Michael Smith, MD (Host): Welcome to The Pulse at Tallahassee Memorial Healthcare. I'm Dr. Mike, and with me is Dr. John Dortch, a fellowship trained trauma surgeon from Tallahassee Memorial Healthcare, and today we're diving into the world of trauma care and support beyond the emergency room. Dr. Dortch, welcome to the show.

John Dortch III, MD: Thanks for having me.

Host: You know, I think it's safe to say that most people think trauma care begins and ends in the emergency room after the surgery if there has to be one. But what does the full journey really look like after leaving the emergency room?

John Dortch III, MD: Yeah, so trauma encompasses a whole spectrum of injury patterns. So every patient's journey can really look a little bit different. I think one of the things that people are always surprised to hear is that trauma care is largely non-operative, so not every patient that comes in as a trauma alert will necessarily find their way into the operating room.

But depending on the injury pattern and the patient's severity, um, a patient will often go straight from the trauma bay into the operating room. If they don't, then they'll work their way into our surgical critical care unit or to one of our surgical postoperative care units on the floor.

Host: How long does somebody in this process, what's the average length of stay? And I know that's probably pretty hard to answer, right, based on the trauma, but what kind of timeframe do you mostly deal with here?

John Dortch III, MD: Yeah, so it could be something as simple as an isolated single system injury who will stay in the hospital for a day after we've arranged all of their support that they need at home. But it can range to, to even as, as far as months if you have a patient who's coming from a complex social situation with multiple system injuries.

So we see a really wide spectrum in terms of the time for the length of stay. On average, I would say that a trauma patient probably is in the hospital somewhere around three to five days.

Host: Now, again, I think most people think of physical injuries with trauma care, but there must be some emotional and psychological impact as well. Can you tell us a little bit about that, and how do the behavioral health teams become involved in that care?

John Dortch III, MD: Yeah, for our team, it's really important for us to understand that when we walk into the room with a trauma patient, we may very well be meeting that person on the worst day of their life. So there's no doubt about it. Trauma can completely upend someone's life, both physically, and emotionally.

 With a traumatic accident, it can completely change the way that you do your job. It can, change the way that you interact with your family members. You may even lose family members in a traumatic accident. So these sorts of things are really important in taking care of the patients as a whole.

We're very lucky at TMH to have an engaged behavioral health center with psychiatrists and clinical psychologists who are really committed to helping us take care of our patients. We've done a lot over the last couple of years in implementing screening programs to try to identify patients who are at risk for things like post-traumatic stress disorder, substance abuse issues that plays a large role in trauma recidivism, and a lot of times trauma patients are, find themselves in the trauma bay because of a drug or alcohol problem. So we have a very strict screening process for how we can identify patients that are at risk for those things, and then get them the appropriate help that they need, whether it's psychiatry or clinical psychology.

Host: How fast do those teams get involved, those behavioral teams? Is it, while they're in the trauma bay or is that something that's usually coordinated when they leave?

John Dortch III, MD: Well, you know, it's a balance. So one of our key partners is our spiritual care team at TMH. So with the chaplain service. For all level one trauma alerts, the chaplain service actually arrives in the trauma bay. They're there to support the patient from the minute they arrive at the hospital.

And they're also there to support the family who arrives within the first 30 minutes or so when a trauma patient comes to us. So they can provide spiritual care to, to not just the patient but their family. So they're involved quite early, and then stay involved throughout the patient's hospital stay.

Another important player that we have with our clinical psychology team is for our brain and spinal cord injured patients. So, in Florida we have a program called the Brain and Spinal Cord Injury program that provides specific state funded resources to people who have new traumatic brain injuries or spinal cord injuries.

And one of our clinical psychologists Jenny Persinger, has partnered with us to identify those patients and come and see them while they're in the hospital. But that's something where we'll have her involved later in the hospital course, once the patient's kind of emotionally processed their trauma, already been through surgery that they may need and they're getting ready to make that transition out of the hospital. Dr. Persinger will come in later in the stay to try to help make sure that they're plugged in with all the resources that are available to them. So it really, the timing of when some of our psychosocial support gets engaged, it varies depending on which resources we're really providing.

Host: And it sounds like these teams are ready to go when somebody comes in. It's, they know somebody's coming in, they're ready to go once, I guess someone like you gives the, okay, all right, come and see them. Is that true? It sounds like they're ready.

John Dortch III, MD: Absolutely. Yeah. Particularly with our spiritual care team, they receive the trauma alerts the same way that we do. So, we're often in the trauma bay before the patient rolls in and, they're actually right there with us prepared and ready to engage with the patients or their families.

Host: Now once a patient has been discharged, what kind of follow up or long-term care do they typically need from the trauma team?

John Dortch III, MD: So we have a weekly survivor's clinic where we'll see patients in our office who have either had injuries that we're managing like rib fractures or have undergone surgery and need specific postoperative care. So that's a weekly clinic that we hold.

Host: Can you talk about how community education and injury prevention fits into your role as a trauma provider?

John Dortch III, MD: Oh yeah, I think that education and prevention is something that you're signing up from the very beginning as a trauma surgeon. For one thing, our state accreditation for our trauma center at TMH, it requires an educational component and a community outreach component. We really try to tie those things to specific injury patterns that we see at our hospital. For instance, we have a large population of patients who've been through motor vehicle accidents, and we know that many of those motor vehicle accidents are tied to substance abuse.

So one of the efforts we had this past year was hosting a project prom night for some of the local area schools where we'll go and we'll provide education about substance abuse and driving and the dangers that are associated with that. And that was really well received. And we try to do that to target specific areas of concern that we have in our community. Another thing that we've been really involved with recently is a program that's hosted by the American College of Surgery called the Rural Trauma Team Development Course. We've hosted two courses for outlying smaller community hospitals who are referral partners with us. And the idea with these courses is to really improve the lines of communication between Towson Memorial Hospital as a referral center and some of the smaller outlying hospitals. But not only improve communication, but also like look at their processes that are in place.

Try to identify ways that we can help them be more efficient. Ways that we can give a patient who presents to one of these rural areas a fighting chance, before they can be transferred to an area of definitive care. So those sorts of outreach projects are really what we focused on and things that we hope to continue to do.

Host: So older adults, kids maybe without stable housing, patients without insurance. It sounds like before they even get in there or once they're in, that you have a plan for them to help them navigate through the system too. Is that right?

John Dortch III, MD: Yeah. Those are vulnerable populations that national data suggest that children, geriatric patients, both require an additional degree of care and attention to help them through traumatic events. We've developed practice management guidelines at TMH specifically for our geriatric population and pediatric population to try to identify common areas of concern in these specific patients and address them early on.

So, for instance, like with geriatric patients, we're focused on polypharmacy, we're focused on, often these patients come to us on blood thinners and we need to have screening processes in place to make sure we know that early, early on, and can manage those different types of medications appropriately. With kids, they have an amazing physiologic reserve, but when it comes to some of the social situations surrounding a kid who goes through a traumatic accident, there might be barriers that we've identified in the home that make it unsafe. So we work with our case management partners to try to ensure a safe discharge plan before those patients are going home.

The other program in the hospital that plays a pivotal role here is our physical therapists. So particularly with our elderly patients who may have mobility issues, fall risks, making sure that they have the appropriate medical equipment they need at home, or sometimes making sure that they get to an appropriate inpatient rehab facility, for their recovery period.

The physical therapists and case managers really work very closely together to make sure that we do the right things for those patients.

Host: Can you quickly review the different types of trauma centers, in terms of like level trauma, level one, level two for the audience?

John Dortch III, MD: Yeah. So your level one trauma center is really the main bastion of trauma center. That's your highest level trauma center that takes care of the highest acuity patients. Trauma centers are deemed a level one trauma center based on volume of patients seen, but also based on resources available to take care of those patients.

A level one trauma center requires 24-7 in-house coverage. And one of the big distinguishing factors between a level one and a level two trauma center is that it is required to be associated with a general surgery training program, and they have to have an active research program. A level two trauma center is very similar to level one trauma center, with the exception of those two requirements.

So you don't have to have a surgical training program, and you do not have to have a research component. But when it comes to the resources provided to patients, the expectations are very similar to a level one trauma center. The lower level trauma center, so currently in Florida we don't use the level three trauma center, however, that is something that we're talking about on a state level.

A level three trauma center is really something that exists for these critical access hospitals and rural areas that allows them to have a standardized way of measuring their trauma outcomes. It gives them some quality parameters that they have to adhere to without necessarily requiring all of the resources that a level one and level two trauma center requires.

Host: So there's a term that we're hearing a lot lately, trauma informed care. What does that mean to you and how does it shape how you treat your patients physically and emotionally?

John Dortch III, MD: Yeah, so trauma-informed care, I think it really focuses on what are the preconceived notions that we come into a trauma patient's room with. I think that there are several things as trauma surgeons that we have to be cognizant of, when we're walking into a patient's room. So for one thing, there's no way that we can truly understand a patient's experience unless we've been through a similar traumatic event ourselves, which is not always the case. So there's a certain degree of humility and openness that you need to have when you're going to engage with a patient who's just been through a severe trauma. I think that you have to create an environment of safety because for one thing, patients who've been victims of violent crimes, they are experiencing something that's very different than we can even understand.

So you have to have an openness and a humility to what that person's going through when you walk into the room. Part of that is also giving them some sense of empowerment and a voice, right? So, a trauma patient is still trying to make sense of the experience that they've just been through. We're seeing them in the first couple of days after these unbelievable life events, so,

having that in the back of your mind as the healthcare provider that this person is still really working through, what does this mean, what is this going to mean for me going forward? And giving them the opportunity to kind of vocalize some of that stuff. Understanding that, if they're exhibiting frustration or things that can be perceived as the difficult patient, you've gotta understand that what this person's going through is contributing to that process and, how they're responding to you might be part of their way of working through the trauma that they've experienced. So to me, trauma-informed care for a trauma surgeon is really having a humility and an openness to helping a patient voice what they've experienced and empowering them to be able to process that, move through it, and incorporate this traumatic event into their life view.

Host: I love that approach, and it sounds exactly like the right thing to do. Dr. Dortch, this was fantastic. Thanks for coming on today.

John Dortch III, MD: Yeah absolutely.

Host: For more information, please visit tmh.org/trauma to learn more about the region's only level two trauma center. If you enjoyed this podcast, please go ahead and share it on your social channels and check out our entire library for many other podcasts and topics that might be of interest to you.

This is The Pulse at Tallahassee Memorial Healthcare. Thanks for listening.