212

Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

  • Upload
    dangnga

  • View
    215

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 2: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphanies in EMS-Trauma – QUALITYKenneth L. Mattox, MD

Baylor

College

Medicine

Ben Taub

Hospital

Baylor-St Lukes

Medical Center

Page 3: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Baylor-St Lukes Medical Center

McNair Campus

Page 4: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 5: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

EPIPHANIES in

EMS

Emergency Medicine

Trauma

System & Networks

Other InnovationsTrauma

Page 6: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

FOUNDATIONS

Governing Principles

How we got here

Agencies, Silos

Resuscitation

ExamplesTrauma

Page 7: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

QUALITY

Page 8: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 9: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1957-2015

Wonderful

EraOverlaping excitement

Page 10: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Overlapping Advances

CardiacVascular

Trauma

Surgical

Critical

CareImaging

Instruments

Plastics

Devices

EMS/EM1950-

2000s

1960-

2000s

1949-2000s

1980-

2000s

No Disclosures, Except……

General

Surgery

Page 11: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 12: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1.

FIRST

A Little Background Example

Page 13: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular

Trauma

Epiphanies

(EMS Surrogate)

Page 14: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Page 15: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

EMS

1950s-1960s

• No EMS agencies

• Ambulances operated by undertakers

• No standards

• No training

Trauma

Page 16: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

EMS – Pre 1975

Emergency Medicine

• Emergency Rooms” – Run by nurses & INTERNS

• All hospital doctors took ER “call”

• No databases, No standards

• No Trauma Centers, etc

• All hospitals assumed to be alike

Trauma

Page 17: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Civilian Vascular Trauma

1950s-1960s

• No Vascular Surgery Boards

• Vascular & General Surgery-SAME

• Very FEW GME sites

• Very Few Hospital Centers of Excellence

• Prosthetic Grafts limited

• Vascular Suture limited

Trauma

Page 18: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Baylor & Vascular Trauma

• 1950s Vascular techniques

• 1960s Peripheral vascular

• 1970s Truncal vascular

• 1980s EMS studies

• 1990s Transvascular tricks

• 2000s Catheter techniques for surgical dummies

Trauma

Page 19: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

TODAY

Page 20: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Injury Challenge

• MAJOR cause of blood loss and death

• “Mystery” of vascular trauma

• Many basic principles no longer taught or understood

• Significant military medicine issues

• Manpower challenges

Trauma

Page 21: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

…..but

…..reflecting….

Page 22: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

How did we

get here?

Series of Epiphanies

EMS-EM-Trauma

Page 23: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

TraumaLine 2000

Years in existence

• Universe - 15 billion

• Solar system-4.6 billion

• Life forms-3.5 billion

• Chordates-500,000

• Small mammals-200 million

Page 24: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

TraumaLine 2000

70 MILLION

YEARS

AGO

Page 25: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 26: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

TraumaLine 2000

CATASTROPHY

Page 27: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

45,000 BC

Page 28: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

45,000 BC

• Wooly mammoth tooth

• Penetrating trauma

• 27 darts & spears in the

heart region

• Blood on the thorax

Page 29: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

8000-4000 BC

• Cities & civilization began

• Warfare occurring

• Metallurgy existed

• Fermentation of alcohol

existed

Page 30: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

4000-3000 BC

• Bishop James Ussher

calculated creation took

place 4004 BC

• City of Ur in Sumaria

• World population 85 million

Page 31: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Sumarian Paralyzed Lion

Page 32: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

3,000 - 2,000 BC

• Egypt a dynasty-pyramids, wrestling a sport, dogs domesticated, great sphinx, glass beads

• Sumerian flood (Bible & Gilgamesh)

• Cuneiform writing replaces pictographs

• Brick temples with colored pillars in Uruk

• Astronomy in Egypt, India & China

Page 33: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

3,000 - 2,000 BC

• Edwin Smith Surgical

Papyrus (written Imhotep

or Iry)

• Sumarians discover

healing qualities of mineral

springs

Page 34: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

2600 BC

Page 35: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Imhotep – Early Egypt

2600 BC…

Edwin Smith Surgical Papyrus

Liberal use of PACKS,

CAUSTICS, & SUTURE

To slow & STOP

HEMORRHAGETrauma

Page 37: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Ibn al Nafis

ابن النفيس

-Quote from ibn Nafis-Quote from ibn Nafis

Page 38: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Ibn Nafis (1213-1288 )

• Described PULSE, Coronary

Circulation

• Described 3 stages of Operation

• Described Capillary Circulation

• Described CENTRAL CIRCULATION

350 years before

William Harvey

Page 39: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Pulmonary Circulation

“..the blood from the right chamber of the heart

must arrive at the left chamber but there is no

direct pathway between them. The thick

septum of the heart is not perforated and does

not have visible pores as some people thought

or invisible pores as Galen thought. The blood

from the right chamber must flow through the

vena arteriosa to the lungs, spread through its

substances, be mingles there with air, pass

through the arteria venosa to reach the left

chamber of the heart and there form the

vital spirit..”

Page 40: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 41: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

1535

Page 42: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

1535

Near Pecos, Texas

Page 43: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca

• Traveled throughout Florida,

Texas, New Mexico, & Arizona

• 100 + men & horses reduced to 2

• Worn out cloths, with his aid,

Estafan

• Medical training in addition to

being an explorer

Trauma

Page 44: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca

• He was brought

an Indian

• Old Arrow head

imbedded in

cartilage near

sternum

• Much pain

Trauma

Page 45: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca

Page 46: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca

• With his knife, he removed the

arrowhead

• Rumor states that BLOOD shot over

his shoulder

• He sutured & packed the wound

• Removed the suture the next day

• Operative report in his diary

Trauma

Page 47: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca

• The Indian recovered without pain

• Cabeza de Vaca became a hero

• Indians escorted him to Mexico City

• He returned to Spain & published

his diary

• Symbol of the Texas Surgical

Society

Trauma

Page 48: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cabeza de Vaca - 1535

• 1st recorded operation in America

• In Texas

• A Trauma Case

• A Thoracic Case

• A Vascular Case

• A Thoracic Trauma Vascular Case

Trauma

Page 49: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

1597

Page 50: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 51: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Merchant of Venice

1597

written by

William

Shakespeare

Shylock & Jessica Portia

Page 52: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Damage Control

“ ..to stop his wounds,

lest he do bleed to

death.”

Shakespeare, The Merchant of Venice,

Act IV, Scene I

Page 53: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

129 Years ago

1884

Page 54: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1894

In June 1894, the French President,

Sadi Carnot assassinated by

Italian anarchist with a stab wound

to the abdomen in Lyon, France.

His ONLY injury-a severed portal

vein. Alexis Carrel intern at Red

Cross & Antiguaille Hospitals

Carrel observed the autopsy

Page 55: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1894

Alexis Carrel

stated,

“There has

to be a

better way.”

Page 56: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1905

In 1905, Carrel at age 31, (11

years later) with Charles C.

Guthrie developed the

technique of “triangulation”

for vascular anastomoses

at the University of Chicago

Page 57: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Alexis

Carrel

1905

Triangulation

Page 58: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1912

In October 1912, (7

years later) at age

38, Carrel awarded

Nobel Prize

Page 59: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is ALWAYS

a BETTER

WAY

Page 60: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

1918-1948

WW I & WW II

Page 61: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW I (Makins)

• <0.1% Arterial injury among casualties

• Injuries (1202)

– Carotid/Vert 128

– Aorta 5 (all died)

– S.Clav/Axil 153

– Forearm 259

– Iliac 5

– Femoral/tib. 648 23% Amputation

Trauma

Page 62: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW I (Makins-Sencert)

• Ligation most common treatment

• SUTURE Repair 29 cases

• Suture recommended as “par

excellence” but logistic & time

required, prevented this method

• Data mixes acute injury & delayed

traumatic aneurysms

Trauma

Page 63: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW II (DeBakey)

• <0.1% Arterial injury among casualties

• Injuries (2471)

– Carotid/Vert 10

– Aorta 3 (2 died)

– S.Clav/Axil 95

– Forearm 1103 26% Amputation

– Iliac 44

– Femoral/tib. 1827 51% Amputation

Trauma

Page 64: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW II (DeBakey)

• Ligation most common treatment

• Concomitant vein injury studied

• 81 suture repairs (3.3%)

– 36% amputation

• 40 vein grafts (2%)

– 57% amputation

• 14 tube grafts (metal) 50% amputation

Trauma

Page 65: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW II (DeBakey)

Recommendations (1)

• Temporary stents

–Glass, silver, vitllium,

magnesium

–Also advocated by Jeger in 1913

• Double tube-vein graft proposed

• No statistical advantageTrauma

Page 66: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

WW II (DeBakey)

Recommendations (2)

• Anticoagulants

• Fasciotomy

• Refrigeration

• Oxygen Therapy

• Posture

• Sympathectomy & Nerve blocks

Trauma

Page 67: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

KLM - Sophmore in High School

Clovis New Mexico

1953

Page 68: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany X 2

General Biology – Mr. John

Gott

Geometry – Teacher’s name

long forgotten

Trauma

Page 69: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Biology Taxonomy

• Kingdom

–Phylum

• Class

–Order

»Family

-- Genus

---SpeciesTrauma

Page 70: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Classification

Organization

Page 71: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 72: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Scientific Method

Evidence Based

Page 73: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

Korean War

Dr. Frank Spencer

General Carl Hughes

1953

Page 74: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Page 75: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Korean War (Hughes)

• Incidence among casualties unknown

• Injuries (304)

– Carotid 11

– Aorta 0

– S.Clav/Axil 23

– Forearm 89

– Iliac 7

– Femoral/tib. 174

Trauma

Page 76: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Korean War (Hughes)

• Treatment (304 arterial injuries)

– Ligation 51% amputation

– End to End 13% amputation

– Vein Graft 11% amputation

– Homograft 33% amputation

– Transverse suture 2.9% amputation

• 64% arterial injuries also had vein

injury

Trauma

Page 77: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room for

IMPROVEMENT

Page 78: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

10 years later

Page 79: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

KLM - Junior in Medical School

Baylor College Medicine

1963

Page 80: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Injuries:

Abdominal

Aorta

SMA

IVC

Nov. 1963

Page 81: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Lee Harvey Oswald 1963

KLM Reaction

• Injuries are only blood vessels

• Sewn together every day in the

Texas Medical Center

• It cannot be that difficult

• There has to be a better way to

expose the supra-renal abdominal

aortaTrauma

Page 82: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

Major Norman Rich

Viet Nam Vascular Registry

1963

Page 83: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vietnam War (Rich)

• Injuries (up to 8,000, 1000 reported in

detail)

– Carotid 50

– Aorta 3

– S.Clav/Axil 70

– Forearm 342 34% of total

– Iliac 26

– Femoral/tib. 568 57% of total

Trauma

Page 84: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vietnam War (Rich)

• Methods of reconstruction

– Vein graft 46%

– End to end 38%

– Lateral repair 9%

– Ligation 1.5%

– Prosthesis 0.4%

– Other 5.1%

• Mortality rate 1.7%

Trauma

Page 85: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vietnam War

Norman Rich

• Vascular surgery/trauma is here to

stay

• We need more detailed data than

after WW I, WW II, Korean War

• We need a vascular trauma data

bank

• Trauma registries are essentialTrauma

Page 86: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room for

INNOVATION

Page 87: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

0.38 Caliber GSW

Abdominal Aorta – IVC

KLM – PGY 4 GS Resident

8/11/1970

Page 88: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 89: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 90: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room for

NEW

APPROACHES

Page 91: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Page 92: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

General (Acute Care)

Surgeons

Multiple Hospitals

1965-1980

Page 93: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Trauma -

Acute Care

SurgeryHistoric Role in Vascular Trauma

Page 94: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room for

LEADERSHIP

Page 95: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

New Vascular Trauma

Leadership

1965-1980

• Provided by EAGER General

Surgeons, frequently residents,

in programs across the United

States (many veterans of RVN)

• Often presented at AAST

J Trauma – 4.2% Vascular papers

Page 96: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Carotid Artery

Trauma

Page 97: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vertebral Artery

Trauma

Page 98: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Subclavian Artery Injury

Trauma

Page 99: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 100: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 101: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Innominate Artery

Trauma

Page 102: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 103: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 104: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 105: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 106: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 107: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 108: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 109: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 110: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 111: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 112: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 113: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 114: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 115: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 116: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 117: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

By 1980, trauma

surgeons had pretty

much worked out

standard approaches to

vascular trauma

…and outcomes were established

Page 118: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

Trauma

Page 119: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

Vascular Surgery

1995-2014

Retooling their own approaches

Page 120: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Surgery 2014

• Endovascular Technology

• Little to no Trauma Training

• Often slow to respond to a

night time call

• New approaches

• Increased costs

Trauma

Page 121: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room for

NEW

TECHNOLOGY

Page 122: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

New

Technology

TraumaNOT ROCKET SCIENCE

Page 123: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Capital Perception

Often driven by INDUSTRY

Page 124: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Endovascular Basics

• Access (incision)

• Wires/Catheters (dissection)

• Sheaths (self-retractor)

• Balloons (clamps)

• Stent/Stent Grafts

• Coils/Glue

• IT IS NOT ROCKET SCIENCE

(clamp, cut, sew, tie)

Page 125: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 126: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Principle

• Surgical needs should

dictate technology

• Technology should not

DRIVE surgery & medical

practice

Trauma

Page 127: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

IRONY

GS ran TO MIS

GS run AWAY FROM

VS

Page 128: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

General Surgeons

Laparoscopic Surgery

Minimally Invasive Surgery

• 1970s-1980s

• New Technology

• General (acute care) surgeons

RAPIDLY endorsed technique

• Changed the face of surgery !

Trauma

Page 129: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1990s…+

Meanwhile, new major

wars were waged

…and 6 different data bases were established

Page 130: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

Iraq/Afghanistan

Wars

1990-2014

Relearning the Lessons of the PAST

Page 131: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

Page 132: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Iraq/Afghanistan Wars

• FST formation

• JTTC, JTC, Vascular Registry

• Hypotensive resuscitation

• Vascular stents, 1:1:1, others

• In FLIGHT Care – SICU

• Landsthul, Walter Reed, & More

Trauma

Page 133: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Capital Reality

Page 134: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Iraq/Afghanistan Wars

JITR(%) NTDB(%)

Carotid 6.6 7.8

Thor Aorta 0.6 3.6

Innom/SC 1.2 3.0

Ax/Br 27.2 37.1

Abd Ao/iliac 7.2 7.2

Fem/Popliteal 46.7 43.2

Trauma

Page 135: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

So…..

Here we are today.

Lots of talk, very little action

Page 136: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Epiphany

Discovery

2012-2013

PRODUCT of frequency harmonics

Page 137: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma PROBLEMS

Educational & Technical

Changes have caused

PROBLEMSTrauma

Page 139: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearn

the lessons of the past?”

AND CREATE NEW PROBLEMS

Page 140: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Root Causes

of

Vascular Trauma

DISASTER

Page 141: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma CRISES

2000’s

• Trainee work hour restrictions

• SOS develop

• Focused practices

• GS/TS/VS tri-trained surgeons disappear

Trauma

Page 142: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma CRISES

1990s-2000’s

• General Surgery decreases training requirements

• Vascular Surgery = ENDO

• VS GME changes (can go to VS without any GS)

• Decreased trauma for BOTH

Trauma

Page 143: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma CRISES

General Surgery Trainees 2000’s

• Vascular experience 50% REDUCTION

• Amputations, AV fistulas, AV access

• No vascular - life threatening experience

Trauma

Page 144: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma CRISES

Vascular Surgery Trainees 2000’s

• Vascular trauma RARE

• Move away from OPEN procedures

• Not comfortable with OPEN neck, chest, abdomen, groin

• Training changing (5-2 to 0-5)

Trauma

Page 145: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma CRISES

Thoracic Surgery Trainees 2000’s

• NO peripheral vascular surgery

• NO trauma experience

• SOS : Lung, Congenital, CAB, Valves, Aorta, Esophagus

• No endotherapy training

Trauma

Page 146: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Been there.

Seen that data before.

…but they DO bleed to death !

Page 147: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

Trauma

Page 148: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma Mortality

1980

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

2015

• EC Thor - 90%+

• Abd Aorta – 60%+

• IVC 35-55%

• Iliac Artery 55%+

• Portal Vein 50%

• Combined 80%+

TraumaWe can & SHOULD do better

Page 149: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Current Military Vascular

Trauma Challenges

• ONLY 15 Vascular Surgeons in

ALL DOD assignments

(Count them 15 !!! )

• Leading cause of Preventable

death is hemorrhage (vascular

trauma) control & reconstruction

• Fear of vascular trauma by Acute

Care Surgeons in DODTrauma

Page 150: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Current Civilian Vascular

Trauma Challenges

• Limited vascular training

• 80-90% trauma preventable

deaths from HEMORRHAGE

• 80-90% current “trauma”

surgeons are uncomfortable in

managing hemorrhage control

and repairTrauma

Page 151: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

REBOA

R - Resuscitation

E – Endovascular

B - Balloon

O – Occlusion

A - AortaTrauma16 hour 2 day course

Page 152: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Discussed and

recommended by

Alex Walt & KLM at

the time of KLM’s

1975 AORTIC trauma

paper to AAST

38 yrs. ago

Page 153: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Just WHAT

is the

PROBLEM ?Contemporary Vascular Trauma

Page 154: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Capability

GAP

Page 155: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 156: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

• Forgotten or Ignored

lessons of the past

• Overlapping

frequency harmonics

• Neutralizing technical

progress

• Competitive education

agendas

Page 157: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Need for a

NEW

CHANGE

Page 158: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Emergency

Trauma

Acute Care

Surgery

Historic Role in Vascular Trauma

Page 159: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Acute Care Trauma Surgeon

• Roles in VASCULAR TRAUMA:

–Gatekeeper

–Own the field of vascular trauma

–Own the field of all vascular

surgery emergencies

–Take the courses

–Master the technology

Page 160: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

• Blood loss to be

markedly reduced

• NO medical

rotation

• Endograft inserted

• Visceral bypass if

necessary

• OTHER innovations

Page 161: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Parable of

the GREAT

SWORD

Page 162: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Great Sword

• Great & Mighty Nation

• Fought great battles with the GREAT

SWORD

– HEAVY, but effective

– Death with ONE blow

• Every warrior used it effectively

• Enemies feared the GREAT SWORD

• Centuries of successful battles

Page 163: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Great Sword

• In the great hall, all warriors sang and

toasted the GREAT SWORD

• The GREAT SWORD hung at the end of

the GREAT HALL

• Legendary songs of the GREAT

SWORD were passed down from

generation to generation

• The legend of the sword struck fear

into all who would dare attack

Page 164: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Great Sword

• While the great nation warriors and

kings sang & drank to the old war

victories from the GREAT SWORD and

grew weak and lazy resting on their

past victories, a new generation of

enemies who knew not of the legend

grew in numbers and strength

Page 165: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Great Sword

• Word came one night that the enemy was

coming to test the great warriors – warriors

whose only knowledge came from passed

down stories of victories

• They rushed to the Great Wall to pull down

the great sword, but it was too heavy for

anyone to lift, much less know how to use

• In trying to lift the sword, it was dropped and

broke into a thousand useless pieces

Page 166: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Broken Heavy Useless

Sword

• A NEW nation was born

• Without a single battle

Page 167: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

There is always

room

AT THE TOP

Page 168: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

2.

SECOND

PRINICPLES

Page 169: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

LEAD AGENCIES

•Government

•Clinical

•Regulatory

Page 170: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

3.

THIRD

Processes

Page 171: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

PROCESSES

• Education

• Guidelines

• Databases

• Network

• Review-Modify

Page 172: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

• Quality– Structure, Process, Outcomes

• Safety– Preventable Harms: Central lines,

Catheters, Retained foreign bodies

• Resource Use/Appropriateness– Use of advanced imaging

– Avoidable procedures

• Patient Experience of Care– CAHPS surveys

– Patient reported outcomes

High Value Health Care

Page 173: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Cause of errors

• Complex processes

• Incomplete information

• Haste, miscommunication

• Inexperience

• Inadequate training

• Infrequent incidence

Page 174: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Performance

• GAP Theory

– “Gaps” in care processes

cause most adverse

events.

– Clinicians constantly

identify and attempt to

bridge these gaps.

• Clinicians make clinical

processes safer.• Cook and Woods

BMJ,2000

Page 175: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Relationship of Performance & Workload

CLINICAL WORKLOAD

C

L

I

N

I

C

A

L

P

E

R

F

O

R

M

A

N

C

E

After Weinger & Englund: Anestesiology 73: 995, 1990

INCREASING

STRESS, FATIGUE

INCREASING

EXPERTISE

Page 176: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Active Failures

Latent Failures

Page 177: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

What Aviation Learned

No matter how

advanced the

technological

system, if humans

are involved error

is inevitable

Page 178: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Technology is Not the Complete Answer

• Aviation recognized that 70% of accidents are based on human error in a team setting

• Error results from physiological and psychological limitations of humans– Fatigue– Workload– Cognitive overload– Poor interpersonal

communications– Imperfect information processing– Flawed decision making

Page 179: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Teamwork Training + Systems

Approach• Error is inevitable -

human limitations

• The key to safety is managing error

• Aviation manages error by training specific team & communication behaviors &implementing systems that require those behaviors

• The behaviors and the systems supporting the behaviors is CRM

Page 180: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

CRM is…• Crew

– Any team…cockpit, maintenance, ATC, etc...

• Resource

– Other team members, equipment, procedures, systems

• Management

– Specific behavioral skills to lead, communicate, decide and catch errors before they become serious /fatal

Managing the Resources of the Crew

Page 181: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Aviation’s Solution

Technology

Teamwork

Skills

Systems

Software + Hardware

plus

plus

Page 182: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Commercial Aviation is

Extremely Safe and Reliable

• 2002, 2003, 2004 – Zero

deaths for jet airline

operations in the U.S.

• In the last 10 years,153

fatalities in U.S.

• 2 deaths for every 100

million passengers

• safest decade in the

country's aviation history

Page 183: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Why Has CRM Worked in Healthcare?

15 years ago

• 70 – 80% of airline accidents are related to interpersonal communications

(Sexton & Helmreich, 99)

Now

• 70 – 80% of medical mishaps are related to interpersonal interaction

(Williamson et al, 93)

• 66% of Sentinel Events have incomplete communications among care givers as a root cause

(JCAHO Alert – Issue 12)

Comparing the root cause of errors, then and now…

HealthcareAviation

Page 184: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Recommending CRM-based safety

• IOM

– Efficient and effective care requires teams with communication and coordination

• National Academy of Science

– All healthcare professionals should be educated to deliver care as part of a team

• National Patient Safety Foundation

– “…the growing complexity of healthcare demands improved communication and cooperation among healthcare professionals.”

Page 185: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Success In Improving Safety

– Lower mortality numbers

– Reduction in wrong surgeries

– 50% reduction in counts errors (Rivers et al 02)

– 53% reduction in adverse outcomes (Garza 04)

– 55% reduction in observed errors (Garza 04)

– Clinical error rate reductions from 30% to 4.4% (Morey et al, 02)

– Better Staff Satisfaction

– Reduced staff turnover

Page 186: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Surgical Infections and

Prophylactic Antibiotics

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

Infe

cti

on

s/1

00 C

ases

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Class I

Class II

Ab's < 1hr

Page 187: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Deaths with Expected Risk of

Mortality < 10%*

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Jan

Feb Mar

AprM

ay Jun

Jul

Aug Sep Oct

Nov

Dec Ja

nFeb M

arApr

May Ju

nJu

l

Page 188: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Examples of the Tools

in the “Safety Toolkit”

• Pre –briefs – pre-op time outs,

morning huddles

• Checklists – room set-up,

holding room exit, line insertion

protocol, pregnant trauma

treatment flow, diabetes care

• Debriefings – post-procedure,

conflict mediation, teaching

moments

• Standardized communication

formatsHardwire the behaviors into daily operations

“This is just the way we do business.”

Page 189: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

DebriefSEE IT - SAY IT - FIX IT !!

Good techniques –

1.Team Leader gather team as soon as possible

2.Team Leader announce the debrief

3.Gather as much of the team as possible

4.Don’t beat a dead horse

5.Record recommendations for process improvement

1. What did we do well ?

2. What do we need to improve ?

3. Did we have everything / everyone we needed ?

Techs -- RNs -- Residents -- Attendings -- Leader last

VUMC (Ver 1.0) Jeff Hill (3-6318)

Page 190: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

190

Page 191: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 192: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 193: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 194: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and
Page 195: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Key Ingredients of Health Care Culture

• Patient centered

• Leadership commitment

• Employee engagement

• Culture of safety

• Transparency

• Performance improvement

Page 196: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Professionalism = Accountability

Page 197: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Vascular Trauma

FINALLY

Page 198: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Machiavelli “The Prince”

“There is nothing more difficult

to take in hand, nor perilous

to conduct, nor more

uncertain in its success than

to take the lead in

introduction in a new (or

RENEWAL) order of things….

Page 199: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Machiavelli “The Prince”

…for the innovator has for enemies, all those who

have done well under the old and lukewarm

defenders those who might do well under the

new.”

Page 200: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Upcoming lectures by

Dr. Mattox

EPIPHANY

Page 201: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

1a

TURFS - Grids

EPIPHANY

Page 202: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

2.

RESUSCITATION

EPIPHANY

Page 203: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

3. LEAD

AGENCIES

EPIPHANY

Page 204: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

4. Example

American College of Surgeons

EPIPHANY

Page 205: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Standards

Databases

Quality

Education

EPIPHANY

Page 206: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

5. Example

SETRAC

EPIPHANY

Page 207: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

Trauma

Pediatrics

STEMI

STROKE

DisastersEPIPHANY

Page 208: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

6. Expectations

EMS

Hospitals

EPIPHANY

Page 209: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

All Hospitals are NOT the same

EPIPHANY

Page 210: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

EMS ERRORS

As perceived by Trauma Centers

EPIPHANY

Page 211: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

7. Expectations

Disaster Medical Responses

EPIPHANY

Page 212: Epiphanies in EMS-Trauma · Epiphanies in EMS-Trauma ... •Blood on the thorax. 8000-4000 BC ... direct pathway between them. The thick septum of the heart is not perforated and

8. Putting it all together

FOR THAILAND

EPIPHANY