. Ann Surg 2011;253:1178-1183.
- Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intraabdonimal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 2002;52:420-425.
- Gervin AS, Fischer RP. The importance of prompt transport in salvage of patients with penetrating heart wounds. J Trauma 1982;22:443-446.
- Ivatury RR, Nallathambi MN, Roberge RJ, et al. Penetrating thoracic injuries: in-field stabilization versus prompt transport. J Trauma 1987;27:1066-1072.
- Clevenger FW, Yarborough DR, Reines HD. Resuscitative thoracotomy: the effect of field time on outcome. J Trauma 1988;28:441-445.