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All trauma articles and education speak to the Trimodal Death Distribution. The interpretation is the reference time after a trauma where people die. This time area is from seconds to minutes to days and weeks. It is defined as immediate deaths, early deaths and late deaths. Immediate deaths are those that take place within seconds of the trauma and relate to lacerations of the brain stem, severe head injury, tearing or laceration of the aorta, heart major vessels or major organs. 50% of deaths occur at the scene of the accident. Early deaths are the focus of TEAM, as they represent the minutes to hours aspect where a HCP has been at the scene and has instituted the immediate care. These individuals may have suffered an epidural hematoma, a subdural hematoma, a pneumothorax, a hemopnumothorax, a ruptured spleen, a liver laceration, a pelvic or hip or long bone fracture or intra-abdominal bleeding. These patients can be survivors if early aspects of ATLS are utilized timely and expertly. They may not all survive as severe blood and tissue loss can sometimes not be corrected in time, but there is at least an opportunity to utilize the finest trauma skills and techniques with a dedicated team to reduce the number of deaths from this category. Lastly, are those who are categorized as late deaths as they have had a speedy scoop and run, a trauma team, but ultimately succumb to the conditions of shock, multi-organ failure and sepsis. They are the combined efforts of all medical caregivers, yet their initial damage was too great to change the prognosis. I mention this to acknowledge that although we try, we are not God and we cannot always be successful. The fact is that we cannot always win, and we need to accept this if we are to maintain satisfaction and commitment to our endeavors.
TEAM principles are to treat the greatest threat to life first; therefore, we utilize the physiologic approach to resuscitation and start with the ABCs: airway, breathing and circulation. This is an integrative system as airway plus breathing establish circulation, which is needed to maintain oxygen delivery to the cells. The endpoint of circulation is to establish that there is no severe bleeding where life fluid is escaping at a great rate. Stopping the bleeding is essential as all of the blood transfusions in the world are useless if there is an equal intake and output of blood products. Another principle is that having a definitive diagnosis is not as important as correcting the immediate problem. A physiological approach is mandatory, and time is of the essence. We need to proceed with the dictum “do no further harm” and remember that teamwork is required for TEAM to succeed.
The TEAM approach consists of the following five aspects:
A- Airway with C-spine protection
B- Breathing/ ventilation/oxygenation
C- Circulation- Stop the bleeding
D- Disability- (Neuro status)
E- Expose/ Environment/body temp
The TEAM sequence is the inclusion of a rapid primary survey, which includes ABCDE and adjuncts; a detailed secondary survey with reevaluation and adjuncts; safe transfer to the appropriate facility, which is a level 1, ll or lll trauma center and, finally, definitive care. Utilizing this sequence prevents overcrowding of a level 1 trauma center to the point that there is failure to survive a trauma because of the loss of immediate care. We need to look no further than the common cold being treated at a major ER to understand how easily resources are utilized and wasted.
The Trauma team consists of a team leader – usually a general surgeon or senior emergency medicine physician, any number of nurses, physician assistants, NPs, and nursing assistants, as well as x-ray and lab services, a runner and the specialized physicians that may be needed, such as Neuro and Ortho. The number of personnel is entirely dependent upon the receiving facility and the type of trauma. There is always a need for communication and pre-hospital planning and preparation, in-hospital preparation and the utilization of standard precautions as set down by OSHA, the CDC and the ACS. Triage rules are strictly followed when addressing multiple causalities and mass casualties. These are all discussed at the course at the AFPPA and GAPA meetings. Our next article on this series will consist of a two part look at the primary survey, and then we will proceed into the secondary survey. Trauma requires commitment, experience, dedication to principles, skill, education and self confidence as well as the ability to work within the framework of a team.
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
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