Trauma: Seconds That Save Lives — with Dr. Babak Sarani & Dr. Marc Chodos - Wellness Musketeers

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:07):
Believe it or not, the single most common mechanism
of injury in the entire UnitedStates is falling from standing.
It is not at all sexy, hot,just like I fell.
Where'd you fall from?
From the roof, from the seventhfloor?
No man, I was just walking andI fell.
That's by far the most commonmechanism of injury.

Speaker 2 (00:25):
It's so true, just in the blink of an eye, how things
can change.

Speaker 3 (00:33):
Hi listeners, aussie Mike here from the Wellness
Musketeers podcast.
In today's special episode,we're taking you inside the
world of trauma care.
You'll hear from Dr Mark Chodos, an orthopedic surgeon, and Dr
Babak Sarani, one of the leadingtrauma experts in the country.
Together they brag down whatactually happens after a major

(00:54):
injury and why trauma isn't justan accident but something we
can often prevent, whether it'sa fall, a crash or an emergency
you hope never happens.
This is a powerful conversationthat could help you or someone
you love stay safer and moreinformed.
Let's get right into it.

Speaker 2 (01:16):
Hi there, I'm Mark Chodas.
Like many people, my firstexperience with the realm of
trauma surgery was through TVShows like ER at the time or
Grey's Anatomy now paint anexciting, if not eccentric,
image of what many people is aforeign world that they will
hopefully never have directexperience with.
From these shows, most peoplethink of the emergency room as

(01:39):
the place where someone goeswhen they get hurt, and the
emergency room doctors is theones who guide the process.
What many people don'tunderstand is that there's an
entire system that's evolved,with special teams and surgeons
who step in after a major injury, for better or worse.
That image was only reinforcedwhen I started my third year

(02:01):
surgical rotation during medicalschool.
The chief resident would playMetallica full blast in the
operating room as they struggledto save an injured person's
life.
It was pretty wild and crazy atthe time and over the years I
think I've gained a betterunderstanding for the trauma
system and the processes that gointo saving someone.

(02:21):
It's much more complicated andalgorithmic than you would think
listening to Metallica in theoperating room.
As a third-year medical student, our goal with this series is
to convey some of this to you sothat you can gain a better
understanding of this system andthe processes and the various
factors that people in the fieldof traumatology face.

(02:43):
In this episode we'll introducethe problem.
We'll go into some backgroundinformation to give you a
setting from which to base Insubsequent episodes.
We'll follow a hypotheticalyouth through the trauma system,
from pavement to the hospitaland beyond.
We will meet some of theplayers in this field, from the
EMT to nurses, doctors andsocial workers.

(03:05):
We'll follow this journeythrough the rehabilitation and
recovery process.
After that we will explore howtrauma is handled in other parts
of the world.
We will venture into the realmof military trauma and look at
how some of these innovationshave transitioned into civilian
trauma-based.
We will conclude with a look atsome of the efforts and

(03:26):
regulations for injuryprevention.
Helping me out on this seriesis Dr Sarani.
Dr Sarani, would you like totell us a little bit about
yourself and what made youdecide to go into a field of
trauma surgery as a career?

Speaker 1 (03:42):
Hi, my name is Babak Sarani.
I am a professor of surgery atGeorge Washington University and
I'm the founder and stillmedical director of the Center
for Trauma and Critical Care atGeorge Washington University
Hospital.
I've been in practice as atrauma surgeon since around 2005
, and I really chose to go intothe field because I just really

(04:05):
enjoyed the breadth practicethat I have.
Trauma surgery is one of thefew elements of true general
surgery, since you never quiteknow where someone's going to be
injured.
I love working in aninterdisciplinary team so I get
to work with the likes of MarkChodos or neurosurgeons or
urologists or emergency medicinedoctors, intensivists, like

(04:26):
pick a type of doctor, and I getto work with them and I really
enjoy kind of that team approach.
And as much as people think thelifestyle is terrible, it
actually isn't.
That's pretty predictable,which I like as well One of the
times we talk about lifestyleand wellness.
So it's just a field thatreally appeals to me in every
aspect socially with mycolleagues, medically with the
patients I take care of, andthen personally, in that I have

(04:49):
some time that's predictablewith my family and my kids.

Speaker 2 (04:53):
I think trauma.
It's very interesting becauseyou watch these TV shows and you
don't really think of trauma asthe same way as diabetes or
heart disease or someone hasappendicitis.
But really, in fact, we talkoften about trauma as being a
disease, not just a randominjury or accident.
Can you talk to us a little bitabout what this concept of

(05:16):
trauma as a disease really means, Exactly what you just said is
that we don't like to use theword accident in trauma surgery.

Speaker 1 (05:23):
That's one of those few forbidden words that we tend
to use at a much more actionoriented term.
So, for example, some peoplewill say he was in a car
accident.
That's actually not true.
He was in a car crash.
He was in a motorcycle accident.
No, no, he was in a motorcyclecrash.
He accidentally shot himself orthe two kids accidentally shot
each other.

(05:43):
They did it.
That was not intentionalfirearm related violence and it
sounds like a bunch of mumbojumbo, big words circa today's
world where we can't use simplespeech.
But it's actually meaningfulbecause when you talk about an
accident right, an accident bydefinition is a freak event.
It's something that could nothave been prevented.
It's just a freak event thatoccurred.

(06:05):
And yes, there are some freakevents that occur.
I go for a walk.
A branch falls on top of me.
That's a freak event, but mostinjuries are preventable.
So the best example are actuallycars.
You know, back in the 60speople would die in car crashes
left and right, because backthen seatbelt laws were very

(06:28):
optional.
The roads were not designed theway they are now.
You know, when I come to workthere's a bunch of curves I have
to go through in myneighborhood and they're banked
so that it helps my car stay onthe road.
There's guardrails.
You know, even if you intoday's world here's something
you might find interesting, youin today's world here's.
Here's something that might youmight find interesting in

(06:49):
today's world.
If you're in your car and youroll over like you're in a
rollover car crash, okay, ifyou're belted in, you're
actually not considered asignificant trauma patient.
You're not considered a traumapatient in an automobile
rollover.
If you're belted in, there's abig.
If there you have to be beltedin, you have to be one with a
vehicle.
And if you become belted in,there's a big.
If there you have to be beltedin, you have to be one with the
vehicle.
And if you become one with thevehicle, then the car is
designed to take its own weight,no matter how it is, so that it

(07:12):
will not crush on top of you,it'll crush around you.
And you see those things allthe time, right, when you look
at the news that someone's beenin a bad car crash and the
driver's kind of okay, that'sthe design, that's an

(07:33):
engineering process that we havecreated.
So the engine block takes theenergy, the A-frame, takes the
rolling energy and, lo andbehold, the passenger
compartment is okay, so long asyou are where you're meant to be
, which is belted in.
You're not belted in, you'regoing to go for flight, and then
we can talk about what a realtransportation looks like.
And so, and same thing withfirearm injuries.
By the way, you know, there'sno reason under the sun, none

(07:55):
whatsoever, why a five-year-oldshould shoot their
three-year-old sibling.
That should never occur if thefirearm is secured properly,
right?
So we don't really talk aboutaccidents, we talk about
collisions, we talk aboutcrashes.
We say that was unintentionalto really emphasize the point

(08:15):
that they're all preventableanyway.
And so if you approach traumawith that kind of mentality,
then it actually makes sensethat it is more of a public
health disease.
Much like you know, many, manythings in public health are
preventable.
And I'll ask you in a sec Mark,once I stop my little soapbox
thing here about maybe ananalogy in the foot and ankle

(08:38):
world, like what can I do toprevent myself from getting
injured?
What would you say, bob?
That was potentially some ofyour own doing, the leading to
cognitive in the United Statesafter about one or so years old,
after your infant years upuntil age 44, is trauma, and
therein lies the problem, right?
So if you are a policy expert,if you're some person who's

(09:01):
trying to lead the country, whodon't you want to die?
Some person who's trying toleave the country, who don't you
want to die?
The persons that I don't wantto die are my young, because
they are the future right.
They're the ones who are goingto invent stuff.
They're the ones who are goingto pay a lot of taxes.
They're the ones who are goingto get married and have
offspring.
They're the ones that are goingto propagate the society, and

(09:21):
so it's key that we keep ouryoung alive, not to not to take
anything out of the elderly.
I'm 50 and I'm starting to likethe elderly more with every
year, but it's the young, and sothat's why that's what we look
at trauma on.
It's not so much how can I fixyou once you've been injured.
My field is more how can Iprevent you from being injured

(09:42):
in the first place?
And yes, of course there willalways be people who are injured
, who will always need our help.
But we start from a premise ofinjury prevention and then we go
into injury management orinjury treatment.
So I don't know, mark, what doyou guys do?
If I was to say to you give mesomething that's preventable in
the world of orthopedics.

Speaker 2 (10:01):
Well, I think what really opened my eyes to this
concept of trauma as a diseasewas when I rotated through shock
trauma back in 2004 inBaltimore and there were people
from multiple differentresidency programs and from the
military.
When someone was admitted tothe hospital as a trauma, they
would go the next day not towhoever happened to be the

(10:24):
person on call that night but towhoever's service they belonged
to, based on where they firstappeared.
So, for instance, if you camein the first time you were
injured when a Hopkins residentwas on call, you were forever
going to go to the Hopkins teamversus the University of
Maryland, whoever the residenthad been on call, and you would
see these people that had comein three, four, five times, shot

(10:47):
multiple times again and againand again.
People that were in caraccidents more than once.
So the concept of trauma beinga disease and not just a random
event there's clearly underlyingfactors and societal things
that are going on that lead tothis.
There's been so many advancesover the years in overall safety

(11:10):
mechanisms out there.
So we see people that aresurviving things that they
normally wouldn't have survivedif you went back to the 1950s,
the 1960s, the 1970s.
We see, for instance, with racecar driving, all the time
there's severe foot and anklelower extremity injuries because
the vehicles have gotten of.
Look at what can be done toprotect against that.

(11:31):
In the past those injuriesprobably happened but people
just did not survive theseaccidents.

(11:52):
In the early 2000s I rememberduring my training we were
seeing a lot of people coming inwith high energy traumas
motorcycle crashes, things likethat that previously probably
didn't survive, and these aremiddle-aged people.
They're coming in with heartdisease and diabetes and other
conditions that you don't see inthe 20 to 25-year-old trauma

(12:16):
person.
It led to a whole new areapurely because people were able
to survive things that maybethey didn't survive before.
There's definitely been a lotof safety and changes with the
road and vehicles.
I feel like the epidemiologyand demographics of injury have
changed over time because ofthese kind of factors.

(12:36):
Do you see that in youreveryday practice?

Speaker 1 (12:39):
Sure, I mean, as I said before, I'm 50 years old,
so I pretty much grew up like inthe 80s and 90s, right.
And so in the 80s drunk drivingwas a scourge Not to say that
we've eradicated it, because wecertainly have not, but back
then you saw really a societalfocus Mothers Against Drunk
Driving, mad or these othertypes of organizations that

(13:00):
really said we are not going totolerate this.
And you saw the beginnings ofsafe rides, free taxi rides.
Remember, for my youngerlisteners, there was no such
thing as Uber.
There were taxis, but you knowyou would get free taxi rides if
you were drunk and they weresubsidized by I don't know who.
These days you still see thesame thing, particularly on
known high-risk events like NewYear's Eve, where you can get a

(13:23):
safe ride home to avoid drunkdriving.
So you see that we have reallydone a pretty good job as a
public health initiative andsaying look, this is a high-risk
behavior, this is a high-riskenvironment.
We know, on Halloween, on NewYear's Eve, on your 21st
birthday, on these very specificevents, on New Year's Eve, on

(13:46):
your 21st birthday, on thesevery specific events the
probability of drunk drivingskyrockets.
So we're going to target thoseparticular times.
I think there's a lot more, andwe've done the same thing as you
and I just talked about inregards to motor vehicle safety.
You know motorcycle safetyhelmet laws are mostly there.
They're not quite ubiquitous inall the states.
There's some ups and downsthere, but regardless, I think
we've done a pretty good job ofaddressing preventability of

(14:10):
injury and safety across a verywide spectrum.
There's still plenty of work tobe done, plenty, the least of
which is firearm relatedinjuries, which really have
become probably the single mostimportant trauma-related public
health challenge of my career.
By the time I retire, I think,when those who are my age will

(14:33):
be making podcasts.
They won't talk about drunkdriving like I just did in the
80s.
They'll probably talk aboutfirearm-related injuries that we
dealt with in the 2000s and Icertainly hope they'll make a
dent there like we did withdrunk driving.
But we'll see.
So that's the answer to yourquestion, mark is I've
absolutely seen a shift in mypractice.

Speaker 2 (14:52):
Do you think there's a different disease in different
parts of the country, so forinstance, if you live in the
southwest versus the northeastversus somewhere, say, in
Florida?
Do you think that injury andtrauma vary around the country a
lot, or is it the same generalthing throughout the United
States?

Speaker 1 (15:13):
I think it's the same general things throughout the
United States but they differbased on populace.
So you know, like urban centers, whether you're in Miami,
detroit, chicago, la, if you'rein an urban center you know
you're going to see basicallythe same type of trauma as you
would if you're in a suburbancenter, in those same regions as

(15:33):
if you were in a rural center.
In those regions you can kindof to a very large degree
predict If you're a 20-year-oldit isn't such a big deal, maybe
you're a bit inebriated, but20-year-old isn't such a big
deal.
Maybe you're a bit inebriated.
But if you're 70 years old andon blood thinners, it's a major
problem and you could have asevere brain injury that could
cause you to die.
So far from standing, allgenerations, all people is the

(15:54):
most common mechanism.
But if I was to bring it downand you said to me that's a
25-year-old, I'd say he's eitherbeen shot or was involved in a
car crash.
You know, if you say he's a 40year old, I'll give you a
different mechanism.
So and if you tell me if he'surban, suburban or rural, I can
partition that a little bitdifferently.
But I don't think it matterstoo much whether you're in the
Northeast, south, midwest orWest.

Speaker 2 (16:16):
The most dangerous place, I feel, is probably the
house too.
I see lots and lots of injuries, and they may not be high
energy trauma injuries or traumaactivations.
The bedroom and the bathroomhave to be two of the most
dangerous places in your house,and we see tons and tons of
things like that every day.
People fall on their hip or,you know, a toe or something

(16:39):
else, you know it's totally true.

Speaker 1 (16:41):
So many, many years ago, when I was still kind of
early in my career, theyactivated the trauma system.
I'm in the elevator with one ofour physician assistants this
is the Frank NDGW and myphysician assistant was like
listen, man, I am so tired offall from standing.
I mean, talk about waking youup at two in the morning, are
you kidding me?
Fall from standing, and I waslike you know, I hear you and I

(17:02):
feel the same.
But anecdotally, it seems likea lot of these people are really
hurt.
And so we actually did a studyon it.
We looked at 808 patients whohad fallen from standing.
That was the mechanism fallfrom standing, 800 people and we
came down with four differentrisk factors.
Four different risk factors IfI remember correctly, it was

(17:26):
something like age over 65 or 55, slightly confused, not
comatose, slightly confused,which for my medical colleagues
is a glass of coma, score 12 orless.

Speaker 2 (17:38):
It's basically where I live my life.
That's why I'm not brother.

Speaker 1 (17:42):
Not drunk and on a blood thinner called warfarin.
And if you had all four riskfactors age, either 55 or 65,
long story short, not that oldIf you were on warfarin,
probability of death was 100%.
Everybody died.
That is shocking to me.
The dude just fell fromstanding.
That's all that happened Atlike age 60 or so.

(18:03):
If you're in your home and youtrip over the rug because your
glasses aren't exactlyappropriate prescription so you
don't really see the edge of therug, or you know you have
Parkinson's disease, you havekind of a shuffling game.
Whatever the reason may be, itdoesn't have to be explosion,
dispatch battalion 12 to make ita potentially lethal trauma.

(18:27):
It could just be.
Hey man, I just fell down andnow I've broken something, or
I've injured my brain, I've hitmy head and I'm in dire straits.

Speaker 2 (18:36):
I think that's really important too is the
recognition of what counts as atrauma.
There was a medical school thatwas in a car accident in a
parking structure.
The car accident was reallythat they had a heart attack and
ended up hitting holes thatwere coming out of the parking
structure.
It was like a big red herringbefore someone realized why this
person was comatose and whatwas going on.

Speaker 1 (18:56):
They actually had a heart attack and came in as a
trauma Because the problems willtell us a lot of times hey, you
know, this is a 55-year-oldindividual in a car crash.
But you know what?
We did not see any skid marksas we approached the vehicle.
And that's kind of a tip-offthat perhaps the person had a
medical problem before theycrashed.

(19:16):
Maybe they had a heart attack,like you said, Mark, Maybe they
had a stroke, whatever, Maybethey had a seizure.
But that actually changes thegame quite a bit.
So the handoff from theparamedic can give all sorts of
clues as to what you should lookfor, and that really alters the
game on how we even start theassessment of the patient as
opposed to the paramedic saysyou know, man, the car was

(19:37):
pulverized and there's skidmarks and there's all sorts of
stuff.
And, by the way, we didn't seeevidence that the guy was belted
in.
Oh well, that's going to be awhole different animal.
So yeah, I totally agree withyou?

Speaker 2 (19:49):
What do you think in a major like DC urban
environment?
What are the main things thatwe're seeing?
Would you say that the vastmajority in the downtown DC area
, like we're in, is it going tobe mostly gun violence or motor
vehicles or a mixture?

Speaker 1 (20:06):
Believe it or not, the most common is still fall
from standing, because, you know, washington DC does have its
fair share of elderly patients,so it's far from standing all
comers.
Having said that, there'sunfortunately a rising incidence
of firearm-related injuries,gun violence, in the district,
just as there is, by the way, inevery major state in the
country as we speak in 2022.
So we've seen a significantuptick in firearm-related injury

(20:29):
that Mark and I actuallypublished an article on
post-COVID, pre-covid-19.
What we don't see in theDistrict of Columbia, within the
district itself very much, ishigh-speed vehicular trauma,
right, so there's nobody in theDistrict of Columbia that's
going like 70 miles an hourbecause it's urban, the streets
are not set up for that.
So once in a blue moon youmight get a high-speed vehicle,

(20:51):
but not commonly those types ofinjuries.
We are seeing more in thesuburban trauma centers that are
flanked by highways If you'reon I-66 around Washington DC or,
to anybody in California, i-5,i-80, anything to that effect.
Man, now you're talking aboutspeeds of 70 to 100 miles an
hour and that's very differentthan what you would see in an

(21:12):
urban setting.
The other thing that you do seequite a bit in Washington DC,
as I suspect you do.
Probably you do in othertourist type centers maybe it's
Manhattan or Chicago, you know,near Lake or something like that
is auto versus pedestrianchecking out the monuments, and
whether the driver is doing thesame thing, checking out the

(21:34):
monuments, and hits thepedestrian or the pedestrian
doesn't quite appreciate thatthe life has changed and
ventures into traffic.
But we do see a lot of auto pedand, to the district
government's credit, they'vetargeted that.
When I came to Washington DCthere was a ton I mean daily,

(21:55):
daily auto versus pedestrian orauto versus bicyclist.
The district government and theDepartment of Transportation
really altered the lanes andthey physically changed the
streets and now we've seen anice drop in auto versus
bicyclist.
Again, room to go.
We're not quite home yet, butit certainly has made it safer.
And so you see governmentresponding to change the way we

(22:19):
behave and to try to increasethe safety profile.
But so in DC it's far fromstanding.
And then you see like autoversus pedestrian, auto versus
bicyclists, and then,unfortunately, absolutely, we
have seen GW alone has seen a300% rise in incidents of gun
violence when I got here in 2011, as compared to today, the end

(22:42):
of 2021.
In 10 years, the incidence ofpenetrating trauma at GW went
from about 8 or 10% to ourcurrent 25%.
So 8 times 3 is 24, closeenough.

Speaker 2 (22:55):
It's amazing how prevalent it is.
Do you think there's any rolewith mental health disease and
illness?
Um, we were talking beforeabout being a little altered,
but not totally altered.
I feel like we see a lot ofpeople that are pedestrian
struck, that were probably notreally minding the intersection

(23:17):
or had other things going onthat may have compounded the
injury.

Speaker 1 (23:22):
Yeah, I guess maybe when we say mental illness, I
think the average persontranslates the words mental
illness to crazy and it's justtoo simplistic to say that.
So I would not say we have alot of crazy people being
severely injured.
I wouldn't say that.
But if you open up the termmental illness to things like

(23:47):
depression or other aspects ofanything other than a good,
well-balanced mental state, thenI would say for sure, but that
opens up a whole spectrum, right?
So again, if we go back torural america and you say mental
illness by and large, we'regoing to talk about depression.
If you come to urban america andwe talk about mental illness,
you're going to talk aboutschizophrenia, bipolar disease

(24:08):
as risk factors for beinginjured.
So yes, and I think it matters,and I think that also then
selects out the type of injuryyou're going to see.
And then you know, I'll alsoput things like personality
disorders and other aspects ofmental illness into the fray.
When we talk about gun violence, it doesn't have to be just
schizophrenia and bipolardisease, and in fact I'll tell

(24:30):
you almost certainly it'susually not that I have not
treated that many schizophrenicswho shot somebody.
I've only treated many peoplewho've had personality disorders
and anger management disordersand unto themselves carry a lot
of post-traumatic stress fromissues in their life,
socioeconomics, upbringingthings like that and then

(24:53):
unfortunately translates over toviolence, unfortunately
translates over to violence.

Speaker 2 (24:56):
Being around the holidays right now, I feel like
every year this time of year weget people jumping off of
freeway overpasses and such.
One of the interesting thingsin the DC area is that there's a
cap on the height of thebuildings, which I think lends
towards more people survivingwith really severe injuries,
typically multiple orthopedicinjuries that we see.

Speaker 1 (25:21):
Yeah, I hadn't thought of that until recently.
And, for those who don't livein the district, there is a law
in Washington DC which basicallylimits the height of the
building relative to the widthof the street, and I would not
have believed this to be true.
It just sounds a little wonkyto me.
Except that at GW we built ahelipad in 2019.

(25:44):
And we have one pad, butbecause next to it are all the
mechanicals of the building,like the HVAC systems and
whatever other water coolingsystems that we have for the
hospital, and so we could onlyfit one helipad.
And I said to the architectwell, why can't you just elevate
the helipad above themechanicals?
I mean, who cares what thehelipad is, it's a helicopter
and then build me two helipadsso we have some capacity in case

(26:07):
something happens.
And from the lawyer's lips Iheard that's physically
impossible because we've tappedout the height of the hospital
relative to the width of thestreet.
And I was like wow, I thoughtthat was just an old wives' tale
.
Come to find out it's not, it'snatural law.
But I had never turned it intopublic health safety like you
just did.

(26:27):
So maybe that's a good thing,because you're right when we
have jumpers who try to commitsuicide or perhaps were
inebriated or some other reasonwhy they jumped.
Pcp is another good one.
As far as why people jump, Ishould say good one.
I should say it's a common one.
It's definitely not good.
You're right.
They can only jump so farbecause the buildings are not
that tall, and so we'vecertainly seen our fair share of

(26:48):
survivors.
Thankfully Now they're severelyinjured, and that's where I
call my favorite orthopedicsurgeon, and then he calls three
of his other buddies becausethere's going to be a lot of
work to do.
But we certainly have manypeople survive, having jumped a
bunch of stories instead of theycan't jump 30 stories.
There's no 30 story building.

Speaker 2 (27:07):
I'd be curious, in a city like New York or San
Francisco, where you have tallerbuildings, to the exact numbers
, of how many people jump andsurvive versus don't.
And I wonder if it's differentin a city like DC, just purely
because of the heightlimitations.
A good question.

Speaker 1 (27:25):
Remember, you and I only get to see that which comes
to us.
In other words, if somebody isinjured and dies on the scene
and they're never brought to thehospital, then the only person
who knows the common denominatorfor all deaths is the medical
examiner in the police office.
But I only know the people whocome to the hospital and then
die.
So you're like, well, for thatwe'd have to go to the ME and
say how many people jumped, howmany of them died, and then we

(27:48):
can figure out the percentage.

Speaker 2 (27:51):
It really is interesting how random it seems
sometimes that you can havesomeone show up, shot once and
paralyze someone else that getsshot nine times or is in a
devastating car accident andmore or less walks away from it.
I think the randomness of thewhole thing is what gets to me
sometimes.

Speaker 1 (28:10):
Yeah, I strongly agree.
You know we have a traumasurvivors event at GW every year
.
It's probably my single mostfavorite event of the entire
year, and there's one area of mylittle introduction speech that
I haven't changed for 10 yearsnow and it kind of puts things
in perspective, which is kind ofwhat you said, mark.
Every day we all get up, youbrush your teeth, you wash your
hands, you put on some clothes,you have a bite to eat and then

(28:34):
you start your day.
Whatever it is you do, youcannot go doctor shopping, you
cannot go hospital shopping.
You just say thank God, I livein the United States, please
take good care of me, and that'sthe system that we have set up.
And never, ever forget, evenwhen you're dealing with a
grieving family, you're dealingwith a difficult patient.

(28:55):
What I try to keep in the backof my mind is you know what?
Three hours ago, this guy waseating a bowl of cereal, like I
was, and just give him a break,because things just changed for
him or her in a way.
They haven't for me, and theyneed time to acclimate and
adjust.
And that's a key difference inthe lives of those people versus

(29:18):
the lives of others who may beill, like my friend is, but at
least have a little bit more ofa predictable aspect to their
illness.

Speaker 2 (29:25):
It's so true, just in the blink of an eye, how things
can change.
Let's shift gears a little bit.
So you brought up some of thesedifferent players in this
trauma system.
Let's talk a bit about thetrauma system that we have in
the United States.
This isn't something that justemerged out of thin air.
This is something that's reallyevolved over a number of years,

(29:46):
probably around the time of theVietnam War.
Let's talk a little bit aboutthis whole concept of the golden
hour and what led to the wholetrauma system we have today.

Speaker 1 (29:57):
Absolutely, I'll do my best.
You have to go back to the1960s.
Trauma centers are reallyreally young.
Trauma centers came into beingaround the mid-1980s and
emergency medicine as adiscipline is really really
young.
There's been orthopedicsurgeons for a long time.
There's been general surgeonsfor a very, very long time.
Internal medicine, all thiskind of stuff Emergency medicine

(30:20):
came into being in the late1970s, early 1980s, and so we're
talking about systems of carethat are really quite young.
I'm going to put a little plugout there for anybody who wants
to go to like YouTube andYouTube a TV show that was
called Emergency.
It was the first TV show evercreated to really talk about

(30:45):
what a paramedic even is and itwas set in the late 1970s in Los
Angeles and it was these twoparamedic firefighters named
Johnny and Roy and they wouldget in their rescue squad and go
places and treat the injuredand it was revolutionary back
then, prior to Johnny and Roy,if you were in a car crash or
something, literally a hearseshowed up, like where you put

(31:07):
the dead people in the coffin.
That's what showed up.
And even in emergency you'llsee the hearse show up, but the
paramedics get inside it.
So I guess that's a step up.
And before Johnny and Roy, youwill go to the local hospital
which had an emergency ward.
There was no department andanybody could attend there,
whether it was family practiceor internal medicine or certain.
You got what you got and didn'tget upset.

(31:29):
There was no specialty and ifyou made it, that was lovely,
and if you didn't make it, Iguess that's an issue Well in
the late 1960s.
Going to make it, I guess that'san issue Well in the late 1960s
, lyndon Burt, johnson, lbj,signed the Highway Traffic
Safety Act and I probably havethe name wrong, but something to
that effect and that was thefirst allocation of federal
dollars to start creating safetysystems for our transportation

(31:53):
and the National HighwayTransportation NHTSA was born.
And the National HighwayTransportation NHTSA was born.
Following that, there's an EMSAct that's signed and dollars
are allocated to create 911,pretty much as we know it today,
with paramedics and all thatand then pre-hospital care.
So that then led to ultimatelythe development of emergency
departments with specializeddoctors that are emergency

(32:17):
medicine doctors, which I am not.
And then ultimately into the80s we get into trauma surgeons,
who are surgeons whosespecialty rests on dealing with
people with actual or potentiallife-threatening injury which

(32:37):
you're not going to see, bobAxarani.

Speaker 2 (32:39):
It's interesting because in Europe, I think it's
a little different.
Don't?
A lot of basic orthopedicthings get handled by a trauma
surgeon?
And I don't know if that'sevolving or not, but there's
been a lot of overlap.

Speaker 1 (32:50):
We should do a whole episode on European trauma or
medicine, because it's entirelydifferent.
Many hospitals in Europe theorthopedic surgeon basically is
the trauma surgeon.
He or she is the first personyou meet.
The most common injury is abroken bone, whether it's your
arm, your leg, your pelvis, yourfoot, whatever it is, that's
the most common injury.
It's just different, to eachhis own right.
But again, remember, in Europethey also don't have firearm

(33:12):
injuries and things that need ageneral surgeon.
In the United States, a surgeonsuch as myself, I will only be
notified by the emergencydepartment that a patient's
arriving.
If they meet certain criteriacreated by the CDC, actually by
the federal government.
That then puts the person atrisk for actual or, I guess,
maybe potential death, where youneed a surgeon to see you on

(33:34):
arrival and then luckily, moreoften than not it's not that bad
.
I wouldn't kind of stand down,but on a regular basis, I would
certainly say every couple ofday basis, we will see somebody
who is at imminent risk of deathand then the ability to
jumpstart the system and getsomebody who can stop bleeding
basically that's my job, ispivotal, and then, once the

(33:55):
bleeding stops, the dust settlesand we can call others for help
.

Speaker 2 (34:04):
Now, that concept of the golden hour that really
evolved out of the Vietnam War,the concept of if you can get
someone to a hospital, a centerto manage their injuries, their
trauma, within an hour, that thevast majority of people could
be saved or salvaged, versus inprior wars there was a
significant delay getting fromthe field to a doctor and many
people died and the concept waswell, if we can take that and

(34:27):
translate that over to civilianmedicine, it really is
interesting that that hour doesmake a big difference.

Speaker 1 (34:35):
There's a very, very famous trauma surgeon my mentor,
frankly.
So I'm pretty happy that I knowthis person.
His name is Dr Bill Schwab, andwhat Dr Schwab wrote about in
one of his addresses to one ofthe trauma societies basically
said every time the country goesto war, the care of the injured
patient improves dramatically,which is true.

(34:56):
It's sad that we have to go towar, but it's true that the
lessons we learn in war wetranslate to our civilian
population.
That's true of the Iraq andAfghanistan experiences.
You know that we just were inrecently.
But if you go back to, like youknow, world War II, you know
you were injured and therereally were no really good

(35:17):
evacuation systems back then.
So if you were severely injuredyou were not going to do very
well.
The lesson that was learnedafter World War II into Korea
was helicopters.
So in Korea we developedsystems to rapidly evacuate
patients and anybody who'swatched the show MASH will know
that.
You see the helicopters landingand they have the MASH
hospitals, they're waiting toreceive them within the

(35:38):
characters Hawkeye and thoseguys In Vietnam.
They took it one step furtherand they said okay, we're going
to keep the MASH-like hospitals,we're going to keep the
helicopters, but now we'rereally going to forward, deploy
corpsmen and medics, and we'regoing to train these people on
how to start IVs.
We're going to train thesepeople on how to give morphine
and pain medications.

(35:59):
Now we're going to basicallyproject forward our capability
to start care at the point ofwounding.
That made a huge amount ofdifferences and there were some
downsides to that.
We discovered a new diseasecalled ARDS and what happens
when you give someone too muchIV fluids, and so when we went
to war in Iraq and Afghanistan,we took those lessons and we

(36:22):
said OK, corpsman or medic, donot give a lot of IV fluids, but
do a ton of other stuff.
Put on tourniquets, decompressthe chest, render pain relief,
keep the person warm.
Oh and, by the way, we're goingto launch Blackhawks and no one
is going to stay on thebattlefield very long when
they're injured.
We can clear the battlefieldand evacuate our wounded.

(36:44):
And lo and behold, in thecurrent wars that have just
ended, we have the lowest casefatality rate of any US military
experience in which we've beeninvolved Now, of any major war.
This had the lowest number ofpercentage dead because we kept
projecting forward.
We kept projecting forward andthose lessons have now been
translated to the civilian arenaover the course of each time

(37:07):
period between the wars.
So now we're telling theparamedics in the field do not
give a lot of IV fluids, becauseall of a sudden this disease
that we saw in Vietnam ARDS orDa Nang lung, napalm lung, all
of which is kind of the samething we just don't see that
anymore.
Do go ahead and utilizetourniquets, do go ahead and

(37:27):
decompress the chest and thenget them to the trauma center as
fast as possible and the traumacenter.
We've kind of started to changeour paradigm where we used to
give a lot of different types ofmedications and blood products
and now we're kind of doing itthe same way the Ranger
Battalion did it in Afghanistanand Iraq and, lo and behold,
we're finding civilians aredoing better.
So you're right, the lessons welearned in war and Bill Schwab

(37:50):
was right the lessons we learnedin war we apply to the civilian
environment and you find we allmove forward.
It's just that, unfortunately,in the world of trauma surgery,
where we deal with injury, itcosts us a war and what weighs
heavy in Dr Schwab's mind and Iknow this because I know
personally and what weighs heavyin all of our minds is the cost

(38:12):
of that knowledge?
Are the lives of the 19 and 20year olds right?
The soldiers, the airmen, thesailors, the Marines?

Speaker 2 (38:19):
It's amazing how quickly people can be moved
around the world.
I think back to 2004,.
We had an injured Marine thatshowed up at shock trauma 72
hours out of the field withdevastating injuries, which is
just amazing how quickly thoselessons get applied to moving

(38:40):
people from a car wreck to atrauma center in the US.
You look up every so often andsee a helicopter flying overhead
and you can tell which of thesehelicopters are the paramedic
rescue helicopters.
It's unfortunate the way theselessons are learned, but seeing
them applied is incredible howit does make such a huge
difference, and I think that'sgoing to be a really interesting

(39:01):
discussion when we pull in somepeople from the military to
talk about what the currentstate is there and get an idea
of where the future is in thecivilian world.

Speaker 1 (39:12):
I totally agree with that when I train nowadays our
residents and our fellows, andeven when I speak to colleagues
outside of the trauma center asan example, someone may call and
say well, I've got a patientover here in my particular
hospital it's not a traumacenter, for example and this guy
is really terribly ill and Isay well, I'm happy to help.
You, send me the patient andonce in a blue moon you'll get

(39:35):
one of these.
Well, he's too unstable totransport.
Like from the military welearned, he's actually too
unstable to stay.
There's no such thing as toounstable to transport, because
if we can provide outstandingcare 37,000 feet between
Afghanistan and Landstuhl,germany, then why can't we do

(39:58):
the exact same thing between,say, I don't know someplace in
Washington DC, an I-66 inboundto DC, right?
So if you can do it in the backof an airlift from Afghanistan
to Germany, surely we can do itwithin the continental United
States.
And that changes the entireparadigm.
And that's kind of my point isthere's no such thing as too
unstable to transport.
There's only too unstable tostay so long as you have the

(40:22):
infrastructure to transport thatperson, right.
So to your point, mark.
Helicopters basically are flyinghospitals.
The ambulance that we createdis a mobile intensive care unit
in every sense of the word.
The only thing I cannot do withthe back of that ambulance is
operate.
The ambulance that we createdis a mobile intensive care unit
in every sense of the word.
The only thing I cannot do inthe back of that ambulance is

(40:42):
operate.
Shy of that.
I can do anything that I can doin the hospital in the back of
the ambulance.

Speaker 2 (40:45):
So what's the problem ?
I think one of the next stepsthat will be interesting to see
from the military perspective.
We spend as a society a smallfortune Some of these traumas
are probably upwards of amillion dollars in care and then
the people are discharged fromthe hospital and oftentimes to

(41:07):
maybe not the best of socialsituations or recovery
situations, and I sometimesshake my head and you see how
much you've invested up frontand then there's just not the
resources afterwards.
So it'll be interesting to seehow the rehabilitation process
and what role that plays in themilitary, and I wonder if that
will be kind of the next thingthat we see here.

(41:29):
You invest all this money andis it wasted?
In some ways it's interestinghow that process moving on.
I feel like there's a voidthere.
That is probably going to beone of the next stages to get
addressed.

Speaker 1 (41:41):
Yeah, I agree with that.
It's probably worth having asocial worker or somebody or a
physiatrist who kind ofunderstands.
This is the intersectionbetween insurance and
rehabilitation, betweeninsurance and rehabilitation.
So you don't need to have adime in your bank or even any
form of health insurance of anysort to receive emergency health

(42:03):
care.
In the United States you don't.
You can be about as poor aspoor gets and have no insurance
whatsoever and the trauma centerwon't take care of you.
I don't know my patient'sinsurance status.
I purposefully never, ever lookit up.
This is my personal policy.
I don't know my patient'sinsurance status.
I purposefully never, ever lookit up.
This is my personal policy.
I don't want to be biased byanything.
I treat the patient as theycome.
I couldn't care less.
But let me tell you, somebodydoes care, and so when it's time

(42:24):
to discharge, that's when allof a sudden the chickens come
home to roost, right, all of asudden, the rehabilitation
centers, which are not under anylegal onus to take you, as the
trauma center is, they justwon't, unless you have some
means to cover that as well assome place to go there after.

(42:44):
The rehab centers don't wantsomebody who's going to be there
for three months, because whenthey're done rehabilitating they
have no place to go.
And so you get into this hugecrunches of trying to get these
people to where they need to beto continue their recovery.
Oh and, by the way, open up thebed in the hospital so the next
trauma patient has a place togo.
So it really becomes a backlog.

(43:06):
The whole thing just backs allthe way up to the front door of
the hospital because there's nothroughput on the back end, and
that's where the patient him orherself suffers, but so too do
the others who are trying to getin and can't because the beds
are blocked with people whoshouldn't be there any longer.
That's a whole societal thingthat we struggle with.

Speaker 2 (43:26):
That's for sure.
I would say a sizablepercentage of the trauma service
on any given day is really madeup of people that are kind of
in that limbo in between injuryand recovery, that are stuck
because they can't walk orbecause of bilateral or
extremity injuries or otherthings like that, and you have

(43:47):
this intersection where thehospital turns into a quasi
rehabilitation center for awhile.
How many trauma centers arethere and how do you qualify to
become a trauma center?

Speaker 1 (43:59):
I don't know how many trauma centers there are in the
United States.
You could get the number.
It would take a little bit ofwork because there are two
different ways to become atrauma center.
One way is the state designatesyou.
So the Department of Health forthe particular state, the
Commissioner of Health,designates the hospital as a
trauma center based onrequirements that the Department
of Health creates and thehospital meets.

(44:21):
The second way of becoming atrauma center is an independent
verifying body called theAmerican College of Surgeons
verifies you.
They actually don't designateyou, they verify you.
All they do is they verify thatyou have met, as a hospital,
the criteria that they havecreated designating or
delineating what a trauma centershould be.
I've got to stay away from theword designating because they

(44:43):
don't designate Delineating whata trauma center should be.
And if they say, look, you'vegot to do this, that and the
other, and then you submit anapplication that says, look, I
did this, that and the other,they will send you a letter that
says we verify you did this,that and the other.
Go ahead and send this letterto your Department of Health and
the Department of Health willbe the designating body, then
the legal authority that saysyep, you did this, that and the

(45:04):
other, you're good to go.
So some states basically haveoffloaded to the American
College of Surgeons and said ifyou do what they say the state,
we will make you a trauma center.
Pennsylvania is a great example, maryland is a good example.
Other states have said we don'tneed the American College of
Surgeons as a verifying body,we'll do that ourselves.
But what you find is 98% of thecriteria that are state versus

(45:29):
ACS are the same.
So really the American Collegeof Surgeons kind of sets the
tone and by and large, thestates fall in line.
They may tweak it a little bitfor their own purposes, but
that's kind of what they.
By and large it's the same.
And so to figure out how manytrauma centers there are, you'd
have to go through the ACSwebsite, which is pretty easy,
but then you have to go throughevery state by state to see how

(45:50):
many are state designated andthen add those in.
That would take some time.
So I don't really know how manytrauma centers there are.

Speaker 2 (45:55):
Common denominators are going to be full-time trauma
coverage 24-7 from a traumasurgeon.

Speaker 1 (46:02):
It depends on the level of the trauma center.
So the trauma centers aredesignated levels one, two,
three and, some places, levelfour, but most of them are
levels one, two and three, onebeing the highest level, level
three slash four being thelowest level.
If you start from a level threeand work our way up, a level
three trauma center has ageneral surgeon doesn't have to

(46:23):
be a trauma surgeon, a generalsurgeon, on call 24-7, 365 with
30-minute response.
So the general surgeon must bewithin 30 minutes of the
hospital at all times and theywill have an anesthesiologist
and an entire OR team within 30minutes of the hospital at all
times and they will have ananesthesiologist and an entire
OR team within 30 minutes of thehospital at all times.
There'll be an emergencymedicine doctor in the hospital
at all times.
They don't have to haveneurosurgeons.
I believe they have to haveorthopedic surgeons, but I could

(46:46):
be wrong about that.

Speaker 2 (46:47):
Probably 30 minutes.

Speaker 1 (46:48):
Yeah, whereas when you get to a level two and a
level one, they're basically thesame thing.
A level two level one differsin only two aspects.
A level one must do research,and so they must publish a set
amount of research papers peryear, and a level one must have
a training program where theytrain tomorrow's surgeons.

(47:11):
You must have a residency.
If you don't have either ofthose, you cannot be a level one
trauma center by definition,but from the patient's
perspective the two are the same.
So you must now have a traumatrained surgeon within 15
minutes of the hospital at alltimes, not 30.
So 15 minutes is not exactly alot of time.
If they call you at two o'clockin the morning, you need to be

(47:32):
physically present at thebedside by 2.15, which means you
either live pretty much acrossthe street or you spend the
night in the hospital, and mostof us spend the night in the
hospital Like I've neveractually taken a call from home.
Every fifth or sixth night Ispend the night in the hospital.
Same with anesthesiology.
You must be within 15 minutesof our nursing staff 30 minutes.

(47:52):
But now for a level one.
You must have a neurosurgeon onyour staff.
You must have a trauma-trainedorthopedic surgeon on your staff
.
So with all due respect to mydear co-host, mark Chodos, who
is a foot and ankle guy and ifit's my ankle Mark's going to be
on my short list of people, tocall Mark doesn't cut it.
We need to have someone who'strauma-orthopedic trained, not

(48:13):
foot and ankle trained.
So you must have cardiac bypasscapability so you can go on a
heart-lung machine.
So by the time you're a levelone trauma center.
The basic premise is or leveltwo for that matter, level one
or level two trauma center.
You can literally take anythingthat walks through your door
period.
There's a carve out forpediatrics, so we are an adult

(48:33):
level one trauma center.
We do no peds whatsoever.
There are hospitals that arepurely pediatric, such as
Children's National MedicalCenter in DC, and there are
hospitals that are both.
They do peds and adults.
So you can kind of decide whichpatient cohort, but the rules
are the same.
And that's the overview oftrauma centers in the United
States and kind of how they are.

Speaker 4 (48:54):
Is there a geographic range?
Are you only going to go to oneclosest to where you live, or
could it vary depending oncertain kind of expertise?

Speaker 1 (49:03):
Yeah, that's a great question.
There are no rules in theUnited States about location of
trauma centers.
There are some places that arejust inundated with trauma
centers.
Florida is the poster child andthere are a ton of trauma
centers in Florida.
I'll dare say Washington DC isalso approaching that because we
have a lot of trauma centersfor the number of people who are
actually injured, and that'sgood and bad.

(49:26):
It's good in the sense that youhave a trauma center really
close by.
That's always good.
It's bad because as you dilutethe amount of trauma patients
that each particular hospitalsees, you're kind of impacting
on their muscle memory, if youwill right.
It's kind of like if you're afootball player and you only
play five games a year, you'renever going to be fantastic, but
if you play 20 games a year,you're going to be much, much

(49:46):
better.
So there is a volume you haveto see so that you don't forget
and kind of learn.
Oh yeah, I saw that case justlast week and here's what we
need to do.
And then, on the other hand, inrural America, when you go down
to Alabama, Mississippi, NorthDakota, South Dakota, you know
the middle sections of thecountry.
You could go well over ahundred miles without having any

(50:07):
trauma center whatsoever.
Texas would be a good exampleas well.
So unfortunately, what you findis trauma centers that are kind
of clustered around majormetropolitan regions and then
the rural areas are leftcompletely blank, and that
presents another challenge.
Trauma centers exist whereverthere is money to support them,

(50:29):
because having a surgeon andeverybody else spend the night
in the hospital isn't exactlycheap, Waiting on the off chance
someone shows up, and maybethey do, maybe they don't.
You can cluster around urbanregions and the rural America is
left out, and that's achallenge.

Speaker 2 (50:42):
It leads to a interesting typical day as a
trauma surgeon, since thestructure is very different than
a normal nine-to-five job.
The day can sure vary dependingon what's happening randomly
out in the rest of the world.

Speaker 1 (50:57):
Yeah, listen if you wanted to be a firefighter when
you were a kid.
You should be a trauma surgeon.
That was me right.
So every day stays in thefirehouse.
You know you go in.
You don't exactly know what'sgoing to happen.
I've certainly had my fairshare of days where I've been
relatively kind of okay and didsome paperwork and maybe said hi
to a few people, but it wasn'tthat bad.
And then I've had days whereI've just drank from a fire hose

(51:18):
and blinked my eye.
It's eight o'clock at night andI'm like dude, I haven't even
gone to the bathroom.
So it just depends.
Your day is whatever it's goingto be.
Every day is Christmas.
You never quite know what'sgoing to happen.
If you like that type ofschedule, then it's a great
field.
If you don't like it, it's notsuch a good field.
But it's also one of the fewfields of medicine where you
punch in and punch out right.

(51:39):
So like right now I'm home,it's Sunday night.
There's not a chance that thehospital is going to call me,
unless there's a masscatastrophe Tomorrow.
When I'm on call, I would neversay let's record a podcast,
because at any moment's notice Icould toned out and have to go
to the emergency department.
So you're on when you're on andyou're off when you're off,
which is why I said at thebeginning of the podcast the

(52:01):
lifestyle actually is prettygood.

Speaker 2 (52:03):
I remember during residency the rounding in the
afternoon.
We used to round twice a day andthe afternoon rounding would
start around four or five in theafternoon and invariably a
trauma would come in and then wewould lose our chief resident
but we could keep roundingbecause we had another resident
that was senior and this processwould slowly continue over the

(52:24):
rounding and we would have aprogressive attrition until we
reached the point where it wasjust the interns who couldn't
round.
Usually it was around 11 or 12at night before we finished our
absolute rounds.
And this process was repeatedday in and day out.
I think we averaged aroundthree and a half hours of sleep
during that time, mostly longperiods where you were sitting

(52:45):
around because you couldn'tround.
You'd count off and realize youwere the only person left to go
down to the trauma that justcame in because everyone else
was in the operating room or,you know, the ct scanner.
It was interesting.
We never made it very far downthe list before the trauma
started to roll in yeah,unfortunately the 4, 30 in the
afternoon.

Speaker 1 (53:04):
Trauma activation is a very well described phenomenon
because that's what everyone'sdriving home right and that
someone's gonna crash, someone'sgonna hit someone else.
And then, just when you thoughtmy day's coming to a close not
quite somebody just showed up.
It's gonna be an hour and ahalf workup.
You're looking at going home atsix if you're lucky.
That is a well-known phenomenon.

Speaker 2 (53:23):
The weather and holidays and days of the week
it's very dependent on.
Even though it's random, it'snot totally random.

Speaker 3 (53:31):
That's it for this episode of Wellness Musketeers
Totally random.
That's it for this episode ofWellness Musketeers.
Big thanks to Dr Chodos and DrSarani for sharing such powerful
insight into trauma care andprevention.
Stay safe, stay curious andwe'll catch you next time.

Speaker 4 (53:49):
Physicians are independent practitioners who
are not employees or agents ofthe George Washington University
Hospital.
The hospital shall not beliable for actions or treatments
provided by physicians.
If you're listening and want toconnect with the staff at GW
Hospital, or call 888-4GW-DOCSto make a virtual or in-person

(54:22):
appointment, Wishing you wellfrom our studio here in
Washington DC.

All Episodes

Trauma: Seconds That Save Lives — with Dr. Babak Sarani & Dr. Marc Chodos

Episode Transcript

Popular Podcasts

Crime Junkie

24/7 News: The Latest

Stuff You Should Know

.css-15opob5{left:0;position:absolute;top:0.8rem;} All Episodes

.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Trauma: Seconds That Save Lives — with Dr. Babak Sarani & Dr. Marc Chodos