Volume 56, Number 1 - Winter 2010

 

By James Hinsdale, MD

The design of trauma systems is one of the most politicized issues in health care. Trauma care is highly specialized and quite demanding when injuries peak in intensity and volume. It is also expensive. Nonetheless, such systems offer great opportunity to save lives if at least three conditions are met: (1) the system is well designed, (2) the right personnel are assembled and work together, and (3) commitment at all levels is maintained to focus on improving quality of care.

What’s needed above all is the will and commitment to design a trauma system. Shortly after I arrived as director of trauma services at Marin General Hospital (MGH) in July 2007, our team began to focus on achieving the holy grail of trauma care: full verification by the American College of Surgeons (ACS). We were awarded this prestigious status in September 2009. It was a tremendous achievement for the entire MGH team, and the esprit de corps of the facility, led by our head trauma nurse Mary Jane Boyd and our ED director, Dr. Jim Dietz, has been exemplary. The commitment of MGH management was essential as well, and they responded by recruiting and training quality staff, including trauma surgeons from the group that I founded in San Jose 24 years ago, the Northern California Trauma Medical Group.

Designing a quality trauma center does no good unless the center is functioning within a system. In other words, the greatest surgeons and nurses may be standing by to stop the bleeding, but their talents will be squandered if the field responders can’t pick out the types of patients who need a trauma center and get them there quickly. Fortunately, we have exemplary EMS leadership in Marin County with EMS Director Miles Juilin and EMS Medical Director Dr. Bill Teuffel. They oversee the field responders of all kinds—fire, paramedics, EMTs, forestry, and law enforcement—who are key to getting patients channeled to the trauma unit.

ACS describes four types of trauma centers. Level 2 is the most common, with full capability to immediately open an operating room to stop bleeding, evacuate brain clots, and restore blood flow to mangled extremities. Levels 1 and 2 are essentially the same, except that level 1 centers typically teach residents and do research. Both levels 1 and 2 have 24/7 neurosurgery requirements, but level 3 does not; nor does it have several other requirements found at levels 1 and 2. Level 4 is basically a category for rural referral hospitals. 

MGH is currently level 3, but it functions as a level 2, like most other trauma centers in the Bay Area.

The major specialties that need to be assembled for rapid trauma care are general surgery, neurosurgery, orthopedics, plastics, anesthesia, ED physicians, radiologists, and OR nurses. These all need to be available 24/7. Given this requirement, many of the trauma surgeons stay in-house 24/7. 

The director’s job is to get everyone to work together. Other duties include constantly monitoring quality of care, dealing with unforeseen problems, and getting MGH to integrate with county services and counties adjacent to us.

Trauma deaths classically fall within a tri-modal distribution: immediate deaths that are largely non-preventable due to exsanguinations or massive head trauma; early deaths that could be prevented by interventions such as stopping bleeding; and late deaths due to relentless advance of infection or organ dysfunction. Late deaths are on the cusp of preventability, and trauma leaders attend endless conferences seeking advances in their special treatment. Trauma centers have been shown to make a difference in both early and late deaths. 

There remains controversy about whether the cost of maintaining trauma centers is “worth it.” That is a societal question. No studies have settled this issue as yet, although an interesting article presented at last year’s national trauma meeting calculated that it cost close to $600,000 to prevent a case of fatal pulmonary embolus in the ICU, using surveillance, prophylaxis, and other treatments.

As a level 3 trauma center, MGH is unique in having 24/7 neurosurgical capability. Indeed, MGH’s trauma services are so extensive that we were chided by ACS for not applying as a level 2 trauma center. Which leads to a sore point: Marin County lacks an approved helipad—a service crucial to linking trauma services to patients in the field or at other facilities. That would have been a crucial component for MGH to function as a level 2 trauma center. 

California Shock/Trauma Air Rescue (CALSTAR), where I serve as medical director, has just had its 25th anniversary. We have flown over 30,000 patients and continue with an unblemished safety record. Marin needs a helipad. It is embarrassing not to have one, given the capability of the trauma center and the quality of air transport care.

To be fair, there are political chafe points that come with trauma. Many Marin residents are insured with Kaiser, which has its own hospital. Triage criteria developed to determine what type of injured patient goes preferentially to a trauma center frequently bring Kaiser patients out of their plan to MGH. These criteria are designed to be widely inclusive, so as not to miss the patient with occult injury who would benefit from rapid care at a trauma unit. We work with our colleagues at Kaiser, and within EMS, to continually reassess our triage criteria, current care guidelines, and outcomes. Kaiser in Terra Linda has put forth its own effort and achieved EDAP status: Emergency Department Approved for Trauma.

Finally, the governance at MGH is slated to change next year, and Sutter’s management is expected to cease. In my opinion, the trauma center has shown excellent ability to function and serve the county under Sutter’s management. My group had been asked to stay on. We would be glad to do so under the new hospital management, and a contract for this transition is being proposed. We are on track to see about 1,000 trauma patients per year. 

Do we think we have made a difference? Emphatically, yes. I have been proud to lead the trauma center for the past two and a half years and to collaborate with other dedicated MGH physicians and staff in achieving the prestigious ACS verification. We hope the citizens of Marin appreciate the level of trauma care available to them and continue to support the trauma system their medical leaders have designed and continue to maintain.