You Won't Believe What Causes Most Injuries in the USA?

Believe it or not, the single most common mechanism of injury in the entire United States 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 7th floor? They're like, no, man, I was just walking and I fell. That's by far the most common mechanism of injury.

It's so true, just in the blink of an eye how things can change.

Hi listeners, Ozzie 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 leading trauma experts in the country. Together, they break down what actually happens after a major injury and why trauma isn't just an accident, but something we can often prevent. Whether it's a fall, a crash, or an emergency you hope never happens, this is a powerful conversation that could help you or someone you love stay safer and more informed. Let's get right into it.

Hi there. I'm Mark Jodis. Like many people, my first experience with the realm of trauma surgery was through TV. Shows like ER at the time or Grey's Anatomy now paint an exciting, if not eccentric, image of what many people is a foreign world that they will hopefully never have direct experience with. From these shows, most people think of the emergency room as the place where someone goes when they get hurt and the emergency room doctors as the ones who guide the process. What many people don't understand 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 reinforced when I started my third-year surgical rotation during medical school. The chief resident would play Metallica full blast in the operating room as they struggled to save an injured person's life. It was pretty wild and crazy at the time, and over the years I think I've gained a better understanding for the trauma system and the processes that go into saving someone. It's much more complicated and algorithmic than you would think listening to Metallica in the operating room as a third-year medical student. Our goal with this series is to convey some of this to you so that you can gain a better understanding of this system and the processes and the various factors that people in the field of traumatology face. In this episode, we'll introduce the problem. We'll go into some background information to give you a setting from which to base. In subsequent episodes, we'll follow a hypothetical youth through the trauma system from pavement to the hospital and beyond. We will meet some of the players in this field, from the EMT to nurses, doctors, and social workers. We'll follow this journey through the rehabilitation and recovery process. After that, we will explore how trauma is handled in other parts of the world. We will venture into the realm of military trauma and look at how some of these innovations have transitioned into civilian trauma-based. We will conclude with a look at some of the efforts and regulations for injury prevention. Helping me out on this series is Dr. Surani. Dr. Serrani, would you like to tell us a little bit about yourself and what made you decide to go into a field of trauma surgery as a career?

Hi, my name is Babak Serrani. I am a professor of surgery at George Washington University, and I'm the founder and still medical director of the Center for Trauma and Critical Care at George Washington University Hospital. I've been in practice as a trauma surgeon since around 2005. And, you know, I really chose to go into the field because I, I just really enjoy the breadth of practice that I have. The trauma surgery is one of the few elements of true general surgery, since you never quite know where someone's going to be injured. I love working in an interdisciplinary team, so I get to work with the likes of Mark Chodos or neurosurgeons or urologists or emergency medicine doctors, intensivists— like, pick a type of doctor. And I get to work with them, and I really enjoy kind of that team approach, you know. And as much as people think the lifestyle is terrible, it actually isn't. It's pretty predictable, which I like as well. One of the times when we talk about lifestyle and wellness— so it's just a field that really appeals to me in every aspect: socially with my colleagues, medically with the patients I take care of, and then personally in that I have some time that's predictable with my family and my kids.

I think trauma, it's very interesting because you watch these TV shows and you don't really think of trauma as, as the same way as diabetes or heart disease or someone has appendicitis. But really, in fact, we talk often about trauma as being a disease, not just a random injury or accident. Can you talk to us a little bit about what this concept of trauma as a disease really means?

Exactly what you just said is that we don't like to use the word accident in trauma surgery. That's one of those few forbidden words. We tend to use a much more action-oriented term. So for example, some people will say, well, he was in a car accident. That's actually not true. He was in a car crash. He was in a motorcycle accident. Nope, nope, he was in a motorcycle crash. He accidentally shot himself, or the two kids accidentally shot each other. They didn't. That was not intentional firearm-related violence. And it sounds like a bunch of mumbo-jumbo big words, uh, circa today's world where we can't use simple speech, but it's actually meaningful. Because when you talk about an accident, right, an accident by definition is a freak event. It's something that could not have been prevented. It's just a freak event that occurred. And yes, there are some freak events that occur. I go for a walk, a branch falls on top of me— that's a freak event. But most injuries are preventable. So the best example are actually cars. You know, back in the '60s, people would die in car crashes left and right because back then seatbelt laws were very optional. The roads were not designed the way they are now. You know, when I come to work, there's a bunch of curves I have to go through in my neighborhood, and they're banked so that it helps my car stay on the road. There's guardrails. You know, even if you— in today's world, here's something that might you might find interesting. In today's world, if you're in your car and you roll over, like you're in a rollover car crash, okay? If you're belted in, you're actually not considered a significant trauma patient. You're not considered a trauma patient in an automobile rollover if you're belted in. Now there's a big if there. You have to be belted in, you have to be one with the vehicle. And if you become one with the vehicle, then the car is designed to take its own weight no matter how it is, so that it will not crush on top of you, it'll crush around you. And you see those things all the time, right? When you look at the news that someone's been in a bad car crash and the car looks like pulverized, but the passenger compartment has this tiny little space and the driver's kind of okay. Well, that's the design. That's an engineering process that we have created. So the engine block takes the energy, the A-frame takes the rolling energy, and lo and behold, The passenger compartment's okay, so long as you are where you're meant to be, which is belted in. You, you're not belted in, you're going to go for flight, and then we can talk about what a real trauma patient looks like. And so, and same thing with firearm injuries, by the way. You know, there's no reason under the sun, none whatsoever, why a 5-year-old should shoot their 3-year-old sibling. That should never occur if the firearm is secured properly, right? So we don't really talk about accidents, we talk about collisions, we talk about crashes. We say that was unintentional to really emphasize the point that they're all preventable anyway. And so if you approach trauma with that kind of mentality, then it actually makes sense that it is more of a public health disease, much like, you know, many, many things in public health are preventable. And I'll ask you in a sec, Marc, once I stop my little soapbox thing here, about maybe an analogy in the foot and ankle world, like what can I do to prevent myself from getting injured? What would you say, Bob? That was potentially some of your own doing. The leading cause of death in the United States after about 1 or so years old, after your infant years, up until age 44, is trauma. And that therein lies the problem, right? So if you are a policy expert, if you're some person who's trying to, you know, lead the country, who don't you want to die? The persons that I don't want to die are my young. Because they are the future, right? They are the ones who are going to invent stuff. They are the ones who are going to pay a lot of taxes. They are the ones who are going to get married and have offspring. They are the ones that are going to propagate the society. And so it is key that we keep our young alive. Not to take anything out of the elderly. I am 50 and I am starting to like the elderly more with every year. But it is the young. And so that is what we look at trauma on. It is not so much How can I fix you once you've been injured? My field is more, how can I prevent you from being injured in the first place? And yes, of course, there will always be people who are injured who will always need our help, but we start from a premise of injury prevention and then we go into injury management or injury treatment. So I don't know, Mark, what do you guys do if I was to say to you, give me something that's preventable in, in the world of orthopedics?

Well, I think what really opened my eyes to this concept of trauma as a disease was when I rotated through shock trauma back in 2004 in Baltimore, and there were people from multiple different residency programs and from the military. When someone was admitted to the hospital as a trauma, they would go the next day, not to whoever happened to be the person on call that night, but to whoever's service they belong to based on where they first appeared. So for instance, if you came in the first time you were injured when a Hopkins resident was on call, you were forever going to go to the Hopkins team versus the University of Maryland or whoever the resident had been on call. And you would see these people that had come in 3, 4, 5 times, shot multiple times again and again and again, people that were in car accidents more than once. So the concept of trauma being a disease and not just a random event, there's clearly underlying factors and societal things that are going on that lead to this. There's been so many advances over the years in overall safety mechanisms out there, so we see people that are surviving things that they normally wouldn't have survived if you went back to the 1950s, the 1960s, the 1970s. We see, for instance, with race car driving all the time, there's severe foot and ankle, lower extremity injuries because the vehicles have gotten so much better and so much safer that people are surviving these high-speed car accidents on the racetrack. And now what we're finding is that as the box collapses around them, it's their feet and ankles that are getting crushed. So there's a lot of look at what can be done to protect against that. In the past, those injuries probably happened, but people just did not survive these accidents. In the early 2000s, I remember during my training, we were seeing a lot of people coming in with high-energy traumas, motorcycle rashes, things like that, that previously probably didn't survive. And these are middle-aged people, and they're coming in with heart disease and diabetes and other conditions that you don't see in the 20 to 25-year-old trauma person. It led to a whole new area purely because people are able to survive things that maybe they didn't survive before. There's definitely been a lot of safety and changes with the, the road and vehicles. I feel like the epidemiology and demographics of injury have changed over time because of these kind of factors. Do you see that in your everyday practice?

Sure. I mean, as I said before, I'm 50 years old, so I pretty much grew up like in the '80s and '90s, right? And so in the '80s, drunk driving was a scourge. Not to say that we've eradicated it, because we certainly have not, but back then you saw really a societal focus Mothers Against Driving Mad, or these other types of organizations that really said, we are not going to tolerate this. And you saw the beginnings of safe rides, free taxi rides. Remember, for my younger listeners, there was no such thing as Uber. There were taxis. But you know, you would get free taxi rides if you were drunk, and they were subsidized by— I don't know who. These days you still see the same thing, particularly on known high-risk events like New Year's Eve, where you can get a safe ride home to avoid drunk driving. So you see that we I think we have really done a pretty good job as a public health initiative and saying, look, this is a high-risk behavior. This is a high-risk environment. We know on Halloween, on New Year's Eve, on your 21st birthday, on these very specific events, the probability of drunk driving skyrockets. So we're going to target those particular times. I think there's a lot more, and we've done the same thing as you and I just talked about in regards to motor vehicle safety. You know, motorcycle safety helmet laws are mostly there. They're not quite ubiquitous in all the states. There's some ups and downs there. But regardless, I think we've done a pretty good job of addressing preventability of injury and safety across a very wide spectrum. There's still plenty of work to be done, plenty. Now, the least of which is firearm-related injuries, which really have become probably the the single most important trauma-related public health challenge of my career. You know, by the time I retire, I think when those who are my age will be making podcasts, they won't talk about drunk driving like I just did in the '80s. They'll probably talk about firearm-related injuries that we dealt with in the 2000s. And I certainly hope they'll make a dent there like we did with drunk driving, but we'll see. So that's, that's the answer to your question, Marcus.

I've absolutely seen a shift in my practice Do you think there's a different disease in different parts of the country? So for instance, if you live in the Southwest versus the Northeast versus, you know, somewhere, say, in Florida, do you think that injury and trauma vary around the country a lot, or is it the same general thing throughout the United States?

I think it's the same general thing throughout the United States, but they differ based on populace. So, you know, like urban centers, whether you're in Miami, Detroit, Chicago, LA, but if you're in an urban center, you know, you're gonna see the basically the same type of trauma as you would if you're in a suburban center in those same regions as if you were in a rural center in those regions. You can kind of, to a very large degree, predict. If you're a 20-year-old, isn't such a big deal, maybe you're a bit inebriated, but if you're 70 years old and on blood thinners, it's a major problem and you could have severe brain injury and that could cause you to die. So far from standing, all generations, all people is the most common mechanism. But if I was to bring it down, he said to me, that's a 25-year-old, I'd say he's either been shot, he was involved in a car crash. You know, if you say he's a 40-year-old, I'll give you a different mechanism. So, and if you tell me if he's urban, suburban, or rural, I can partition that a little bit differently. But I don't think it matters too much whether you're in the Northeast, South, Midwest, or West.

The most dangerous place I feel is probably the house too. I see, uh, lots and lots of injuries, and they may not be high-energy trauma injuries or trauma activations, the bedroom and the bathroom have 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 and break their hip or, you know, a toe or something else.

You know, it's totally true. So many, many years ago when I was still kind of early in my career, they activated the trauma system. I'm in the elevator with one of our physician assistants. This is before I came to GW. And my physician assistant was like, listen, man, I am so tired of fall from standing. I mean, talk about waking you up at 2 in the morning. Are you kidding me? Fall from standing? And I was like, you know, I hear you and I feel the same, but anecdotally, it seems like a lot of these people are really hurt. And so we actually did a study on it. We looked at 808 patients who had fallen from standing. That was the mechanism, fall from standing, 800 people. I mean, came down with, um, it was 4 different risk factors if I remember correctly. It was like something like age over 65 or 55, slightly confused, not comatose, slightly confused, which for my medical colleagues is a Glasgow Coma Score 12 or less.

It's basically where I live my life.

That's where I am now, brother. Um, not drunk, and on a blood thinner called warfarin. And if you had all 4 risk factors— age either 55 or 65, long story short, not that old, you're on warfarin— probability of death was 100%. Everybody died. And that is shocking to me, that the dude just fell from standing, that's all that happened, at like age, you know, 60 or so. If you are in your home and you trip over the rug, because your glasses aren't exactly appropriate prescription, so you don't really see the edge of the rug. Or, you know, you have Parkinson's disease, you have kind of a shuffling gait. Whatever the reason may be, it doesn't have to be explosion dispatch battalion 12 to make it a potentially lethal trauma. It could just be, hey man, I just fell down and now I've broken something or I've injured my brain, I've hit my head. And I'm in Dari Streets.

I think that's really important too, is the recognition of what counts as a trauma. It was a medical school that was in a car accident in a parking structure. The car accident was really that they had a heart attack and ended up hitting poles that were coming out of the parking structure. It was like a big red herring before someone realized why this person was comatose and what was going on. They actually had a, had a heart attack and came in as a trauma.

Because the families will tell us a lot of times, Hey, you know, this is a 55-year-old individual in a car crash, but you know what, we did not see any skid marks as we approached the vehicle. And that's kind of a tip-off that perhaps the person had a medical problem before they crashed. Maybe they had a heart attack, like you said, Mark. Maybe they had a stroke, whatever the issue, maybe they had a seizure. But that actually changes the game quite a bit. So the handoff from the paramedic can give all sorts clues as to what you should look for. That really alters the game on how we even start the assessment of the patient, as opposed to the paramedic says, you know, man, the car was pulverized and the skid marks and there's all sorts of stuff. And by the way, we didn't see evidence that the guy was belted in. Oh well, that's going to be a whole different animal. So yeah, I totally agree with you.

What do you think in a major like DC urban environment, what are the main things that we're seeing? Would you say that the vast majority in the a downtown DC area like, like we're in? Is it going to be mostly gun violence or motor vehicles or a mixture?

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. But so it's fall from standing, all comers. Having said that, there's unfortunately a rising incidence of firearm-related injuries, gun violence in the District, just as there is, by the way, in every major city in the country as we speak in 2022. So we've seen a significant uptick in firearm-related injury that Mark and I actually published an article on post-COVID, pre-COVID-19. What we don't see in the District of Columbia, within the district itself very much, is high-speed vehicular trauma, right? So there's nobody in the District of Columbia that's going like 70 miles an hour because it's urban, the streets are not set up for that. So once in a blue moon you might get a high-speed vehicle, but not commonly. Those types of injuries we are seeing more in the suburban trauma centers that are flanked by highways. If you're on I-66 around Washington, D.C., or to anybody in California, I-5, I-80, anything to that effect, man, now you're talking about speeds of 70 to 100 miles an hour. And that's very different than what you would see in an urban setting. The other thing that you do see quite a bit in Washington, D.C., as I suspect you do, probably you do in other tourist-type centers, maybe it's Manhattan or Chicago, you know, near, near the lake or something like that. Is auto versus pedestrian. And so a lot of times we see a lot of tourists in Washington, D.C. and they're kind of looking around, checking out the monuments, and whether the driver is doing the same thing, checking out the monuments and hits the pedestrian, or the pedestrian doesn't quite appreciate that the light has changed and ventures into traffic. But we do see a lot of auto-ped. And to the District Government's credit, they've targeted that. Like when I came to Washington, D.C., there was a ton, I mean daily, auto versus pedestrian or auto versus bicyclist. The district government and the Department of Transportation really altered the lanes and they physically changed the streets. And now we've seen a nice drop in auto versus bicyclist. Again, room to go. We're not quite home yet, but it certainly has made it safer. And so you see government responding to change the way we behave and, and to try to increase the safety profile. But so in DC, it's far from standing. And then you see like auto versus pedestrian, auto car versus bicyclists. And then unfortunately, absolutely, we have seen— GW alone has seen a 300% rise in incidents of gun violence when I got here in 2011 as compared to today, the end of 2021. In 10 years, the incidence of penetrating trauma at GW went from about 8 or 10% to our current 25%. So 8 times 3 is 24, close enough.

It's, uh, amazing how prevalent it is. Do you think there's any role with mental health disease and illness? Um, we were talking before about being a little altered but not totally altered. I feel like we see a lot of people that are pedestrian struck that were probably not really minding the intersection or had other things going on that may have compounded the injury?

Yeah, I guess maybe we say mental illness. I think the, the average person translates the words mental illness to crazy, and it's just too simplistic to say that. So I would not say we have a lot of crazy people being severely injured. I wouldn't say that. But if you open up the term mental illness to things like depression or other aspects of anything other than a good well-balanced mental state, then I would say for sure. But that opens up a whole spectrum, right? So again, if we go back to rural America and you say mental illness, by and large we're going to talk about depression. If you come to urban America and we talk about mental illness, you're going to talk about schizophrenia, bipolar disease as risk factors for being injured. So yes, and I think it matters. I think that also then selects out the type of injury you're gonna see. And then, you know, I also put things like personality disorders and other aspects of mental illness into the fray when we talk about gun violence. It doesn't have to be just schizophrenia, bipolar disease. And in fact, I'll tell you, almost certainly it's usually not that. I have not treated that many schizophrenics who shot somebody. Certainly treated many people who've had personality disorders and anger management disorders and onto themselves carry a lot of post-traumatic stress from issues in their life— socioeconomics, upbringing, things like that— that then unfortunately translates over to violence.

Being around the holidays right now, I feel like every year this time of year we get people jumping off of freeway overpasses and such. One of the interesting things in the DC area is that there's a cap on the height of the building. Which I think lends towards more people surviving with really severe injuries, typically multiple orthopedic injuries that we see.

Yeah, I hadn't thought of that until recently. And for those who don't live in the District, there is a law in Washington, D.C., which basically limits the height of the building relative to the width of the street. And I, I would not have believed this to be true. It just sounds a little wonky to me, except that at GW we built a helipad. In 2019, and we have one pad. And but because next to it are all the mechanicals of the building, like the, you know, HVAC systems and whatever other water cooling systems that we have for the hospital. And so we could only fit one helipad. And I said to the architect, well, why can't you just elevate the helipad above the mechanicals? I mean, who cares what the helipad is? It's a helicopter. And then build me two helipads so we have some capacity in case something happens. And from, from the lawyer's lips, I heard that's physically impossible because we've tapped out the height of the hospital relative to the width of the street. And I was like, wow, I thought that was just an old wives' tale. Come to find out it's not, it's an actual law. But I had never turned it into public health safety like you just did, so maybe that's a good thing. Because you're right, when we have jumpers who try to commit suicide, or perhaps were inebriated or some other reason why they jumped. Uh, PCP is another good one as far as why people jump. I should say good one, I should say it's a common one. It's definitely not good. You're right, they can only jump so far because the buildings are not that tall. And so we've certainly seen our fair share of survivors, thankfully. Now they're severely injured, and that's where I call my favorite orthopedic surgeon, and then he calls 3 of his other buddies because there's going to be a lot of work to do. But we certainly had many people survive having jumped bunch of stories instead of— they can't jump 30 stories. There's no 30-story building.

I'd be curious in a city like New York or San Francisco where you have taller buildings to the exact numbers of how many people jump and survive versus don't. And I wonder if it's different in a city like, uh, DC just purely because of the height limitations.

A good question. Remember, you and I only get to see that which comes to us. In other words, If somebody is injured and dies on the scene and they're never brought to the hospital, then the only person who knows the common denominator for all deaths is the medical examiner, the ME's office. You and I only know the people who come to the hospital and then die. So you're like, well, for that we'd have to go to the ME and say how many people jumped, how many of them died, and then we can figure out the percentage.

It really is interesting how random it seems sometimes that you can have Someone show up shot once and paralyzed, someone else that gets shot 9 times or is in a devastating car accident and more or less walks away from it. I think the randomness of the whole thing is what gets to me sometimes.

Yeah, I strongly agree. You know, we have a trauma survivors event at GW every year. It's probably my single most favorite event of the entire year. And, you know, there's one area of my little introduction speech that I haven't changed for 10 years now, and it kind of puts things in perspective, which is kind of what you said, Mark. Every day we all get up, you brush your teeth, you wash your hands, you put on some clothes, you have a bite to eat, and then you start your day, whatever it is you do. You cannot go doctor shopping, you cannot go hospital shopping. You just say, thank God I live in the United States, please take good care of me. And that's the system that we have set up. And never ever forget, even when you're dealing with a grieving family, you're dealing with a difficult patient. What I try to keep in the back of my mind is, you know what, 3 hours ago, this guy was eating 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 they need time to acclimate and adjust. And that, that's a key difference in the lives of those people versus the lives of others who may be ill like my friend is, but at least have a little bit more of a predictable aspect to their illness.

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 these different players in this trauma system. Let's talk a bit about the trauma system that we have in the United States. This isn't something that just emerged out of thin air. This is something that's really evolved over a number of years, probably around the time of the Vietnam War. Let's talk a little bit about this whole concept of the golden hour and what led to the whole trauma system we have today.

Absolutely. I'll do my best. You have to go back to the 1960s. Trauma centers are really, really young. Trauma centers came into being around the mid-1980s, and emergency medicine as a discipline is really, really young. Like, there's been orthopedic surgeons for a long time, there's been general surgeons for a very, very long time, internal medicine, all this kind of stuff. Emergency medicine came into being in the late 1970s, early 1980s. And so we're talking about systems of care that are really quite young. I'm going to put a little plug out there for anybody who is— who wants to go to like YouTube and YouTube a TV show that was called Emergency. It was the first TV show ever created to really talk about what a paramedic even is, and it was set in the late 1970s in Los Angeles. And it was these two paramedic firefighters named Johnny and Roy, and they would get in their rescue squad and go places and treat the injured, and it was revolutionary back then. Prior to Johnny and Roy, if you were in a car crash or something, Literally a hearse showed up, like where you put the dead people in the coffin. That's what showed up. And even in emergency, you'll see the hearse show up, but the paramedics get inside it. So I guess that's a step up. And before Johnny and Roy, you would go to the local hospital, which had an emergency ward. There was no department, and anybody could attend there, whether it was family practice or internal medicine or surgery. You got what you got and didn't get upset. There was no specialty. And if you made it, that was lovely. And if you didn't make it, I guess that's an issue. Well, in the late 1960s, Lyndon B. Johnson, LBJ, signed the Highway Traffic Safety Act. And I probably have the name wrong, but something to that effect. And that was the first allocation of federal dollars to start creating safety systems for our transportation. And the National Highway Transportation— NHTSA was born. Following that, there's an EMS Act that's signed and dollars are allocated to create 911 pretty much as we know it today with paramedics and all that and prehospital care. So that then led to ultimately the development of emergency departments with specialized doctors that are emergency medicine doctors, which I am not. And then ultimately into the '80s, we get into trauma surgeons who are surgeons whose specialty rests on dealing with people with, with actual or potential life-threatening injury. But you're not going to see Botox or Radiesse.

It's interesting because in Europe I think it's a little different. Don't a lot of basic orthopedic things get handled by a trauma surgeon? And I don't know if that's evolving or not, but there's been a lot of overlap.

We should do a whole episode on European trauma or medicine because it's entirely different. Many hospitals in Europe, the orthopedic surgeon basically is the trauma surgeon. He or she is the first person you meet. The most common injury is a broken bone, whether it's your arm, your leg, your pelvis, your foot, whatever it is. That's the most common injury. It's just different. To each his own, right? But again, remember, in Europe they also don't have firearm injuries and things that need a general surgeon. In the United States, a surgeon such as myself, I will only be notified by the emergency department that the patient's arriving if they meet certain criteria created by the CDC, actually by the federal government, that then puts the person at risk for actual, or I guess maybe potential death, where you need a surgeon to see you on arrival. And then luckily, more often than not, it's not that bad and we can kind of stand down. But on a regular basis, I would certainly say every couple of day basis, we will see somebody who is at imminent risk of death. And then the ability to jumpstart the system and get somebody who can stop bleeding, basically, that's my job, is pivotal. And then once the bleeding stops, the dust settles, and we can call others for help.

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 center to manage their injuries, their trauma within an hour, that the vast majority of people could be saved or salvaged versus in prior wars, there was a significant delay getting from the field to a doctor. And many people died in that. The concept was, well, if we can take that and translate that over to civilian medicine, it really is interesting that that hour does make a big difference.

There's a very, very famous trauma surgeon, my mentor, frankly. So I'm pretty happy that I know this person. His name is Dr. Bill Schwab. And what Dr. Schwab wrote about in one of his addresses to one of the trauma societies basically said every time the country goes to war, the care of the injured patient improves dramatically, which is true. It's sad that we have to go to war, but it's true that the lessons we learn in war we translate to our civilian population. That's true of the Iraq and Afghanistan experiences that we just were in. Recently. But if you go back to like, you know, World War II, you know, you were injured and there really were no really good evacuation systems back then. So if you were severely injured, you were not going to do very well. The lesson that was learned after World War II into Korea was helicopters. So in Korea, we, we developed systems to rapidly evacuate patients. And anybody who's watched the show M*A*S*H will know that, right? You see the helicopters landing and they have the M*A*S*H hospitals there waiting to receive them within the characters Hawkeye and those guys. In Vietnam, they took it one step further and they said, okay, we're going to keep the MASH-like hospitals, we're going to keep the helicopters, but now we're really going to forward deploy corpsmen and medics. And we're going to train these people on how to start IVs, we're going to train these people on how to give morphine and pain medications. Now we're going to basically project forward our capability to start care at the point of wounding. That made a huge amount of differences, and there were some downsides to that. We discovered a new disease called ARDS and what happens when you give someone too much IV fluids. And so when we went to war in Iraq and Afghanistan, we took those lessons and we said, okay, corpsman or medic, do not give a lot of IV fluids, but do a ton of other stuff. Put on tourniquets, decompress the chest, render pain relief, and keep the person warm. Oh, and by the way, we're gonna launch a Blackhawks, and no one is going to stay on the battlefield very long when they're injured. We can clear the battlefield and evacuate our wounded. And lo and behold, in the current wars that just ended, we have the lowest case fatality rate of any US military experience in which we've been involved. Out of any major war, this had the lowest number of percentage dead because we kept projecting forward, we kept projecting forward. And those lessons have not been translated to the civilian arena over the course of each time period between the wars. So now we're telling the paramedics in the field, do not give a lot of IV fluids because all of a sudden this disease that we saw in Vietnam, ARDS or Da Nang lung, napalm lung, all of which is kind of the same thing, we just don't see that anymore. Do go ahead and utilize tourniquets. Do go ahead and decompress the chest and then get them to the trauma center as fast as possible. And the trauma center, we've kind of started to change our paradigm. Where we used to give a lot of different types of medications and blood products, and now we're kind of doing it the same way the Ranger Battalion did it in Afghanistan and Iraq. And lo and behold, we're finding civilians are doing better. So you're right, the lessons we learn in war— and Bill Schwab was right— the lessons we learn in war, we apply to the civilian environment, and you find we all move forward. It's just that unfortunately, in the world of trauma surgery, where we deal with injury, it costs us a war. And what, what weighs heavy in Dr. Schwab's mind, and I know this because I know him personally, and what weighs heavy, I think, in all of our minds is the cost of that knowledge are the lives of the 19 and 20-year-olds, right? The soldiers, the airmen, the sailors, the Marines.

It's amazing how quickly people can be moved around the world. I think back to 2004, we had an injured Marine that showed up at shock trauma 72 hours out of the field with devastating injuries. But just, just amazing how quickly those lessons get applied to moving people from a car wreck to a trauma center in the U.S. You look up every so often and see a helicopter flying overhead, and you can tell which of these helicopters are the paramedic rescue helicopters. It's unfortunate the way these lessons are learned, but seeing them applied is incredible how it does make such a huge difference. And I think that's going to be be a really interesting, um, discussion when we pull in some people from the military to talk about what the current state is there and get an idea of where the future is in the civilian world.

I totally agree with that. When I train nowadays our residents and our fellows, and even when I speak to colleagues outside of the trauma center, as an example, someone may call and say, well, I've got a patient over here in my particular hospital, it's not a trauma center, for example, And this guy is really terribly ill. And I say, well, I'm happy to help you, send me the patient. And once in a blue moon, you'll get one of these, well, he's too unstable to transport. Like, mm, from the military we learned he's actually too unstable to stay. There's no such thing as too unstable to transport because if we can provide outstanding care 37,000 feet between Afghanistan and Landstuhl, Germany, then why can't we do the exact same thing between, say, I don't know, someplace miles from Washington, D.C., on I-66 inbound to D.C., right? So if you can do it in the back of an airlift from Afghanistan to Germany, surely we can do it within the continental United States. And that changes the entire paradigm. And that's kind of my point, is there's no such thing as too unstable to transport. There's only too unstable to stay, so long as you have the infrastructure to transport that person, right? So to your point, Mark, those helicopters basically are flying hospitals. The ambulance that we created is a mobile intensive care unit in every sense of the word. The only thing I cannot do in the back of that ambulance is operate. Shy of that, I can do anything that I can do in the hospital in the back of the ambulance. So what's the problem?

I, I think one of the next steps. It'll be interesting to see from the military perspective. We spend as a society a small fortune. Some of these traumas are probably upwards of $1 million in care. And then the people are discharged from the hospital and oftentimes to maybe not the best of social situations or recovery situations. And I sometimes shake my head and you see how much you've invested up front. And then there's just not the resources afterwards. So it'll be interesting to see how the rehabilitation process and what role that plays in the military. And I wonder if that will be kind of the next thing that we see here. You invest all this money and is it wasted in some ways? It's interesting how that process moving on, I feel like there's a void there that is probably going to be one of the next stages to get addressed.

Yeah, I agree with that. It's probably worth having a social worker or somebody or a physiatrist who kind of understands this is the intersection between insurance and rehabilitation. So you, you don't need to have a dime in your bank or even any form of health insurance of any sort to receive emergency healthcare in the United States. You don't. You can be about as poor as poor gets and have no insurance whatsoever, and the trauma center will take care of you. I don't know my patient's insurance status. I purposefully never ever look it up. I don't want to be biased by anything. I treat the patient as they come. I couldn't care less. But let me tell you, somebody does care. And so when it's time to discharge, that's when all of a sudden the chickens come home to roost, right? All of a sudden the rehabilitation centers, which are not under any legal onus to take you as the trauma center is, they just won't unless you have some means to cover that, as well as someplace to go thereafter. The rehab centers don't want somebody who's gonna be there for 3 months because when they're done rehabilitating, they have no place to go. And so you get into this huge crunches of trying to get these people to where they need to be to continue their recovery. Oh, and by the way, open up the bed in the hospital so the next trauma patient has a place to go. So it really becomes a backlog. The whole thing just backs all the way up to the front door of the hospital. Because there's no throughput on the back end. And that's where the patient, him or herself, suffers, but so too do the others who are trying to get in and can't because the beds are blocked with people who shouldn't be there any longer. That's a whole societal thing that we struggle with.

That's for sure. I, I would say a sizable percentage of the trauma service on any given day is really made up of people that are kind of in that limbo in between injury and recovery that, that stuck because they can't walk or because of bilateral lower extremity injuries or other things like that. And you have this intersection where the hospital turns into a quasi-rehabilitation center for a while. How many trauma centers are there and how do you qualify to become a trauma center?

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 of work. Because there are two different ways to become a trauma center. One way is the state designates you. So the Department of Health for the particular state, the Commissioner of Health designates the hospital as a trauma center based on requirements that the Department of Health creates and the hospital meets. The second way of becoming a trauma center is an independent verifying body called the American College of Surgeons that verifies you. They actually don't designate you, they verify you. All they do is they verify. That you have met as a hospital the criteria that they have created designating what it— or delineating what a trauma center should be. I got to stay away from the word designated because they don't designate— delineating what a trauma center should be. And if you go— if they say, look, you got to, you got to do this, that, and the other, and then you submit an application 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 letter to your Department of Health, and the Department of Health will be the designating body. They're the legal authority that says, yep, check, you did this, that, and the other, you're good to go. So some states basically have offloaded to the American College of Surgeons and said, if you 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, we don't need the American College of Surgeons as a verifying body, we'll do that ourselves. But what you find is 98% of the criteria that are state versus ACS are the So they really— the American College of Surgeons kind of sets the tone, and by and large the states fall in line. They may tweak it a little bit for their own purposes, but that's kind of what they— by and large it's the same. And so to figure out how many trauma centers there are, you'd have to go through the ACS website, which is pretty easy, but then you have to go through every state by state to see how many are state-designated and then add those in. That would take some time. So I don't really know how many trauma centers there are.

Common denominators are going to be full-time trauma coverage 24/7 from a trauma surgeon.

Depends on the level of the trauma center. So the trauma centers are designated levels 1, 2, 3, and some places level 4, but mostly they're levels 1, 2, and 3. 1 being the highest level, level 3/4 being the lowest level. If you start from a level 3 and work our way up, a level 3 trauma center has a general surgeon— doesn't have to be a trauma surgeon— a general surgeon on call 24/7, 365 with 30-minute response. So the general surgeon must be within 30 minutes of the hospital at all times. And they will have an anesthesiologist and an entire OR team within 30 minutes of the hospital at all times. There'll be an emergency medicine doctor in the hospital at all times. They don't have to have neurosurgeons. I, I believe they have to have orthopedic surgeons, but I could be wrong about that.

Probably 30 minutes. Yeah.

Whereas when you get to a Level 2 and a Level 1, they're basically the same thing. And Level 2, Level 1 differs in only 2 aspects. A Level 1 must do research, and so they must publish a set amount of research papers per year. And a Level 1 must have a training program where they train tomorrow's surgeons. You must have a residency. If you don't have either of those, you cannot be a Level 1 trauma center by definition. But from the patient's perspective, the two are the same. So you must now have a trauma-trained surgeon within 15 minutes of the hospital at all times, not 30. So 15 minutes is not exactly a lot of time. If they call you at 2 o'clock in the morning, you need to be physically present at the bedside by 2:15, which means you either live pretty much across the street or you spend the night in the hospital. And most of us spend the night in the hospital. Like, I've never actually taken a call from home. Every 5th or 6th night, I spend the night in the hospital. Same with anesthesiology. You must be within 15 minutes, or our nursing staff, 30 minutes. But now for a level 1, you must have a neurosurgeon on your staff. You must have a trauma-trained orthopedic surgeon on your staff. So with all due respect to my dear co-host Mark Chodos, who is a foot and ankle guy, and if it's my ankle, Mark's gonna be on my short list of people to call. Mark doesn't cut it. We need to have someone who's trauma orthopedic trained, not foot and ankle trained. So you must have cardiac bypass capability so you can go on a heart-lung machine. So by the time you're a Level 1 trauma center, the basic premise is— or Level 2 for that matter, Level 1 or Level 2 trauma center— you can literally take anything that walks through your door, period. There's a carve-out for pediatrics. So we are an adult Level 1 trauma center. We do no peds whatsoever. There are hospitals that are purely pediatric, such as Children's National Medical Center in DC. And there are hospitals that are both, that they do peds and adults. So you can kind of decide which patient cohort, but the rules are the same. And that's the overview of trauma centers in the United States and kind of how they are.

Is there a geographic range? Are you only going to go to one closest to where you live, or could it vary depending on certain kind of expertise?

Yeah, that's a great question. There are no rules in the United States about location of trauma centers. There are some places that are just inundated with trauma centers. Florida is the poster child. There are a ton of trauma centers in Florida. I'll dare say Washington, D.C. Is also approaching that because we have a lot of trauma centers for the number of people who are actually injured. And that's good and bad. It's good in the sense that you have a trauma center really close by, that's always good. It's bad because as you dilute the amount of trauma patients that each particular hospital sees, you're kind of impacting on their muscle memory, if you will, right? It's kind of like if you're a football player and you only play 5 games a year, you're never gonna be fantastic. But if you play 20 games a year, you're gonna be much, much better. So there is a volume you have to see so that you don't forget and kind of learn, oh yeah, I saw that case just last week and here's what we need to do. And then on the other hand, in rural America, when you go down to Alabama, Mississippi, North Dakota, South Dakota, you know, the middle sections of the country, you could go well over 100 miles without having any trauma center whatsoever. Texas would be a good example as well. So unfortunately, What you find is trauma centers that are kind of clustered around major metropolitan regions, and then the rural areas are left completely blank. And that presents another challenge. Trauma centers exist wherever there is money to support them, because having a surgeon and everybody else spend the night in the hospital isn't exactly cheap, waiting on the off chance someone shows up. And maybe they do, maybe they don't. Clustered around urban regions, and then rural America is left out. And that's a challenge.

It leads to an interesting typical day as a trauma surgeon since the structure is very different than a normal 9-to-5 job. The day can sure vary depending on what's happening randomly out in the rest of the world.

Yeah, listen, if you wanted to be a firefighter when you were a kid, you should be a trauma surgeon.

That's—

that was me, right? So every day feels like a firehouse. You know, you go in, you don't exactly know what's going to happen. I've certainly had I've had my fair share of days where I've been relatively kind of okay and did some paperwork and maybe said hi to a few people, but it wasn't that bad. And then I've had days where I've just drank from a fire hose and blinked my eyes, 8 o'clock at night, and I'm like, dude, I haven't even gone to the bathroom. So it just depends. Your day is whatever it's going to be. Every day is Christmas. You never quite know what's going to happen. If you like that type of schedule, then it's a great field. If you don't like it, it's not such a good field. It's also one of the few fields of medicine where you punch in and punch out. So, like right now, I'm home, it's Sunday night, there's not a chance the hospital is going to call me unless there's a mass catastrophe. Tomorrow, when I'm on call, I would never say let's record a podcast because at any moment's notice, I could get toned out and have to go to the emergency department. So, you're on when you're on and you're off when you're off, which is why I said at the beginning of the podcast, the lifestyle actually is pretty good.

I remember during residency, the rounding in the afternoon, and we used to round twice a day, and the afternoon rounding would start around 4 or 5 in the afternoon, and invariably a trauma would come in, and then we would lose our chief resident, but we could keep rounding because we had another resident that was senior, and this process would slowly continue over the, the rounding, and, and, uh, we, we would have a progressive attrition until we reached the point where it was just the interns who couldn't round. Usually it was around 11 or 12 at night before we finished our afternoon rounds, and this process was repeated day in and day out. I think we averaged around 3.5 hours of sleep during that time, mostly long periods where you were sitting around because you, you couldn't round. You'd count off and realize you were the only person left to go down to the trauma that just came in because everyone else was in the operating room or, you know, the CT scanner. It was interesting. We never made it very far down the list. Before the trauma started to roll in.

Yeah, unfortunately, the 4:30 in the afternoon trauma activation is a very well-described phenomenon because that's when everyone's driving home, right? And that someone's gonna crash, someone's gonna hit someone else, and then just when you thought my day's coming to a close, not quite. Somebody just showed up, it's gonna be an hour and a half workup, you're looking at going home at 6 if you're lucky. That is a well-known phenomenon.

The weather and holidays and, and days of of the week. It's very dependent on, even though it's random, it's not totally random.

That's it for this episode of Wellness Musketeers. Big thanks to Dr. Troodos and Dr. Sairani for sharing such powerful insight into trauma care and prevention. Stay safe, stay curious, and we'll catch you next time.