Tag: ATLS

Don Trunkey 1937–2019 from Injury Journal

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Nothing lasts forever. However, for most of us, Don Trunkey was the innovator of modern trauma care and it’s hard to imagine a world which he is not part of. As Ralph Waldo Emerson stated it is not length of life, but depth of life that matters. Indeed, his talent, passion for improvement, and vision to look into the future were unique and his contributions to the evolution of trauma care have been priceless.

Donald D Trunkey FACS, was born in Eastern Washington and went to medical school at University of Washington. He served in the US Army in the mid 60 s in Germany and completed his surgical training in San Francisco. It was from San Francisco that his seminal “Two Counties” [1] paper was published where he convincingly showed that where a trauma system existed the mortality was substantially lower than where it did not. It was this paper, more than any other in the contemporary literature which led to the drive to systematise trauma care around the world.

Another of Don’s seminal papers was that on the trimodal pattern of death after injury which was published in Scientific American in 1983 [2]. In that paper he outlined that death after trauma was either immediate, usually as a result of catastrophic brain or torso injury, in hours as a result of uncontrollable haemorrhage, or in 2–3 weeks as a result on multiple organ dysfunction itself, a long term consequence of poor initial control of haemorrhage. While true in 1983, the trimodal pattern of death no longer exists because, through the efforts of Don and other trauma surgeons, effective early trauma care, particularly consequent on near-universal uptake of ATLS/EMST teaching, has resulted in effective early haemorrhage treatment.

Noteworthy, he was also a leading figure in highlighting the challenges of managing multiple injured patients with associated head injuries what he described as a ‘crisis’ in trauma care [3]. He suggested that ‘neurosurgery should step up to the plate and provide coverage for Level I and Level II trauma centres at a reasonable cost, and went as far as to state that ‘If neurosurgery cannot or does not want to provide coverage, they should let other surgeons provide coverage’ [3].

Professor Trunkey also was one of the first clinicians to express his concerns about the omissions of the USA public policy in relation to recreational use of drugs such as heroin, cocaine, methamphetamines, and marijuana and reported a direct link between alcohol or drug use and crime, corruption, violence, and health problems, calling for the need of formulating a workable public policy [4].

Professor Trunkey’s academic record lists 317 publications and 10,118 citations but his only publication in Injury occurred in 2000 and was a comparative study looking at trauma outcomes in Oregon Health Sciences University and Stoke-on-Trent [5]. This paper, co-authored by John Templeton and Peter Oakley amongst others showed that although raw mortalities were different, when casemix was considered there were no significant differences between the centres. This highlighted how important it was to carefully consider casemix in any comparison of trauma outcome.

Don’s early military career was bookended by a role in the First Gulf War 1990–1991 where he served as an advisor to the US Forces in Saudi Arabia. He dealt with a number of operational and cultural obstacles that prompted him to publish a commentary in the March 1993 edition of Archives of Surgery called “Lessons Learned” [6]. This document paved the way for how the U.S. Department of Defence trained its trauma personnel.

Don was a giant on the US trauma stage but also a frequent traveller who spread his knowledge and influence around the world. Apart from his Honorary FRACS and FRCS(Eng) he was also an honorary fellow of the surgical colleges of Ireland, Edinburgh, Glasgow, South Africa and Brazil.

Don was inspirational, enigmatic, friendly and forceful all at the same time. He influenced generations of young doctors, in surgery and in other disciplines, to improve trauma outcomes and contribute to the teaching and delivery of optimal trauma care. At conferences and courses he was an enthusiastic teacher and a challenging mentor. He conveyed the absolute necessity of taking action when time critical injuries were present and was never afraid to do so.

Donald D. Trunkey was a legend in every aspect of the word and the trauma community will be much poorer with his passing. His legacy however, of improved trauma systems, trauma care and trauma outcomes, is very much alive and society as a whole will be grateful for the career long contribution of this trauma giant.

https://www.nattrauma.org/don-trunkey-giant-in-trauma-remembered/
https://www.injuryjournal.com/article/S0020-1383(19)30303-1/fulltext?dgcid=raven_jbs_etoc_email

References

  1. West, J.G., Trunkey, D.D., and Lim, R.C. Systems of trauma care: a study of two counties. Arch Surg. 1979; 114: 455–460
  2. Trunkey, Donald D. Trauma. Sci Am. 1983; 249: 28–35
  3. Trunkey, D.D. The emerging crisis in trauma care: a history and definition of the problem. Clin Neurosurg. 2007; 54: 200–205
  4. Trunkey, D.D. and Bonnono, C. A rational approach to formulating public policy on substance abuse. J Trauma Inj Infect Crit Care. 2005; 59: S61–S66
  5. Templeton, J., Oakley, P.A., MacKenzie, G., Cook, A., Brand, D., Mullins, R.J. et al. A comparison of patient characteristics and survival in two trauma centres located in different countries. Injury. 2000;31: 493–501
  6. Trunkey, D. Lessons learned. Arch Surg. 1993; 128: 261–264

A standard for the trauma surgeon by Dr Collicott

I first had the pleasure of meeting Don when we introduced ATLS® to the west coast in 1981.  I was a community surgeon interested in the task of improving the early care of the trauma patient.  Don, at that time was already an experienced trauma surgeon on his way to becoming an icon in trauma and American surgery.  He accepted the ATLS® approach with his full commitment without any undue criticism as many of his peers did initially.

My interactions with Don became quite frequent when he became chair of the American College of Surgeons Committee on Trauma (COT). We became well acquainted at the various meetings we attended together during his tenure as the COT chair. He never lost his enthusiasm for teaching all who participated in the care of the trauma patient.  We came to learn that our childhoods and values were very similar having been raised in rural America not being stymied by hard work to reach our goals.

The unselfish dedication and commitment of his professional career to the improvement in the care of the injured patient; his clairvoyant incorporation of the concepts of preventable death methods and evidence-based practice in support of trauma systems: his initial investigations of cellular response to injury; his élan as an educator, role model and friend to countless surgical trainees; his unpretentious personality;  and his exemplary compassion in the care of the injured patient will always remain as standard for the trauma surgeon.

I am proud to have known him for over 30 years.

                                           Paul “Skip” Collicott

Fearless Mentor by Lenworth Jacobs MD, MPH, FACS

Don Trunkey was a trailblazing pioneer for patient care, trauma management and educating multiple levels of trainees in surgical management. I first had the pleasure of meeting Don in the mid 1970s when I was directing EMS for Boston and Boston City Hospital.

He came and site visited the Trauma Center and insisted on spending time observing the Emergency Medical System both in the prehospital phase as well as in the Trauma Center.
This was a particularly challenging time since paramedics and emergency prehospital care were in their infancy. He was so helpful both in concept and in detail as to how the system could be improved. He took the time to meet everyone and was particularly kind to me in those early days. He was particularly helpful in persuading the Commissioner of Health and Hospitals on the importance of physician led medical direction and medical control of the system.
The very next year he invited me to join the Committee on Trauma and paired me with Norman McSwain. His ability to include everyone both professionally and socially had an indelible effect on me. His straightforward no nonsense attitude coupled with an incredible sense of humor and the willingness to include young surgeons in the decision making process has stayed with me forever.
He was always open to ideas and encouraged younger people to present their ideas and concepts at the national level. As you can imagine this was intimidating for a young surgeon to be asked to present somewhat new and different ideas before the icons of trauma surgery. He would always give encouragement and constructive criticism which improved the concept and ultimately it’s implementation.
He taught me the importance of knowing every single detail of a new initiative or program.  Then being prepared to fearlessly defend it with the use of data and good humor. 
He championed so many positive concepts that have dramatically improved trauma care in the United States and in the world.

The ATLS program, trauma center verification, trauma system implementation, modernization of battlefield care, the inclusion of younger people on on numerous trauma committees which allowed them to learn the process and spend a lifetime in trauma care.
I think his ultimately legacy was that he always wanted to do the best thing for the patient and his willingness to be a fearless mentor for countless younger surgeons myself included. I will miss his leadership and friendship terribly. 
Lenworth Jacobs MD, MPH, FACS

A Surgeons’ Surgeon by Dr. David B. Hoyt

I first met Dr. Trunkey when he was on a T.V. show on Lifeline in 1978. I was a resident, I was thinking of going into trauma and seeing him being followed around the hospital at San Francisco General and actualize the job, talk about coordination of care to the patient, get after people that weren’t doing their job, and generally be a model of leadership created a distinction that I had not seen in my residency and modeled what I had been thinking about.

Dr. Trunkey was a surgeons’ surgeon. He was big – yet jovial, he was charismatic – yet kind, and he called it like he saw it. He championed things and pushed for things, even when they created controversy. Those of us following in his footsteps saw that as a model for how to implement a program that would challenge the very fabric of health care delivery. His leadership affected hospital-based systems, prehospital care, the American College of Surgeons, and essentially everything he touched. He was certainly no man’s fool but tolerated people whose heart was in the right place in working toward the ultimate goal.

My next encounter with Dr. Trunkey was again when I was a resident, I had decided to go into trauma and ATLS was being offered. We put on a course at the University of California which was led by Norm McSwain and Skip Collicott. Don Trunkey and Frank Lewis came out of the North at San Francisco General, both as leadership icons and participated in our course. Again, rather than as many trauma leaders at the time did, he did not dismiss ATLS but saw it as an opportunity for creating a common language. He threw himself into the course in all respects and we all had a great time getting to know him and following his leadership.

Above all I recall his emblematic commitment to the trauma patient and their care. He led this through his positive influence perhaps more than can be currently measured. He did it with a sense of fun, a sense of purpose, and a devotion to the intellect and history that made things the reason to proceed.  One seldom meets a person who when you mention their name gets the same reaction. For Dr. Turnkey it is immediate respect and a broad smile showing his friendly nature and his ‘never take yourself too seriously’ attitude. America trauma is different, as is trauma around the world because of his major contributions over forty years.

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.

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.