Trauma: When care is critical

Vital Signs » Spring 2014

Kelly Long’s date with trauma began one predawn morning last year when the normally “super-cautious” cattle farmer made a rare misstep. She was sure there was a safe distance between the newborn calf she was about to tag and its 1,400-pound mother. But this was no ordinary mother—cow No. 6051 was a first-time mom new to Long’s Lynchburg, Ohio, farm and in a particularly cranky mood that morning.

Within seconds, the cow charged Long, clearing a feed bunk along the way, and leveled the 130-pound farmer with her first blow. She then trampled her target as the 47-year-old lay helpless, barely conscious and covered in feed pen muck. “They’ll come at you with their head like a bull, cows will,” Long recalled months later. “If they feel their calf is threatened, they won’t stop, and she didn’t stop. From then on, everything is blurry.”

During those blurry moments, Long later learned, a four-legged first responder came to her rescue — her dog Danica, a 2-year-old border collie who specializes in cattle herding. Evidence later revealed that Danica must have attacked the cow during those harrowing moments, giving Long the brief reprieve she needed to stumble out of the pen and into a barn, where she found a five-gallon bucket, sat down and phoned for help. Family members rushed to her aide, and when it was clear Long couldn’t catch her breath and couldn’t get up from that bucket, they called 911. “The EMS squad was there in, like, two seconds,” Long remembered.

First responders from Lynchburg Fire and Rescue rushed Long to Highland District Memorial Hospital in nearby Hillsboro, a rural community about 60 miles southeast of Dayton. Long’s blood pressure bottomed out along the way. At Highland, doctors inserted a chest tube while a helicopter and EMS team from CareFlight Air and Mobile Services waited to whisk Long to Miami Valley Hospital, a Level I Trauma Center.

At Miami Valley (MVH), a trauma team that included Kimberly Hendershot, M.D., an assistant professor in the Boonshoft School of Medicine Department of Surgery, assessed the damage: eight broken ribs on Long’s right side, a collapsed lung and a “shattered” liver. Long would spend the next two weeks at MVH recovering from her injuries. She would return on two more occasions because of complications, but today is otherwise healthy. Most grateful, too.

“I love them all, from the EMS crews to my doctors, nurses, and therapists,” Long said. “They took such good care of me.”

Wright State integral partner in region’s trauma care

At a time when trauma care’s role in our society seems increasingly vital, as last year’s Boston Marathon bombing and other tragedies of the last decade remind us, Long’s experience illustrates how a trauma system is supposed to work: An EMS crew responded quickly to an injury scene. Absent a nearby trauma center, a local hospital stabilized a patient, communicated clearly with the nearest appropriate trauma center, and sent her there. From emergency department care through physical rehabilitation, the trauma center nursed a patient back to health. A life was saved.

Long’s story also shows Wright State’s role in trauma care through its affiliation with local trauma centers and the physicians and caregivers it educates, trains, and employs. Besides Hendershot, a 1999 Boonshoft graduate, almost the entire faculty in the Department of Surgery is on staff at a local trauma center. That includes A. Peter Ekeh, M.D., professor of surgery and interim director of Trauma Services at MVH, and his predecessor in that role, Mary McCarthy, M.D., chair and professor of surgery, who founded MVH’s trauma program in 1991.

“Virtually all Level I Trauma Centers are affiliated with a university setting because research is an extremely important component, as is injury prevention and education,” said McCarthy, a member of the American College of Surgeons (ACS) Committee on Trauma. “The Wright State University faculty have participated in the development of the Miami Valley program throughout its existence. So what we have here is nationally recognized quality care, and it’s provided through the resources of the university and the participation of its faculty at a national level.”

Preparing for disaster

In the aftermath of the Boston Marathon bombing, Level I Trauma Centers at six area teaching hospitals treated hundreds of patients, many with serious injuries. Three people died at the scene, but everyone who made it to the hospital that day survived.

“It’s remarkable how well the system worked,” said Daniel Butler, M.D., trauma program medical director for Atrium Medical Center in nearby Middletown.

Speaking last September at Wright State as a panel member for a discussion on the region’s trauma centers, Butler noted that within three minutes of the blast, all trauma centers in Boston were notified. Within four minutes, mutual aid requests had gone out to emergency personnel. Eighteen minutes after the blast, the scenes were all cleared, and within 30 minutes, all of the injured were in a hospital. All survived.

“You know why?” asked Butler. “Because of the lessons learned from 9/11 and other disasters since then. They prepared, they practiced, practiced, practiced, and when something happened, they were ready for it.”

Similarly, hospitals in the Dayton region have plans in place should a natural or man-made disaster strike this area. The region has five trauma centers: Miami Valley at Level I, Kettering Medical Center and Dayton Children’s Hospital at Level II, and Atrium Medical Center, Soin Medical Center in Beavercreek and Greene Memorial Hospital in Xenia at Level III. The entire state has 44 trauma centers in all, 14 at Level I, according to the ACS.

The different levels (I-V) refer to the kinds of resources available in a trauma center and the number of patients admitted yearly, according to the American College of Surgeons, the authority that verifies hospitals as trauma centers. Level I is the highest level, meaning the hospital must be ready at a moment’s notice to respond to large-scale disasters and is capable of providing total care for every aspect of injury—from prevention through rehabilitation.

“If there is an occurrence like the Boston Marathon bombing, we are prepared for such a calamity,” said Ekeh.

MVH was designated in 2006 by the National Foundation for Trauma Care as one of the top five “highly prepared” trauma centers in the nation for its preparedness to respond to large-scale disasters. The hospital joined four other medical centers nationwide that received the accolade.

Ekeh said MVH’s disaster plan involves virtually every facet of hospital operations, from the emergency department to the operating rooms to the patient floors. Mock disaster training helps staff determine how and where best to use hospital resources, and determine who is most seriously injured and who is too injured to be saved. Working with other area hospitals, including competitors such as Level II Trauma Center Kettering Medical Center, is an integral component, too, he said.

“We’re working on how we can work together more on responding to disasters,” he said.

Working with the military— lessons from war, staying sharp at home

Doctors say advancements in trauma care are largely driven by the symbiotic relationship the military and civilian medical communities enjoy.

“The trauma center here has a close relationship with Wright-Patterson Air Force Base,” Ekeh said. “Their surgeons come here and rotate with us to keep them in a state of perpetual readiness. We’re also involved heavily in national and international meetings where we interface with the military and exchange ideas.”

Butler, the trauma surgeon in Middletown, is a colonel in the Army Reserves who has served three tours in Iraq and Afghanistan in recent years. He said in every war there have been medical advances, and “as we learn from each war we try to translate that knowledge into better civilian trauma care.” He pointed to three advancements in particular:

  • The use of tourniquets, long frowned upon in civilian medicine because they were believed to increase morbidity and mortality. “But in war we found that tourniquets do save lives and they’re an absolute necessity to first responders, surgeons, and other medical personnel in combat zones,” Butler said. In civilian medicine today, he noted, most EMS squads carry tourniquets.
     
  • Blood transfusions. The old industry standard was to pump a bleeding patient full of I.V. fluids and red blood cells until the bleeding could be stopped on the operating table. But in the 1991 Gulf War, the military learned that method could actually increase bleeding. During the Afghanistan and Iraq wars, the military discovered whole blood transfusions produced better outcomes. Bleeding patients are loosing whole blood, after all, not just components. So today the standard is to start a “1:1:1 transfusion” (one unit of red cells, one unit of platelets, and one unit of plasma) to match whole blood components that were lost from bleeding.
     
  • Damage control surgery. This type of surgery has been around since the 1980s, Butler said, but it really came into focus during the Afghanistan and Iraq wars. Military doctors learned they could save more lives by focusing on the most serious damage first and leaving the rest for the operating room or ICU at a medical facility with a higher level of care. “You don’t do any fancy surgery, you do ‘meatball surgery’ to get the patient more stable,” Butler explained.

Butler also mentioned the military’s use of cots instead of backboards as an important lesson, but it’s been slow to catch on in the civilian arena. “We know from the data that lots of patients are injured by being on a backboard, more so than from not being on a backboard,” he said. “Some EMS units are slowly changing to get rid of backboards... Sometimes it’s not easy to translate what we’ve learned on the battlefield into civilian medicine. It takes time and lots of education.”

The military benefits from civilian medicine, too.

McCarthy, the surgery department chair, said the first Air Force attending surgeon to join MVH’s staff joined in 1991. “It’s like an embedded journalist; we have an embedded trauma surgeon,” she said.

McCarthy said Wright State and MVH have been training Air Force residents since 1974, and that half of Wright State’s eight surgical residents each year are from the Air Force.

The latest to join is Lt. Col. John Bini, M.D., under an Air Force program called the Sustainment of Trauma and Resuscitation Program (STARS-P). The program allows Air Force attending surgeons, nurses, and medical technicians to rotate through Level 1 Trauma Centers to hone their war readiness skills. The rotations are considered part of their normal duty time.

Bini came to Wright-Patterson in September from San Antonio, Texas, where he was chief of general surgery at Wilford Hall Medical Center on Lackland Air Force Base. Wilford is the Air Force’s flagship hospital and serves as a Level 1 Trauma Center in Texas.

“It’s providing us a platform to maintain our surgical proficiency,” Bini said of STARS-P. “I think as we progress in our peacetime mission that all areas of military medicine will find themselves looking for these collaborative civilian ventures in order to maintain proficiency.”

Bini brings considerable wartime experience to his latest post. He’s been deployed to Afghanistan and Iraq three times, including as a chief of trauma and as a surgical flight commander. He’s also an instructor and provider of Advanced Trauma Life Support, and he has served as the course director for the Defense Medical Readiness Training Institute’s Emergency War Surgery Course since 2007.

In his current duties, Bini said he spends the bulk of his time working for Wright State and MVH, but he also works one day a week fulfilling clinical and educational responsibilities at Wright-Patterson Medical Center.

Why trauma care?

It’s a brutal profession on several fronts. Long hours, calls in the middle of night, injuries that are downright grisly, and patients and families whose lives have been shattered, sometimes violently and almost always needlessly. Then there’s the emotional hangover that follows.

But for those who work in trauma medicine, there’s nothing else like it and nothing else they’d rather do.

“Every day is different, you never know who’s going to come through the door,” said Alyssa Gans, M.D., a 2009 Boonshoft graduate and fifth-year surgical resident at Miami Valley Hospital. “The other thing is this is a place where you can make a very big difference very quickly. You really do watch people who come in knocking on death’s door get better. It’s very rewarding to take care of them and see them walk back out the door.”

Echoed Wright State nursing graduate Lisa G. Weaver, R.N., Trauma Program director for MVH: “Trauma is a great way to immediately impact patients and families during a time when their lives have been turned upside down in a matter of seconds. We can’t always fix the patient, but we can provide the best care available, compassion to the patient in their last moments, and reassurance to the family that their loved one was never alone.”

Weaver said she fell for trauma care during her first job as a nurse working in the emergency department at Wilson Memorial Hospital in Sidney, about 30 miles north of Dayton. She grew more committed when she joined MVH in 1991 and then CareFlight Air and Mobile Services soon thereafter, first as a flight nurse and later as chief flight nurse/ clinical operations manager.

Weaver said the job can be “emotionally taxing,” but trauma team members lean on each other for support. “I cope with tragedy knowing that we make a difference in so many lives, and that when trauma patients are brought to our facility—we have over 30 years of caring for high acuity trauma patients—they are being cared for by the best.”

Gans said she found her calling working with MVH’s night trauma team when she was a fourth-year medical student on her surgery rotation. “I loved it,” the Cleveland native recalled. “I looked forward to coming to work every night. It was the most fun I had in medical school.”

Gans heads this summer to the University of Cincinnati for a one-year fellowship in surgical critical care. She credits her education at Boonshoft and the training she’s received from faculty for getting her to this point.

“Wright State does a very good job of getting us into the operating room and into clinical settings very, very early, which is one of the things that sets us apart from other places,” Gans said. “You get much more of a hands-on education. We jump right in, and that prepares us well for our future.”

—Anthony Gottschlich

Top Photo: Assistant professor Kimberly Hendershot, M.D., (right), cared for Kelly Long when she was brought to the Miami Valley Hospital Level I Trauma Center.

Cattle farmer Kelly Long and her dog Danica, who came to her rescue when she was seriously injured by a 1,400-pound cow.

 

Last edited on 07/27/2017.