Trauma Specialists, LLP : History of Trauma Surgeon and Physicians Contribution to the Development of a Level 1 Trauma Center at Emanuel Hospital

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History of Trauma Surgeon and Physicians Contribution to the Development of a Level 1 Trauma Center at Emanuel Hospital
History of Trauma Centers and Trauma Systems

TS, LLP, evolved from the stresses of a rapidly changing medical marketplace in the Pacific Northwest and the increasing commitment of medical and surgical specialists providing trauma care.

During the 1960's and 70's, the north Portland neighborhood became known for the high incidence of violence, causing a high number of patients to come to Emanuel Hospital, located in north Portland. In 1977, a group of general surgeons at Emanuel Hospital realized that an organized approach to trauma is needed for successful outcomes and asked the hospital administration to begin developing a trauma program. The first step was the development of a hospital based emergency medical services helicopter program, named Life Flight (In 1978, Emanuel Hospital became the fourth hospital in the USA to form one). The general surgeons at Emanuel, all in private practice, provided a general surgeon in the hospital 24 hours a day, 365 days a year to be immediately available to perform life saving surgery.

In 1983, the general surgeons and the general surgical leadership asked the Emanuel Hospital administration to recruit and pay for a Trauma Medical Director with specific skills and fellowship training in trauma and surgical critical care to develop the trauma center at Emanuel Hospital to meet or exceed the highest level of trauma care commitment defined by the American College of Surgeons Committee on Trauma.

Dr. William Long became the Trauma Medical Director for Emanuel Hospital in the fall of 1983. Dr. Long, trained in both trauma and cardiothoracic surgery, brought a new perspective for resuscitating the most severely injured patients using cardiac surgical principles for restarting the heart or restoring cardiopulmonary function. Dr. Long began building Emanuel's trauma program by establishing infrastructure that would support technically advanced ways of restoring life and function.

Listed below is each of the functions of this infrastructure, created in order.

Trauma Registry (1983 & 1984)

CREATION OF A COMPUTERIZED TRAUMA REGISTRY

Originated by Ben Bachulis, MD, Chief of Surgery and Gerald Hynes, RN, computer programmer, this registry, one of the first DOS based trauma registries in the USA, could be managed by a personal computer. This registry enabled the trauma medical director to gather essential data points in the patients' medical records to record all the diagnoses or injuries a patient had, all the operations and procedures performed, and all the complications or problems the patient encountered during the hospital stay. The registry also recorded the patient outcomes and functional status at the time of patient discharge. Using mathematical formulas developed by Dr. Long, Dr. Sacco and others to calculate severity of injury in each patient and groups of patients, the trauma registrar could provide data comparing the Emanuel trauma program's clinical performance with other trauma centers collecting similar data.

Most trauma registries have an assigned person, usually a nurse, who enters patient data into the trauma registry, sometimes days or weeks after patient admission. With this system, data not captured at time of patient arrival, is lost, because it is not recorded and no one can remember the exact detail for the data entry point.

Dr. Long persuaded the Emergency Department nurses and later trauma resuscitation nurses (TRN’s) to enter the data on a patient concurrently, and completely before they assumed care on a new patient and recorded new data. This approach achieved a 95% completeness of data, but not accuracy of data entered.

Trauma Resuscitation Nurse Program (TRN)

The TRN Program began at Emanuel with a former cardiac surgical ICU nurse. Michelle Haun-Hood, RN who was manager of the Medical Surgical ICU and became the trauma program's first trauma coordinator. The TRN program (developed by Dr. Long) provided ICU nurses 300 hours of education in surgical physiology and pathophysiology, especially in the subject of trauma, shock, and post-operative care. 56 critical care nurses were trained in 1983 and 1984.

These nurses (TRN's) were given new roles apart from the ICU environment. They became part of the Trauma Resuscitation team in the Emergency Department (ED) and operating room, and functioned as the monitoring nurse responsible for critical care monitoring and delivery of vasoactive drugs if needed. They provided continuity of patient care as the trauma patient moved from the ED to the Operating Room and to the ICU. They later provided the delivery of the Massive Transfusion Protocol. These roles contrasted sharply with the traditional territorial nature of ED, OR, and ICU nurses, never functioning outside of their geographic environment.

The TRN Program started a career ladder for nurses that led to Life Flight nurses, trauma nurse clinicians and coordinators, trauma nurse specialists, organ donor program and hospital trauma leadership positions.

TRN Career Ladder

OR Nurse Career Ladder

Trauma OR nurses need to have a wide variety of OR nursing skills in multiple specialties in order to be skillful in a level 1 trauma operating room environment. It is unrealistic and unfair to nurses, trauma specialists, and trauma patients to expect a newly trained OR nurses to function effectively in an operating room where simultaneously, Neurosurgeons and OMFS surgeons are working on the head, the thoracic surgeons on the chest, the general surgeon on the abdomen and the orthopedic surgeons on the lower extremities. It takes very experienced OR nurses to keep their wits and their instruments available and organized in such a situation.

Dr. Long proposed that an OR trauma nurse career ladder be established to provide the OR nurse training for the resuscitation and stabilization of the critically injured trauma patient and mobile surgical transport team patient.

OR Nurse Career Ladder

Direct to Operating Room with Unstable Trauma Patients (1983)

Traditional hospital designs are almost 75 years old, and the emergency departments and operating rooms are usually widely separated, sometimes by floors with only an elevator providing access and sometimes by hundreds of yards on the same floor. Patients with stab wounds of the heart and unstable blood pressure in this scenario, get their chest opened in the Emergency Department, almost always in a nonsterile environment with inadequate lighting, instrumentation, and skilled personnel. The mortality rate for these operations in most places was and is greater than 90%. Patients with blunt rupture of the heart from automobile accidents or falls carried almost 100% mortality, leading many emergency medical systems authorities to state that pre-hospital care providers should not transport blunt trauma patients who lost signs of life at the scene or en route.

Dr. Long asked the Emanuel Administration to dedicate an Operating Room and OR staff for unstable patients needing an immediate operation to stop bleeding.

The Emanuel Trauma Program reported in the American Journal of Surgery a 10 year experience with blunt cardiac rupture (world's second largest reported series) a 40% meaningful survival rate which was twice the survival of any other reported series prior to that time. (Article)

A thoracic surgeon at Harborview Medical Center led a multicenter retrospective review of trauma centers treating unstable patients with penetrating chest wounds. Emanuel Hospital and UCSD Medical Center provided a 17 fold better survival rate that other centers without a direct to OR capability. (Dr. Long started the USCD "Direct to OR" in 1983, prior to coming to Emanuel Hospital.)

Anesthesiology Support (1984)

The fourth building block was the development of a commitment from the anesthesiologists to be in the hospital 24 hours per day. In 1983, there were no anesthesiologists spending the night in the hospital. For emergency surgery needs, the anesthesiologist was called in from home, often delaying life saving surgery for at least 30 minutes.

The anesthesiologist has special expertise with the management of a difficult airway, making them valuable members of the trauma resuscitation team if they can be persuaded to be present at the time of patient arrival. They can also provide an anesthetic and are experts in acid-based management and ventilation.

Long found that members of the anesthesia group at Emanuel Hospital were all Board Certified in Anesthesia and many were certified by two or more specialties. Long approached Kerry Keeler, MD, Board Certified in Anesthesia, Internal Medicine and Critical Care to ask his group to provide in house anesthesia service in the hospital for the trauma program 24 hours a day. Dr. Keeler responded, enabling the Direct to the OR Program to have an anesthesiologist present at the time of a patient arrival, and surgery to begin immediately. Under Dr. Keeler's leadership, the anesthesiologists at Emanuel all took rotations on the trauma call schedule, including the cardiac anesthesiologists, the neuro-anesthesiologists, the pediatric anesthesiologists, etc. This provided a wide range of expertise and experiences among the anesthesiologists, which they shared at their CQI meetings.

As the trauma program grew in patient volume, the number of in-house anesthesiologists became two, with two on-call from home. As many severely injured trauma patients survived predicted deaths, and recovered to return to normal function, the Emanuel anesthesiologists became convinced of the value of their commitment.

Massive Transfusion Protocol (MTP) (1984)

Massive Transfusion has been a concept since the Korean War, when platelets became available but usually were given too late to stop transfusion coagulopathies during massive transfusion of banked whole blood. (Whole blood stored in blood banks starts to lose its clotting capabilities and platelet function after 24 hours of storage.)

Active Blood Component Therapy began in the 1970's when the American Association of Blood Banks and the American Red Cross began taking donated blood and dividing it into components, such as red blood cells, plasma, platelets, and cryoprecipitate. Not all patients getting transfusion need all the components of blood, and it was more efficient and less wasteful to use blood components as needed. The availability of fresh whole blood largely disappeared as the general population of the United States became increasing exposed to transmittable diseases from donor to recipient. Blood banks were and are required to do comprehensive testing for transmittable diseases, a process that lasts 48 hours.

At Shock Trauma in Baltimore, also known as the Maryland Institute for Emergency Medical Service Systems (MIEMSS), Ben Dawson, MD, a hematologist/pathologist with an interest in coagulopathies, recognized that many severely injured patients bled to death from the effects of transfusion coagulopathy long after the surgeons had tied off all the major bleeding vessels. Ben recreated whole fresh blood (which does clot) by giving component blood products in a set formula. Dr. Long, a Fellow at Shock Trauma, took the formula to UC San Diego where he became a fellow in cardiothoracic surgery and the Clinical Trauma Director. He implemented the MTP for UCSD, which is still used in some form by cardiac surgery, trauma, and transplant services.

In 1983, Dr. Long worked with the Emanuel pathologists in charge of the blood bank to revise the MTP already in practice and similar to the Dawson protocol. (MTP Protocol) The revision allowed TRN’s to provide blood components by protocol without the direct supervision of a surgeon, anesthesiologist, or pathologist. If given an arterial line provided by the resuscitation team, the TRN could draw from the catheter every 15 to 30 minutes, blood for gas and pH analyses, clotting factors including ionized calcium, and hematocrit. A runner takes the blood samples to the Coagulation laboratory for analyses and in 30 minutes, the results are available to the trauma team in the operating room. A graph of clotting is plotted over time to determine the trends, and the trauma surgeon could then modify the MTP to meet the needs of the individual patient. This protocol frees the anesthesiologist(s) to provide the anesthetic, the ventilation, the vasoactive drug support, and adjust the acid base balance. The surgeon can concentrate on stopping the surgical bleeding. The TRN’s follow the protocol, which they do with 99% compliance rates. The TRN’s also are experts in the use of the blood warmers, and the avoidance of hospital and environmentally induced hypothermia, which adversely affects clotting.

The MTP Protocol allows the blood bank personnel to batch process blood components in the following ratios: 4 units packed red blood cells, 4 units fresh frozen plasma, 5 units platelets, and 5 units cryopreycipate.

Mobile Surgical Transport Team (MSTT) (1985)

Rural states have higher per capita trauma mortality than urban states. Rural hospitals have less equipment, less staffing, less blood bank supplies, and usually less surgical expertise in management of major injuries. In addition, accidents or trauma in remote areas mean longer discovery times, longer response times for ambulances, less skilled emergency medical technicians with less equipment than urban communities have.

Traditional communications and emergency services connecting most rural communities and urban trauma centers involve a phone call from a rural hospital physician to an urban trauma center surgeon, and a request to transfer the patient that needs more resources and expertise than the rural hospital can provide. For the very stable patient, the rural hospital will send the patient in the local ambulance, taking it out of service for the rural community until it returns. For seriously injured patients with time sensitive injuries or life threatening injuries, the urban trauma surgeon usually dispatches an urban-based fixed wing aircraft or rotorcraft medically equipped and staffed by critical care nurses and/or EMT's to the rural hospital to pick up the patient and transfer the patient to the urban trauma center. This works well for trauma patients who have normal blood pressures and are not actively bleeding. For those patients needing immediate and expert surgery to stop bleeding, this system of care does not work to the patient's benefit. It takes too long for the aircraft to come and get the patient and transport to the urban trauma center.

Dr. Long observed that the Advanced Trauma Life Support Course (ATLS) helps non surgeons providing emergency care in rural hospitals to follow protocols that help keep seriously injured patients alive long enough to reach urban trauma centers. ATLS does not teach rural surgeons, many of whom have very little complex trauma management experience, how to operate on and stabilize patients with life threatening injuries and bleeding. He postulated that a team of trauma experts (trauma surgeon, TRN, and a Trauma Operating Nurse) with surgical instruments and enough blood products to support massive transfusion for 4 hours could go to rural hospitals and help the rural surgeon or physician stabilize the unstable patient there, and then transport the patient.

Dr. Long presented to the Western Trauma Association the 10-year and 15-year experience with the MSTT in February 2003. The MSTT achieved a 50% survival rate for severely injured trauma patients whom the referring rural physicians thought would not survive the delays in resuscitative surgeries. The MSTT also provided services to non-trauma surgical emergency patients as well.

Outreach to Rural Communities with Prehospital Trauma Life Support and Farm Rescue Courses to Rural Communities (1985)

Since 1983, Dr. Long has been Medical Director of Life Flight multiple times. With Bill Alguire, a Life Flight EMT, Dr. Long was the first to provide for EMT’s in Oregon, the Pre-hospital Trauma Life Support course (PHTLS) written and endorsed by the American College of Surgeons Committee on Trauma for training emergency medical technicians in trauma assessment and management at the scene of an accident. Farm Rescue courses developed in conjunction with the John Deere Corporation train rural EMT's how to extricate farmers from farm equipment, and treat common injuries sustained on the farm. Dr. Long, working with Life-Flight personnel, provided these courses to rural EMT’s throughout the state of Oregon.

Outreach to Referring Hospitals and the Region with Educational Courses in Trauma, Quality Assurance of Their Emergency and Trauma Patient Care, and Seminars for Coordinated Care Between EMT's and Rural Hospitals (1986)

With John Hopkins, Outreach Director/Coordinator, Dr. Long began to visit rural and suburban locations in Oregon and Washington, to offer lectures in various aspects of trauma and emergency care. As relationships between rural surgeons, emergency physicians and nurses and hospital administrators developed, rural hospitals asked Dr. Long to provide quality assurance for their care of patients transferred to Emanuel Hospital. Some rural surgeons asked Dr. Long to provide locum tenens coverage of their practice when they went out of town for vacations and seminars. Some surgeons and rural hospital administrators asked Dr. Long and Mr. Hopkins to help them find replacement surgeons or new surgeons to join a busy surgical practice at the rural hospital.

These relationships became the basis for Trauma Net, a consortium of rural and suburban hospitals working with Emanuel’s trauma surgeons to provide an annual Regional Trauma Conference for EMT’s , RN’s, PA’s, emergency physicians, and surgeons. The conference features case studies of extraordinary cooperation between all parties, outstanding and unexpected “saves”, as well as problem cases.

The introduction of the Mobile Surgical Transport Team facilitated these relationships even further. Thirty-eight hospitals in Washington and Oregon participate in the Trauma NET Program. The referrals from the rural and community hospitals and hospitals from outside of the Portland Metropolitan area have increased from 50 patients per year in 1983, to 900 patients in 2005. All administrative trauma surgeons and the surgical specialists participate in trauma outreach. Seth Izenberg, MD, leads this program with Dr. Long.

Dr. Izenberg also provides a liaison to the civilian law enforcement agencies (he is a deputy sheriff), to the US Coast Guard, and Oregon National Guard.

Obtaining Commitment to Trauma From Surgical Specialists

Head and Neck Trauma
In 1983, there were four specialties supplying emergency services to the head and neck body area: Plastic Surgery, Otolaryngology (Ear, Nose, and Throat), Oral Surgery, and Ophthalmology. For a patient with multiple facial fractures and soft tissue injuries, the competition between these specialists as to who was responsible for treating certain injuries led to frustration and confusion between all parties. Some surgeons had and have more expertise and training in managing certain injuries than others, and the results were not the same. In many academic training centers, the following residency program directors would badger the trauma director and/or the Emergency Department director to maintain a call list for periorbital facial fractures that would include residents for ENT, Oral Surgery, Plastic Surgery, and Ophthalmology, none of whom would get any meaningful experience in managing these fractures.

In 1985, Dr. Long identified one surgeon who had the credentials and experience to deal with any injury of the face except ocular trauma. When this surgeon was out of town, Dr. Long had to find 4 specialists to cover the head and neck trauma. Dr. Long decided to build a head and neck trauma service with this surgeon as the leader. Dr. Long contracted with Bryce Potter, DDS, MD who not only had a dental degree and oral surgical training that qualified him to deal with all dental misalignments related to trauma, but also a medical degree and ENT training to deal with all sinus, midface, and periorbital trauma. Both Dr. Long and Potter recruited another surgeon with similar credentials, Dr. Erik Dierks, to guarantee 24 hours a day, 365 days a year coverage of the trauma service for facial or head and neck trauma.

Dr. Long contracted with Head and Neck Associates (Drs. Potter and Dierks) to provide for the trauma program exclusive coverage of the following areas: Facial Plastics, Otolaryngology (ENT), Oral Surgery and Dentistry), and Pediatric Airway. By contract, the Head and Neck Surgeons are the "captains of the ship" for any facial trauma ranging from the frontal sinuses to the larynx, excluding ocular trauma, which is dealt with by the Ophthalmologists. Ophthalmologists taking trauma call must follow the Head and Neck Associates' lead for any periorbital traumatic injuries. Neurosurgeons consulted for frontal bone fractures involving the frontal sinuses must follow the Head and Neck Associates' lead for facial injury management.

Within 5 years of this business arrangement, Drs. Potter and Dierks had developed such a regional identity in the management of Head and Neck Trauma and Surgery, they had enough patients to train residents and fellows in Oral, Maxillofacial Trauma and Head and Neck Cancer. Both men got additional training in Facial Plastic Surgery, allowing them to add cosmetic reconstruction skills to their repertoire. Head and Neck Associates have added Brian Bell, MD, DDS, an Oral Surgeon, and Jason Potter, MD, DDS, Oral Surgeon and Facial Plastic Surgeon to their group.

The American Association for Oral Maxillofacial Surgery has recognized the quality of training that Head and Neck Associates provides fellows and supports from national organizational dues, a fellowship in Head and Neck Cancer with Head and Neck Associates. A fellow competing for this program must have an MD and a DDS degree, and completed a residency in Oral Surgery.

Both University of Washington and Oregon Health Sciences University send residents in oral surgical training programs for an experience on this service.

Head and Neck Associates see approximately 15% or 350 trauma system patients per year.

Neurosurgery
Neurosurgeons with an interest in trauma of the brain, spine and spinal cord, and peripheral nerves are very rare. There are too many competing areas of interest within the field of neurosurgery (neuro-oncology, neurovascular diseases, degenerative spine surgery, dyskinesia neurosurgery, pediatric neurosurgery, seizure neurosurgery, etc,) to attract "neurotraumatologists". The hours for neurotrauma patient care are bad for home life, and a professional career. There is also the large number of people who do not have medical insurance to pay for emergency/neurotrauma care.

Most neurosurgeons working at trauma centers in community hospitals share the burden of ED/Trauma call, but do not share a common neurotrauma management philosophy for the nurses, house staff to understand and follow. Because most neurosurgeons feel that emergency/trauma care is a burden, they demand from the hospital money to take call, as an offset from the time they take away from their private practice to take care of trauma patients.

For 20 years, neurotrauma call coverage at Emanuel has been a problem. Of the 38 neurosurgeons in private practice in the Portland metropolitan area, only six have ever offered to cover neurotrauma call, and the call coverage has been less of a commitment than an obligation. A neurosurgeon on call could choose to put the trauma center on divert for neurotrauma if there was another surgical case the neurosurgeon would rather be doing. From 1983 until 1994, Dr. Long and Emanuel Hospital contracted with a variety of community practiced based neurosurgeons to try to get reliable coverage of the trauma program.

In 1995, the Emanuel Hospital administration contracted with one group of neurosurgeons, who moved part of this base of operations to Legacy Emanuel Hospital. For the next 4 years, there was excellent coverage and quality of emergency/trauma neurosurgery by essentially 6 neurosurgeons, but the human cost of providing this level of trauma commitment to the trauma program was high. In 1998, the group made a demand to Emanuel Hospital that they needed $1.5 million to recruit and hire more neurosurgeons if the same level of neurotrauma coverage and service was to be maintained. Based on a nationally recognized neurosurgeon’s advice, Emanuel Hospital chose not to renew or extend their contract.

In 1999, the Emanuel Hospital Administration chose to hire two neurosurgeons to help cover the trauma program, with support from some of the private practicing neurosurgeons on the Emanuel medical staff. This arrangement lasted for two and a half years. In 2002 the two neurosurgeons chose to enter private practice. One of these neurosurgeons is Dr. Jefferson Chen, MD, Ph.D. who became the Director of Neurotrauma, based on skill, training and interest. The other is Dr. David Adler, a trauma and spine neurosurgeon.

Dr. Chen brings a sense of focus and purpose to the neurosurgeon program. He coordinated the call schedule, provides a clinical research program, and leadership for The Oregon Neurosurgical Association. He also provides a twice-yearly seminar on what is new in neurosurgery and neurotrauma.

Currently, there are 5 neurosurgeons providing trauma call at Emanuel Hospital. All of them have independent contractor relationships with Trauma Specialists, LLP. They meet as a group, but function independently through their own corporations. They cross cover each other's practice. There are currently no common Neurotrauma protocols for patient management solely provided by neurosurgeons.

Neurosurgeons see approximately 40% of all trauma patients admitted to the Emanuel Hospital's trauma service-almost 1000 patients per year.

Evolution of Cardiothoracic Trauma at Emanuel Hospital

Cardiothoracic surgical coverage of the trauma program began in the 1970s when Adel Matar and his colleagues began to provide trauma call coverage. In 1982, Jonathon Hill joined Dr. Matar's practice of cardio-thoracic surgery. In 1983, Dr. Long, a cardiothoracic surgeon and a trauma and critical care specialist came to Emanuel Hospital as Trauma Medical Director. Together, Dr. Hill and Long developed Cardiothoracic Trauma and Thoracic Aortic Diseases as specialties of cardiothoracic surgery at Emanuel Hospital.

In November 1983, Dr. Long working with Robert Wilson, an orthopedic surgeon, repaired a flail chest with a pelvic reconstruction plate-the first to be done in the Pacific Northwest. Over the next 20 years, Drs. Hill and Long have repaired over 100 patients with significant flail chests with a variety of internal fixation devices. The techniques progressed from the 3.5 mm thick pelvic reconstruction (made of stainless steel) plates placed perpendicularly to the ribs and holding the flail segment in place like a suspension bridge, to plating individual ribs with the same type of plate, to plating with titanium reconstruction plates and locking screws. This series represents one of the largest experiences with open reduction and internal fixations of ribs in the USA. Included in this series are four patients with traumatic lung hernias, where the lung herniated through broken ribs and intercostal muscles and overlying musculature into the subcutaneous space.

Also, in November, 1983 Dr. Long repaired a patient's ruptured bronchus and subclavian artery injured during a motor vehicle crash. Over the next twenty-one years, Drs. Hill, Long, and colleagues have repaired over 100 thoracic aortas and/or arch vessels. There has been only one paraplegia resulting from their surgical management, in contrast to a 15% paraplegia rate in most trauma centers.

The experience with injured thoracic aortas led Drs. Hill and Long to developing interest and experience with thoracic aortic dissection, a life threatening surgical emergency caused by degeneration of the lining of the thoracic aortic wall. Dr. Hill has become the cardiothoracic surgeon within the Legacy Health System with the most experience and success with management of this disease.

In 1985, the C. R. Bard Company produced a scaled down version of a standard cardiopulmonary bypass machine (weighing almost a ton) to a mini-cardiopulmonary bypass unit (weighing 150 pounds and portable within the hospital environment). This unit was designed by two perfusionists to help the resuscitation of patients in cardiac arrest. C. R. Bard also developed two cannulas for the femoral artery and vein that can be inserted percutaneously.

Drs. Hill and Long immediately saw the application of this technology for the trauma patients dying from hypovolemia, hypoxemia, hypothermia, and coagulopathy and acidosis. Most of these patients are dying of cardiopulmonary failure caused by prolonged shock. Cardio-pulmonary bypass technology allows large amounts of blood and blood products to be infused rapidly, supports the heart's diastolic perfusion, oxygenates the patient, and rewarms the patient, improving the patient's cardiac performance and the ability to clot.

In 1986, Dr. Hill was the first surgeon to use this new technology to resuscitate and support a multiple trauma patient, dying from hypovolemia, hypoxemia, hypothermia, coagulopathy, and acidosis. The patient survived and made a complete recovery. Since then, Drs. Hill and Long have used this technology on approximately 50 multiple trauma patients, some of whom are recorded in the surgical literature.(Article) To date, Drs. Hill and Long are the only surgeons in the USA to use this technology for resuscitation of the severely injured patients who cannot be resuscitated by any other means.

In 1987, Dr. Hill and two perfusionists, Jim Parsons and John Bennett, miniaturized the portable cardiopulmonary bypass even further to fit inside a helicopter or fixed wing aircraft, enabling Drs. Hill or Long to take the Mobile Surgical Transport Team and a perfusionist to other hospitals where patients need this expertise for resuscitation. To date, over 50% of patients placed on emergency cardiopulmonary bypass at other hospitals have survived resuscitation, transfer to Emanuel Hospital for care, and returned to normal life. Some of this experience has been recorded in the surgical literature. (Article)

In 1995, Drs. Perchinski (a general surgical resident at Emanuel), Hill and Long published a 10 year experience with blunt cardiac rupture. Their 40 cases represented the second largest reported series in the world literature. Because the heart is ruptured, blood leaking from the surface of the heart into the pericardial sac compresses the heart and prevents it from filling. A large rent in the heart means that most patients will die at the scene of an accident or en route. Those that reach hospitals alive need immediate surgery and suture repair of the heart for survival. Emanuel Hospital is one of the few hospitals with a trauma operating room next to the ED, and an in-house attending trauma general surgeon who has been trained and encouraged by Drs. Hill and Long to perform subxiphoid pericardial window, median sternotomy, and cardiorrhaphy.

All Emanuel trauma general surgeons have been trained to cannulate the right atrium, place epicardial-pacing wires, and do intra-aortic root injection of epinephrine, and defibrillate the heart with internal paddles. The clinical results speak for themselves. Emanuel's trauma team has a 40% survival compared to the next best-reported series, which has a 20% survival. (Article)

The Emanuel cardiothoracic surgeons see approximately 100 trauma patients per year (4%), of which 6 to 10 patients has arch vessel and/or aortic injuries, and 30 to 40 have flail chest severe enough to warrant consideration for operative fixation. Riyad Karmy-Jones, MD, joined Drs. Hill and Long in 2006, to help cover thoracic trauma. Dr. Karmy-Jones has credentials in trauma, surgical critical care, cardiothoracic surgery, and invasive vascular radiology.

Orthopedic Surgery for Trauma

The Portland Orthopedic Clinic, formerly one of the most established orthopedic specialty groups in Oregon, provided trauma orthopedic services at Emanuel Hospital for years before 1979, when formal trauma orthopedic services became available. Robert J. Wilson, MD, a graduate of the University of Michigan orthopedic training program, became the clinic's first traumatologist. Dr. Wilson recruited Gregory Irvine, MD, who also had great interest in severe orthopedic trauma, and he too trained at the University of Michigan.

The next phase in the evolution of trauma orthopedics started in 1996, when the first orthopedic surgeons with fellowship training in trauma orthopedic surgeons joined the practice. Fellowship training means 2 years of additional experience with complex pelvic fracture and extremity injury management.

Two orthopedic surgeons were trained at the University of Iowa, where there is a nationally renowned orthopedic residency. Jim Krieg, MD did trauma orthopedic fellowship training with the Harborview/University of Washington group, and became the second Oregon Orthopedic surgeon with that credential. Steve Madey stayed at the University of Iowa to do a Hand and Microvascular Surgery Fellowship. Doug Beaman, MD later became one of Oregon's first foot and ankle fellowship trained orthopedic surgeon.

In 2000, the Portland Orthopedic Clinic dissolved, and a splinter group (Beaman, Krieg, Madey) formed the Portland Orthopedic Specialists, LLC (POS) with whom TS, LLP contracted exclusively to provide trauma orthopedic trauma care.

The Portland Orthopedic Specialists (POS) subcontracted with former colleagues, Drs. Chris Achterman and David Noall to help with orthopedic trauma call coverage. One year later, the POS recruited two additional fellowship trained orthopedic surgeons: Greg Thomson, MD, a Trauma Orthopedic specialist, and Richard Gellman, MD, a Trauma Foot and Ankle specialist. In 2004, the POS added Tammy Simpson, MD, fellowship trained in sports and trauma orthopedic surgery. In 2006, the group hired Britt Fromme, MD, a fellowship trained hand surgeon to join Dr. Madey.

Clinically, the trauma orthopedic surgeons see approximately 1500 patients per year (55%), most of who are transported by ambulances from the scene of the accident; other patients are referred to them from hospitals in Oregon and Washington.

In 2000, two trauma orthopedic surgeons, James Krieg, MD and Steven Madey, MD, came to Dr. Long and requested help in building a Biomechanics laboratory to facilitate orthopedic research, teaching of residents and Fellows, and to attract a promising leader in biomechanical research. They had in mind Michael Bottlang, a PhD in Biomechanics at the University of Iowa where Drs. Krieg and Madey had trained. Long, Krieg, and Madey formed a corporation, Center for Applied Biomechanical Research to protect innovative and patentable concepts. They also approached Legacy for start-up funding for the laboratory and Michael Bottlang. In 2001, the Legacy Biomechanical Laboratory became operational with Michael Bottlang as the director.

With Drs. Krieg and Madey's leadership and ideas, and Michael Bottlang's research talents and energy, the Legacy Biomechanical Laboratory obtained within two years a Naval Research Grant to develop a Pelvic Sling (wrap) to stabilize complex pelvic fractures at the accident scene or at referring hospitals. A U.S. Patent was awarded in 2003. The sling is sold commercially throughout the world.

The Legacy Biomechanical Laboratory has attracted world wide attention for excellence in research. German students regularly come to work at the laboratory for specific projects. Five to six research papers a year are regularly published in scientific peer reviewed journals. (Legacy Biomechanics Laboratory Publications) Several additional patents have been awarded.

In 2004, Dr. Bottlang organized and hosted in Portland the International Meeting of American Society for Biomechanical Research.

Trauma and Surgical Critical Care

Surgical critical care began at Emanuel Hospital in 1973, when Phil Parshley, a general surgeon trained at a burn center in Boston, Massachusetts, began to develop a Burn Care unit, the first and only one in Oregon. From humble beginnings, the Burn service, now called the Oregon Burn Center, has grown in stature and size to a 300 patients a year program located in a separate building on the Emanuel Hospital campus.

In 1983, Dr. Long became Emanuel's first trauma and surgical critical care fellowship trained surgeon, and Oregon's second trauma fellowship trained general surgeon (Robert DuPriest, MD of Eugene, Oregon, was the first). Dr. Long introduced the concept of multidisciplinary Continuous Quality Improvement, which involved all medical and nursing specialties treating trauma patients. From these meetings arose patient care trauma protocols, which defined the team approach to patient care with assignment of a role for each participant, as well as the first decision trees used for patient care in trauma surgery in Oregon. In conjunction with William J. Sacco, PhD in Mathematics, and Susan Coombs, a nurse now an administrator at Legacy, Dr. Long developed Mathematical models for injury severity and disability outcomes for Trauma patients (FIMS index-Functional Independent Measurement System). (Article)

In 1986, Dr. Long hired Tony Borzotta, MD, whom the American College of Surgeons certified as having Special Competence in Surgical Critical Care, to be Medical Director of the Medical and Surgical ICU at Emanuel Hospital, a title that Dr. Long held previously. Dean Gubler, DO, MPH is the current Director of Surgical Critical Care at Emanuel Hospital. All subsequent fall time trauma surgeons (Izenberg, Karmy-Jones, Kaufmann, Michaels, Ramzy, Wang) are fellowship trained in trauma and surgical critical care.

Design of a Trauma Center To Maximize Efficiency of Trauma Care Providers

In 1987, the trauma program at Emanuel Hospital had grown in patient volume to the point that more rooms were needed in the Emergency department, Operating area, and Intensive Care unit to take care of severely injured trauma patients by professionals with special interest and training in trauma. Dr. Long was fortunate to influence the Emanuel Hospital administrator (Fred Eaton) and medical colleagues to create a floor plan incorporating the following concepts:

1. ONLY STABLE PATIENTS SHOULD BE EVALUATED AND TREATED IN THE EMERGENCY DEPARTMENT.
The Emergency Department has no equipment or supplies for any complex surgery and ED nurses are not trained as operating nurses. There is no sterile environment in the Emergency Department. There is usually no anesthetic equipment or inhalation anesthetic drugs in the ED.

2. UNSTABLE PATIENTS NEEDING IMMDATE SURGERY SHOULD GO DIRECTLY TO THE OPERATING ROOM.
These patients need resuscitation, evaluation and surgery, where there is a sterile environment and all the necessary equipment immediately at hand to do almost any type of surgery, and experienced OR nurses to assist with surgery.

3. A CAT SCANNER NEEDS TO BE LOCATED IN THE EMERGENCY DEPARTMENT.
Emergency Department personnel should not leave the E.D. area with a patient to go to the radiology department which can be a considerable distance away, and which does not have equipment, staff, and capacity to deal with unstable patients with major injuries. ED staff that does not have to leave the ED area can move rapidly more trauma patients in and out of the scanner. As Emergency Departments get busier with increasing numbers of patients, the time ED staff spend taking patients to the main Radiology Department becomes burdensome to the staff and less efficient for ED operations and patient flow.

4. A TRAUMA OPERATING ROOM(s) SHOULD BE IMMDATELY ADJACENT TO THE EMERGENCY DEPARTMENT AND THE CAT SCANNER(S).
This arrangement avoids the transporting unstable patients into public corridors and to the main Radiology Department where there may be other patients waiting for the CAT scanner. This arrangement facilitates the movement of an OR patient to go directly into an adjacent CAT scanner and return to the operating room with a minimum of inconvenience to the trauma staff and the patient. This is especially helpful for emergency neurosurgical patients who may need several surgeries and CAT scans to get the optimal surgical result.

5. THE TRAUMA INTENSIVE CARE UNIT NEEDS TO BE ADJACENT TO A CAT SCANNER(S) AND TRAUMA OPERATING ROOMS.
Patients with severe brain, chest, and abdominal injuries frequently have coagulopathies which continue to bleed despite the administration of blood clotting factors. The close proximity of CAT scanners and operating rooms allows the ICU staff and trauma specialist’s opportunities to use the CAT scanner for monitoring bleeding and organ perfusion, and to take the patient quickly to the operating room for postoperative or new surgical bleeding.

6. THERE SHOULD BE NO ELEVATORS SEPARATING THE EMERGENCY DEPARTMENT, THE TRAUMA CAT SCANNERS, AND THE TRAUMA OPERATING ROOMS.
Elevators are notorious for breaking at the worst possible time, and stranding the patient, and the staff, thereby jeopardizing patient care. Most hospital elevators are too small for patients on significant life support.

7. THE HELIPAD AND AMBULANCE BAY SHOULD BE A SHORT DISTANCE FROM THE TRAUMA OPERATING ROOMS AND CAT SCANNERS.
The trauma patient, bleeding from every "pore" should get to the operating room in the most direct route possible, and not wind through a labyrinth in the ED or hospital.

The Trauma center design on the first floor of the new West Wing patient tower on the Emanuel Hospital campus includes these concepts. The trauma center opened in 1988, and is still in use. There are 5 resuscitation bays in the ED, 2 light speed CAT scanners in the ED/Trauma area, 4 Trauma ready operating rooms, all with the capability for cardiopulmonary bypass, and a 14 bed Trauma/Surgical Intensive Care Unit. The "Corridor of Life" is the short passageway from the helipad/ambulance bay entrance, past the 5 resuscitation bays in the ED, to the end of the corridor where the ED/Trauma CAT Scanner and the 4 Trauma/Cardiac/emergency operating rooms are located.

Further Development of Trauma Physical Plant

Trauma Acute Care Unit - TRACU
By 2000, the trauma in patient census had risen to 40 to 50 patients per day, thirty of which were not in the intensive care units. Many of these patients were scattered over several medical and surgical units on different floors in the hospital. Rounding on these patients sometimes took all day, interfered with the resident education and training experience, and made nursing care and progression of patient care to discharge a lengthy process.

Dr. Long suggested to Stephanie White, Vice President of Emanuel Hospital, and Michelle Haun-Hood, RN to create a TRACU where the most severely injured trauma patients, not in ICU, could be managed by specially trained trauma nurses oriented towards recovery and rehabilitation. This team of nurses would be supported by physical therapists, occupational therapists, speech therapists, nutritionist, physiatrists, psychiatrists, psych nurses, and social workers to optimize efficient patient care and discharge planning.

In support, the attending trauma surgeons, residents, and physician assistants would round daily on all trauma patients, even those with single specialty injury to provide efficient coordinated care. This arrangement freed the specialty surgeons, predominately the orthopedic surgeons and neurosurgeons, to focus on getting their surgeries done in a timely manner.

Creation of Trauma Multidisciplinary Clinic
In many trauma centers, trauma patients who have been discharged from hospital are followed up in the different specialist’s private offices, usually not located in the same office building. For patients, this arrangement is very frustrating, leading to hours lost in waiting rooms, getting logged in and repeated questions by the specialty doctors. Furthermore, both patients and doctors are frustrated by the lack of concurrent information flowing between doctors, which lead to duplication of tests, conflicting orders, and follow-up appointments.

Dr. Andy Michaels proposed a trauma multidisciplinary clinic to aggregate all the trauma specialists in one office suite at the same time, to get the following efficiencies:

One patient visit for all specialists
Coordinated diagnostic tests
Coordinated Therapies (PT, OT, ST)
Coordinated pain control managed by clinic nurses working under protocol
Coordinated re-admissions to hospital as necessary
Coordinated disability assessment
Timely reporting to insurance agencies and employers
Summation of trauma care in documented form
Complete outcomes data for research

The clinic was created and placed next to the pain clinic (run by anesthesiologists), the complex wound clinic, and one floor away from the outpatient physical and occupational therapy clinic. Interpreters are available to overcome language barriers, thus decreasing the costs to any one specialist’s office. The clinic achieves 95% follow-up of all admitted trauma patients.

Stephani White, VP and Michelle Haun-Hood, RN championed the concept to reality.

The Development of Physician Assistant Program in Trauma

In 2002, the Residency Review Commission, responding to congressional mandates, made sweeping changes in resident education and training. The most significant impact on patient care services was the limitation in the number of hours a resident could work, coupled with no increase in the number of resident positions to offset the in hospital presence of residents to provide care around the clock.

In 1986, the Portland Surgical Society supported the idea of a limited number of trauma centers as long as attending trauma surgeons were in the hospital 24 hours a day to supervise them. The reduction of resident hours and the increasing number of trauma patients forced the attending trauma surgeons and Emanuel to look to the use of physician assistants to help provide continuity of care and depth to the trauma team admitting multiple patients.

Mark Kestner, MD, a trauma surgeon hired by the Hospital to be chief of surgery, lobbied successfully the administration to provide physician assistants for the trauma services. The PA’s, initially employees of the hospital but supervised by the trauma surgeons, could not serve two masters.

In January 2006, trauma surgeons of Pacific Surgical, PC became the employers of PA’s recruited to join Pacific Surgical, PC. (Link to PA program)

Growth and Development of Associate Trauma Medical Directors to Meet the Standards of the Surgeons Committee on Trauma

In 1985 Anthony P. Borgotta, MD became the first Medical Director of Surgical Intensive Care at Emanuel Hospital. He was charged with the responsibility to establish clinical research trials in the Surgical Intensive Care Units.

In 1988, Linda Erwin, MD became Director of Violence Prevention and Trauma Quality Assurance. Steve Datena, MD with credentials in surgical critical care became Director of OUTREACH to community hospitals and Director of the Advanced Trauma Life Support Courses provided at Emanuel Hospital.

In 1997, Andrew J. Michaels, MD with an MPH degree from the University of Michigan became the Director of Trauma Outcomes Research and Informatics. He later changed focus to become Director of Trauma Quality Assurance and the Trauma Multi-Disciplinary Clinic.

In 1999, Seth Izenberg, MD became responsible for the Trauma Acute Care Recovery Unit (TRACU), ATLS Courses and liaison with paramilitary agencies such as The Oregon National Guard 1042nd Aeromedical Wing, Coast Guard, and Clackamas County Sheriffs Department. He is now the Resident Liaison with Madigan Army Medical Center in Tacoma, Washington.

In the year 2000, Ameen Ramzy, MD became Director of Prehospital Care, responsible for prehospital emergency communications, protocol development and training for EMT’s, aeromedical transport, and quality assurance for Trauma Care by EMT’s.

Drs. Borzotta, Datena, and Erwin left the trauma program and TSI for other opportunities.

In 2001 Dean Gubler, DO, MPH, a retired Navy captain and Director of Critical Care at the Navy hospital in San Diego, became the new Associate Medical Director of Trauma and Surgical Intensive Care. After the 9/11 terrorist attack, he became the expert with the Oregon Health Division on Disaster Preparedness for bioterrorism.

In 2002, Chris Kauffman, MD, MPH, formerly Associate Chief of Surgery at Uniformed Services University and an army colonel, became the director of ATLS for Emanuel and Director of Trauma Education for Trauma Fellows, Residents and Physician Assistants. Dr. Kaufmann is the national and international ATLS chairperson and serves on the National Committee of ACSCOT. Dr. Kaufmann is responsible for resident and physician assistant education in trauma.

In 2004, Richard Edlich, MD, Ph.D., retired from the University of Virginia Medical School, chose to come to Oregon. He became the Director of Trauma Prevention, Research and Technical Course Development.

These associate medical directors assure that every aspect of their directorships fulfills the requirements of The American College of Surgeons Committee of Trauma.

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