The History of Shock Trauma Andrew Burgess MD Conflicts: - - PowerPoint PPT Presentation

The History of Shock Trauma

Andrew Burgess MD

Conflicts:

• Consultant to Stryker

Orlando Regional

Medical Center

Maine Med Private Hopkins Shock

ORMC Hospital Employed

Albany Med

Injured Patient

Traditional Trauma System

Treated Patient

Injured Patient

Mature Trauma System

Harborview Tampa Baltimoreetc.

Treated Patient

SAM POWERS, MD

ALBANY MEDICAL CENTER

• Started Trauma Unit in 1968; a cooperative, NIH funded center
• Rensselaer Polytechnic Institute
• General Electric Research and Development
• Clarifying problems of the injured (renal, pulmonary)
• Often staffed by an Orthopaedic “Shock Fellow”

Partners

R ADAMS COWLEY

• A pioneering heart surgeon (MASH)
• Shock research
• 2-4 bed unit
• “Death lab”
• Medivac
• 1969 Maryland State Police
• Envisioned a Statewide system

1917-1991

R ADAMS COWLEY

• 1960’s: Trauma at that time…
• Closest Hospital
• Often no Doctor, Not equipped for major trauma
• University Hospitals
• Trauma and ER run by interns
• No specialty of Trauma Surgery
• Get the patient to the right place at the right time
• Shock is a “momentary pause in the act of dying”
• The term “Golden Hour” is born

THE OLD MAN

• A Pariah
• To the established medical hierarchy
• Within the University
• The National Organizations (ACSetc)
• Challenged the wisdom of the time

ORIGINAL TRAUMA CENTER

GOVERNOR MARVIN MANDEL

Medical School

&

Hospital

Critical Alliance

Shock Trauma MIEMSS Maryland Institute for Emergency Medical Services Systems

1970’S-1980’S

• Development of systems approach
• Lobbying State Government
• Funding-Design of New Trauma Center
• OrthoTrauma participation in design

EARLY, POST-BROWNER ORTHO STAFF

• Secure enough to accept each other’s strengths
• Put Mission First

• Eglseder
• Copeland
• Bosse
• Turen
• Pollak
• Bathon, Molligan

Brumback Poka

Johnson Swiontkowski Et al Hansen Winquist

Maryland Trauma Centers

Cumberland Memorial Washington County Hospital Suburban Hospital Prince George’s Hospital Center Peninsula Regional Medical Center

Johns Hopkins Bayview Medical Center Sinai Hospital Johns Hopkins Hospital L1

Shock Trauma Center

I II III V IV

1989

• New Trauma Center opens
• Goal: A National Center of Excellence
• Multiple Injuries, Spine and Head Injury

PRIMARY ADULT RESOURCE CENTER

• More resources than Level One
• Dedicated Trauma ORs (6)
• Dedicated staff
• Trauma Surgeons ( ATLS instructors only)
• Orthopaedic Surgeons (all fellowship trained)
• Neurosurgeons
• Trauma Anesthesia, CRNAs
• Dedicated trauma Imaging
• Plain films, CAT, Angio, MRI

Shock Trauma (PARC)

PARC Level I Level II Level III

Burn Eye Hyperbaric Perinatal Head and Spine Pediatric

H H H H

Hand

Echelons of Care

Trauma Centers

Specialty Referral Centers

Local Emergency Departments

STC

• Off site
• Political allies

EMS Patient Distribution

5% 10% 85%

Specialty Referrals Areawide Trauma Centers Local ED

SYSTEMS DESIGNS

• Admission by mechanism and vital signs
• Trauma unit attached to standard hospital
• Medical staff “shunned” by Medical School
• Necessitates trauma-multispecialty professional corporation

STAPA

Therefore…

• Adult trauma patients become a “Purified product”
• Admission by mechanism and vital signs
• Design placed Resuscitation Area next to ORs
• Yields…
• High energy, complex musculoskeletal injury
• Dedicated resources
• Trauma subspecialties financially co-aligned

• Optimum circumstance for developing clinical skills
• Few institutional impediments to mission
• Adult patients
• High energy musculoskeletal injury
• Dedicated resources; ORs6, ICU beds72, etc
• Trauma subspecialties financially co-aligned

The Package

Center Of Excellence

• Preventable death rates
• Outcomes research
• Traditional benchmarks
• Partnerships with:
• University School of Medicine

UMd

• University School of Engineering

UVa

• University School of Public Health

JHU

Quality Assurance and Academic Partnerships

Ellen MacKenzie

UVA

Mark Scarboro

Hopkins

On Call

Sabbatical

Shock Trauma UVA

National Study Center for Trauma and Emergency Medical Systems (NSC)

Jeff Crandall

CENTER OF EXCELLENCE: EXAMPLE

Shock Trauma Orthopaedics

• Hazmat
• Crash Rescue
• Structure Collapse
• Trench Rescue
• Residents from 7 programs
• 4 fellows,
• Multiple publications
• Go team

CENTER OF EXCELLENCE: EXAMPLE

• Orthopaedic Leadership in the State
• Maryland Health Care Commission
• Baltimore County Fire Surgeon
• Medical Director/EMS Washington, DC
• Team Docs: Baltimore Ravens

Shock Trauma Orthopaedics, 2000

CENTER OF EXCELLENCE

• Relationships with traditional institutions
• EMS, Fire, Law Enforcement
• Competing Hospitals
• Within your own system
• All made more efficient by a center of excellence,
• As are….
• Private practice colleagues
• Medical School

Conflict Avoidance

• Now you’re a super-specialist…. But…
• Have you become the musculoskeletal hospitalist?

1999 2017

NOT SO FAST: REALITY TEST

CENTER OF EXCELLENCE

• In trauma care, you are held accountable for how you

perform on your worst day

• Redundant equipment, design
• Always hire better than the boss

CENTER OF PREPAREDNESS

Pause

LEAP: Lower Extremity Assessment Project

8 US Level I Trauma Centers 600 Patients with significant lower extremity injury Followed for 2, 6, 10 years

Factors Influencing Outcome Knee Dislocations with Vascular Injury Complications Insensate Foot Impact of Smoking on Healing Factors Influencing Decision to Amputate Chronic Pain at Seven Years Functional Outcome of Bilateral Limb Threatening Characterization of Patients Ability of Scores to Predict Gait Symmetry and Walking Speed Analysis Beneficial Effects of Physical Threrapy

12

Additional 11

LEAP

Lower Extremity Assessment Project

600 patients; Ten year follow-up 8 Level I Centers 26+ articles NIH funded Changed protocols for severe injury

Major Extremity Trauma Research Consortium

metrc

• Multi Center (13-20)
• UT- MHTMC leadership
• 110 million dollars+ funding
• 16-18 major studies
• Musculoskeletal injuries

METRC

Major Extremity Trauma Research Consortium

Josh Gary, MD

Burn Center

Funding

Andrew Burgess

THANK YOU