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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