Search This Blog

Follow by Email

Wednesday, November 9, 2011

Advanced Trauma Life Support

My 2 year "sabbatical" started a week ago. It has not, so far, involved much sleeping late or eating bon bons, which is fine, I guess. I am working several 24 hour shifts this month for our local hospital, covering the "hospitalist" service. This involves care of hospitalized patients who have no primary doctor or whose primary doctor is unable to take care of them in the hospital. Some of these patients are critically ill, some have fallen through the cracks of our health care system and others have doctors who choose to do only outpatient or specialty practices.  In some communities, especially in big cities, doctors who have office practices are just too busy to be available to their patients at the odd times that hospital medicine requires and so nearly all of the patients in the hospital belong to designated hospitalists. In our community, most of the doctors do at least some hospital medicine, which is good for continuity of care.

After quitting my primary care practice the first item on my agenda has been to take some continuing medical education classes that I have been too busy to take in the past, and ones which significantly broaden my scope of practice. The first one that I have done is Advanced Trauma Life Support, a course sponsored by the American College of Surgeons to help bring physicians who treat injured patients up to a basic level of competence in the process and procedures involved in good care.

There are various courses that physicians take that are represented by initials. I have recently updated my skills in ACLS (advanced cardiac life support) and PALS (pediatric advanced life support.) The ACLS course involves memorizing several algorithms for treating patients who present with life threatening heart events. These patients are familiar to me, because internal medicine, my specialty, involves lots of work with cardiac issues. Since my patients very rarely die or threaten to in my presence, it is good to review the steps involved in resuscitating them so that when fast action is required, I don't have to delay while trying to remember what to do. I have taken the course many times, and it is now familiar and easy despite the fact that recommendations change a little bit each time. PALS involved lots of studying and working through scenarios online and then a practical test. It was fine, but not remarkable. I now feel entirely capable of saving digital and rubber babies from various near death events.

I chose to take ATLS because feeling confident in taking care of victims of assaults or motor vehicle accidents is basic to being able to provide emergency care, and I may end up doing some of that. When I decided to take the class I had to find a location that offered it at a time that was convenient. I asked friends who had taken it what their experiences were and I searched online and eventually decided to take the course at Harborview Medical Center in Seattle.  I had done several months of residency training at Harborview and found it to be staffed with skilled and committed doctors and nurses who saw lots of very sick and injured people and who were at the front line of innovations to make care better. I wasn't sure that a structured course like ATLS would be different when taught at a major trauma center like Harborview.

The ATLS curriculum started after a doctor crashed his small plane in Nebraska and observed from the inside just how fragmented and inadequate trauma care was.  His wife died instantly and three of his children were critically injured. In the year that followed he and others in the medical community began to design a course that would standardize trauma care in a way that would dramatically improve its quality. What is taught now has been changed and honed and continues to change based on research and experience. The class involves lectures and practical sessions, scenarios and written and oral testing. Harborview did a terrific job. The course director, Dr. Sam Arbabi, is a trauma surgeon who is actively involved in caring for injured patients as well as doing research in public health and teaching students and residents. The different systems were covered by a diverse array of surgeons from all over the country, all of whom had different practices and experiences which they incorporated into  their course material.  The students were also extremely diverse, from small town emergency physicians to surgical residents to primary care physicians who needed trauma background to meet the needs of their injured patients when specialty care was not always available. In some continuing medical education courses, students, despite the fact that they are MDs, are assumed to be stupid. ATLS at Harborview was very collegial. We, the students, were recognized as the front line in trauma care. Patients with multiple severe injuries often end up at Harborview when the small hospitals that initially see them are unable to provide the kind of care that they need. If we, at these small hospitals, take good care of them, Harborview will be much more likely to save them.

We learned a method of thinking about injured patients that allows us to make good decisions when our brains might be overloaded with emotionally relevant pieces of data that can lead to being unable to do the right thing first.  The process involves the familiar ABC mnemonic, standing for Airway, Breathing and Circulation. No matter how bad a person looks after being hit by a car or beaten up by a gang or trampled by elephants, if air moves in and out of their lungs and their heart continues to beat, they are alive and their other injuries can be treated in good time. The details of how to do all of this are made up of thousands of hours of training throughout medical school and residency and beyond, but remembering that it is necessary to support movement of breath in and out of the lungs and to staunch bleeding is basic to trauma care and can provide an anchor for the rest of what we do.  Beyond this, each professor taught us about a specific area of care, including broken bones, injured brains and spinal cords, lungs which may be popped, contused or bleeding, hearts with similar issues, and the whole collection of innards which work so beautifully when unmolested, but so very poorly when squashed, skewered, perforated or macerated.

The final exam, which leads to certification, involved a practical demonstration of my ability to verbally and physically walk through treatment of a volunteer paramedic or nursing student with gorey makeup and rubber wounds associated with a realistic scenario, such as having been run over by a truck after falling off of a motorcycle or running into a bridge abutment. There was also a wickedly tricky multiple choice exam, with which I didn't entirely agree given the fact that much of what is right to do in any given situation depends on things which aren't possible to clarify in one paragraph. The very last activity of the very last day of the class was a small group discussion of triage of patients in disaster or multiple victim events. Who among the hurt and dying can best benefit from the limited resources available? These discussions allowed us to get to know each other and the course directors better and work through our conflicting values to come up with a consensus that will probably be helpful in future apocalypses.

So the class was excellent. I heartily recommend ATLS at Harborview in Seattle.

As I drove back home, the 5 1/2 hours from Seattle to Idaho, I thought about the fact that the vast majority of traumatic injury that leads to death, disability and dismemberment is directly due to our unconditional love for the internal combustion engine, particularly the automobile. Without motor vehicle crashes, trauma medicine would be a significantly smaller specialty. I clung somewhat more tightly to my steering wheel and drove more slowly and wished I could be footloose without driving my car.

No comments: