|Volume 33 Number 1||Stony Brook, NY||< January 2020 >|
|PJ Poppers Memorial||Visiting Professor||January Calendar||STARS|
|Kudos||Welcome||CA-3 Spotlight||Chief's Corner|
|ERAS News||PGA 2019||Alumni Reception||Holiday Party|
|Dr. Sadean Retires||New Publications||Where is That?||Monthly Muscle Chillaxant|
Chief's Corner - General Anesthesia Division
Trauma Center at Stony Brook
Daryn Moller, MD
“Code T Level four Critical Care ER”. The words echoing over the hospital PA system make many a call resident cringe at the thought of what lay in store for their night…
What does it mean to be a Trauma Center? Trauma Centers are categorized in Levels 1 through 4; a Level 1 Trauma Center has the most resources and a level 4 the least. In areas of sparse resources such as a rural setting, level 4 facilities provide stabilization of injured patients and expedited transfer to a facility that can provide definitive care. Level 4 trauma facilities may only be staffed by a mid-level provider such a as Physician Assistant or Nurse Practitioner where Level 3 trauma facilities are capable of providing some rudimentary damage control surgical procedures. Both Level 3 & 4 Trauma Centers lack many resources that we take for granted, yet they are a vital part of a functional trauma system network. It allows the most rapid access to care possible, regardless of the geographic location the injury occurred.
Both Level 1 and Level 2 centers have a breadth of resources to allow for all aspects of definitive care of the injured patient such as neurosurgery, complex orthopedics and cardiothoracic surgery. Level 2 centers may be either private or academic centers, but frequently lack specialized resources such as the capability to replant digits, oral-maxillofacial or ophthalmologic services. In both Level 1 & 2 Trauma Centers, resources must be available in a timely fashion to the injured patient: An trauma surgeon must be available at the bedside within 15 minutes. Ancillary services such as neurosurgery, interventional radiology must also be available within 30 minutes of activation. (Please remember to sign and date the Trauma flow sheet for every Code T, it documents the timely presence of Anesthesia Services.)
Stony Brook is one of 18 Level 1 Trauma Centers in New York State that have been verified by the American College of Surgeons. Our re-verification visit occurred in October 2019 and typically occurs every three years. Every Level 1 trauma center is expected to have a minimum volume of trauma admissions (1200/yr) including 240 admissions with an Injury Severity Score (ISS) greater than 15. (ISS is a scoring system that tallies the severity of the injury in different regions of the body). At Stony Brook, there is a graded system of activation based on the severity or injury the patient received. Here are a few of the commonly encountered activation criteria for higher level actions.
• Cardiac Arrest after Trauma
• Airway obstruction or compromise
• Confirmed SBP < 90 mm Hg at any time
• Advanced airway requirement from the scene
• Penetrating injury to head/neck/chest or abdomen
• GCS <= 8 with a presumed Trauma mechanism
• Suspect Spinal Cord injury
• Traumatic Amputation above wrist or ankle
• Inter-Hospital Transfer receiving blood/pressors to maintain vital signs
• Penetrating injury of extremity with concern for Vascular Injury
• Femur/ 2 or more long bone fractures
• Fall > 20 feet
• Burns > 15% BSA
• Amputation below wrist or ankle
• Pedestrian struck > 15 mph
• Motorcycle crash > 20 mph or separation of rider from bike
• GCS 9-12 with presumed Trauma mechanism
• >20 weeks pregnant with abdominal pain or potential significant injury mechanism
• Interhospital transfer with intracranial injury
• Patients with reduced physiologic reserve what may have intra-abdominal or thoracic injury
Another one of the differences between a Level 1 and Level 2 trauma center lay both at the bedside and behind the scenes. Performance Improvement and Patient Safety requires a Level 1 trauma center to focus in on specific issues that it encounters and develop a solution that functions within its existing hospital workflow. At Stony Brook, low level falls in the elderly are one of the most common injuries for adults with over 250 hip fractures per year. The current standard is to have a door to fixation time of less than 48 hours. Stony Brook has been a high outlier for several years and a push was made to expedite the trauma a medical workup of these patients including echocardiograms and cardiology consults. In order to decrease the patients pain while awaiting hip fixation, the Acute Pain Service has been placing fascia Iliaca blocks. With the increased attention and new processes, almost every hip fracture is currently fixed within 48 hours of ED arrival time. To prevent these injuries from happening in the first place, Level 1 Trauma centers need to have a community outreach role. The Trauma Center has provided Tai Chi lessons at senior centers and nursing homes to improve patients balance and strength to prevent falls. Other community outreach has included “Stop the Bleed” classes that have been held at schools and community centers throughout the county. For adolescent drivers, the trauma center has worked with local high schools and defensive driving classes to bring attention to distracted and impaired driving while pediatric community outreach has included traffic safety and helmet safety in schools
All behind the scenes as well as direct clinical activities are monitored and reported to Trauma Quality Improvement Program that tracks a programs performance in comparison to its peers. This risk adjusted data base reports back to each of the institutions how they are doing in comparison to their peer group. Stony Brook has received a “better than expected” response for 30 day trauma mortality for at least the past year. So when someone sees a hip fracture for a pre-operative block or sees the same patient in the late afternoon as an add on case, please understand that there is a reason behind it all; as members of the trauma group, we are all trying to provide the most timely and optimal care of the injured patient.
Stony Brook Anesthesiology at PGA 2019
Where on Campus is That?
Monthly Muscle Chillaxant
SleepTalker, the Stony Brook Anesthesiology Newsletter is published by the Department of Anesthesiology
Stony Brook Medicine, Stony Brook, NY
Tong Joo Gan, M.D., MHS, FRCA, MBA, Chairman
Editorial Board: James P. Dilger, Ph.D.; Stephen A. Vitkun, M.D., M.B.A., Ph.D.; Marisa Barone-Citrano, M.A.; Ramanjot S. Kang, M.D.