Sunday, May 27, 2018
Health

Orlando shooting showcased the benefits of a Level 1 trauma center

TAMPA — The men and women who suffered injuries when bullets cut through an Orlando nightclub early last Sunday had one thing break their way.

They weren't far from help.

The club where gunman Omar Mateen opened fire, killing 49 people, stood just blocks from one of Florida's 10 Level 1 trauma centers, each poised to respond with an all-out, life-saving blitz of staff, expertise and equipment. The centers are also the subject of a major health policy debate over how many of them Florida needs and how that should be decided.

The trauma center at Orlando Regional Medical Center, one of the state's busiest, treats more than 5,000 seriously injured patients each year, including about 1,000 with gunshot wounds. The morning of the shooting, a trauma surgeon was on call in the hospital, and a team of specially trained doctors, nurses and technicians were ready to execute a mass-casualty plan.

Experts say the club's proximity to a Level I trauma center was a key reason 35 of the 44 victims who arrived at the hospital survived. Level I trauma centers across the state and nation train for disasters — and have the resources to handle them.

"They would have never ever had the same number of survivors" if the shooting happened closer to a community hospital, said Connie Potter, a national trauma expert. "They did surgery in the ICU. They did surgery in the ER. They were able to call in capable people and get them in there very quickly, and they had adequate supplies."

The only Level I trauma center in the Tampa Bay region — Tampa General Hospital — has a plan for mass-casualty incidents, trauma director Dr. David Ciesla said. The team practices annually and has completed additional training in emergency management.

"I don't know if anyone is ever really ready," Ciesla said. "But that's why you do these things."

Trauma centers specialize in the immediate care of life-threatening injuries. They have far more resources than most hospitals, said Dr. Nicholas Namias, who chairs the Florida Committee on Trauma.

"Your regular hospital doesn't have an anesthesiologist on hand for immediate deployment, an operating room staffed and ready to go, a blood bank stocked and ready to go, a trauma surgeon prepared for an immediate arrival," he said.

Nationwide, trauma centers are classified based on the level of care they provide. A Level I designation indicates the facility has in-house coverage by at least one general surgeon and a wide variety of specialists available around the clock. Florida's 21 Level II centers cover fewer specialties.

In addition to the Level I center at Tampa General, west central Florida has two Level II trauma centers: St. Joseph's Hospital in Tampa and Bayfront Health St. Petersburg.

Johns Hopkins All Children's Hospital in St. Petersburg has a pediatric trauma center.

In recent years, policy makers and hospitals have had a heated debate over how many trauma centers Florida should have. Since 2009, the state health department has approved 11 new facilities, and other hospitals have expressed interest in opening trauma centers of their own.

Trauma can be a lucrative business line. A 2014 investigation by the Tampa Bay Times detailed how the for-profit hospital chain HCA turned trauma care into a statewide money maker.

But some hospital executives say increasing the total number of trauma centers in Florida would hurt patient outcomes. Carlos Migoya, CEO of the public Jackson Health System in Miami, said facilities like Jackson's Ryder Trauma Center need a high volume of patients to be sustainable.

Top trauma centers "can deal with this kind of big crisis at a moment's notice," he said. "Obviously, it is expensive to be able to have the staff that's necessary to do that."

The health department will consider revising its rules on awarding trauma licenses at a hearing Tuesday.

For the trauma team at Tampa General, last Sunday's shooting in Orlando was a gut check. The TGH trauma center has just four general trauma surgeons, but neurosurgeons, orthopedic surgeons and plastic surgeons are also available.

The hospital handles about 3,000 trauma cases a year, according to Ciesla, the trauma director. Most are falls or traffic crashes. About 10 percent are gunshots or stabbings.

Each time a "trauma alert" is called — meaning an emergency services worker identifies a trauma patient in the field — a trauma team quickly assembles. It includes an attending trauma surgeon, an attending emergency department physician, a senior emergency department resident, several trauma resuscitation nurses, a radiologist and a respiratory therapist.

On most days, the trauma pager goes off once or twice.

Wednesday saw a patient with stab wounds show up around 11 a.m. The pager didn't go off again until 9:30 p.m., when two people who had been in car crashes arrived by ambulance.

One was minutes away from death, Ciesla said. She survived.

Tampa General's mass-casualty plan starts with the on-call surgeon calling the back-up surgeon and any others who are needed. The hospital can also send out a mass page to all doctors.

In the event of a disaster, the team would set up a triage area in the hospital's new Bayshore Pavilion. Serious cases would be sent to the emergency room, where trauma surgeons would decide which patients needed immediate operations.

The team practices the plan once each year in partnership with local emergency service providers. The drills help, Ciesla said, but it is impossible to practice things like taking patients into the operating room.

"It is a big, busy hospital," he said. "We've got a couple hundred operations going on every day. To pause all of that is not practical and probably way too expensive."

Still, Ciesla said, he has faith in his team and his hospital.

"You rely on your training and your experience, and the expertise of the people who are working with you," he said. "And you just go from there."

Contact Kathleen McGrory at [email protected] or (727) 893-8330. Follow @kmcgrory.

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