Despite huge advances in medicine and technology, trauma care has in many ways remained in the past century. A soldier wounded in Afghanistan will receive the same salt solution that was used in Korea. Military doctors in the field have the same problems storing blood today that plagued doctors decades ago. No one yet knows the best way to treat a head injury, and it is still unclear whether drugs can stem internal hemorrhage.
It's critical that we improve the treatment of trauma--and the key to that improvement
Trauma and Emergency Care Research Is Critically Important to Public Health
Traumatic injury is a major, largely unrecognized public health problem in the United States. Trauma knows no bounds – trauma deaths cut across age, race, gender and economic boundaries.
Each year, trauma accounts for 37 million emergency department visits and 2.6 million hospital admissions and kills three times the number of Americans killed during the entire Vietnam conflict. Injury remains the leading cause of death in the population between the ages of 1 and 44. Trauma is the leading cause of the death of children in this country. Among people 65 years and older, falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma, adding significantly to Medicare costs. Moreover, the combined number of deaths from Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) just reached 5,000, and the number of injuries resulting from these wars exceeds 34,000.
The effect of trauma on productive life years lost exceeds that of any other disease. The economic cost of 50 million injuries in the year 2000, alone, was $406 billion.1 This includes estimates of $80 billion in medical care costs, and $326 billion in productivity losses.
Despite these alarming facts and the recognition that advances in trauma care and trauma care systems can significantly improve survival and function, improving public health and decreasing the associated costs, trauma research is still inadequately funded.2
Research Improves Survival
Since 1981, the first year the HIV epidemic was officially recognized, federal funding for HIV/AIDS research has increased significantly. From FY 1995 to FY 2004, federal HIV/AIDS research funding increased by 97%, from $1.5 billion to $3.0 billon. Funding for prevention ($638 million in FY 1995 to $933 million in FY 2004) significantly heightened public awareness. CDC programs and a brochure titled “Understanding Aids” that went to every residential address in the United States increased basic knowledge about HIV transmission and prevention, reducing risky behavior within populations at risk for infection.
The extraordinary success of the federal HIV research program has resulted in a significant decline in the morbidity and mortality from this disease over the last 10 years.3 NTI anticipates similar success once research funding has been achieved.
Trauma and Emergency Care Research Has Always Been Under-funded
More than 45 years ago a National Research Council (NRC) report, “Accidental Death and Disability,” first focused attention on the inadequacy of emergency and trauma care research.4 Since the publishing of that NRC report, traumatic injury has surpassed heart disease as the most expensive category of medical treatment.
In 1994, the National Institutes of Health (NIH) convened a task force to study the trauma research needs and gaps and produced the “Report of the Task Force on Trauma Research”5. This report recommended doubling funding to trauma research centers, but sufficient funding was never appropriated to carry this out.
For each year of potential life lost (YPLL) NIH gives $16,000 to HIV, $3,000 to breast cancer and less than $200 to trauma.
Funding for the Peer Reviewed Medical Research Program (PRMRP) established in 1999 and managed by the Congressionally Directed Medical Research Program (CDMRP) to promote "research directed toward specific health issues relevant to the military forces" totaled $628 million in Congressional appropriations from 1999 to 2009. While trauma is the number one killer of our fighting soldiers, only 10% of CDMRP funding went to research related to trauma. The bulk of the grant money went to cancer (66%) and other programs, such as chronic illnesses, and infectious diseases (24%).
A 2006 Institute of Medicine Report also discussed the lack of trauma and emergency care research funding and recognized the need for a multi-disciplinary approach7 In recent years, some areas of trauma research (traumatic brain injury, post-traumatic stress disorder, and orthopaedic trauma) have received federal funding. NTI fully supports this funding but more funding is needed to cover the vast majority of trauma-related medical conditions.
Importantly, all of these reports have pointed out the lack of a centralized, organized infrastructure to guide the direction of study and the dispersal of funds.2,4,5,7,8 The National Trauma Institute exists to address this problem and to provide a centralized clearing house for research funding, and for dissemination of research results to the medical community.
The Beneficiaries of Trauma Research are Countless
Millions of civilians and military personnel are affected directly by trauma, and millions more are affected indirectly as loved ones, dependents and caregivers of trauma victims. Injuries from motor vehicle crashes, falls, assault, burns, and other accidents occur every day across the country. Trauma does not discriminate among ages or social groups, and the rates are not declining. The threat is magnified with the potential for unexpected natural and man-made disasters, and terrorist activities.
The Multi-Disciplinary Nature of Trauma and Emergency Care Poses Substantial Research Challenges
Trauma and emergency care research has its foundation in basic laboratory science. But translational research--the process of applying ideas, insights and discoveries generated through basic scientific inquiry to the treatment or prevention of human disease--is the most active area of this discipline.
Trauma is a complex disease that involves direct mechanical injury to tissues as well as systemic disturbances of the entire body. The field of inquiry involves many disciplines and cross-cutting themes. Transport and admission of one patient to a trauma center may involve paramedics; trauma and burn surgeons; trauma nurses; personnel from radiology, blood bank, respiratory therapy, rehabilitation and other ancillary disciplines; along with selected physicians from 16 specialties ranging from neurosurgery to OB/GYN.
Unlike many other areas of medical research, trauma is not strictly defined by organ systems or types of conditions. Rather, it is uniquely defined by the urgency and location of treatment. Trauma research needs to be applied in the acute setting, at the scene of injury (pre-hospital EMS or military medic), at the patient’s bedside in the hospital (ICU, OR), and during recovery and rehabilitation.
Currently targeted urgent subject areas of translational research include: hemorrhage control, resuscitation, coagulation disorders, burn care, elimination of hospital-acquired infections, ventilation management, head injury, and development of technology in all areas of trauma and critical care treatment. Specialty areas for pediatric and geriatric treatment and care exist within all of these research topics. These are areas defined by NTI, but have been pressing research recommendations for almost a decade.9,10
For the greatest impact, research must be based on the establishment of large-scale, multicenter research collaborations. Multicenter networks enable researchers from the diverse disciplines of trauma and emergency care research to assemble sufficiently large data sets to establish robust research findings. This is the most efficient use of funding to provide fast, meaningful results for the improvement of patient care.
At the Intersection of Civilian and Military Practices,
The National Trauma Institute is here To Coordinate Effective Trauma Research
Historically, trauma research was clinically focused on treatment of injury and was strongly influenced by advances in trauma treatment learned from battlefield experiences. Currently in Iraq and Afghanistan, medics, nurses and physicians are using new tourniquets, new wound dressings, new resuscitation techniques, better methods of damage control surgery, and innovative CT scans to save the lives of military personnel and civilians injured in mass casualty events.
NTI, with its connections to both civilian and military trauma researchers and clinicians and their institutions, is the natural starting point to translate these battlefield innovations to civilians at home. No single trauma center admits enough critically injured patients to support the type of randomized, controlled research projects needed to provide substantial support for steady, rapid and significant improvements to medical care.
In addition to fostering connections between military and civilian doctors, NTI also funds diverse multi-center translational trauma trials are required to provide sound, unbiased scientific evidence to change clinical practice. NTI is particularly qualified to oversee and manage trauma research that is comprehensive, community-based and planned for all populations, incorporating the unique needs of children and the elderly.
NTI has experience in establishing data registries and awarding research grants for translational projects, targeting those that will lead to fast, effective outcomes and then disseminating these results to the national medical community within one to three years. NTI has organized and sponsored multiple national investigator and educational meetings.
1Finkelstein, E.A., Corso, P.S., & Miller, T.R. The Incidence and Economic Burden of Injuries in the United States. USA: Oxford University Press. 2006.
2Carrico CJ, Holcomb JB, Chaudry IH. Scientific priorities and strategic planning for resuscitation research and life saving therapy following traumatic injury: report of the PULSE Trauma Work Group. Acad Emerg Med. 2002;9(6):621-626.
3Evolution of HIV/AIDS Prevention Programs--United States, 1981-2006. CDC MMWR Weekly. June 2 2006;55 (21):597-603.
4Committee on Trauma and Committee on Shock, Division of Medical Sciences. Accidental death and disability: the neglected disease of modern society. Washington, DC: National Academy of Sciences, National Research Council.; 1966.
5A Report of the Task Force on Trauma Research. Bethesda, MD. National Institutes of Health; 1994.
6NIH Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC). [Online]. Available: http://report.nih.gov/rcdc/categories/ [accessed June 22, 2009]. 2009.
7Committee on the Future of Emergency Care in the United States Health System, Board on Health Care Services. Hospital-Based Emergency Care: At the Breaking Point. Washington, D.C.: Institute of Medicine of the National Academies; 2006.
8Committee on Injury Prevention and Control, Institute of Medicine. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: National Academy Press; 1999.
9Becker LB, Weisfeldt ML, Weil MH, Budinger T, Carrico J, Kern K, Nichol G, Shechter I, Traystman R, Webb C, Wiedemann H, Wise R, Sopko G. The PULSE initiative: scientific priorities and strategic planning for resuscitation research and life saving therapies. Circulation. 2002;105(21):2562-2570.
10Hoyt DB, Holcomb J, Abraham E, Atkins J, Sopko G. Working Group on Trauma Research Program summary report: National Heart Lung Blood Institute (NHLBI), National Institute of General Medical Sciences (NIGMS), and National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH), and the Department of Defense (DOD). J Trauma. 2004;57(2):410-415.