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RESEARCH IN TRAUMA
Current Status of Research Support
Research in trauma has suffered from the lack of recognition of
trauma as a major public health problem. This is, in part, due to
the present practice of evaluation of research support requests by
study sections or otl~er advisory committees of granting agencies
identified with "disease" entities, rather than those related to
"accidents," "injuries," or"trauma." An analysis of grants in 1965
identifies only $5 million in support of research related to trauma
by six of the Institutes of the National Institutes of Health and
other bureaus of the U.S. Public Health Service. National expendi-
tures for all medical research in 1964 were estimated to be $1675
million of which $1134 million was from Government, $395 mil-
lion from industry, and $146 million from private sources. On
the basis of these vast sums, it is estimated that current research
expenditures by the National Institutes of Health and the Division
of Chronic Diseases of the U.S. Public Health Service for fiscal
year 1963 were 50 cents for each of the 10 million persons dis-
abled by accidental injury, $220 for each of the estimated 540,000
cancer cases, and $76 for each of the estimated 1,420,000 cardio-
vascular cases. The 1966 federal budgets for research on cancer
and cardiovascular diseases alone are estimated to be in excess
of $280 millions
There remains no doubt that society is reaping dividends from
investments devoted to research in disease, and that this effort
deserves continued support and expansion. Lack of a proportion-
ate degree of support in accident prevention and care of the victims
of trauma cannot be ascribed to unwilling legislators or directors
of voluntary and philanthropic organizations. The most obvious
reason for current lack of emphasis on the kinds of research re-
quired and the ways and means of utilizing knowledge we already
have is that there is no unified mechanism, federal or nonfederal,
to present the full picture of needs, to identify and encourage
necessary research, to enlist financial support, to serve as a clear-
inghouse for information, or to offer advice and consultation.
During the years of expansion of the National Institutes of
Health and other federal agencies and voluntary organizations
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concerned with national health problems, emphasis has been prop-
erly focused on fundamental research. A charge of the President
to his Commission on Heart Disease, Cancer, and Stroke was to
recommend practical steps to reduce the heavy losses exacted by
these diseases, not only through the development of new scientific
knowledge, but also through the use of lifesaving medical knowl-
edge we already possess but fail to bring to so many stricken
American families. The dispatch with which the program was
defined and was supported by Congress was due in large part to
the knowledge gained in recent years through generous support
of basic research and to the wealth of information and assistance
available through the American Cancer Society and the American
Heart Association, both of which recognized years ago the neces-
sity of joint participation of professional and lay organizations
and of the general public, and which have pioneered for decades
in the support of health research, public education, training of
physicians and allied personnel, and direct service to patients. The
need for such organized effort in the field of trauma is apparent.
Potentials in Fundamental and Clinical Research
To determine accurately the physiological changes produced by
trauma alone, studies must be initiated promptly on persons who
are otherwise healthy at the moment the stresses of trauma are
imposed. Only by this approach can the hemodynamic, metabolic,
ultrastructural, and other changes of diseases be compared with or
differentiated from the hypoxia, collapse, and other effects of
trauma as the sole etiological factor.
Relatively little has been done in fundamental studies on acutely
injured subjects on wound healing; wound infection; hemodynamic,
metabolic, cardiac, and respiratory changes following trauma;
ultrastructural alterations in injury and shock; the effects of head,
spinal cord, and nerve injuries; paralytic ileus; posttraumatic renal
insufficiency; fracture healing; resuscitation' and many other areas
of basic importance. To a limited extent these problems are now
under investigation in laboratories devoted to studies on acute
and chronic disease and malignancy, but rarely in relation to
trauma specifically.
Many of the most important advances in surgery have evolved
from discoveries at the war front. Wounds from high velocity
missiles and the environmental factors that prevail in military
combat areas produce changes that cannot be simulated in civilian
life. Although contributions to the care of military casualties can
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be made through research In noncombat medical centers, there is
as great a need for contributions that can be made only by so-
phisticated research in military front line medical installations.
The opportunity should be fully grasped in Vietnam, as it was in
Korea, to improve the care of the injured throughout the world by
seeking, in an organized manner, improved ways of treating the
critically injured person.
Specialized Centers for Clinical Research in Shock and Trauma
In the very recent past, owing in large part to stimulation and
encouragement of the Committee on Shock of the National Acad-
emy of Sciences-National Research Council and with the support
of federal and private Ranting agencies, basic and clinical scien-
tists have been installed in highly sophisticated laboratories devoted
to studies in shock and trauma in human patients in a limited
number of medical centers. It is a tribute to the profession
that these pioneer groups of investigators willingly devote long
hours to research in trauma, a disease predominantly of nights and
weekends. These units are designed to combine the highest devel-
opment of patient care with research facilities that enable inves-
tigation to proceed without hampering therapy. For example, in
one institution the space previously occupied by three. surgical
wards has been converted to laboratories to support intensive care
and study of not more than four patients at a time. In this and
other units the basic scientists in physiology, microbiology, bio-
chemistry, electronics, isotopes, engineering, etc., collaborate with
clinicians in carrying out highly complex studies in man that were
previously limited to animal studies. Repetitive observations are
rapidly computed and relayed to the clinician, providing moment-
to-moment hemodynamic and biochemical measurements. The
improved therapy that results from these studies is gradually
modifying previous concepts of irreversibility in those suffering
from hemorrhage, burns, and sepsis.
Units of this type must be adapted to measure and treat the
overall effects of trauma, sepsis, or critical nonsurgical conditions,
but additional studies might take one of several directions, depend-
ing on patient load and local research interests and talent. For
example, a 10- or 1 2-bed burn unit might embrace the whole
panorama of the burn problem, from the time of injury through
rehabilitation. Another unit might be geared toward early hemo-
dynamic or metabolic changes, shifts in the various body fluid
compartments, oxygen utilization, or energy production. Others
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might center on severe head injuries, or abdominal injuries, or
fractures. To date, no unit of this type has been developed for
research in head and neck injuries, arid such units are vitally
needed.~a
Such facilities might Include ancillary equipment for hemo-
dynamic measurements in the emergency department, so that the
earliest possible changes as well as the response to resuscitative
fluids and other therapeutic agents could be measured. These
observations would then be continued in the operating room, the
intensive care unit, or the special research unit for uninterrupted
study throughout all phases of response to injury and recovery.
Research on tile acutely injured requires numerous personnel of
many disciplines. The critical nature of the illness is such that
research must continue around the clock. Nursing and laboratory
personnel requirements are costly.
Numerous studies now point convincingly to the conclusion that
moment-to-moment hemodynamic and biochemical measurements
in the acutely ill or severely injured patient offer the best available
guidelines for improved therapy. Information gained by these units
proves valuable guidance for the treatment of injured patients In
other less specialized hospitals where research is not feasible.
These clinical research units involve very specialized facilities
with unusual demands for staffing and equipment, and for parallel
facilities for animal experimental studies. The survival of critical
medical and surgical cases has been increased, and many useful
techniques have been adopted in other areas of the hospital.
The most significant obstacle at present is the lack of long-term
funding. Unpredictability of financial support hinders recruitment
of competent scientists and technicians, retention of key personnel,
and procurement of necessary equipment.
The few clinical research units for the study of the acutely in-
jured have been supported mainly by the National Institute of
General Medical Sciences, the Medical Research and Development
Command of the Army, and the John A. Hartford Foundation.
Very recently the National Institute of General Medical Sciences,
recognizing a need for coordination and identification of research
needs in trauma, conducted a workshop conference on the man-
agement of trauma, including hospital arrangements and training;
the physiology of shock, considered from the systems and organ
level; and study of trauma at the cellular and subcellular levels.
This Institute has now appointed a director for development of
a program of research in the therapy of trauma, aIld is encouraging
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expansion of support in this direction. The needs for research in
resuscitation, shock, trauma, and emergency conditions related to
acute and chronic illness, for academic career training and fellow-
ships in thaumatology, for improved facilities and equipment,
and for experimental and clinical laboratories in direct support of
emergency departments and intensive care units warrant serious
consideration of establishment of a National Institute devoted to
trauma and emergency medical care.
RECOMMENDATIONS
1. Increased federal and voluntary financial support of basic and
applied research in trauma.
2. Long-term financial support of specialized centers for clinical
research i n shock and trauma.
3. Expansion of clinical research in war wounds.
4. Expansion within the U. S. Public Health Service of research in
shock, trauma, and emergency medical conditions, with the goal of
establishing a National Institute of Trauma.
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Representative terms from entire chapter:
specialized centers
