ACS COT 100 Years: Emergency Medical Services and Trauma Systems

Highlights

• Summarizes key turning points in the evolution of the EMS and trauma systems
• Identifies the roles of ACS COT leaders in developing modern EMS and trauma processes
• Highlights future goals, including advancing a NTEPS at the federal level

As the American College of Surgeons Committee on Trauma (ACS COT) celebrates 100 years of service, milestones of the systems of care that have been built over the past century have been acknowledged and celebrated. Perhaps the most notable milestone is the evolution of emergency medical services (EMS) and the creation of the trauma system itself. Herein we explore the history and impact of each.

EMS

The ACS COT has had a significant impact on the evolution of modern EMS throughout the committee’s history. George G. Davis, MD, FACS, presented a lecture on Transportation of the Injured at the Conference of Traumatic Surgery Symposium during the 1929 ACS Clinical Congress, highlighting the importance of stabilizing fractures, using tourniquets, and avoiding delays. The EMS Committee, which first started as the Subcommittee on the Ambulance Equipment in the Emergency Treatment of Fractures in 1931, chaired by Robert H. Kennedy, MD, FACS, has grown from a small group to a committee of more than 40 members and organizational liaisons. 

The EMS Committee has consistently emphasized the importance of the trauma continuum of care that begins when and where injury occurs. From educating first responders through the Prehospital Trauma Life Support (PHTLS) Course, to forming a seminal relationship with the National Association of Emergency Medical Technicians (NAEMT), to the development of the STOP THE BLEED^® program that emphasizes the role of the public as immediate responders, the EMS Committee has had, and will continue to have, a profound impact on saving lives around the globe.

Although modern EMS had its major evolution in the 1960s, the COT has always had an interest in transporting injured patients. Robert T. Findlay, MD, FACS, published a review in 1931, “First Aid for Fractures: Methods and Equipment for the Treatment of All Fractures at the Site of Accident and on the Ambulance during Transportation to the Hospital” in The Journal of Bone & Joint Surgery. In the June 1933 issue of the Bulletin of the American College of Surgeons, Dr. Kennedy published the article “Transportation of the Injured,” discussing transportation considerations and splinting techniques. In 1936, a report from the Subcommittee on the Transportation of Fractures recommended basic equipment on ambulances, including splinting devices and proper training for the responder. This committee became the Subcommittee on the Transportation of the Injured in 1949 and continued to call for the transition of the ambulance attendant role from a transporter to a caregiver. 

The growth of the automobile industry and the subsequent highway system underscored the need for organized civilian EMS systems. In fact, military personnel returning from World War II were quick to note that emergency care was often better on a remote battlefield than at an intersection down the street. The COT was pivotal in highlighting the need for organized civilian EMS systems for both the government and public. Members of the COT helped publish “Let Them Lie, A Manual of First Aid for the Motorist” in 1955 to educate the public about the importance of avoiding significant movement of motor vehicle crash victims. In 1956, the ACS COT developed and proposed to the US Congress the concept of an emergency medical care system serving travelers on federal highways. 

In the 1960s, there was no unified way to contact EMS providers, no standards on ambulances or attendant training, and few functioning EMS agencies at that time. As Chair of the COT Subcommittee on Transportation of the Injured (1965−1974) Joseph D. Farrington, MD, FACS,  published “Death in a Ditch” in the June 1967 issue of the Bulletin. This article was one of the first to highlight, on a national level, the training required for ambulance attendants. It also provided the first ambulance equipment list outlining the minimum equipment necessary for emergency vehicles or ambulances.

In 1966, two notable events occurred that started what Dr. Farrington referred to as the “7 Years’ War.” Accidental Death and Disability, the Neglected Disease of Modern Society, published by the National Academy of Sciences National Research Council, assessed the mortality and injury rate among civilians at a time when the number of people killed on the nation’s roadways was near epidemic proportions. This report led to passage of the National Highway Safety Act the same year. 

After 1966, the COT and the Subcommittee on Transportation of the Injured played a key role in changing the face of EMS. The National Highway Safety Act had been enacted without built-in guidelines for the proposed action. A minimal equipment list for ambulances, originally created by Oscar P. Hampton Jr., MD, FACS (COT Chair 1964–1968), in 1961, was revised in 1966, although fewer than one-third of the ambulances were equipped as recommended at that time. To this day, the EMS Committee continues to actively support the revision of the list. 

The Airlie Conference on Emergency Medical Services, a joint venture of the COT and American Academy of Orthopaedic Surgeons (AAOS) Committee on Injuries, occurred in 1969. A total of 53 representatives of American medicine and government participated in this meeting, during which they developed guidelines for ambulance services, personnel and education, and emergency facilities. In 1969, ambulance design criteria were developed, ensuring that care could be rendered to a patient in the back of an ambulance. 

To ensure the ambulance attendant was professionally trained, the COT collaborated with other organizations to develop training criteria. In 1966, the ACS published a pocket manual, Emergency Care of the Sick and Injured. Two years later, the National Academy of Sciences Research Council released Training of Ambulance Personnel and Others Responsible for Emergency Care of the Sick and Injured at the Scene and During Transport: Guidelines and Recommendations.  

In 1971, the AAOS published Emergency Care and Transportation of the Sick and Injured. The textbook was first conceived by Walter A. Hoyt, MD, FACS—father of David B. Hoyt, MD, FACS, COT Chair (1998–2002) and Past-Executive Director of the ACS. Subsequent editions have featured ongoing contributions by members of the COT, and this textbook, now in its 11th edition, remains one of the bestselling EMS textbooks available on the market. Finally, the National Registry of Emergency Medical Technicians was formed in 1970 to unify examinations and certifications of prehospital providers on a national level.

In 1973, the US Congress passed the Emergency Medical Services Systems Act. Managed by the Health Resources and Services Administration (HRSA), this act provided funding for more comprehensive state and local government EMS systems. In 1981, the President of NAEMT asked Norman E. McSwain Jr., MD, FACS, to investigate developing a trauma course based on Advanced Trauma Life Support^® (ATLS^®) principles but focused on prehospital care providers. This course soon became the PHTLS Course. The PHTLS Course was founded on the principle that prehospital care providers could make reasoned decisions regarding patient care when educated on appropriate anatomy and physiology, mechanism of injury, patient assessment, and treatment principles.

After several pilot courses took place in 1983, national promulgation of PHTLS began in 1984 through several regional faculty workshops that trained individuals to administer the course. In 2001, the US Army adopted PHTLS as a standardized program for all Army medics. Undoubtedly, PHTLS has significantly contributed to the improved outcomes of countless trauma patients, and this achievement would have been impossible without the ACS COT’s support.

The goal of trauma care in the field is to establish an airway, treat life-threatening injuries such as hemorrhage, and stabilize fractures, all while maintaining minimal scene times before transport to a trauma center. The COT was pivotal in creating the first field triage guidelines for destination determination of the injured patient in 1976. In 2006, the COT worked with the National Highway Traffic Safety Administration (NHTSA) and the Centers for Disease Control and Prevention (CDC) to support the evidence-based revision of these guidelines along with subsequent revisions in 2009 and 2011. In 2021, with the NHTSA’s support, the EMS Committee led a multidisciplinary technical expert panel, which included feedback from EMS and a comprehensive literature review, in the latest revision of these guidelines (see Figure 1).

Liaison relationships make the EMS Committee unique and offer a specialized ability to both connect and communicate across professional boundaries. These relationships have been a priority since the beginning of committee activities. For example, the EMS Committee was instrumental in the development of the STOP THE BLEED^® program. Beginning in 2013, Eileen M. Bulger, MD, FACS, EMS Committee Chair (2012–2015), convened a multidisciplinary panel to conduct a systematic review of the literature and make recommendations regarding external hemorrhage control for EMS providers. Additionally, ACS COT has partnered with the American College of Emergency Physicians (ACEP), NAEMT, and the National Association of EMS Physicians (NAEMSP), on a series of consensus-based guidance documents. These topics include spinal motion restriction practices, the prehospital use of ketamine, prehospital hemorrhage control, prehospital use of tranexamic acid, and spinal motion restriction (see Table 1). 

EMS will continue to evolve, and the ACS COT will continue to change as well to meet the needs of patients and providers. Gone are the days when the goal of EMS was to reach a trauma center quickly. EMS is now bringing critical care to the patient. EMS has also moved out of the traditional prehospital setting. Community paramedics are treating patients in their homes and assisting in managing chronic conditions. How do we use community paramedicine to care for the trauma patient? Can we keep a trauma patient who may have to travel hours for follow-up appointments at home to be seen by a community paramedic with telemedicine capability? Providers around the world will look to the COT EMS Committee for guidance on answering these questions and more, and we will deliver. Finally, we need to continue to get young trauma surgeons engaged in EMS. It is the young trauma surgeons who will continue the work of the committee and lead the care of the injured patient of any age, across the entire continuum, into the future.

Trauma Systems

The concept of the modern trauma center emerged in the mid-20th century. Indeed, it was not until the 1960s that the approach to caring for injured patients shifted toward a dedicated institutional healthcare focus. The 1966 publication of the National Research Council report, Accidental Death and Disability: The Neglected Disease of Modern Society, is the cornerstone of EMS development and systems of trauma care. The report crystallized key concepts in caring for the injured patient and continues to drive progress in trauma system development. A fundamental concept from this report was that all hospitals are not created equal, and injured patients should be taken to a facility that best meets their needs. This assertion relates to another key concept of trauma care—hospitals do not function in isolation but are part of an interconnected network. This complex includes the prehospital system, the hospitals providing care in the region, and the rehabilitation care needed to get patients back to their preinjury level of function. Taken together, these elements are the components of what we now recognize as a regional trauma system.

After the Accidental Death and Disability report was published, the 1966 Highway Safety Act mandated that all states develop EMS systems and established NHTSA as the federal compliance and oversight authority. Additional legislation supported emergency medical technician training and aeromedical evacuation capabilities. This progressive focus on transport and definitive care facilities was the beginning of the nascent trauma system. The seminal paper, “Systems of Trauma Care: A Study of Two Counties,” published in 1979 in the Archives of Surgery by John G. West, MD, FACS, Donald D. Trunkey, MD, FACS (COT Chair 1982–1986), and Robert C. Lim Jr., MD, FACS, compared outcomes for injured patients in Orange County and San Francisco County, CA, and demonstrated a dramatic reduction in preventable death after injury because of the organized trauma system in San Francisco. These findings led to revolutionary efforts to organize trauma care nationwide.

Figure 1. National Guideline for the Field Triage of Injured Patients

Patients meeting any one of the above RED criteria should be transported to the highest-level trauma center available within the geographic constraints of the regional trauma system.

Patients meeting any one of the YELLOW CRITERIA WHO DO NOT MEET RED CRITERIA should be preferentially transported to a trauma center, as available within the geographic constraints of the regional trauma system (need not be the highest-level trauma center).

Sample of published multiorganizational guidance papers from 2003 to 2020, in which COT EMS Committee either led or participated.

The ACS initially concentrated on refining the concept of a trauma center to focus on care provided at the individual hospital level. The COT’s Optimal Hospital Resources for Care of the Seriously Injured published in 1976 was instrumental in standardizing quality care for the injured. The subsequent revision of this document in 1979, Hospital Resources for Optimal Care of the Injured Patient, shifted focus to further define necessary institutional commitments to provide optimal care to the trauma patient. This document was foundational in creating a trauma center verification program that the Board of Regents approved in 1986, with the first site visit conducted in 1988.

The subsequent expansion of trauma centers in both number and sophistication highlighted the need for parallel development of a systems-based approach to trauma care that extended beyond the reach of a single, high-functioning trauma center. The few high-level trauma centers were a good fit for urban areas but would be impossible to create or sustain in less populated settings. To optimize resource use and improve outcomes, the COT envisioned an inclusive trauma system model in which all health facilities in a region provided care for the injured to the extent of their capacity. 

The first attempt at a formal trauma system evaluation was conducted in Palm Beach, FL, in March 1994 and predated any formal COT committee tasked to evaluate trauma systems. Leading this effort was C. William Schwab, MD, FACS, and a multidisciplinary team. This evaluation system highlighted the need for formally established standards and a formal COT-driven evaluation process. ACS Past-President A. Brent Eastman, MD, FACS (COT Chair, 1990–1994), created a multidisciplinary Working Group for Trauma System Evaluation in 1994, which was charged with developing standards, metrics, and processes for evaluating trauma systems. The Model Trauma Care System Plan, developed in 1992 by the HRSA, served as a template for creating the ACS COT Trauma System Consultation Program, known internally as the “Gray Book.” The consultative service was designed to work cooperatively with regions to facilitate the development of trauma systems based on the inclusive trauma system model.

The Working Group for Trauma System Evaluation became the Ad Hoc Committee on Trauma System Consultation in 1999. That same year, the ad hoc committee conducted the first formal COT-sponsored consultation visit in Montana. This visit was conducted by a multidisciplinary team led by Dr. Eastman that included two ACS Past-Presidents: Ronald V. Maier, MD, FACS, and J. Wayne Meredith, MD, FACS (COT Chair, 2002–2006), among others. The report from this first consultation visit generated more than 150 recommendations for systematic improvements that the Montana system implemented in subsequent years. This was the start of operationalizing Dr. Eastman’s vision for a regionalized trauma system. “Envision me standing before a large map of the US with a dart in my hand and being blindfolded and throwing a dart at the map. It shouldn’t matter where the dart lands, only that somebody injured at the particular geographic location should be expeditiously transported to the level of care commensurate with their injuries,” Dr. Eastman said.

As the second Chair of the Trauma Systems Consultation Committee in 2002, Robert C. Mackersie, MD, FACS, continued to refine and expand the new consultation program. During this time, HRSA updated the Model Trauma Care System Plan, incorporating the CDC’s model of public health and, in 2006, published Model Trauma System Planning and Evaluation, which expanded on the inclusive trauma system concept and added sections on benchmarks, indicators, and scoring (BIS) that provided a means to evaluate trauma systems in various settings and various levels of maturity. The committee’s name was subsequently changed to the Trauma System Evaluation and Planning Committee (TSEPC), and the “Gray Book” was revised under the leadership of Michael F. Rotondo, MD, FACS, who had become the third Chair of TSEPC. Avery B. Nathens, MD, MPH, PhD, FACS, FRCSC, led this effort with 25 contributing authors who published the manual Regional Trauma Systems: Optimal Elements, Integration, and Assessment: The System Consultation Guide in 2008, christened the “White Book,” which continues to serve as the basis for the trauma systems consultation process (see Figure 2).

In the first years of the consultation program, nine consultations had been completed from 1995 to 2005. With a mission to visit all 50 states, Dr. Rotondo completed 14 consultations and two facilitated BIS assessments, including five consultations in both 2008 and 2009—a pace that remains an annual record.

Dr. Rotondo’s tenure coincided with the wars in Iraq and Afghanistan. During these conflicts, the military approach to care of the injured was refined, leading to significant improvements in survival, and for the first time, many surgeons called to duty had experience with civilian trauma systems and the COT. By 2007, the military’s deployed Joint Theater Trauma System (JTTS) was operating at an elevated level, capable of treating combat wounded at forward surgical facilities within 1 hour of injury, with evacuation to high-level care at Landstuhl Regional Medical Center in Germany within 24−72 hours, and to top-level facilities within the US as soon as 72 hours from injury. There were growing concerns this hard-won knowledge would be lost with the eventual end of the large-scale conflicts. In response, TSEPC codified the structure and function of the JTTS within the framework that TSEPC used in civilian trauma systems, resulting in the Joint Trauma System: Development, Conceptual Framework, and Optimal Elements published by the US Army Institute of Surgical Research in 2012 (see Figure 3). This project illustrates the growing partnership between the military and the ACS COT and TSEPC that has characterized the past 20 years. 

Robert Winchell, MD, FACS, became the fourth TSEPC Chair in 2010 and spent his 8-year tenure completing numerous consultation visits and helped to create the initial Needs-Based Assessment of Trauma System (NBATS) tool to provide objective data to support policy decisions in selecting trauma center designations. In 2016, the National Academies of Science, Engineering, and Medicine (NASEM) published A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

This publication brought a renewed focus on trauma systems development in parallel with the military, thereby presenting a new opportunity to seek policy change at the national level and are now a priority for the COT. With the support of NASEM and NHTSA, the COT, under the direction of Ronald M. Stewart, MD, FACS (COT Chair, 2014–2018), convened a broad stakeholder group with the aim to develop specific plans for implementation of the NASEM report findings. A subsequent COT workgroup then developed a set of essential trauma system elements that would define the minimum standards for a framework of trauma care. Today, the guiding document for the consultation process, the White Book, is being revised to align with the new essential elements while retaining the inclusive systems approach and public health roots (see Table 2).

Brian J. Eastridge, MD, FACS, a US Army Reserve surgeon and the original deployed JTTS Trauma System Director, is the fifth and current TSEPC Chair, appointed in 2018. Within 2 years, Dr. Eastridge pushed the number of completed state visitations to 39. The COVID-19 pandemic response highlighted opportunities for TSEPC to not only improve the consultation processes, but also advance the concept of the Regional Medical Operations Center (RMOC). The goal of the RMOC is to strengthen regional care delivery through enhanced coordination and facilitate the most appropriate level of care based on each patient’s acuity for as many individuals as possible, while maintaining patient safety and keeping as many patients as possible within local facilities that can provide quality care. The ability to “load balance” patient care needs across healthcare facilities and systems would prevent any individual facility transitioning to crisis mode. The RMOC bolsters the ongoing groundwork for a national trauma system. 

The core mission of TSEPC remains grounded in its founding tenets, one of which is that hospitals do not function in isolation, but, rather, are part of an interconnected network. The TSEPC consultation program’s future work will be to refine metrics of trauma system performance, research the efficacy of trauma systems, and identify best practices for system implementation while incorporating the newly refined essential elements.

The overarching long-term vision of TSEPC is to develop a National Trauma and Emergency Preparedness System (NTEPS) architecture at the federal level, building upon the 2016 NASEM report, and incorporating the lessons learned during the COVID-19 pandemic (see Table 3). NTEPS will be predicated upon strong leadership at the federal level, operationalizing the recommendations of the report and ongoing advocacy and trauma system leadership from the ACS COT.

Acknowledgments

The authors would like to acknowledge the contributions of Jean Clemency to the content of this article.

Dr. Samuel Wade Ross is the pediatric trauma medical director and assistant professor of surgery, Division of Acute Care Surgery, at the CMC F.H. “Sammy” Ross Jr. Center, Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC. 

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