UTHSC Trauma Centers: Working Miracles in the Golden Hour
The golden hour. The 60-minute difference between life and death. What happens to a person in this first critical hour starting with the impact of a steering wheel crashing into the sternum, a bullet blasting into the spleen, or a knife thrust in the belly will make all the difference in the world.
"We've got to take the right action fast to save lives," said Don Barker, MD (UT COM '75), professor and medical director of the Erlanger Health System Level I Trauma Center in Chattanooga, who succinctly summarized the role of a trauma team.
A team is just what it takes to enter this golden hour day after day, night after night, around the clock, 365 days a year. They are working miracles that would not have been possible little more than 30 years ago. Today, thousands of lives are saved thanks to the development of Level I Trauma Centers and new medical procedures designed to stabilize blunt trauma or penetration injuries within the first hour of occurrence.
UTHSC - Providing a Safety Net for the Greater Part of Tennessee
Leading the way to ensure Tennesseans have access to Level I trauma care across the state are University of Tennessee Health Science Center medical school faculty and the hospitals in which they serve. "UT programs are providing a safety net for a large part of Tennessee," said Phillip Burns, MD, chair of the Department of Surgery at the Chattanooga campus. "In fact, we have been at the forefront of trauma center certification from the beginning."
Three of the state's six Level I Trauma Centers are UTHSC facilities: The Regional Medical Center (The MED) in Memphis, Erlanger in Chattanooga and the UT Medical Center in Knoxville. Vanderbilt's Level I Trauma Center covers Nashville, and two smaller facilities operate in Johnson City and Kingsport.
Strongly supporting the drive to create this statewide network in the early 1980s were UTHSC surgeons Tim Fabian, MD, and Dr. Burns. Along with James Pate, MD, professor emeritus, they were instrumental in launching the nationally recognized Elvis Presley Memorial Trauma Center at The MED. They lobbied the state legislature for a full year to get approval for the centers and wrote the criteria for certification as well. With Dr. Burns in Chattanooga, Andrew Rittenberry, MD, (UT COM '69) drove the Erlanger certification process. Kimball I. Maull, MD, chairman of surgery at UT Knoxville in the 1980s, was also a key player in getting the statewide trauma system established, as well as getting the trauma center at Knoxville certified.
The Vietnam Experience – Birth of Trauma Care
The significant number of soldiers saved during the Vietnam War gave impetus to the institution and institutionalizing of trauma centers. "Surgeons at the time (in the 1970s) realized that soldiers in the jungle were getting better care than many patients stateside," Dr. Burns recalled. "The key was getting to the downed soldier as soon as possible after injury."
Helicopters played a major role by plucking the injured out of harm's way and treating them en route to the field hospital. Back home, helicopters were quickly adopted to supplement the ambulance fleet as part of the plan to launch trauma units. "It is critical to start treating shock before organs start to fail," explained Dr. Burns.
Martin Croce, MD, professor and trauma surgeon at The MED, continued, "If the paramedics can quickly stop the bleeding and get the heart working to deliver oxygen to the tissue, we'll have fewer complications to deal with by the time they get to the trauma center, and outcomes will significantly improve. In fact, if a patient can survive the first 24 hours, his chance of dying is 2 percent." It should be noted that referring to a trauma patient as "he" is not necessarily politically incorrect. Statistics show that a solid 70 percent of trauma patients are male and the vast majority are under age 45.
Thanks to the lessons learned in Vietnam and trauma research since that time, more and more people are surviving once fatal injuries. According to Dr. Croce, today, the overall mortality rate is about 6 percent including patients who arrive basically dead on arrival. Dr. Burns added, "Trauma specialists will learn so much more from the Iraq War; we'll be able to take today's treatment up another notch. It's staggering."
The Level I Trauma Center - More Than Hanging Up a Shingle
"You can't just hang up a sign and call yourself a trauma center; much less a Level I Trauma Center," explained Dr. Burns. The American College of Surgeons is the official governing body and determines the criteria that separate a Level I Trauma Center from the typical hospital emergency room and lower level trauma units:
- Surgical capability 24/7/365 - A typical trauma team includes a general surgeon, neurosurgery, orthopedic surgeon, radiologist, anesthesiologist and trauma nurses.
- Clinical research conducted and published
- Medical education offered
- Public education promoted
Blaine Enderson, MD, professor and head of the UT Medical Center Level I Trauma Center in Knoxville, pointed out another distinction: "We treat severely injured people from the point of injury throughout hospitalization to rehabilitation."
Because a Level I trauma unit must be manned 24/7 and specially equipped, they are expensive; but because they are also critically necessary to saving lives, they are strategically located regionally. As Dr. Fabian describes them, "A Level I Trauma Center is a hospital within a hospital." Level I trauma units have their own:
- Communication center for triage consultation with ambulances and helicopters en route;
- Critical care assessment area with CT scanners and other high-tech radiology equipment;
- Operating and recovery rooms;
- Laboratory and technicians;
- Intensive care units;
- Ambulances and helicopters;
- Ambulance and helicopter access directly to the trauma unit.
UTHSC trauma specialists agree that the development of high-resolution CT scanners and ultrasound are the number one reason trauma care has improved equipment in the last 15 years. "Twenty years ago, we had to do surgery to discover blunt trauma damage," recalled Dr. Barker. "But now, because we have better diagnostic equipment and much more information on the first examination, we only operate on about 20 percent of this type of trauma." This explains why high-tech radiology equipment is located within seconds of the trauma bay.
UTHSC Trauma Research Leads the Field
In addition to the 24/7 mandate and the special staffing and equipment requirements, what sets a Level I Trauma Center apart is the stipulation to conduct research, which explains why most of these centers are located in university-affiliated hospitals.
"UT Health Science Center trauma centers have led the world in research advances in trauma care for the past 25 years," Dr. Croce noted. "Our research has completely changed the way liver and spleen injuries are treated, for example. Treatment of cerebral vascular injuries has improved significantly because of the work done at our trauma centers."
Critical care for trauma patients is considerably different from that for other ICU patients, and much of the progress made in this arena has been due to discovery and clinical exploration at the three UTHSC trauma centers.
"Research done at our trauma centers has changed the entire pattern of care," said Dr. Barker. "Now surgery is the last resort on the kidney, liver and spleen. We've learned to let patients stabilize first, and very often we save the organ."
In spite of the headway made in trauma research, Dr. Croce acknowledged that much more funding is needed. "Trauma accounts for more years of lives lost than heart and cancer combined, yet receives a minuscule amount of federal research dollars in comparison."
Education in the Fast Lane
Justifiably proud of UTHSC's contributions to trauma care research, our Level I Trauma Center leaders are also focused on education, another criteria for Level I designation. According to Dr. Barker, the UT health care system has had a long and intimate involvement with training surgeons to care for injured patients. "No matter what our students end up doing, their stint with trauma care trains them to take care of really sick people," he noted.
In addition to regular work days, trauma team residents and attending surgeons are typically on call nights, weekends and holidays. In spite of the arduous shifts, Dr. Barker pointed out, "A lot of residents have learned a tremendous amount from trauma patients."
Trauma Is No Accident
"Trauma is a preventable disease," noted Dr. Enderson, "Everyone thinks in terms of 'accidents' but a big part of our job is to get people to understand that they can be prevented."
"Trauma is no accident," stated Ben Zarzaur, MD, assistant professor at the Memphis campus. "We don't let the word 'accident' enter our vocabulary when we're training residents."
Dr. Zarzaur, who also holds a master's degree in public health, is particularly focused on educating the public, the fourth mission of a Level I Trauma Center. "We can save one life at a time or impact thousands at a time and leave a bigger footprint."
Level I Trauma Centers must have outreach programs to prevent the injuries they see most often, many of which are alcohol related. Alcohol screening programs are run regularly and interventions are required for those who screen positive.
Promoting safety, thereby preventing trauma, is evident in poster campaigns throughout the UTHSC trauma centers. In addition to drinking and driving campaigns, they focus on prevention in a variety of other situations: motor vehicle safety (wearing seat belts), bicycle safety, water safety and infant/child safety, even anger management counseling.
"Trauma centers and trauma surgeons are at the point of the spear when it comes to prevention," summarized Dr. Zarzaur. "We see the consequences of preventable injuries, and we have a duty to publicize and participate in prevention efforts."
UT Health Science Center
Level I Trauma Centers
The MED – Memphis
- Covers west Tennessee, eastern Arkansas, northern Mississippi, boot heel of Missouri and parts of Alabama and Kentucky
- Treats approximately 5,000 cases annually; 20-25 percent penetrating injuries; 75-80 percent blunt trauma
- Eight trauma surgeons
- Four dedicated trauma operating rooms
- One recovery room
- 23 trauma ICU rooms plus eight neurosurgery ICU rooms
- Dedicated radiology suite
- Four helicopters
UT Medical Center – Knoxville
- Covers a 21 county East Tennessee region, also, western North Carolina and parts of Kentucky
- Treats approximately 3,700 cases per year; 10 percent penetrating injuries; 90 percent blunt trauma
- Six trauma surgeons
- 26 operating rooms
- One recovery room
- 32 ICU rooms
- Dedicated radiology suite
- Four helicopters
Erlanger Health System – Chattanooga
- Covers southeast Tennessee, northeast Alabama, north Georgia and western North Carolina
- Treats 2,800 patients a year; 90 percent blunt trauma; 10 percent penetrating injuries
- Five trauma surgeons
- Eight operating rooms
- 21 adult recovery rooms
- 12 ICU rooms
- Three helicopters
Where the Action Is
Trauma care, which became a subspecialty of general surgery about 15 years ago, is not everybody's idea of a good time. While trauma docs come in all types of personalities, the profession does seem to attract a certain kind of person. They could be called the fighter pilots of the medical profession. "Trauma is definitely where the action is," observed Dr. Burns.
"I guess you could say we're adrenalin junkies," said Dr. Barker. "You have to be able to do this day and night. But let me be clear: we're not risk takers with our patients' lives."
"We don't know from one minute to the next what we'll be doing," explained Dr. Enderson. "We can't have a steady practice because we have to be able to drop whatever we're doing on a moment's notice. People who do this thrive on unpredictability."
"Anybody can play if you're tough enough," added Dr. Barker, "Sometimes you really have to suck it up. We see teenagers injured beyond repair."
"Think about it. Our patients leave home perfectly healthy one moment and the next, something horrible happens and they're on their way to us," reflected Dr. Croce. "It's fun getting these people back on their feet, because, when they finally leave us, they're well again."
"Fun" is the prime motivator for those who choose the trauma route; money isn't. Statewide, up to 15 percent of trauma patients don't have insurance, and a total of 30 percent never pay a dime. Those numbers are much worse in Memphis. Bringing patients back from the brink on a regular basis is what inspires these men and women to keep coming back for more. "They've come in with double-digit bullet holes and we get them back to near 100 percent, but it takes a team, and I want to emphasize that," concluded Dr. Croce.