[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
STRENGTHENING OUR NATIONAL TRAUMA SYSTEM
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
JULY 12, 2016
__________
Serial No. 114-160
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILLY LONG, Missouri JOSEPH P. KENNEDY, III,
RENEE L. ELLMERS, North Carolina Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)
C O N T E N T S
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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 6
Prepared statement........................................... 7
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 8
Hon. Joseph P. Kennedy, III, a Representative in Congress from
the Commonwealth of Massachusetts, prepared statement.......... 91
Witnesses
Jorie Klein, BSN, RN, Director, Trauma Program, Rees-Jones Trauma
Center at Parkland............................................. 10
Prepared statement........................................... 12
David Marcozzi, MD, University of Maryland Department of
Emergency Medicine............................................. 23
Prepared statement........................................... 26
C. William Schwab, MD, FACS, Professor of Surgery, Penn
Presbyterian Medical Center.................................... 32
Prepared statement........................................... 34
Craig Manifold, DO, FACEP, Committee Chair, American College of
Emergency Physicians........................................... 46
Prepared statement........................................... 48
Answers to submitted questions \1\........................... 103
J. Brent Myers, MD, MPH, FACEP, President-Elect, National
Association of EMS Physicians.................................. 58
Prepared statement........................................... 60
Answers to submitted questions \2\........................... 106
Submitted Material
Statement of the American College of Surgeons, submitted my Mr.
Pitts.......................................................... 92
Statement of America's Essential Hospitals, submitted my Mr.
Pitts.......................................................... 98
Statement of the American Hospital Association, submitted my Mr.
Pitts.......................................................... 101
----------
\1\ Mr. Manifold did not respond to questions for the record.
\2\ Mr. Myers did not respond to questions for the record.
STRENGTHENING OUR NATIONAL TRAUMA SYSTEM
----------
TUESDAY, JULY 12, 2016
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m., in
room 2322 Rayburn House Office Building, Hon. Joe Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Guthrie, Shimkus,
Murphy, Burgess, Blackburn, Lance, Griffith, Bilirakis, Long,
Ellmers, Bucshon, Brooks, Collins, Upton (ex officio), Green,
Engel, Butterfield, Castor, Sarbanes, Matsui, Schrader,
Kennedy, Cardenas, and Pallone (ex officio).
Staff present: Rebecca Card, Assistant Press Secretary;
Paul Edattel, Chief Counsel, Health; Bob Mabry, Fellow, Health;
Graham Pittman, Legislative Clerk; Adrianna Simonelli,
Professional Staff Member; Heidi Stirrup, Health Policy
Coordinator; Sophie Trainor, Policy Coordinator; Jeff Carroll,
Minority Staff Director; Waverly Gordon, Minority Professional
Staff Member; Tiffany Guarascio, Minority Deputy Staff Director
and Chief Health Advisor; Samantha Satchell, Minority Policy
Analyst; Kimberlee Trzeciak, Minority Health Policy Advisor;
Megan Velez, Minority FDA Detailee; and C.J. Young, Minority
Press Secretary.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. The time of 10 o'clock having arrived, the
subcommittee will come to order. I ask unanimous consent to
recognize and allow our colleague, Representative Rick Hudson,
who's on the full committee, to waive onto the Health
Subcommittee for today's hearing. Without objection, so
ordered.
I recognize myself for an opening statement. Today's
hearing is an important discussion that will examine the areas
where we can improve our national trauma system and the care
provided by emergency responders.
The recent events in Orlando, Paris and San Bernardino
remind us of the very real threat of mass casualty events that
can produce large numbers of traumatically injured casualties.
Terrorism, criminal violence and road traffic accidents all
produce traumatic injuries which is the leading cause of death
for those under age 46. Because it disproportionately affects
young people, trauma is the number-one cause of productive life
years lost, greater than cancer or heart disease.
A recent Institute of Medicine report released just last
week estimates that one in five trauma deaths may be
preventable or, in other words, about 30,000 people might be
saved every year if your nation's trauma system is better
optimized today.
We'll hear from witnesses on ways to address our trauma and
emergency medical systems. First we will hear from three
authors of IOM report entitled ``A National Trauma Care System
Integrating Military and Civilian Trauma Care to Achieve Zero
Preventable Deaths After Injury.''
They will discuss a number of recommendations included in
the report aimed at improving trauma care. Our other two
witnesses will discuss legislation introduced by Congressman
Richard Hudson designed to ensure our first responders have
access to critical medications needed to treat emergency
conditions in the field.
One of our main challenges in addressing emergency and
trauma care is leadership. Responsibility for planning,
coordination, communications, and response are divided across
multiple agencies and jurisdictions.
The axiom when everyone is responsible no one is
responsible applies. Leadership at the federal level is
required to achieve coordination and ultimate accountability.
While strong national leadership is needed, we must also
bolster those on the front lines at the local level. Here we
can look to the military's incredible advances in trauma care
over more than a decade of war.
Lessons learned during war time often drive innovation in
civilian trauma care. This is not surprising, as many
experienced combat medical personnel often leave the military
and go into civilian practice during peace time. Outside of war
our military trauma teams have few opportunities to care for
severely injured patients at their base hospitals. The IOM
proposes integrating military trauma teams into busy civilian
trauma centers in order to improve not only military trauma
care but civilian trauma care.
I look forward to the discussion and encourage the
thoughtful dialogue about these critical issues. I look forward
to hearing our witnesses today and yield the balance of my time
to Dr. Burgess.
[The prepared statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The Subcommittee will come to order.
The Chairman will recognize himself for an opening
statement.
Today's hearing is an important discussion that will
examine areas where we can improve our national trauma system
and the care provided by emergency responders.
The recent events in Orlando, Paris and San Bernardino
remind us of the very real threat of such mass casualty events
that can produce large numbers of traumatically injured
casualties.
Terrorism, criminal violence, and road traffic accidents
all produce traumatic injuries, which is the leading cause of
death for those under age 46. Because it disproportionally
affects young people, trauma is the number one cause of
productive life years lost, greater than cancer or heart
disease.
A recent Institute of Medicine report released just last
week estimates that one in five trauma deaths may be
preventable. Or, in other words, about 30,000 people might be
saved every year if our Nation's trauma system is better
optimized.
Today we will hear from witnesses on ways to address our
trauma and emergency medical systems. First, we will hear from
three authors of the IOM report entitled, ``A national trauma
care system: Integrating military and civilian trauma care to
achieve zero preventable deaths after injury.'' They will
discuss a number of recommendations included in the report
aimed at improving trauma care.
Our other two witnesses will discuss legislation introduced
by Congressman Richard Hudson designed to ensure our first
responders have access to critical medications needed to treat
emergency conditions in the field.
One of our main challenges in addressing emergency and
trauma care is leadership. Responsibility for planning,
coordination, communication, and response are divided across
multiple agencies and jurisdictions. The axiom ``when everyone
is responsible, no one is responsible'' applies. Leadership at
the federal level is required to achieve coordination and
ultimate accountability.
While strong national leadership is needed, we must also
bolster those on the front lines at the local level. Here we
can look to the military's incredible advances in trauma care
over more than a decade of war. Lessons learned during wartime
often drive innovation in civilian trauma care.
This is not surprising as many experienced combat medical
personnel often leave the military and go into civilian
practice during peacetime. Outside of war, our military trauma
teams have few opportunities to care for severely injured
patients at their base hospitals. The IOM proposes integrating
military trauma teams into busy civilian trauma centers in
order to improve not only military trauma care but civilian
trauma care.
I look forward to the discussion and encourage a thoughtful
dialogue about these critical issues.
I yield the balance of my time to ------------.
Mr. Burgess. Thank you, Mr. Chairman. I appreciate your
yielding.
I'm glad we're doing this today. It's timely, given the
events of last Thursday and Friday. The nation was riveted upon
the emergency rooms at Parkland, at Baylor Hospital and the
country stands in awe of the service that was rendered to
fallen police officers during that sad interval in our nation's
history.
I do want to recognize and thank Dr. Robert Mabry, the
Health Subcommittee's Robert Wood Johnson Fellow, for the work
he has done in this area and certainly for his service to the
country.
As a lieutenant colonel in the Army and an emergency room
physician Dr. Mabry brought a lot of expertise to bear for this
subcommittee on this issue particularly.
Mr. Chairman, as you mentioned, we have recently received
the National Academy's report and it identifies a unique
opportunity to improve the state of trauma care for Americans
at home and in combat. A partnership between our military and
civilian health systems could bolster the availability of an
expert work force in two ways, first by integrating military
providers into civilian systems and second, military providers
would be able to continue practicing and maintain their skill
levels between deployments.
The Military, Civilian, and Mass Casualty Trauma Readiness
Partnership Act would facilitate this partnership through grant
program which would allow us to examine how federal support of
such partnerships could strengthen our trauma capabilities.
This bill has the potential to save American lives here at
home as well as abroad. Again, I want to thank all of our
witnesses for being here today. This is an important topic, one
that, again, unfortunately, because of recent events in Dallas,
Texas we've seen just how critical your service is to the
country.
Mr. Chairman, I will yield back.
I yield to Mr. Hudson.
Mr. Hudson. I thank the gentleman and thank you, Mr.
Chairman, for holding this very important hearing and allowing
me to join in today.
Regarding our first panel, I know firsthand the experience
and expertise of our military trauma teams. So I want to thank
my colleagues, Dr. Burgess and Dr. Bob Mabry, Army physician,
along with the committee for their work and expertise on this
important legislation.
I am also excited to hear from our second panel today as
this is an issue I have personally been invested in for over a
year. I want to ask everyone to imagine for a moment that a
loved one has been injured or the excruciating pain with the
responding EMS personnel trained to treat them are helpless to
do anything about their pain. Under current law, this could
become a reality.
Congressional action is needed immediately and that's why I
authored the bipartisan Protection Patients' Access to
Emergency Medications Act with my colleague, Mr. G.K.
Butterfield, to clarify existing law so EMS personnel can
continue to administer lifesaving medications to patients.
This is vital for our patients and EMS personnel in North
Carolina and across the United States. I want to thank you,
Chairman Pitts, for your leadership and holding this important
hearing.
I want to thank Mr. Butterfield for his partnership and I
want to underscore the importance of this being a bipartisan
measure. There's a lot of issues here that become very highly
partisanized. But this is one that doesn't have to be and it
hasn't been because of the strong work of Mr. Butterfield and
others working with me. And I want to thank all of my
colleagues for this opportunity today and look forward to
working to move this legislation into law.
Thank you, Mr. Chairman. I yield back.
Mr. Pitts. Chair thanks the gentleman. I now recognize the
ranking member of the subcommittee, Mr. Green, 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. And we're here today to
examine two distinct but important ideas. The first is H.R.
4365, the Protecting Patient Access to Emergency Medications
Act is authored by our colleagues on the committee,
Representatives Butterfield and Hudson from North Carolina.
This legislation would clarify the oversight of care
provided by emergency medical services practitioners through
standing orders. Standing orders allow physicians and medical
directors to establish preset protocols for EMS practitioners
to follow when delivering emergency care on the ground.
They are especially important in the administration and
delivery of controlled substances in emergency situations when
time is of the essence.
The second proposal is a discussion draft to authorize a
tiered grant program to civilian trauma centers that are
engaged in military-civilian partnerships. This proposed bill
will also require a study on how trauma care is reimbursed.
Last month, the National Academies of Science, Engineering
and Medicine--NASEM for short--released a report entitled ``A
National Trauma Care System Integrated Military and Civilian
System to achieve Zero Preventable Deaths After Injury.''
Trauma injury is the leading cause of death of those under
age 46 and it is the third leading cause of death overall.
Trauma has definitive causes which establish method of
treatment and prevention.
Frequent forms of trauma include motor vehicle accidents,
gunshot wounds, and falls. Traumas also result with large-scale
manmade or natural disasters, too many of which we have seen
recently and will continue to experience regardless of the best
prevention efforts.
Survival among severely injured patients requires
specialist care delivered promptly and in a coordinated manner.
Care begins at the scene of injury, continues to the emergency
department and on to the hospital operating room and on to the
hospital operating room and intensive care unit.
This is true in both civilian and military context. Also
true is the optimal response and care depends on advanced
planning, preparation and coordination to produce smooth
transitions and the proper sequence of interventions. Trauma
care systems are the backbone of preparedness.
Unfortunately, despite clear evidence of its value in war
zones and here at home, one in seven Americans, 45 million
people, lack access within one hour, known as the golden hour,
to a trauma center able to treat their severe injuries.
The NACEM report states that the military has made
significant strides over the past decade in improving trauma
care based on lessons learned during wartime.
And Mr. Chairman, years ago when we were heavily involved
in Iraq and Afghanistan our committee, Health Subcommittee,
went to Baghdad, Balad and in Afghanistan to see the
coordination between what they do and the success they were
having.
And at one time in the Houston area we--at our Level 1
trauma centers at Memorial Hermann and Ben Taub they trained
our military physicians because on a Friday or Saturday night
you would see things in there that you would see in a war time.
But after Iraq and Afghanistan now we need to work together
because I was so impressed. I would see a hurt soldier come in
and have the many disciplines working on that soldier at very
primitive conditions compared to what we have in our
communities.
But I think there's a lot we can learn from the military.
There are nearly 30,000 preventable fatalities for trauma
injury every year that could have been avoided if optimal care
was provided through coordinated trauma care's system.
The NACEM envisions a national trauma care system and
allows the continuous and seamless exchange of knowledge across
military and civilian health care sectors. This would better
provide optimal delivery of trauma care to save the lives of
Americans injured in the United States or on the battlefield.
Improving our national trauma care system is an issue that
I've championed for years with my colleague and fellow Texan,
Representative Mike Burgess. We worked to shore up our trauma
centers, expand access to care and improve the regionalization
of our nation's trauma systems.
On a bipartisan basis we worked to enact and sustain
federal trauma programs that enhance access to trauma care for
all Americans. We currently have two bills to strengthen the
future availability of trauma care which the House of
Representatives passed 9 months ago and are awaiting action in
the Senate.
I am encouraged by this subcommittee's attention to such an
important and overlooked issue and appreciate our witnesses for
their thoughtful testimony today.
I look forward to hearing more about the proposed
legislation and our continued work to improve trauma care both
for our men and women in combat and civilians and veterans here
at home.
We must ensure that the proper systems and sites of care
are in a place to provide timely lifesaving care to all injured
Americans. As we grapple with how to best support our men and
women in uniform and respond to tragedies at home we cannot
assume that trauma care will miraculously be there.
It's the responsibility of Congress to make certain that
the right care is available at the right time and we can make
the most impact over the difference between life and death.
And again, Mr. Chairman, I thank you for calling this
hearing. I yield back.
Mr. Pitts. Chair thanks the gentleman.
I'll now recognize the chair of the full committee, Mr.
Upton, 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr, Upton. Well, thank you, Mr. Chairman.
Trauma causes such tremendous economic and human costs in
Michigan and every state across the country. New National
Academy of Medicine, NAM report, underscores that we need to do
more and this report cites nearly 30,000 preventable civilian
deaths per year due to trauma. Not overseas in distant war-torn
land but here at home in the U.S.
NAM points to a number gaps in our national trauma system,
including the inconsistency in trauma care quality over time
and in specific geographic areas.
They also found a diffusion of responsibility across
agencies of the government. Additionally, they found
significant gaps in our ability to exchange knowledge and best
practices, the result of which is significant variation in
trauma care deliver which in turn, of course, leads to
unnecessary suffering and lives lost.
The NAM report puts forth several recommendations on how to
move forward including improving the leadership of trauma care,
integrating military and civilian trauma data system best
practices and research, reducing regulatory barriers and, of
course, improving trauma care quality processes.
Today, we're going to hear from two emergency medical
service physician medical directors. The practice of medicine
in a pre-hospital environment is very unique and is a key part
of our health care system.
Our EMS folks, physicians, paramedics, other first
responders are the front line of our emergency medical and
trauma care system. They got to have the tools, training and
support to rapidly stabilize and treat a variety of emergency
conditions 24/7 in every community across the country.
These EMS physicians will discuss the implication of H.R.
4365, the Protecting Patient Access to Emergency Medications
Act of 2016 introduced by Mr. Hudson, to ensure first
responders have critical emergency medications needed to treat
a variety of emergency and life-threatening conditions.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
Trauma causes tremendous economic and human costs to
Michigan and our nation. A new National Academy of Medicine
(NAM) report underscores we need to do more. This report cites
nearly 30,000 preventable civilian deaths per year due to
trauma--not overseas in a distant war torn land--but here at
home in the United States.
The NAM points to a number of gaps in our national trauma
system, including the inconsistency in trauma care quality over
time and in specific geographic areas. They also found a
diffusion of responsibly across agencies of the government.
Additionally, they found significant gaps in our ability to
exchange knowledge and best practices, the result of which is
significant variation in trauma care delivery which in turn
leads to unnecessary suffering and lives lost.
The NAM puts forth several recommendations on how to move
forward, including: improving the leadership of trauma care;
for integrating military and civilian trauma data systems, best
practices and research; reducing regulatory barriers; and
improving trauma care quality processes.
Today we will also hear from two emergency medical services
physician medical directors. The practice of medicine in
prehospital environment is very unique and is key part of our
healthcare system. Our EMS physicians, paramedics and other
first responders are the front line of our emergency medical
and trauma care system. They must have the tools, training and
support to rapidly stabilize and treat a variety of emergency
conditions 24 hours per day in every community in the US. These
EMS physicians will discuss the implications of HR 4365, the
Protecting Patient Access to Emergency Medications Act of 2016,
introduced by Mr. Hudson to ensure first responders have
critical emergency medications needed to treat a variety of
emergency and life-threatening conditions.
I would like to thank the witness for coming here today and
look forward to their testimony.
Mr, Upton. I yield the balance of my time to Mrs.
Blackburn.
Mrs. Blackburn. Thank you, Mr. Chairman. Welcome to our
witnesses. We are pleased that you are here.
I represent Fort Campbell and also right outside of my
district is the Vanderbilt University Medical Center and I want
to tell you I am so pleased that Mr. Hudson has brought the
bill forward and that we are having the hearing today and
talking about the report from the academies.
I think this is very appropriate for us to do. Taking down
the barriers between the military and civilian healthcare, the
exchange of information, looking for how best to make the
appropriate response is something that is timely.
I think that it is also needed and looking at the delivery
model and optimal delivery. Important for us to have this
discussion.
So Mr. Chairman, I thank you for the time and with that I
yield back.
Mr. Pitts. Chair thanks the gentlelady. I now recognize the
ranking member of the full committee, Mr. Pallone, 5 minutes
for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
Whether it's a gruesome sports injury or an injury from an
accident on the interstate or a gunshot wound, we depend on our
trauma care system to provide the services necessary to save
lives and prevent disability.
In the case of an emergency no one should be forced to
wonder whether quality services will be available and we're
fortunate to have access to some of the best trauma care in the
world, ensuring access to quality trauma care based on the best
available evidence.
However, there are gaps in our current system and
unfortunately sometimes the determination of whether a person
survives or dies depends on if the injury occurs near a good
trauma center and I think we'd all agree that this is
unacceptable.
All of our trauma services should be world class and that's
why I'm eager to hear today about recommendations from the
recent report that aimed to strengthened our trauma systems to
ensure that patients get the services they need when a health
emergency arises.
In particular, one of the recommendations which is the
subject of draft legislation being examined today encourages
the development of military and civilian partnership by placing
military trauma teams and personnel in civilian trauma care
centers and I look forward to hearing more from our witnesses
about the legislation's impact on our trauma care system.
In addition to ensuring the availability of trauma care
services we must also make certain that providers have the
flexibility they need under federal law to treat patients in
emergencies. Another topic of discussion today is H.R. 4365,
the Protecting Patient Access to Emergency Medications Act.
This bill would amend the Controlled Substances Act to clarify
that emergency service personnel can administer controlled
substances under a standing order from a physician, medical
director who oversees emergency care.
I understand this would codify what is current practice and
ensure that patients have ready access to important and often
lifesaving drugs in emergency situation.
This bill would also streamline the emergency medical
services registration process and would also hold the MS
agencies responsible for receiving, storing and tracking
controlled substances.
While I support the intent of this legislation I understand
the drug enforcement agency wasn't to ensure the proper
safeguards are in place under this framework to limit the
potential for diversion or misuse.
And so again, I look forward to hearing more from our
witnesses today about how EMS agencies can and will ensure a
appropriate regulatory safeguards are in place to prevent
diversion of controlled substances and I look forward to
continuing to work with my colleagues and the sponsors, the DEA
and stakeholders, to address these issues.
Mr. Chairman, these are critically important issues. I'm
glad our committee continues its track record of working to
improve the public health care system to better serve our
communities and protect patients, and I yield the remainder of
my time to Mr. Butterfield.
Mr. Butterfield. Thank you very much, Mr. Pallone, for
yielding time and thank you, Mr. Chairman, for convening this
hearing today on strengthening our national trauma system.
This is a subject that we all care so deeply about and I
know our five witnesses today feel very strongly about this
issue and so thank you for the hearing and I thank the five of
you for your willingness to testify.
Mr. Chairman, trauma can occur in many forms from
concussions or burns to injuries on the athletic field or even
highway accidents. Pediatric trauma is the most frequent killer
of children in our country.
Trauma does not need to lead to death or even permanent
disability. By providing access to trauma care within what is
known as the golden hour or the time immediately following the
injury and I'm sure our guests will talk about that today, we
can dramatically reduce those threats.
Of approximately 1,200 hospitals in the country, only about
one out of every five hospitals are designated for trauma. Even
fewer are equipped to handle the challenges of pediatric trauma
care.
And so in May, Congressman Richard Hudson, my dear friend
and colleague that usually sits on the other side of the aisle
but today he's on my side of the aisle--I don't know if that's
an omen, Mr. Upton--Mr. Upton has left. But thank you for
sitting with us today, Richard.
But in May, Richard and I launched the Pediatric Trauma
Caucus to work to ensure that the U.S. trauma care network has
the appropriately trained workforce, resources and evidence-
based practices to meet the challenges of pediatric care. And
so I'm pleased today that we are considering 4365. This
bipartisan bill clarifies existing law so that EMS personnel
under the supervision of a physician can administer lifesaving
medication to patients in their care.
This legislation ensures EMS personnel have the necessary
tools to help victims of traumatic events receive medically
appropriate treatments before arriving at the hospital.
In rural communities such as mine and congested urban areas
alike, such as Dr. Myers, hospitals and clinics can be
difficult to access and in many cases the administration of
treatments can prevent death or permanent disability.
So I thank you. I look forward to the hearing. I yield
back.
Mr. Pitts. Chair thanks the gentleman. That concludes the
opening statements verbal. All written opening statements of
members will be made a part of the record.
I have a UC request. I'd like to submit the following
documents for the record: statements from the American College
of Surgeons; America's Essential Hospitals; and the American
Hospital Association.
Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
We have one panel of witnesses today. I'll introduce them
in the order of their presentation. We'll start with Ms. Jorie
Klein, director, trauma program, Rees-Jones Trauma Center at
Parkland.
Then Dr. David Marcozzi, University of Maryland, Department
of Emergency Medicine, Dr. Bill Schwab, professor of surgery,
Penn Presbyterian Medical Center, Dr. Craig Manifold, committee
chair, American College of Emergency Physicians. Finally, Dr.
Brent Myers, president elect of the National Association of EMS
Physicians.
Thank you for coming today. Your written testimony will be
placed in the record. You'll each be given 5 minutes to
summarize your testimony. And so at this time the chair
recognizes Ms. Klein 5 minutes for her summary.
STATEMENTS OF JORIE KLEIN, BSN, RN, DIRECTOR, TRAUMA PROGRAM,
REES-JONES TRAUMA CENTER AT PARKLAND; DAVID MARCOZZI, MD,
UNIVERSITY OF MARYLAND DEPARTMENT OF EMERGENCY MEDICINE; C.
WILLIAM SCHWAB, MD, FACS, PROFESSOR OF SURGERY, PENN
PRESBYTERIAN MEDICAL CENTER; CRAIG MANIFOLD, DO, FACEP,
COMMITTEE CHAIR, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS; AND
J. BRENT MYERS, MD, MPH, FACEP, PRESIDENT-ELECT, NATIONAL
ASSOCIATION OF EMS PHYSICIANS
STATEMENT OF JORIE KLEIN
Ms. Klein. Mr. Chair, Ranking Members Pallone and Member
Green, thank you very much for the opportunity to be here with
you. I am a trauma nurse. I am the director of the trauma
program at Parkland Hospital and I also am chair of the State
Trauma Systems Committee.
It is my privilege to participate in the National Academy
of Science Committee that has brought forward this report. I
would like to also recognize Dr. Burgess, who I have trained at
Parkland Hospital and is very familiar with our environment.
So when we talk about trauma we often talk about it as the
neglected disease and that is not a term that's new to us.
Actually, R.A. Cowley from the shock trauma center introduced
that term back in 1966. The sad thing is that those terms and
many of the things that were pointed out in that report 50
years ago are still true today. You heard about the stats. Many
of you read them.
I'll just give you some stats from my state. Our state
reported 121,000 injuries in our trauma registry last year.
This year so far from January my trauma center has evaluated
4,322 trauma patients. When we talk about those patients they
all need quick response care.
So what we would like to do is have you consider our
report, look at the federal investment in trauma care. If you
look at the number of individuals that are dying from trauma
care and you look at the number of dollars that are
appropriated for trauma care, trauma advances, trauma research
you will find that there is a disparity there.
So, again, we're asking you to reconsider some of that or
help us move forward with that. The key concepts of the
National Academy Report, again our committee called for
developing a national trauma system and that national system
includes integration of the civilian as well as the military,
which includes all aspects from the prehospital to the acute
care, inside the hospital for stabilization as well as research
in prevent activities.
I'm here today also representing the Trauma Center
Association of America which strongly supports the bill that's
being produced--the grant programs being developed that will
actually create an opportunity for military teams to be inside
the trauma centers. And, again, this could be very, very
helpful.
Many of the trauma centers, again, are growing. Our trauma
center last month had a 35 percent increase in our number of
trauma patients and, unfortunately, nothing else in the system
increased 35 percent. I don't have 35 percent more nurses,
dollars, or resources to manage those patients.
So some of the points, again, embedding the military teams
as they would be fully integrated into the team and they would
learn to work as a team. If you don't know how to work as a
team in trauma you set the patients up for risk and that is one
of the most critical things that we see.
One of the other things that the report called for is a
study. If you look at the deaths that were produced from the
reports from the military as well as civilian, there are
preventable deaths and when we talked about preventable deaths
we're talking about after the injury occurred. And so we would
like to see research and funding to address that and to create
a nation that has zero preventable deaths.
Again, appropriate funding would help support that and a
national place to call home for trauma. We need a trauma center
cost study that includes an opportunity to look at different
billing systems. The billing system that we currently have and
things that we can bill for trauma, for example, if the patient
arrives by ambulance you can bill for it. If the patient is
transferred you can bill your trauma activation fee. On
Thursday night, several of those patients arrive to our trauma
center in the police car, which means we cannot bill for some
of the most critical patients that we have cared for and that
means the bill falls back to other resources.
So we must establish a national research action plan again
to look at these deaths, to look at our system and to create
systems that every echelon of care there's appropriate handoff
and knowledge and the receiving provider knows and is competent
how to manage a trauma patient.
So in conclusion, I would like to say thank you for the
opportunity to be here with you and, again, I would like to
engage any other further discussion that you might have
regarding these proposed bills.
Thank you.
[The statement of Ms. Klein follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Chair thanks the gentlelady and now recognizes
Dr. Marcozzi 5 minutes for his summary.
STATEMENT OF DAVID MARCOZZI
Dr. Marcozzi. Good morning, Chairman Pitts, Ranking Member
Green and members of the subcommittee.
I'm honored to have served on the committee that we're
discussing here to release the report on trauma care. The
committee is part of the National Academies of Sciences
chartered by the Congress in 1863 to advise the government on
matters of science technology. Thank you for your invitation to
testify today. It was an honor to serve on this prestigious
committee under the leadership of Dr. Don Berwick. I want to
begin my remarks by pausing to remember those who lost their
lives during the recent tragedies in Dallas, in Orlando, and
thank those who answered the call to respond to those crises.
My sympathies go out to those affected by these and all
tragedies due to trauma. Additionally, I want to recognize a
legendary trauma surgeon and committee member from New Orleans,
Dr. Norm McSwain, who passed away during the drafting of our
report. His death was a great loss. Finally, I want to thank
the sponsors of this work, the Department of Defense, the
Department of Homeland Security, importantly, for its
supporting a comprehensive deliverable aimed at improving our
nation's approach to trauma care.
One could say I've worked on both sides of multiple aisles.
Within the legislative and executive branches of government,
under Republican and Democratic administrations as a policy
maker and practising physician and finally working within the
military and civilian sectors. It is these experiences that
help shape my remarks today.
Right now, regardless of time, age of payer, emergency and
trauma systems across our nation are diagnosing and treating
those who are ill, injured, or depressed. Those two health
delivery systems are inextricably linked. That care has an
impact on their community and the populations they serve.
Appreciating this, I reflect on a prior hearing by the House
Oversight and Government Reform Committee on June 22nd, 2007.
This committee hearing was in response to a 2006 Institute of
Medicine report that released their reports on the state of our
nation's emergency care. Dr. Schwab likely remembers that well
as he was one of the presenters there testifying that day. At
that time, Ranking Member Tom Davis commented, ``Emergency
critical care services are in critical condition.'' He went on.
``Such a fragile, fragmented system holds virtually no surge
capacity in the event of a natural disaster or terrorist
event.''
Representative Cummings, who chaired that meeting, further
remarked, ``After providing a thorough overview of the
challenges facing our nation's emergency care system, the time
for action is long overdue.''
Our nation's trauma care systems are a vital component of
both our nation's health delivery system and our nation's
resilience. As the leading cause of death under those at the
age of 46, preventing injury is certainly an optimal strategy.
But unfortunately, people still fall or are involved in motor
vehicle accidents, get assaulted, are shot or are stabbed.
In addition to those unfortunate daily occurrences of
traumatic injury, recent events and remarks by CA Director
Brennan and Secretary of Department of Homeland Security
Johnson, strongly compel us to assure that our nation's
emergency and trauma systems also stand at the ready for mass
casualties.
Coining a phrase from a comprehensive federal guidance on
how best to respond to terrorist bombings, a robust system
needs to be ready to respond in a moment's notice to injuries.
Simply, that system delivers optimal trauma care and lives will
be saved. Designing that system to achieve optimal outcomes is
also important economically as care to victims of trauma
totaled $600 billion in 2013.
The title of a famous book, ``Good to Great,'' allows me to
put in context advances in trauma care and highlight findings
in two recommendations that I'll discuss I hope you'll fine
germane to our discussion today.
We are good in many aspects of trauma care but we aren't
great. As an example identified by the committee on this
dichotomy was the finding that approximately a thousand service
members died of potentially survivable injuries from 2001 to
2011. One thousand. Here at home, nearly 150,000 trauma deaths
occurred in 2014. As many of 30,000 of those deaths were
preventable. That's 80 deaths a day that potentially are
survivable that we don't yet act on.
First and foremost, we are good at leadership but we aren't
great. There are federal offices and programs that attempt to
address this issue. But those civilian entities have small
staff and little or no funding to influence and improve our
nation's emergency trauma systems.
Within the military, the joint trauma system's future
remains tenuous and it is not currently utilized across all
combatant commands. This is a glaring omission by the
Department of Defense.
In short, there is no single entity within entity within
HHS or DoD with the authority and accountability to guide the
delivery of optimal trauma care.
Prehospital care has achieved success due to tireless
champions for improving the care the lives that are saved when
we recall 911 due to paramedics, emergency technicians, and
physicians. Chief James Robinson, Lieutenant Colonel Bob Mabry,
Captain Frank Butler, Colonel Russ Kotwal are just four of
those champions that worked to shape the recommendations of
this committee in pre-hospital care.
We are good but we aren't great. EMS remains a patchwork of
symptoms, fragmented and largely isolated from health delivery
and health delivery reform efforts. Unfortunately, and as
dictated by Congress, prehospital care is considered only a
transport mechanism, not part of the health delivery mechanism
and apparatus of the nation.
As a result, we don't have a seamless construct that
includes medical care provided before you enter the doors of a
hospital. The report outlines recommendations on how to address
this.
In conclusion, traumatic injury is nonpartisan and the
delivery of optimal trauma care is a shared responsibility by
Democratic and Republican leadership alike. Both sides of the
aisle can and should support a system that benefits service
members sitting in harm's way as well as every American.
The report on National Trauma Care System Integrating and
Military Civilian Systems to Achieve Zero Preventable Deaths
after Injury Presents a vision for national trauma care--for a
national trauma care system with a bold aim of zero preventable
deaths after injury and minimal trauma-related disability. The
committee's work on this report serves as a dedication to the
lives cut short because of trauma whether on our streets, at a
dance club, at a marathon, within our towns, our schools, our
movie theaters, our places of worship or work. We are good, but
we aren't great and we should be.
Thank you, and I look forward to your questions.
[The statement of Dr. Marcozzi follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Chair thanks the gentleman.
I now recognize Dr. Schwab 5 minutes for his summary.
STATEMENT OF C. WILLIAM SCHWAB
Dr. Schwab. Thank you. My name is Bill Schwab and I'm a
trauma surgeon. I'm a professor of surgery and I've trained
military and civilian trauma surgeons for the last 40 years of
my life.
I think as we focus on what's going on in the streets of
America it's appropriate to take a moment and realize that we
have soldiers, airmen, Marines, and Navy in harm's way.
Yesterday, a letter arrived from one of my trainees who is
currently six miles from Fallujah, Iraq, and I read this letter
from Lieutenant Colonel John Schavonis, a surgeon: ``I write
this sitting in my tent about five or six miles from Fallujah,
Iraq. The tent is pretty big and it has great air conditioning.
We have hot showers, three minutes combat style, no more, and
fresh fruit.
``Outside it's about 104 degrees, a dry heat we mockingly
like to say. Our spirits are good. Over the past few weeks I've
done over dozens of major operations--thoracotamies,
exploratory laporatomies, amputations, craniotomies and all of
them to save soldiers' lives.
``Now an intense battle rages in Fallujah. We are quiet for
the time being. I am as ready as I can be for whatever comes
through these doors and the reason is because of what you
taught me. Your insights, your intellect, your skills, your
cell phone always being on brings me the strength and the
courage to go on.''
I am the product of a military civilian partnership. The
United States Navy put me through medical school and trained me
as a trauma surgeon during Vietnam. Every one of my teachers in
surgery had served in Vietnam. Trauma surgery became my genes.
I'm going to discuss briefly recommendation 11 of the National
Academy report which calls for integrating and optimizing the
civilian network of America's best and busiest trauma centers
as robust platforms to train, sustain and retain military teams
in an expanded expert trauma workforce necessary to perform the
primary mission of the Department of Defense's military health
system readiness, battlefield medicine, and combat surgery.
I'm going to share some data with you that we gleaned and
published after 2 years of extensive research. I won't bore you
with the methodology but let me just say it was extensive and
involved. Over 40 face to face interviews with leaders from the
United States military medical corps, all three services as
well as civilian leaders. We looked at how well prepared
surgeons were to go to war, and I want to clarify I'm going to
use the word surgeons just to abbreviate the time. But this
also relates to physicians, nurses, allied health professions
and administrators. Our research showed that the best word to
describe the preparation prior to deployment to go to battle is
inconsistent. Inconsistent in training, inconsistency in skills
and inconsistency in competency.
And please don't blame the men and women that wore the
uniform, because the military has very little opportunity to
train in trauma surgery in their hospitals. The most common
invasive or surgical procedure done in military hospitals is
obstetrical delivery. The most common diagnosis and treatments
rendered by military physicians and surgeons are the care of
the diseases of aging among beneficiaries.
There is only one level of trauma center in the entire
Department of Defense at its 51 hospitals. As important, when
war ramps up there is very little time to train physicians and
nurses to go to war. What was necessary and what is necessary
is to provide a constant training platform, a network of
national military civilian excellent trauma centers that has
embedded full trauma teams interdisciplinary that are
continuously practicing trauma night after night, day after
day. And when called upon can rapidly deploy to support the
modern war machine.
Let me give you some statistics that might be a bit
shocking. What was the average age of the general surgeon that
deployed to Iraq and Afghanistan? Thirty-six. How many years of
practice did they have under their belt? Two. How many times
were they accompanied by another surgeon who had combat
experience? Eighteen percent of the time. That implies
tremendous flaws in preparing to serve those men and women put
in harm's way to defend our freedoms and our democracy.
This has been studied before. The Rand Corporation in 2008
did an an extensive study and documented that the best place to
prepare military providers for combat and battlefield medicine
are in the busy trauma centers of the United States. They also
went on and studied with nine health organizations any problems
that might arise--financial, business, statutory licensing, and
interestingly enough, none of the problems, one, were
identified as insurmountable, number two, the nine healthcare
organizations were optimistic and said they would even be
willing to do cost sharing, and last, from 2009 to 2014 when we
interviewed the leaders of the five current military civilian
trauma training hospitals, no problem had arisen with any of
the things that I mentioned.
Mr. Pitts. Your time has expired. Would you wrap up,
please?
Dr. Schwab. I would like to just show you one map because
it's very important, if I could.
This map is actually a map that we generated looking at
American Colleges Surgeon data. These are the busiest and the
best academic trauma centers in the United States. We asked the
question whether it was capacity to absorb as many as 20 to 25
of these teams by looking at this data and the answer is yes,
there is. I will also point out that in those orange and yellow
dots are some of the most stressed hospitals in the United
States, the safety net hospitals in inner city America who
could greatly benefit from the placement of these military
teams to health care of those victims of violence that you're
reading about in the papers.
Thank you very much, Mr. Chairman.
[The statement of Dr. Schwab follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Chair thanks the gentleman and now recognizes
Dr. Manifold 5 minutes for your summary.
STATEMENT OF CRAIG MANIFOLD
Dr. Manifold. Thank you, Mr. Chairman.
My name is Craig Manifold and I'm an EMS medical director
in San Antonio, Texas and current chairman of the American
College of Emergency Physicians EMS committee. And on behalf of
the 35,000 members of the American College of Emergency
Physicians I'd like to thank you for the opportunity to testify
today regarding House Resolution 4365, Protecting Patient
Access to Emergency Medications Act of 2016.
A critical component of EMS care is the ability of
paramedics to administer controlled substances to patients when
they follow the EMS medical director's treatment protocols,
more commonly referred to as standing orders. However,
patient's access to these lifesaving medications is in jeopardy
and Congress must take action quickly, and I emphasize and
request quickly, to codify the use of standing orders in the
prehospital setting.
In my written testimony I provide a brief synopsis on why
this legislation is needed at this time and briefly the DA does
not believe the standing orders comply with the 1970 Controlled
Substance Act, which was the beginning of the Emergency Medical
Services. And so the issues and procedural processes could not
have been envisioned at the time of the enactment of the
Controlled Substance Act. But the DEA was prepared to
promulgate a role prohibiting the use of these standing orders
for EMS personnel.
ASEP, in conjunction with National of EMS Physicians and
the National Association of EMTs determine the legislation
would be needed to codify the current practice of medicine and
ultimately lead to the introduction of this resolution by
Representatives Hudson and Butterfield. And thanks to the
efforts of our groups, our coalition partners, the bill has
received the support of over 120 bipartisan cosponsors and
stakeholder organizations at this time.
While codifying the use of standing orders for EMS
personnel is essential, we also want the legislation to advance
policies that would provide uniformity, clarity and certainty
for EMS agencies and their medical directors around the
country. One of the easiest solutions to reduce confusion and
duplicity with regard to the primary point of contact between
the EMS agency and the DEA is to simplify the registration
process.
Currently, most EMS medical directors rather than the EMS
agency itself register with the DEA and then their agency
obtains and administers the controlled substances associated
with these processes. This utilizes the medical director's
individual DEA number and places a tremendous burden on these
often volunteer positions because of the potential liability of
the medical director if the ambulance services a drug
diversion. Many of my colleagues and I believe it makes sense
for the EMS agency to be registered with the DEA. It should be
an agency, not an individual, which assumes the responsibility
for ordering, storing, dispersing and administering these
controlled substances. EMS agency registration would also allow
for the entire organization to be united under one enrollment,
thereby streamlining the process and reducing administrative
costs while still preserving accountability. Maintaining a
separate registration for individual locations and vehicles
under the purview of the EMS agency is extremely time
consuming, duplicative, and expensive. Preventing the misuse or
unintended use of the medications and controlled substances is
a solemn comment on the EMS medical director's job.
We as the medical directors and the associated management
staff work diligently to oversee the implementation,
administration, and monitoring of these controlled substances
within their agencies. My colleagues and I take this
responsibility very seriously and we believe that provisions of
House Resolution 4365 will actually reduce the opportunities
for drug diversion. Although diversion is not a common
occurrence, in fact one recent survey of large EMS agencies
across the U.S. showed less than 20 diversions were
investigations over the last 5 to 10 years for nearly 70,000
doses administered annually.
As I previously mentioned, many EMS agencies rely on their
medical director's DEA license to order, transport, and
administer controlled substances. These medications can only be
delivered to the address associated with the registration. In
the recent past, that meant these controlled substances were
delivered to my house. Alternatively, I could have waited for
address changes and ordering processes to be updated. But this
would have placed patient care in jeopardy and I was not
willing to do that. It makes sense for these substances to be
delivered to a central location operated by the EMS agency
where there would be direct supervision of these medications at
all times.
It's also vital that the EMS agency has the ability to
transfer controlled substances within its own organization. A
colleague in Houston, Texas, has over 100 DEA registrations due
to the requirement of meeting a specific DEA registration for
every brick and mortar facility or fire station where
medications are stored. Completing a distributorship
registration requires a complex procedure, expense, and
increases potential for diversion. The ability for an EMS
agency to track and monitory these controlled substances within
the agency will improve the efficiency and the medical care
provided.
In conclusion, if the DEA prohibits the use of standing
orders in EMS, patients will needlessly suffer and potentially
die. Thankfully, the DEA has given us time to pursue
legislative and relief that will codify the use of standing
orders and make other common sense changes that will improve
the delivery of care in the prehospital setting.
However, I do not believe this grace period is unlimited.
Congress must take action quickly to ensure millions of
Americans who require emergency medical services each year are
not prohibited from receiving these live saving medications.
On behalf of ASEP and myself, I would like to thank the
members of Congress who have supported this resolution, our
coalition partners who have helped advance this legislation and
the National Association of EMTs in particular for their work
who have added to this critical issue in today's hearing. I
look forward to answering questions you may have about this
bill and my testimony.
Thank you, Mr. Chair.
[The statement of Dr. Manifold follows:]
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Mr. Pitts. I know recognize Dr. Myers 5 minutes for his
summary.
STATEMENT OF J. BRENT MYERS
Dr. Myers. Good morning, Chairman Pitts, Ranking Member
Green, distinguished members of the subcommittee. My name is
Brent Myers and I serve as the president elect of the National
Association of EMS Physicians, 1,500 members strong, the vast
majority of whom are EMS physicians providing daily oversight
for the EMS care that's rendered in the streets of the United
States. I would like to thank you for holding this particular
hearing as it relates to strengthening our trauma system and
the National Academy's report recommendation number ten which
focuses on EMS and this ties directly in to the bill that we're
talking about this morning, the Patient Access to Emergency
Medicines Act of 2016. Our membership would like to thank
Representative Hudson, Representative Butterfield, and their
more than 100 co-sponsors of this very important legislation.
Dr. Manifold and I committed that we would not have
duplicative testimony so he has covered the issue of
registration and I'm going to move directly into standing
orders and talk about the direct importance for daily patient
care of this very important concept.
The beginning of the Controlled Substances Act referenced
normal medical care as we think about it in a hospital. So if
you think about a patient that comes in a hospital and I, as an
emergency physician encounter that patient I would write an
order in the chart or put it into the electronic medical record
and a nurse would enact that single order for a single
registered patient. That simply does not apply in the EMS
environment. We encounter patients who are trapped, who are
burned, who have near amputations, who have overdoses on
cocaine or other medications, and place our providers at risk
and we must be able to immediately provide lifesaving and
safety-preserving medications to those patients. And the way
that that is accomplished in almost every community in the
United States is via a standing order or a written protocol.
For 12-and-a-half years I've had the honor and privilege to
serve as the medical director for Wake County EMS in Raleigh,
North Carolina. During those twelve and a half years, over 1
million EMS responses occurred under my medical direction. The
ability of those 250 paramedics, 1,500 firefighters and 200
emergency medical dispatchers to work on a standing order is
the only way that the important care for those patients was
provided and, indeed, is true across the country.
I'm going to use just a little bit of my time to give a
couple of examples from our community about how these standing
orders are so important. Before the end of the day today, a
paramedic in Raleigh, North Carolina, based on a standing order
will provide a seizure control medication to an actively
seizing patient, many of whom are pediatric patients and in the
absence of a standing order those patients would continue to
seize and potentially suffer brain damage. Before the end of
the day today, a paramedic in Raleigh, North Carolina will
administer a medication to a cocaine overdose that will provide
control to that situation and provide safety for the
providers--law enforcement, firefighters and EMS--who have
responded to that situation.
In the next 3 hours and every 3 hours until the end of the
day a paramedic in Raleigh, North Carolina, based on standing
orders will provide pain medication to a severely injured
patient. These include in the past year a 2-year-old that
experienced burns over 40 percent of their body who was able to
receive immediate pain medication. Seventy-seven year old
active individuals who were in their work shed at their house
and amputated three digits of their fingers. How wonderful to
be 77 years old but how horrible to be there if we could not
have provided immediate pain control for that citizen based on
the standing orders. Five-year-olds with 20 percent body
surface area burns, a 34-year-old male who suffered near
complete amputation in a motor vehicle crash and was
uncontrollable due to pain and could not be extricated from
that severe environment were it not for medications on standing
orders.
So these are not theoretical concepts. This is day to day
practice of medicine in the United States and what we are
asking with this particular bill is not anything new. It is the
preservation and codification of our current practice.
And with that, I yield my time. Thank you very much.
[The statement of Dr. Myers follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Chair thanks the gentleman. That completes the
opening statements of the witnesses. We'll begin questioning.
I'll recognize myself 5 minutes for that purpose. Start with
you, Ms. Klein.
The National Academy of Medicine Committee called trauma
care in the military and civilian sectors ``a portrait of
lethal contradiction.'' On one hand, we have never had betters
systems of care but on the other hand so many trauma patients
don't receive the benefit and needlessly die or sustain
lifetime disabilities.
The committee's report essentially called for overhauling
our national trauma system to integrate military and civilian
trauma and this is a sea change from where we are today.
What do you believe are the most critical components to
changing this paradigm and achieving the committee's goal of
zero preventable deaths?
Ms. Klein. I would say it has to start with the national
leadership. Second to that it needs to start with the
infrastructure. The great trauma centers that you hear talked
about are typically in an urban area and that means if you're
in the rural areas of the United States you're at great risk.
And so we've got to figure out systems to move these people
out and have current systems in the rural area and move them
swiftly into the trauma centers to take care of them and the
ideal is to have an integrated system with the military and the
civilian hospitals working hand in hand to accomplish that.
Mr. Pitts. Thank you.
Dr. Marcozzi, in the last few years we've seen much
destruction as a result of manmade and natural disasters and
responded to significant threats from infectious diseases such
as Ebola, influenza, now Zika.
Six months ago, this committee held a hearing focused on
another IOM report focused on improving the health care
response to cardiac arrest. Are we building parallel systems
for these conditions?
Should we be or should we be taking a more strategic look
at where the gaps are in emergency care delivery system and
approaching this with a broader perspective?
Dr. Marcozzi. Thank you for the question, Chairman.
I think that, in those conditions that you just described,
minutes matter, and when minutes matter system design has to be
precise and accurate to affect the care of those individuals
whether or not it's a cardiac arrest patient, a gunshot victim,
or a victim of a mass casualty, be it a bombing.
So to that end, I think we are slightly building different
systems and I also think that the way the health delivery
systems are evolving are to encourage minimization of surge
capacity, the minimization and just in time staffing, just in
time supply chains, which is at odds with the concepts of mass
casualty and surge development, and that's a challenge for us
as a nation.
But there's a way to proceed forward, and you mentioned is
there a strategic path forward and I think there is, and the
way to do that is to take some concepts that are championed by
preparedness colleagues across the nation that are championed
by trauma surgeons and emergency physicians and move them into
the health delivery reform aspects. So we don't develop two
different systems of care.
We develop a uniform system of care that is able to be
applied to both the cardiac arrest patient, the stroke victim,
the trauma patient, or the gunshot victim because when minutes
matter, getting the system right is important. And to do that
effectively I think both the military and the civilian sectors
need to learn from each other, develop one system that actually
is a learning health system and this is what's described in our
report. The vision is there. The means to accomplishment is
there.
I think that strategically both the Congress and the
executive sides of government, the authorizing language and the
appropriators need to think about how we can best shape not
just a grant program because I don't think we can grant our way
to success on this. I think we need to include what we think
about as delivery of care, what we're discussing today, and
move it within the health delivery construct of what we do
every day. Thank you, sir.
Mr. Pitts. Thank you.
Dr. Schwab, we know that historically many surgical and
medical advances are made during war time. What happens to
these lessons? How are they integrated in the medical practice?
How are they passed on? Are these lessons truly learned? If
not, why not?
Dr. Schwab. Thank you, Mr. Chairman. It's a good question.
Medical history shows that actually it takes about a year
of war time for physicians and nurses to actually perfect their
skills.
It takes much less time for those physicians and nurses to
work back or to move back into civilian communities and not use
those skills. So the lessons learned from war are not readily
adapted or inconsistently adapted to the civilian practices.
What the National Academy and its recommendations are
trying to do is to formalize a bidirectional platform for
learning, for teaching, for education, for creating experts
that can go back and forth between the military and civilian
sector and as important to focus those people rendering care
and seeing the problems as the translators to the research
laboratories.
And so in that way in the future the vision is is that
lessons learned will be lessons maintained and shared. From the
military to the civilian and during peacetime from the civilian
to the military.
Thank you, sir.
Mr. Pitts. The chair thanks the gentleman. My time has
expired.
The chair recognizes the ranking member, Mr. Green, 5
minutes for questions.
Mr. Green. Thank you.
Ms. Klein, I understand that Parkland took seven patients
from the Dallas attack on the police last week. Can you
elaborate on the kinds and degrees of costs that it takes for a
major trauma center like Parkland to be prepare to handle
devastating injuries and mass casualty incidents?
Ms. Klein. Yes, sir. Well, the first thing I will just have
to say is that a hospital has to be integrated into the system
and the system is EMS and for Texas we are very blessed.
We have a very strong trauma system which includes our
regional system and part of the regional system means in 19
counties the hospital's EMS agencies, public health come
together to look at plans, how to execute and how to manage
these plans.
On this particular night, we knew that there was an event
going on downtown. No one knew that there was significant
danger in this event. And so all of a sudden how we were
notified is that we had a police car with an injured officer in
it on our dock.
At that time we began to activate and be able to move
forward. So our activation process we have three levels of
disaster response. We spoke immediately to downtown to our
office of emergency management and we also talked to our
regional trauma advisory council to put them on alert this had
occurred.
In a few minutes we had six of our faculty surgeons that
were downstairs. Three remained downstairs. The others went to
the operating suite to wait in that particular area. Anesthesia
was downstairs.
Those officers--three, four of them were severely injured.
The others had wounds that obviously needed operative
intervention and stabilization but they were not in a life
situation distress.
And so the message needs to be that the trauma center, as
far as I'm concerned, is the absolute foundation for disaster
response. Then you have to expand it out. It has to be a
system. The system has to be able to respond and, again, it is
the foundation.
So, and last year, or 2 years ago when Ebola hit I happened
to be the director of disaster response at that time as well.
Our hospital spent $750,000 to mitigate should a patient with
Ebola hit our system.
We never got one patient. We have critiqued our response
and asked ourselves what would we do different and the answer
is the same. We feel like we were strongly prepared.
We had people that were trained for medical decontamination
that stood up and were immediately available. But we bought the
suits that you needed and so we felt like our response was
adequate.
Mr. Green. In the Metroplex in Dallas/Fort Worth is there
another level one trauma center other than Parkland?
Ms. Klein. Yes, sir. There is. There is Baylor's, a level
one trauma center. Methodist is a level one trauma center and
we are very fortunate to have Children's that sits right beside
us as a level one pediatric trauma facility.
Mr. Green. OK. So you have three in the Metroplex?
Ms. Klein. Yes.
Mr. Green. OK.
Ms. Klein. And that particular night one of the other
hospitals got patients and then all of a sudden we were
notified that all the other trauma centers had shut down and we
remained open.
In the course of 7:00 p.m. to 7:00 a.m. we received 17
trauma activations, motor vehicle crashes, motorcycle crashes,
and severe burns and our trauma center remained open the entire
time caring for all the citizens that hit our doors.
Mr. Green. My frustration is Houston. Our two level one
trauma centers are right next to each other, at Memorial
Hermann and our public hospital, Ben Taub.
Ms. Klein. Yes.
Mr. Green. And relatively recently the one in Galveston at
UTMB has opened up so we have three within a 50-mile radius.
In your opinion what does the National Academy of Medicine
Committee focus on creating a national trauma care system? How
do you picture that to fit in with the state trauma system
would fit with the national picture?
Ms. Klein. Well, again, I think there needs to be national
infrastructure just like R.M. Caley called for in the neglected
disease. There has to be some type of national voice to say
this is what we're going to do and set the stage. That should
trickle down to the state level.
The state level should be held accountable for that and
then it's going to trickle down to the regional. Everything, to
me, is regional. You can't create something in North Carolina
that's going to specifically work every single time in Texas or
New Mexico or New York.
But there has to be structures that say these are the
pieces that you have to have and you have to be compliant with
this in some way to hold people accountable to address that,
plus the funding. Our hospital last year spent $65 million on
uncompensated trauma care.
We have a little bill back that we can get money from the
state. We got $7 million back. So there has to be some way to
fund that infrastructure because these citizens are usually the
ones that are at their most productive years of life. So we can
not only save them but put them back on the street so they can
return to work. Then we have done a good job.
Mr. Green. Thank you.
I'm almost out of time. But I agree with our other
witnesses about the military and because, like I said, I saw
the success in Iraq and Afghanistan, the quickness that may not
happen in even our level one trauma centers back 10 years ago.
But I appreciate you all being here today because I think
there's a lot of coordination we can do to help, and again,
thank you for being here.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the vice chair of the health subcommittee,
Mr. Guthrie, 5 minutes for questions.
Mr. Guthrie. Thank you, Mr. Chairman, and I appreciate it.
And Dr. Marcozzi, I want to ask you a question based on
your role on the committee on military trauma care learning and
health systems.
One of the recommendations from the committee was to ensure
that EMS be made a seamless component of health delivery system
rather than merely a transport mechanism. Why the emphasis on
prehospital care? I just want you to elaborate and give you an
opportunity to elaborate.
If we really wanted to eliminate preventable deaths
shouldn't the focus be on getting the patient to the hospital
as quickly as possible and can you explain what really can be
done by paramedics and EMTs and what do you propose needs to be
done to improve prehospital care?
Dr. Marcozzi. I think the committee did a good job in its
due diligence and learned the lessons from what the military
learned and if you look at the data from those thousand service
members what should be palpable to everyone, every American,
that a thousand brothers, sisters, fathers, daughters, could
have been saved from potentially survivable death, of those the
majority of those deaths occurred in the prehospital sector.
So before they hit the doors of a hospital, not coined a
hospital overseas, their deaths were potentially survivable
with the right care. Now, why is that? It's not the medics.
It's not the physicians.
It's not the PAs necessarily don't or aren't providing as
optimal care as they could but we're not providing the system
of care and integrating that delivery of care in the
prehospital sector with the hospital sector's care. So why is
that? And you start to pull that string and fundamentally
that's a congressional--the Social Security Act has not defined
prehospital are as one of the service types defined by CMS.
So therefore it is subject to a different set of--it's a
different look than how we deliver care in the hospital sector
and the long-term care sector versus what we do in the
prehospital sector.
But the truth of the matter is when someone has anaphylaxis
or someone gets shot that care that's delivered in the back of
an ambulance should be seamless. From a patient-centered
standpoint, that care is delivered on scene in the back of a
rig and to the emergency department to the trauma suite.
That team of providers has to be all integrated and
coordinated and right now, unfortunately, prehospital care is
subject to a fragmented system and championed by good folks
like Dr. Myers in North Carolina to try and do the right thing.
But federally I think we can shepherd that system better
and make it part of a system of care and not necessarily as an
outsider. That requires leadership and a leader to help do
that.
Mr. Guthrie. Thank you for those comments. I appreciate you
elaborating further.
And Dr. Schwab, in your testimony you describe the benefit
to both civilian hospitals and military combat readiness,
utilize military trauma teams in civilian hospitals as a way
they can hone their skills and be best prepared for high-level
traumas on the battlefield. Can you elaborate on why you
recommend the entire military team be assigned to civilian
centers and not just military surgeons?
Dr. Schwab. Well, thank you. By saying the military trauma
team, military trauma team defines a little bit less of a work
force than actually the entire medical corps of the Army, Navy,
and Air Force.
In discussion with the Department of Defense after the
report came out, there's actually been discussion about all
military medical personnel ought to have some knowledge about
what's going on on the battlefield. But there are core
specialties--I'm using that word to describe physicians--and
core practices among nursing and allied health professions that
are necessary for trauma and combat casualty care.
Three specialties are necessary for rapid deployment and,
again, both the Rand study and our study found that very
quickly in the early war years general surgery--trauma
surgery--orthopedic surgery and anesthesia providers were the
three specialists that were absolutely necessary but quickly
the military ran out of those specialties because they were so
rapidly deployed and they needed rest periods.
So we're not saying the whole military medical provider
core be assigned to them. But those specialties, those nurses
and allied health professions that are necessary or combat
designated, need to be placed into these trauma centers in
order to train and sustain their proficiencies.
Mr. Guthrie. OK. Thank you very much.
And that concludes my questions and I yield back.
Mr. Manifold. Mr. Chair, if I perhaps could add to the
comments.
Mr. Guthrie. Yes. As long as I get my 30 seconds back. OK.
Mr. Manifold. I apologize. I give you the perspective of an
emergency medicine physician and military physician with the
United States Air Force and developing the critical care, air
medical transport teams and mobile field surgical teams.
That component of a field perspective is critical on a day-
to-day basis on trauma care, being faced with that. I trained
at Milford Hall Medical Center in San Antonio and we had trauma
patients every day and when we went to war when I was deployed
to Afghanistan with my team we were ready to go from day one.
That doesn't occur in every environment, particularly in
the military setting and that's where the advantages of these
programs recommended by the National Academy of Sciences
through their program report is integrating those teams into
the civilian community allows us to prepare and deploy those
folks at a moment's notice.
Not only does it enhance your combat readiness but also our
disaster response and domestic response capabilities by having
these folks prepared. And as the joint surgeon for the Texas
National Guard, it allows me to assure that my medical members
are prepared to walk out the door and also enhances the
opportunity to have additional military medical personnel
perhaps serve in the military without a full-time response
component but being able to serve in a part-time reserve
component capacity.
Mr. Guthrie. I think I agree and I'm supportive. I
appreciate that and I yield back.
Mr. Pitts. The chair thanks the gentleman.
I know recognize the gentlelady from Florida, Ms. Castor, 5
minutes for questions.
Ms. Castor. Well, thank you, Mr. Chairman and Mr. Green,
for calling this hearing on how we improve trauma care and
thank you to all of the witnesses here today.
Our discussion draft of the Military-Civilian and Mass
Casualty Trauma Readiness Partnership Act being considered
today would encourage civilian trauma systems to accept the
placement of military trauma teams into the civilian care
delivery system and I wanted to say I strongly support this. I
am so pleased that the committee is being proactive on this
because I have seen it work back home in Tampa.
Tampa is home to MacDill Air Force Base where we have the
headquarters for Central Command and Special Operations
Command. We have the Air Mobility Wing and they are all
supported by the Sixth Medical Group and they have started a
partnership with our level one trauma center, Tampa General
Hospital, back in 2011 starting with nurses and it has now
evolved to surgeons and then the full team approach.
It has been a benefit to the community because we have
fantastic specialists and dedicated military members taking
care of my neighbors. But it has also provided the training
that the medical group has needed on--where they wouldn't get
it in other places because the Air Force and military has
scaled back a lot of their hospitals on bases across the
country.
So this is going to be an important part of the future.
Tampa General Hospital is our safety net hospital. It's the
only level one trauma center on the west coast of Florida, big
metropolitan area. It's the home of one of our only burn units
in the state and it's our teaching hospital.
So it's a perfect place. So I wanted to drill down into
some of the criteria as we--this discussion draft says we're
going to provide grants.
We don't have all the money in the world to do this
everywhere. We're going to have to be particular. So Dr.
Schwab, what criteria should be fundamental to these kind of
partnerships?
What kind of invectives and specifics do we need to build
into this so that we get we're efficient with the tax dollars?
Dr. Schwab. Thank you very much. It's a great question, and
one of the things that we've published earlier is the chance of
survival in this country is based on where you get hurt and we
know from the data in Tampa that you do pretty well. So
congratulations on that.
Let me just say that I don't want to define for the
Department of Defense what they need. But we know from other
studies and comparative studies between what combat physicians
and surgeons see on the battlefield and what is seen in our
large very, very busy trauma centers that it's a good match.
First, you need very, very high volume. The medical
terminology is you need extremely high case severity indexes,
which means that the cases are life threatening or limb
threatening and unless receiving some type of operative or
invasive intervention in a time manner, death is loss.
Penetrating injury, unfortunately, in this country, all too
common, but gun wound injury is a great thing. And then the
ability to have mass casualty. Where does that come exclusive
of what you're reading about and seeing in newspapers?
It actually comes with inner city violence and specifically
gun violence. Again, in report this is cited but our own work
and publications actually from the trauma center in New Jersey
shows that many times when there is warring factions in urban
violence, trauma centers receive two, three, five, six, seven
wounded people at one time.
What is interesting about that a terrible liability to our
country is the asset is training teams how to respond to mass
casualties.
The other piece, and you mentioned it is, these happen to
be in academic centers because another part of recommendation
11 is that the Department of Defense and specifically the
secretary of the Department of Defense create career paths for
military physicians and nurses to become trauma experts and be
able to run their own trauma centers or their own trauma
programs.
So placing these in academic medical centers is extremely
important. And the last thing I would say, and it was on the
map, one of the things that's fascinating, if you look at who
responded to the questionnaire where we got all of our data--
this is in 2014--86 military physicians responses.
They were divided pretty equally between active duty
reservists, recently separated, and retirees. So these are gray
grizzlies. These are people that had been to war, deployed
multiple times.
It's fascinating. Where do they go when they leave the
military? They go to the urban centers, one of which is Tampa.
But they go to the urban centers and they're there. So there's
this symbiosis that we're looking for, this efficiency that we
have combat experienced teachers already in many of these
academic medical centers.
To quote one of the other representatives, we have the
right model with the right people in the right places. It's
just waiting to be nationalized, memorialized, and funded.
Thank you very much.
Ms. Castor. Thank you very much.
Mr. Pitts. The chair thanks the gentlelady.
Now recognizes the gentleman from Pennsylvania, Dr. Murphy,
5 minutes for questions.
Mr. Murphy. Thank you. This is a fascinating discussion. I
particularly want to thank Dr. Marcozzi and Dr. Schwab. I'm
also a Navy Medical Service Corps. And I currently work at
Walter Reed Hospital and we also have a unit in Pittsburgh at
our 911th Air Force where C-130s have an air med evacuation
unit. So Dr. Manifold, your thoughts are important too, as I
look at this.
And I certainly see that as things have ramped down at
Walter Reed we don't have the same number of trauma cases.
There has been other things which the hospital has done. I
think it's an important model whether it's oncology or
orthopedics, et cetera, to maintain the skill set of
physicians.
But I do think this idea of having military physicians
embedded in civilian trauma units is important.
But there's another level to this I want to ask about. One,
who is in charge in the country? Is DOD, VA, HHS, CDC--is there
a system already in place where people work together? Anybody?
Is anybody in charge?
Dr. Schwab. So one of the questions we ask leading up to
the publication that came out in 2015 using interviews. The
responsibility for combat readiness--trauma combat casualty
care is diffuse across many leaders and many programs and
departments in the Department of----
Mr. Murphy. But it needs to be united, doesn't it, and if
some----
Dr. Schwab. Not only needs to be united but there needs to
be actually one particular leader and one of the
recommendations actually we--there's 11 main recommendations
and 61 subordinate recommendations. It was hard to go through
those.
But one of the very strong recommendations amongst
leadership is that the Department of Defense and specifically
the secretary recognized that within the military medical
health system--that there be one commander, one person in
charge of readiness in trauma and combat casualty care. It's a
strong recommendation supported by other recommendations to
support that office so that policy, standardsand assessment of
medical care for combat is put in place.
Mr. Murphy. To add to this too is that I remember
participating in a exercise called Operation Lycoming Reach
with the 911th and then NOSC, Naval Operations Support Center,
in Pittsburgh, and as well as other military and civilian
trauma physicians and nurses participated.
So, first, the volunteers were made up to look like various
trauma victims, put on C-130s, flown out to different parts of
New York and Pennsylvania, where then they did a triage of a
mass casualty, and then brought back. Then, the hangar was set
up with lots of cots and other triage and emergency care was
done there, and then they were put in ambulances at various
hospitals in Pittsburgh, really followed the whole way through.
And I want to say, do you think that with regard to these
grant programs that gives us enough robust training? Because,
obviously, when you have a mass casualty event--and as we heard
Nurse Klein who also said--it is going to go to multiple
hospitals.
Not only is there a tremendous value in having a military
physician embedded in the emergency area and trauma areas, but
also the cross-training that takes place with regard to we have
got some military reservists who are trauma physicians,
emergency physicians, and nurses, and we are going to have to
be ready if we have a mass casualty event that is from a
terrorist attack or something else, to send teams into areas
and pull patients out around the country.
Should we beef this up and add more robust parts to this?
Bill? Anyone? Colonel, can you comment on that? Or----
Dr. Marcozzi. So just to harken back to your first
question, and then I will just jump to your second. So the
first question Dr. Schwab mentioned around the DOD leadership,
and DOD leadership needs to be on two sides on the defense. We
recognize that the Rangers did it right. The Rangers did it
right because Colonel Kotwal talked to then-Colonel Stanley
McChrystal and said, ``Sir, you need to shoot, move,
communicate, and do medical.'' And so the Rangers dropped their
preventable deaths from 27 percent to 3 percent. Across the
combat and commands right now, we don't have that, so there
needs to be two ownerships to this discussion today, both the
medical and the line.
Second, on the civilian side of the house, right now there
is certainly an ownership from the CDC on preventing injury at
the CDC. But owning potentially survivable deaths at HHS right
now, to coin a medical phrase, is bradycardic. And I think that
it requires some energy and motivation, either from the
Congress or injected as a result of appropriations to help them
improve this neglected area of delivery of trauma care, to that
end, on mass casualty development between the civilian and the
military sector.
I think that if we realize what the report describes and
what Dr. Schwab did a great job of kind of coining with regard
to military coming into the civilian sector, they are standing
shoulder to shoulder. I would be shoulder to shoulder with a
civilian who has never been deployed. This trauma surgeon would
be shoulder to shoulder with someone who has never seen the
type of injuries we saw in Afghanistan and Iraq.
So I think that that hybrid model is joint. It is not joint
just across all services. It is joint because it is a civilian-
military construct to get right because both sides of that
house need to reduce their potentially survivable deaths. So,
and this doesn't require a lot of funding. It just requires two
different systems and an encouragement and a nudge to have them
work together to achieve this.
Mr. Murphy. I know we are out of time. I hope you will give
us a response, Ms. Klein.
Mr. Chairman, this might be one of those areas I would
recommend that perhaps the committee might want to go over to
someplace like Walter Reed and some other areas and meet with
the trauma teams there onsite and see what takes place.
Thank you very much. I yield back.
Mr. Pitts. The chair thanks the gentleman. I now recognize
the gentleman, Mr. Cardenas, for 5 minutes for questions.
Mr. Cardenas. Thank you very much, Mr. Chairman, and thank
you for having this hearing.
I am not a doctor, and I have never played one on TV, and I
don't pretend to play one in Congress. But I have been a 20-
year veteran of being a legislator now, and I have played the
role of being a budget chairman when I was the Chairman of the
Conference Committee in California, where for the first time we
oversaw a budget of $100 billion. Sounds like a lot of money
but, unfortunately, it wasn't enough to do all the wonderful
things that you are talking about here that we would like to do
there.
But let's bring it back to our national situation. When it
comes to our emergency room preparedness, why are you talking
to Congress? Isn't this a free market issue? What does Congress
have to do with increasing our capacity here? That is a smart
aleck question. I just hit the softball right there, ladies and
gentlemen. It is all yours.
Dr. Manifold. I think part of the address, without getting
into the specifics of financing, is we feel that the response
component----
Mr. Cardenas. Call it resources, call it whatever you
want----
Dr. Manifold [continuing]. The resourcing for response
capabilities, the disaster, the contingency components are not
adequately funded in today's environment. We have attempts, we
have----
Mr. Cardenas. Is the free market going to pay for it? Come
on, let's be honest. Is the free market going to pay for what
you are asking us to have in the United States? The answer is
no. Now continue.
Dr. Manifold. No. Yes.
Mr. Cardenas. OK. I was hoping one of you would say that,
but go ahead.
Dr. Manifold. No, I am happy to say that. I was just trying
to get around to that without getting myself in trouble in the
Federal Register. I think that that is true. We have this
piecemeal approach. And particularly from an emergency
healthcare system, that is one of the things in the federal
component of this that is very fragmented is that there is not
a single federal agency responsible for emergency healthcare
systems.
The medical care through the Health and Human Services, we
have a response component primarily through Department of
Homeland Security, we have a robust EMS component through
Department of Transportation, and so there is not a coordinated
federal effort to put those resources together. And so I think
there is opportunity. It will not be a free market component to
currently structure our response and disaster component with
that.
Mr. Cardenas. Anybody else like to add? Nurse? Go ahead.
Ms. Klein. I was just going to comment that the free market
in healthcare usually means that I am going to go and look for
the patients who have some type of funding. And when you are
dealing with disasters, not everybody has funding. And so there
have been facilities who stood up and said, ``Hey, I want to be
the mecca, I want to be this,'' and the first time there is a
real event and they have uncompensated patients that they have
in their hospital, sometimes not three months, five months, or
six months, but a year, because there is nowhere to place them,
they very quickly change their tune.
So it should be for all, not just the patients who have
funding.
Dr. Marcozzi. Thank you, sir. Thanks for the question. I
think a lot bubbles down to the economics of this. I mean, the
truth is, a bomb affects a Democrat just as much as it affects
a Republican, affects a payer, an insured patient just as much
as a non-insured patient.
But I think that right now the current construct of our
government is that we either have supplementals for the next
latest disaster, or we have a $250 million approximately
hospital preparedness program to try and influence a $3
trillion health delivery system.
The economics just aren't there, so I think that we have to
figure out a more strategic way to blend what we do every day
and prepare this construct in that, so that we are ready for
the mass casualty and we deliver the right economically
optimized, best outcome, delivery system that we are able to
achieve. And, right now, I think that those two agendas--there
is a chasm between the two.
Mr. Cardenas. So right now, when it comes to the federal
funding component of everything you are describing today, we
are woefully short on funding the various aspects of what we
should be considering and hopefully potentially funding, so
that we could bring to fruition all of the things that you are
advocating today.
Dr. Marcozzi. I am speaking on behalf of myself, not the
committee.
Mr. Cardenas. Sure.
Dr. Marcozzi. But I don't think we can grant our way to
success. The $3 trillion industry is set up to be a head in the
bed, and to try and shift to an outpatient market delivery
system versus an inpatient system, and capitated systems. And
certainly in Maryland that is where we are going.
So we have to think about the healthcare delivery system
today, right now, and then figure out a way to weave in
concepts of preparedness into that healthcare delivery system.
But setting up isolated, individual systems that are disparate,
one for preparedness and one for how we do things today right
now, it just won't get us where we need us to be.
Mr. Cardenas. Yes.
Dr. Schwab. I just want to comment from the military point
of view, and that is, military health is a $50 billion a year--
--
Mr. Cardenas. Or so.
Dr. Schwab [continuing]. Or more. What is interesting is is
that almost all of that goes to beneficiary care. Beneficiary
care dominates what military physicians, nurses, must deliver
every day. There is no direct appropriation for readiness
trauma combat casualty care.
Believe me, I am a surgeon, I am not an economist, but
maybe reappropriating or redirecting appropriations, one of
which is talked about in the recommendation, saying to the
military, ``You must recognize that your funds have to go to
have readiness force.'' And the reason is no one else can
deliver this on the battlefield but the military health system.
Mr. Cardenas . Thank you for your perspectives. I
appreciate it, ladies and gentlemen.
Mr. Pitts. The chair thanks the gentleman and now
recognizes the gentleman from Texas, Dr. Burgess, for 5 minutes
for questions.
Mr. Burgess. Thank you, Mr. Chairman. And, again, I want to
acknowledge that Ms. Klein and I did work together a number of
years ago. I won't identify how many years ago it was.
And I also want to acknowledge the presence of William
Garner here in the committee room. William was on the committee
staff when Chairman Dingell was chairman of the committee. And,
William, we appreciate now your service at Parkland Hospital
down in Dallas.
So we have the report that several of you worked on, and we
appreciate your service in that regard, and now the
recommendation of a civilian-military partnership. And I think
we have heard several different angles on some of the
difficulties that will be inherent in starting this. At the
same time, there are going to be difficulties on the scaling
side.
But I wonder if, Ms. Klein and Dr. Marcozzi and Dr. Schwab,
if you would all just try to summarize some of those inherent
obstacles that will have to be overcome. And, Dr. Schwab, we
will start with you and then move back down the line.
Dr. Schwab. Thanks very much. Let me just say that we are
going to build on something. We have five military-civilian
trauma training centers since 1998. We have three for the
military, for the United States Air Force, we have one for the
Army, we have one for the Navy. They have been the prototypes.
They have been the pilot studies.
We know from interviewing both the military and the
civilian leaders of the programs that many of the things that
one might perceive have been worked through--licensing, state
stature, state medical society authorization. They have been
worked through.
We do know that each state is slightly different, and so,
again, depending on what states the center went into, there
would be certain things that had to be worked through through
state statures and through licensing.
As far as the other thing that needs to be worked through--
and, again, I didn't get a chance to go through this--is the
capacity. We don't want these military teams to interfere with
post-graduate training for our doctors and nurses.
Now, if you think about it, we have 9 trauma centers that
admit 5,000 patients a year. Some of them are safety net
hospitals that are paying moonlighting fees for doctors,
surgeons, and nurses just to staff. What is fascinating is that
both Rand and our study found that those would be centers where
those military teams would supplement and possibly be cost
effective in delivering care as well as training.
Mr. Burgess. Thank you.
Dr. Marcozzi?
Dr. Marcozzi. I don't have anything.
Mr. Burgess. Ms. Klein?
Ms. Klein. I would just comment from the nurse's
perspective is, if you look at putting a trauma team in, let's
say, Parkland, so there would be some significant advantages to
Parkland. For example, we have, you know, 10 nurses vacant in
the ICU, 15 in the ER. The nurses that come from the military,
obviously, we could plan in there and take that position, so we
wouldn't fill that position.
If you look at our physicians, in the academic world, they
want to do more publications, and they want to do more
research. And so if there was another person there to take
call, then that would give everybody a little bit more time to
do that. So I can see where it would be a significant advantage
to have these experts join us.
And somebody asked about disaster preparedness. When we do
our drills, when we do actual responses, having the military
there with us, we will all learn command and control and
incident command and what we call, you know, disaster medicine,
which means you are going to move them forward and do the
minimal care to get them to the next echelon of care. We will
learn it together.
Mr. Burgess. Ms. Klein, let me just ask you because you
referenced it in your opening statement. Some of the first
patients you got Thursday night were in automobiles, whether
they were police cars or private cars, and then that affects
your reimbursement down the line. Can you just kind of walk us
through that and some of the inherent difficulties Parkland now
is likely to experience from that?
Ms. Klein. Right. So, in the trauma center, the only fee
that we can put--and we call it the readiness fee, to be honest
with you. So that means that everything you have you have to
have 24 hours a day, you know, to be a trauma center, we bill
into our trauma activation fee.
So in our trauma activation fee, for every patient that
comes in that arrives by transport, meaning from transfer or
transported by our EMS agency, that trauma activation fee can
be applied. If the patient arrives by private vehicle, then it
doesn't.
So in this case, on that night, there were three patients
critically wounded that we have to say we cannot bill that
trauma activation fee for that patient. So we do that. CMS
spent a couple of years with this, as you are familiar with.
And one of the things they looked at very carefully was our
trauma activation billing. And so we are meticulous to make
sure that we have validated whether that fee is applicable to
those patients.
So if we could, we are allowed to do the appropriate
activation fee for every patient that came through those doors,
it would be a much more fair process for the trauma centers,
and it would also make sure that that readiness fee is
applicable across every patient that hits the door that meets
the trauma criteria.
Mr. Burgess. Now, Mr. Chairman, I would just point out,
that is a very important point because, as Ms. Klein pointed
out, they are the court of last appeal in North Texas. They
don't get to say, ``We are full.'' They don't get to say, ``We
are tired.'' That is where you go when all the chips are down
and everything is stacked against you.
Thank you, Mr. Chairman. I will yield back.
Mr. Pitts. The chair thanks the gentleman, and I now
recognize the gentlelady from North Carolina, Mrs. Ellmers, for
5 minutes for questions.
Mrs. Ellmers. Thank you, Mr. Chairman, and I want to thank
the panel for being here today for this subcommittee hearing.
This is so vitally important. As a nurse, I understand that,
and I just want to thank everyone--Ms. Klein, Dr. Marcozzi, Dr.
Schwab, Dr. Manifold, and Dr. Myers.
Dr. Myers, I did not realize until you started your
testimony that you are in the Raleigh area. So thank you for
what you are doing, and all of you. Your service is amazing,
and so needed, and we do need to fix this problem.
Ms. Ward, I will start with you. I just want to know--in
particular, as we know, there are always inside politics in all
hospitals. Do you find that hospitals are embracing the idea of
a trauma military team coming in?
Ms. Klein. Well, I certainly haven't discussed it with all
the trauma centers, but I know in our hospital I think it will
be a welcome addition. Again, I think the challenges, I mean,
we all know about credentialing, licensure.
Mrs. Ellmers. Yes.
Ms. Klein. All of that would have to be addressed by the
regulatory system before it was ever implemented. But for our
system, we are an academic hospital, just like Dr. Schwab, and
we embrace education and have new people there frequently. I
think one of the things that we would probably ask for is that
the people who are sent there at least have 12 months and not a
rotator of every 3 months, so then you are really doing
orientation.
Mrs. Ellmers. So that it is more of a----
Ms. Klein. A consistent basis.
Mrs. Ellmers [continuing]. Consistent issue.
Ms. Klein. Right.
Mrs. Ellmers. So that there is a consistency there. I
agree. I agree.
Dr. Schwab, I just want to tell you, I represent Fort
Bragg, and a couple of months ago I had the opportunity to
actually go down and visit their combat training in the field,
their trauma readiness, and I was amazed by what they were
doing, and the evolution since being at war for so long, how
things have changed over time, and the differences that I see
in that ability.
So I thank you, and I see the importance of this, and I
hope that we can move forward with this. I think these are
incredible ideas to move forward on.
And, Dr. Manifold, you spoke about the inventory, the
controlled substances inventory process now, incredible, and
absolutely--I know we also talked about the fragmentation of
all of these services. It sounds like an absolute nightmare.
Can you expand a little more on what you were speaking about?
Dr. Manifold. The concerns with management of the
controlled substance are we all have the same goal of
effectively being able to administer those medications to our
patients in need, at the same time balancing and minimizing any
potential for diversion of these type of medications. And so we
understand that component of wanting to be able to track
medications through.
And so what happens currently in an ideal situation is a
medication is ordered on a special form. It arrives from the
manufacturer. It may come to an office, what is directed on the
physician's license, and that is then inventoried, put in a
safe place. It may be placed in a vial or with a tracking
number, and then be put in the place it would be administered
to a patient.
In a physician's office or a hospital setting, that is the
model that was placed for the Controlled Substance Act that was
written in 1970. For emergency medical services, we have
vehicles and personnel that are on the move continuously. They
may not be at that brick-and-mortar station. They may be moving
to the hospital, and they may have to go back to a supervisor
or a central location, which takes them out of their response
area to be restocked with those controlled substances.
And, again, from a medical director standpoint, when I have
to have a direct--or a separate license for each one of those
facilities, it can be very problematic in trying to manage and
control that. If I have a license or a product that is sent to
that facility, and the individual there doesn't recognize the
name, doesn't understand the importance of this delivery, who
knows where that goes to because it has not been entered into
our system.
And, hence, we want to with this legislation try and
enhance that process of tracking and monitoring the control
system.
Mrs. Ellmers. And I can see, Dr. Myers, that you very much
agree with that as well. And I can see how this probably
contributes to a lot of errors. Not that anyone would make
those errors knowingly, obviously, but I can see how there is
just an incredible disconnect between efficiency and the
ability to be in a controlled environment, because that is
essentially what we are talking about here is trying to control
chaos.
So, Dr. Myers, would you like to also, in just the few
seconds that I have----
Dr. Myers. Sure. Just succinctly, 4365 does one thing that
helps us all, and that is it creates a mechanism that actually
applies to EMS that officers from the DA can utilize. The
problem we have today is there is no mechanism, and so every
person in the enforcement arm is trying to do the best they can
under a law that just does not fit the practice. And so we end
up with this disparate way of doing it, through no one's
intention. This is the solution to that problem.
Mrs. Ellmers. Well, thank you, again.
And thank you, Mr. Chairman, for bringing this important
subcommittee hearing. Thank you.
Mr. Pitts. The chair thanks the gentlelady.
I now recognize the gentleman from New York, Mr. Engel, for
5 minutes for questions.
Mr. Engel. Thank you, Mr. Chairman. The state of our trauma
system is I think something that most of us have likely given
relatively limited thought to until a personal national tragedy
brings it to the forefront. I would imagine every one of us has
relied on our trauma system for care either for ourselves or
for a loved one, so I would like to start out by saying thank
you to all the healthcare professionals present today who have
dedicated their lives to caring for those in trauma situations.
Your work is truly lifesaving.
Ms. Klein, I found the portions of your testimony
concerning trauma activation fees very alarming. If my
understanding of your testimony is correct, a gunshot victim
might have to wait in a trauma bay for a full half-hour before
moving to an operating room in order to ensure that the trauma
center receives the activation fee it needs to pay its bills.
Is that true? Is that the case?
Ms. Klein. No. There has to be 30 minutes of critical care.
It can be applied at any time, and, you monitor that. So if a
physician is there looking at the X-rays, putting in chest
tubes, managing the airway, you can clearly see where that 30
minutes is addressed.
In our situation, I will be honest with you, if a patient
is, what you described is in our trauma bays more than 30
minutes, then we have an issue with that. So most of our
gunshot wounds to the chest or to the abdomen come into our
trauma rooms and go straight to the operating suite.
Mr. Engel. OK. Let me ask you about partnerships between
civilian trauma centers and the military. You contended that
such partnerships might, and I am going to quote you, ``enable
a military team to be mobilized, not just overseas, but also to
respond to a mass casualty event like the one we have just
experienced in Orlando.'' Can you elaborate on how these
partnerships would help facilitate such response?
Ms. Klein. Sure. So obviously, the expectation is that
these military teams would be embedded in our trauma center, so
they would become our colleagues, not people that were visiting
us. And so when you go through a disaster response, everybody
should be trained for the hospital response, as well as how
they are going to work in the region.
So I will give you a perfect example. When Katrina hit, we
had 21,000 people visit Dallas. Houston had the same amount.
And so when you look at that, we activated a health care
facility in the convention center. So that means that we had to
take people from the hospitals, from our EMS off their normal
jobs and put them in this convention center to take care of
patients.
If we by chance had a military team embedded in us, that
would give us additional resources to be able to do that. So we
would have the opportunity as a civilian hospital to learn, but
they would also have the opportunity to learn.
Now, in those situations there weren't a lot of critical
gunshot-wound type of events like that, but had we had them
embedded with us during the event that happened Thursday night,
they might have been the one that took the patient to the OR
and the civilian trauma surgeon, wait for the next patient to
come through. And that is the expectation that we see
happening.
Mr. Engel. Thank you. Dr. Marcozzi, you cited a startling
statistic during your testimony. And I quote you again.
``Approximately 1,000 service members died of potentially
survivable injuries from 2001 to 2011 in Iraq and Afghanistan.
Here at home, nearly 150,000 trauma deaths occurred in 2014.''
Can you elaborate on that?
Dr. Marcozzi. Certainly, sir. So there was a study done and
it was championed by a trauma surgeon who started to ask, well,
of the lives that we lost in Iraq and Afghanistan, could I have
saved any of those? So I asked the right questions and actually
did a very unique way to look at were those lives lost and
looked at the autopsy reports of those patients and then
started to quantify how many of those patients could have had
lives saved. And then he quantified that and found out that by
his potentially survivable definition that approximately 1,000
service members from 2001 to 2011 were deemed potentially
survivable.
The majority of those cases were in the pre-hospital
sector, as I mentioned, and of those in the pre-hospital
sector, the majority of those died of three different reasons.
The first was hemorrhage, the second was airway, and the third
was pneumothorax. So addressing those in the pre-hospital
sector would certainly mitigate or decrease those number of
potential lives lost, and you saw a significant pivot by the
Department of Defense to embrace some of that literature,
although late. And you saw tourniquets being employed much more
readily in theater to save some of those lives.
So that and Secretary Gates' 1 hour. Minutes matter in
trauma care, and when the Secretary came out with the 60-minute
golden-hour rule, that a patient needed to be transported back
to a military treatment facility within 60 minutes, that
changed and decreased our mortality in theater. So those two
were significant changes to the way the military does things
and speaks to that, 1,000 service members.
Mr. Engel. Thank you, Mr. Chairman. I see my time is
expired. Thank you. Thank you to the witnesses.
Mr. Pitts. The chair thanks the gentleman. Is the gentleman
Mr. Collins ready or do you want me to--the chair recognizes
the gentleman from New York, Mr. Collins, 5 minutes for
questions.
Mr. Collins. Yes, thank you, Mr. Chairman.
As the former county executive of Erie County, Erie County
Medical Center is a trauma one. We are the go-to trauma center
for anyone and everyone in western New York. And so I guess, I
am certainly familiar with how lifesaving a nearby trauma
center--and you were saying minutes matter. I know what we are
talking about with the military, making sure we share best
practices. What we have learned here, we share there.
And so I guess perhaps part of my question is we had a case
with the Buffalo Bills several years back, a spinal cord injury
on the field, and lo and behold, and it was a trauma surgeon
who was the Bills' doctor went and used what they called
moderate hypothermia, cold therapy, which frankly had probably
never been used before on the football field. And the prognosis
then of this player was night and day, night and day different
than what a traditional therapy might have been, somebody
thinking truly out of the box.
So I guess my real question is if anyone would want to
weigh in on how we are in fact communicating one trauma center
to another, whether it is military, civilian, or civilian or
even with trauma physicians. The best of the best save lives
every day, and we know too tragically in some cases folks who
might have been near Erie County Medical Center would have
lived and those not near did not.
So, you know, I think that is a general thing of what
Congress might be able to do to help move that along.
Dr. Schwab. Well, having been born and brought up in
upstate New York, moderate hypothermia is present 6 months of
the year.
But let me just say that your question is how well does
communication take place. Communication on the civilian side
actually in all of the disciplines I think proceeds fairly
well. There are established academic societies where research,
observation, data is presented, peer review is accomplished and
those that are felt worthy are published and people learn
pretty quickly. And by pretty quickly I mean within a matter of
years what is going on.
Where there seemed to be a wall that occurred and was
really strengthened after Vietnam for whatever reason, probably
just the adversity to the Vietnam War, where that all broke
down was between the military and the civilian worlds. There is
very little formal bidirectional way the military can
communicate with civilians. It does occur, but it is much more
informal.
Interestingly enough, one of the things that we are talking
about that would be interesting to this committee is reusing
and asking information technology, data people, software
developers to make all of our electronic medical records and
our decision-support tools proactive at the bedside so that we
can be informed about the latest data at the bedside while we
are making decisions. That would lead to some standardization
and therefore decrease actually mistakes that are made and even
potentially save more lives.
So I think one of the things and one of the reasons we were
asked to serve on the committee was to increase and find ways
to formally promote bidirectional flow across all disciplines
but between the military and civilian sectors. Thank you, sir.
Mr. Collins. So another issue, we talk about NIH funding a
lot, 21st Century Cures in particular, looking at increased
funding, in my cases, that leads to cancer and other illnesses.
Is there a way that trauma centers can access NIH funding of
any significance, or is that not a normal pathway that we see?
Dr. Schwab. So, again, one of the things that the report
really focused on is if you look at the burden of injury, both
death, disability, and you look at long-term disability,
especially because trauma is the leading cause of death and
long-term disability in people under 46----
Mr. Collins. I have only got 30 seconds but----
Dr. Schwab [continuing]. You basically see that there is
very little funding.
One of the things I would invite your attention to on
chapter 4, 33, is looking at NIH funding measured against the
burden of disease for Americans and injuries at the bottom of
the list. So the answer is there is no formal trauma funding in
the NIH for trauma----
Mr. Collins. I think that whole issue is one we are going
to have to look at because in many cases what was happening has
just continued and maybe it is time to re-jigger that, the
priorities.
Dr. Schwab. Yes.
Mr. Collins. Yes. Thank you.
Dr. Schwab. Thank you.
Mr. Collins. Thank you, Mr. Chairman. I yield back.
Mr. Pitts. The chair thanks the gentleman and now
recognizes the gentleman from Indiana, Dr. Bucshon, 5 minutes
for questions.
Mr. Bucshon. Thank you, Mr. Chairman.
I was a cardiovascular and thoracic surgeon for 15 years
prior to coming to Congress, so thank you all for what you do
on behalf of your patients. It is appreciated. I know. I have
been there. I was also a Navy Reserve officer from '89 to '99,
never got called up but I was ready.
So my question is going to be maybe to Dr. Schwab and Dr.
Marcozzi about manpower issues. First of all, I support this
idea, this concept about integrating the systems. It is
important. I think it makes sense.
That said, even though I was in a community hospital,
obviously I had had a lot of background in trauma surgery and
still did a fair amount on the thoracic side. I would have been
willing, had I been--I wasn't on IRR or anything but had I been
called, I would have been willing to go in a heartbeat for a
month or two to Afghanistan or to Iraq and helped if needed or
somewhere else to support--to Germany to support people from
Germany that were going in theater. But that isn't really a
possibility. And when I became a Member of Congress, I
discussed that with the head of the Navy Reserve from the
formal admiral, Admiral Debbink was his name. Any thoughts on
that in not only helping train people that are active-duty in
the trauma setting but having the ability to access potential
people who you may not think would be otherwise available to
you if needed? Any thoughts?
Dr. Marcozzi. So, as a reservist, it is palpable to me that
there is a better way to address these issues. I think that
from a military standpoint this requires DOD, which is going to
be kind of a change for them to make dedicated billets at some
of these major civilian trauma----
Mr. Bucshon. Yes, I guess I should clarify. I was not a
reservist. I wasn't in the reserve. Through the reserve, I
understand there was ways to access that. But for a variety of
reasons, I wasn't still in the reserve. I had been in and was
out.
Dr. Marcozzi. Yes, sir. So I think that there is a way that
DOD can help shape what these joint military civilian trauma
centers look like. It requires dedicated billets and dedicated
staffing. And the center itself has to understand, during a
deployment, those assets will be removed from there, so
building in a safety mechanism so that the care is kind of
continuous when they get deployed, that system can absorb that
loss because what will likely occur will be they will become
part of the infrastructure of the center and then the center
will just adopt them as part of their own. Unfortunately, they
will get deployed and then the center will have to absorb that.
So strategically thinking about how to employ them correctly is
important.
And the second piece of this is how do you blend an
approach between the reservist, the IRR, which I think are a
potential untapped resource to actually achieve what we are
trying to describe. Right now, I think that the Department of
Defense doesn't do that entirely right. I think that there was
a lot of testimony to the committee that says that reservists
who are deployed went potentially before their training was
complete on how to manage trauma care. So better training prior
to deployment contiguous is going to be important.
Mr. Bucshon. Because for me, just the economics of it and,
where I was in my practice and with my family it would have
been difficult to rejoin the reserve, but to be called for 6
months or a year, it is just not a practical situation. But for
a month or two, it would be something that I would have done in
a heartbeat.
Dr. Marcozzi. One of the things that is not so apparent is
that this is aimed across the DOD, the military health system,
reservists, National Guard, and even some other contract people
that work for the DOD.
But let's just look at this reserve thing. If you look at
the map of the United States and you look at where our busiest
trauma centers are and you just say that you are a reservist
and I will pick on you and you are in a busy practice in a
community and you want to do your 2 weeks and you want to re-
certify or sustain in your trauma aspect, by creating this
national network with these centers regionally, you could do
that and go home every night as opposed to now, which is
reservists being stationed and sent for 2 weeks of training
actually all over the Department of Defense. And so there is
some real cost-efficiencies here for reservists that need to
train or learn new or sustained skills by creating a national
network of these training centers, especially among the high-
volume centers. Thank you.
Mr. Bucshon. Thank you. I yield back.
Mr. Pitts. The chair thanks the gentleman.
That concludes the first round. We will have one follow-up
per side. The chair recognizes Dr. Burgess 5 minutes for
follow-up.
Mr. Burgess. Thank you, Mr. Chairman.
We have been talking about the possibility of setting this
up, scaling it, building on what has already been there. Let me
ask a question from a different perspective and primarily I am
directing this at Ms. Klein, Dr. Marcozzi, and Dr. Schwab. But
is there a danger in becoming over-providered on the trauma
side?
Dr. Schwab. One of the recommendations--let me back up. We
asked the same question and were asked the same question on the
committee. Currently, there seems to be a surge among the for-
profit health corporations to establish level 2 and even level
3 trauma centers in the more affluent communities, therefore,
decreasing the volume going to our level 1 trauma centers,
which are the training centers.
One of our recommendations, therefore, may be on the
surface contradictory. One of our recommendations is that,
where appropriate, a sample, a group of military treatment
facilities--that is military hospitals--become American College
of Surgeons verified trauma centers and participate in the
civilian system.
We think that is doable and will not take away from the
other trauma centers that are charged with the education and
research of the civilian sectors and may be these training
centers. The DOD would have to be selective, and they would
probably have to follow a model that was created in San Antonio
because San Antonio has the only level 1 trauma center in the
military which is fully integrated into the civilian trauma and
emergency system.
Dr. Marcozzi. Dr. Burgess, my comment would be, wouldn't
that be a nice problem to have, was my first initial reaction.
I think that when we start to try and strategize----
Mr. Burgess. It was difficult for me to ask the question. I
just want you to know that. And I also want you to know that I
can't believe I used provider as a verb.
Dr. Marcozzi. So I think that there is a deficit right now
in our go-to-war mission for the Department of Defense, and it
primarily revolves around the ability to care for soldiers on
battlefields. And when I say soldiers, generally all services
on battlefields. And that is a neglect that we need to address
as a nation, as a Congress, as a White House because we can't
do our nation's--we can't ask young service members to go in
harm's way and not provide them the best ability to save their
life if they were injured on a battlefield.
So I think that I would like to have another congressional
hearing on how do we reduce our trauma capability in 5 years
for the Department of Defense when we get there from here, but
right now, I think that there was a recognition from the
committee that the current strategy that DOD uses to best care
for soldiers on the battlefield is inadequate, and I think the
report describes a vision on how to get there from here.
Mr. Burgess. The genesis of asking the question, a couple
of years ago we had the Ebola crisis, if you will, in the
Dallas-Ft. Worth area, and you did have patients showing up at
one of these ancillary--they were actually not ancillary. They
are full ERs. And how do you--scarce resource, the moon suits
that were available, how do you deal with the distributional
problems that when a patient--you can't control where the
patient accesses. So that was one of the reasons that made me
think in terms of is there going to be some problem with our
designation.
So I realize it may be a good problem to have and I would
obviously welcome working through that, but at the same time,
from a planning standpoint where we are talking about planning
being one of the primary foci of this, from the planning
standpoint, I think that is one of the things that we have to
consider.
I am sorry, Ms. Klein. You wanted to say something as well.
Ms. Klein. There are two ways we can look at this. So,
first, to take a patient to a facility that you know is going
to have to turn around and transfer that patient to another
facility in some ways to me doesn't make sense because they
should go where they are needed to go in the first place. And
so some of these facilities, especially in Texas we are having
the standalone ERs; and don't get me wrong, I think there is
definitely a role for the freestanding emergency departments--
but to be engaged in some of these critical pieces, they need
to be prepared, yes. But if you know you are going to take a
patient there that is going to have to be transferred, there
are some questions there. It doesn't mean it can't happen, but
we just need to look at that.
But one of the things I really want to talk about is data
management. So to answer your question and some of the other
questions is that this should be a data-driven system. And the
performance improvement process in a trauma center is the DNA
of that trauma center. If it is a strong PI process, then you
are going to have a strong program. And why? Because you are
looking every day at what you are doing right, what needs to be
fixed, what needs to be adjusted.
And so part of what this model that we are talking about is
to bring together the civilian trauma center's data and
performance improvement with the military and asking who is
doing it right and who is doing it best and how do we learn
from you? We have a thing called Trauma Quality Improvement
Program through the American College of Surgeons. We call it
TQIP. And in TQIP we compare our hospitals. We call it
benchmarking. And so the ideal is to provide that same
opportunity in the military world so we can see where are our
best performers and how do we get there? How do we follow their
lead to be best performers ourselves?
Mr. Burgess. Thank you. Thank you, Mr. Chairman. I will
yield back.
Mr. Pitts. The chair thanks the gentleman and now
recognizes Mr. Green, 5 minutes for a follow-up.
Mr. Green. Thank you, Mr. Chairman. And as I said earlier,
at University of Texas Health Science Center in Houston where
Dr. Burgess went, we had an ER doctor who actually was the one
who told me back before 9/11 that they were training a lot of
their--they were doing rotations from the military through Ben
Taub Hospital and Memorial Hermann, which is right next door to
each other. And when I was in Iraq, I was surprised even at
Landstuhl in Germany the military would call up neurosurgeons,
anesthesiologists, and they would serve their 90-day rotation
so they could still have a practice back home.
But because of our issues with the lack of level 1 trauma
centers in our country, I think it is a great idea to see if we
can partner with the Department of Defense and say these are
facilities that you can be trained in, and it helps us with the
funding, too, because, again, we have second and third level
may be easy in some areas, but level 1 takes a big investment,
whether it be Parkland or in Houston. So I think that is a
great idea to do that.
Dr. Marcozzi, you had the opportunity to participate in
both the military and civilian trauma from so many vantage
points, so do you believe this Federal leadership is important
by improving our ability to serve both our military and our
civilians in trauma? And to what extent does the military
medicine for trauma differ for civilian trauma care?
Dr. Marcozzi. Yes, thank you, sir. I appreciate the
question. So believe it or not, last night anticipating
questions I actually did a back-of-the-envelope look on who
would own this report from at least the congressional side. And
in a quick look, the Senate Armed Services Committee, the
Senate Finance Committee, the Senate HELP Committee, the Senate
Veterans' Affairs Committee, House Armed Services Committee,
the House Ways and Means Committee, the House Energy and
Commerce Committee, the House and Senate Appropriations
Committee, and the House Committee on Veterans' Affairs would
have and has equities within this report.
Mr. Green. Yes.
Dr. Marcozzi. So to that end on the executive side not only
does the White House and policymakers have ownership of this
but so does OMB. And both of those, from an administrative
standpoint, have to embrace what we have described here
because----
Mr. Green. Yes.
Dr. Marcozzi. And the only place to execute a multi-
departmental effort has to be championed at the White House.
What the committee realized is to have this be a successful
effort, both need to be successful. If one arm of that fails,
then both arms fail. So the White House needs to own this.
Congress can certainly help the administration, encourage them
to embrace some of the recommendations here. But if the White
House does that and calls the Department of Defense and the
Department of Health and Human Services to task on this and
says create a nidus for leadership and accountability and data
collection, then both will actually succeed in their efforts.
Mr. Green. Well, of course, in Congress the Energy and
Commerce Committee would like to have all the jurisdiction, but
you are right, Homeland Security, Armed Services, of course
appropriators, and so that makes it sometimes difficult to be
able to put these all together, and that is why there does need
leadership from the White house, I guess, in doing that.
But you have given me some ideas and, like I said,
Congressman Burgess and I for years have authorized funding for
trauma care, but it is tough to get the money out of the
appropriators. And so this gives us a way that maybe we can
bring in other resources because a partnership between the
private sector and the military has worked on medical research,
breast cancer research. It has helped us in the private sector
as well as the military so there may be a way that we could do
that on trauma. And again, I am more interested in level 1
trauma because of the need for it in our urban areas.
So, again, Mr. Chairman, thank you for the hearing. I think
it has been real educational for members and I look forward to
working with you on it.
Mr. Pitts. Thank you. The chair agrees. And we have heard
some very good recommendations and issues that need to be
addressed here today and some important information.
That concludes the questions of the members present. We
will have some follow-up questions in writing, other members
may have in writing. We will send those to you. We ask that you
please respond. I remind members that they have 10 business
days to submit questions for the record, so they should submit
their questions by the close of business on Tuesday, July 26.
With that, this hearing is adjourned.
[Whereupon, at 12:04 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Joseph P. Kennedy, III
Thank you, Mr. Chairman. Recently, I spoke with a
constituent whose family was forever changed by the Boston
Marathon bombing and the life-saving work of first responders
and trauma care providers especially those at Brigham and
Women's Hospital (BWH). The story the Reny family shared with
me is inspiring and critically relevant to today's hearing, and
I would like share some of their words now.
On April 15, 2013, Gillian Reny, an eighteen year old high
school student and aspiring dancer, stood near the finish line
of the Boston Marathon with her parents, Steven and Audrey
Epstein Reny, waiting for her sister Danielle to finish the
race. Then two bombs went off and a beautiful day turned to
heartbreaking tragedy for the Renys and all of Boston.
When first responders rushed the Renys to Brigham and
Women's Hospital, doctors and nurses worked heroically to save
Gillian's life. In the process, they also saved both of her
legs, a miraculous outcome.
Inspired by Gillian's resilience and forever grateful to
the BWH team that saved her life, the Reny family established
the Gillian Reny Stepping Strong Fund in February 2014.
The goal is to fund innovative trauma research, training
world class clinicians, and transforming outcomes for trauma
survivors. The Stepping Strong Fund fuels innovative research
and clinical programs in trauma healing and limb
reconstruction.
To date, the Stepping Strong Foundation has raised over $7
million and counting. With this momentum, BWH is moving to the
next level, with the creation of the Stepping Strong Trauma
Center. The program will now from a virtual catalyst for change
into a physical hub, anchoring a sustainable network dedicated
to the collaborative research endeavors in trauma, limb
salvage, and tissue regeneration.
Whether we are talking about caring for victims of mass
violence such as the Boston Marathon bombing, responding to
natural disasters, or treating America's injured men and women
in uniform, a strong trauma system plays an invaluable role in
our nation's health care system. While the Affordable Care Act
included funding for several trauma care programs, including
regional systems for emergency care and trauma care centers, we
must continue to provide robust funding to ensure that an
experienced, collaborative trauma system is there when we need
it most.
I am grateful to the Reny family for their bravery and for
allowing me to share their story today.
Thank you, Mr. Chairman. I yield back.
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