Trauma medicine

In medicine, the area of trauma medicine practice principally is concerned with severe multisystem physical injury that can progress into irreversible shock. It encompasses both trauma surgery and trauma critical care. Victims of physical trauma may indeed suffer trauma (psychological), both acute and delayed-onset, but that is not the focus of this article.

The background of physicians who treat trauma varies by countries. In the United States, while it is not a specialty board, many of the leading practitioners are general surgeons who have had fellowship training in trauma. In other countries, it may be considered a collateral duty of general or orthopedic surgeons. Emergency physicians, obviously, are often the initial managers of the trauma patient.

Current concepts

"The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation" - Lord Moynihan

A key aspect of trauma practice is that multiply injured patients die of a "lethal triad" of three interacting factors:

• trauma induced coagulopathy
• hypothermia
• metabolic acidosis

Field medicine

See also: Field medicine

While viewers of television emergency dramas often think of intravenous fluids as the most important paramedic intervention, aggressive fluid resuscitation, in trauma, can kill the patient. The standard of care for most trauma with blood loss is permissive hypotension, where just enough fluid is given to keep oxygen flow to the brain, but deliberately not restoring the systolic blood pressure to normal. A normal systolic blood pressure is high enough to dislodge the clots the body produced to stop bleeding, and start a new cycle of hemorrhage.

As one esteemed trauma surgeon put it, the treatment for trauma-induced hypotension is surgery, not fluids. While TV paramedics may fidget getting more intravenous flow, "scoop and run" is often the best possible treatment. Field personnel indeed should establish intravenous lines since veins may collapse, but not necessarily put any substantial volume through them until the first surgical facility is reached. Animal models, however, show that controlled fluid replacement can improve survival when surgical care is delayed; colloid (i.e., hydroxethyl starch) showed benefit over crystalloid (i.e. Lactated Ringer's).

Before DCS had a theoretical base, it was still practiced — devotees of M*A*S*H would recognize it as "meatball surgery".

Policy, legal and ethical challenges

While their principal responsibility is treatment, trauma specialists are very aware of the potentially preventable causes of trauma and may become involved in education. They also may be key advisers to field medicine on the prehospital care of the trauma patient.

Trauma physicians often see victims of accidents or violence, who are otherwise in good physical condition but have injuries incompatible with life. As such, they are potential organ or tissue donors, and obtaining consent is often stressful for all involved.