Through time and attrition, most practicing emergency physicians have not experienced life without EMTALA.

For that matter, I am one of the small number who can add having experienced life without CT scans, ultrasound, procedural sedation, real-time sports scores on the hospital computer, etc. The closest we came to an EMR was static electricity when messing with carbon paper filled multicopy forms. In those days, securing patient transfers could be a Herculean task compared to most situations now.

Side note: Psych transfers seemed to go in reverse in many parts of the country. As for trauma, many of us dealt with no regional trauma systems, or trauma services. I recall those multi-trauma patients transferred to our tertiary center for ortho repair of their fractured femur. The emergency physician provided the “trauma evaluation” and, back in the 80s, got our only available CT study – the head. We might often get the general surgeon on call to consult, but often his anatomical DMZ ended beyond the abdomen.

As the docs who were getting the best overall perspective on the big picture, emergency physs (working with enlightened surgeons) were integral in developing trauma services and regional trauma systems in many parts of the United States.

When one adds in the variable of pregnancy, the old days saw many cases of mis-focused priorities on the pregnancy rather than the trauma. It was not uncommon for a receiving hospital doc to request that the OB in the rural hospital “check out the baby” before you send the mom who had altered LOC and unstable vitals.

I had the privilege of working with a grand team in Oklahoma under the enlightened direction of Dr. John Sacra, an emergency physician and leader in trauma system development. This was a collaborative effort between the Oklahoma Institute for Disaster and Emergency Medicine at the University of Oklahoma Department of Emergency Medicine and the Oklahoma State Department of Health.

The collaboration resulted in the production of: “Interfacility Trauma Triage & Transfer Guidelines – Trauma Reference Manual.”

A major goal was stated in the introduction: “Regionalization of trauma systems in a defined geographical area is essential to provide the highest level of care possible without unnecessary duplication of resources. … Coordination of emergency medical services, hospitals and rehabilitation facilities in a unified approach is imperative.”

A study of the impact of this system has shown favorable survival outcomes.

One of my responsibilities on this project was to look at obstetric patients and apply a concept stated in our introduction: to get the right patient to the right place in the right amount of time.

A companion publication, “Quick Reference Guide,” was produced that allowed key providers and transfer coordinators in Oklahoma’s Trauma Referral Center (TReC) to have an easy to use reference.

The figure at right is the section on Obstetric Patients. Similar Quick Reference Guides were developed for Priority-1 and Priority-2 Adult and Pediatric patients, as well as for patients with burns or single system injuries such as hand, eye, and maxillofacial injuries. I hope this provides a valuable tool to those of you trying to refine your management of injured obstetric patients.

Dr. Roemer is an Adjunct Associate Professor, Department of Emergency Medicine, OU School of Community Medicine, Tulsa, Okla.

Special thanks for his review and contributions to this article go to John C. Sacra, M.D., FACEP, Consultant – Trauma Systems Development, Oklahoma State Department of Health, Chief Medical Officer, Paramedics Plus.

References

1. Sacra J, Goodloe J, Roemer H, et al. Interfacility Trauma Triage & Transfer Guidelines – Trauma Reference Manual. Oklahoma Institute for Disaster and Emergency Medicine and the Oklahoma State Department of Health. 2008.
2. Garwe T, Cowan LD, Neas B, Cathey T, Danford BC, Greenawalt P. Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers. Acad Emerg Med. 2010 Nov;17(11):1223-32. doi: 10.1111/j.1553-2712.2010.00918.x.
3. Sacra J, Goodloe J, Roemer H, et al. Interfacility Trauma Triage & Transfer – Quick reference Guide. Oklahoma Institute for Disaster and Emergency Medicine and the Oklahoma State Department of Health. 2008.