committee on trauma – Don Trunkey

A Tribute to Donald D Trunkey by M. Margaret (Peggy) Knudson MD, FACS

To me and to many trauma surgeons around the world, the word “Trunkey” is synonymous with the word “Trauma”. Most of us completing our residencies in surgery in the 1980s never considered trauma surgery as a career……it was just something you did when you were on call for the emergency room.

When I moved to California after finishing my chief year in surgery at the University of Michigan, my plan was to be a pediatric surgeon. But sometime during my first year of pediatric surgery fellowship at Stanford University, I realized that I didn’t actually like that field and was considering other areas of specialization.

Around that same time, the state of California was beginning to organize trauma systems by county, spurred on by the seminal work of Trunkey, West, and Lim demonstrating the high rate of preventable deaths after injury in areas of the state without trauma systems. (1) I decided to visit the Department of Surgery at the San Francisco General Hospital (SFGH) to scope things out and had the great privilege of meeting with Trunkey in person.

He told me that I belonged in the trauma world and when I asked him how he knew he replied: “I just noticed how your face lit up when you talked about trauma”! And so, I became a trauma surgeon, making frequent trips to San Francisco to learn from the masters at SFGH while we set up the trauma system in the county of Santa Clara.

Even after Dr. Trunkey moved to the University of Oregon to assume the position of Chair of the Department, he continued to mentor me in both my clinical and my academic endeavors. In 1989, I was offered a position at SFGH under the leadership of Dr. Frank Lewis, only the second woman to be on their faculty after Dr. Muriel Steele.

Shortly thereafter, Dr. Trunkey and I, along with Colonel Don Jenkins (US Air Force, ret.) traveled to Australia where we taught numerous trauma courses from Melbourne to Sydney. Of course, with Trunkey there was always fun mixed in with work. One day, we traveled to the Blue Mountains, the home of many fine Australian wineries.

We stopped at numerous tasting rooms and at every stop Dr. Trunkey would pull out his credit card and join their wine club so that he could have a continuous supply of Australian wine shipped to his home in Portland. But international travel can wreak havoc on your time zones and one morning during a teaching conference in Liverpool (AU) we were both in need of caffeine. We found ourselves in the kitchen of the hospital but no one was there. I decided to brew coffee and must have hit the start button too many times because not only did we fill the first carafe but also the entire floor with coffee! I was mortified of course, but Trunkey just looked at me and responded with his well-known laugh. I don’t think the kitchen staff ever did figure out who spilled all that coffee!

In 2006, we initiated the Senior Visiting Surgeons Program that allowed non-military surgeons to work as volunteers at the Landstuhl Regional Medical Center (LRMC) in Germany. Landstuhl became the evacuation hospital for all wounded US troops from Afghanistan and Iraq.

Dr. Trunkey (Col, US Army, ret) was a frequent visitor to LRMC, mentoring young military surgeons in the ICU and operating room, caring for the injured, and assuring that LRMC would pass their inspection by the American College of Surgeons/Committee on Trauma Verification Review Committee (VRC) (a committee he helped to found while he was the COT Chair) to become a level 1 trauma center. (2,3) (See also attached Photos)

I think my very favorite story about Dr. Trunkey occurred in Hawaii. We were both asked to speak at the Hawaiian Trauma Conference and at the conclusion were heading to a traditional Hawaiian luau. We invited Don to my cousin’s home in Oahu and offered to drive him to the party. When the doorbell rang my young twin daughters answered it and then ran to me saying: “Mom there is this really big man out there in a grass skirt”!. Yes, I said, that in a nutshell is Dr. Trunkey.

In many ways, Dr. Trunkey was my professional father. Even my own father (an engineer) knew his name and how important he was to me in my career and to the world of trauma. To me, Trunkey was larger than life and his death (like my own dad’s) leaves a void that will never be filled.

M. Margaret (Peggy) Knudson MD, FACS

Professor of Surgery, University of California San Francisco

Medical Director, Military Health System Strategic Partnership, American College of Surgeons

References

West JG, Trunkey DD, Lim RC: Systems of Trauma Care: A Study of Two Counties. Arch Surg 1979;114:455-460.
Moore EE, Knudson, MM, Schwab CW, Trunkey DD, Johannigman JA, Holcomb JB: Military-civilian collaboration in trauma care and the Senior Visiting Surgeon program. NEJM 2007, Dec 27;357:2723-7.
Knudson MM, Mitchell FL, Johannigman JA: First trauma VRC site visit outside the US: Landstuhl Regional Medical Center (Germany). Bull Am Coll Surg 2007;92:16-19.

Legends for Figures

Figure 1: Dr. Trunkey helping to load an injured soldier onto the bus at Landstuhl for his trip to Ramstein Air Base and the beginning of his journey home.

Figure 2: The COT Verification Review Committee at Landstuhl Germany.

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

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.