Local Frontiers

Trauma 101—A Crash Course on Trauma Care at Memorial Hospital

By Abdul Harris, MD

In the past few years, the trauma center at Santa Rosa Memorial Hospital—the only Level II regional trauma center in Sonoma County—has become an integral part of our community’s approach to treating victims of blunt and penetrating trauma. Through its involvement in many outreach projects and emergency medical services, the center has developed into one of the region’s most recognized and respected hospital-based programs. As the population in the North Bay has grown, so has the need to provide emergency specialized care to more patients, not only in Sonoma County but also in adjoining areas.

The trauma center is equipped to handle any level of emergency care for critically injured patients 24 hours a day, seven days a week. Highly trained medical personnel form the nucleus of the trauma team, providing direct patient care and emergency medical and/or surgical intervention, as well as radiology, lab, and other ancillary services. The team leader is the primary trauma surgeon, who carries the burden of a 24-hour on-call shift, 7 a.m. to 7 a.m., alternating with a small panel of other trauma surgeons. A backup surgeon is also available for when the primary surgeon is encumbered, or in times of multiple casualties. Many other specialists provide needed expertise and consultative help in caring for critically injured patients.

The on-call trauma surgeon, and sometimes the backup surgeon, also handles various emergency, elective, and semi-elective nontrauma surgical consults and cases. The work can be grueling, mentally and physically exhausting, and sometimes overwhelming. With the average trauma census bulging at the seams, the on-call surgeon carries the greatest responsibility and liability for the care of 20 to 30 trauma patients per day—plus hospital inpatients from the surgeon’s own private practice and nontrauma emergency patients admitted and cared for by each surgeon individually.

In many respects, the level of acuity at Memorial’s trauma center is no different from that of a Level I trauma center with a full complement of interns and residents. The biggest difference is that in our system, the trauma surgeon performs all the assigned tasks and is ultimately responsible for the daily care and outcome of the trauma patient. The trauma surgeon is the intern, the resident, and the attending physician conveniently rolled into one package.

A typical day for a trauma surgeon begins with a brief 7 a.m. meeting with the off-going surgeon to review all patients on the trauma service. For the next 24 hours, you receive a litany of digital or overhead pages from every nursing station in the hospital, from the transfer center, from the ER and OR, and from outside referring physicians. You conduct daily work rounds on every trauma patient in the ICUs and hospital wards. You hold impromptu meetings with the trauma director and the program coordinator in the hallways or byways. Family meetings and care conferences spring up at a moment’s notice. You make numerous phone calls to neurosurgeons, orthopaedic surgeons, otolaryngologists, ophthalmologists, infectious-disease specialists, pulmonary/critical care specialists, and others. Trauma codes/alerts in the emergency department, discharge planning, and the ever-popular visit to medical records punctuate the eerily quiet moments of your day. Depending on scheduling, you may find yourself “back in the saddle” another 24 or 48 hours later to do it all over again.

When patients are admitted to the trauma service, most remain under our care until discharge (even for some isolated injuries). Trauma patients are identified by special markers and labels on their charts, and most issues affecting patient care are addressed by the trauma surgeon-of-the-day.

Many patients come into the trauma center or emergency department unfunded, as medically indigent, or underinsured. Many live on the outskirts of society, while others are hard-working and productive. Some are homeless, suffer from mental illness or polysubstance abuse, or have many comorbidities that make their care and disposition challenging. Nonetheless, trauma happens to all people, spanning all age ranges, and affecting all socioeconomic levels and nationalities. For trauma, there are no boundaries; it does not discriminate.

Not surprisingly, one may ask, “Who signs up for this?” Here is my anwer, for which I admittedly have a certain bias. In our existing model of trauma care, the primary trauma surgeon is typically young and energetic and enjoys the nature of trauma surgery and taking care of surgical patients. The backup surgeon is generally an older community general surgeon who wants to help out but is already well established and desires less call. Often, the primary surgeon serves as the backup surgeon on his or her “off” days.

Despite declining reimbursement and an ever-increasing workload, trauma surgeons continue to perform the job—but burnout is a huge problem. For those of us who also enjoy the challenge of trying to keep a private practice afloat, the task is that much more difficult. Recruitment is often marred by disruptive forces, such as the fragmentation of health care in our community, market competition, lack of quality referrals, less than overwhelming support of hospital administrators, and the high cost of living and lack of affordable housing in Sonoma County and surrounding areas.

With current medical students and residents opting out of many surgical disciplines, including trauma surgery, we are at a crossroads. Since moving to Sonoma County in 2001, I have seen several talented young surgeons come and go, many disillusioned by the arduous task of building a solid surgical career in our community, without much support. I think it’s time for a change.

Change starts by recognizing the contributions and hard work of the busy surgeons who are always there when you need them. It involves a commitment from our medical community and administrators to provide better resources for managing the workload involved with trauma and emergency care. Nurse practitioners, physician assistants, and a fully functional trauma outpatient clinic would ease the burden and improve the quality of life for our trauma surgeons, thereby improving the quality of patient care.

Sonoma Medicine, Volume 56, Number 2 (Spring 2005).