The UVM Medical Center is Vermont’s only Level I Trauma Center. Here to tell us more about what this certification means for patients, families and physicians is Dr. Ajai Malhotra, division chief of acute care surgery.
Listen to the interview at the link below or read the transcript that follows.
UVM Medical Center: Every year in Vermont and Northern New York, tens of thousands of people go to the emergency room at their local hospital for everything from the flu to asthma attacks to broken bones. For nearly 2000 of those patients their problems are so severe and life-threatening that they need to be taken to the UVM Medical Center because it has the only level one trauma center in this area.
There are only 100 of these high-level centers in the nation and the medical center just went through a rigorous process to receive certification of its adult and pediatric trauma programs. We’re going to find out much more about trauma services on our show today and also learn about a new effort to educate the public about how to control bleeding in an emergency from Dr. Ajai Malhotra, he’s division chief of acute care surgery at the UVM Medical Center and professor at the Larner College of Medicine. Thanks for coming.
Ajai Malhotra: You’re welcome.
UVM Medical Center: First, as basic as you can get, how is trauma defined from a clinical standpoint?
Ajai Malhotra: Trauma essentially is all injuries. It could be as small as a stubbed toe to as big as being shot in the belly or involved in a major motor vehicle collision.
UVM Medical Center: It doesn’t have to be life-threatening?
Ajai Malhotra: It doesn’t have to be life-threatening but the whole concept of developing trauma centers and particularly level one centers is to be able to get the most severely injured to the level one center in as rapid a time as possible.
UVM Medical Center: For folks out there who are familiar with their local emergency room what’s the difference between that and a trauma center?
Ajai Malhotra: The difference is that when we get informed that major trauma might be coming in, a whole team is rapidly assembled in the emergency department consisting of physicians, nurse practitioners, physician assistants, X-ray technicians, blood bank technicians, so that whatever the patient needs can be rapidly provided to him or her in a timely fashion.
UVM Medical Center: As I understand it there’s even dedicated facilities. Like an OR is unreserved all the time?
Ajai Malhotra: That is correct. Our OR functions in a way that with a 15 minute notice we can take a patient to the operating room for fixing whatever the problem is.
UVM Medical Center: You talked about the range of the team there. What kind of special training, extra training, do trauma folks go through?
Ajai Malhotra: Well, they go through the full general surgical training so all, of course, the general surgeons. In addition, all of us have done a fellowship in trauma and critical care. That is taking care of the sickest of the sick in the ICU. That is surgical critical care. Also, these trainings are usually done in level one trauma centers where we have seen a lot of injured patients.
UVM Medical Center: I also understand you have to have people on-call that live close enough to get there? I’m just ticking through things that make level one centers different.
Ajai Malhotra: Yes, the Medical College of Surgeons requires that the senior-most surgeon be available within 15 minutes. However, it can be logistically difficult and that’s why at Vermont Medical Center the senior surgeon or attending surgeon is in the hospital 24/7.
UVM Medical Center: You mentioned folks getting transported in here. Talk a little about those relationships that we have. More can be done I guess in an ambulance now than was probably the case 20 years ago. How important is that to the whole scene?
Ajai Malhotra: The whole concept of a trauma system, which we are trying to develop in Vermont, comes down to rapid transport to the definitive level of care. For a seriously injured patient it will be at the level one center here.
Another part of the concept is that the care should not deteriorate at any point after the patient encounters medical personnel. When the ambulance team arrive they rapidly assess, start the resuscitation process, if they need they can call air medical support. They will rapidly transport the patient to the nearest hospital or, in some cases if the patient is severely injured and will benefit from bypassing the local hospital, they can bring them directly to the center. Again, the concept is to get the correct patient to the correct hospital in the correct time.
UVM Medical Center: They can do a lot to stabilize them. I think one of our series of ambulances we have for critical transport between hospitals has been called a rolling ICU. Talk about that a little bit.
Ajai Malhotra: Yes, if a patient is not directly brought to the University Medical Center they are taken to the closest hospital where they are rapidly evaluated and if the hospital makes a determination that this patient needs to be transferred to the medical center they call the medical center and we send our ambulance which is fully equipped. Again, the concept being the care of the patient should not deteriorate from the point they encounter a medical personnel. This ambulance is capable of providing ICU-level of care while in transit to the medical center.
UVM Medical Center: You’re listening to Dr. Ajai Malhotra. He is the division chief of acute care surgery at the UVM Medical Center and professor at the Larner College of Medicine at UVM. Acute care surgery encompasses trauma, emergency, general surgery, and surgical critical care. I’m talking about level one trauma center services here at the UVM Medical Center. Just went through a rigorous recertification process. Talk about that a little bit.
Ajai Malhotra: The American College of Surgeons has established this program in which it’s an external verification of what we say we are doing. We say we meet all the standards that are required for a level one trauma center. However, it’s nice to be externally validated. The American College of Surgeons sends reviewers who themselves work at usually level one centers so know the whole process.
They evaluate multiple things. Number one, they look at charts to see how good or otherwise our care was. Second, a very important part of this whole process is performance improvement. The other big aspect they look at is that when we do identify problems how do we identify problems and what do we do to correct it?
On the same note, as a demonstration to how our care is, we also participate in national trauma quality improvement project where we provide our patient data to an American College of Surgeons-run process where they compare our outcomes to other similar centers. What the most recent report said, that was in the spring of 2017, is our mortality, that is the people who died, was lower than the national average by at least one percentage point.
UVM Medical Center: That’s terrific. That’s been the case for quite some time. Is there a lot of interaction with the Jeffords Institute for Quality in this quality improvement process?
Ajai Malhotra: We do interact in the quality improvement part but where we rarely interact with the Jeffords Institute is in research. Another aspect of being a level one trauma center is that not only do you provide the care for the injured today but you also do community outreach, do research to further the care and improve the processes of care.
UVM Medical Center: What’s some of that research we’re doing?
Ajai Malhotra: Vermont currently does not have what we call an organized trauma system. That does not mean that we don’t take care of patients. There are some criteria that have to be met to call an organized trauma system. Dr. Daniel Wolfson, who is the EMS Director, and I are together looking into first of all establishing a clear trauma registry statewide. Looking at every patient who was injured, where they were taken, what the quality of care was, and how many of them died, how many of them were left with a disability.
That gives us a starting point to where we need to go to develop a statewide trauma system. The others are more related to how we manage injured patients. For example, the amount of radiology that is being used nowadays has really skyrocketed. We are looking at a project in which we look at all radiology that was done on trauma patients for the last 15 years. We think a lot more is being done for very minimal gain so we are looking at that very carefully through the Jeffords Institute.
UVM Medical Center: I also mentioned at the beginning that pediatric trauma was certified. Talk about that. What are the differences between adult and peds?
Ajai Malhotra: Pediatricians love to say that children are not just small adults. There is some truth to that. There are special needs that children have. That is why children in every specialty are treated slightly differently with the additional resources in terms of social work and their emotional needs.
Similarly with trauma, in recognition of that, the American College of Surgeons actually has a separate process for pediatric trauma center verification. Recently when we went through our verification process we were verified as a pediatric level two trauma center.
UVM Medical Center: What would people recognize as different in pediatric trauma than in adult trauma? Are there special spaces or something?
Ajai Malhotra: Yes, starting with the emergency department where the injured patient is received, the pediatric resuscitation area is different from the adult resuscitation area. The instruments and the tools, the medication dosages, everything is different to ensure that mistakes are not made. Specially trained personnel who have pediatric training attend to the pediatric injured patient in a specially designed pediatric resuscitation room.
It proceeds within the hospital, they are managed on floors where the nurses and other personnel are trained in pediatrics, and they are managed with other pediatric level patients. Not in the same floor as the adult patients.
UVM Medical Center: I should mention we have a children’s hospital so there’s a wide array of services beyond trauma that are here. A couple minutes left. I wanted to get to the bleeding control issue because it really seems interesting. As I understand it, the trauma community is trying to create another thing that the public can be aware of like the Heimlich Maneuver or CPR. Talk about the origin of that and what your goals are.
Ajai Malhotra: This specific program came from a very unfortunate incident that happened in Newtown a few years ago where a deranged gunner attacked a school with machine guns. What was realized was that the school was put down on lockdown. Whoever was injured inside, stayed inside. Whoever was outside, stayed outside. That is where the care providers stayed outside until it could be declared safe.
Somebody came up with the idea that the only people who could help the injured who were locked inside were the people who were also locked inside. That’s where the idea came from that we should provide the lay public, especially in a high target area and especially in high occupancy areas like malls and et cetera, that while the situation is being brought under control by law enforcement the bystander can provide care in the form of controlling the bleeding, particularly from extremities by applying tourniquets.
Specially-made tourniquets, or if there are no specially-made tourniquets available then being able to use whatever is available, a tie, a belt, to stop the bleeding. What was realized was that so many people died from uncontrolled bleeding from the extremities which could well have been controlled by a tourniquet application.
UVM Medical Center: How difficult is the learning curve on putting on a tourniquet?
Ajai Malhotra: The learning curve is actually very small. It’s very easily taught. We had a discussion about this as to what age should we be targeting? How low can we go? People generally felt that at least high school and maybe at the 12/13 age group, well taught. It does not take more than two hours to do the course. We are planning those types of courses in local hospitals and other places.
UVM Medical Center: Would it be a situation where you’re going to try to get materials out there? Like there’s defibrillators and that sort of thing.
Ajai Malhotra: Yes, and that’s exactly the concept: to be able to put a bleeding control kit right next to that automatic defibrillator for bleeding situations. We are trying to garner some funds so that wherever we go we can actually leave a kit that can be hung right next to the defibrillator.
UVM Medical Center: Well, we’ll have to keep our eye on that. That’s very interesting. I’m sure a lot of people listening probably would be interested to know how to do that. I’m sorry to say we’re out of time. I want to thank my guest today Dr. Ajai Malhotra who is division chief of acute care surgery at the UVM Medical Center. Also, a professor at the Larner College of Medicine at UVM. Thanks very much for being with us.
Ajai Malhotra: Thank you for having me.