Trauma care has come a long way in the past decade. For Stanford Trauma Surgery Chief David A. Spain, patients who 10 years ago wouldn't have survived a serious trauma are coming back to him for follow-up surgery. "I even had one patient who needed a major hernia repair ask if he was still under warranty," says Spain, professor of surgery. He points to a variety of performance improvement projects, including aggressive adoption of "damage control surgery" protocols, as responsible for increased survival after serious trauma.
"In the old days, we would go into the OR and often work on a patient for six or seven hours, until we fixed every problem," says Spain. "Along the way, we gave the patients tons of blood. Well, for multiple reasons a huge number of these patients did not survive."
So starting in the late 90's, damage control surgery evolved nationally and Stanford was an early adopter. "During their first trip to the OR, you do just enough to stop the bleeding and stop the contamination. Next you send the patient to the ICU to resuscitate them and warm the patient up. Then in 24 to 48 hours you take them back to the OR for the definitive operation, and follow-up later with more surgery as needed," Spain explains.
These improvements have not only saved lives, but they have changed the way that Trauma surgeons practice medicine. "Patients that years ago would not have survived are returning in six months for a hernia repair or an abdominal wall reconstruction."
Spain often does these reconstructions himself, often using laparoscopy. Or he performs or collaborates with plastic surgeons on fascil component separations. Spain says while damage control is a good example of a lifesaving innovation, the overall reduction in mortality is the result "probably of a half dozen little things," that have been rigorously studied and then implemented as performance improvement projects. For example, in 2004 the team launched a transfusion protocol that slashed mortality rates among severely injured patients who had received large blood transfusions. Deaths following transfusions dropped from 43 percent in the early 2000s to 6 percent in 2005. Now, based on a patient's diagnosis, blood, plasma and platelets are ordered prospectively.
"What we learned as part of this performance improvement project runs in tandem with what we learned when we initiated staged surgeries: once you start playing catch up with blood you're in trouble. Among other things, blood right from the refrigerator impedes clotting and retards warming of the body temperature. If the blood and plasma are ready to be used, that's one less thing you have to react to during a difficult surgery. It's part of what we learned about anticipating and planning."
Stanford's trauma volume has grown significantly, from about 800 patients in 2001 to over 2000 in 2007. A majority, says Spain, come from outside San Mateo and Santa Clara counties as far out as the Oregon border to Bakersfield, Reno and sometimes beyond.
For physicians in the region who might care to refer a trauma patient to Stanford, Spain offers these thoughts and advice:
Know when to call – A case that can be handled at a local emergency room on a slow day may not be possible on a busy day. And staged surgeries everywhere have altered the balance. A hospital may have a trauma surgeon today, but the referring ER doctor has to make sure that a specialist will be available later in the week for followup surgeries at the local hospital.
Choose the right facility – Stanford offers particularly sophisticated service in the region for the most complex patients, including those with pelvic or spine fractures, neurosurgery, and aortic trans-sections, "but there's really nothing in the way of trauma care that we and our multidisciplinary colleagues can't provide."
Remember the transfer center number 800-800-1851 – The center is "onestop shopping," for inpatient referrals including dispatch, if needed, of Stanford's Lifeflight helicopter.
Avoid ambiguity – "We don't have multiple callbacks while a resident checks with someone higher up before a decision can be made." When you call the transfer center, be assured that you will be connected directly with the trauma surgeon on call, not an intermediary.
Consider a trauma surgeon for certain complex procedures – Things like abdominal wall reconstructions for ventral hernias, an entrocutaneous fistula or a laparoscopic splenectomy draw upon the skills trauma surgeons have perfected, often making them the right surgeons for the job.