As many as 1 in 5 people may be needlessly dying from car crashes, gunshots or other injuries, say government advisers who stress that where a person lives shouldn't determine if they survive or not.
After this week's massacre in an Orlando nightclub, the findings in a report from the National Academies of Sciences, Engineering and Medicine takes on new urgency. The Orlando shooting happened just blocks from a major trauma care hospital -- geography that undoubtedly saved lives.
But swaths of the country don't have fast access to top care, and government officials are urging the establishment of a national system that puts the military's battlefield expertise to work at home. The ultimate goals: Zero preventable deaths after injury and minimizing disability among survivors, said the report.
Since no single organization is in charge of trauma care in America, the high-ranking advisers called on the White House to lead the effort, but they also said local and state improvements could begin immediately.
"The meter is running on these preventable deaths," said Dr. Donald Berwick of the Institute for Healthcare Improvement, who chaired the NAS committee.
Trauma is the leading cause of death for Americans 45 and younger, killing nearly 148,000 people in 2014, and costing an estimated $670 billion in medical expenses and lost productivity.
The report found a patchwork of results across emergency medical systems -- which often include volunteer first responders -- to death rates that vary twofold between the best- and worst-performing trauma centers nationwide.
The biggest opportunity to save lives occurs well before reaching a doctor or hospital. About half of deaths occur at the scene of the injury or en route to the hospital.
"The answer's always been to drive faster or fly faster. We're almost at the limit of that. Minutes really do count in these critically ill patients. But we can do things to stop bleeding, resuscitate better, while we're flying or driving faster," said panelist Dr. John Holcomb, a trauma surgeon and retired Army colonel now at the University of Texas Health Science Center in Houston.
Lessons can be learned from military emergency care. The percentage of wounded service members who died of their injuries in Afghanistan decreased by nearly half between 2005 and 2013, the report found. The improvement resulted from systematic study of battlefield deaths that led to new policies such as equipping soldiers with tourniquets so the wounded didn't have to wait on a medic to stop catastrophic bleeding.
Military findings suggest about 20 percent of deaths could be prevented with optimal care, Holcomb said. That translates into "81 patients a day dying in the United States - every day - that are potentially preventable," he said.
But the military still needs improvement, too, the panel said. Nearly 1,000 battlefield deaths between 2001 and 2011 were from potentially survivable injuries. The panel recommended that military surgeons keep their skills sharp by working in civilian trauma centers between combat tours.
Whether in combat or civilian life, hemorrhage is the leading cause of preventable trauma death. Panelist James Robinson, assistant chief at the Denver Health EMS, said that's one reason bystanders begin "the chain of survival."
The shooting at the Pulse nightclub last weekend left 49 victims and the gunman dead.
There's an urgent need for improvement, Berwick said. "The shadow of Orlando is on everything we're doing today. Everything we're learning about injuries in the battlefield has a lot to do with our preparedness and ability to respond to mass casualties," he said.
Creation of an expert workforce is key, said panelist and trauma surgeon Dr. C. William Schwab of the University of Pennsylvania. That includes every area, from first responders to trauma centers to the rehabilitation care that survivors receive.
Statistics show about two-thirds of Americans have access to a Level I trauma center - such as the Orlando Regional Medical Center - within an hour by land or air. But compared with nearly 90 percent of urban dwellers, only 1 in 4 rural residents live that close to one.
In some regions, a third of severely injured patients aren't transferred to either a Level I or Level II trauma center. The CDC has triage guidelines for emergency medical workers to help them determine the type of care a trauma patient needs, but as of 2011, only 16 states had at least partially implemented them, the panel found.
Hospitals that can't handle severe injuries have to transfer patients, and those patients are nearly 25 percent more likely to die than victims taken immediately to a trauma center, the report found.
Experts have called for improvements in trauma care for years. The American College of Emergency Physicians, a U.S. professional organization of emergency medicine physicians, for example, in January of this year, approved the creation of a multidisciplinary "high threat emergency casualty care task force".
Dr. Jay Kaplan, president of ACEP, said this week in a statement that the new task force is "dedicated to understanding, tracking and responding most effectively to mass casualty incidents" like the one in Orlando.
"Since the inception of the specialty, emergency physicians have been on the front lines in the prehospital environment and in our nation's emergency departments, responding to incidents of violent mass casualty, such as this one. As a specialty, we will continue to lead and to collaborate with partners across the emergency response continuum, in efforts aimed at reducing potentially preventable deaths and disability due to these horrific attacks," Kaplan said.
Report collaborator Holcomb said, "This time maybe the difference is we've just completed a big war. People are very concerned about it. We do have terrorism going on on our own soil. We do have a civilian trauma system that although not perfect, is ready to receive some of these lessons-learned."