Month: October 2018

Icon in Surgery by Karen Deveney, M.D., F.A.C.S.

Don Trunkey is being honored by the American College of Surgeons (ACS) this month at their annual Clinical Congress as an “Icon in Surgery”, an honor which he richly deserves. Don was the leader among a small cohort of surgeons who played a major role in improving the care of the injured not just in the U.S., but across the world, by advocating for the development of standards of care for trauma patients and defining what specific expertise, resources, and personnel needed to be in place for a hospital to provide optimal care to those patients.

After a rotating internship under Dr. J. Englebert Dunphy at the University of Oregon followed by two years in the U.S. Army in Germany, Dr. Trunkey travelled to the University of California, San Francisco (UCSF) to train in surgery, where Dr. Dunphy had assumed the chairmanship. He developed an interest in a career in trauma during his rotations at the San Francisco General Hospital (SFGH), which was then developing a reputation as a leader in the new specialty of trauma surgery under the direction of the skilled and charismatic chief of surgery, Dr. F. William Blaisdell.

Don heeded Dr. Blaisdell’s advice to study with Dr. Tom Shires at Parkland Hospital in Dallas, one of the most prestigious centers for both care of the injured and trauma research. At Parkland, Don learned research techniques for studying cellular mechanisms in shock and fluid resuscitation. He returned to San Francisco and joined the staff at SFGH, continuing his basic research under an NIH Program Project Grant in 1972, at the exact time that Federal recognition of Trauma Centers was beginning. SFGH was one of the first such centers recognized. At that time, however, most injured patients across the U.S. were taken to the nearest hospital for care, without regard for their preparedness to care for traumatic injuries.

The network of young surgeons who had trained at UCSF extended up and down the state of California, and among them was John West, a surgeon in private practice in Orange County who had completed the surgery residency at UCSF in 1973, just two years after Don. John was distressed at what he felt were unnecessary deaths from basic traumatic injuries such as splenic rupture due to delays in recognition and prompt treatment of their condition. He and Don co-authored a landmark study comparing mortality from equivalent injuries in community hospitals to that at SFGH, a well-equipped and well-staffed trauma center. The study demonstrated the superiority of the trauma center in saving lives.

Throughout the U.S. were hospitals such as SFGH that had also demonstrated their expertise in trauma care. Surgeons at these hospitals were the major members of the Committee on Trauma of the ACS, a committee that had been originally formed as the Committee on Fractures in 1922, but formally reorganized as the Committee on Trauma in 1950. At about this time, trauma was being recognized as a major public health issue, with increased highway accidents due to the development of higher speed automobiles and the interstate highway system as well as inner city violence from knife and gunshot wounds.

Don Trunkey had been appointed to the ACS Committee on Trauma where he served as its chair from 1982 – 1986, joining a small group of like-minded “rabble-rousers” to lobby the ACS for designating hospitals according to a system of standards of trauma care, described first in 1976 in a manual called Optimal Hospital Resources for the Injured Patient. It set standards for what resources, personnel, and policies a facility need to have to render ideal care and divided hospitals into Levels I, II, III, or IV based on minimum standards at each level. They also advocated for providers to be taught and tested in a rigorous course, the Advanced Trauma Life Support (ATLS) course, now in its 9th edition, but a hard-fought battle for acceptance in its earliest days. Don Trunkey was a key leader in development of all of the elements of effective trauma care. These now well-accepted principles, processes, and programs were not initially so readily embraced by the power structure in American surgery, because they represented radical new ideas in the staid, traditional field of surgery. They were, in a word, disruptive to the status quo.

Don went on to lead the American Association for the Surgery of Trauma as its President in 1986, disseminate trauma systems standards, verification, and ATLS teaching throughout the world.

He also served in the U.S. Army as a reservist since his days on active duty in the early 1960’s, and was deployed to Saudi Arabia during the first Gulf war in 1991, where he served as commander of the U.S. army hospital based in Riyadh. In the aftermath of that experience, he issued a white paper that suggested necessary changes in military combat care to improve outcomes. Again, this report was met with resistance by those in positions of authority, but all of his recommendations have subsequently been adopted : most specifically, for improved pre-combat training of military surgeons for combat and standardized protocols of care, with damage control care near the combat lines and air evacuation as soon as possible to progressively higher levels of care.

Don Trunkey was, more than any other single person, responsible for the development of sophisticated, state-of-the-art trauma programs in the U.S. His promotion of systematic, sound trauma care worldwide has saved countless lives. He has been tireless in his devotion to the cause and is a larger-than-life figure to all who know and love him. He is the perfect individual for the ACS to honor as an Icon in Surgery.

Karen Deveney, M.D., F.A.C.S.

The above remarks are drawn from both personal recollection as well as from the excellent account contained in the book, The History of the Surgical Service at San Francisco General Hospital authored by Drs. William Schecter, Robert Lim, George Sheldon, Norman Christensen, and F. William Blaisdell.

Influential Champion for Optimal Care of Injured Patients by Richard J Mullins

Dr. Donald Trunkey’s skill, judgment and indefatigable determination as a trauma surgeon has saved the lives of thousands of patients. In addition, his leadership in the development of trauma systems has saved the lives of millions around the world. In the late 1960s Don was trained as a trauma surgeon at San Francisco General Hospital, a busy urban trauma center. Don recognized that a reason for the success of San Francisco General Hospital was that a surgical team capable of managing a wide range of injuries was always available in the hospital and ready to respond immediately when an ambulance delivered an injured patient to the emergency department.

The team approach was essential to prevent immediate death in injured patients from obstructed airway, impaired breathing and shock. As Don Trunkey pointed out in his manuscript Trauma published in Scientific American (1983; Vol. 249:28-35) a coordinated team was able to establish quickly a list of the patient’s injuries, and with prompt treatment prevent death during the “golden hour” following injury. The foundation of Don Trunkey’s advocacy for trauma systems was based upon lessons he had learned in the care of individual injured patients.

Don Trunkey has been a prolific scholar. He has written over 100 manuscripts and book chapters in which he described the optimal treatment of a wide range of specific traumatic injuries. Additionally, Don Trunkey has authored over forty manuscripts that examined the influence of implementation of trauma systems of the survival of injured patients. His influential scholarship in support of trauma systems are evidence of his strategic vision regarding optimal health care.

A seminal paper published by Don Trunkey with co-authors John West and Robert Lim entitled: Systems of trauma care. A study of two counties (Arch Surg. 1979 Apr;114(4):455-60.) had an enduring influence. The authors studied the patients who died of injury in Orange County, California, which did not have a trauma system, and patients who died of injury in San Francisco, California, which did have a trauma system. These authors determined that in Orange County many injured patients died preventable deaths, while it was a rare event in San Francisco. This study was used to convince the Orange County government officials to implement a trauma system.

After the trauma system was established, and injured patients were taken to designated trauma centers, the outcome study was then repeated; preventable deaths had declined substantially in Orange County. This classic paper has been praised as a model of a process that could bring about implementation of a trauma system. The West, Trunkey and Lim study of preventable deaths in injured patients was duplicated by researchers around the United States who made similar observations of high rates of death among seriously injured patients treated in a hospital that is not a trauma center. These preventable death rates became the incentive for implementation of multiple other trauma systems.

Don Trunkey has been an influential leader in Academic surgical organizations around the world. From the leadership podiums of these organizations Don Trunkey advocated for these organizations to make optimal trauma care of injured patients a priority. His influence on public understanding of medical issues has been enhanced by his persuasive style of presentation and articulate speeches. On one occasion he was featured on a documentary television show (Operation Lifeline. 1978-79) demonstrating the fulltime commitment that surgeons needed to make to treat seriously traumatized patients in those first critical minutes following injury.

In the time period 1978 to 1985 Don Trunkey was an active participant and then leader of the Committee on Trauma of the American College of Surgeons. Don Trunkey described that he and his colleagues on the Committee were “busy trauma surgeons, and we wanted to change the care of trauma patients in the United States.” Don worked with the other members of the Committee on Trauma to establish programs that delivered enduring improvements to the care of injured patients. These programs include the Advanced Trauma Life Support course that has subsequently achieved worldwide distribution.

The Committee members published a book that described what trauma centers needed to provide optimal care-i.e. Resources for Optimal Care of Injured Patients. During Dr Trunkey’s leadership of the Committee on Trauma that organization established a program that verified hospitals had the resources needed to function as trauma centers. There were critics of the process to provide oversight of trauma centers. Undeterred, Don persisted as a candid advocate for having seriously injured patients treated in trauma centers where an experienced team was continually ready.

During his military service also called for optimal of casualties of war.
From 1962 to 1964 Captain Don Trunkey, US Army Medical Corps, Reserves, served in Germany as a general medical officer. He returned to a military in service 1985. He was 48 years old, Professor and Chair of Surgery at Oregon Health & Sciences University and decided to apply for a commission as a surgeon the US Army reserves, explaining that he was “concerned there were not enough surgeons in the Army”. He would later say his only regret was that he did not return to the Army reserves sooner.

Colonel Trunkey and his hospital unit was called to duty for Desert Shield and Desert Storm in the fall of 1990. His military hospital was in Riyad, Saudi Arabia and treated injured form the SCUD missile attacks, and wounded soldiers evacuated from the battlefield. At the end of what was a brief war, when others were proclaiming success with a low death rates, Colonel Trunkey wrote an after-action report that was critical of several aspects of the Army Medical Corps response to casualties. He provided several recommendations for how the care of casualty could be improved.

One enduring influence of Colonel Trunkey on the care of casualties of war was implementation of training programs in busy civilian trauma centers where military surgeons could acquire experience in the care of seriously injured patients. Multiple training programs were implemented and substantially improved the care provided to wounded soldiers, sailors and Marines during the war on terror following September 11, 2001 attack.

Thousands of surgeons have met Don Trunkey and been inspired by his wisdom and dedication to the care of injured patient. Many young surgeons have vivid memories of Professor Trunkey taking an interest in their work. His ability to inspire surgeons has meant that Don Trunkey will have an enduring influence on the optimal care of injured patients long after his retirement through the work of subsequent trauma surgeons who perpetuate his commitment to the optimal care of injured patients.
October 8, 2018
Richard J Mullins, MD, FACS.

The Don Trunkey Years at San Francisco General Hospital by Karen Deveney

Don Trunkey spent 14 years on the faculty at San Francisco General Hospital (SFGH), the last 8 as the chief of surgery. He was an outspoken, confident, and decisive leader beloved by the staff, faculty, residents, students, and patients because of his warmth, self-deprecating humor, fairness, obvious regard for the opinions of others, and courageous stance to defend “doing the right thing”. He never hesitated to take what he felt was the right and necessary step to improve patient care, even if it was politically unpopular or raised the hackles of someone in power who had a secondary agenda to maintain the status quo or simply save money at the expense of the largely poor or minority patients who relied on SFGH for their care.

After he had completed his surgical residency at the University of California, San Francisco, he spent one year with Dr. Tom Shires at Parkland Memorial Hospital in Dallas doing trauma research on cellular function in shock, then returned to join the faculty at SFGH in 1972. At that time the chief of surgery at SFGH was Dr. F. William Blaisdell, who had been a mentor of Don’s when he was a resident and had played a large role in influencing him to follow his footsteps as a trauma surgeon.

Don established his academic research at SFGH on the pathophysiology of shock under an NIH grant and published extensively on the subject, while focusing his clinical activities on trauma and burns. He had learned a great deal about burn treatment while in Dallas, where the Parkland Burn Center was already established as a national model for care of the burn patient. At SFGH at that time, burn patients were admitted to any surgical bed that was open, not ideal for prevention of infection and management of the patients’ sometimes extensive wounds. They lacked, for example, a (hydration tank) or dedicated procedure room for dressing changes. Don wanted to establish a dedicated burn unit, which Dr. Blaisdell agreed would be a worthwhile and important step in improving their care. Unfortunately, Don discovered that the hospital director was opposed to the idea of a separate burn unit for financial reasons.

Dr. Trunkey nevertheless pressed on, identified some empty ward space, recruited nurses for the unit, found an old bathtub to use, and invited the mayor of San Francisco, Joseph Alioto, to dedicate the “Alioto Burn Center.” Dr. Blaisdell invited the famous chair of surgery at Louisville, Dr. Hiram Polk, to give a talk at the dedication ceremony. City dignitaries were invited. Only on the day of its opening did the hospital director find out about it, but it was already a fait accompli, lauded by the mayor and Director of Public Health, who had found funding for it!

When Dr. Blaisdell left San Francisco in 1978 to assume the chair of surgery at the University of California, Davis, Dr. Trunkey was appointed chief of surgery at SFGH. He served in that capacity for 8 years, until becoming the chair of surgery at the Oregon Health and Science University in 1986. Although he was only 41 when he became the chair of surgery at SFGH, he had already achieved international stature as a trauma surgeon due to his research, his publications, and his larger-than-life persona. Just the year before, he had co-authored a landmark study that demonstrated the superior outcomes of injured patients who were cared for in a trauma center rather than a private community hospital without special expertise in trauma. He became chief just as a property-tax limitation measure, Proposition 13, had been passed in California that severely decreased the funding available for public services, such as supporting a city/county hospital for the poor. Fortunately, SFGH had by then gathered such high regard as THE place to go if you were injured, that it was able to survive as an institution. Its survival was in no small way due to the skill, personality, and great accomplishments of its leader.

Over the next 8 years he solidified the importance of organized systems of care in achieving good outcomes for the injured patient. He and a small cadre of his contemporaries on the American College of Surgeons Committee on Trauma (COT) established the Advanced Trauma Life Support (ATLS) system as a mandatory aspect of trauma care and developed a system of certification and verification of hospitals’ ability to manage trauma patients. He served as chair of the COT from 1982 to 1986. He became a director of the American Board of Surgery, President of the Society of University Surgeons, and President of the American Association for the Surgery of Trauma.

Although Dr. Trunkey was required by his many national roles and his growing international fame to travel from San Francisco frequently, he assembled a distinguished and highly capable cadre of surgeons at SFGH, each of whom had gained expertise in the broad range of surgical and medical skills needed to provide the highest level of care for the most critically injured and ill of our society. He continued the research program begun under Dr. Blaisdell’s leadership, but expanded it to include more clinical and collaborative research. He developed the Trauma Foundation as a major force in trauma prevention.

By the time Dr. Trunkey left San Francisco for his position in Oregon, SFGH had been firmly established as one of the nation’s foremost trauma centers and its existence was secure. He left an indelible mark on the institution.

Karen Deveney, M.D., F.A.C.S.

The above remarks are drawn from both personal recollection as well as from the excellent account contained in the book, The History of the Surgical Service at San Francisco General Hospital authored by Drs. William Schecter, Robert Lim, George Sheldon, Norman Christensen, and F. William Blaisdell.