Level 1 trauma center – 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.

Changing hearts and minds by Robert C. Mackersie, M.D., FACS

My first encounter with Don Trunkey was as an impressionable 4^th year medical student, doing an externship on the trauma service in the fall of 1977. I had spent some time at SFGH previously doing computer programming for Frank Lewis and was beginning to understand that these trauma surgeons (Blaisdell, Trunkey, Lewis, Sheldon, et. al.) were not only impressively smart; could work wonders with their hands (and intellect), but seemingly had great fun at the same time.

Trunkey epitomized it all – with a command of surgery (and medicine); a lightening-quick wit; and an ability to inspire. And it didn’t stop there. When I happened to identified a tune Dr. Trunkey was whistling one day on rounds (Rhapsody on a Theme of Paganini), he immediately replied: “Yeah, and now tell me who Paganini was…”. Gulp.

However, I was hooked. I was fortunate enough to be able to return to UCSF for residency during which Dr. Trunkey was the Chief of Surgery at SFGH. Already an imposing figure, Trunkey became larger than life. Striding around in his colored OR hat and white bucks for OR shoes, he was clearly in command of his realm. Trunkey was a television star (Operation Lifeline, 1978); he was a bon-vivant (rushing back to the hospital OR one time in black tie), he was a wine-maker – I still have a bottle of Trunkey/Deveny/Upshaw Pinot Noir in my cellar – hopefully it doesn’t “taste like socks” (Trunkey’s opinion of one of his early vintages).

Don Trunkey was internationally famous – in fact he travelled so much, the surgery residents laughingly posted a sign on his office door that read: “TWA Visiting Professor of Surgery”. His travel (and writings/lecturing) made him one of the most recognized figures in American surgery – and it wasn’t limited to purely medical settings. Many years later, when I happened to be with a surgical group visiting Sydney, Australia, we dined at a place named Doyles on the Beach. There the restaurant maitre’d was heard to remark: “American surgeons ay? Do you know a guy named Trunkey?”

Trunkey wrote prolifically – on many topics including shock, sepsis, intestinal injury and resuscitation. He used to remind us that crystalloid fluids were toxic and more than once I remember the senior residents being accused (by DDT) of “salt water drowning” by an overly aggressive crystalloid resuscitation of a patient in shock. Of course we know recognize that Don was absolutely correct and that crystalloid solutions contributed to immune suppression, coagulopathy, and abdominal compartment syndrome among other things.

His most notable efforts at changing hearts and minds were probably in the area of trauma center and trauma systems development. With his charisma and energy, he made a superb spokesman. Two of his most memorable articles were “Systems of trauma care. A study of two counties” that he wrote with John West from Orange county in 1979, documenting the (staggeringly) high percentage of preventable deaths that could occur in the absence of an organized trauma center/system. These concepts were further reinforced in a piece he wrote in Scientific American (1983) where he became one of the first to remind us that trauma accounted (and still accounts) for more productive years of life lost than heart disease and cancer combined.

As a surgical educator, Dr. Trunkey was a blast to work with. He was always the master of the ‘pimp’ question, yet held forth with such persistent good humor that one never minded being skewered. He could be very direct – reserving use of the term “clean kill” for only the most egregious transgressions, but while appropriately critical of residents’ management, he was never, ever mean – a characteristic of his – unusual for the day, that I always admired. He used to give an introductory lecture to 1^st year medical students in the middle of which an agitated person would burst into the lecture hall exclaiming: “Dr. Trunkey, Dr. Trunkey, there’s been a horrible accident – someone has been hit by a bus in front of the hospital!!” Following this, the “victim” (a perfectly healthy, uninjured volunteer, in full moulage) would be brought to the front of the room and a number of students called up to help with the “resuscitation”. It was wonderful theater and made for an experience that the students (and ‘assistants’) would never forget.

He could be irreverent at times also – usually hilariously so. One Saturday morning, during the old Morbidity and Mortality conference, our surgical Chairman, Dr. Paul Ebert (one of the most accomplished pediatric cardiac surgeons in the country) was in the midst of an unusually long-winded explanation of a complicated heart operation. After going on for many minutes (to the increasing confusion and puzzlement of those listening), Trunkey finally blurted out: “Oh hell, Paul, just give the kid a new set of gills & throw him back in the water”. The place erupted in unconstrained laughter, (and even Dr. Ebert may have had a faint smile on his face).

I will remember Don Trunkey as one of the two individuals who most sparked my interested in surgery in general, and trauma surgery specifically. He did the same for many of his residents and fellows who now occupy important positions in academic & community trauma across the country. Trunkey was one of a kind – extraordinarily bright, articulate, committed, forceful, and charismatic, but with unwavering good humor and grace, and a clear devotion to and love of what he did. They don’t make ‘em like this anymore. Our community has lost one of our icons – a mentor, friend, and role model. We will remember and honor him best by continuing to work towards the goals that he espoused and try to similarly spark the interest of the next generation of general/trauma surgeons who will carry forward the legacy.

My Friendship with Jane and Don By Dr. Lew Flint

When I arrived to begin my trauma research fellowship at the University of Texas, Southwestern Medical Center in August of 1971, I was assigned to share laboratory space with another trauma fellow. Upon entering the lab, I noticed my new colleague concentrating on the electrical wave forms displayed on the screen of a very complicated piece of machinery. He turned, showed the grin that would become the defining characteristic of his personality, and welcomed me.

Don, my new lab-mate, proceeded to introduce me to all the research team members. I soon met Jane, Kristi and Derek; after my first son was born in February of 1972, Jane became his baby sitter. We had a wonderful professional and personal friendship during that year; fortunately for me, that relationship continued throughout our entire careers.

Don returned to San Francisco General Hospital and I stayed for a second year of research before finishing my training and joining the faculty at the University of Louisville. Don was making major contributions to the knowledge of trauma systems in the late 1970’s and early 1980’s; his advice and guidance were invaluable as I began to develop a trauma system for the state of Kentucky.

I loved watching Don use humor and intelligence to become a surgical leader and to work with him while he became, in my opinion, the foremost academic trauma surgeon of the last half of the 20th and the first two decades of the 21^st century.

Most valuable, though, was the personal relationship with Jane and Don. For nearly two decades the “Sun-fun family”, our group of four trauma surgeon couples, vacationed each January on a select Carribean island. We cooked, ate, drank, told tall tales, made up funny names for one another, and laughed constantly. Jane and Don set the tone that guided the Sun-funs. To be able to live that experience was a joy, a privilege, and an honor that I will treasure forever.

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.