This team cares for the sickest of the sick
Upstate trauma care draws national recognition
BY AMBER SMITH
It’s 8 a.m. on a Friday. Members of Upstate University Hospital’s trauma team, dressed in cranberry scrubs, gather in a conference room.
Some have been here all night. Some are coming in fresh.
They discuss the progress of each of the current patients whose injuries have left them hospitalized. Later, the team visits each patient: a snowmobiler who crashed, a pedestrian run over by a car, a man who slipped from his roof, and more.
“When we’re on duty, we’re on call for the entire Central New York region. Twenty-four hours a day, seven days a week, 365 days a year, with a response time of under 15 minutes — now that’s dedication! Anybody with a major injury, complex surgical problem or who is critically ill, comes here,” explains Robert Cooney, MD, Upstate’s chief of surgery and a member of the trauma team.
Being a Level One trauma center means that an operating room is always on standby, along with every medical and surgical specialist a trauma patient might need. Upstate’s adult trauma service, for anyone 15 and older, evaluates more than 6,000 trauma patients each year. Between 2,600 and 2,700 are admitted. Another 800 children under age 15 are admitted by the pediatric trauma team.
“If you look at our emergency surgery outcomes, we are one of the top hospitals in the country,” Cooney proudly notes. “We have an outstanding team of trauma and emergency surgery specialists.”
The American College of Surgeons National Surgical Quality Improvement Program recognized Upstate for meritorious outcomes for high-risk surgical patients in 2018. Cooney is proud of this recognition because it comes from “the most highly regarded quality assessment program for surgical outcomes in the country,” partly because the data collected goes beyond a patient’s hospital stay.
Composite scores are based on a weighted formula that combines eight outcomes. They include mortality, unplanned intubation (insertion of a tube into the windpipe to aid breathing), ventilator use for more than 48 hours, kidney failure, cardiac incidents (such as heart attack or cardiac arrest), development of pneumonia, surgical site infections and urinary tract infections.
Trauma was the third leading cause of death in the United States in 2019, behind heart disease and cancer. Trauma care is a high-adrenaline specialty, with interventions that can save lives. Doctors who specialize in trauma must be expert surgeons, even though treatment is constantly evolving and sometimes doesn’t involve operating. All nine of the trauma surgeons at Upstate are also board-certified in critical care medicine.
“Because this is Syracuse, we have a zone defense,” Cooney quips, in reference to the style of basketball defense for which Syracuse University is known. He means that his team is qualified to care for the wide variety of patients in the surgical intensive care unit, many of whom are not victims of trauma.
Patients transferred from smaller hospitals
Among the patients the team is caring for on a recent day, for example, are two elderly women who needed complex abdominal surgeries, and a critically ill young woman with severe heart failure in need of a high-risk surgery. All were transferred to Upstate from smaller, outlying hospitals. Such transfers account for about one-third of the trauma service’s patients.
“We take care of the sickest patients in the region who need surgery, and I think this quality designation shows that we do a great job of doing that,” Cooney says.
The trauma team depends upon a big infrastructure: caregivers from neurosurgery, orthopedics, vascular surgery, radiology, the emergency department and others, depending on the needs of each patient.
And because they practice at an academic medical center, the surgeons and resident doctors are constantly teaching and learning, helping to advance the specialty of trauma care – and ultimately save more lives.
Each day, the team visits the hospitalized trauma patients together.
Auto and snowmobile accidents; falls from roofs
On this day, they see a pedestrian who broke multiple bones when he was hit by a car. Both of the man’s legs are wrapped in splints. His spine was repaired. His pelvis was stabilized. He’s been here for two weeks so far and had many ups and downs.
The plan is to finally get him out of bed today. He will also be evaluated for his ability to swallow on his own – and maybe have the tube removed from his throat.
Another patient is a man who slipped on ice and fell from his roof while trying to install an antenna.
“It’s my hip that hurts,” the man tells Cooney. “I swore it was broken.”
But it was only bruised.
Cooney asks the man how physical therapy is proceeding. “The guy’s a monster,” the man says, lovingly, of his therapist. Soon he’ll be able to continue healing at home.
Then there’s the snowmobiler who is recovering from a crash that left him with broken ribs, a lacerated liver, a collapsed lung and an injured spleen.
Cooney uses a stethoscope to listen to the man’s bowel sounds, and he gently taps his abdomen, which sounds like a drum. He suspects the intestines are distended with air. To be sure that this is nothing serious, Cooney orders an X-ray.
The man’s belly was full of blood when he arrived at the hospital. Surgeons would have drained it — if they had operated to remove his spleen.
Instead, an interventional radiologist “embolized” the organ using a catheter (hollow tube), coils and clotting materials. It’s a procedure that has revolutionized how doctors treat patients with splenic trauma, Cooney says, and one example of how treatments evolve over time. He says not to worry about the excess blood in the belly; it will be reabsorbed by the body as the man heals.
It’s a raw, late winter day, and the conference room table contains a tub of pretzels and a box of half-eaten Thin Mint cookies, sustenance for surgeons who on busy days will not have a chance to sit and eat a proper meal. They cannot predict when traumatic injuries will occur, but when weather is cold or rainy, there is usually a dip.
On this day, Cooney and two resident doctors, a physician assistant, a nurse and some medical students gather to discuss medical issues that relate to some of the patients who are currently hospitalized.
For instance: management of the open abdomen.
It used to be, trauma surgeons would fix everything that was wrong with a trauma patient in one lengthy and taxing surgery, even if the patient was unstable and not doing well.
Now, survivability is higher for many patients if the surgeons focus on stopping the bleeding, getting rid of any contamination and letting the patients stabilize before bringing them back to the operating room for more definitive surgical repairs. Sometimes it makes sense to leave their wounds open during this process, usually 24 to 36 hours.
Up to 25 percent of trauma patients who undergo abdominal surgery should have their incisions left open while they are healing in the intensive care unit, says resident physician Matthew Sporn, MD. This allows for better control of their blood pressure, changing of packing, access to vascular shunts to help remove excess fluids, and a better ability for doctors to assess the bowel’s viability.
The group also talks about methods to control bleeding. “Damage control resuscitation” is the use of blood and plasma (the liquid part of the blood) to treat patients who are in danger of bleeding to death before they get to the hospital. Should paramedics carry plasma to trauma patients, as is done on battlefields?
Cooney acknowledges that “more rapid use of blood and blood products has been shown to reduce bleeding-related complications and mortality.” As knowledge evolves and new research is published, new protocols will need to be put into place, he explains.
He goes on to describe a modern way to stop life-threatening bleeding, once the patient arrives at the hospital. REBOA stands for resuscitative endovascular balloon occlusion of the aorta.
A vascular surgeon developed the procedure that involves inserting a catheter through an artery in the leg, threading it to the appropriate spot and inflating a balloon to stanch arterial bleeding.
Cooney says patients are alive today because of REBOA. He says the new procedure is much faster than the way surgeons used to stanch bleeding — by cutting into a patient’s chest to clamp the great vessel that comes from the heart — and another example of how the field of trauma care continues to grow.