EDITOR’S NOTE: This is the second in a three-part series.
In trauma medicine, speed to definitive care is often the most important thing in determining whether a victim will live. This concept is known as “the Golden Hour.”
Originally coined in a 1975 article by R. Adams Crowley, founder of Baltimore’s Shock Trauma Institute, the Golden Hour refers to “the first hour after injury,” which may largely determine a critically injured person’s chances of survival.
Suzanne Prentiss, the executive director of the American Trauma Society, a group dedicated to the elimination of needless death and disability from injury, said speed is especially crucial for treating penetrating traumatic injuries, such as bullet wounds. In 2010, researchers at Baylor University Medical Center found that a majority of traumatic injury-related deaths occur almost immediately after the injury. The next most frequent time of death was within four hours of someone being injured. These are known as “early deaths,” and Prentiss said they are the ones that proper trauma care can have a chance of preventing.
“Time is important in any trauma,” Prentiss said. “There are only so many tools you have in the field, and you’ve got to get them to an operating room. You’ve got to get to a place where they can find the source of the bleeding.”
Researchers have linked physical distance from trauma centers with an increase in mortality from gunshot wounds, with studies in Chicago, Detroit and southern Los Angeles.
Dr. Eileen Bulger, who chairs the American College of Surgeons’ Committee on Trauma, a group that aims to help patients get the best care after suffering a traumatic injury, said that although it is impossible to issue a blanket protocol for all patients, it generally makes more sense for shooting victims to be taken to the closest trauma center where surgery can be done, versus the closest hospital.
In Durham, Emergency Medical Services Director Mark Lockhart said the abundance of trauma centers in the area is part of the reason why more shooting victims there survive.
“We’re trauma-center-rich, if you will,” Lockhart said.
Durham County is home to Duke University Hospital, a Level I trauma center, and neighboring Wake and Orange counties also have Level I trauma centers. Shooting victims in Durham County are almost always taken directly to a trauma center, Lockhart said.
On paper, High Point may also be considered an area that’s “trauma-center-rich,” with Winston-Salem’s Wake Forest Baptist Medical Center 20 miles to the northwest, and Greensboro’s Moses H. Cone Memorial Hospital 20 miles to the northeast.
But in High Point, from 2017 to 2019, 14.1%% of shootings in the city were fatal, according to data obtained in a public records request. In Durham and Greensboro, 9.8% of shootings in the same time period were deadly.
From 2017 through 2020, Guilford County EMS took 48 of the 206 shooting victims it treated in High Point to the hospital there. The other victims were taken to Winston-Salem and Greensboro. The data available on these victims didn’t include the severity of each patient’s wounds, only that they were gunshot wounds.
Kyle Paschal, deputy director of Guilford County Emergency Services, said the ambulance crews take shooting victims to the hospital they feel is the best place for the patient’s condition at the moment.
“If there’s an airway compromise that we can’t resolve in the field we would certainly have to take them to the nearest facility because there’s no way they can live through that,” he said.
Often, High Point patients who have been shot need to be transferred to either Wake Forest Baptist Medical Center or Moses H. Cone Memorial Hospital. The entire transfer process usually takes one to one-and-a-half hours, according to interviews with doctors, nurses and flight paramedics in North Carolina.
According to North Carolina’s policies on where emergency medical services should take patients, which are based on CDC recommendations last updated in 2011, trauma patients who are not in extreme shock and are able to breathe on their own are supposed to be taken to the nearest trauma center — even if it is 30 minutes away. However, Dr. Darrell Nelson — an emergency physician at Wake Forest Baptist Medical Center who helps write those policies — said policy should not supplant medical workers’ judgment.
“If you think someone is injured enough that they could die in that 30 minutes, it makes it tough, and I can see how you defer to High Point for stabilization,” Nelson said.
He said High Point’s location about 30 minutes away from two trauma centers puts paramedics in a difficult position.
“Unfortunately, just the position of the city of High Point in relation to trauma centers leaves a lot of gray area because you have to allow for a lot of judgment,” he said.
The North Carolina Department of Health and Human Services, which oversees the N.C. Office of EMS, referred questions about the trauma policy to local EMS departments.
For paramedics treating shooting victims in High Point, Paschal said the destination policy makes it clear which hospital to go to, preventing a clear decision from becoming needlessly complex.
“Is it difficult for those guys to make that decision?” he said. “No. I think they make a lot harder decisions during their shifts.”
Wednesday: High costs are usually cited as the reason for closing a trauma center, as was the case in High Point.
Lee Sanderlin is an investigative reporting fellow at the Columbia University School of Journalism’s Stabile Center for Investigative Journalism. He previously worked as a reporter for The Enterprise.