Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ......

Epiphanies in EMS-Trauma – QUALITYKenneth L. Mattox, MD

Baylor

College

Medicine

Ben Taub

Hospital

Baylor-St Lukes

Medical Center

Baylor-St Lukes Medical Center

McNair Campus

EPIPHANIES in

EMS

Emergency Medicine

Trauma

System & Networks

Other InnovationsTrauma

FOUNDATIONS

Governing Principles

How we got here

Agencies, Silos

Resuscitation

ExamplesTrauma

QUALITY

1957-2015

Wonderful

EraOverlaping excitement

Overlapping Advances

CardiacVascular

Trauma

Surgical

Critical

CareImaging

Instruments

Plastics

Devices

EMS/EM1950-

2000s

1960-

2000s

1949-2000s

1980-

2000s

No Disclosures, Except……

General

Surgery

1.

FIRST

A Little Background Example

Vascular

Trauma

Epiphanies

(EMS Surrogate)

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

EMS

1950s-1960s

• No EMS agencies

• Ambulances operated by undertakers

• No standards

• No training

Trauma

EMS – Pre 1975

Emergency Medicine

• Emergency Rooms” – Run by nurses & INTERNS

• All hospital doctors took ER “call”

• No databases, No standards

• No Trauma Centers, etc

• All hospitals assumed to be alike

Trauma

Civilian Vascular Trauma

1950s-1960s

• No Vascular Surgery Boards

• Vascular & General Surgery-SAME

• Very FEW GME sites

• Very Few Hospital Centers of Excellence

• Prosthetic Grafts limited

• Vascular Suture limited

Trauma

Baylor & Vascular Trauma

• 1950s Vascular techniques

• 1960s Peripheral vascular

• 1970s Truncal vascular

• 1980s EMS studies

• 1990s Transvascular tricks

• 2000s Catheter techniques for surgical dummies

Trauma

TODAY

Vascular Injury Challenge

• MAJOR cause of blood loss and death

• “Mystery” of vascular trauma

• Many basic principles no longer taught or understood

• Significant military medicine issues

• Manpower challenges

Trauma

…..but

…..reflecting….

How did we

get here?

Series of Epiphanies

EMS-EM-Trauma

TraumaLine 2000

Years in existence

• Universe - 15 billion

• Solar system-4.6 billion

• Life forms-3.5 billion

• Chordates-500,000

• Small mammals-200 million

TraumaLine 2000

70 MILLION

YEARS

AGO

TraumaLine 2000

CATASTROPHY

45,000 BC

45,000 BC

• Wooly mammoth tooth

• Penetrating trauma

• 27 darts & spears in the

heart region

• Blood on the thorax

8000-4000 BC

• Cities & civilization began

• Warfare occurring

• Metallurgy existed

• Fermentation of alcohol

existed

4000-3000 BC

• Bishop James Ussher

calculated creation took

place 4004 BC

• City of Ur in Sumaria

• World population 85 million

Sumarian Paralyzed Lion

3,000 - 2,000 BC

• Egypt a dynasty-pyramids, wrestling a sport, dogs domesticated, great sphinx, glass beads

• Sumerian flood (Bible & Gilgamesh)

• Cuneiform writing replaces pictographs

• Brick temples with colored pillars in Uruk

• Astronomy in Egypt, India & China

3,000 - 2,000 BC

• Edwin Smith Surgical

Papyrus (written Imhotep

or Iry)

• Sumarians discover

healing qualities of mineral

springs

Epiphany

2600 BC

Imhotep – Early Egypt

2600 BC…

Edwin Smith Surgical Papyrus

Liberal use of PACKS,

CAUSTICS, & SUTURE

To slow & STOP

HEMORRHAGETrauma

Epiphany

1258 AD

Ibn al Nafis

ابن النفيس

-Quote from ibn Nafis-Quote from ibn Nafis

Ibn Nafis (1213-1288 )

• Described PULSE, Coronary

Circulation

• Described 3 stages of Operation

• Described Capillary Circulation

• Described CENTRAL CIRCULATION

350 years before

William Harvey

Pulmonary Circulation

“..the blood from the right chamber of the heart

must arrive at the left chamber but there is no

direct pathway between them. The thick

septum of the heart is not perforated and does

not have visible pores as some people thought

or invisible pores as Galen thought. The blood

from the right chamber must flow through the

vena arteriosa to the lungs, spread through its

substances, be mingles there with air, pass

through the arteria venosa to reach the left

chamber of the heart and there form the

vital spirit..”

Epiphany

1535

Epiphany

1535

Near Pecos, Texas

Cabeza de Vaca

• Traveled throughout Florida,

Texas, New Mexico, & Arizona

• 100 + men & horses reduced to 2

• Worn out cloths, with his aid,

Estafan

• Medical training in addition to

being an explorer

Trauma

Cabeza de Vaca

• He was brought

an Indian

• Old Arrow head

imbedded in

cartilage near

sternum

• Much pain

Trauma

Cabeza de Vaca

Cabeza de Vaca

• With his knife, he removed the

arrowhead

• Rumor states that BLOOD shot over

his shoulder

• He sutured & packed the wound

• Removed the suture the next day

• Operative report in his diary

Trauma

Cabeza de Vaca

• The Indian recovered without pain

• Cabeza de Vaca became a hero

• Indians escorted him to Mexico City

• He returned to Spain & published

his diary

• Symbol of the Texas Surgical

Society

Trauma

Cabeza de Vaca - 1535

• 1st recorded operation in America

• In Texas

• A Trauma Case

• A Thoracic Case

• A Vascular Case

• A Thoracic Trauma Vascular Case

Trauma

Epiphany

1597

Merchant of Venice

1597

written by

William

Shakespeare

Shylock & Jessica Portia

Damage Control

“ ..to stop his wounds,

lest he do bleed to

death.”

Shakespeare, The Merchant of Venice,

Act IV, Scene I

Epiphany

129 Years ago

1884

1894

In June 1894, the French President,

Sadi Carnot assassinated by

Italian anarchist with a stab wound

to the abdomen in Lyon, France.

His ONLY injury-a severed portal

vein. Alexis Carrel intern at Red

Cross & Antiguaille Hospitals

Carrel observed the autopsy

1894

Alexis Carrel

stated,

“There has

to be a

better way.”

1905

In 1905, Carrel at age 31, (11

years later) with Charles C.

Guthrie developed the

technique of “triangulation”

for vascular anastomoses

at the University of Chicago

Alexis

Carrel

1905

Triangulation

1912

In October 1912, (7

years later) at age

38, Carrel awarded

Nobel Prize

There is ALWAYS

a BETTER

WAY

Epiphany

1918-1948

WW I & WW II

WW I (Makins)

• <0.1% Arterial injury among casualties

• Injuries (1202)

– Carotid/Vert 128

– Aorta 5 (all died)

– S.Clav/Axil 153

– Forearm 259

– Iliac 5

– Femoral/tib. 648 23% Amputation

Trauma

WW I (Makins-Sencert)

• Ligation most common treatment

• SUTURE Repair 29 cases

• Suture recommended as “par

excellence” but logistic & time

required, prevented this method

• Data mixes acute injury & delayed

traumatic aneurysms

Trauma

WW II (DeBakey)

• <0.1% Arterial injury among casualties

• Injuries (2471)

– Carotid/Vert 10

– Aorta 3 (2 died)

– S.Clav/Axil 95

– Forearm 1103 26% Amputation

– Iliac 44

– Femoral/tib. 1827 51% Amputation

Trauma

WW II (DeBakey)

• Ligation most common treatment

• Concomitant vein injury studied

• 81 suture repairs (3.3%)

– 36% amputation

• 40 vein grafts (2%)

– 57% amputation

• 14 tube grafts (metal) 50% amputation

Trauma

WW II (DeBakey)

Recommendations (1)

• Temporary stents

–Glass, silver, vitllium,

magnesium

–Also advocated by Jeger in 1913

• Double tube-vein graft proposed

• No statistical advantageTrauma

WW II (DeBakey)

Recommendations (2)

• Anticoagulants

• Fasciotomy

• Refrigeration

• Oxygen Therapy

• Posture

• Sympathectomy & Nerve blocks

Trauma

Epiphany

KLM - Sophmore in High School

Clovis New Mexico

1953

Epiphany X 2

General Biology – Mr. John

Gott

Geometry – Teacher’s name

long forgotten

Trauma

Biology Taxonomy

• Kingdom

–Phylum

• Class

–Order

»Family

-- Genus

---SpeciesTrauma

Classification

Organization

Scientific Method

Evidence Based

Epiphany

Korean War

Dr. Frank Spencer

General Carl Hughes

1953

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Korean War (Hughes)

• Incidence among casualties unknown

• Injuries (304)

– Carotid 11

– Aorta 0

– S.Clav/Axil 23

– Forearm 89

– Iliac 7

– Femoral/tib. 174

Trauma

Korean War (Hughes)

• Treatment (304 arterial injuries)

– Ligation 51% amputation

– End to End 13% amputation

– Vein Graft 11% amputation

– Homograft 33% amputation

– Transverse suture 2.9% amputation

• 64% arterial injuries also had vein

injury

Trauma

There is always

room for

IMPROVEMENT

10 years later

Epiphany

KLM - Junior in Medical School

Baylor College Medicine

1963

Injuries:

Abdominal

Aorta

SMA

IVC

Nov. 1963

Lee Harvey Oswald 1963

KLM Reaction

• Injuries are only blood vessels

• Sewn together every day in the

Texas Medical Center

• It cannot be that difficult

• There has to be a better way to

expose the supra-renal abdominal

aortaTrauma

Epiphany

Major Norman Rich

Viet Nam Vascular Registry

1963

Vietnam War (Rich)

• Injuries (up to 8,000, 1000 reported in

detail)

– Carotid 50

– Aorta 3

– S.Clav/Axil 70

– Forearm 342 34% of total

– Iliac 26

– Femoral/tib. 568 57% of total

Trauma

Vietnam War (Rich)

• Methods of reconstruction

– Vein graft 46%

– End to end 38%

– Lateral repair 9%

– Ligation 1.5%

– Prosthesis 0.4%

– Other 5.1%

• Mortality rate 1.7%

Trauma

Vietnam War

Norman Rich

• Vascular surgery/trauma is here to

stay

• We need more detailed data than

after WW I, WW II, Korean War

• We need a vascular trauma data

bank

• Trauma registries are essentialTrauma

There is always

room for

INNOVATION

Epiphany

0.38 Caliber GSW

Abdominal Aorta – IVC

KLM – PGY 4 GS Resident

8/11/1970

There is always

room for

NEW

APPROACHES

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Epiphany

General (Acute Care)

Surgeons

Multiple Hospitals

1965-1980

Trauma -

Acute Care

SurgeryHistoric Role in Vascular Trauma

There is always

room for

LEADERSHIP

New Vascular Trauma

Leadership

1965-1980

• Provided by EAGER General

Surgeons, frequently residents,

in programs across the United

States (many veterans of RVN)

• Often presented at AAST

J Trauma – 4.2% Vascular papers

Carotid Artery

Trauma

Vertebral Artery

Trauma

Subclavian Artery Injury

Trauma

Innominate Artery

Trauma

By 1980, trauma

surgeons had pretty

much worked out

standard approaches to

vascular trauma

…and outcomes were established

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

Trauma

Epiphany

Vascular Surgery

1995-2014

Retooling their own approaches

Vascular Surgery 2014

• Endovascular Technology

• Little to no Trauma Training

• Often slow to respond to a

night time call

• New approaches

• Increased costs

Trauma

There is always

room for

NEW

TECHNOLOGY

New

Technology

TraumaNOT ROCKET SCIENCE

Capital Perception

Often driven by INDUSTRY

Endovascular Basics

• Access (incision)

• Wires/Catheters (dissection)

• Sheaths (self-retractor)

• Balloons (clamps)

• Stent/Stent Grafts

• Coils/Glue

• IT IS NOT ROCKET SCIENCE

(clamp, cut, sew, tie)

Principle

• Surgical needs should

dictate technology

• Technology should not

DRIVE surgery & medical

practice

Trauma

IRONY

GS ran TO MIS

GS run AWAY FROM

VS

General Surgeons

Laparoscopic Surgery

Minimally Invasive Surgery

• 1970s-1980s

• New Technology

• General (acute care) surgeons

RAPIDLY endorsed technique

• Changed the face of surgery !

Trauma

1990s…+

Meanwhile, new major

wars were waged

…and 6 different data bases were established

Epiphany

Iraq/Afghanistan

Wars

1990-2014

Relearning the Lessons of the PAST

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Iraq/Afghanistan Wars

• FST formation

• JTTC, JTC, Vascular Registry

• Hypotensive resuscitation

• Vascular stents, 1:1:1, others

• In FLIGHT Care – SICU

• Landsthul, Walter Reed, & More

Trauma

Capital Reality

Iraq/Afghanistan Wars

JITR(%) NTDB(%)

Carotid 6.6 7.8

Thor Aorta 0.6 3.6

Innom/SC 1.2 3.0

Ax/Br 27.2 37.1

Abd Ao/iliac 7.2 7.2

Fem/Popliteal 46.7 43.2

Trauma

So…..

Here we are today.

Lots of talk, very little action

Epiphany

Discovery

2012-2013

PRODUCT of frequency harmonics

Vascular Trauma PROBLEMS

Educational & Technical

Changes have caused

PROBLEMSTrauma

Prefect storms produce DISASTERS

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

AND CREATE NEW PROBLEMS

Root Causes

of

Vascular Trauma

DISASTER

Vascular Trauma CRISES

2000’s

• Trainee work hour restrictions

• SOS develop

• Focused practices

• GS/TS/VS tri-trained surgeons disappear

Trauma

Vascular Trauma CRISES

1990s-2000’s

• General Surgery decreases training requirements

• Vascular Surgery = ENDO

• VS GME changes (can go to VS without any GS)

• Decreased trauma for BOTH

Trauma

Vascular Trauma CRISES

General Surgery Trainees 2000’s

• Vascular experience 50% REDUCTION

• Amputations, AV fistulas, AV access

• No vascular - life threatening experience

Trauma

Vascular Trauma CRISES

Vascular Surgery Trainees 2000’s

• Vascular trauma RARE

• Move away from OPEN procedures

• Not comfortable with OPEN neck, chest, abdomen, groin

• Training changing (5-2 to 0-5)

Trauma

Vascular Trauma CRISES

Thoracic Surgery Trainees 2000’s

• NO peripheral vascular surgery

• NO trauma experience

• SOS : Lung, Congenital, CAB, Valves, Aorta, Esophagus

• No endotherapy training

Trauma

Been there.

Seen that data before.

…but they DO bleed to death !

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

Trauma

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

2015

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

TraumaWe can & SHOULD do better

Current Military Vascular

Trauma Challenges

• ONLY 15 Vascular Surgeons in

ALL DOD assignments

(Count them 15 !!! )

• Leading cause of Preventable

death is hemorrhage (vascular

trauma) control & reconstruction

• Fear of vascular trauma by Acute

Care Surgeons in DODTrauma

Current Civilian Vascular

Trauma Challenges

• Limited vascular training

• 80-90% trauma preventable

deaths from HEMORRHAGE

• 80-90% current “trauma”

surgeons are uncomfortable in

managing hemorrhage control

and repairTrauma

REBOA

R - Resuscitation

E – Endovascular

B - Balloon

O – Occlusion

A - AortaTrauma16 hour 2 day course

Discussed and

recommended by

Alex Walt & KLM at

the time of KLM’s

1975 AORTIC trauma

paper to AAST

38 yrs. ago

Just WHAT

is the

PROBLEM ?Contemporary Vascular Trauma

Capability

GAP

• Forgotten or Ignored

lessons of the past

• Overlapping

frequency harmonics

• Neutralizing technical

progress

• Competitive education

agendas

Need for a

NEW

CHANGE

Emergency

Trauma

Acute Care

Surgery

Historic Role in Vascular Trauma

Acute Care Trauma Surgeon

• Roles in VASCULAR TRAUMA:

–Gatekeeper

–Own the field of vascular trauma

–Own the field of all vascular

surgery emergencies

–Take the courses

–Master the technology

• Blood loss to be

markedly reduced

• NO medical

rotation

• Endograft inserted

• Visceral bypass if

necessary

• OTHER innovations

Parable of

the GREAT

SWORD

Great Sword

• Great & Mighty Nation

• Fought great battles with the GREAT

SWORD

– HEAVY, but effective

– Death with ONE blow

• Every warrior used it effectively

• Enemies feared the GREAT SWORD

• Centuries of successful battles

Great Sword

• In the great hall, all warriors sang and

toasted the GREAT SWORD

• The GREAT SWORD hung at the end of

the GREAT HALL

• Legendary songs of the GREAT

SWORD were passed down from

generation to generation

• The legend of the sword struck fear

into all who would dare attack

Great Sword

• While the great nation warriors and

kings sang & drank to the old war

victories from the GREAT SWORD and

grew weak and lazy resting on their

past victories, a new generation of

enemies who knew not of the legend

grew in numbers and strength

Great Sword

• Word came one night that the enemy was

coming to test the great warriors – warriors

whose only knowledge came from passed

down stories of victories

• They rushed to the Great Wall to pull down

the great sword, but it was too heavy for

anyone to lift, much less know how to use

• In trying to lift the sword, it was dropped and

broke into a thousand useless pieces

Broken Heavy Useless

Sword

• A NEW nation was born

• Without a single battle

There is always

room

AT THE TOP

2.

SECOND

PRINICPLES

LEAD AGENCIES

•Government

•Clinical

•Regulatory

3.

THIRD

Processes

PROCESSES

• Education

• Guidelines

• Databases

• Network

• Review-Modify

• Quality– Structure, Process, Outcomes

• Safety– Preventable Harms: Central lines,

Catheters, Retained foreign bodies

• Resource Use/Appropriateness– Use of advanced imaging

– Avoidable procedures

• Patient Experience of Care– CAHPS surveys

– Patient reported outcomes

High Value Health Care

Cause of errors

• Complex processes

• Incomplete information

• Haste, miscommunication

• Inexperience

• Inadequate training

• Infrequent incidence

Performance

• GAP Theory

– “Gaps” in care processes

cause most adverse

events.

– Clinicians constantly

identify and attempt to

bridge these gaps.

• Clinicians make clinical

processes safer.• Cook and Woods

BMJ,2000

Relationship of Performance & Workload

CLINICAL WORKLOAD

C

L

I

N

I

C

A

L

P

E

R

F

O

R

M

A

N

C

E

After Weinger & Englund: Anestesiology 73: 995, 1990

INCREASING

STRESS, FATIGUE

INCREASING

EXPERTISE

Active Failures

Latent Failures

What Aviation Learned

No matter how

advanced the

technological

system, if humans

are involved error

is inevitable

Technology is Not the Complete Answer

• Aviation recognized that 70% of accidents are based on human error in a team setting

• Error results from physiological and psychological limitations of humans– Fatigue– Workload– Cognitive overload– Poor interpersonal

communications– Imperfect information processing– Flawed decision making

Teamwork Training + Systems

Approach• Error is inevitable -

human limitations

• The key to safety is managing error

• Aviation manages error by training specific team & communication behaviors &implementing systems that require those behaviors

• The behaviors and the systems supporting the behaviors is CRM

CRM is…• Crew

– Any team…cockpit, maintenance, ATC, etc...

• Resource

– Other team members, equipment, procedures, systems

• Management

– Specific behavioral skills to lead, communicate, decide and catch errors before they become serious /fatal

Managing the Resources of the Crew

Aviation’s Solution

Technology

Teamwork

Skills

Systems

Software + Hardware

plus

plus

Commercial Aviation is

Extremely Safe and Reliable

• 2002, 2003, 2004 – Zero

deaths for jet airline

operations in the U.S.

• In the last 10 years,153

fatalities in U.S.

• 2 deaths for every 100

million passengers

• safest decade in the

country's aviation history

Why Has CRM Worked in Healthcare?

15 years ago

• 70 – 80% of airline accidents are related to interpersonal communications

(Sexton & Helmreich, 99)

Now

• 70 – 80% of medical mishaps are related to interpersonal interaction

(Williamson et al, 93)

• 66% of Sentinel Events have incomplete communications among care givers as a root cause

(JCAHO Alert – Issue 12)

Comparing the root cause of errors, then and now…

HealthcareAviation

Recommending CRM-based safety

• IOM

– Efficient and effective care requires teams with communication and coordination

• National Academy of Science

– All healthcare professionals should be educated to deliver care as part of a team

• National Patient Safety Foundation

– “…the growing complexity of healthcare demands improved communication and cooperation among healthcare professionals.”

Success In Improving Safety

– Lower mortality numbers

– Reduction in wrong surgeries

– 50% reduction in counts errors (Rivers et al 02)

– 53% reduction in adverse outcomes (Garza 04)

– 55% reduction in observed errors (Garza 04)

– Clinical error rate reductions from 30% to 4.4% (Morey et al, 02)

– Better Staff Satisfaction

– Reduced staff turnover

Surgical Infections and

Prophylactic Antibiotics

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

Infe

cti

on

s/1

00 C

ases

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Class I

Class II

Ab's < 1hr

Deaths with Expected Risk of

Mortality < 10%*

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Jan

Feb Mar

AprM

ay Jun

Jul

Aug Sep Oct

Nov

Dec Ja

nFeb M

arApr

May Ju

nJu

l

Examples of the Tools

in the “Safety Toolkit”

• Pre –briefs – pre-op time outs,

morning huddles

• Checklists – room set-up,

holding room exit, line insertion

protocol, pregnant trauma

treatment flow, diabetes care

• Debriefings – post-procedure,

conflict mediation, teaching

moments

• Standardized communication

formatsHardwire the behaviors into daily operations

“This is just the way we do business.”

DebriefSEE IT - SAY IT - FIX IT !!

Good techniques –

1.Team Leader gather team as soon as possible

2.Team Leader announce the debrief

3.Gather as much of the team as possible

4.Don’t beat a dead horse

5.Record recommendations for process improvement

1. What did we do well ?

2. What do we need to improve ?

3. Did we have everything / everyone we needed ?

Techs -- RNs -- Residents -- Attendings -- Leader last

VUMC (Ver 1.0) Jeff Hill (3-6318)

190

Key Ingredients of Health Care Culture

• Patient centered

• Leadership commitment

• Employee engagement

• Culture of safety

• Transparency

• Performance improvement

Professionalism = Accountability

Vascular Trauma

FINALLY

Machiavelli “The Prince”

“There is nothing more difficult

to take in hand, nor perilous

to conduct, nor more

uncertain in its success than

to take the lead in

introduction in a new (or

RENEWAL) order of things….

Machiavelli “The Prince”

…for the innovator has for enemies, all those who

have done well under the old and lukewarm

defenders those who might do well under the

new.”

Upcoming lectures by

Dr. Mattox

EPIPHANY

1a

TURFS - Grids

EPIPHANY

2.

RESUSCITATION

EPIPHANY

3. LEAD

AGENCIES

EPIPHANY

4. Example

American College of Surgeons

EPIPHANY

Standards

Databases

Quality

Education

EPIPHANY

5. Example

SETRAC

EPIPHANY

Trauma

Pediatrics

STEMI

STROKE

DisastersEPIPHANY

6. Expectations

EMS

Hospitals

EPIPHANY

All Hospitals are NOT the same

EPIPHANY

EMS ERRORS

As perceived by Trauma Centers

EPIPHANY

7. Expectations

Disaster Medical Responses

EPIPHANY

8. Putting it all together

FOR THAILAND

EPIPHANY