I Am No JD Richardson - c.ymcdn.com · • Co-sponsored by Rep. Bo b DeWeese (MD) and Rep. Mary Lou Marzian ... Training in SCC NRMP.org. 9/22/2015 14 ... • Define who we are

9/22/2015

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Trauma Centers:Challenges for the

Future

Glen A Franklin MD

Professor & Vice Chairman for Education

The Hiram C Polk, Jr MD Department of Surgery

University of Louisville

I Am No JD Richardson

• J David Richardson MD

• President-Elect of American College of Surgeons

• Professor & Vice Chairman Faculty Affairs

• Director Emergency Surgical Services

• Avid Horseman

• My Mentor, Colleague & Friend

J David Richardson

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University of Louisville Hospital

Louisville Trauma History

• Louisville “Accident Service” opens 1911 at Louisville City Hospital• Dr William O Roberts assigns 4 UofL Medical

Students to be on hand at all times to provided accidents victims with instant attention

• Credited with performing the first successful operation on a human abdominal stab wound

• Dr R Arnold Griswold (1932)• City’s first blood bank (developed auto transfusion)• Revolutionized fracture care (Griswold machine)• Operative intervention for penetrating cardiac injury• Equipped police cars and fire trucks with medical

supplies• Challenged Ford to design safer cars – collapsible

steering column, and probably the first advocate of seat belts in cars

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Access to Trauma Care

13 states lack Level 1 Trauma CenterMap shows those within 1 hr of Level 1 or 2 Centers

Traumamaps.org

US Highway Fatality

Ky State Police Data

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KY Trauma System

• House Bill 371• Co-sponsored by Rep. Bob DeWeese (MD) and Rep.

Mary Lou Marzian (RN), both of Louisville, was passed in 2008. It charged the Department for Public Health and the Kentucky Trauma Advisory Committee with developing and implementing a statewide trauma care system, integrated with the public health system for injury prevention.

• No money

• Entirely a grassroots effort!

KY Trauma Centers

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KY Trauma Centers

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New TechNew Tech FinancesFinances Private vsAcademicPrivate vsAcademic

EducationEducation Surgeon InterestSurgeon Interest

Trauma Center Challenges

New Tech FinancesFinances Private vsAcademicPrivate vsAcademic



Medical Advances

• We are in the “techno age”

• Tablets, iPhones, Twitter, Instagram, iWatches

• Medical knowledge and technology is advancing more rapidly than ever before

• “He who has the best toys, wins”

• High tech = high costs

• When does a new technology suddenly become the “standard of care”

New Tech

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Adopting New Technology

• Real consequences for cost of care (albeit they may be better)

• FAST• Easy to learn, several early adopters, training for both

surgeons and emergency medicine• Noninvasive, advertised as part of the “physical exam”• Ultrasound machine costs ~$20,000• DPL costs ~$150 (kit costs & procedure fee to patient)

• Virtually no major EDs without one in less than a decade

Resuscitation Tech

• Thromboelastography (TEG)

• Rotational thromboelastometry (ROTEM)• Method for testing the efficiency of blood

coagulation• Very little data

• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)• AAST Trial – 8 Trauma Centers (DuBose et al)

• Compared open occlusion vs REBOA• No difference in survival

• Angioembo pelvic fracture (Tesoriero et al)• ~5 hours to hemorrhage control• 60% deaths due to uncontrolled hemorrhage• Recommended early packing, REBOA and hybrid angio

suites with surgeon performed embolization

Other New Tech

• da Vinci Robot• ~$2 million• GU, GYN, ColoRectal, Thoracic,

ENT will want it• “Unless we inform the patient population

on this, there will be a drive from the consumer that trumps everything else, because at that point hospitals and physicians are caught in a difficult dilemma,” Michelassi said. “Hospitals and physicians are caught in the dilemma to either continue to deliver optimal care or to respond to market requests.” Fabrizio Michelassi MD

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Really Cool Tech

• DARPA (Defense Advanced Research Projects Agency)• Arsenal Foam Technology• “Wound Stasis System”

• Animal models reduced blood loss six fold and 72% survival rate vs 8% in controls

• EMS cannot afford the cost• Will need partners in Trauma

Centers to assist

• Will it matter in civilian penetrating or blunt trauma?




New TechNew Tech Finances Private vsAcademicPrivate vsAcademic



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Finances

• Money seems to be the primary driver

• As hospitals align in ACOs, where will trauma fit?

• UofL single most profitable activity is:• Basketball - $39 million

• Football - $24 million

• Trauma - $40 million

• More beds – NO

• New ED – NO

• Expanding Papa John’s Cardinal Stadium - YES

Finances

Who is Making the Money?

• Examined hospital and physician financial charges, cost and reimbursement

• Direct cost attributed on the basis of cost accounting system that attached resources used by the patient to the trauma hospital product line

• Commercial (55%), Govt(21%) & Indigent (24%)

Rodriguez, J Trauma, 2005

Trauma Center & Surgeon DichotomyInsured All Patients

• Trauma Center margin was 182-fold greater than the surgeons

• For every cost dollar generated by the surgeon, it recouped its cost plus 2 cents

• For every cost dollar generated by the hospital, it recouped its cost plus 47 cents

• Trauma Center margin was 31-fold greater than the surgeons

• For every cost dollar generated by the surgeon, it recouped its cost plus 35 cents

• For every cost dollar generated by the hospital, it recouped its cost plus 71 cents

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Trauma Centers Bleeding

• Texas: -$20 million

• California: -$400 million

• Georgia: -$70 million

Med Care, 2009

J Trauma, 2005

Impact of ACA

• Joseph et al, AAST 2015, July 2012 – Sept 2014

• 15% decrease in uninsured, 14% increase in reimbursement

• Decrease in commercially insured patients




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New TechNew Tech FinancesFinances Private vsAcademic



Private vs Academic

• Rural trauma centers are primarily private facilities

• Private health care systems are rapidly developing trauma systems and centers• HCA & CHI

• They are frequently located in suburban areas which may offer better payer mixes than urban

• ACS only verifies, states designate

• Should there be documented “need” prior to trauma center development

Private vsAcademic

Florida’s Trauma Centers

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There’s a lot to read about

Best to let Dr John Armstrong tell the story




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Education Surgeon InterestSurgeon Interest


Education

• ATLS, RTTDC, ASSET, ATOM, DMEP

• Surgical Education• Trauma vs Critical Care vs Acute Care Surgery

• ? Burn Surgery, Endovascular, Thoracic

• Maintaining surgical skills in the era of non-operative management of so many injuries

• Can others be trained to care for many non-operative patients freeing up more time for elective cases?

Education

Acute Care Surgery

• Trauma Surgeons believe the specialty must change

• Broader practice, emergency and elective surgery

• ACS is attractive to Trauma Surgeons

• Many lack some of the operative skills or an elective surgery practice

J Trauma, 2008

J Trauma, 2006

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Surgical Resident Case Volume

Drake, JAMA Surg, 2013

Trauma Case Volume

Drake, J Trauma, 2012

Decreased number of trauma

cases

Decreased number of abdominal cases

Training in SCC

NRMP.org

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Programs & Positions Filled

Research & Scholarship

• Valsangkar, et al, AAST 2015

• Most crazy, extensive, complete, database search ever

• Scholarly metrics for 3,850 faculty at top 50 NIH-funded and 5 hospital-based surgery departments

① Junior TS had fewer papers than junior GS and Subspecialties

② Decreased NIH funding

③ Senior TS equally as productive

④ Are we just freeing up time for our colleagues to be more productive?




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EducationEducation Surgeon Interest


Surgeon Interest

• Survey 140 programs• PGY3 & above• 49% response

• Most (82%) had no interest in trauma being a major part of their practice

• Only 22% had any interest in in-house call as an attending for any surgical service

Surgeon Interest

J Trauma, 1992

Interest in Trauma

• Numerous negative responses• Several graphic

• Complaints about access to doing general surgery

• Lifestyle

• Even those interested in trauma as a career, were not interested in fellowship training

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What’s Up With Trauma?

• Cryer HM. The future of trauma care: At the crossroads. J Trauma. 2005;58:425-436.

• Esposito TJ, Rotondo M, Barie PS, et al. Making the case for a paradigm shift in trauma surgery. J Am CollSurg. 2006;202:655- 667.

• Moore EE, Maier RV, Hoyt DB, et al. Acute care surgery: Eraritjaritjaka. J Am Coll Surg. 2006;202:698-701.

• Moore EE. Trauma surgery: is it time for a facelift? Ann Surg. 2004;240:563-564.

• Esposito TJ, Leon L, Jurkovich GJ. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma. 2006;60:8-16.

• Ciesla DJ, Moore EE, Moore JB, et al. The academic trauma center is a model for the future trauma and acute care surgeon. J Trauma. 2005;58:657-662.

• Rodriguez JL, Christmas AB, Franklin GA, et al. Trauma/critical care surgeon: a specialist gasping for air. J Trauma. 2005;59:1-7.

• Roettger RH, Taylor SM, Youkey JR, et al. The general surgery model: a more appealing and sustainable alternative for the care of trauma patients. Am Surg. 2005;71:633-638.

• Richardson JD. Is there an ideal model for training the trauma surgeons of the future? J Trauma. 2003;54:795-797.

• Ciesla DJ, Moore EE, Cothren CC, et al. Has the trauma surgeon become house staff for the surgical subspecialist? Am J Surg. 2006;192:732-737.

The Painful Truth:The Documentation Burden of a Trauma Surgeon

• Golob et al, AAST 2015

• EHR to examine documentation by 8 trauma attendings

• 3,111 admissions (2014) with 26,455 entries (74% were daily progress notes, 5% op notes

A Discipline in Crisis?

• Steven Green MD• Loma Linda University

• Trauma Surgery: a discipline in crisis

• Golden Age of Trauma Surgery was ¼ century ago

• Shift to non-operative care

• Non-surgeon management in Europe & Canada

• Decline of Trauma Surgery within General Surgery

• Lack of ABS approved subspecialty

• Shortage of Trauma Surgeons

• Attempt to “reinvigorate” our field by redefining it as Acute Care Surgery

Green, Annals of Em Med,

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Will General Surgeons Do the Work?

• Expresses concern over the availability of trauma care outside of the Trauma Center model

• Concerns raised over the lack of general surgery for those who choose trauma as a career

• General surgeons can and should provide trauma care in areas where it is needed

Presidential Address AAST 1999, J Trauma, 2000

What About Trauma Surgeons Doing General Surgery?

• Total Trauma Service admissions averaged 3,003 patients per year (34% nontrauma)

• Minor procedures decreased as DPL gave way to FAST and CT

• 33% of operations were on nontrauma, particularly as non-operative management increased

J Trauma, 2000

What Can We Do?

• Don’t give up hope

• Trauma Centers are as necessary as air and water

• Continue to partner with Local, State and Federal Government (they need to know, they need us)

• Work with other specialties, we are all part of the “team”• Advocacy work with OTA, NNA, STN, ATS, SCCM, COT,

AANS, ACEP, AAST, EAST

• Define who we are (General Surgeons who practice urgent care)

• Strengthen our practice with evidence based care

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• We will face many challenges in the future• Costs, external forces, reimbursement models,

recruitment and retention

• We are sometimes a specialty looking for it’s true identity• General surgery, trauma surgery, critical care, emergency

surgery, acute care surgery

• We are no longer the “only ones” interested in trauma

• But, we will evolve to meet the challenge

• The future is bright and just around the corner

Questions

Thanks to the Trauma Center Association of America

Documents

I Am No JD Richardson - c.ymcdn.com · • Co-sponsored by Rep. Bo b DeWeese (MD) and Rep. Mary Lou Marzian ... Training in SCC NRMP.org. 9/22/2015 14 ... • Define who we are