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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 30

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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 31

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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 32

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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 33

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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. 34