00:00:02:00 - 00:00:24:12 Adam Hocking None of us ever expects to be in a bad car accident, or that will take a hard fall. But it happens every day. According to the American Association for the Surgery of Trauma, traumatic injuries are the leading cause of death for people 45 years old or younger in the United States. When a person experiences a traumatic injury, time is of the essence and so is close access to a high level of trauma care. 00:00:25:03 - 00:00:49:08 Adam Hocking The people who provide this care must be incredibly skilled and highly collaborative. They have to make life and death choices quickly and repeatedly throughout the course of their day. To such experts join us today to talk about their daily work in trauma care. Dr. Ivan Maldonado is a trauma surgeon at Marshfield Medical Center in Marshfield. There he works alongside our other guest, Gina Brandl, who is trauma program manager. 00:00:49:19 - 00:01:08:17 Adam Hocking We'll speak with them both about what trauma care is. We'll look behind the scenes at how this care is provided and we'll discuss the emotional challenges of providing care in such an intense environment. Our first question is really to help our listeners understand the topic itself. So can you talk to us about what a trauma center actually is? 00:01:08:18 - 00:01:10:09 Adam Hocking What's the definition of a trauma center? 00:01:11:06 - 00:01:50:01 Dr. Ivan Maldonodo Well, a trauma center is a hospital facility which, besides the parent processes, this is a retreat. They specialize in the management of the acutely injured. That's a trauma center. The whole facility in the emergency room, the operating room, regular beds, ICU, physical therapy, occupational therapy. Every every component that touches, intervene and assess, evaluate that trauma patient, use the trauma center. 00:01:50:01 - 00:02:01:17 Dr. Ivan Maldonodo Everybody in the building is a member of the trauma team and intervenes in a patient, which is the are involved in a motor vehicle accident or so forth in some way. 00:02:02:16 - 00:02:31:11 Gina Brandl And our trauma center is really equipped to handle those life threatening emergencies or injuries that that really require that immediate treatment. You know, it would be, for example, the person involved in a motor vehicle crash or somebody who's a motorcycle accident, an ATV or UTV accident or even a gunshot wound. We are really, really lucky here to have six board certified critical care surgeons that work in our trauma department and care for the patients that we see here. 00:02:31:11 - 00:02:34:05 Gina Brandl And that is a really good thing in this rural area. 00:02:34:21 - 00:03:06:08 Dr. Ivan Maldonodo Yeah. The other issue with a trauma center is the facility, as I talked before, that is designated as a trauma center for a while, several entities that can do that for you. But it's a facility that has developed through time, through training, through commitment to the prompt, timely, efficacious, aggressive care of the injury. And that is a culture of by itself. 00:03:06:18 - 00:03:43:10 Dr. Ivan Maldonodo It is a mindset. It is an attitude that the people in that institution have to feel the the compassion for the care of the injuries, that they are not afraid of, the significant stress of that situation. And they're used to that and they're trained through that. And they can respond even if they like a knee jerk reaction. They have this training to get their sleep, roll up and jump to a case which is complex. 00:03:43:10 - 00:03:57:20 Dr. Ivan Maldonodo It is difficult and it is full of uncertainty. There is no script for that. It is. They know what they have to do in a timely fashion and they do it without hesitation. 00:03:58:17 - 00:04:06:22 Adam Hocking And what is the process like for credentialing a trauma center? How do you become an official trauma center? 00:04:07:20 - 00:04:33:20 Gina Brandl Trauma centers can either be state verified or they can be verified by an outside agency. The state of Wisconsin verifies level three and level four trauma centers. The American College of Surgeons, who works with the level one and level two trauma centers, go through that accreditation process with us. So every three years, it's a two day process to become verified or re verified as a trauma center. 00:04:34:03 - 00:04:58:23 Gina Brandl And the same process is done with the state in a decreased period of time. But those levels of trauma are really the critical access hospitals, level threes and level fours. So they have some level force of some capabilities. But really the idea behind that is that they will immediately treat any life threatening interventions, but they will do that and they will transfer them to a higher level of care. 00:04:59:06 - 00:05:20:14 Gina Brandl Level threes have some specialties there. They're able to take care of those patients. Orthopedic. General surgery might even have some neurosurgery coverage. But really, anything of higher level care that would require an ICU type patient or poly trauma would come to a level one or level two facility. Typically, the closest highest level is where that patient would go. 00:05:21:11 - 00:05:42:19 Adam Hocking Can you talk above the significance of the network of trauma centers that we offer across rural Wisconsin? You know, you read every day, it seems like when you're in the health care industry about the access issues that rural communities face, whether it's primary specialty care, emergency care, mental health services, and the effect on outcomes that that has. Not to mention patient experience. 00:05:43:05 - 00:05:49:23 Adam Hocking Can you talk about what it means for small, rural Wisconsin communities to have access to the care that we can provide? 00:05:51:12 - 00:06:44:03 Dr. Ivan Maldonodo Well, first, I would like to make a comment as you're checking the data about that. In the last ten years, more than 130 rural hospitals in the US up close. That means that people will not have access to basic basic care. The significance of our presence here as a level two trauma center is the fact that we are in proximity to all these underserved areas with top notch, highly specialized, comprehensive trauma care that makes a world difference because the network of hospitals with the Marshall Clinic will provide the immediate access that level four and the level three, and they do the immediate intervention. 00:06:44:03 - 00:07:05:18 Dr. Ivan Maldonodo And then the patient comes to us for further care. So the continuum of care is from the get go. From the moment of the accident, EMS response transferred to acute care facility and then to off and trauma. Time is of the essence and that's how we provide a timely intervention to save a life. 00:07:06:16 - 00:07:23:06 Adam Hocking And can you talk about, you know, especially the timely piece, the fact that we do have our lifeline helicopter service and we can get people from A to B quickly across big distances? Can you talk about that partnership and what our capabilities mean in that respect? 00:07:24:12 - 00:07:52:14 Dr. Ivan Maldonodo Yeah, we can talk about it and the issue is very important. Life link. It is not only about transport, it is a unit of critically ill traumatic patient care, meaning they at the scene or the other facility that they assess the patient and they start the transfer process. They do interventions that are alive saving. They get blood transfusion. 00:07:52:15 - 00:08:16:00 Dr. Ivan Maldonodo They use medications. They protect the airway by or tracheal intubation for those patients. They relieve decompress the lung if necessary. They collapse with a temporary measure. They do so much in a little space in the middle of the air. When you think about that, they are do a magnificent job and they count all the things in that little bird. 00:08:16:18 - 00:08:24:14 Gina Brandl They are a comprehensive transport system. That provides the highest quality of care, air, medical can and possibly give us. 00:08:25:15 - 00:08:48:19 Adam Hocking Dr. Maldonado and Gina as well, how you you know, you guys are all trained for this. But obviously, it's a it's an intense type of of care that you guys provide. How how do you sort of manage that from a personal standpoint of, you know, checking in with folks and providers and staff? Can you just kind of talk to me about that is sort of the psychology of that. 00:08:49:17 - 00:09:15:15 Dr. Ivan Maldonodo From the provider side? I can talk about it. I mean, they psychology's very, very challenging, very challenging. And that's why this kind of service functions thing, our chief model is the only way to do it is that chef model, team based approach approach and with there is one of us in the in-house 24 seven all the time to respond for patient. 00:09:16:05 - 00:09:45:14 Dr. Ivan Maldonodo The emergencies and so forth, and for the patients that are transported here for care. We do 12 hour shifts between those shifts. We provide we do a very detailed sign out from one provider to the other. We are supported by other providers that we have training ourselves in this facility by being adult and pediatric care and specifically adult critical care and trauma care. 00:09:46:01 - 00:10:28:18 Dr. Ivan Maldonodo So it is a team approach. We do we pass the baton or between shifts. We had that then that time off that everybody needs to decompress and then we come back for the next shift. So even though that we have that kind of process still it takes a toll on you. It is it it's inevitable that the experience of care of people that are severely injury takes not only in the provider takes you from them in terms of their mental capacity, but all the whole team and the providers which are part of this team. 00:10:28:18 - 00:11:06:22 Dr. Ivan Maldonodo They're well experienced after years of experience. One of the key who is this, this group or people that we call the trauma team, comparing the 80 or the ICU or whatever in the institution is led by a team of people that will be the the leaders on those teams under It is our leader in a situation of critical decision making and the critical decision making needs the support of that team and the decision making person leaders who are there to support them. 00:11:06:22 - 00:11:46:10 Dr. Ivan Maldonodo There is a symbiotic relationship between the providers, nurses, respiratory therapies, transport all their physician as emergency room physicians or other specialties that come to help us. So the most difficult part is to get a cohesive team that will be able to focus, that will be able to perform and deliver and finish their mission. And their mission is to get that patient back to society in a productive and be productive again on most possible. 00:11:46:10 - 00:12:17:11 Dr. Ivan Maldonodo And then that their focus on that requires not only the trauma surgeon, that requires the neurosurgeons, orthopedic, physical therapy and rehabilitation, nutrition and pain management, psychology psychiatrist. And it's a whole category of people that are part of this team. So all of our everybody goes to the psychological stress because this patient comes in with we don't know anything about the menu of the time with another co-morbidities, with another past medical history. 00:12:17:12 - 00:12:42:22 Dr. Ivan Maldonodo Sometimes we even don't know how it happened, the accident and then the quest for defining a walking a very fine line. The fine line is like, I have to keep this person alive. What? I figure out what is going on. And that's the experts piece of this team to sustain life and to define the problem and intervene. And let me tell you this. 00:12:42:22 - 00:13:24:08 Dr. Ivan Maldonodo Oftentimes our partners and I myself, after 30 years doing this every night, every shift I finish is like for the first time, you are exhausted. Psychologically, the support of each other is key. We shoulder not only among providers but nursing personnel and others. We have a blessing in this facility that we have a chaplain, chaplains that attends the trauma activations for the support of their families, and you start to go through the process with them and these depression of an unplanned, unanticipated, life changing event, You are not prepared for that and will never be prepared for that. 00:13:24:16 - 00:13:49:22 Dr. Ivan Maldonodo Nobody is prepared for that. And this team, as I told you at the beginning, is the whole institution brings this family the support to go to an unplanned, unprecedented, life changing event that maybe their loved one will not be the same, will not be able to be productive in the same way, will not be able to do the things that they love so much in the same way. 00:13:50:07 - 00:14:16:00 Dr. Ivan Maldonodo And and that is, I think, music and significant path with this team in this institution have been doing for the last 20 years and will continue to be doing that. But definitely the society needs this this community need this because they they put so much into their communities themselves that will then we have to deliver this to the community that support us here. 00:14:16:10 - 00:14:24:15 Dr. Ivan Maldonodo And it's a symbiotic relationship which is the most rewarding experience that you can have. 00:14:25:14 - 00:14:35:03 Adam Hocking Did life changed dramatically for for you guys day to day because of the pandemic? I'm just curious what the what the pandemic meant for kind of your day to day work. 00:14:35:17 - 00:15:05:08 Gina Brandl You know, the pandemic changed in a lot of ways, especially with the unknown. It forced us to change some of our practices in the trauma bed bars, our equipment resources. And so we were really able to utilize resources as additional resources to to supplement our current traumas. So in the case in point, you know, we brought extra nurses down there so that we didn't have nurses going in and out of a room. 00:15:05:20 - 00:15:28:04 Gina Brandl You know, it just made a lot of sense. Helped take some of the stress off of that. Nurse sits in the room taking all of your stuff off and putting it all back on, working in the room. So some of that sort of stuff we did. But it is physically exhausting to have these masks on and all this all these extra equipment on in a trauma bag and you're resuscitating a patient. 00:15:28:12 - 00:15:36:13 Gina Brandl But a staff is very diligent, very good about doing that. I think we've had very good outcomes along along the COVID spectrum. 00:15:37:12 - 00:15:44:21 Dr. Ivan Maldonodo We remained as busy, but it didn't change our statistic that we found out was not affected by the virus. 00:15:45:01 - 00:16:05:07 Gina Brandl We were we were forced to change how we did things in the trauma band. We adapted to that. We did a lot of education and the education just wasn't to the nurses or to the respiratory therapists. This education went through the entire trauma team, which is the doctors, the nurses, the rest of our therapists, the lab people, the X people, the CT people, and on down that spectrum. 00:16:05:07 - 00:16:17:17 Gina Brandl So it's the way we did things that had to change. Everybody adapted well to that, but it is physically exhausting when you come out of a trauma, a very busy trauma, both mentally and physically exhausting. 00:16:18:08 - 00:16:30:04 Adam Hocking We touched on that just a bit on what a level four and a three is, but maybe talk about the transition from or the aspiration to get from a level two to a level what what that might mean. 00:16:30:04 - 00:16:53:01 Gina Brandl So we really do everything the same as what a level one facility does, and that includes our pediatric trauma care that we do. But in our world, really very little is going to change going to a level one facility. You know, we have all the care and the treatment capabilities. What we're really working towards and have worked very hard on is the research component to this that's required for level one designation. 00:16:53:09 - 00:17:17:07 Gina Brandl So we partnered with the Farm Medicine folks and with the Research Foundation to bring bring onboard the required research specifications for research that we're going to need. And so, you know, this is really one of the big things for us was that research component and patient volume. And both of those we had we had met the patient volume. 00:17:17:13 - 00:17:25:22 Gina Brandl But what we were really working on is that research component of this. But we function the same as what a level one facility would do. We have the same capabilities that they do. 00:17:26:21 - 00:18:09:13 Dr. Ivan Maldonodo Partnering with a farm medicine is the logic is a logical partnership. Here we are a rural trauma center surrounded by farming equipment everywhere and farming endeavors. And one of the big activities of the farm medicine department is prevention, prevention, medicine, not only regular infectious diseases and so forth, but also traumatic injuries in their workplace. They have been doing that for years and that the trauma center has a three main components, have the preventing component, the acute care and then the rehabilitation component. 00:18:10:00 - 00:18:34:19 Dr. Ivan Maldonodo So in the prevention component, we already we have a trauma prevention person that has been working throughout the years getting grants for research and so forth, very in a very successful way. Now we partner with farm medicine to expand on that and at the same time be able to do research with them on that because they they do a fair amount of research on prevention. 00:18:35:08 - 00:19:04:00 Dr. Ivan Maldonodo So the level one will expand our horizon there in terms of prevention, because it's one of the missions we, we we don't want people to go through there somewhere who is part of the mission of any trauma center is to have a prevention program. And and this level one initiative have created the created create a synergism with our specific component of a geographic region, which is fantastic. 00:19:04:00 - 00:19:38:23 Dr. Ivan Maldonodo Kind of the other component is that when you do research, you learn how to do learn about the nature of the disease in trauma and deterring environment, and then you can target your preventive efforts. Boston Based upon the research. So that opens the door for more interesting, more interesting and significant for the community interventions that will benefit everybody, that that is a wide open door for significant initiatives that immersive clinic can contribute to the surrounding geographical area. 00:19:39:16 - 00:20:06:05 Dr. Ivan Maldonodo So that's what what that is one angle there. The way we expect to see growth in the institution of being a level one and and as we portray our research nationwide in journals, presentation on Flipboard in the future will be able to share that information with the scientific community, which is what the level one does. And in the end, in our region. 00:20:06:05 - 00:20:19:09 Dr. Ivan Maldonodo So it is it is a combination of things. There are the Level one initiative. It will impact the prevention, avoid injuries, and that will impact also the care. 00:20:20:12 - 00:20:40:20 Adam Hocking So we talked about so we've talked about the prevention piece, we've talked about the resources available to someone when they come in. And Dr. Maldonado, you talked a little bit about whether it's physical therapy or something that that sort of post-acute care can one or both of you talk about our our sort of our program and our offerings in terms of after the acute period is over? 00:20:42:01 - 00:21:10:20 Dr. Ivan Maldonodo Yeah, Well, we have adult and pediatric rehabilitation, both inpatient. It's outpatient. As a matter of fact, in the last couple this is from the American College of Surgeons. There have been a major for the facilities in this location is specifically in the pediatric section there. So those are well developed programs there do inpatient, inpatient and outpatient. They are available for consultation. 00:21:10:20 - 00:21:39:14 Dr. Ivan Maldonodo They are available for assessment for possible continuation of admission here in our facility. So we are very, very lucky to have such developed programs here in-house available for outpatient. Well, we have a very close collaboration with them. So definitely this facility, that aspect of comprehensive care to the trauma patient in terms of their rehabilitation part. 00:21:40:13 - 00:21:51:21 Adam Hocking And we talked about life like a little bit, but we didn't talk about partnerships with with EMS and first responders. Can you talk about how those partnerships form and why they're so important? 00:21:52:17 - 00:22:21:01 Gina Brandl Sure. Our partnerships with our local EMS provide feedback letters to those EMS services that bring patients to our facility, opportunities for improvement, things that went well, things that we could improve on. But we also provide education to outlying community and to our EMS partners. And that's one of the things that we have made a mission of doing, is providing that we have EMS coordinators that work with the EMS community and providing feedback with them also. 00:22:21:16 - 00:23:02:05 Dr. Ivan Maldonodo So one of the most important aspect of trauma care is to learn to have a continuous learning process here as they have. Our medical director is one of our physicians listed, I think is Dr. Feely and Dr. McKee is involved. Yeah, those are the ones I have been involved with being medical director. So from our point of view, there is significant feedback back and forth that goes about between services and the way we provide is we provide a location to the to the mass whenever we, we see anything that can be improved. 00:23:02:12 - 00:23:40:09 Dr. Ivan Maldonodo There are initiatives that we develop. We did that for pediatrics in terms of airway and intubation and so forth. That has been very successful and we continue to really get feedback, especially complicated cases that they they have handled with us. We are we have been discussing and discussing lessons learned from those cases because they they they face significant challenges, especially in the rural or ivory culture or accidents that are significant patients that are very, very injure, significantly injured and feedback to them has. 00:23:40:09 - 00:24:09:22 Dr. Ivan Maldonodo But has been very welcome. We also do that for them with the Marshals, fire department and so forth. So there is a real time feedback community process in order to improve care and is now very amicable, very close relationship. They have been here through years, through the years with the AMA. And I think it's a wonderful thing that you kind of know everybody in this small community. 00:24:09:22 - 00:24:34:09 Dr. Ivan Maldonodo Can you develop those relationships to everybody, see the value of this collaboration, which is unique? I practice in urban centers and you don't you don't see that here. It is very close, very personal, and all the feedback to go back and forth on improved care of any neighbor and difference is is well received welcome. 00:24:35:10 - 00:25:00:09 Gina Brandl And those EMS providers are seeking input and information in any education that we can give them, but we just don't provide that to them. They provide it to us. So they do outreach also, they do trainings. They invite us to those trainings. So it's a collaborative effort that goes both ways. But we really are seen as the leader in providing that educational opportunities from a standard from a hospital standpoint. 00:25:01:04 - 00:25:19:06 Adam Hocking So can you talk about, you know, we've got this network of hospitals and trauma centers that of of various levels that we can give local care, but we can also transfer folks. Can you talk about sort of that network of trauma centers and how they work together and what the advantage of that is? 00:25:19:06 - 00:25:43:07 Gina Brandl Yeah, we currently have I believe it's nine hospitals within our health system and it's a it's a one call to here and it goes through our call center and cares. And they it is a physician to visiting physician talk they say yes and that patient here on that same line we have that person in IMC cares who says yep, I'll arrange transport for you. 00:25:43:07 - 00:26:01:00 Gina Brandl And that patient is brought down here. So it doesn't matter if you're in the Northwoods, in in a back road by the lake, we still have access to that to that medical system. And if it requires a helicopter, we can get that helicopter to you and get that patient here. They always talk about the golden hour of trauma. 00:26:01:00 - 00:26:19:12 Gina Brandl So we want to get those patients here as quickly as we can and get them treated. But again, that we have a nice referral base that patients come from into our system. And so it's a one call and we get to down here. It's a really good network that we have, we have created. And it's it's a system. 00:26:19:12 - 00:26:31:15 Gina Brandl And the thing is, is if somebody else wants to use our health system, they know the call goes to here and that's how that is done. So the referrals are done through call centers. And so it it really is a good thing to have put together. 00:26:32:21 - 00:26:53:16 Dr. Ivan Maldonodo Yeah, it is a work in progress because you have facilities that have been there have been level three and level four in the past facilities that we acquire, and they already have some of that trauma culture I call it the trauma culture is the mindset to intervene in this process. And then we have facilities, new facilities on our own. 00:26:54:08 - 00:27:30:22 Dr. Ivan Maldonodo So we have been actively supporting them and Gina has done a great job getting those facilities to evolve from a new facility to a training facility. And that's definitely a significant point there because those facilities from the construction to the opening their doors, they had the support on a level of mature level two trauma center. So they can treat those patients with the the ease that OC will stabilize the patient themselves to the level, the next level, which is our sister hospital. 00:27:31:15 - 00:28:09:11 Dr. Ivan Maldonodo And that has a balance in itself because the providers over there can do their job with the mindset that, okay, I'll do my job, sterilize this patient. I know that the patient, the patient care will continue highest level in one of our facilities, and that for providers is a significant relief of that burden because they know that they just want to make one phone call and the patient will be transfer wildlife link and get here our facility very quickly and continue of care for this patient is preserved and in a very timely fashion. 00:28:09:11 - 00:28:35:02 Dr. Ivan Maldonodo So I will love to say maybe we will have year so of life to see how this system will mature. But to be the master clinic can develop his own trauma system within itself, which can be portrayed to the whole state in terms of an example of how we will work collaboratively in this endeavor and save lives and help our citizens. 00:28:35:02 - 00:28:42:12 Gina Brandl We have the support and leadership to do bigger and better things here, and level one is not out of reach for for us. 00:28:43:05 - 00:28:50:17 Adam Hocking So Brand manager of our trauma program, and Dr. Ivan Maldonado, a general trauma surgeon, thank you both for joining us. 00:28:51:22 - 00:28:54:03 Dr. Ivan Maldonodo Well, thank you for having me. 00:28:54:03 - 00:28:55:20 Gina Brandl Thank you. It's our pleasure. 00:28:57:04 - 00:29:12:04 Adam Hocking You can subscribe to The Rounds and download episodes via iTunes or by visiting Shine365.MarshfieldClinic.org, thank you for joining us tonight. I'm Adam Hocking and I hope you'll join us next time on The Rounds.