Faye Chiou Tan, MD Chief PMR, Harris Health Professor PMR, Baylor College of Medicine WHAT IS...

Faye Chiou Tan, MD

Chief PMR, Harris Health

Professor PMR, Baylor College of Medicine

WHAT IS TRAUMATOLOGY?

Definitions for Traumatology

• American Heritage Dictionary – “ The branch of medicine that deals with the treatment of serious wounds, injuries, and disabilities”• Random House – “A branch of medicine dealing with major wounds caused by accidents or violence”

History

Edwin Smith Surgical Papyrus• Edwin Smith, pioneer Egyptologist, purchased the

papyrus which bears his name at Luxor in 1862. The original text was written about 3000 B.C.

• It is the oldest known surgical (and scientific) treatise. 47 different cases of injuries and affections of the head, nose and mouth, together with methods of bandaging.

• Ref: Zimmerman & Veith's "Great ideas in the history of surgery" (1967; pp 3-13).

History• “Nei Ching” – Canon of Medicine – 2,600 BC

by Yu Hsiang, debridement of ulcers• Ancient Indian – 2,500 to 1500 BC

Sushruta, leading physician- described surgical tools

• Greek – 2nd century, BCHippocrates – “iatros” – extractor of arrows“Wound” in Greek = Tραvμα is where the word Trauma is derived

History

• American Heritage Dictionary – “ The branch of medicine that deals with the treatment of serious wounds, injuries, and disabilities”• Random House – “A branch of medicine dealing with major wounds caused by accidents or violence”

History

Roman Empire – 5th century AD• Theodoric, Bishop of Cervia (surgeon)

Healing by secondary intention: “It is not necessary,… as modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice,… hinder(s), prolong(s), … and prevent(s) consolidation of the wound.

• Anaesthesia: “Opium, juice of morel, hyoscyamus, mandrake, ivy, hemlock, and lettuce”. “Hold it under the nostrils of the patient until he goes to sleep”.

History• Persian empire – preserved Greek and Roman

knowledge after the fall of Rome• Arabs preserved above after Mohammedans captured

Alexandria – 640 AD• Rhazes, Arab surgeon used cat gut to suture

wounds (850-932 AD)• Middle ages – 1453 AD – regulation of training,

licensing exams, Royal College of Surgeons (15th century), hospitals, nursing care, compassionate care.

History

17th and 18th centuries• De Motu Cordis – William Harvey,

circulation of blood• 1666 – Lower – blood transfusions

• Cavitation – like a game of pool or bowling (Norman McSwaim, Jr in Textbook Trauma)

• Permanent cavity and temporary one• Muscle spread without tearing• Liver and spleen inelastic and rupture

Kinematics of Trauma

Kinematics of Trauma

Bullet bow shock wave – Shadowgraph or Schlieren images

Types of TraumatologistsOrthopedic surgeons

• Polytrauma – no consensus on definition of this term – two separate body areas

• Subspecialty of Orthopedics - Trauma Surgery“Because of the complex nature of injuries seen today, a special area of orthopaedics is now related to the management of persons with critical or multiple injuries to the musculoskeletal system. This specialty is largely surgical in nature and involves close cooperative efforts with many other specialties in surgery.” American College of Surgeons

Types of Traumatologists

Emergency Medicine / Critical care:ACCME accredited fellowships

General Trauma SurgeonsTextbook “TRAUMA” 4th edition, Mattox, Feliciano, MooreFluids, nutrition, organ repair, swelling, fasciotomy, DIC

Types of Traumatologists

Types of Traumatologists

Mental health professionals• 2004 Green Cross Academy of

Traumatologists• Organized in 1995 after the bombing of

Oklahoma City Murrah Federal Building.• International• Non-profit

Green Cross AcademyStages of help

Wave I (Day 1-10) – Crisis stabilizationWave II (Day 5-15) – Stress management, social supportWave III (Day 10-20) – Training, referrals, resourcesWave IV (Day 15-40) – Grief and loss counseling

Green Cross Accreditation• Compassion fatigue educator – teaching self

care and compassion fatigue stress mgmt• Compassion fatigue therapist – fatigue

prevention, PTSD• Certified Traumatologist – must pass trauma

theory (dissociative and DESNOS phenomena, Herman triphasic treatment, compare and contrast 6 treatments of PTSD)

Disorders of Extreme Stress, Not Otherwise Specified (DESNOS).

DESNOS phenomena

Herman’s Stages of Recovery

• Stage 1: dealing with and overcoming such problems, and of any helpful therapy or counseling.

• Stage 2: ‘remembrance and mourning.’• Stage 3:reconnecting with people,

meaningful activities, and other aspects of life.

Types of Traumatologists

• Forensic physicians/pathologists –• Study nature, size, impact of force (blunt,

penetrating), type of agent (chemical, caustic)

Types of Traumatologists

Trauma Nurse Practitioner (TNP)Not agreed upon core competencies

Physical Medicine and Rehabilitation – NEW!• Expertise in handling complex, multiple injuries• Fracture healing, skin, metabolic, compartment

syndrome, hematoma, delayed manifestations on rehabilitation unit

• Increasing function – “Exercise is Medicine” walking, ADL’s

• Decreasing sequelae – secondary late complications such as arthritis, contractures, atrophy

Types of Traumatologists

Rehabilitation Traumatology – proposed definition

• Traumatology -– “ The branch of medicine that deals with the treatment of serious wounds, injuries, and disabilities” (American Heritage® Dictionary)

• Rehabilitation – “To restore to good health or useful life, as through therapy and education” (American Heritage® Dictionary)

Traumatology program at Baylor• Level 1 Trauma Center – hospital with leadership role

in optimal trauma care, QI, education, and research.• Trauma survey – for level 1 trauma center –

rehabilitation is a mandatory component. Continuity of care of the trauma patient.

• Multidisciplinary Traumatology meetings – trauma surgeons, neurosurgeons, orthopedic surgeons, trauma nurses, rehabilitation traumatologists.

• Research program • Educational program

Center for Excellence in Trauma Rehabilitaton Research

• Founded in 2000 at Harris Health and Baylor• “Dum spectas volare”• Production of rehabilitation traumatology

related peer-reviewed articles, case reportsJ Computerized Axial Tomography – Anatomic seriesElectrodiagnostic medicine in trauma rehabilitation in

EMG Secrets, Tan, editor.

• Two tracks – SCI and TBI• Two year research program with up to 20% clinical5 Research Fellows over 6 year grant• Offerings include – neuropsychology, robotic

rehabilitation• Collaboration and electives with other facilities

including – Rice University, University of Houston masters of public health program, etc.

• Clinical rounds with physicians

Training of NIDRR- ARRT research fellows (2002-2014)

Education component

• Dr. Pandit – Education Director• Resident Traumatology Program and

Rotation• Traumatology Journal Club• Traumatology Fellowship Program

Application

Rehabilitation TraumatologyFellowship funding

• Texas Higher Education Coordinating Board

• Emergency and Trauma Care Education Partnership Program

• Baylor receives $475K for• Emergency medicine residency• Surgical critical care fellowship

Example Rehabilitation Traumatology EMG Questions:

Can you perform NCS and needle on a skin graft?Yes, once surgeon says graft has “taken”, usually at least 5 days

What are clinical signs of peripheral nerve injury due to hematoma?Painful ROM, tenderness to palpation, sensory deficit, decreased peripheral pulses

What are symptoms of anterior compartment syndrome?Severe limb pain, weak dorsiflexors, sensory deficit, pain with passive stretch of compartment muscles, tenderness to palpation. Tissue pressure > 60 mmHg (NL < 15 mmHg).

What is the most common traumatic nerve injury? Radial nerve

Suggested References

Traumatology Journal of TraumatologyOrthopaedic and Trauma SurgeryOrthopaedics and TraumatologyTRAUMA – Mattox et al.Trauma rehabilitation – Robinson, Larry

• Please stay for a Traumatology SIG: Q and A immediately after this meeting

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