E98 Martin Schreiber on Trauma Research and Resuscitation
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Chad Ball 00:12
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We've had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features, such as debate and companion formats. We hope you relish the podcast as much as we do.
Ameer Farooq 01:13
Dr. Martin Schreiber is a trauma and critical care surgeon at Oregon Health and Science University in Portland. He has had a major impact on our understanding of resuscitation and trauma, among many other topics. We talked to Dr. Schreiber about his experience with the military, his advocacy around trauma research, and trauma resuscitation. To get us started, can you tell us a little bit about where you grew up and where you did your training pathway?
Martin Schreiber 01:39
Yeah, yeah, absolutely. Well, first of all, thank you for inviting me. It's a pleasure to work with my colleagues to the north. Actually, interesting story, I grew up in Cleveland, Ohio, within about 200 yards of Harvey Cushing's grave, Harvey Cushing, George Kreil. Both were in the same cemetery. I didn't know that until 2005, when I went to Iraq, and I read Harvey Cushing's biography, autobiography, actually. And so, at the end of the book, it says he's buried in the cemetery that I grew up across the street from. So, I got back from Iraq, I went to that cemetery, I found Harvey Cushing. George Kreil. Harvey Cushing is buried about 20 feet from Nelson Rockefeller. Elliot Nass is in there. It's a pretty impressive place. But that's sort of how life started: across the street from some great surgeons. From there, I went to college at the University of Chicago and then back to Cleveland at Case Western Reserve for medical school. I did my internship at Madigan in Tacoma, Madigan Army Medical Center, and finished residency at the University of Washington and then spent four years at William Beaumont Army Medical Center on active-duty time. Couple years at Ben Taub as the Chief of Trauma there. And then I've been here since, the last 19 years, I've been in Portland. So, I've had the opportunity to live in every time zone and really experience the United States.
Ameer Farooq 03:20
Wow, that's an amazing story about that cemetery. That's like a who's who of just legends and surgery and just legendary people in general. So that's fascinating.
Martin Schreiber 03:31
Yeah, if you come to Cleveland, you know, all my buddies come to Cleveland, that's about the first place we go. Take a little tour of the greats. President Garfield is in there as well.
Ameer Farooq 03:41
Sir, you've talked at length previously on your military experience, but we did want to talk to you a little bit about it on the podcast today, because obviously, it's something that's really shaped you and you know, it was a powerful experience for you. And you talk about many powerful experiences that you've had, while you're part of the military. Can you describe a little bit about sort of how you got involved with the military? And what impact it's actually had on your career and your life going forward?
Martin Schreiber 04:17
Yeah, it's a little bit of a documentary on life. It's interesting, your intentions don't always end up the way that you thought they would. So, what happened to me was, as I was growing up, I saved up every penny I could to go college and had a bunch of jobs. And this is, you know, early 80s. We're talking about 1980. You know, I had a couple of jobs. I saved about $20,000. I went to the University of Chicago. And they said, well, we're not going to give you any aid. So that was gone pretty quickly. And then I went into debt. By the time I got done with college, I was about $20,000 in debt, which at that time, believe it or not, seemed almost catastrophic. I'd always sort of been enamoured by the military, but sort of the main initiative that caused me to join was this debt. And, you know, in retrospect, the money part of it really means nothing. It really didn't play much of a role at all. But I kind of fell into a life opportunity because it's developed into an incredible career that has shaped the way I practice medicine and my research. You know, I've really learned the most about taking care of trauma patients while I've been deployed. I've been deployed three times: 2005 in Iraq, 2010 in Bagram, Afghanistan, and then 2014, again in Afghanistan. In 2010, I was a joint theater trauma system director, and I had a piece of paper in my pocket that said, I could go anywhere I wanted basically. I just take it to the airport, or the airfield. And the pilots would take me wherever I wanted to go. And I traveled all throughout Afghanistan. I served kind of as a surveyor. I'd look at resources and move people and resources around throughout theatre, and make decisions, help create the clinical practice guidelines, and we hold a weekly video teleconference reviewing all the critical patients. I met people that I ended up being lifelong friends with. In fact, John Holcomb was at William Beaumont, I mentioned, I was there for four years, and we actually ended up having a double wedding, and have been close friends. So, some of my closest friends were from the military. It really shaped who I am as a surgeon and researcher, and really kind of enhanced my life. So, you know, it's funny how a $20,000 debt could end in such an opportunity that really is life changing.
Chad Ball 06:53
I wanted to take a pause and ask you specifically about something I've seen you talk about recently, a fair bit. And that's really your voice for both national and international reform on funding trauma and injury related research. I'm curious, just to start off, why is the advocacy so important to you? What are the metrics that you really use to frame that discussion? And what have your struggles been in terms of getting this message out to date? Because I think, struggle is probably the right word. At least it certainly is in Canada and the US.
Martin Schreiber 07:26
Yeah, you know, if you think about it, in terms of the pandemic, I think trauma is the great, unrecognized pandemic. And drawing some parallels, I think, you know, first of all, a few months ago, we reached 500,000 deaths from COVID in the United States, and the flags were flown at half mast. So, you think about that number 500,000. It's about the number of Americans that die from trauma, every single year. About the number that die from trauma every single year. If you look at the number across the world, about twice as many people in the world, die every year, from trauma, compared to how many have died in the height of the COVID pandemic. So, who's aware of this? And what's anybody doing about it? The answer is nobody. Nobody's aware of it, and nobody's doing anything about it. So, we as trauma surgeons, the ones that are taking care of these patients, I feel are obligated to educate the public, and our legislators about the magnitude of the problem, to awaken them to this and to change and really make a significant change in what's happening. If you look at NIH funding and DOD funding for trauma, something about like around 3% of all NIH dollars go to trauma. So, this is the leading cause of death for young people between the ages of one and 44, the leading cause of working years lost in the country, and only 3% of NIH dollar go to trauma research. There is no home for trauma research at the NIH. The funding for trauma at the NIH is spread across all of the institutes. With NINDS, National Institute of Neurologic Diseases being the number one, they're funding TBI, it's about 10% of their overall budget. But if you look at the magnitude of disease, so if you measure magnitudes, these numbers of deaths, the impact on society, and then you look at the numbers of dollars that are being utilized to study that disease, trauma is the absolute worst of all disease processes. The worst. In terms of matching burden of disease to dollar spent. And even if you look at the DOD, only about 20% of DOD dollars goes toward trauma research. And you know, this is kind of shocking, right? Because one of the major purposes of the DoD, Department of Defense is to support the injured war fighter. But yet only 20% of the dollars go to that. And a lot of that, in our country is congressionally directed. DoD dollars, a large portion of the DoD dollars are congressionally directed and go to a number of diseases. Some of them, you may not even know what it is, like Fragile X syndrome, arthritis, all types of different diseases. And a lot of that funding is determined by the lobbying efforts, and where the money goes and getting people elected. So, I've served in a couple of different areas that makes this important to me. I was on the Board of Governors of the American College of Surgeons, and I was the head of the advocacy committee. So, I was deeply involved in these legislative activities, with trauma being a focus of that. I'm also the chair of the Trauma Center Association of America. And one of our pillars is advocacy. So, teaching people, learning how to advocate at the federal and state level. And educating the population, I think, is the critical element to making a paradigm shift, and how trauma is viewed and how it's funded. From a research standpoint.
Chad Ball 11:37
You know, every time you talk about this, and you frame it in that exact way, I sort of get goosebumps because on one hand, it excites me about potential. But on the other side of things, it really disappoints me in terms of historical performance, which you've outlined, you know. I don't know, you know, I think there's a lot of similarities between Canada and the US with regard to all the elements that you're talking about. When you guys teach physicians or recommend strategies to physicians in terms of trying to be more of an advocate for all the issues that you're talking about that surround injury on this continent, what are some of the mechanics of those recommendations: the nuts and bolts? What can we do both in the US as well as Canada?
Martin Schreiber 12:23
So, I think number one, you know, we work in level one trauma centers, high level trauma centers, I think part of our mission, as a level one trauma center is outreach and education. So, I think working locally and regionally to educate the population, you know, prevention is a big issue as well, right? So, all level one trauma centers need to be involved in prevention efforts. Part of prevention is education. You know, why should you wear helmets and seatbelts and change the shoes and glasses of the elderly? Because they're at risk for trauma. So, it's an educational process. So, at the local regional level, I think that a lot of that is the responsibility of the level one trauma centers working with their local governments, in educating the population, the fire department, the police department, educating, you know, doing things like stop the bleed, which, you know, getting that out to every individual. So now, the average citizen becomes a first responder. So, I think it has to start at the grassroots level. And it has to start, we need to turn "stop the bleed" into the same success that ACLS has had. And the American Heart Association. You know, everybody pretty much is trained how to do CPR, everybody should be trained to do stop the bleed. And now we start to elevate the level of trauma to some of the other major disease processes that are much better funded. I think the advocacy has to also be done at the federal and local level. And this means getting to know your legislators. And, you know, in the current era with COVID, it's now very easy to meet with your legislator, you know? You can do a WebEx or a zoom, just like we're doing today. Get to know your legislator, you know, educate them. So, we at the level one trauma centers, we have analysts' data. We can tell them everything they need to know about gun violence and how it's increasing in the United States and what a problem it is. So that needs to be done, not only at the federal level, but also at the state and regional level. So, for instance, we're working with our local area on a program called Healing Hurt People, and what Healing Hurt People does is when there is a gun violence event in a young person, Healing Hurt People comes to the hospital within four hours, offers resources, offer support. And then they go back out into the community and intervene and try to prevent retaliation. If this is like a gang event, they will actively stop retaliation. And these are typically people that had been in gangs themselves, who have been rehabilitated who know the people involved and will actually intervene and stop violence. That type of program needs to be supported and needs to be funded. And that happens at the regional local level. So, I think this is a multi-faceted, multi-pronged effort that starts with education in the region, propagation of "stop the bleed", working with your local government, and then the state and federal governments in the equivalence, I think in Canada as well. I think all of that may have you know, there's provinces instead of states. But I think all of it's exactly the same and analogous. That's sort of how I think we should promote it. And I think, you know, one of my major efforts is that we are working in the TCAA, with the other trauma organizations to find a home at the NIH, and Institute of trauma so that we can really accelerate the research. So, there's a lot of work to do. And, you know, everyone needs to get involved with this, because it's so critical for society.
Chad Ball 16:33
I couldn't agree more. I mean, if you look after injury, and I would extend, you know, a lot of your comments and your direction, and certainly in Canada, you know, given the geography and the widespread distances, beyond even trauma centers and trauma fellowship trained surgeons to general surgeons. We're all looking after injury at some level, despite regional transfer agreements and provincial wide trauma systems. And so, it really does impact all of us. And I particularly like your idea of using stop the bleed as a sort of an important clinical, but even more than that, you know, an advertising vehicle to generate that sort of momentum. I'm curious, with all the work that you've done over so many different platforms in a lot of years, what are some of the early returns that you maybe have seen or stories that you could share with us?
Martin Schreiber 17:21
Well, I think number one, I think "Stop the Bleed" has been a really successful program that has been disseminated throughout the region. It has kind of made a paradigm shift in causing, you know, just the regular civilian to now become a first responder. So, I think that effort really did well. There's probably been some delay now with further success because of the COVID pandemic. But I think the early efforts and the dissemination of "Stop the Bleed" went a long way toward not only arming people with the knowledge of how to save lives, but also, you know, the devastating natures of trauma itself. So I think that's a success. I think there's been some other successes in the research world, the National Trauma Institute in the United States is funded and is now, you know, funding projects, and that's propagating. There have been some very, very well funded networks. One is "LITES" - Linked Investigations and Trauma, and emergency services. This is a DOD contract for up to $90 million. And it's a multicenter effort; a panel of experts picks casually relevant research, and these institutions actually execute the research. So that's a major effort by the Department of Defense, to fund significant hazard research. Similarly, on the NIH side, there's SIREN. So obviously, people were trying to be funny, and they came up with LITES and SIREN. SIREN is an NIH network. And the way that one works is you become part of the network. And people submit RO1 grants. And when those grants are funded, the network executes the research. So, both the federal government through the NIH and the DOD, have set up these networks that can do a lot of critical research, and really start to change how we understand trauma and improve the care of trauma patients. So slowly but surely, I think that efforts are increasing. Unfortunately, there was a lot more funding in the United States for trauma related grants and activities. But as the Trump regime came through and efforts were made at dismantling Obamacare, a lot of that funding went away. So, now there are new efforts to revive that and to increase the funding for trauma. I think one area that we can really state is a success in the United States is the now funding of gun related research. So essentially, the CDC and NIH, almost were mandated not to do any research related to firearm related illness. But now in the last few years that has been revived, and we're now seeing research related to firearms: looking at epidemiology, and really looking at it as a disease process, not in the manner of gun control, which is, you know, a dirty word to a lot of people, but more in the manner of saying, okay, this is a social disease process, and we need to control the effects of that. Treat the disease and prevent injury, minimize injuries, find new ways to make guns safe. And I think there's been a lot of success in that area. So, there are early signs of increasing knowledge, disseminating "Stop the Bleed", increasing research dollars, NIH and DOD, and actually addressing firearm related injury now. But I think we're just taking baby steps. We've got a really long way to go. But there are some great areas here that look promising.
Ameer Farooq 21:42
Well, if you're taking baby steps, we haven't even begun to move at all up here in Canada. So, you may need to come a couple hours north and help us out to really get things going here. Amazing stuff that you've been talking about Dr. Schreiber. We did want to take this opportunity to talk to you a little bit about some of the research that you've done. Obviously, you've done work on so many different things. But one thing in particular that stands out is the amazing work that you've done on resuscitation. And we wanted to highlight one of the studies that you recently published in JAMA on out of hospital tranexamic acid, and impact on neurological outcomes. And we'll link to the study in the show notes. Can you talk to us a little bit about the motivation for doing this study?
Martin Schreiber 22:25
Yeah, so that was the last major study for a previous consortium, the Resuscitation Outcomes Consortium. Resuscitation Outcomes Consortium: very, very interesting Consortium. It was funded by the NIH, the DOD, the American Heart Association, and the equivalent organizations in Canada, and consisted of multiple centers throughout North America, both the United States and Canada. Vancouver was a big player in that as was Toronto, and Ottawa actually, as well. And basically, this consortium was put together to study trauma and cardiac related emergencies. The very last study that we did was funded through the ROC and the Department of Defense. And we looked at giving tranexamic acid to patients with moderate to severe traumatic brain injury in the field. The lens of this study was really largely from a DOD standpoint, and we were looking at the feasibility of delivering the drug and trying to make it easier. So, you know, the standard dosing for TXA is a one gram bolus followed by a one gram infusion over eight hours. That really evolved out of the studies in elective surgery and isn't really relevant to trauma cases, particularly traumatic brain injury. So looking at this from a feasibility standpoint, if you're in theatre and you've got a patient who's either in hemorrhagic shock, or has TBI, it would be much easier to give that two gram dose as a single bolus, as opposed to a one gram bolus and a one gram fusion. So, we compare the two gram pre-hospital bolus to the standard one gram dose of placebo. And you really have to read that article pretty hard to find it. But what we found was the two-gram bolus...now that this bolusing was started within 42 minutes of injury and as a median. And that resulted in a statistically significant improvement in survival. And all of the difference was really in the first 10 hours. So, we found that to be incredibly exciting. The military through tactical combat casualty care, the Committee on tactical combat casualty care has already changed their guidelines to two grants TXA, pre-hospital both for brain injury and for hemorrhagic shock, and centers around the United States are making that change. Part of the problem when you do a study like this, a pre-hospital trial, it turns out that a significant portion of the patients almost, you know, more than 40% of them, in fact, didn't actually have a brain injury on CT when they arrived. So, when you focus on the patients with brain injury documented by CT, that's where you see the survival benefit. A strong survival benefit. And we're gonna publish another paper, hopefully, in Lancet that focuses just on the patients with brain injury that will show very clearly the survival benefit of giving TXA. But this was really done through a DOD lens, with thoughts about feasibility and the logistics of giving a single bolus of the two grams total dose early after injury. And we found that our medics were more than 95% compliant with the protocol, including following inclusion exclusion criteria, and initiating the drug in the field within 40 minutes of injury. So really exciting trial, really exciting results. And, you know, it really turned out really well for us. We ended up enrolling about 1000 patients across North America. And when we looked at those patients with documented brain injury, we saw the strong difference.
Ameer Farooq 26:29
This is really a gargantuan effort on your part to put on a trial like this. So can you talk a little bit about what actually goes into creating a multicenter, multinational trial, such as this, especially in a setting where you're actually relying on our first responders to actually administer a drug like this, which they may not be used to doing.
Martin Schreiber 26:54
So this, you know, as I mentioned, this was the last major study of the resuscitation outcome consortium. It actually existed for about 10 years. Over those 10 years, we did numerous studies, and the cities that were involved got really good at this. So, problem number one is: you have to have a mechanism to put patients in a study, in an environment where you cannot get consent. You know, patients in hemorrhagic shock or brain injury, you can't consent those patients. And you're in the field. So, we developed, the FDA, and I don't know the regulations in Canada, but the FDA has exception from informed consent. And what you do is you educate your community, you create forums through social media, the internet, and actually meeting with people in the region, you do consultation with them, educate them about the study, survey them to ensure that you have support of the community, focusing on the people at risk to be in the study, and giving people opportunity to opt out with bracelets. So having a consortium that exists for 10 years, lets people get really good at this. And it allows people to train their prehospital services to also get really good at this. And so, what you do is you develop the means to rapidly do the community consultation for the ethic and to rapidly train your EMS providers. So what you're actually doing is you're creating a platform. And the platform, you may change the intervention. But the mechanism to reach the exception from informed consent, and the mechanism to train the medic stays the same. So, you know, just to give you an example, you know, we did this TXA study. Well, you know, now, with a subset of the ROC sites, we're doing a K Setra trial. And it's exactly the same thing. Except we're using K Setra, instead of TXA. And we've got the mechanism in place, we rapidly got through the ethic process, it gets faster and faster, the more you do it. And we rapidly got through the training for the medics. And, you know, you can change the name of the drug or the intervention. But we have set up mechanisms across North America to rapidly execute these types of trials. And so it took 5, 6, 7, 8 years to get really good at this. But once you set up the platform, you can really efficiently study just about anything.
Chad Ball 29:44
Yeah, the devils in the details. There's no doubt. It's tremendous from those of us in the rest of the world to have watched, you know, your collective do this over and over and over again. Really contributed, you know, field changing studies and findings. One of the papers that I like very, very much that you just published, I think was last month in the Journal of Trauma, was a sort of a review or an overview on pre-hospital resuscitation. And you appropriately draw the links between some of the things that you've talked about already, but the strong connection between what goes on in the military side of things, and how that's extrapolated into the civilian side of things, I was curious if you could put that into a bit of a historical context and maybe lead into where you see the future of resuscitation, you know, as a 30,000 foot entity going from here.
Martin Schreiber 30:35
So I think, number one, almost everything that's written in that paper came from my experience in the military. My civilian training. I trained at Harbor View and Seattle, and I found the shirt just the other day. It has all these equations on it: cardiac, oxygen delivery, oxygen consumption, the equation for map. The whole front of the shirt has all these equations on it. And it says, "Harbor View: where the answer is always fluid". And so, my training was, you essentially, we went by the pneumonic, you can't get well, unless you swell. And maybe Chad, you've heard that as well. I doubt Ameer has. But we flooded patients with... we put swans in everybody, we flood them with crystalloid. And we tried to make them flow independent, meaning that we increase the oxygen delivery until actual consumption didn't increase anymore. And all we really achieved was increasing mortality and creating open abdomens. So, you know, with the work in Houston, the New England Journal paper published in 1994, that kind of started a paradigm shift of the work in Houston, looking at super normal oxygen delivery with fluid also showed us these negative outcomes. And then the wars came in Iraq and Afghanistan. And essentially, we then now started to throw the Crystal Light out. And first we were resuscitating with components. And then we realized that well, now we're going to put the components, you know, the proper study led by John Holcomb, we're going to put the components back together in a one to one-to-one ratio to recreate whole blood. We finally said, okay in the United States, why do that? Just use the whole blood. And that really came from the experience that we had in theater, using fresh old blood, which I have to tell you, frankly, the liquid cold stored whole blood that we use in in the United States is really nothing compared to fresh whole blood. You know, in theater, at the height of the wars, you could have a fresh Old Blood Drive, and have a warm bag of blood with 100% of all coagulation components in it within an hour of asking for it. And I gave up to 21 units to a single patient in a day where we had multiple casualties, all getting whole blood. So, you can mobilize huge amounts of whole blood. So, I think the things we learned in theater and these wars, number one, the emphasis and the focus needs to be on stopping the bleeding. That was a paradigm shift from resuscitation as the first thing to do. Stopping the bleeding became the critical element, that started with tourniquets and hemostatic dressings, and rapid surgery to stop bleeding. And then the resuscitation shifted entirely toward fresh whole blood and liquid cold stored whole blood and completely away from anything that was clear. And so that had a profound impact ultimately, back in the civilian world. In terms of the future, I think that the next thing that I'm really trying to do right now here at OHSU and I'm getting some positive feedback is I want to start a walking blood bank. Obviously, to provide the fresh Old Blood, that's what you need. And I believe that within the next few years, walking blood banks will proliferate because we're going to see some incredible blood shortages. And platelets will be the most problematic. And it may become true that at some points, even in civilian medicine, the only way to get platelets is with fresh whole blood. So, I think that's going to happen. It can be done safely. It requires a low-risk population that is screened for infectious diseases every 90 days, and a rapid call-in system and then skilled people to get the blood efficiently. But it's doable. And I think that'll happen. I wonder if as we go forward, we're going to see a little bit of a shift away from early use of blood products in the field more toward concentrates. Things like prothrombin complex concentrate, which will provide the coagulation activity and fibrinogen concentrate. These things can be stored in ambulances. And we can see early coagulation correction without the massive logistical problems that it generates if you try to put blood on ambulances and blood products. So, I wonder, you know, this is happening in Europe, I wonder if we'll see more of a movement toward concentrates in the future. I wonder, you know, one thing I wonder about, I'm not a huge supporter. But there is a movement to start earlier interventions in the field: things like putting the bolas and doing [inaudible]. I'm not loving it. But there does seem to be some movement toward that. So I think there will be a lot of change in the next years. I think we're really going to focus on hemorrhage control, and hemostatic resuscitation, but that hemostatic resuscitation may move more toward concentrate in a way from the blood products, at least in the field.
Chad Ball 36:06
Yeah, that's so interesting. And it's been particularly relevant, you know, to watch systems like Houston, for example, Dr. Holcomb and lots of the work that you've done whole blood on helicopters and ambulances. And we're starting to have that discussion in Canada. But it's, as you point out, there's a lot of hurdles. It's a hard sell, for a lot of our administrators, for sure. You know, one of the papers I reviewed for the Journal of Trauma, not too long ago was a comprehensive review, essentially, of the morbidity and mortality process for the special forces over the entire duration of the desert war. And it was a fascinating thing to actually read in black and white. I think a lot of us who have either been there on the Canadian side or have never been there and just learn through experiences when folks like yourself talk and understand, to some extent the closed loop capabilities of that system. And it was remarkable to read in that paper, you know, you guys would identify issues, you would study these issues, you would provide an intervention, study them again, and then you would change the protocols and the policies and the pathways and the algorithms with which you treated these soldiers. That sort of closed loop, highly motivated, maybe even hierarchy sort of structured environment seems to have incredible benefits. How do you translate that sort of high-speed nature of that entire process, back to the civilian world in our trauma centers, where we simply don't seem to have the capability to, you know, provide a lot of those components within that cycle of quality improvement that's so rapid?
Martin Schreiber 37:55
So Chad, that's a great question. And it is something I'm trying to do here in Portland as well. I think we can do it. So just to put some finer points on what you're saying. So, you're basically describing the algorithm for the joint trauma system, which is you take care of patients, you study the patients that you're taking care of. You create clinical practice guidelines, and then you study them and alter them. That's something that you know, I think level one trauma centers do in their own centers. But we need to regionalize this. So, one of the main ways that this was successful in the military was a Thursday video teleconference, which continues to this day. And what happens, you know, a fixed time on Thursday, across continents, people get on a video teleconference just like this, very feasible. And they present all the patients that were evacuated to launch tool for the last week. The presentation starts with the medics in the dirt in Afghanistan, it goes to the Ford Surgical hospital. And then it follows the patient to the combat support hospital back to Germany, and then back to continental United States, and sometimes even to the VA. And each individual or individuals that cared for the patient at each of these levels, presents the patient. And then the presentation is correlated with the clinical practice guidelines. And points are made. Well, you know, the clinical practice guideline, this patient had an eye injury, why didn't you put an eye shield on? And that's how people learn and that's how PI is done. And I don't think there's any reason in the modern era that we can't do that in the United States. Why can't we...you know, we have a lot of rural centers. You do as well. Why couldn't the medics who pick up the patient in the rural center be on a video teleconference with the level three or rural hospital who then presents their part of it? And the follow up is given from the level one trauma center, why can't we do that? And then why can't we create guidelines and talk about efficiencies of care and due process improvement as we do this. I think that the model exists. We're trying to recreate it in Portland, I think that everyone can do it. And, you know, with this pandemic, one of the benefits is we've gotten really good at these zoom conferences. And you know, Chad, for all I know, you're in the north of Canada, in the middle of nowhere all by yourself with no one around you for hundreds of miles. And you could present a patient that you cared for there and the presentation then could go to a regional hospital and then back to Vancouver. There's no reason we can't do this. And I think we should.
Chad Ball 40:47
You're speaking music to my biased ears for sure. You know, there's two caveats that I always like to frame exactly what you've said. The first one is, you know, I think a lot of us have sort of visited and done visiting prof rounds in Australia, and it's remarkable to watch, you know, somebody in Brisbane at their trauma center help guide through essentially telecommunication video and audio resuscitations in the north of Australia in Darwin, in real time. That technology is not new as we all know, it's extremely old, but it's certainly under utilized in the civilian world. The other thing that fits exactly with what you're saying is, you know when I was in Atlanta at Grady, we had monthly morbidity and mortality rounds. And each of those groups were represented in person in that room. And I'm sure a lot of places do that. So, you know, you'd say, well, why is the scene time 19 minutes here in this gunshot? And the police chief would immediately thunder in and say, well, it's because we didn't have the scene control. And then you would sort of deal with those issues all the way through as you went for, as you point out, immediate quality improvement. I don't think we've leveraged that enough, certainly in this country, on the civilian side at all. I am curious how common it is across the US, because it seems to be low hanging fruit, to your point with, you know, the recent uptake of all this teleconference technology. It would be so easy, eh?
Martin Schreiber 42:15
Yeah, you know, I don't think it is common. I do know, there are some systems that do it well, I think the pen system in Philadelphia, and, you know, they've created a system of somewhere around 20+ hospitals, that are tightly organized to do systematic review in that system. But I'm not aware of a lot of other systems that have done this. So, I think, you know, this is an opportunity, and we really need to focus on it, and do a much better job. I think it's particularly pertinent for a state like Oregon, and much of Canada where you have sort of, you know, we have one big city, and two level one trauma centers in that city, but you know, this is a massive state. And patients can come from anywhere in the state. So, we need to, you know, standardize care across, you know, vast distances. And the way to do this is through communication and presenting cases. One of the things that happened in theater, when I was the at the joint theater trauma system, director of the Secretary of Defense said, okay, we're going to have a one-hour rule, a Golden Hour Rule. And an injured patient needs to be in the hands of a surgeon within an hour. So, one of the things I did was I reviewed every single case where the patient wasn't in the hands of a surgeon within an hour, and it was about, you know, five, six or 7% of the cases. And it was almost always equipment failure, weather, or the tactical scenario, it was rarely, you know, failure to move the patient because of some problem with care. It was a technical problem or logistical problem or a battle related problem. We don't have those problems in the United States, but we do have problems with weather. And we have other challenges. But you know, I think that's another way to do this: create a standard. And if the patients don't meet the standards, specifically review those patients as a system and come up with solutions. I think that's what we need to do better. And that would be a lesson we can learn from our military experience.
Chad Ball 44:21
I like the word standard, and I don't mean this as a fanboy. But I mean, in all honesty, and being genuine, I think you really do set the standard in the current era of not only trauma care, but also perspective and trauma research. I'm curious what you tell your residents, your surgical trainees in Portland with regards to advice as to how to be so engaged and so productive and in particular, be so successful academically and clinically over such a sustained period of time.
Martin Schreiber 44:57
Yeah, you know, I think it's about…a couple of words I really like are: situational awareness. I think as you know, residents, and this is something I teach, residents, interns, residents, early trainees - they're very focused on the patient in front of them, and they should be. But as you gain experience, you start to be more aware of the system. And, you know, okay, it's not just this one patient, but there's another patient on the way. The other trauma center is very busy. And you know, they may go on diversion, the weather is bad, we're not going to be able to get patients from the coast today, we need another plan for that. So, I think one of the things I teach in terms of residents is very difficult because they do focus on a patient in front of them is to be circumspect. I think an important thing to teach is, you know, very early on in your career, you need to start thinking about what type of surgeon are you going to be? Are you going to be a private practice person, not really interested in research, are you more interested in academics and systems? Then you need to start thinking about time management. Because even the early career people coming out of fellowship, you know, the tendency is to really engross themselves in surgery. And what happens is you start engrossing yourself in surgery, then you start to have a family. And research becomes sort of the last thing on the list, and it doesn't happen. So, if you want to be academic, if you want to do research, it really has to be a priority. Because for most people, it just becomes the last thing on the list that doesn't happen. The only thing I teach people is that the system that they work in, the system they choose to work in, as they look at jobs, they need to look at that very closely. Does the system focus on research? Does it provide protective time? Are there mechanisms in place to assist you with getting IRB submitted, getting grants submitted? You can't walk into a place and be expected to work hard as a surgeon, have no infrastructure and be productive. So, I teach people to look at those factors as they look at jobs. You know, if they're going to go into private practice, go to a place where they focus on being good surgeons, they're supportive. They help you if you're in trouble, etc., etc. But if you want to do research, go to a place that emphasizes it and has infrastructure to support it, and will provide you with the time to do it. So those are, I think, some of the critical elements that goes into educating people. So, education needs to be not only about where to put the stitches and who to operate on, but it needs to be about how to take care of yourself, how to maintain your sanity, how to, you know, get enough sleep, make sure you're well fed. Take care of your colleagues, your other residents, and partners. Take care of your family and have balance in your life. There's a lot to it, that goes just beyond putting in the stitches.
Ameer Farooq 48:17
You talked about your advice to your residents. If you could go back in time and give yourself advice, perhaps as an early attending, having gone through what you've gone through now, what would the advice be to yourself as maybe an early attending?
Martin Schreiber 48:32
You know, it's the advice I give. I think, you know, at heart, we are all surgeons. We went through surgical residencies, and we are surgeons. Tackle the tough cases. You know, don't avoid anything. Once you start to avoid cases, what happens is, you know, before you know it, you're afraid to do a hernia or an appy. So, get embroiled, take on tough cases, use your partners. Take advice from them and balance your life. You know, maintain some kind of balance in your life. Take care of yourself, take care of your family. Develop balance. And pick an environment to work in, where you feel part of a family that is a very healthy environment. Supportive. Will help you through those tough cases, and help you achieve your career goals regardless of what those are. So, make sure if you want to do research, make sure you're in an environment that supports it. But do not shy away from the tough cases. Take them on, get busy. Get your hands working. Those first few years out of training play a big role on who you're going to be. And if you're not really, you know, embroiled in surgery, then it's possible that you'll shy away from it in the future and you'll lose your identity as a surgeon. That's what I advise. I mentioned I was in the army. The army's a unique environment, particularly in the mid- 90s. I was able to do just about every kind of surgery there was. I mean, we did lobectomies, Whipple's and liver resections. And so, that's a great way to start a career. Because you're really not afraid of anything. And it starts you on a path toward being a competent and confident surgeon. And I think that's critical for people in our profession.
Ameer Farooq 50:46
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.