Tag: Gulf War

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

50th General Hospital, by Dr. Tom Hutchinson, COL USA (Ret)

As the Commander of the 50th General hospital during Operation Desert Shield/Desert Storm (1991), I got to know Col. Don Trunkey pretty well.  He was our Chief of Professional Services and was always busy keeping the medical/surgical side of things on a straight and narrow path.  He presided over our M and M (Morbidity and Mortality) Conferences, and tolerated no nonsense in professional performance or behavior.  This was accomplished in the company of a splendid sense of humor.

When LTG Yeosock, our 3rd Army Commander, developed a gallbladder infection and needed surgery, I asked Don to manage the situation as I knew if I were to get involved, I would end up as a middleman which would create a problem-prone situation, not to mention adding unnecessary delays .  Don met with GEN Schwarzkopf (the Central Command Commander-and LTG Yeosock’s boss) to advise him how medical treatment for LTG Yeosock could be managed; and a decision was made to evacuate the general from the theater of operations and have him treated in Germany. Don and Col. Dan Cavanaugh, one of our General Surgeons, went to Germany with their patient, and performed the surgery.  A quick recovery and return to duty followed; setting the stage for the initiation of the Allied ground offensive.

As one of the nation’s leading trauma surgeons, Don was always an advocate for documenting wound management and preserving this data for analysis; so that any information that could be identified as ‘lessons learned’ would be on record.  He was particularly interested in seeing that this was done during Operation Desert Storm.

I remember sitting down with Don at Fort Lewis as we were being out-processed for discharge from active duty, and together working on a large stack of Officer Efficiency Reports which were due at that time.  Misery does love company.

Don was recognized by the AMEDD (Army Medical Department) for his distinguished career and his contribution to military medicine by induction into the Order of Military Merit.  Recognition he justly warranted.

After the first Gulf War, Don joined with us in the 50th General hospital Association.  In spite of the considerable distance between Seattle and Portland he and Jane were able to make several of our reunions, and enjoyed seeing old friends and visiting the Fort Lewis area.

Tom Hutchinson, MD,

COL, USA (RET)

Orthopedic Surgeon

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.