Emergency dispatcher, what’s the address of the emergency?

[sirens] It’s sudden, it’s unexpected... Fire rescue AP west transport.

It’s traumatic.

And where you go now may be the difference between life and death.

[music] Funding for this program was provided by Desert Program Partners.

911, what’s your emergency?

Okay, stay on the line for the emergency dispatcher.

Emergency dispatcher, what’s the address or location of the emergency?

We’re right in the intersection.

And what are you reporting?

I have no idea.

Whoa!

All units responding Kolb and Speedway.

We have a report of a rollover northeast quad.

Rescue to the rescue.

[sirens] He can’t breathe.

It’s going to be painful to breathe, bud.

Hold on, man.

We’ve got to look.

[sirens] All right, guys.

So who’s going to do airway?

Okay, Dr. Schmidt.

And Allison you’re going to do the lines.

Lines.

And then Michael you’re going to put in peripheral lines?

Yes, sir.

Good.

Watch this one.

Do we have respiratory here?

Respiratory’s here.

And who do we have at pharmacy for drugs?

We’ve got pharmacy here.

She complained of feeling dizzy or not feeling well, kind of went out on them.

22... We defibrillated her one time, we were going to do a white complex tach, she looks like she’s button stopped, she looks like she’s back in it.

Do you guys want to defibrillate her again before we move her?

Yeah.

All right, go ahead.

Everybody clear out.

Two FEs, one D50.

Hold on a minute.

Everybody clear?

Yes.

Clear.

Let’s transfer her.

Let’s transfer her over and start doing the compressions.

Want to take the board?

Yeah.

Continue compressions.

Let’s verify the airway.

When was the last epi?

Stop for just one minute and check pulses please.

I have pulses.

I have pulses here.

I have pulses.

If you take a patient who’s been in a car accident, which is by far the most common mechanism of being really hurt, and you go to a place where you’re a trauma center versus a place that’s not, you have a better chance for survival and that’s been scientifically shown that your survival rate is increased by 25 percent.

When was your last prenatal appointment?

A trauma center is the last place most people would ever expect to find themselves.

Yet, trauma injuries will affect one out of every three people.

More people under the age of 44 will die from trauma injuries than heart disease, AIDS and cancer combined.

Not great odds but better than they once were.

The Trauma Center, it’s a fairly new concept.

It hasn’t been around in many ways and if you go back to the ancient times.

Now their doctors were there when you had wars and people were stabbed with swords and spears and things like that but they weren’t actually a trauma surgeon per se and if you look at modern medicine, this is a relatively new field and to have doctors who are surgeons primarily ready to take care of people who are severely injured has been around for maybe about 20, 30 years at the very most.

Well, have I been in an accident?

That’s what it looks like.

The changes in the evolving field of trauma care are mostly indistinguishable to the patients.

Many have never even heard about trauma centers and assume they’re being treated at the emergency room or ER as it’s commonly called.

Depending on the hospital, many doctors and nurses will work in both the emergency department and the trauma center.

However, the distinctions between the ER and a trauma center are numerous, specific and significant.

Do you know where you’re at?

No.

If you come into the hospital and you need to go to the emergency room and you have things like medical illnesses where they don’t have to have surgery done such as asthma problems or heart attacks or strokes, then those will go to the emergency room and the emergency medicine physicians, their expertise is to stabilize you, triage you and then get you to the appropriate specialist if needed.

The emergency room is a vital aspect of trauma care and we work in the emergency room but what we do is that we have a section of the emergency department which is specifically for severe trauma and for that type of injuries, what we’ve done is we put a surgeon in charge of those severely injured.

If it’s a life, limb-threatening, severe bleeding situation, if there’s an airway they’re not breathing correctly, if they go unconscious, you need to go to the trauma center.

If you cut your finger when you’re cooking, you don’t need to go to the trauma center.

If you trip and fall and maybe break your ankle, you don’t necessarily need a trauma center.

A lot of emergency departments will have a surgeon on call but they may have 30 minutes to an hour to respond to that.

Ours, you have to be here in-house.

We have to have neurosurgery, we have anesthesia in-house, the OR team has to be ready to go.

And when was the last time you ate?

And a trauma center is required to have specific types of equipment, rapid blood supply, rapid infusers, fluid warmers and all of the resources, again, it’s the human resources that the trauma centers require to have that other emergency departments aren’t required to have.

I need to check your hips.

I need to check your hips.

Would you tell me if this hurts when I move this...put out your arm...your leg for me.

There are thousands of emergency rooms nationwide but only about 200 level one trauma centers which provide the most comprehensive care available.

They treat the same types of injuries and nearly all face the same challenges to provide that care.

The University of Arizona Medical Center in Tucson is the only level one trauma center to serve all of Southern Arizona, an area of more than 20,000 square miles that’s home to nearly one and a half million people.

Except for those who have been treated at one themselves, most people learn about trauma centers from the news.

[sirens] A at the shooting at the Safeway at Ina and Oracle.

We have a caller who believes that Gabrielle Giffords was shot at the multiple victims...

I was shot just seconds after the Congresswoman.

I will need every ambulance we have out here.

I was in a lot of pain and I was very happy when I began to hear those boots on the ground rushing and jumping over us.

I was told later that I was laying so still they thought I had died and so they were rushing to the living.

More people down.

I’m counting at least 10.

A lot more units over here.

I’d never ridden in an ambulance before and I thought, ’I thought it would be a smoother ride.’ I remember the radio conversation where they said, ’A 63 year old woman, two GSW.’ And I asked, ’What is a GSW?’ And they paused, there was a slight pause and then he said kind of quietly, ’Gunshot wound.’ [sirens] I was in a lot of pain and I was so incredibly grateful that I knew that I was now at a place where I was going to get taken care of.

It’s gone through my mind many times that the outcome for many of us would have been probably much different, certainly for the Congresswoman, if it had been somewhere where we would have had a long distance to travel.

The everlasting effect of the January 8th incident, one of it has been that in the past trauma systems has not been as well orchestrated or as sophisticated as some of the other fields, for example cancer or heart disease and children’s.

We got a lot of media attention.

I think that the media attention was fabulous for our organization and also for my profession nationwide because we had an opportunity to explain to people what we do.

My update’s going to be fairly short then I’m going to turn it over...

But I would say at least once a month we have a mass casualty type event.

Then we get a whole bunch of people coming to us at once like again the pileups with the cars, those are the most common type of scenarios.

I think the value of trauma systems, I think we need to relate to any mass casualty.

We’ve had now the Boston Marathon incidence bombings.

They have nine trauma centers in their community to absorb hundreds of patients.

[sirens] We’ve now had a bombing in Texas.

There’s always something happening.

I think what people don’t recognize is a lot of these communities have trauma centers and that’s where these people are going.

You just don’t know when something’s going to happen and we take it for granted.

It’s the first responders on scene following set protocols who determine the severity of the injuries and whether the patient will be sent to a trauma center.

If so, the protocols require communication with the hospital prior to or during transport.

The paramedics, the people in the field who triage you out there and work with you to stabilize you, know through set criteria, if he has been shot or stabbed from the chin to the knees for example, if they have a missing arm, if they have three or two long bone fractures, that type of thing, in addition to the fact that physiologically you look bad, you’re unconscious so you can’t communicate, your blood pressure’s falling ’cause you’re bleeding, your heart rate’s really high because you’re having problems breathing, those are things that tells them check boxes, ’Hey, this one is bad.

I’m taking them to the trauma center.’ [sirens] We’re transporting Code 3 with an 18 year-old adult male involved in a vehicle crash.

How do you copy?

Good copy.

Go ahead.

He was on a motorcycle.

Patient has multi-system trauma, dual dislocations, multiple long bone fractures.

Based on the information they receive, trauma centers assign incoming patients a code that corresponds to their condition and severity of injuries.

This enables the medical staff to have the right personnel and resources ready upon arrival.

At University of Arizona Medical Center green is for the least injured, white is for moderate injuries and red is for the most severe cases.

I have one line in, we’re trying to get another.

There was a positive loss of consciousness.

Doesn’t remember the event.

The middle of his chest does hurt.

Good copy.

We’ll see Rescue 70 in 10 minutes.

Re-contact for changes, University clear.

He’s got multiple long bone fractures, he’s got mid leg to sternal chest pain, tachy 166.Yeah.

Red?

I’d call him red.

Yeah, his BP is 140 over 110.

Significant ejection from bike?

What does that mean?

He went far?

Probably.

What’s your number?

Bed zero.

They’ve got one line, they are attempting the second.

I think the biggest misconception when I talk to people is, ’All you take care of is criminals and gangbangers and people doing bad things,’ and I think they forget about really who are trauma patients and who make them up.

It could be your brother, your sister, your mother, your father.

Hi guys.

Hello.

This is Zane, 18 year old male involved in a motorcycle accident.

Unknown rate of speed, the traveling speed in the area was about 25.

Positive loss of consciousness prior to arrival.

He has multiple long bone fractures, dislocations.

I was at work and I received a voice mail from an unknown number.

We have a dislocation of the left lower extremity at the knee.

A woman who came to the accident and luckily she had a medical background and so her message to me was very calm.

She just said that he had been in an accident and that he was going to be going to the UMC trauma center and that I should go there.

Do you take any medications?

I’m allergic to penicillin.

Allergic to penicillin, okay.

Have you ever had surgery?

No, all right.

He was talking when he came in.

He was completely alert and oriented and then quickly decompensated.

So we were able to get a little information from him but also watching, with the extensive injuries that we could actually see without even having to scan him or x-ray him we knew that he needed to be intubated right away.

Good color change.

All right, let’s get the x-ray in there, let’s get the x-ray in there.

Well, my husband was there so I just went and sat with him and said, ’Okay.’ And he goes, ’It’s far worse than she told you.’ Okay, back on three.

One, two, three.

We weren’t there that long and we were taken into a small room and it was with two doctors and they explained the level of his injuries and then they said we could see him.

Third unit of blood starting.

And then they’re setting for... We’ve discovered mostly orthopedic injuries, so significant orthopedic injuries, multiple fractures both upper extremity as well as lower extremity.

On the lower extremity, the left side worse than the right but...and we’re also concerned about a vascular injury, an arterial injury accompanying those fractures so the fractures are that bad we’ve been having trouble picking up his pulses in his foot.

They tried to explain that there was going to be a vascular team that had to establish his left leg and if it could be saved or not because they couldn’t get a pulse in that leg so they had concerns about that.

Next unit of blood, fourth unit of blood starting.

Because he’s a kid and I’m a parent, I have a 17 year old at home, he’s 18, and just as a parent knowing what they must be going through, that’s just tough.

All right, let’s lock and load.

Do we have our labs drawn?

And I didn’t know if we were going to get to see him again because they were really honest about the fact that he might not survive surgery.

[unintelligible] The thing about trauma, it happens so suddenly, you’re not prepared.

I think sometimes if a person gets a cancer diagnosis, you have some time to prepare for how this diagnosis is going to impact your family.

You’re getting a call at a random hour that someone’s injured and you...all of a sudden you have to make a lot of decisions very, very quickly and in the scope of that decision making, it becomes more immense as it goes on.

The length of time spent in a trauma bay varies significantly.

Patients leave in one of several ways.

There’s the operating room for surgery or perhaps a transfer to another specialty department in the hospital such as the ICU or intensive care unit.

The lucky ones leave under their own power but some trauma victims don’t.

Nationwide approximately 150,000 will die every year.

One, two, three.

To prevent that, trauma centers use their significant resources from the moment the patient first arrives.

I don’t see anything.

He’s got a big heart, though.

In our situation we’ll have a team of maybe about 12 people there waiting for you.

If you come in and you’re sick and dying of trauma, then my role is to be the maestro of the orchestra that’s going to take place.

It’ll be a symphony, I have lots of people in that room working at once.

We work as a team.

We have respiratory therapists, physical therapy and rehab, speech therapists, occupational therapists mobilizing these patients.

Pharmacists, we have pharmacists at the bedside, there’s complex antibiotics, pain management.

It takes a lot of different people who do their special things.

It takes housekeeping.

When we get a mass casualty in here, I need a team to clean and turn over our rooms very rapidly so the next patient that once we’re stabilized and move one patient to the OR, the ICU or we can downgrade them to another treatment room, I need that room immediately cleaned to get that next patient in.

They’re a vital component that a lot of people don’t think about.

It’s an orchestra.

You have your flute player and you have your drum player, the violin player, they all sound great independently, they do great work independently, but how beautiful does it sound when they’re all like working together.

Most importantly the person who stays with the patient probably all the time throughout their whole stay in the hospital is the nurse so the trauma nurse I think is a unique breed because they have to be a master of all systems ’cause you don’t know which system is actually injured.

So they really have to be highly educated and highly trained.

Yes, ’cause you guys are going to be caged up for the weekend.

She likes the park.

I know.

Was spinning crowded?

Some things are harder to leave behind than others.

My drive home, it’s about a 20 minute drive from UMC to here so that’s kind of like my debriefing, decompression time.

Come on, guys.

Come on.

I really do try to leave it before I walk in the door.

There you are.

We’ve always had dogs.

They just look at you when you come home, they could care less if a patient yelled at you or a drunk person tried to hit you or...they really don’t care so it kind of puts things in perspective.

Patients just keep coming and the very next patient deserves the best care from us that we can possibly give and they have nothing to do with what just happened in the trauma bay next door.

All righty, we’re going to get you out of here.

It’s such a stressful environment and it just can go from zero to 100 in a nanosecond.

We have to rely on each other back there in the trauma bay and whoever I’m working with has to know that I have their back and vice versa and that we just have to work in sync.

Yeah, that’s good.

That’s good.

It’s kind of like a bunch of siblings.

We love each other, we can joke with each other and be mean to each other but at the end of the day it’s just...it’s like a big family.

I love my job.

I can’t see myself doing anything else.

[sirens] In catastrophic situations, many patients are unable to communicate even the most basic information, including their name.

Consequently, all incoming patients are given a pre-assigned trauma name that stays with them throughout their care.

We’ve got a 25 year old male, guys, was driving approximately 35 miles an hour on a motorcycle, no riding gear whatsoever.

He’s got a full thickness laceration to the meaty portion of the right side of his hand.

One, two, three.

Does that mean you’re back now?

You just hung yourself.

You want off collar, right?

Yes.

Do you have any pain where I’m pressing?

No.

How about here?

No.

You have a lot of injuries.

...two, three.

We will follow up on your chest x-ray make sure there is no fractures.

You remember every single thing that happened?

Uh huh.

Can you touch your chest with your chin?

Any pain here at all?

No.

All right.

I got dirt falling out of my ear.

Mm hmm.

I’ve got to clean it out.

There’s no two ways about it.

If I don’t do it now, the doctor’s going to want me to do it before he stitches it up.

Looking good.

Ouch.

I should have worn a helmet.

It’s not your fault.

Hey, Mitch.

Hey, how’s it going?

How you doing, buddy?

Not much.

All right.

Well, I’m Dr. Tang.

So tell me what happened.

Okay.

I was coming around a blind corner, there was an SUV in my lane when I came around and they were coming right at me so I went off the road...I lost control of the bike and when I realized I had lost control I dived off of it.

Anything hurting on the back?

No.

This thumb here, right between these two joints is hurting.

Okay.

But...

I hear you.

We’re going to wash this out, okay?

It’s going to hurt a little bit.

So okay, give us about 10, 15 minutes we’ll get these washed up and cleaned up for you.

I was very fortunate.

I was doing 40 miles an hour and I tucked and I rolled but it could have been far, far worse.

If I would have hit the asphalt, I probably wouldn’t be talking to you right now.

So wear a helmet.

Hello, ma’am.

Are you there with him?

I’m right here, yes.

The overwhelming majority of trauma center visits begin with a three digit phone call.

Blood’s coming out of his ear.

He’s having an allergic reaction.

I’m on a roof and my leg’s broken.

He must have shot himself.

She’s conscious right now but she’s getting weak.

He was walking... 911.

What’s your emergency?

A lady passed out in a vehicle.

A 911 operator determines what the problem is, whether it’s a fire or medical problem or a police problem, they determine where the call is.

Can you spell that for me?

Once they’ve determined that, they transfer the call.

Okay.

Stay on the line for the emergency dispatcher.

Do not hang up.

The call goes to an emergency dispatcher.

How many vehicles are involved in the rollover?

And as soon as they get a determination of the severity of and what the problem is exactly, they’ll dispatch the call.

Battalion 1, EC2, Engine 16, Ladder 16, Medic 9, Medic 7, Speedway Blvd.

and Kolb Road.

While they’re talking on the phone, help is on the way.

What else?

Anything else?

Any other information?

What happened?

That’s the frustration is that you want to help, you’re here to help.

Is she... No.

No, no, no.

Is she bleeding?

But they’re so caught up in their distress that they’re not listening, they’re not doing what you’re trying to get them to do to help the family member or friend until units get on scene.

...in the lane to the right of her.

Right, okay.

Okay.

We do have units in route.

They should be there very soon.

The dispatcher can pick up pretty quickly on the fact that it’s a trauma call and the severity of the call.

A rollover accident for instance, a shooting, something along those lines.

As soon as we hear some key words... He’s choking.

Okay, hold on.

He’s having trouble breathing and swallowing now so you need a medic.

Boom - a determination is made and the help is on the way.

So a lot of times and in most cases I would say help is sent probably more quickly to a trauma call because it’s more easily recognized.

I hear sirens.

You hear the sirens already?

I can hear them, yeah.

Okay, good.

I’m going to stay on the phone with you until they’re there with you, okay?

Thank you.

[Spanish] There are different ways to determine whether air support is needed.

Sometimes we determine just based on the information we get.

Secondly, we get calls from dispatch centers around the southeast region and we have direct radio contact with field units who will just over the radio say, ’We need a helicopter launched,’ or the helicopter put on standby.

We’ll try to get an address or a local area and then we use whichever helicopter is the closest.

You’ll see there’s these little white indicators, those tell you where the helicopters are and so we’re looking for the closest helicopter.

So we would let whoever just called us know that we needed Airvac 24 on standby or launched ’cause they’re the closest helicopter.

Then we call that helicopter and let them know.

[Spanish] It does take a special kind of person.

These are dedicated people.

They really are.

It’s shift work so you work nights, you work weekends, you work holidays.

You’re away from your family at times when a lot of people aren’t.

And is he having trouble swallowing?

I don’t know.

He’s been vomiting.

He’s vomiting?

All right.

Stay on the line.

Let me get some help started, all right?

To be successful here I think most people compartmentalize pretty well.

I realize it’s your emergency, not mine.

My job is to stay calm, to stay in control and get you the help that you need.

It’s not my family member that’s sick or hurt or something else so my job is to step back a little and try and see the bigger picture to get you what you need.

All right, we do have units in route.

They should be there very soon, all right?

You’re welcome.

Few of the calls end up with the patient at the trauma center but the first responders attend to every call day or not.

Wiggle your right foot for me.

I got your wallet right here.

You’re all right, bud.

Just lay still, dude.

Just lay still.

Joey, do you have your pad?

Right inside the door.

We can get on scene within four minutes of a 911 call and another four minutes from that time have a patient in the hospital.

One, two, three.

These are the clothes that he had on, can you see if you can find a wallet, ID or anything.

Keep your head down, bugger.

You’re all right.

Keep your hands across your chest.

Keep them right there for me, all right.

I’d say the number one transport is usually from assaults.

There’s a lot of assaults in the area, whether it just be from a fist fight or whether there’s penetrating trauma from a gunshot wound or stab wound.

It’s very popular in this area.

Rescue 8, I’ll keep you guys here to help with traffic and clean up.

We get trauma every shift.

It’s a very busy area.

We run a lot of calls.

There’s a lot of traffic, a lot of violence.

She’s now complaining of dizziness and vertigo.

How are you?

All right.

What happened?

He hit me with a rock.

You’re saying it was this rock here, right, ma’am?

Yeah.

That’s the one he hit you with?

There was two of them.

There’s your ride right there, so...

Rescue 8 is sending in a 48 year old female.

Chief complaint of bleeding from her right ear accompanied by multiple bumps from an assault.

Denies loss of consciousness.

She’ll be transported by Meds 841 to University Main.

ETA 15 minutes.

We do run into a problem with a lot of our system abusers that continually use the 911 system for their drug refills, for their just checkups and whatnots and we don’t send those patients to the hospital of their choice, we go to the closest hospital for data collection so we can keep a close eye on them.

Okay, what’s going on today?

You’re just shaking ’cause you’re off your drugs?

Yeah.

Put your finger in here for me.

And you said you haven’t used any drugs today?

No.

Yeah, I have.

I have used drugs.

What did you use?

I used meth.

Meth?

What would you like to do today?

You need to go to rehab, what’s going on?

Would you walk for us?

Here, I’ll help you up.

I find that patients have a preference for what hospital a lot of times.

Sometimes they’ve had a good experience at a hospital or a bad experience at another hospital.

Meds control, Rescue 8 is sending in a 22 year old male with Meds 840 to University main campus.

Sometimes it’s related to a family member dying.

’Oh, my family member died at this hospital so I don’t want to go there.’ The family member was probably going to die at any hospital, it just happened to be at a hospital but it creates a bad stigma for them so they feel like it’s a bad place or it just has a negative connotation for them.

[sirens] Trauma centers are categorized and verified by the American College of Surgeons according to state and local standards.

The categories range from one to four.

Level one is the highest and provides the most comprehensive care, from injury prevention to rehabilitation.

In addition to the staff or facilities available on site, one of the most important measures for surviving traumatic injuries is the clock.

[helicopter whirring] Time is of the essence for us.

You can’t get a person here fast enough.

We found the best results overall is when you have the trauma specialist in the hospital that’s equipped to take care of those types of injuries waiting for you 24/7.

His I&R is 124 and his hemoglobin went from 15 to 12 so I think that’s good.

You can only bleed out so long.

There’s a joke that the trauma surgeons will say, ’Eventually all bleeding will stop.’ The thing is you have to get the patient who is bleeding, who has a large open wound, you have to control that area.

The only way you’re really going to do it is definitive care and getting them to the right place that knows how to do it and they can do it within a time.

If you don’t, tissue dies.

The body compensates only for so long and then you really just need it fixed, whatever is broken.

The golden hour stem from long history, I think it was our Adams Cowley at Shock Trauma Center who kind of coined that phrase and when you look at that, they just wanted to theoretically define a timeframe.

But we almost call it the platinum 15 minutes.

We got them in from the field, that usually takes 15 to 20 minutes, 30 minutes.

Now we have only another half hour when you’re looking at that golden hour to really do what we need to do in the emergency department to identify the airway, the breathing and the circulatory issues that can kill them in the next 30 minutes to 45 minutes, get them to the OR and stabilize them.

In a community without a trauma system they’ll go to the nearest ER and then there would be a transport to a trauma center and that moves you out of the golden hour.

[sirens] In the 1980s Tucson was that type of community, without a trauma center.

Within a few years there were two.

One at both TMC, Tucson Medical Center and UAMC, The University of Arizona Medical Center, the two largest hospitals in Southern Arizona.

The fact that both hospitals established trauma centers at that time was indicative of the emerging specialization and science of trauma care.

Despite the novelty, the reality of finances became a factor.

as it is today.

By the late 1990s it was clear that the trauma system was losing a substantial amount of money.

We talked a lot about this being a public good that was provided in a private marketplace and so TMC and UMC commissioned a report in the late 1990s to look at the trauma system in Southern Arizona and began a dialogue with local, state government officials about how we might better fund the system.

It was losing...TMC was losing $3.3 million a year on about 1,000 patients and that was unsustainable.

In 2001 in the fall, UMC and TMC came to the Council and said that they were having a difficult time financially and would the city please find some funds to help them.

They were looking for immediate funding and of course that was a difficulty for Tucson because cities in Arizona don’t usually provide healthcare.

While I was still on the council, TMC, which incidentally is in my ward, Ward 2, closed their level one trauma care center.

They just absolutely could not keep on.

TMC exited the level one trauma business on July 1st of 2003.

TMC is a standalone community hospital and every day every year we have to take a very careful look at every service that we provide and every activity that we do so that we can remain financially viable.

There are difficult decisions that are made today, there were difficult decisions that were made 10 years ago.

We are now in Southern Arizona with six counties with just one level one trauma center.

You compare that to Phoenix, it has six level one trauma centers.

Tucson Medical Center remains the largest provider of emergency medical care in Southern Arizona.

As its name implies, University of Arizona Medical Center has had an educational commitment since its inception in 1971.

We take our mission as an academic medical center very seriously and we think that by being a trauma center we provide not only a service to the community but also an opportunity for learning for the medical students and the residents in Arizona and so it was important for us to keep the trauma center open because of those two different missions that we have that really no other facilities in Tucson have.

Frankly, the costs of readiness require a certain level of volume so you have to see enough trauma patients in order to make the cost make sense.

Just a little bit.

Hurts here?

Okay.

We estimate that we spend about $20 to $25 million a year on what we call trauma readiness costs which are the cost of having the physicians, the trained nurses and all of the infrastructure here on site 24 hours a day seven days a week to provide that care.

That $20 to $25 million number, it doesn’t include the cost of all the care that’s provided to the patient once they’re here.

Only three percent of the cost of the trauma center at UMC comes from private insurance.

If they don’t have insurance, then the hospital has to absorb that cost so it’s really essential that we find some ways to cover this.

I think we need to educate the public that when they require emergency services, many people think of fire, police, first responders that where are those first responders going to take you.

They are going to bring you here.

I feel like we’re a public servant no different than firemen, no different than police officers and so on and you need us to be here all the time and it shouldn’t be a really a cash fee-for-service type of practice.

One way or the other that we need to have public support in order to make this go forward, otherwise we’ll be back to the way it was when the system wasn’t so good and that only hurts the people of Tucson.

So if we decided we’re not in the trauma care business, we can’t afford the readiness, we don’t want to absorb all this volume any longer, what happens is the playing field becomes equal in our region so all injured patients would go to the closest emergency department.

Airway breathing, circulation gets stabilized, a decision is then made, ’Does this patient need to transfer to Phoenix?’ That transfer of over 100 miles takes the patients out of the golden hour and diminishes their chances for survival.

But long distances and added transport time are daily realities to rural, non-level one trauma centers that provide critical, immediate care to their patients, many of whom are neighbors.

I love working rural.

I love taking care of people I know.

People are so nervous, so afraid, they’re hurting so bad and then they land in this emergency room out in the middle of nowhere and that makes them that much more afraid and I love watching them understand that we know what we’re doing and understand that we’re going to take care of them and relax into it and let us just take care of them and it’s the best feeling ever.

A lot of times people who are in the far outlying areas, if they’re 25, 30 minutes out of town, they won’t wait for an ambulance to get to them.

They will just load a patient up in their backseat and they will come to town with that patient.

Emergency department.

This is Kelby, how may I help you?

And so it was last night that it started, right, you said?

We get gunshot wounds, stabbings.

One thing that’s a little more unique to here is farming accidents, ranching accidents and those are the guys who don’t call the ambulance, they just show up at the door with a skill saw to the leg, hand amputations, things like that we get a lot of just showing up at the door.

My name’s Julie and I’m the nurse practitioner here today.

This is Kelby, she’ll be our nurse.

What’s up, buddy?

[baby crying] He started throwing up yesterday.

Okay.

But he didn’t have anything else to go with it like a fever.

How you doing in here?

Not okay.

How’s the pain compared to what it was when you came in?

Well, I was doing pretty good...

I would say for me, I transfer somebody probably almost every shift.

NIDDM patient with hypertension.

He started having his chest pain intermittently last night and it got worse around 2:00 this morning and I just want to put him in to rule him out based on his history and his diabetes.

We call and just say, ’I need to talk to a trauma surgeon,’ and they connect us right away.

If we need to start any additional treatment here, then we’re collaborating with the trauma surgeons before they go.

No, I won’t be sending you home.

I’ll let you know, okay?

Okay.

All right.

Thank you.

You bet.

We just get them stabilized with blood or fluids and pain control and get them in the air into them as quickly as we can.

It’s about 40 minutes from here via the helicopter when they’re on our pad and so we try to do our best and get them out the door and to Tucson.

[helicopter whirring] Do you know where we’re going?

Yeah, trauma four.

She fell on her bathroom floor about four o’clock.

No noticeable trauma.

No complaint of any trauma.

We intubated her about 8:10 with a 7.0.

One, two, three.

Hi.

This is... Not from our understanding of Chip’s report.

Let’s call pharmacy.

Let’s get a Foley in her, get blood work drawn and then let’s go to CAT scan.

How many IVs does she have?

She’s got one 22 gauge.

Jessica, can you switch DT to this side?

So they brought her to you?

Yeah.

She apparently was complain...after her fall she was complaining of some hip pain.

Okay.

So the family took her in to the Copper Queen ER at that time.

We have no blood pressure cuff on right now, right?

No blood pressure cuff.

Yeah.

Remember you’re with Moses now so you’re in good hands, okay?

Yeah.

All right.

Then we’ve got David over here on the side so even better.

Okay.

Moses and David.

Absolutely.

And you’ve got Angel around too.

I’ll find Jesus later on, okay?

All right.

[Spanish] One requirement of level one trauma centers is education.

This can range from preventing injuries to training perspective doctors.

Big poke here, sir.

Before this rotation I was really not considering a surgical specialty.

Really the breadth of cases and patients that come in and all the just fast paced critical decisions that need to be made it’s...you have an idea of what it’s like from stories and from the news but you don’t actually know what it’s like.

I actually started out wanting to do surgery so this kind of helped me consolidate that I do want to do it.

I like that you get to work with a lot of different people in all aspects of healthcare field as well as nons.

Raise this leg up for me.

Lift it up off the bed.

We’re sort of told that there’s all these different subspecialties and there’s all these different fields that you go into but what you end up finding out is it’s all very much a blend.

It’s a team effort and at the end of the day you realize that you can’t do this alone.

Trying to do the best for your patient isn’t necessarily what you can do for the patient, it’s who you can call in, who you can get to help you so that it’s patient centered, it’s not physician centered.

This is what all of us do in a level one trauma center.

We educate ourselves and we educate the public, we educate the community.

This is called outreach and it’s just part of our job.

So first I just want to take a minute to talk about how important it is to identify the critical trauma patient.

You have to stay current and this is the way we do it.

If you look at the data, the data shows that ultrasound is actually very good for helping us diagnose these injuries.

The level one’s are responsible for helping give that information to the people who are here.

It is part of their license requirement as well that they stay current.

We have to have people that are interested in changing the way we work and always looking for a better way to do it.

It’s an under recognized or current part of trauma, at least one in five women in the ED.

Three question 20 second screen will solve most of the issues and I implore you, please ask the question.

We know that four women are murdered every day in this country by husbands, boyfriends or exes.

The most important thing is to screen for the problem.

There’s a three question, 20 second screen, basically asks, ’Have you been hit, kicked, punched, slapped or otherwise hurt by somebody you know within the last year?

If so, whom and is anybody making you feel unsafe?’ 20 seconds.

Almost a quarter of them will have been to the emergency department six to 10 times prior to the diagnosis being made and another 20 percent will have had 11 emergency department visits before anybody figures out what’s happening so we have lots of chances to intervene that we’re just plain missing.

It’s an honor to serve those who serve and to be in this field where what we do for a living is an honorable field and to get paid at it at the same time, we’re very fortunate so we try to make it as fun and enjoyable for them as we can.

What about hypertonic saline in transit?

There are probably more studies and literature on hypertonic saline than there are anything else.

Don’t we need to prescribe that?

Yes, you do and I just did.

[laughter/clapping] We have these types of meetings all the time.

This is in addition to the academic meetings where we go and present our information and show what our data shows and that’s a huge aspect of what I do as a trauma medical director as well.

I’m traveling two, three times every single month for these types of events.

This is a very important part of what I do.

How do you define our humor?

Well, drunks aren’t funny.

People throwing up aren’t funny.

The doctors aren’t funny but people throwing up on doctors is hilarious.

[laughter/clapping] Thanks a lot, have a good day.

I think the other thing the trauma centers do is provide a lot of public education and public awareness.

They train you to be safer, be smarter, wear your seatbelts, don’t text and drive, don’t drink and drive, and all of those messages and we work with our policymakers as well as our community to prevent injuries.

We have that responsibility.

Every year nearly 300,000 teenagers are seen in trauma centers nationally as a result of car crashes often associated with alcohol or distracted driving.

So as part of their injury prevention efforts, UAMC takes the trauma to the teens.

At Tombstone High School in Southeastern Arizona, UAMC assisted with this mockup of a car crash that was presented by local first responders and students themselves.

[sirens] This mock car crash is something to just try to grab kids’ attention.

This time of year with prom and graduation can be the deadliest time of year for high school students with car accidents and we want them to just think about it beforehand.

Can you hear me?

[sirens] Being myself in the accident I honestly felt like it was real because one second me and the people...me and my friends in the car, we were all talking and everything and then the next second like the crash happened and I’m out the window dead.

Cover him up.

We’re going to take the roof off Michelle and then we’re going to take the doors off, all right?

All right.

All right guys, all the seatbelts are cut, right?

Bruce, don’t let it fall on these girls.

Personally, I take away the fact that your phone can wait.

It’s not that important.

Nothing’s more important than you getting from Point A to Point B safely.

It’s not that important.

It can wait.

Get this one out first.

I’ll get the other one out there.

I haven’t been able to...yeah, I haven’t been able to get a response.

Joannie, can you hear me?

I think it’s important for students to see this crash to realize that it does happen and it could happen to you and maybe they could prevent it if they understand how dramatic and how it can change people’s lives.

[helicopter whirring] [chatter] No, she was with some friends but they’ve already been transported.

That’s what the whole event is for is to try to get the kids to think before they get in a car with somebody who’s been drinking or driving, think before they drink or drive and when they are in the car think about that text message can wait, leave that phone alone.

[cheering/fireworks] Perhaps due to the outreach done by UAMC and others there were no teenage crash deaths in the region during this graduation season.

But unfortunately, there was still trauma.

No, we have everything.

Is there a small...

Thanks.

You’re welcome.

Got 3 here... Can somebody call trauma and make sure they’re in the room?

Thank you.

I’ll take it down.

Yeah.

She’s in PEA currently.

She’s had a total of three milligrams EPI down the tube, multi-system trauma.

We kind of just scooped her and went.

She has an extensive history, family’s on their way.

Sugar of 83.

One, two, three.

Let’s look in the belly and see if there’s blood Oxygen.

She was agonal when we got to her and then lost her pulse on a PEA.

She’s been PEA the whole time for us.

How long has it been?

She’s an elderly lady who was involved in a motor vehicle crash and sounds like she had been without any vital signs meaning blood pressure or heart rate for going on 30 minutes so essentially when she came here she was dead on arrival.

There are rare circumstances where we will continue the resuscitation process and rarely we do bring patients back from the dead but by and large that’s not common and by and large that doesn’t happen in someone her age and who’s been down for that long and that’s the reason why the minute she arrived we decided to cease all further resuscitation process.

A level one trauma center must provide the full range of care and healing its patients need, from the critical first moments through rehabilitation and discharge.

Of all the services provided and technology used, the most essential component is the people who provide the care, the doctors, nurses, therapists and specialists who assist the patient along every step of the journey.

It’s a costly and emotional process that can take years, weeks or months, as it did for motorcyclist Zane Cox.

This is Zane, 18 year old male involved in a motorcycle accident.

We have a dislocation of the left lower extremity at the knee.

Fourth unit of blood starting.

I ended up having three compound fractures through my right arm, I shattered my wrist, I had radial nerve damage from my elbow down, I fractured my femur, my tibula, I dislocated my shoulder, I dislocated my knee, I broke some ribs, I collapsed a lung.

Before this I’d never broke a bone really.

He had 15 units of blood given to him that first night in surgery.

We only have 12 units in our body.

There was a team of two trauma doctors that stayed with us through the entire process and kept us in communication.

The vascular team delivered us the good news that they didn’t have to do anything, that it was just because of the lack of blood flow that they couldn’t get a pulse in that leg so that they were going to be to go forward and actually try and mend the leg.

You could just tell whenever he came out to give us more news that they were going to be able to keep going, that they were just like... ’cause I’m like thinking, ’You guys have been at this for how long?

How exhausted are you at this point?’ ’cause you kind of have a sense of, ’This isn’t easy.

What you’re doing can’t be easy,’ but they were just...you could tell they were just like so excited about being able to keep going.

We were in ICU for nine days.

And to have the level of empathy and care they had because this is what they do every day, you’re just another patient but I never felt like that, ever.

The bird walking, check it.

I still have a little bit of struggles, a little bit of pain but not to what it was.

I’m doing very well with physical therapy and healing in general.

It’s given me a really good outlook on life to tell you the truth.

There’s no doubt in my mind he’s alive today because of the care he received and if we had been someplace else that might not have happened.

To know that they are here in our community and to know that they’re available to us and we just take it for granted until we need it.

[music] Funding for this program was provided by Desert Program Partners.