Development of a Comprehensive Emergency Medical Service: The Seattle Story – 7-11-2018

[MUSIC] DOUGLAS E. WOOD: Good morning. I’m happy to welcome you to our first grand
rounds of the new academic year, and we’re lucky to have one of our own giving us an
important story. We’ll talk about that in a moment. But Dr. Hugh Foy, professor of surgery and
a longstanding faculty member in the Department of Surgery, and a leader, previously, our
program director, but also a major leader in the medical school programs, has been a
stalwart in the trauma critical care division at Harborview. And I remember Hugh, when I first came here,
already well established as a surgeon at Harborview, and taking me through and getting me through
cases when I was Harborview, trying to learn first where things were and also keep out
of trouble on trauma patients that I did not have a lot of experience with. And in my practice as a resident, I was only
doing elective thoracic surgery and not emergency thoracic surgery. So Hugh is one of those individuals that was
patient and kind with me and helped me feel like I knew something about trauma when I
became a new faculty member. And Hugh is going to be talking with us about
the development of the emergency medical system and the Seattle story. So Hugh, thank you very much. HUGH M. FOY: Thanks, Doug. Well, it’s a real honor and privilege to be
here talking to you this morning. When Deb Marquardt approached me six months
ago, I thought, well, sure, no problem. And then the closer you get to something like
this, sometimes the more difficult it becomes. This is a picture of Harborview as it exists
today, pretty much. So like Stephen Covey would say, we’ll begin
with the end in mind. But since I stepped into there, knees shaking
and with sweaty palms 40 years ago as an intern, it was a fraction of that physical facility. The “East Hospital,” then known as North Hospital,
was only five stories high, not nine. And so it’s just continued to build and build
and build. And the real thing that I think I helped Doug
was find the bathroom. And just when I get it figured out, they change
it again. So some of us like that think of it as the
Alzheimer’s training unit. I have no disclosures to make, except that
this is more of a personal and a historical version of the story, and there’s very many
perspectives on how this came about. I developed this talk years ago, and then
have embellished it as time goes on, and even as some of you are painfully aware this week,
to update it. But there were a lot of things that even I
wasn’t aware of that had changed in the interim. So the goal is twofold, really. Is one, to educate those of you who are new
to our system, or new to Seattle, perhaps. And also to update those of you who’ve been
around for awhile, like myself. Anybody know where this is? It’s a geography lesson. Probably one of the most beautiful places
in the Northwest. That’s the north side of Sucia Island, which
is the northernmost of the San Juans. And I put that up there, A, to say, welcome
to summer. There’s no place finer to be in July and August
than Seattle, particularly if you’re a trauma surgeon. Because this is our busiest time of the year,
where you just add sunshine and maybe a dose or two of alcohol and that really helps fuel
a lot of what we do, not to mention bad luck. But when you think in a bigger perspective,
this is our region. And this somewhat relief map that extends
all the way from Anchorage to nearly Cheyenne, Wyoming is our great Northwest. And you can see that the most dramatic two
features of it are mountains and water. That has impacted a lot on our trauma system
and how it was developed. So again, I’m going to go over the components,
not just Harborview, but the whole system, if we can, which includes our emergency medical
services. That is Seattle Paramedic Training, Medic
One, . Airlift Northwest. The link between them all, not only the Seattle
Fire Dispatch Center, but also Harborview Transfer Center, and then Harborview Medical
Center as well. And we’ll just talk about how that pre-hospital
EMS was developed, how the Harborview grew and was developed, and also Airlift Northwest. Most importantly, I think it’s a great example
of the conceptual framework of what put this together, and it was really an attitude of
cooperation and coordination and dedication to service. When I think back, coming here as a resident
and over the years, I think that the dedication to service and the spirit of cooperation is
really the momentum, or the spin, on the bullet that keeps us in flight, despite all of the
different things we have to deal with, not to mention fiscal constraint. So we’ll start with the patient, which is
not a bad idea. This is a 21-year-old who was driving with
a friend and they went through a fence, and then the fence splintered and went through
him. His friend died at the scene, and he was taken
to a local hospital over in central Washington. I’ll never forget, and I just had a conversation
with that doc just the other day at the Western, or excuse me, at the state chapter meeting. I said, Bill, I’m busy. We’ve just admitted a guy. We’ve got to take him to the OR. It was 2:00 in the morning. It looks like we’re going to have to do a
Whipple on this guy that this sign. And he says, look, I can’t get this board
out of this guy. I said, please, you’re well-trained. I know where you’re trained. You’re very good. Take him to the OR and give it a try. And he reluctantly said, OK. Called me back two hours later and he said,
no way that is coming out of this guy. And he had a two by six that was really straddled. It was on his left ASIS and came all the way
across to the front of his pelvis. And I’m always a little bit leery of this
deal, but the board literally flew right through him. So he couldn’t get it out. And in retrospect, we thought when he was
seated and the board went through him, then when you lie him supine, the board was trapped
under his anterior abdominal musculature, particularly his rectus muscles. So Eileen was coming on. And I had been on that night and I said, OK,
what do you want to do? Do you want to do the Whipple or do you want
to do the board? And she took the board. Door 2, I’ll take the board. So she and Meissner went down there. And like many impalement injuries, this had
tamponaded his iliac artery and vein. And the guy ended up with a femoral– they
got the board out, fixed him up, got the vessels repaired, but he ended up with a femoral nerve
palsy, which he still has to this day. But number 2, because of his friend’s death,
he was accused of vehicular manslaughter. And once he went through his serial operations
in an attempt to reconstruct his abdominal wall with some very early iterations of so-called
bioprosthesis, most of which did not work very well, the judge cut him some slack and
says, I’ll tell you what. If you do harm reduction talks to students
in central Washington about the dangers of drinking and driving, I’ll let you free. During his hospitalization, his dad used to
bring us the best apples I’ve ever eaten in my life. And to this day, he’s doing well and really
a pillar of his community. The second patient was a 17-year-old woman,
who was really quite accomplished at showing horses, who was, as the story goes, riding
in the bucket of this small loader, also known as a bobcat. And best anybody could tell, she bounced out
and the wheel caught her heel, and the blade caught her hip and just hindquartered her,
pulled her leg off immediately and broke her pelvis. Not quite in half, but nearly so, as you can
see in the bottom right. The woman, she was working with being a plucky
Montana horse woman, looked down at that wounded, and having delivered dozens and dozens of
calves and colts, stuck her knee in the wound, held her as tight as she could, and screamed
for help. And the local medics came out, helped pressure
on the wound, took her to a local hospital. Again, staffed by very well-trained surgeons. And I know if I get a call from Bozeman, I
start shaking, because they don’t send us trivial problems. And they got her bleeding under control, wrapped
her up. And it was three hours after she came out
of the OR that she presented to the Harborview ER, being transferred by Airlift Northwest. We got her bleeding under control. The wound was full of horse manure, and we
cleaned her up serially day after day after day after day. Finally, we’re able to close this pretty sizable
vaginal defect of her hemiacetal pelvis, swing that remaining viable gluteal flap over, and
close her. She had 18– count them– 18 operations. She had a short stay in rehab. But she went back to show her horses. A paraplegic saddle maker in Texas built her
a special saddle to ride with one leg. And she went on to finish in the top 10 in
that national competition and graduated high school on time, go to college, and now she’s
a schoolteacher. So those are just two stories that illustrate
how this system can work well from rural community hospitals to our transport system, and what
we can offer for people that Harborview as a tertiary and quaternary referral center
and level 1 trauma center that supplies that whole area. Somebody says, yeah, we’re the medical school–
Mark Whipple told me he’s now our Associate Dean for the colleges– we’re the medical
school from everything from Russia to Nebraska, which is true. Now, people who are injured will oftentimes
go to Portland, and they might go to Salt Lake if they’re in Wyoming, or other place. But really, for the medical school, we serve
that whole area and we’re available to help people as well. Well, if we start back a bit. We’ll just talk about our county EMS and our
pre-hospital care, so-called Medic One. It consists both of city and county paramedics,
as well as our flight service, a communication system, that through Seattle Fire and Harborview’s
transfer center. And really, the hospital care is an integral
part of that, and I think the conceptualization, how it was started and organized, and also
for rehab. But equally, if not more importantly, the
thing that distinguishes a level 1 from a level 2 trauma center is it’s attached to
a research institute. And led by Dr. Mayer and his predecessors,
and many, many others, it’s been a phenomenal and international standard of clinical and
bench research. The medic program, too, is held in wide esteem
throughout the entire world, and it’s almost a full-time job for someone to tour visiting
dignitaries and medical professionals, both in pre-hospital and other care, through the
facility. Each year for the last 20 years, an entourage
of 12 people come from Nagoya, Japan to visit Harborview, spend 10 days, and as they used
to say, visit with Sensei Copass and learn the Seattle way. So whether they’re from Japan, or as this
plaque in the Medic One headquarters, with stamps from throughout the world, commemorates–
they used to have a whole line of helmets that have been dedicated or donated to them
from firefighting services, which was kind of a tradition. Like exchanging your shirt, if you’re a soccer
player– this being the World Cup week– firefighters exchange patches and helmets as a sign of
honor and gratitude. So how did it all get put together in these
components? Well, it was this “cooperative effort that
began as a research experiment,” to quote Dr. Leonard Cobb. The person who was inspired by this individual,
Dr. Pantridge in Belfast, who, in 1967, developed the first mobile intensive care unit to take
medical care to victims of cardiac arrest in the street. And it was known by a study at that time that
60% of those deaths from a sudden cardiac incident occur in that first hour. So they had the idea, well, we’ll take the
ICU to the patient. At that same time was an explosion of technology,
as well as some other factors. And here in Seattle, Physio-Control had developed
the first portable defibrillator. That thing weighs about 40 pounds compared
to the ones right now. But there were a lot of other things that
went on, coincident with that sudden increase in death from coronary artery disease. There was recent medical experience in the
Vietnam War of people who were returning from residency, not only in trauma, but acute medicine. Believe it or not, at that time in our society,
there was a greater emphasis on care of our entire population. That was soon after the Medicare bill was
passed in 1965, which established a health insurance program for the elderly, as well
as funding, believe it or not, your paycheck, those of you residents sitting in this room. Your paycheck comes from the Medicare budget,
through the hospitals, based on a formula of how many Medicare patients they take care
So it’s so-called “Medicare pass through money.” It’s not chump change, somewhere in the range,
in this country, of about $12 billion. But still, we had these topographical constraints
in Seattle that had to be contended with. So the factors that worked together, with
a cooperative effort at the University of Washington and the Department of Cardiology,
the Seattle Fire Department, which at first was somewhat reluctant. We had a bunch of willing and available firefighters,
mostly because there’s not very many fires, sitting around the firehouse just waiting
and deciding what they’re going to cook for their next meal. So this unique alliance started, and at that
time street emergency medical service was ambulance companies, as depicted on the left
there, which was chaotic, disorganized, and really not under any medical supervision or
control. On the right side, after the development of
the Medic One training program, it was organized, it was structured, and under medical supervision
and control. First on scene and in transport, but later,
only by radio. Wasn’t easy. There were a few things that had to be overcome. One, like in many other countries around the
world, Japanese of note, which we have a tight relationship, there were laws against non-physicians
doing doctor’s work that had to be passed. And that happened in 1971, the legislature
for legalized mobile intensive care. Politically, we had to have someone to buy
into this idea, and chief Gordon Vickery at the Seattle Fire Department was really big
on the idea, and really that was a major impetus. But then we had to figure out, well, what
about all those mountains and water? Well, so it started as, really, a clinical
experiment in sudden coronary death, when this study showed that so many people died
in that first hour. And Dr. Cobb– who’s still alive, lives right
down the street– once in awhile, 2 o’clock, I’ll wander down to the cafeteria and there’ll
be Leonard having a bowl of soup and salad. Wonderful man. He got together and they just designed and
conceptualized this idea of paramedics. So this research project in 1969 really wanted
to ask two questions. Is out of hospital cardiac care effective? And can it be done by non-physicians? And mind you, these were high school educated
firefighters at the time. So they were trained, and nobody knew how
much it was going to take to train these people, but there was so much skepticism. So like many other things, they probably overstated
it and overdeveloped it. Again, it was initially staffed by physicians,
but it went through many different stages of development. They had a grant for vehicles, personnel,
the equipment. They developed the first mobile intensive
care unit, known as Moby Pig, which is in the bottom left there, an, old converted Winnebago,
that nice, loose shocks and that would amble up the James Street hill. But you can see there in that first few years
how things continued to improve. All the firefighters were instructed in CPR,
and a select group were placed in that first class and trained. Chief Vickery thought, this is not enough. We can use the citizenry. And so he started a program called Medic Two,
where you could walk into any fire station and be trained and certified in CPR. And as it said, by Morley Safer in 60 minutes
said, Seattle is probably the best city in the world, statistically, to have a heart
attack because of their success of resuscitating people from sudden cardiac death in ventricular
fibrillation. It might be one of the worst to faint because
you’re going to wake up on the floor of somebody pounding on you and a bunch of rib fractures. But nonetheless, that’s better than the latter. They started with four medic units in 1975. So this idea of taking physicians, not just
physicians, but intensive care, to the street through their long extended arm of these very
highly trained paramedics began. And the training was not just didactic lectures,
but procedure and skills lab, hospital patient care, an extensive amount of patient care,
and then also an apprentice system, where the medics rode in the rigs. They hired a young recently returned from
Vietnam neurologist, Michael Copass, who, for over 35 years, ran the emergency room,
developed the Medic One training program, conceptualized and developed Airlift Northwest,
and for a long time ran that whole thing. His idea was this field stabilization was
really a critical portion. He was one of the earlier introductions, by
myself and many other residents, to quality assurance. And this plaque given to him by graduating
chief residents– does anybody know which year of chief residents gave this plaque to
Copass? Yes. Elena, was that your year? It was 2008. 2008? Yeah, yeah. Well, I inherited this deal when they were
cleaning out his office. He had a stroke five years ago, and so they
were cleaning out his office and they brought this up to me. So we can put it in the department archives
or someplace else. But that red grease pin that many of us were
taught through and his inimitable review of every single run sheet. And many of you know, I’ve got this obsession
with precise medical record documentation. That’s where it comes from. If your write up wasn’t absolutely thorough
and perfect, you would have a little bit of answering to, and what we would call a tightening
up exercises there at 6 o’clock every morning at the Harborview [INAUDIBLE] counter. Medic Two, we talked about, where you can
go into there and learn CPR. So it looked like this, in terms of vehicle
configuration, back in the ’70s when I was an intern. Up in the top left, those small vans, and
they realized they needed more room. And rather than buying big, fancy ambulances,
they just went up the Jackson Street to Gai’s Bakery and said, those bread delivery trucks
look pretty good. And they went down and they outfitted them,
not with fancy stuff, but mostly metal bins, like you would a plumber’s truck. So for a long time, it was red stripes on
a white background, in the bottom right. Those blue vehicles, shepherds, are known
to many of us residents in the ER as, for those of you who speak a little Spanish, los
perros azules– the blue dogs, or shepherd ambulance– were our commercial transport
units. And I’ll talk a little bit about the triple
layer response. When AMR, a national company, bought out shepherd
in 1995, they came to town with that same color configuration. So in order to not confuse people, Medic One,
despite the fact they didn’t want them red, because red and blood, I was told by Doctor
Cobb and Dr. Copass, they went to a white stripe on the red background. And there you can see in progress the lower
tiers of our triple layer response. There’s a commercial ambulance. So the aid car’s there. hey deemed that this is not something that
needs the paramedics, right? When the call goes to dispatch, they send
out your neighborhood fire station, which can be there in several minutes, a maximum
of three. The regional aid car, and the only way you
can tell a medic unit from an aid car is it says A instead of M on the side, and one of
seven Seattle paramedic units, which has that M on it. So that triple layer response goes out. If they deem it’s a simple problem and not
worthy to tie up the most advanced trained people, they’ll quote “green light” that medic
unit to put them in service for the next important call. If they don’t need the medics, if they don’t
need the EMTs on the aid carts, which are oftentimes staffed by paramedics, they will
then call commercial ambulance to transport somebody. Now, the beauty of this, some of that socialist
ideal of the ’60s and ’70s persists, in that if you get hauled by the fire department,
it’s free, but if it’s a trivial problem and you go commercial, you’re going to get a bill. And that, really, probably disincentivezed
overutilization to a certain extent. So that’s how we exist today. Here’s a map of the city, with the various
medic units in the blue balloons there that are scattered and strategically located on
sides across water, bridges, et cetera, so no single community is isolated. And someone remarked that, well, when your
folks retire and move to Seattle, you want to study this map to see where you want them
to move. But we have seven medic units, twice as many
aid cars. And that’s the on-scene scene performance
standards, where that triple layer response, when the medics go out, it’s seven, seven,
seven. Seven to the scene, seven at scene, and seven
coming back. Now, that’s different than many big metropolitan
areas, say like Houston, which, as somebody described it as flat as a chapati, right,
where it’s a large, flat area and ground transport is an easy way to get around. But the seven at the scene was important in
Seattle because at times, you cannot get from point A to point B with ground transportation. So field stabilization was thought to be important
in the training of Seattle medics, as opposed to so-called “scoop and run” that was popular
in many places, LA, Houston, and other municipalities that have large level 1 trauma centers. So the mission was to train these people to
perform at the level of a physician in the field and to master critical thinking. And sure, indeed, they have protocols, but
they wanted them to be able to think, and also to become leaders in the medical community. And a paramedic training model in Seattle
on the right is much different than most others around the country on the left. This is a closed enrollment. These people are highly selected. First priority is to replenish the Seattle
Fire departments, not recidivism, but retirement of their medics. 90% of the didactics are taught by physicians. It is a regional agency for First Seattle
Fire, then King County Fire. And then, also, select populations and fire
districts around Washington state will then apply to send some of their medics to Seattle. These are full-time positions and almost twice
as many hours in training than any other paramedic training program in the country. So this yearlong training course consists
of 500 hours of didactic lecture, 250 hours of lab, skills labs, procedure labs, as well
as 15 hour, or excuse me, 500 hours clinical work. And you see the medics working alongside us
in the ER, down in the OR, and in the intensive care units, really helping out and getting
clinical experience. They then have 15 hours in the field with
a senior paramedic to supervise them. And vast clinical experiences, as you can
see in the bottom, 800 patients, 10 to 15 live CPR incidences, 45 intubations, IV starts,
et cetera. So this idea, like surgery residency, of progressive
or graded responsibility that goes from the classroom to the clinical stage in the field,
is phased in, one to the other. As the classroom diminishes, the time is spent
more in clinical, and then finally with in-field training. And this week, our current class, class 44,
have taken their final exams to be nationally certified. They also have continuing education, so-called
“Tuesday Series.” Every first Tuesday, you’ll see a bunch of
rigs parked out in front of Harborview from all over the county. And they come there for their continuing medical
education, of which many of us routinely are honored to participate as lecturers and instructors
in the Medic One program. So that’s how it works in the street. What about the house? Harborview was started, really, in 1877, again,
by a local statute that says the local government must provide for the care of the indigent
and infirm. And it started as the Poor Farm, which was
down in Georgetown, with a six bed unit, staffed by the Sisters of Providence, who were really
the medical pioneers in the Northwest. It then developed a larger hospital that you
see in the middle in Georgetown. And then finally, in 1931, money was passed
to build the new facility where we currently exist on First Hill– at that time, a 500
bed hospital, now 431, as care has evolved– in its current location there between 8th
and 9th Avenue. 1946, we started a medical school. This is a pretty young institution. And it was the first teaching hospital. And until the University Medical Center was
built in 1959, the clinical teaching for the School of Medicine was conducted at King County
Hospital, which was then, after a contest by the Seattle Times, named Harborview for
its commanding view over the sound. In 1973, paramedic training class number 1
was graduated. Those numbers are a little fuzzy. And I went to the wall yesterday just to check
and talk to the Medic One people, but for a few years there weren’t classes. So the numbers don’t quite work out. And actually, class 1, I think, was either
1969 or 1970. Nevertheless, in 1974, after the University
assumed– so this is different than San Francisco General and other places. The building and land are owned by the county,
but it’s been operated since 1967, I think, ’69, by the university. But in 1973, the dean says, I want you to
go get me a first class trauma service to organize this place. And they went to Texas and they hired G. Tom
Shires, who was the chief of surgery and chairman at UT Southwestern. He was a chief of surgery at Parkland. And he brought an entourage of people, 45,
in fact, which include attendings, nurses, research personnel, and they even brought
a newly finished intern, who they thought might have some promise, a guy named Ron Mayer. So the Texans came to town in 1974, organized
Harborview’s trauma service in the like of how they had organized it at Parkland. So at that time, the cardiologists had established
Medic One. The medics were bringing cardiac patients,
but now they started to bring injured people to the emergency room in increasing numbers
as well. A lot of MDs were coming back from Vietnam,
so-called “Berry Plan,” where they would be pulled out of their residency, literally drafted
into military service as a physician. And they were coming back and they had an
enormous experience with taking care of injured patients, and severely injured patients. Some of them had studied European techniques
of open reduction internal fixation, and so this joint operating agreement began. So the Texans came to town, and they were
very bright, very organized bunch of people, many of whom were standing around that fateful
day in 1963 when President Kennedy was shot. And I’ve had the– I would say good fortune–
I think it was good fortune to hear the story of that fateful day by the mouths of some
of the people who were there. Charlie Baxter of the Baxter Formula was the
attending on call that day. And he and Malcolm Perry, the chief of vascular
surgeon, explored Kennedy’s neck wound, while a young, new onboarded general surgery attending,
a guy named Robert McClelland, or Mac, as he was known, the editor of selected readings. They said, hey Matt, come here and hold this
retractor. You want to read any about any of this, you
might listen to, or read, Dr. McClelland’s plenary address to the Association of ER Physicians
he gave five years ago on the 50th anniversary of that horrible day. Nevertheless, Shires was out of town. Chirico was the [INAUDIBLE] two in the pit
who intubated Kennedy, and the involvement of those people in that horrible day is a
subject of quite a few stories. The guy that brought AO, or ORAF, to North
America via Harborview was a young orthopedic surgeon named Sig Hansen. And he was first reviled as a heretic for
this. You cannot put metal in an open, dirty fracture,
the orthopedic community said. But he said they’ve been doing it in Europe
for quite some time. So he was a major thing as well. At the same time, due to a tragic accident
in a cornfield outside of Lincoln, Nebraska, a former Harborview-trained surgery resident,
Skip Caldecott, and his colleagues at Lincoln General Hospital in eastern Nebraska, sat
down and wrote a trauma course for general practitioners and first responders, based
on their experience that they had gleaned in their surgery residencies in Vietnam. And that became ATLS. So we’ve got quite a legacy at Harborview
of people. And Then Dr. Copass and George Longenbaugh, who
is a surgeon in Sitka, Alaska, took ATLS throughout the entire state. And they started to collect data. And this was one of the first studies done
that validated this controversial idea of endotracheal intubation in the field by non-physicians,
and where they showed a decrease of almost 50% from people who jumped off the Aurora
Bridge. Now since that time, not only has prompt intubation
been instituted, but also the Seattle harbor patrol police boat is parked at the bottom
of that bridge, and there’s motion detectors and now nets and everything else to try to
prevent that tragedy before it happens. But data started to accumulate from around
the world, in this country, that trauma centers were a good idea. In early ’90s, Dr. Mayer and one of the fellows,
Tom Exposito, with the help of Janet Griffith– who, at that time, was chief of nursing at
Harborview– sat down, and in a collaborative effort with people from around the state–
Dr. Nania in Spokane, Dr. Pinkers in Bellevue, and Dr. Marvin Wayne from Bellingham, and
a variety of people– established the Department of Health’s Washington State trauma system,
which was the first comprehensive statewide trauma system that was based on population-based,
in terms of who’s going to be a level 1, who’s going to be a level 2, et cetera, et cetera,
all the way down to level 5, which is just a little clinic in a very rural community. Because again, as you can see on this map,
we have vast expanses of very low population and scarce medical resources. So the trauma system began. Again, it was an inclusive system. Although it was determined that Harborview
should remain the only level 1 system, or level 1 facility, it was data driven and had
a multi-disciplinary governance, which still exists to this day, and many of our faculty
serve on that Department of Health Committee. So what’s it like there? Well, I think we’re licensed for 430 beds,
as most of the residents are very aware. We don’t count our occupancy rate. We count, at Harborview every morning, how
many people were over. And I think the maximum I’ve seen is 71. The minimum in the last decade, I think, was
12 people, who are over 100% census. 40 years ago, they said the hospital was working
perfectly when it was 65% occupied. So at Harborview, we’re always full. We have expansion units, as many of the residents
and faculty know, to put those 71 patients above our 100% census. So there will be people down there in the
ER whose hospital room is a stretcher separated from their neighbor by merely a curtain. We are the level 1 pediatric burn and trauma
center as well. And these people, as we know, are sick, because
they’re really a distillation of pathology from this huge region, where very complicated,
multi-system organ injury, as well as this growing population of necrotizing soft tissue
infections that we enjoy. It’s not unusual. We’ll admit three in a day. And with a very high ISS in the injured people. Again, it’s owned by the county, managed by
the university, and it’s governed by a board of trustees that are appointed from the community. So the mission is to take care of everybody
and whoever shows up. It has the highest total volume, the highest
percentage of charity care in the entire state, except for maybe– now, I’m not sure how they
do this adjusted revenue thing. The only people that have a higher percentage
of indigent care is the Navos psychiatric unit west Seattle, which serves mostly our
indigent population. So it really has specialized emergency services. Not just emergency service, but also elective
surgical lines, and that’s what helps keep us afloat. The spine service, where people will come
from far away. My own brother from Portland, who could go
anywhere in the world, came here for two serial, and his third and fourth back operations. Neurosurgery. A good portion of their elective service is
based there, as well as foot surgery, which serves a huge referral practice as well with
months waiting list. So that not just trauma emergency cardiac
arrest, but it’s evolved for really excellent care, and I know, myself included, many of
my family members have been patients of the surgical services at Harborview as well. Because we all know it’s a teaching institution,
right? We have hundreds of residents in very, very
many specialties. One time I sat down and counted, when I had
the opportunity to be the program director and I counted. At Harborview, at one given moment, only 40%
of our residents staffing comes from within our own department. But there is not only medical students, residents,
fellows, but also medics and special forces medics, as well, that you’ll meet down in
the emergency room. Critical care services, led by Dr. Robinson
and Dr. Cuschieri, are really par excellence. When we built the mailing extension over there
with the beautiful skybridge, we concentrated all the surgical intensive beds on one floor. And as you know, we have 24 beds up there
and 16 across the street at the burns and pediatrics. Well, it’s not just hot air and smoke. In fact, if you look at the t-quip data that’s
gathered by the American College of Surgery, that trauma quality improvement program, and
you look at how Harborview compares, in terms of mortality statistics to other level 1 trauma
centers around the country, you can see that our odds ratio of mortality, in the green
down there, is outside the range, much outside the range of average, than comparable institutions,
not only with adult, but also with pediatric patients as well. So one of the main forces, I think, that helps
drive this concept of excellence is quality assurance. And every other week, the trauma committee
meets, the trauma council meets. Every other week, the surgical council meets. Every other week, the critical care council
meets. And the room is full of about 40 people, not
just physicians, but nurses, therapists, and administrators, to, in an ongoing basis, review
the data, see how we’re doing, and try to move the care ahead. That standardization of care and that quality
insurance program are key. Also, injury prevention through the Harborview
Injury Prevention Center is really a national model, and was one of the seven original CDC-funded
injury prevention centers in the whole country when it started. Education and outreach have expanded as well,
trauma Survivors Network, and ongoing research. And the leadership at Harborview, headed by
our Chief of Surgery, Dr. Mayer– not just of our department, he oversees the entire
surgical operation of Harborview– and others, Dr. Mayer now being the president of the American
College of Surgery, following in Dr. Pellegrini’s footsteps. Dr. Bulger is now the head of the American
College of Surgery Committee on trauma. Sam Arbabi is our Region Chief. Bryce Robinson is now our State Chief, and
on down, and Sam Mandell, on and on down the line, we have lot of people that are poised
in national and international leadership. The research, innumerable trials, clinical
trials as well as bench research, and really, training grants, which have been maintained
now for over 35 years or more. Dr. Mayer, I think, under his direction, have
trained a cadre of people, not just in clinical care of injured and critically ill patients,
but also many of them going through the MPH program, so they can be people who can design
and lead trauma programs around the country and the world. Other new stuff. The ECMO program, of which many of you are
aware, the Extracorporeal Membrane Oxygenation, where we take people who are dying, or almost
completely dead, put them on bypass, and sustain their life, while their lung injury or their
cardiovascular system, or whatever, improves. The Trauma Survivor Network, and then the
outreach with the “Stop the Bleed” program. Last winter, we took it to our state capitol
in an effort led by Maria Paulson and Dr. Bulger. How do they get there? Airlift Northwest is an interesting story
as well. This is a slide. This is a first helicopter transport into
Harborview in 1967. This slide was given to me by Roland Folse,
who, again, is an alumni of our surgery program, who then went on as chair at the University
of Southern Illinois in Springfield to become, really, the godfather of surgical education,
and really take surgical education and develop it into its national prominence. In those days, it was the military, the army,
who hauled us the patients in the helicopters, this military assistance of surface and traffic,
to keep their pilot skills fresh. But that started to dry up as their funding
followed suit. But we still were stuck with all of this water,
these mountains, et cetera, in this rugged northwest territory, for which we had to transport
people. But it was a house fire in Sitka, Alaska in
1977 that truly inspired the development of Airlift Northwest. And Dr. Copass flew up there in a converted–
it was either one of the corporate Learjets, where they pulled the seats out. And they would do it on an ad hoc, as needed,
basis, to haul these people. And Sitka’s only 800 air miles away. So they went up there in this horrible house
fire and brought one of these children down to Harborview. So he said, we’ve got to do better. These poor docks up in southeast Alaska, the
archipelago of islands that hangs off the BC coast, are really stuck and isolated. There’s no way out of there except boat or
plane. And the weather, of course, is challenging. So hence, it became Airlift Northwest. And unlike helicopter or air medical transport,
most other US cities, which were hospital-based loss leaders, come to St. Elsewheres because
we have a helicopter, just like we have a laser, or we have a whatever. This was, again, a co-operative consortium
between four hospitals in Seattle, Harborview for trauma and burns, the University for Cardiac
Surgery and High Risk OB, Children’s for pediatrics, and at the time, Providence Hospital, their
flagship, now known as Swedish Cherry Hill, which at that time had the biggest volume
of cardiac surgery. So it was really a co-operative effort. It’s a nonprofit corporation. It’s staffed by experienced ICU nurses, or
ER nurses, that literally, but not completely, audit the Seattle paramedic training course. It began as a fixed wing, or airplanes, exclusively,
but then expanded into rotary service, or helicopters, as well, to supply not just our
state, but southeast Alaska and the surrounding area. Currently, there’s nine aircraft. They have an average of 11 missions a day. Chris Martin told me that last weekend, every
single aircraft was in the air simultaneously. And obviously, in the summer, it’s much, much
busier, and so they’re up there quite a bit. They’re fully equipped with state-of-the-art
ventilators, two trained nurses, and now, like the medic units, two units of paxils,
two units of fresh frozen plasma, and TXA for resuscitation of bleeding victims. Here’s just a picture of the aircraft. I’m kind of a recovering aircraft junkie. There’s the one remaining Lear. This is another thing I learned this week. There’s only one Lear left. The jet is in Juneau. But the new kid on the block is the Pilatus
12C, which is the plane, that single engine prop plane on the left. It looks small. It looks like a little beechcraft, but in
fact, that fuselage is bigger than that Lears. And it has a single engine and one pilot,
much better fuel efficiency than the Lears. And the speed is almost 2/3 to 3/4 that which
you can achieve with a Learjet, and the same 25,000 foot ceiling in a pressurized cabin. So the new kid on the block is this Pilatus,
designed and built in Switzerland, now with a factory in Broomfield, Colorado as well. And then, of course our helicopters, the Augusta,
that sleek, retractable landing gear deal on the left, and then the EC 135. Both European models, Italians and Germans,
respectively. Helicopter service will go right out to the
scene. The trained nurses will intubate the patient,
if necessary, provide IV access. And they are based around Puget Sound. Believe it or not, there is no helicopters
any longer based in Seattle. There’s a new base in Bremerton, and they’re
in Bremerton, Puyallup, Arlington, and Bellingham. So they serve the Puget Sound base with about
150 mile radius. In Seattle, the aircraft we have remaining
is a Pilatus. There’s a Pilatus in Seattle. There is a Pilatus– Pilatus, Pilatus, tomato,
tomato– Seattle, and another one in Juneau to augment the Lear, and in Yakima. Here’s a map of the service. That’s pretty much up-to-date, date except
the icon for the Lear in Seattle is now a Pilatus, with the helicopter base, as you
can see, the newest being in Bremerton. Bellingham service used to have their own,
near and dear to my heart, as my wife in precipitous labor came from Lopez Island six weeks early
to enjoy the birth of our first son. So Airlift Northwest is near and dear to my
heart. Here’s a map of the Alaska service based in
Juneau. Again, is current with the Pilatus and the
Lear, based in Juneau. Juneau is about, let’s see, what does it,
Eric? You’re Alaskan. It’s about two hours and 10 minutes, 3:15,
in a Pilatus, and to Seattle in a jet is 2. So just 15 minutes longer– excuse me, an
hour and 15 minutes longer if you had to take a Pilatus from Juneau. But that’s why they’ve kept the Lear up there,
because it’s a bit faster for transport from there. I know that from call to patient arrival from
Bozeman, 550 miles away, it’s under three hours, and I’ve had that many, many times. There’s the range of the Lear 31 out of Juneau. And all this stuff is on their website, so
if you want to refer to that. So what happened to the jet? I mean, isn’t a jet better than a single engine? Now, this is a single engine plane, but this
is like the Porsche Carrera of small aircraft, OK. This is a high performance aircraft with a
big fuselage, great fuel efficiency, and a big back door. The big back door is to serve our growing
patient population. And actually, a couple of years, I was visiting
with a friend in Montana who was a hospital administrator and was doing a visit over in
Kalispell. And the guy turned me on to the Pilatus. And he says, it’s got a big door, Hugh, and
it’s got a hoist. It’s the going rage. And so now we have the Pilatus with the big
back door, a hoist, and a maximum patient payload of 500 pounds. I thought, wow. And I started to look that up. And indeed, Tricare ambulance now has a special
bariatric transport unit available. The other thing that’s good about airlift
is air care membership. And if you hike or if you travel in the Northwest,
you should really think about spending the $79 per family. What that covers, basically, is your co-pay
above your– you have to be insured. But it’ll pay your co-pay if you need aeormedical
transportation. Having even seen two of those bills, spaced
25 years apart, to haul my son from Lopez Island first in utero and then having come
off a ladder with a head injury, I can tell you it went from $4,100 to $14,000. So it’s not cheap. So that’s he story, and we’ll end there with
a picture that’s near and dear to many of us. You know who those two guys are? So that was at the once annual department
picnic, our founding chairperson there in really dashing plaid sportcoat, Henry Harkins,
wishing his vice chair, John Stevenson, well when water skiing. Ties it together. As the story goes, as told by L.T. King, one
of the senior surgeons at Providence, Henry could never get up on a slalom ski. And that day at the picnic, he finally did. And he walked up on the beach with a big smile,
grinning ear to ear, suddenly turned blue as a goose and collapsed in vfib arrest at
the department picnic. As the story was told, they intubated him
with the garden hose from Norm’s resort up by the Bothell landing. He went to town in an ambulance before I-5
through Lake City Way Sunday afternoon traffic, which took over an hour, probably about the
same now. And by the time they got to the hospital,
of course, he was neurologically devastated. So now, hopefully, we’ve got a better system
to prevent such tragedy due to the hard work and cooperation of a lot of different people,
some of whom I owe a debt of thanks. Of course, to Dr. Copass and Dr. Cobb, who
were great teachers and mentors, not to mention Dr. Mayer and his protege, Dr. Bulger, who
is doing a phenomenal job running our trauma system and as well as directing that for the
country. Dave Carlbom, who took over Copass’ job as
director of the Michael Copass Seattle Paramedic Training Program. Rich Utarnachett, who is the medical director
of Airlift Northwest. And Chris Martin, who is the executive director. And all those people are instrumental, not
only in making the place work. But most important, to thank all of you residents
and students. Because as we all know, you are the glue that
puts it together. It keeps it running. Not just you all, but as all of you know as
well, it’s the can-do hospital. It’s let’s go for it hospital. That’s OK. The only right answer when somebody asks you
for help at Harborview is, sure, let’s go. Let’s do it. We’ll work out the details later. You need something, you need help, people
are there to help you. It doesn’t matter if you’re Dr. Ronald V.
Mayer, MD, FACS, or you are Gordon, the guy who turns the rooms over with your vet on
7 East so that we can get another patient to the floor and to upstairs. We’ll have some questions. I want to share with you a beautiful poem
that hangs in the Harborview TICU that was written by the father of one of our patients,
that gal who fell out of that bucket loader. He said, “We lay her at your doorstep, our
child, tattered and torn. You rushed to her with no obligation, save
an oath you had sworn. You doctored her and nursed her. You braided her hair, though her only connection
was an oath you did swear. It’s a marathon you counsel for patient and
family both, but you still ran alongside us as you practiced your oath. Your science healed her body. You restored what was broke. Your art healed her spirit through the oath
that you spoke. This covenant is more than words. It is life. It is hope. It’s the miracle of existence wrought with
love in an oath. Now the joy of your healing cometh to us each
dawn, while your heart and your oath, to another, move on.” Thank you. [APPLAUSE] Do you happen to take any questions or comments? Eggs? Vegetables? Very good. Dr. Wood? DOUGLAS E. WOOD: Thank you. That’s an inspiring story and you weave it
well. I have a question about stabilizing versus
scoop and run. Because is it correct that we do a bit of
a combination, that we don’t truly fully stabilize in the field, but we do some level of that,
compared to, for example, some European trauma systems, who spend a long time in the field
in a period of stabilization? The accident of Princess Di coming to mind. How would characterize, for example, an instance
like that and how it would be handled in Seattle compared to how it was handled in Paris? HUGH M. FOY: Well, I think our medics are
taught to only do what they absolutely need to in the field to stabilize the patient and
not linger. They want to get to the trauma center as soon
as possible. As you probably know, the Paris system is
quite different. All of their rigs are staffed with physicians,
as is pretty much the norm in Europe. Maybe the docs want to do too much and perhaps
aren’t the optimal utilization of the resource. But through extensive training and protocols
and peer review of the paramedics, I think we’re able to keep that under better control. Dr. Bulger you have a comment? EILEEN M. BULGER: I think it’s like Goldilocks,
you want just the right amount. So there’s some cities where they say, oh,
just let the police scoop them up and transport them. That’s probably too little. And putting physicians in the field in Paris
is probably too much. So it’s just figuring out what is just the
right amount. There are some patients who can’t take a 10
minute trip without an airway, and there are some patients that need to come right away
without an airway. So we’re always trying to strike that balance. And I think what’s special about Seattle is
the QI program for the pre-hospital service is extensive. Every case is reviewed. Every cardiac arrest is reported. And actually, every second of every cardiac
arrest resuscitation is reviewed. They look at very metrics around how much
time they spend on the chest, how fast do they get to the patient, all those things,
and we’re doing the same for trauma. So I think it’s a constant titrating of just
the right amount, but it shows in the outcomes. We absolutely get patients to the hospital
that we would not get otherwise. It’s a constant effort, but I think it’s a
really modest system [INAUDIBLE]. HUGH M. FOY: Right. And you’ve done extensive clinical research,
too, to validate the approach, as a result of the QI process, which is, again, very rigorous
and very extensive. Well, happy summer. Thank you all for your attention. Have a great day. [APPLAUSE]

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