"THE HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)


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Week: 570.6 Guest: Dr. David Hoyt, Director, San Diego Trauma System Topic: Trauma - prevention and juvenile program Producer/Host: Steve Girard

NEMA: Trauma is a killer...and we have great people at highly specialized facilities around the country trying to save the lives of those who are seriously injured. We have the director of one of the best with us today... Dr. David Hoyt of the University of California, San Diego Trauma Center. Dr. Hoyt... looking at the numbers... one out of three of us will have a traumatic injury this year...

HOYT: Well the way I think of it is, we think of approximately a thousand seriously injured patients per million population. What that translates to is about... between 65 and 70 deaths a year across the country and approximately a thousand seriously injured patients per million population. So, in San Diego County, we get approximately 2 to 3 thousand seriously injured patients per year. In addition we admit to trauma centers another 2 to 3 thousand.

NEMA: Most people don't think of trauma as a disease... but also, they don't realize that trauma is the biggest killer of people under 45 in the country.

HOYT: Well that's true, you know some of the more traditional diseases we think about really get you when you're older, but the leading killer of all diseases is injury-related death under the age of 45, and that's actually true probably to the age of 54. And it includes everything. It includes gunshot wounds, all kinds of penetrating trauma... includes all kinds, what we call, blunt trauma... motor vehicle accidents, motorcycle accidents, falls, etc.

NEMA: Now I notice your working with something called the National Trauma Data bank. Can you tell me about that a bit?

HOYT: The National Trauma Data bank is something that starting with the American College of Surgeons. And what it is intended to be is a data repository into which all existing trauma centers will be able to share data, allowing them to compare themselves to each other - to benchmark themselves against national data and really give us a picture of what's going on across the country.

NEMA: Will that also include access to information on programs that might be making a difference in one place over another?

HOYT: Well it's our hope, this is a brand new project, it's just coming up as we're having this conversation, and it's potential, I think, is unlimited. But at this point it's primarily to allow comparative data and look at trends and differences in outcomes, differences in care... and improve care through that mechanism by making people aware of each others outcomes and what's going on. We hope that people will be able to learn from each other.

NEMA: In another of your many jobs, you are the prime investigator or lead investigator for violence prevention for the California Wellness Foundation....?

HOYT: The intention of the grant is, through a very broad based initiative, to introduce prevention, violence prevention, through a variety of mechanisms. The part that we're working on is to actually train physicians or nurses in techniques of epidemiology, how to measure the problem... and then how to design ways to fix the problem and implement violence prevention programs. The idea is that although trauma systems, trauma care, are an important component of our responsibility, designing prevention programs is an equal part. Right now in the state of California and probably pretty much across the country, violence related trauma has actually surpassed motor vehicle accident as the leading cause of death, particularly in young people. So most trauma surgeons and trauma programs across the country have responded by feeling obligated to somehow get involved. We chose to take on trying to train individuals in the actual methods of violence prevention, so that's so there'd be a long term solution for the next several decades.

NEMA: Now, you have a pilot program going on involving juvenile offenders trying to get to them and impact, and give them the importance of what it actually means to be in a trauma center and to experience firsthand the expertise of the people in the trauma center. How was that designed and how is that working right now?

HOYT: Well, that's a very important program and we're very proud of it, because we think it's been very successful. Basically what we have is a law that allows a judge to give a juvenile offender for drunk driving a sentence which includes participating in the coroners office and in a trauma center for a period of time. They usually spend 2 evenings with us, and then having to write an essay on their experience. And there's been a very dramatic affect both in terms of the insight a lot of these individuals reflect in their essays, which suggests that the program is having a very positive benefit. But the actual rate of repeat, or what we call the recidivism rate, in these juvenile offenders has been almost zero. And that's compared to a similar population, that wouldn't undergo a similar kind of program, running somewhere between 5 and 6 percent. So, we think that kind of interaction, bringing these young kids into the community, really showing them what's going to happen if they don't bring their behavior under control, has a positive affect.

NEMA: This looks like a long term project... working on the idea with the Corrective Behavior Institute...?

HOYT: Based on successes in our place and throughout California, they have now spread their program throughout the country. I can't tell you exactly how many states it's in to date, but people have realized the same benefit in other trauma centers, and are rapidly adapting similar kinds of programs.

NEMA: In this experience, bringing young people in, what seems to get to them the most, what has the biggest impact?

HOYT: Well, they're very impressed by the way in which the trauma team works together. I think it probably indirectly affects them to realize just how much work and resources are involved in helping if they were to get injured and maybe that somehow gets them to think twice. They're impressed by just the professionals they interact with during those 2 days. They're impressed, I think, when they go to the coroners office and see some people that have not made it. So I think it's a little bit of everything. But the overall experience seems to get the message across.

NEMA: Would you mind going on, and talking a little about trauma systems for the future?

HOYT: We are still actively involved in developing trauma centers throughout this country... and the American College for Surgeons has been involved in certifying those trauma centers in an attempt to set a high standard of care, etc... The challenges in the future get back to what's going on in medicine and health care in general right now, and that is to integrate it into a system that is also something that we can afford, and do that in the context of the people who are going to pay for care in the future, the managed care organizations. So I think that's a major challenge right now. I think there's sometimes a conflict in understanding exactly what the point is. I think a community is forced to deal with the same issues, because often times the purchasers of health care will dominate an area and be as important an influence in decisions that are made with regard to health care in that area as the local government. So I think those are the issues, and we're all struggling very hard to keep them in perspective and come out with, at the end, what is a system that provides the best care to people in the community and at the same time is affordable. The biggest challenge to that is the fact that we still have a large portion of patients in this country that have no real visible means of supporting their health care, other then the government or cost shifting on to the traditional payers of health care. And as those opportunities go away it makes the opportunity to pay for that less... and so it potentially threatens trauma systems. And so, for those of us who are involved in it, we've got to be very careful and try to balance all those things, and make it works. And I don't think we can look to the government or any one person to solve these problems for us. I think we'll have to solve them locally, in each community, by working together with the community resources that exist... and try to do the best that you can for a particular community.

NEMA: Are there other ways you see trauma centers interacting with the community?

HOYT: Oh absolutely. I think the trauma center has a visibility that allows it to really offer itself as a resource, in a number of areas, of all types of prevention - whether it's how to build highways or how to investigate a particular crash in the area of motor vehicles, how to participate in violence prevention, how to participate with the managed care organizations in the community to assure that the highest quality trauma care exists ... and yet its done within the context of what's affordable. It's very interesting that most trauma centers have leaders that are, in general, very involved in the running of the hospitals - simply because the model of how you take care of a trauma patient is a very efficient, directed way to take care of many problems. And as a result, the systems that work for trauma work for a variety of other diseases. I think it's a very important principle in medicine today... and it's why trauma has been so visible.

NEMA: The operation of a trauma center necessitates highly organized procedures and management... providing a model for all hospitals in improving general care. Preventing death has been their goal...and now, preventing the injuries, using their insight to create programs of community interaction, is also part of their job. Thanks to Dr. David Hoyt, director of the Level 1 UCSD Trauma Center in San Diego.

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.NEMAhealth.org ...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.

 

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