Trauma as a Disease

Medical Intel

The effects of traumatic injury can linger long after initial recovery. Dr. Jack Sava explains why trauma is a disease and should be treated as such.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

In today’s episode we talk to Dr. Jack Sava, chief of trauma at Medstar Washington Hospital Center about visualizing trauma as a disease in itself.

Host: Thanks for joining us. We’re talking to Dr. Jack Sava, chief of trauma at Medstar Washington Hospital Center. Welcome, Dr. Sava.

Dr. Jack Sava: Well thank you, I’m happy to be here.

Host: Thinking about trauma as a disease in itself, could you explain what you mean by that?

Dr. Sava: Well, it’s interesting to think about injury and how is injury similar or different to something like a heart attack or cancer or stroke or asthma and so forth, and many people today I had somebody tell me a week ago that injury is not a disease really, it’s something that happens. And i think that’s the general perception, and you might ask well why does it matter? Why are we talking about the words? And the reason it matters is because it turns out that looking at injury or trauma as a disease is very helpful and makes a lot of sense and leads us to a lot of sensible policies and a lot of sensible practices. So why is it a disease? Well, trauma, like heart disease has risk factors. It’s related to poverty, substance abuse, mental illness and many, many other things in the same way that hardening of the arteries is related to smoking and diabetes, etc. so really even though you might think because it’s behavioral, it’s different, the idea of risk factors leading to illness is really the same. It also has an acute phase where there’s an event kind of like a heart attack, and that requires some time in the hospital. And then it also has this long tail end, just like other diseases where you have to recover, the recovery is slow, the recovery may not be complete, it may impact your quality of life forever, it may impact your family, and then even more so you’re going to be at risk for recurrence, so if you have a tumor removed from your stomach, you’re always going to have to worry about recurrence of that, and we’ve found that in many of our patients who’ve had an injury, they’re at higher risk for having another injury than other people are, especially whatever led them to that injury, whether it’s their driving habits or their substance abuse problem, or their tendency toward bad luck. If none of those things have been fixed, then they’re at risk for having it happen again.

Host: It’s sort of an umbrella term too, so like mental health would cover a huge spectrum of diseases, is the same true for trauma?

Dr. Sava: Yea, trauma is an unfortunate term in some ways, because it’s been borrowed by so many people in so many ways, so a lot of people use the term to refer to an emotional trauma, like a bad divorce. And a bad divorce is a very bad thing, but it’s not the sense in which I use the word trauma, that’s why I sometimes use the word injury instead. That one’s also tricky but, it’s really not that complicated in principle, I think most of us know what a physical injury is. It’s when an external force causes damage to the tissues of your body, that’s the sort of theoretical definition. What does it mean practically? It means violent injury, like shootings and stabbings, it means vehicular injury like car crashes and motorcycle crashes and bicycle crashes. One of the most important things it means is falls. That could be a fall from three stories or it can mean an elderly person tipping over out of their wheelchair. That is a huge cause of injury in America. It can include intentional self-harm, a suicide and suicide attempts, and it can include workplace injury, and that’s a big problem also.

Host: So why the shift in mindset from trauma is the thing that happens to you to trauma is a disease? When did that occur and how is that impacting your practice now?

Dr. Sava: Well, it’s interesting. Maybe 30 years ago, people started looking at trauma through that lens and immediately a bunch of really profound things became apparent. If you look at injury or trauma and you put it side by side with other diseases, you see some very interesting things. The most obvious way that you might think to grade the importance of a disease would be is it a common cause of death? And so that’s why something like heart disease usually comes out on the top of that list. Because you think about it that everybody whose heart eventually stops beating has a heart problem, so a lot of people in their 90s who eventually their heart gives out, they get put in that category, and so a lot of people have a quote cause of death that’s heart disease. But the center for disease control started asking the question what actually kills young people? Or what kills people at different ages. And when you look at that data it’s fascinating because it turns out it’s all trauma. What kills people in their first second, third, fourth, fifth decades of life is injury, and if you look in your own family, and ask well what took a young person away from my family, you know, most of the time those answers are that somebody got hit by a car, somebody dove into a swimming pool, they’re traumatic incidents. So, the CDC developed a new term, a new metric, to describe the importance of diseases, rather than what’s the number one cause of death, they started asking, or in addition to that, they started asking what are the important causing of lost life years in America? And that was a radical change when they started asking that question, because again the answer is trauma. So, if you want to know what takes away American life years, whether it’s the tragic car crashes or the falls, or the people who die in war time, whether it’s America or worldwide, injury and trauma are the most important cause, and they really eclipse everything else.

Host: So, given the impetus of trauma and traumatic events on our health as a nation what’s next in research and what’s next in treatment?

Dr. Sava: When we started thinking about trauma as a disease and started thinking about how can we impact that like we impact other diseases, we realized a couple of things about trauma and about death from injury, and one of them is that people who die from injury, one of the ways they die is instantly at the moment of their injury. So, if somebody has a horrific car crash, they’d probably die in milliseconds or seconds. So, we have to think about how do we prevent that death? And that’s led to a whole growing field of inquiry about injury prevention, and that takes a lot of forms as well, making cars safer making drivers safer, preventing distracted driving. Workplace safety, helmet use, traffic safety all these things can be very effective in preventing the initial injury in the first place, which you can imagine is the best way to prevent death from it. The most important next time of death for an injured patient is in the initial period, what we typically call the golden hour. And what happens during that period is people might be unable to breathe because they’re injured so badly, and more commonly they’re bleeding to death. So, a lot of stopping trauma deaths has to do with creating systems that can prevent people from bleeding to death, and that starts with people on scene whether they’re professionals or just civilian bystanders, knowing how to stop bleeding there, and then it continues through having protocols with the paramedics and the EMTs for stopping bleeding. Protocols that get patients to the hospital really quickly, and then having dedicated trauma centers where there are whole teams of people who are in the hospital 24/7 with expertise and experience in stopping bleeding, both immediately with the right type of pressure, and also with complicated operations. So, for us, that means in many cases on the average Saturday night people come to us and they come through the door of our trauma center, and they might have major surgery on their chest and abdomen to control catastrophic bleeding within 90 seconds of arrival. So how do you do that? Well, obviously, that doesn’t happen by rolling into a local, local sleepy hospital and starting to get on the phone to call people to leave the dinner table to come in, that’s not going to work. You have to have all these resources, all this readiness, that means surgeons, emergency room physicians, trauma room nurses, blood bank, operating room personnel, anesthesiologists, and on and on. All these people have to be there and have to be either at the door when the patient comes in or ready to be there in a few seconds.

Host: How do you work with the EMS teams so that they’re aware they should bring those trauma patients to Medstar Washington Hospital Center and perhaps not another facility without a trauma center?

Dr. Sava: Well, fortunately over the last couple decades, emergency medical services in most metropolitan areas have developed protocols that they know in advance what kind of injury is going to go where. And what that means is that most cities in America, since trauma was identified as an important disease and in most cities in America if you stub your toe, you’re going to go to a local ER, if you’re shot in the chest, you’re going to go to a trauma center. So in other words, there’s field triage where the paramedics, EMTs can look at a patient and either by the story of what happened (hundred mile an hour car crash) or by the patient's vital signs, or by their judgement, they can pick the right patients and bring them to a trauma center, and it works out much better when critical patients go straight to a trauma center. And that was a bit of a hurdle you can imagine getting people to understand that the sickest patient doesn’t necessarily go to the closest emergency room, that it might actually be better to bypass them and go to the right emergency room rather than the closest one.

You know, we talk a lot in talking about diseases about death and mortality rates and causes of death. It’s important with trauma and injury to recognize that for every patient who dies with injury there are many, many lives irrevocably changed. There’s a whole ocean of suffering that exists for every patient that actually dies. This can take the form of physical disability, but also post-traumatic stress disorder, and depression, and many other consequences of injury. People often after serious injury, have to develop a completely different conception of their body integrity, they can have lost limbs, they can have lost functions, and these things can obviously snowball, especially if not given the proper care, into a patient losing their job, becoming depressed, their relationships falling apart, or they quit school, that makes the depression worse. And even the emotional problems can in turn make the physical problems like pain worse, so it’s very easy to enter into a downward spiral. So even patients who aren’t in the data set of patients who died are often the ones who are suffering their whole life and so we need to have systems in place and resources for those people, because it’s easier to simply talk about mortality rates, often that’s where we focus

Host: How do you triage those individuals who are going to need that extra care even that emotional support after they leave the trauma center?

Dr. Sava: well we screen people in the hospital and we screen people on subsequent visits for post-traumatic stress disorder. I think that there’s still a long way to go in American trauma care to help people, especially people without resources, with the emotional fallout of injury. I think that the care of mental illness for people with no resources, generally speaking, with or without injury, is an opportunity in America and a place where we can make a lot of progress.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.