Conemaugh Memorial Medical Center

Level 1 Regional Resource Trauma Center

1086 Franklin Street
Johnstown, PA 15905-4398

Conemaugh Memorial Medical Center

One Call Referral/Physician Line

1-866-310-2826

TRACS
TRAUMA AND ACUTE CARE SURGERY
December 2015

conemaugh.org

Directors Corner
Russell D. Dumire, MD

Conemaugh Physician Group - Surgery

This edition of TRACS highlights the

benefits of a teaching facility within a
community. As Trauma Director and
the Director of the Surgical Residency
Training Program, I am in the unique
position to see and appreciate the
intimate relationship between quality
improvement and education and
the resulting community impact.
Pennsylvania has three community
based Level 1 trauma centers, which
includes Conemaugh, Geisinger
Medical Center and York Hospital. It
is very difficult to support and staff a
Level 1 center outside of the university
setting in this era of escalating
health care cost and decreasing
reimbursement. Overcoming some
of the myths and prejudice against
teaching centers is crucial to their
ultimate long-term viability. What
many people do not realize is if there
is continued outmigration of patients
for care which can be provided locally,
residency training programs may
be adversely affected and this effect
will ultimately be transmitted to the
community in the form of diminished
or lack of access to crucial clinical
services. For instance, if the specialty
volumes decrease enough to impair
the internal medicine programs
ability to provide quality educational
rotations, the program may lose its
accreditation and ultimately close. If
this happens, subspecialists initially
recruited for clinical services and
education will relocate to the larger

metropolitan centers; i.e. cardiology,

pulmonary care, gastroenterology,
rheumatology, endocrinology, and
many more. Now our families and
neighbors are forced to travel up
to 2 hours to receive this routine
care. Time sensitive, life threatening
processes are no longer survivable
simply because we chose to live in
rural communities. The same goes
for general surgery, vascular surgery,
trauma services and cardiothoracic
surgery which cant exist without
cardiology and so on. The concept
of use it or lose it applies not
only to acquired skills and athletic
ability but also to scarce regional
medical assets. These intricate and
far reaching relationships between
clinical services, quality improvement
and education demand we dispel
these myths associated with care
in a teaching facility and encourage
community participation in order
to insure the long term viability of
these unique community resources.
Although I may not alleviate the
concerns of all who read this, I will at
least dispel many of the myths and
concerns associated with the care
provided at teaching facilities and
if you choose to continue to drive
hours to receive the same care that
you could receive minutes from home
and support the residency training
of those distant facilities, it will be
solely based on opinion and have no
factual basis in the vast majority of
cases. This applies to physicians who
routinely influence patient decisions
with their political and personal, but
non-evidence based, opinions to seek
care outside of the region because it

is Better. These practices are not in

the best interest of the patients, their
families, or the community in general.
There is no statistical data which
demonstrates that care rendered
outside of our area is any better that
the care within our region. I know my
comments may be upsetting to some,
but the reality of the times mandate we
set personal opinion aside and rely on
factual data. Ultimately, the patients
are in charge of their own care but their
decisions should be based on facts
free of prejudice and fear. The future
of health care is clear. The physician
shortage will be most pronounced
in rural communities, as most new
graduates will peruse specialty training
with fewer choosing to practice in
rural communities. Rural health care
demand will increase as the average
age of patients in rural communitys
increases. If we as a community and
region want to preserve the long term
viability of our existing medical assets,
we must start now with increased
utilization so that we may weather
the approaching storm and preserve
the quality of medical and surgical
care here in our own communities
otherwise we relegate our fate to
chance and become a victim of
resource consolidation and relocation/
redistribution of medical assets in the
very near future. The comments above
are my opinion, based on currently
available evidence-based reports in
addition to my 28 years of clinical
experience as well as involvement in
resident education.

Pediatric Head Trauma continued

This can even include time off from school. (4) After
the player is symptom free with cognitive rest, which
normally occurs within a week of the event, they should
resume normal cognitive activities. If the player remains
symptom free with cognitive activities, then they can
begin a staged return to physical activities. Prior to
resuming physical activity the player must be symptom
free, be off any medication for treatment, have a normal
neurologic examination and have a return to normal
cognitive functioning. The return to physical activity is not
recommended until 10-14 days after the incident. (4) This
is performed in a stepwise fashion with each step requiring
a minimum of 24 hours, and must remain symptom free
during the exercise. Here are the stages for returning: (4)
Light aerobic exercise - stationary biking, swimming
Sports-specific exercises running drills, etc.
Non-contact training drills Passing drills, etc.
Full contact practice
Return to play
Back to the original case, you remove the quarterback
from the game to protect him. The next day he is seen
by his family doctor and is symptom free. He returns to
school within 48 hours. At day 10 he begins his return to
play evaluation and completes it with no difficulty.
REFERENCES
1. Centers for Disease Control and Prevention (CDC). Nonfatal
traumatic brain injuries from sports and recreation activities--United
States, 2001-2005. MMWR Morb Mortal Wkly Rep 2007; 56:733.
2. Meehan, WP. OBrien, MJ. Concussion in children and adolescents:
Clinical manifestations and diagnosis. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on August 29, 2015.)
3. Schonfeld, Deborah, et al. Pediatric Emergency Care Applied
Research Network head injury clinical prediction rules are reliable in
practice. Archives of disease in childhood (2014): archdischild-2013.
4. Meehan, WP. OBrien, MJ. Concussion in children and adolescents:
Management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accessed on August 29, 2015.)

Prevention Corner

Distracted Driving

Some tips from http://safety.lovetoknow.com to avoid

distractions when driving and teach your kids how to be a

careful and safe driver.
1. Put away the phone talking on the phone while
driving can increase your risk of crashing by 4 times. If
you find it necessary to use your phone, pull over to the
side of the road before you dial the number
2. Dont even use a headset many think it is safe to
talk on the phone as long as you are using a headset.
Statistics have shown there is no difference than using
the cell phone still too much of a distraction.
3. Pull off road when your sleepy there are as many
as 6,000 fatalities related to falling asleep at the
wheel. Sleepiness attributes to slower reaction time,
less capable of making informed decisions and less
attentiveness. Pull off the road as soon as possible.
4. Never drink and drive. Alcohol impairs driving function!
5. Driving is not the time to groom, dance or eat lunch
these activities require attention in themselves and takes
away the attention needed to drive a motor vehicle. Save
these activities for when you are not behind the wheel.
Be a role model for your children.
Kids imitate your behavior and dont even realize they
are doing it. Talk openly about
ways to avoid distractions on
the road with your children.
This will help them gain
understanding and keep
them safe!

Jami Zipf, RN, BSN

Trauma Program Manager

is significant as well. Training programs

range from 3 to 6 years and during
this time period, the trainee along
with their possible family are often
viable contributors to the community
both through local taxes as well as
community involvement.
The current economic environment
is also an impediment to innovation,
education and continuous process
improvement due to skyrocketing
health care costs and decreased
reimbursement. Although this problem
affects all health care institutions and
environments, it is the smaller rural
facilities in communities that are most
adversely affected. Smaller facilities
often find it difficult to recruit and
retain new physicians due to dwindling
resources
and
reimbursement.
Approximately 80 to 85% of graduating
residents choose to sub-specialize
therefore leaving only a very small
fraction available and willing to practice
in rural communities. By the year 2025,
it is projected that the United States
will have a shortage of over 90,000
to 95,000 physicians and current data
shows that older physicians are retiring
more quickly than we can replace them
with new graduates. The largest gap in
supply and demand is projected to be
in rural communities. It is institutions
like Conemaugh which train young
physicians in rural communities
helping to ensure a steady stream
of highly skilled individuals who are
available to fill the gaps and improve
health care in the near future. In many
cases, residents training in communitybased facilities often return to practice
in rural facilities. Conemaugh is proud
to be a member of the 1100 teaching
facilities across our nation. A great
deal of commitment of both time and
resources are required to maintain the
status of Excellence in Patient Care as
well as educating the physicians and
surgeons of the future. It is because
of this commitment that Conemaugh
is able to provide subspecialty
services not otherwise available in
rural communities such as: cardiology,
endocrinology,
gastroenterology,

cardiothoracic in vascular surgery,

neonatology, trauma services and
advanced critical care. Typically
the services are relegated to larger
teaching facilities in metropolitan areas.
It is also because of this commitment
that Conemaugh was able to obtain its
level I trauma certification and in doing
so becoming the only level I center
between Pittsburgh and Hershey. The
level I status by definition, implies the
highest commitment to education,
research, process improvement and
community outreach and has allowed
us to establish an emergency medicine
training program which significantly
enhanced the quality of emergency
care within the region. All of these
enhancements directly benefit the
community and are a direct result of
Conemaugh being an established
teaching facility.
One final comment, if past patients
of your current attending physicians
would have said, "I do not want any
residents involved in my care", your
current attending physicians would
not have received the vital clinical
experience required to provide the
excellent care to the patients of
today(you) who are trusting their lives
and well-being. Is it not worth a little of
our time now to ensure that our children
(and ourselves for that matter) have
high quality, cost-effective, evidence
based care available to them.
We are becoming a part of the solution
to this very real problem and insuring
a bright future for our families and
communities through our support of

the local teaching facility.

If rural communities are to retain
their healthcare assets in the future,
they must now actively embrace and
involve themselves in the education of
these young physicians and utilize the
resources of their region, otherwise,
they may ultimately lose these assets
and be forced to drive hours to receive
routine care and be at the mercy of
chance if they or their family members
require immediate lifesaving care, only
to find that it is more than two hours
away by ground or 30 to 40 minutes
by air if weather permits. Resident
physicians are also available to
respond to in-house emergencies 24
hours a day, 7 days a week at teaching
facilities; which ensures immediate
access to qualified and trained medical
personnel who can initiate lifesaving
care before the arrival of the attending
physician minutes later. Sometimes,
minutes really do make a difference. It
is our honor at Conemaugh to serve
the regions health care needs within
minutes and sometimes hours closer
than the only comparable facilities
located in Pittsburgh and Hershey.
All of this is made possible due to
Conemaughs commitment as a
teaching facility. It is through education,
outreach and continuous process
improvement that we will continue to
enhance the resources and assets
of the Laurel Highlands ultimately
making our communities safer and
preserving healthcare assets in the
Laurel Highlands for years to come.

Pediatric Head Trauma

Douglas Schiller, DO, MPHT

The school year is now under way and we are well into the
season of contact sports. Imagine you are working at a
local high school football game; the quarterback is sacked
in the fourth quarter. He is slow to get up and you are
called out onto the field. He is slow to answer questions
and you are concerned that he may have a concussion.
The coach wants him to return to the game and says he
only got his bell rung, what do you do?
Concussions are one of the most frequent injuries to school
age athletes. The CDC estimates that 3.8 million sportsrelated traumatic brain injuries occur on a yearly basis, the
majority of these are concussions. (1) The most common
sports involved are football, hockey and lacrosse for males
and soccer, lacrosse and field hockey for women. (2)
Typically concussions occur immediately after a direct
force to the head, but any force (impact to the neck, chest
or back) can transmit forces to the head and cause a
concussion as well. Patients can present with a number
of possible symptoms such as:
Loss of consciousness
Confusion/disorientation
Headache
Nausea and/or vomiting
Difficulty walking
Difficulty following tasks
Most symptoms are short lived and resolve spontaneously,
but some of these can persist up to 1-2 weeks. (2)
Whether an EMT, sports trainer or physician, the majority
of the initial evaluations are conducted on the sideline.
When conducting the initial examination it is important
to evaluate for the possibility of injuries to other areas
of the body such as the cervical spine. After obtaining
a full set of vitals, a full neurologic examination should
be performed which would include orientation, balance,
and gait. In addition, motor function and sensory testing
should be performed in each extremity. This is important,
as motor and sensory function should be preserved in a
concussed patient; any deficit should prompt consideration
of intracranial injury or spinal cord injury.

The diagnosis of concussion is a clinical diagnosis; it does

not require any imaging or laboratory work. Any person
who complains or shows signs of the above symptoms
after an impact or transmitted force to the head should
be diagnosed with a concussion. Concussions were
previously graded based off loss of consciousness and
severity of symptoms. We now know that these did
not predict long-term outcomes and therefore we no
longer grade concussions. After the initial evaluation,
the question becomes who needs to go to the hospital.
As previously discussed, anyone with motor or sensory
deficits should be transported immediately. In the
emergency department for pediatric patients we use the
guidelines from the PECARN consortium to determine
who needs any advanced imaging. If the patient has a
Glasgow Coma Scale of 15, no signs of a basilar skull
fracture (no raccoon eyes or battle sign), no vomiting and
no severe headache the chance of a clinically significant
traumatic brain injury is <1%. (3) This would lead us away
from the use of advanced imaging. If any one of the above
findings is present the patient needs transported to the
emergency department for further evaluation.
There are several feared complications with concussions.
These include prolonged symptoms, second impact
syndrome and chronic traumatic encephalopathy. When
players return too early and do not allow enough recovery
time, the symptoms of concussion can be prolonged,
this has been shown in case studies (4) Second impact
syndrome is probably the most feared complication of
concussion. It refers to death or massive brain swelling
from a second traumatic injury occurring prior to complete
resolution from the initial injury. This can be devastating
and have mortality rates as high as 9%. (4). Chronic
traumatic encephalopathy refers to permanent changes
in mood, cognition and other behaviors from multiple
concussions. This disease received a lot of recognition in
April of this year due to a large NFL settlement to players
with the disease.
Once diagnosed with a concussion the brain needs to be
protected and rested. In the case given at the beginning
of the article this would mean that the player is removed
from the game immediately. As mentioned above, any
secondary injury can be devastating. After removal from
the game, the player should be placed on physical and
cognitive rest. Cognitive rest includes time away from
reading, video games, television and computer screens.

continued

The Value of a
Teaching Program
to Communities!
Graduate medical education has come

a long way since Henry Pritchett, the

president of the Carnegie Foundation
for the Advancement of Teaching,
commissioned Abraham Flexner to
examine the state of North American
medical education in 1908. Over a
two-year period, Flexner visited 155
medical schools in the United States
and Canada which resulted in the
1910 Carnegie Foundation Report
Number Four - "Medical Education
in the United States and Canada", in
which he described the very poor and
unstructured state of medical education
across the United States resulting in a
large number of certified but unskilled
practicing physicians. In this report, he
also included his conceptual model
of how medical education should be
structured and conducted based on
his experience and studies in Europe.
Over the next decade, the number of
medical schools decreased from 155
to 85 accredited schools. In addition,
state licensing boards across the
United States refused to recognize
and/or license anyone graduating from
schools other than these accredited
institutions. This was the first step
towards ensuring quality medical
education and medical care in the
United States. The surgical discipline
was one of the first to follow suit.
William Halsted graduated from Yale in
1874 with a doctor of medicine degree
and then traveled to Europe where
he studied under several prominent
surgeons; the most notable of which
was Theodore Billroth who introduced
him to the European model of surgical
training which he brought back upon
his return to New York in 1880. Halsted
is credited with the development of the
very first structured residency program

in the United States at Johns Hopkins

University in 1889 which ensured a
gradual progression of responsibility
as well as the quality of graduate
medical education. In order to provide
a means for continuing education and
quality improvement for practicing
surgeons, the Clinical Congress of
Surgeons of North America was
formed in 1910 and it was out of
this organization in 1913 that the
American College of Surgeons was
born. The founding tenets of this
organization included promoting
the highest standards of surgical
care through surgical education and
research, patient welfare, hospital
standardization, ethics of practice,
and interdisciplinary collaboration
to enhance overall patient care and
outcomes. The American College of
Surgeons has been the lead agent
in many of the quality improvement
initiatives of the last century to
include forming the Committee on
Trauma in 1922. It is important to
remember this history as it highlights
the concept of patient centered quality
improvement
which has formed
the foundation of the academic
medical profession in general and
the surgical disciplines specifically.
In addition, all of these advances
predated the Institute of Medicine's
1999 publication - "To Err is Human"
which highlighted the enormous
number of potentially preventable
deaths and misadventures within the
medical facilities of the United States
and charged the physicians and
institutions to significantly decrease
this rate over the next decade. This
new surgeon quality improvement has
been the largest since the Flexner
report in 1910.

From the very beginning, quality

improvement and education have been
intricately related. It has been through
research and education that many of
these quality improvement initiatives
are perpetuated into the practice of
the next generation of physicians and
surgeons and the areas effecting the
greatest change have been through
1100 teaching institutions within the
United States. Despite the great works
being done at teaching facilities, there is
a very common misconception among
patients and within communities that
the addition of medical and surgical
training programs, known as residency
programs, somehow detract from the
care rendered in these institutions.
This could not be further from the
truth, but this myth is so deeply
ingrained and perpetuated by the
media, it is very difficult to break. There
are approximately 5700 registered

Abraham Flexner

hospitals in the United States of which,

approximately 5000 are communitybased facilities and 1100 of these are
teaching facilities, and approximately
400 of which are community-based.
As you can see based on numbers
alone, the vast majority of care in
the United States is rendered in
community-based,
non-teaching
facilities. The data used by the Institute
of Medicine which highlighted 94,000
potentially preventable deaths was
collected and tabulated from both
teaching and nonteaching facilities
with the latter constituting the greater
proportion. Despite this, all too often
the lions share of blame for medical
mishaps is attributed to teaching
facilities. As a practicing physician,
as well as the Director of the Surgical
Resident Training Program here
at Conemaugh Memorial Medical
Center for the last 12 years, I have
encountered many of these attitudes
that ultimately impede our journey
through the quality improvement and
education process. It is however my
firm belief, it is the responsibility of our
major teaching centers (Conemaugh
included) to serve as models for
process and quality improvement
through excellence in education and
outreach and to perpetuate these
practices throughout the region which
will ultimately improve the overall
well-being of the communities which
they serve. Although there are sparse
but highly publicized reports of how

the addition of residents in training

programs result in a lower quality
of care, usually quickly picked up
by the tabloids, the overwhelming
preponderance of data and studies
show an enhanced quality of care at
training institutions along with lower
mortality and complication rates. The
tabloids just seem to leave this vital
piece of information out. We often see
reports in the newspaper that teaching
hospitals have a high residence of
adverse events; but what they don't
report is the fact that the vast majority
of complicated and complex patients
are cared for at these major teaching
facilities due to their enhanced
abilities and resource availability.
When you further drill down this
data, it also clearly demonstrates that
these adverse events are not due to
negligence but are in fact due to a sick
patient population and associated comorbidities. Teaching facilities are far
more likely to employ state-of-the-art,
evidence-based
recommendations
earlier and more consistently than
nonteaching facilities resulting in
overall better quality of care and lower
30 day mortality rates. The in-hospital
mortality rates are significantly lower at
teaching hospitals despite the fact that
the patient population is significantly
older and sicker than nonteaching
facilities. The rate of preventable
adverse drug reactions is also lower
in teaching facilities despite the larger
number of patients and medications

dispensed in these institutions. There is

however, some give and take with this
enhanced quality of care provided at
a teaching institution. Education takes
just a little bit longer. For instance, a
patient will be seen by more than one
provider and often have to provide
the same information more than once
which can be irritating for some. What
is often overlooked however is many
times additional facts are uncovered
during these multiple interviews which
ultimately result in overall more efficient
and improved care for the patient at
the cost of a little extra time spent up
front. Remember also, these young
physicians in training are generally
the cream of the crop comprising the
top 10% of graduating students from
various universities across the country.
They have also completed four or
more years of medical education
at this point and are by no means
lacking in diagnostic ability or medical
knowledge. They are lacking only in
clinical experience in application of
this knowledge. Resident physicians
are encouraged to spend more time
with the patient and consequently
supervising physicians are required
to spend more time with the resident
and the patient to ensure the accuracy
of the residents history and physical
examination; which translates to
more face time with the attending
physicians in teaching institutions. The
very nature of teaching inspires and
drives innovation and enhancements
in patient care. Teaching facilities
often serve as centers of research
and innovation and are instrumental
in the development of new treatments
and techniques which results in
improved patient care both locally as
well as nationally. There are numerous
other community benefits associated
with teaching facilities such as
health screenings, health fairs,
patient education centers, significant
community outreach and involvement,
various support groups, and access to
charity care which is often limited or
unavailable at nonteaching facilities.
The economic impact to communities