For those of you who don't know, obviously it's on the title here. I'm a Stony Brook surgeon, also the trauma medical director at Long Island Community Hospital. So what we plan to talk about today is the sort of the lessons that I learned by being a surgeon at a level one and level three trauma center. So in terms of my background, obviously I trained primarily to be a level one trauma surgeon. That was my goal. And then we were asked to help out at a level three trauma center. And there's many things that I learned from going there and we'll try to address and talk about some of those things here. So just in terms of disclosures, much to my wife's dismay, I don't have any, so none of this is funded. It's just sort of my take on things and how things are. So I thought we would go through some cases in order to better elucidate what it is that's different about the level ones, level threes, and the things that we learned. We'll go through some background information first, but just to get everybody thinking about cases, one of the first ones we'll talk about is, these are all real cases, but a 42-year-old male who was involved in a high-speed MVC and EMS noticed him to be tachycardic and hypotensive when they arrived to first help take care of him. So just in terms of overview, obviously we're all trauma people, so we won't belabor any of this, but trauma systems are designed to provide an organized response to injury. As we all know, the American College of Surgeons designates levels of trauma centers, one, two, three, four, and certain level fives. And basically a trauma center capability is based on resource availability. So as the different level trauma centers change, you go from a level one to a level two and three and so on, really what that trauma center can do is based a lot on where they're located and what their specific resources are. So one of the things that we learned very quickly is that not all trauma centers are created equally, but that doesn't mean that they're not all beneficial. So why is understanding trauma and trauma systems important? As again, as we all know, traumatic injuries are responsible for about 60% of all deaths for people age one through 44, and the system impacts both patients and providers. And what we mean by that is, again, coming from my perspective, as we'll get into a little bit more, when you're a level one trauma surgeon, you sort of think that you're responsible for everything. So the reason that we're a level one center is just because of the surgeon. And what you find out very quickly is that's not true. It's the whole system and how everybody works together. So you can take the level one surgeon and bring them to the level three center, and you're not always able to do the same amount of things that you can do, and you also become a lot more reliant on the system. So again, the system impacts both us and the patients. And one of the important things about trauma is to remember that it's a judgment-free zone. So again, different level trauma centers are designed for different things. And they all wind up helping each other. So whether a patient stays at one center or gets transferred to another is really how the system's supposed to function. So if you have to go up in the echelon to get the patient the care they need, that's obviously important and beneficial to all. And if you're able to keep them at the quote-unquote lower level trauma center, a lot of times we can stabilize patients there and their outcomes are better because they did stop there first. So just quickly, the way that we realize this is going through history and looking at the background of things. So originally, when you look way back at the early World Wars, there was successive echelons of care that people went through. And originally the priorities were controlling hemorrhage, splinting fractures, and controlling pain. But as we focused a little bit more, we realized that resuscitation was the important part. So that became fluids and blood products. And what we really realized as time progressed in the Korean and Vietnam Wars, when helicopters were able to transport patients much more quickly, was that there was a true survival benefit of early access to definitive care. And that's really what the trauma centers are about, is getting patients to definitive care as quickly as possible. So with that, urban trauma centers started incorporating the system that was pioneered during wartime. So we adopted that and we realized that hemorrhage control, resuscitation, and definitive care applied just as well in the civilian world as it did in the battlefield. And when you got patients quickly to define trauma centers, you had improved outcomes for those patients. So there were only a few trauma centers, obviously initially when things were developing, and they found that trauma patients that were brought to smaller hospitals, the care there for trauma patients was really rudimentary at best. And that's why they started the whole process of developing different trauma centers and really trying to have people follow ATLS protocols and get people on the same page in terms of care and managing the trauma patient. So with that, just to give you an idea, the reason that this slide is important is, as was mentioned, I'm a surgeon out at Long Island, but every trauma system is a bit different. So obviously Long Island is a relatively small area and we have many trauma centers here. So when you look just at Suffolk, which is where I practice, Stony Brook, our major center is the only level one trauma center here for adults and pediatrics. And that's kind of, I don't know if you can see the pointer well, but it's on the North shore up here. Then we have a couple of level two hospitals, which are down on the South shore, Good Samaritan and Southside Hospital. And then there's a series of level threes, one that I'm the trauma medical director for, which is Long Island Community Hospital, one over in Huntington. And then we have two provisional level three hospitals out on the East end. Obviously that's not important for everybody to remember in terms of how all trauma systems function. But one of the things that you have to realize when you're involved in the trauma system is where your resources are and how far apart they are. So again, Long Island's pretty small in terms of mileage, which means that the level one, the level two, and the level three are all pretty close to each other. So for instance, the level one that I work at against Stony Brook is only about 20 minutes or so from the level three that I cover, which is Long Island Community Hospital. So when you're deciding where a patient should go, a lot of times distance is involved. So if you're in a more rural area where the trauma centers are spread out a bit more, it could be a lot more travel time, a lot more distance. And that's why having the level three centers become more and more important the farther apart that these systems are. So with that being said, just again, in terms of background a little bit, the orange book we all know very well and verification is a voluntary process. This is important though, because it really shows that all of us are dedicated to becoming a trauma system and developing our individual trauma centers to work well together. It's a peer review process, and obviously we all know it involves the hospital visit that we all enjoy so much, but the ACS doesn't really designate trauma centers. It just verifies that they have the appropriate resources. And that's what becomes important to know, especially when you're covering different trauma centers, what those resources are that you have available to yourself. So that begs the question, what is the difference really? And the truth is not all trauma centers are created equally, but there's certain core criteria that each trauma center should have. And these obviously are based on level. So this gets more into the heart of the talk, which is the lessons learned from my double life as a level one and level three trauma center. So the misconceptions I had when we were first asked to help out at the level three center and get over there and help to develop things was that the capability of the center was determined solely by the surgeon. So our initial thought, or at least my initial thought when I was gonna start taking call and covering the service there was really that I could do everything at the level three that I do at the level one. So whatever patient came in there, there would never be a reason to transfer them because I'm the same surgeon there as I am at our level one center. That sort of led to other questions about maybe all patients should actually be transferred to the level one. So when we first started working at the level three center, we realized that things were a little bit different there. And that led to the question about should everything just be transferred out? Should everything go to the level one center? What I mean there when I say unless I'm there was actually a twofold question. So first was, if there's not one of us, so my whole group is sort of interesting, all of us that cover Stony Brook go and cover a Long Island Community Hospital as well. So the thought was, well, if any of us are on call, we're level one surgeons, let's just keep everything there. And then the other thought was they should transfer everything unless we're on call at Stony Brook because then we're gonna get too busy over here. So we started questioning why have they been transferring things? So what was it that made patients have to leave the level three to come to the level one? And then similarly, and we'll get into this as we go through some of the cases, why have they been keeping certain cases? Are there things that should be transferred from the level three to the level one? And again, there was a certain level of, to be honest with you, arrogance when we first started there about how we would probably transfer less because we felt like we would be able to keep everything wherever we were. So that's really the series of sort of misconceptions that I started with. So looking at some of these things, what is the difference between the level one and the level three? What's on paper and there's what's in place. And what I mean by that is what's on paper is what all the requirements are to be a level one center, to be a level two center, to be a level three center. But there's also what's in place to make the hospital function well. How do you run a level one trauma center versus how do you run a level three trauma center? And what resources do we have available there? What kind of PI is in place to make sure that every time we see patients and we treat patients, we're gonna make things better. So when you look at paper, level one hospitals are obviously the comprehensive regional resource we're supposed to be available really to take any trauma patient ever and be capable of providing the total care for every aspect of their injury. This would include prevention, intervention and also rehabilitation. So the core elements, I highlighted and sort of bolded the most important ones. There's 24 hour in-house coverage by trauma surgery, which means that we're in the hospital readily available to operate whenever. There's immediately availability of an operating room. So there's always an OR on standby for us to go if we think a patient needs to go back. And all of our colleagues are always available, whether it's subspecialty services, advanced nursing services, everything's always available. And then there's obviously the things that we do for community. And of course, with level ones, there's a minimum volume requirement of severely injured patients. So that keeps your skills sharp because you're guaranteeing you're seeing at least 240 of the sickest trauma patients a year. The level three is a little bit different, obviously. What it has to do is demonstrate an ability to provide prompt assessment, resuscitation, surgery if needed care and stabilization of injured patients. And honestly, it also frequently treat patients who may require transfer. I always pause with that because again, part of our misconception was that if you transferred someone, it was a failure on your part as the trauma surgeon that you weren't able to handle them at the institution you were at. But honestly, sometimes knowing who needs to be transferred and making that decision quickly is best for the trauma system as a whole. And most importantly, in a way, best for the trauma patient who's being cared for at your institution. So the core elements of the level three are really 24 hour immediate coverage by our emergency medicine physicians. This again was a change for us. And it was, again, sort of a part of what I mean by the double life that we lead because at the level one, since we're in house, we go down to every trauma immediately. And if we're preactivated, we're there before the patient and we're helping to manage the patient from the get-go. At the level three center, we've become much more reliant on our colleagues, especially from emergency medicine who really are the first ones to assess the patient, determine if they need us. And a lot of our conversations with them on the phone do revolve around how quickly we need to get there. And if the operating room needs to make itself available for us. The other point that you always have with a level three is the prompt availability of general surgeons and anesthesiologists. This may seem like a small point, but again, at the level three, it's not always being covered by trauma surgeons. It can be a general surgeon who has a large interest in trauma or really no interest in trauma. So the gamut of who takes care of patients at these hospitals is pretty broad. And this is also important when it goes back to my question about why some things used to be transferred. Obviously when your specialty is trauma, there are certain things that you're more comfortable fixing than people who don't see it routinely. And also, as mentioned, when you're at the higher level trauma center, you see more of the sickest patients every year, which keeps you more in tune with some of these skills. That being said, we do have very skilled general surgeons that we work with at the hospital that we cover as well, who are able to take care of a lot of trauma issues as well. Importantly, there's a transfer agreement that's established with the level one or level two center, and that helps to expedite transfers. One of the luxuries that we've had that not all trauma programs have, again, is that since we're the surgeon team at both hospitals for trauma, basically when we're transferring someone from the level three to the level one, we're really transferring it to ourselves, which makes the transfer process a bit easier. So this just kind of summarizes the differences between the level one, two, three, and four. Again, I bolded the level one and level three because that's where my, again, double life is. So the level one, just to summarize again, has a volume requirement of 1,200 cases per year, at least 240 major cases. Surgeon and specialists need to be immediately available. At the level three, there is no volume-specific requirement. Our surgeon response time has to be within 30 minutes, and there may or may not be a specialist on. This goes again to talking about the resources of your hospital, because for instance, at Long Island Community Hospital, we have a team of neurosurgeons who are available. Not all level threes are required to do that. What's also important here, and that people forget often, is that every level trauma center has to have a quality program. And those are exceptionally useful for us because as you'll see as we talk about some of the cases, the PI process and going through some of the pitfalls that we hit really helped to improve the program, not just at the level three, but also at the level one trauma centers. So that being said, our initial experience was that there was originally not a very well-defined quality assessment program when we started covering at the level three centers, and we had no specific trauma protocols. And by that, I mean, we didn't have specific reasons or criteria that the emergency room would reach out to us. We didn't have a plan in place that was specific to trauma to get people to the operating room, to get our anesthesiologists and our OR nurses in. And also we didn't have specific protocols for care of our traumatically injured patients in the ICU. Also from our standpoint, there were no dedicated trauma protocols that we had shared really with the hospital or others about how we were gonna manage our trauma patients on the floors. A lot of trauma patients that were initially admitted were just admitted to specific providers instead of a service, which made things a bit more challenging. And so we tried to develop protocols for each of these areas. So with that being said, back to the first case we were gonna discuss, there was a 42-year-old male who was involved in a high-speed motor vehicle collision. He was thrown from the vehicle. As we mentioned, he was hypotensive tachycardic, and he was initially altered. I sort of told you the geography of our area. So the patient, when he was picked up by EMS, was about five minutes away from our ACS verified level three trauma center and about 20 minutes away from the level one trauma center. Again, if you're in a more rural area or an area where there's a greater distance between hospitals, this doesn't become as much of a choice for EMS because if the distance between the level three and the level one is a 45-minute or hour difference, obviously you're gonna go to the level three. But one of the decisions our EMS crew has to make is are they gonna go to the level three or level one? We're also a bit unique in a way because we have a ton of volunteer ambulance services out here, so there's a lot of education that goes on in the community as well. That being said, the patient was brought into our level three center. And just sort of looking at it, there's a couple of CAT scan pictures that I put in here. So this is his initial CAT scan. You can see that there's sort of free fluid around the pelvis. There's free fluid around where the spleen should be. And basically it was a tough call from the EMS to make, but they decided to come to the level three center. Showing you those, obviously I didn't put up all the slides, but the patient was found to have bilateral pneumothoraces, pelvic fractures, also a femur fracture, grade five splenic injury. The actual read on that CAT scan was essentially that there was no spleen and also a grade two liver injury. So again, the patient was brought to our level three center and this is when we started identifying a couple of pitfalls. But again, this was very, very early on in our tenure there. So one of the first pitfalls was getting to the operating room again. It was a mistake that I made. This was actually my case. I pictured myself as being at a level one center. And so I called the operating room and thought that they were immediately there, that anesthesiologist was in house and that the OR staff was waiting just to go into the operating room. So that's obviously not the case. So one of the things that we came up with instead of having to activate all these teams individually was that we had developed what we call a code OR stat there now, where when the trauma surgeon or the emergency room activates the operating room, instead of an individual person having to call each of these people to bring them in, a page goes out to all those people who are on call and they automatically respond to come into the operating room. For this patient, our preoperative resuscitation was with bilateral tube thoracostomies and we obtained central venous access in an arterial line placement. We were able with a little bit of resuscitation to get him stabilized and then we brought him to the operating room. In the operating room, we performed essentially a splenectomy, but the spleen was really a vault. So it was really just a ligation of the splenic artery and splenic vein. And then we controlled his liver hemorrhage. What we did postoperatively then was that we transferred him to the level one trauma center. And that was for his complex pelvic fractures and his femur fracture, which were subsequently repaired at the level one center. What we learned from that was sort of what I touched on a little bit at the start of this case. We needed to develop an operating room protocol. We needed to come up with a way to have anesthesia activated, blood product availability. We better define our postoperative transfer system. And what we did learn was the good function of the level three trauma center because we were able to identify the patient's injuries. We were able to stabilize him with his operation. And then we were able to transfer him for tertiary care to have his other complex fractures and things repaired. Just looking at this, again, the operating room protocol improved drastically because after this case, we realized what it would take. And obviously the hospital itself was very dedicated to becoming a trauma center and maintaining good care of the trauma patients and really becoming a dedicated part of our trauma system. So we had our PI, we quickly sat down. Everybody was there between anesthesia, the OR staff, nursing, and the emergency room about how we can better expedite these things. Again, that led to the operating room stat call, which has really helped us out along the way for the last couple of years now. And the OR stat call can be made by us or the emergency room physicians, which is helpful. For instance, when we get penetrating trauma there, gunshot wound to the abdomen. Again, we're not in house, we're 30 minutes. We have a 30 minute response time. But if there's someone who clearly needs to go to the operating room, even before we get there, the operating room and anesthesia is activated and they're basically on their way in and meet us there, which gets us to the operating room a bunch more expeditiously than before. Blood product availability was also an issue that we addressed. We improved upon the massive transfusion protocol, developed a stat pack system that was a little bit, again, more expeditious. And we also learned about setting up these postoperative transfers while we're in the operating room. So we would reach out to the level one if we felt they needed to be there and discuss with our colleagues who were gonna be accepting the patient what our plans were in the operating room. We would essentially have things set in motion that a patient was gonna need to be moved. And then we would stabilize them. And once they were stabilized enough for transfer, we already had everything in motion to get them to where they needed to be for final definitive care. With that being said, it leads us to our second case, which was a 55-year-old gentleman who presented to the level three trauma center, again, status post to high-speed MVC. He was initially normal tensive and then had complaints of abdominal pain. So this is one of those cases that can really sort of go either way. He can be perfectly fine. So there's really, off the cuff, there's no reason that he would need to go to the level one center. He's got normal blood pressure. He has a little bit of complaints of belly pain, but he was involved in a high-speed MVC. So as we all know from our experience, he can either be pretty grossly injured or he can have nothing wrong with him. So his initial blood pressure was in the one teens. His heart rate was in the eighties and he was setting reasonably well in room air. Note, 92% may seem a little bit low, but he had a long smoking history. So in the end, we found a diagnosis of COPD for him. You don't have to, we won't go through all the physical exam, but basically he had a little bit of tenderness in the left upper quadrant, no real peritoneal signs or anything of that nature. And he had some seatbelt bruising signs to the abdomen. So he had basic lab work there performed pretty much as soon as he arrived. And it was honestly quite normal. And then he went for a classic sort of pan scan given the mechanism of his injury. So with that, a couple of the CT images, you can see over on the right side, just around the liver, there's some free fluid. And then also around the spleen, there's some free fluid, which is obviously in the setting of trauma consistent with hemoperitoneum. We'll be just focusing a little bit more on the spleen. The spleen had what was somewhere between a grade three and grade four injury. Be honest with you, the timing on the contrast wasn't perfect, but it was probably a grade three splenic injury there. So on reassessment after the imaging was performed, the patient was again reevaluated by the emergency room team. And he was noted at this point to have dropped his blood pressure pretty significantly from the high 100s and 110s down into the systolic blood pressure of 60s. And he had developed some lethargy. At this point, a code T was activated given the new onset hypotension, the mechanism of injury, and also because it helps expedite other things. Once the code T was called, we responded immediately. Again, this was a case of mine. And given the findings and the hypotension, a code OR stat was activated while I was en route to the hospital. So part of the activation with the code OR stat was also the massive transfusion protocol was activated. Blood products were immediately available and he was being transfused actively by the time I arrived at the hospital. He was in the OR within 20 minutes of my arrival, which was a drastic improvement from before and showed that these patients can get quickly into the operating room. Our goal for our trauma patients at the level three is to get them into the operating room within an hour of basically their arrival or the decision-making that they need to be in the operating room. We did perform a splenectomy on the patient. He stayed at the level three post-operatively. He recovered quite nicely and was discharged to home. This also does lead to some questions about is there a difference in management of patients sometimes between the level three and the level one hospital? And the truth is that there can be. So in some situations, whether I was at the level one or level three, I would plan on taking this patient's spleen out because he had an episode of hypotension and needed a lot of blood product transfusion, but some would argue for possible embolization. That's when you need to know your resources and interventional radiology and embolization at some level threes isn't as readily available and that can significantly delay definitive management of the patient. So for me, either way, the patient would have gone to the operating room, but one of the things that you could consider, obviously, again, is splenic embolization, but that's, again, as mentioned, where knowing your resources comes into play. So this patient, his outcome was greatly improved from prior by understanding the system and really by the PI process saying, okay, these are the things that didn't work before. And once you get everybody behind you in the trauma system, we get these things activated and it works quite well. So this case, this third case, was really sort of a combination that sort of puts all these factors together. So what we had was a 19-year-old male who was a pedestrian struck. Our field report was that his blood pressure was 87 over 59, but he was essentially normal cardiac, so to speak, with a heart rate in the 80s, sat in 98% and he had a GCS of 14. He did have a right femur deformity, and so he was activated as a code T activation. I won't tell you off the bat which hospital he went to, but what we do realize and what we put together from, we should be able to put together from these previous cases was much like our basic life support and advanced cardiac life support, trauma care and assessment should always be systematic. And this is true whether the patient's at the level one or level three. And so we teach both things at both places and you should never deviate from these. By staying protocol driven, that prevents missing life-threatening injuries. So while it starts in the emergency setting for our trauma patients, it could also be done within the inpatient setting as well, which you'll see is particularly important in this case. So in the ED assessment of this patient, his airway was intact. He was, again, breathing quite well. This was sort of going on to a secondary assessment as SATs improved. His blood pressure did drop a little bit to 80 over palp, but his heart rate stayed essentially the same. So when we were looking at circulation here, we looked at everything else. He got a stat pack for his hypotension. His FAST was negative, so we weren't concerned about intra-abdominal bleeding. Obviously it doesn't rule out retroparts and the other. And his GCS was 15. At this point, he improved a little bit and we didn't see any other significant additional injuries on our initial exposure. So here we did our detailed history and physical. We repeated the primary assessment, did our chest x-ray, pelvic x-ray. Obviously, like I mentioned, we did the FAST and then we went off to CAT scan. So when we scanned him, he was found to have multiple injuries. He had a right proximal femur fracture. He had a thoracic aortic injury, a grade four renal injury, right superior and inferior pubic rami fractures, and also a right sacral alla fracture. So you can see he's pretty well hurt from his accident. So the question is, where does this patient go? Should this patient be brought directly to the level one trauma center? And if the patient went to the level three trauma center, should he stay there? And the honest answer from the first part of the question is the patient really could wind up at either the level one or the level three trauma center. If he needed an initial stabilization, it depends again on the distance like we were talking about. For us, would I prefer this patient went directly to the level one trauma center? Yes, but that's knowing what his injuries were. If he had gone to the level three trauma center, we would identify these injuries and then given the complexity of the fractures and the kidney injury and all the other sort of devastating injuries he has, we would transfer him over to the level one trauma center. Again, if your trauma system has the centers a lot farther apart, then it's 100% accessible and acceptable and probably beneficial for the patient to stop off at the level three trauma center, be resuscitated, identify his injuries and then move him along to the level one trauma center once he's stabilized. So this patient was actually brought to the center here and he was admitted to our ICU. His femur fracture was repaired and he had some screws placed for the pelvic fractures. And with his aortic injury, it was determined that it didn't need to be repaired immediately. So he was actually placed on therapeutic Lobinox for his aortic injury. Of note, given the high dose anticoagulation he was on, the renal injury and the like, we elected to repeat a CAT scan on him shortly after his hospital stay began, about 24 hours later, first to check for propagation of the aortic injury and then secondarily, after a few days of being on therapeutic anticoagulation, we wanted to ensure that the kidney hematoma remained stable. So he actually clinically improved and we downgraded him from our ICU to our ICR. On hospital day number seven, the patient complained of some chest pain at an early afternoon and he had a new onset sinus tachycardia. And then he had an episode of vomiting that was due to what he reported as overeating during breakfast and lunch. Obviously, some of these things were a bit concerning to us, so we kept an eye on him, especially with some of the tachycardia, but his crits in other labs remained stable. The next day, however, the patient became lethargic and had an acute drop in his hemoglobin and somatic rate to about four over 15. For us, a rapid response was called and then we weren't sure what the source of his bleeding was gonna be. Obviously, if a patient came in like this as a trauma, he would go directly to the operating room, but we weren't sure where he was hemorrhaging from. So with the thoracic aortic injury, it could have been in the chest. With his kidney injury, it could have been a larger retroperitoneal bleed. So the plan was to take him down for a CAT scan, pretty much in route to the operating room so that we would know what we were going after. In the CAT scanner, he was found to have a significant splenic injury. So he went to the OR emergently for a splenectomy. So this is one of his CAT scans from that day. You'll have to kind of believe me that the first few CAT scans showed that the spleen was normal. But part of the reason I was stressing that he had two previous CAT scans was that the spleen honestly was 100% normal, even on review of the prior two CAT scans in hindsight. You can see that there's now significant fluid around the spleen and it's consistent with a new hemorrhage. So this is just a coronal cut to show you that there's basically a hemoperitoneum now on both sides of the abdomen and his abdomen had been cleaned before, except for the renal injury. So the patient was brought immediately to the operating room. He actually, right before we began our skin incision, he rested on the table. We were able to emergently explore him and get aortic control, did the splenectomy, and then performed a temporary abdominal wall closure. This is just sort of the fun pictures, but this is the spleen in the bucket at the end of the case with some of the surrounding clot. So it was a pretty significant bleed that he had, which obviously led to his arrest in the operating room. So again, going back to the questions that we've asked multiple times, where should he have gone? I still say that he could have gone to either the level one or the level three. I wouldn't have been disappointed if I saw him at the level three and I still would have done my initial management and workup at the level three center. There's no shame in transferring. And once we recognize this patient's injuries, he should be transferred. So as you can see, the renal injury didn't require any surgical intervention. The thoracic injury also didn't require any surgical intervention. But the patient had a constellation of injuries that we had to start in our heads planning for the complication. And that's where you sort of get to lead this double life as a level one and level three trauma surgeon, because again, we would say, oh, I can take care of a thoracic aortic injury anywhere. I can take care of these hemorrhages anywhere. But the truth is that you can't because it's resource specific. So the level three, again, is more than proficient at doing this workup. If he had come in with a splenic rupture, we would have been more than capable of taking care of it over there. But with the constellation of his injuries, again, you have to plan for the complication. And the complication for this patient would be, none of us saw the spleen coming, but would be the kidney needing to emergently come out or the thoracic injury extending and him needing an emergent procedure. So again, assessment, initial management can be done at either place, but we always have to remember there's no shame in transferring. And this patient in the end belonged at the level one. As a remainder of his hospital course, the patient did quite well. He actually improved back to his baseline, had no deficits and was able to be discharged. So with that, go on to sort of the pop quiz question. If anybody wants to chime in, they're welcome. But we had a recent patient that was a 49-year-old male prisoner who was found down in a gym and he was normal tensive with a GCS of nine. So the question is, where should he go? All right. So this is one of those situations where, again, you could say that the answer is not clear. So again, it comes down to knowing your resources. Does the story point towards trauma? Does this change your decision-making scheme? Does he need to be stabilized and can he make it to the level one? So again, I've been stressing this sort of throughout the talk. You really need to know what your resources are. Again, for us at our level three center, we have neurosurgery available. So this seems like a head injury off the bat and you'd want him to wind up at a place with neurosurgical capability. What we don't have available at our level three center is the ability to take care of aneurysms and things with interventional neurosurgery. So the question that you first ask yourself is, does this point towards a trauma? Do we think that he was assaulted or that this is related to a traumatic injury? Or do we think that he had an aneurysm that blew? This would change sort of our decision-making scheme because if we think it's aneurysmal and he's stable, we would try to get him to our level one center. If we think it's purely traumatic and he may need a emergent crani, we would still try to push to get him rapidly to the level one center, again, because of our immediate availability. But if we think he's relatively stable, then we may take him to the level three center. For him, EMS was concerned about his airway because of the depressed GCS. So they made the decision to bring him to the level three center to get him stabilized. So he was brought there. And again, originally he was a bit combative and then his GCS became more depressed. He was intubated and he had some bleeding from the left ear noted. So that was indicative of a likely trauma situation versus more so than an aneurysm. So he had a CT head there performed rapidly after intubation, which doesn't necessarily show so well here, but he had some subarachnoid all along the left side. This led to the next question. What now? Do we keep him here? Do we transfer him? You know, we also know that they had a temporal bone fracture but when we were speaking to our neurosurgery colleagues, the question based on the distribution was, is this again aneurysmal subarachnoid or is this from the fall and the temporal bone fracture or did he have the aneurysm rupture and then had the temporal bone fracture when he fell? So given this concern, we elected to transfer the patient to the level one trauma center. He came here, he had a formal angiogram which did not demonstrate an aneurysm and this was a traumatic subarachnoid. But again, we made that decision based off of the resources that we knew were available at each center. So with that sort of my kind of conclusion again, is that what we do know from all this is that in-hospital risk adjusted mortality rate is significantly lower at trauma centers. What we have to remember about our different trauma centers is that we're not trying to say which trauma center is better, we're trying to look and get patients to the resource rich trauma centers when they need them. So that again talks about immediate availability of surgeons, OR and blood products and immediate availability of specialists. Those things are classically at the level one but with a good resource distribution can be made more available at the level three centers and also standardizing your treatment protocols for major trauma as well as standardizing your approach to getting patients to the operating room and postoperative care is paramount. So what we do know as well though is that there's an effectiveness of regionalized trauma systems. And what is helpful is taking the most severely injured patients to the high volume center and limiting the overall number of high volume centers. So that is where the numbers come from that you should have at least 240 patients with major trauma annually. With that, you need about one or two level one or two trauma centers per about million population. So the level threes are actually exceptionally important in the trauma system because in order to keep the trauma system running you can't just have everybody patient line about the level one or the level two trauma center but you do need to sort of keep your patients that are the sickest at the level one trauma center to keep everybody's skills sharp and keep the system running well. The use of more inclusive trauma systems helps to mitigate these effects. So we need to be immediately available to resuscitate patients. And we have to accept the systemide protocols that expedite transfer when appropriate. So trauma education and quality improvement initiatives improve these outcomes. Careful case review and PI and acceptance of constant need for improvement is paramount to developing these systems. So pre-hospital providers, nursing and physician education happen all along. And again, what I was hoping to get everybody to take away from these cases was that the level one and the level three trauma center should work in concert with each other. And that the way that the levels of the trauma centers really work best is based on the resources that you have available there. Becoming most familiar with your system and knowing what the resources available at each hospital and your transport times are really kind of paramount to care. Again, my misconception that everything's gonna be based off of what surgeon you have, and we're just gonna walk in and be able to do everything at the trauma center just because we're there isn't true. Trauma, as everybody knows, is a team sport. And having these inclusive systems helps you to function as a system and also helps to improve the quality of care for the patients. So in summary, again, what I learned is all trauma centers are not created equally, but all trauma centers serve a purpose to our patients and communities. Protocolization of trauma procedures is paramount. And the most important aspect of working at any trauma center is knowing your resources. Thank you. Thank you, Dr. Urbano. We have some time for questions and I see a question in the chat from Amanda Daniels. She asks, what work do you do with EMS to make sure they know what resources your level three has so they know how to make that decision pre-hospital? So we're sort of lucky because we have a bunch of community outreach here. So the trauma medical director from Stony Brook and the rest of the team go out to a lot of the EMS groups in the area. We also had an EMS outreach person that worked with us who would really go out and explain what the differences are between the resources available at the level one and level three and go over different scenarios of which patients should be brought where and why. Great. Thanks. If you have questions, please put them in the Q&A box. I see one here from Colin. What differences, if any, do you have between your trauma activations between the level one and level three center? So we actually have more activation, so to speak, at the level three center so that we're made aware of patients earlier. For instance, at our level one center, falls that are on anticoagulants and antiplatelet agents aren't automatic trauma activations in large part because we're in-house already. So if the patient turns south, we can get there quickly. For our level three center, we ask the emergency room to notify us of these patients when they arrive as sort of a second tier trauma activation so that we're aware of them. This way, if anything changes, we sort of have it in the back of our mind that we may have to be heading in. And if the ER is more concerned about someone, but they don't think they quite meet co-tier or highest level activation, we still have the direct communication with the ER physicians. Okay, great. Deb actually asks, do you have a benchmarking timeframe to transfer out from a level three? So, yeah, we try to have our final disposition for the patient within, for our highest level activations within an hour of their arrival and for the other patients within an hour of their final diagnoses that would require a transfer. So for instance, the other night a patient went there who was quite stable, but had a complex acetabular fracture that was identified on workup that, you know, was a bit advanced, you know, to not be at the tertiary care center. So our goal is once that's identified and we know the patient needs to be transferred to have them here within an hour. Okay, great. Just waiting, we still have a few minutes for questions. So if you have any questions, please submit them in the Q&A box or in the chat. Everyone's quiet now all of a sudden. You went through a lot of information there. They're probably digesting it. I think it's enough information for the day, right? Time to turn the brain off. Okay. So Alexandra asks, do you have any challenges with doing PI in a level 2 versus a level 1? Initially, I would say yes. Or level 2. Level 2 versus what is level 3? Level 2 versus level 3. Yeah. So I would say initially we did because at least the hospital that not everybody knows the area, but at least Brookhaven or Long Island Community Hospital now was really a community hospital at the time. So initially, a lot of the PI for the hospital in its entirety was done by the same group, and it wasn't necessarily trauma specific. So when it was determined that they really wanted to push their trauma program forward and become an ACS verified center, we made a dedicated trauma PI team there. We were also able, again, we were lucky. We were able to get some help from our home institution of Stony Brook to get people quickly trained in the trauma registries and how to go through these processes. And then because we had already done a lot of the PI process here, we were able to basically bring our PI process directly over to the level 3 and get things running. But it does, as everybody knows, it takes a lot of buy-in to be a trauma center because it's not just scanning people and then putting them on a service. It's trying to provide them with the highest level care and meeting, if not exceeding, all the trauma standards. Another question, do you have any challenges with prompt transport availability? Typically, no. You know, obviously, if there's any weather related issues, you know, we just had the blizzard up here, that'll slow things down. But we were pretty expeditious. Again, the distance between our level 3 and our level 1 is about a 20 minute ride. You know, so once we activate the transfer system, the way that things are sort of set up out here is that Stony Brook manages the transfers, you know, so our EMS crew from Stony Brook will come to whatever hospital in the surrounding area and transport the patient over. What advice would you give administration at a level 3 center regarding the differences between level 1 versus level 3? It's a good question, right? Yeah, so what I would tell administration is that you have to very well define what services you're going to have available and when, and if it's going to be a 24-7 availability, because sort of like using the spleen case as an example of the grade 3 or grade 4 spleen, you're at the level 1 in a way you'd be more comfortable sitting on it for a little while for two reasons. One, if the patient quickly turns south, you can get directly into the operating room, you know, with no weight. Two, you may give them a trial of embolization. If that's going to happen, obviously that's something that the interventional radiologist or the vascular surgeons, depending on where you are, do. So administration would have to very well define what resources they're going to have available all the time. You know, one of the critiques you sometimes face when you're a level 3 with, you know, a lot of subspecialties is, are those subspecialties going to be immediately available to you? So again, also using neurosurgery as an example, just because you have a neurosurgeon on staff, if that neurosurgeon is covering multiple hospitals, it doesn't mean that they're going to be able to get to the bedside, you know, within 20 or 30 minutes. So, you know, it's kind of along with the way of saying the advice to administration is to make sure that you define your criteria and your goals for each of the services that are going to take care of these patients and to sort of not let hubris get in the way of the trauma patient care. So one of the things that we recognized at our level 3 was that to get the interventional radiology suite up and running in the middle of the night, you know, one or two o'clock in the morning, wasn't something that was going to be able to happen. So if we have a pelvic fracture that comes in, you know, with a bleed at, you know, two or three o'clock in the afternoon, we may hold on to that and send it down for an embolization. If that patient comes in during quote unquote off hours or on the weekend, that patient's likely going to require a transfer just so that things don't become emergent when the resources aren't available.

level one trauma centers

level three trauma centers

resources available

surgeon experiences

protocolization of trauma procedures

EMS role in decision-making

trauma education

optimal patient outcomes