The History of Shock Trauma

Andrew Burgess MD Conflicts:

• Consultant to Stryker Hopkins Maine Med Private

Hospital Employed ORMC Albany Med

Orlando Regional Medical Center

Shock Injured Patient

Traditional Trauma System

Treated Patient Injured Patient

Mature Trauma System Harborview Tampa Treated Patient Baltimoreetc. SAM POWERS, MD ALBANY MEDICAL CENTER

• Started Trauma Unit in 1968; a cooperative, NIH funded center

• Rensselaer Polytechnic Institute Partners • General Electric Research and Development • Clarifying problems of the injured (renal, pulmonary)

• Often staffed by an Orthopaedic “Shock Fellow” R ADAMS COWLEY

• A pioneering heart surgeon (MASH) • Shock research 1917-1991 • 2-4 bed unit • “Death lab” • Medivac • 1969 Maryland State Police • Envisioned a Statewide system 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

Critical Alliance

Medical School & Hospital

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 Hansen Winquist

Brumback Poka

• Eglseder • Copeland • JohnsonBosse •SwiontkowskiTuren Et al • Pollak • Bathon, Molligan Maryland Trauma Centers Sinai Hospital Johns Hopkins Shock Trauma Center Bayview Medical Center I III II Johns Hopkins Washington County Hospital L1 Hospital

Cumberland Suburban Memorial Hospital IV V Prince George’s Hospital Center

Peninsula Regional Medical Center 1989

• New Trauma Center opens • Goal: A National Center of Excellence • Multiple Injuries, Spine and Head Injury PRIMARY ADULT RESOURCE CENTER Shock Trauma (PARC) • 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 Echelons of Care PARC Trauma STC Burn Centers Level I Eye Specialty Referral Centers Hand Level II Head and Spine Level III Hyperbaric

H Pediatric H H H Perinatal • Off site Local Emergency Departments • Political allies EMS Patient Distribution

Specialty Referrals 5%

Areawide Trauma Centers 10%

85% 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 • Adult patients The Package • High energy musculoskeletal injury • Dedicated resources; ORs6, ICU beds72, etc • Trauma subspecialties financially co-aligned

• Optimum circumstance for developing clinical skills

• Few institutional impediments to mission Center Of Excellence

Quality Assurance and Academic Partnerships

• 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 Mark Scarboro National Study Center for Trauma and Emergency Medical Systems (NSC) On Call

Sabbatical Ellen MacKenzie

Shock Trauma Hopkins UVA Jeff Crandall

UVA CENTER OF EXCELLENCE: EXAMPLE • Hazmat Shock Trauma Orthopaedics • Crash Rescue • Structure Collapse • Trench Rescue • Residents from 7 programs • 4 fellows, • Multiple publications • Go team CENTER OF EXCELLENCE: EXAMPLE

Shock Trauma Orthopaedics, 2000

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

Conflict Avoidance • 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 NOT SO FAST: REALITY TEST

1999

• Now you’re a super-specialist…. But… 2017 • Have you become the musculoskeletal hospitalist? CENTERCENTER OF OF PREPAREDNESS 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 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 Chronic Pain at Seven Years

Knee Dislocations with Vascular Injury Functional Outcome of Bilateral Limb Threatening

Complications Characterization of Patients

Insensate Foot Ability of Scores to Predict

Impact of Smoking on Healing Gait Symmetry and Walking Speed Analysis

Factors Influencing Decision to Amputate Beneficial Effects of Physical Threrapy

12 Additional 11 LEAP metrc Lower Extremity Assessment Project Major Extremity Trauma Research Consortium

600 patients; Ten year follow-up

8 Level I Centers 26+ articles NIH funded Changed protocols for severe injury METRC

Major Extremity Trauma Research Consortium

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

Burn Center Andrew Burgess THANK YOU