Summer unofficially began a couple of weeks ago with the Memorial Day holiday.
That means people are out swimming, riding bikes, taking hikes, driving boats and wave runners on the rivers, staying out later than usual and, in general, engaging in riskier behavior than they do other times of the year, said Dr. Bret Riegel, medical director of the emergency department at Mercy Hospital Washington.
All of that tends to mean there will be more accidents, often very serious ones.
“Summer is the busiest time for traumas,” Dr. Riegel remarked.
Here in Franklin County, Mercy Hospital Washington operates a Level III trauma center. You may have heard that term before and not paid much attention to what it really means.
Basically, it means trauma patients are in good hands here. More specifically, though, a Level III designation means that a trauma center meets certain criteria for the number and types of specialists who are on-call to respond when trauma cases present in the emergency department, said Joan Frost, chief operating officer at Mercy Hospital Washington.
“The state has, through its regulations and protocols, set up three levels of trauma care in the state of Missouri,” said Frost.
Level I is the most comprehensive with a trauma team of surgeons and anesthesiologists on site at all times.
“A patient presents in the emergency room, and they can whisk them into surgery right away because they’ve got the team right there,” Frost explained, noting Level I trauma centers are only ever located in big cities where the population and number of severe traumas warrants them — St. Louis, Kansas City, Jefferson City, Springfield.
Level I trauma centers also have every type of specialist available for every type of injury, Dr. Riegel pointed out.
“The big one that limits most (trauma centers) is neurosurgery,” he said, adding that neurosurgery is one of the highest specialties in medicine with a very long residency requirement.
“(Neurosurgeons) are hard to come by, period,” Dr. Riegel remarked. “There are not a lot of them, and they are busy where they are already.”
In fact, having neurosurgeons on staff or on call is mainly what separates trauma centers from each of the three designated levels, said Dr. Riegel.
To be a Level II trauma center, there has to be a team of neurosurgeons available, since one has to be on-call at all times.
“They don’t have to be in house to receive a Level II, but within a certain time frame away, probably 30 minutes,” he said.
Level III trauma centers, like Mercy Hospital Washington, do not have neurosurgeons on call.
“We can have our trauma surgeons here within 30 minutes of a call, and our anesthesiologists here within 30 minutes,” said Dr. Riegel. “We have a pretty broad spectrum of specialists.”
For the number and types of trauma cases that present at the hospital here, that system works well.
“Level III is the right level for us,” Frost remarked.
‘All Hands on Deck’
The most common traumas in this area result from motor vehicle accidents, but the trauma team also treats patients hurt in farm accidents, construction accidents, industrial accidents, falls from any number of things . . . as well as the various summertime activities mentioned earlier.
First responders on the scene of any trauma are in communication with the hospital right away to alert them that a trauma case will soon be arriving. That’s when the trauma team is activated to respond.
“That means that our surgeon is contacted, our X-ray, our lab are notified,” said Frost. “It’s all of those points of coordination when we send out a trauma alert.”
One of the rules for being on the trauma team for Mercy Hospital Washington is that you have to live within 30 minutes of the hospital, said Dr. Riegel, noting most live much closer. And when the calls come in, the team responds.
“It’s well orchestrated,” said Frost. “It’s a process that’s been perfected and worked on . . . It’s all hands on deck.
“A lot of times they are meeting the patient at the door. That’s the key to trauma care — being fast.
“When you think about a trauma and the EMS crews who are responding, they have to make that decision through their medical director when they’re on the phone, what they think they are dealing with. If it’s clearly ‘we can get air transport here, and this needs Level I,’ then don’t bring them here if you can get them there quickly.
“But the patient may need to be stabilized before they can be transported any further, and so they would bring the traumas here and we would do some of the stabilization to prepare them if they needed to go to a higher level of care,” said Frost. “It really is an individual call, case by case, what’s best for the patient to get them the right people to care for them as quickly as possible.”
In addition to trauma centers being designated Level I, II or III, the trauma cases themselves are designed I, II and III based on the extent of injuries, said Dr. Riegel.
“The main thing that does not stay here when it comes to trauma is someone who has a severe head injury,” he said. “Severe head injuries are the one thing that needs to be taken to a higher level of care. And multiple complex fractures.
“In general, we can take care of all of them in the emergency room and then maintain their care here in Washington.”
“And for those who need that higher level of care, Mercy has that in St. Louis,” added Frost. “And that transfer process is also well coordinated as part of our trauma response.
“We have clear, quick communications with Mercy St. Louis. We share the same electronic records, so they get the same information and they get it quickly from us.”
Only Trauma Center Between Jefferson City and St. Louis County
It was 1996 when then-St. John’s Mercy Hospital earned its Level III trauma center designation. Prior to that, the hospital wasn’t designated a trauma center.
“We were looking for a way to standardize emergency department care of trauma patients, and to include all involved parties in an organized manner,” said Dr. James Cassat, who was then chief of surgery. “The state of Missouri had just designed the three-tiered system, and we used their original standards to pursue their accreditation.
“Laura Carder was the original trauma nurse coordinator and did most of the paperwork then.”
Currently, Mercy Hospital Washington is the only trauma center located between Jefferson City and St. Louis County with Hermann serving as the dividing line, for which cases go where.
“Anything west of (Hermann) goes to Jeff City or Columbia. And then east of there comes to us or, if they needed to be flown, would go directly to a Level I or Level II,” Dr. Riegel explained.
Over the years, the number of trauma cases treated here has increased incrementally every year. Last year (July 11 to June 2012) there were just over 1,000 traumas treated at Mercy Hospital Washington, of which 760 were motor vehicle accidents.
“This year we’re on track for more like 1,200 traumas,” said Dr. Riegel.
Most of that increase is due to a growing population, he said, but another reason is better understanding of services available here.
“We’ve been doing it for a while now, and the EMS has been trained better on what should be flying and what they should be bringing us directly,” Dr. Riegel noted.
“So we get a higher percentage of the wrecks, and the flights are way down because they are appropriately being brought to us instead of being flown to St. Louis which is a huge cost — it’s great when it’s necessary, but it also needs to be used appropriately.”
Looking back 17 years to when the hospital earned its Level III trauma center designation, Terri McLain, current president of Mercy Hospital Washington, said the community owes “a debt of gratitude” to those who did the work.
“They recognized the importance of establishing consistent, standardized and accountable trauma care,” she said, noting the designation set an advanced code of standards in the emergency department.
The hospital must meet or exceed those standards to retain its designation. Throughout the years, the standards have progressed as specialty services have been added throughout the hospital. Physicians and services have been added, from better imaging technologies to advanced heart care. These things make the emergency department more advanced, too.
“What we provide is an emergency department that brings peace of mind and better care to the community. If you’ve never used it, someone you care about probably has,” McLain said. “It’s state designated for quality. The staff is caring and amazing, and lives are saved there every day. We’re fortunate to have the emergency department we have in our community.”
Maintain Education, Involved in Community Disaster Preparedness
There’s more that comes with being designated a Level III trauma center than just caring for the patients. The staff also has a responsibility to educate all of the participants/first responders who provide trauma care.
“Part of the trauma care regulations is that we maintain education,” said Frost.
“That education starts with EMS at the scene, prehospital. We get involved in training them.”
Dr. Riegel, along with Tim Norton, RN, Mercy’s trauma nurse coordinator; Tom Nuernberger, Mercy’s EMS coordinator; and all of the EMS chiefs, make sure that all players are well educated in providing care at the scene and where to send them for care.
The hospital holds one annual daylong symposium and periodically through the year offers different educational opportunities. And the trauma center staff are required to do community outreach.
“We are involved in community disaster preparedness,” said Frost. “We work with Abe Cook (director of the Franklin County Emergency Management Agency), local Franklin County STARRS (St. Louis Area Regional Response team) and the Trauma Task Force in Jeff City.”
Along with requirements for continuing education and community outreach, there also are inspections to verify the information.
The state Department of Health and Human Services comes in to inspect and verify information, said Frost. There is a five-year cycle, but they also make visits in between.
“Besides them coming in to evaluate us, we have to report our data and outcomes to the state,” she said. “That’s an ongoing process.
“We do that concurrently as patients come in. We submit to their database.”
And it’s not just information about while the patient was treated in the emergency department. It includes everything from the moment the patient began being treated by first responders to the time they are discharged from care.
“When we do have to care for patients in our hospital or ICU or one of our inpatient units, we are following their care . . . the data that we report includes that whole stay, even if we may send them to rehab afterwards,” said Frost.
So while many people may not realize it, being a Level III trauma center involves much more than just being equipped to care for certain types of injuries.
“It really means that we are constantly working to make sure we are up-to-date and knowledgeable about trauma care, and that’s to provide a better service,” said Frost.