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The purpose of this still-photo narrative tour is to provide some sense of our trauma center and to impart a bit of flavor. The tour will take you through the ER, up to the OR, and to the Surgical Intensive Care Unit. You will have a window to our pass-on rounds, ICU rounds and ward rounds. Finally you will attend a weekly morbidity and mortality conference.
Nestled between the shadow of bustling downtown Los Angeles and the foothills of the majestic San Bernardino Mountain Range, Los Angeles County+University of Southern California Medical Center is strategically located at the confluence of Southern California's complex and busy freeway system. Easy freeway access and a mild annual climate combine to produce busy emergency room conditions and plenty of trauma surgery year round. The division of trauma surgery and critical care is divided into three trauma services (A, B, and C). Each service is on call for a 24 hour period (0700-0700), every third day. The on call trauma team admits to its service during their on call period. The pre-call day is either spent in the trauma clinic or in the OR performing elective cases.
Patients typically arrive via LA City or County Fire Department paramedics or by private transportation. An extensive radio system coordinated by the Los Angeles County Emergency Medical Services (EMS) triages emergency patients to the nearest accepting medical facility capable of handling that particular medical emergency. Advance notice is given to the accepting facility. If a trauma patient meets the criteria for Trauma Team Activation (TTA), the trauma team, led by the trauma attending, is present in the ER before the patient arrives.
Critical patients arriving off "the ramp" are immediately taken to a special procedures area of the emergency room, known as "C-booth". C-Booth can accommodate about 5 critical trauma patients at one time. When this scenario occurs, as it frequently does on weekend nights, the ER becomes a very exciting place. Emergency room physicians and surgeons work together in this area to stabilize and quickly resuscitate the trauma patient. It is here that the decision to immediately intervene, transport to the OR, or triage to surgical admitting is made. At the LAC+USC Trauma Center, emphasis is placed on selective operative management.
If immediate surgical intervention is required in the ER with successful resuscitation, the patient is rushed to the OR. The term "RB" is applied to any super-emergent operative case. In previous years, a red blanket would be thrown over the patient as the guerney whisked by to the OR, hence the term. Such situations are obviously very dramatic. At our institution, every surgical case is staffed by an attending trauma surgeon, assisting the surgical resident. Medical students are present for most cases and generally follow a patient from the time he comes off "the ramp" to the time of discharge. The multiple operating rooms run 24 hours a day, 7 days a week. At this level-1 center, all injuries are the domain of the trauma resident, and it is up to that person to request consultation from other surgical specialties. This provides for an extremely diverse operative experience for the trauma surgery resident, and is in fact a highlight of the general surgery residency at LAC+USC.
The Surgical Intensive Care Unit is state-of-the-art. It includes 16 isolated computerized beds with sophisticated monitoring devices and a highly trained energetic staff.
The SICU is witness to some miraculous comebacks and cures, partially borne of the hard work and efforts of the entire team. It is also a hotbed for learning. It is a place where physiology, anatomy, pharmacology, and many other disciplines coalesce and come to life.
Patients at the brink are nursed back using not only common sense medicine but also the latest advances in critical care. All clinical decisions are once again the responsibility of the surgical resident. Critical care and trauma surgery attending staff is always present overseeing patient management and ensuring that only the very best possible care is administered to our patients. Staff is always available to the general surgery resident for consultation.
Because of the very heavy trauma volume at our institution, occupancy is nearly always 100%, and beds are in much demand. An additional role of the chief surgical resident is delegation of ICU beds and resources.
Because of the intensive nature of surgical critical care, a large portion of the team's time is spent here. Learning occurs at all stages of training. A fellowship (residency) in surgical care has recently received accreditation and information on the fellowship is available.
Multidisciplinary ICU Rounds occurs every day and takes several hours. The surgical resident, after presenting the case generally opens the discussion. Current treatments as well as a clear care plan are formulated. Related information regarding recent publications are exchanged. ICU Rounds have proven to be an indispensable tool toward optimizing patient care. Because individual patient condition can change dramatically in a short period of time, it is crucial to review each patient closely in an organized and collaborative way. Since the time period of postoperative ICU care constitutes a substantial fraction of trauma related deaths, staff involvement in this portion of the tri-modal distribution of trauma mortality has positively contributed toward improving overall patient survival at our institution.
The nurses of 9300, the SICU, are an energetic and hard working group, considered by many to be among the finest nurses in LA County, and probably in the nation. Our good success is due in large part to their efforts and non-stop diligence, optimism, and care. They are a highly skilled - most are CCRN certified - and culturally diverse group. There is probably not an emergent clinical situation they cannot handle. They are, in essence, an indispensable part of the trauma team.
The SICU utilizes electronic charting to track patients. The computer system is user-friendly, versatile, and accessible from multiple terminals in the unit. Future plans include access to resident and attending physicians from home, and electronic radiology. A separate division of medical information specialists is working with us on these projects as well as remote field telemedicine.
Every morning at 0700, the on call trauma team meets with the new on-call team in the surgical admitting area - Ward 1202 - for what has come to be known as "pass-on" rounds. All of the trauma consultations and admissions from the previous 24-hour period are reviewed and critiqued by both trauma teams. Patients requiring further observation or work-up are passed on to the new team and become its responsibility. Patients are directly examined and work-up studies are reviewed. A clear care plan is generated. Mandatory attendance by faculty contributes to overall patient care and resident learning.
Medical students and their education comprise an integral aspect of these rounds. Time is set aside at the end of the pass-on rounds to review radiological studies and patient presentation in a little more detail. Because of the large patient volume, a diverse collection of films are generated on a daily basis. This provides a good educational resource for students and residents.
The trauma attending staff at LAC+USC are very involved in all aspects of patient care. Ward patients receive a proportionate amount of attention. Patient presentation on ward rounds are generally delivered by a medical student although all levels of physicians are present. Patients are seen continuously by staff from the time they enter the hospital until the time of discharge. Thereafter, they are followed in the trauma clinics, which are becoming an increasingly important component of the healthcare system nationwide.
Every Thursday morning, the entire division assembles for the weekly Trauma Morbidity and Mortality Conference. Nursing Administration and Quality Assurance personnel are routinely present reviewing and recording the proceedings. This crucial conference is an institutional internal mechanism for monitoring patient outcomes and trends. Individual physician actions are scrutinized and assessed. Justification and rationale for specific management decisions are explored and weighed against the particular clinical situation and the pertinent existing literature. Trauma M&M Conference is distinct from trauma cases presented at the Departmental M&M Conference. Division of Trauma cases are presented there every six weeks.
Two other conferences deserve mention at this point and they are both held on a weekly basis. A core curriculum involves presentations by staff of basic intensive care or trauma surgery concepts, which conference alternates with an in-depth "advanced" critical care symposium targeting senior residents and the critical care fellows. Conferences are also attended by nurses and affiliating personnel. Complementing this conference is the weekly Journal Club. Routinely presented by the senior trauma residents, interesting, controversial, or landmark papers are discussed. Both of the aforementioned meetings are loosely informal and generally sponsored. Lunch is usually provided and contributes to the conferences' popularity.
An Advanced Trauma Life Support (ATLS) course, under the aegis of the American College of Surgeons (ACS) is offered biannually and is required of third year residents and above.
As busy as things get with the heavy trauma load and conference and rounding schedule, a humane approach not only to patients but also towards residents and students alike is emphasized. This provides for some opportunity for trauma personnel to enjoy some of the benefits and wonders of living in Southern California.
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