When R. Todd Maxson, MD, FACS, a pediatric trauma surgeon, left Texas for Little Rock, AR, in 2009 to help establish the Arkansas Trauma System, little did he know that eight years later he would get a firsthand education in how well that system works today.
“It was Friday, September 1, 2017, and I had worked until just before midnight the day prior. I was on call at the Arkansas Children’s Hospital, and we had had a long day with many cases, and we were still operating at around 11:00 pm,” said Dr. Maxson, chief, trauma program, Arkansas Children’s Hospital; professor of surgery, University of Arkansas for Medical Sciences (UAMS) and Consultant on Trauma, Arkansas Department of Health (ADH), Little Rock.
He decided to take a short break and go home to change into fresh clothes and feed his pets. He rode his motorcycle for about a mile when he was struck by a car. He laid in the street for a few minutes before a couple of passersby came to check on him. “I had one call 911 and one call Children’s Hospital because I was still on trauma call. I got hold of the resident who was on call and asked her if she would call my backup, one of my partners, so that we would be covered. The ambulance arrived a few moments later,” he said.
A trauma system in action
When the paramedics arrived, Dr. Maxson requested that he be taken to UAMS Hospital (also known as University Hospital)—the only American College of Surgeons (ACS)-verified adult Level I trauma center in the state. “The Children’s Hospital is verified as well, but the only adult center is University Hospital,” Dr. Maxson said. “I made sure that the paramedics knew that was the only acceptable place to go—the ACS-verified center.”
Meanwhile, the residents at Children’s Hospital had already started making phone calls to their colleagues at University Hospital, so that they would be prepared for Dr. Maxson’s arrival. He was greeted by emergency physicians and nurses, the surgical attending, and residents whom he had helped train. “They all did exactly what they trained to do and what they knew to do,” he said. “They started the resuscitation, and the on-call surgeon called in the chief of trauma surgery”—Ronald D. Robertson, MD, FACS—one of Dr. Maxson’s closest friends for 25 years.
The crash left Dr. Maxson with a shattered pelvis and right femur, torn ligaments and a fibial fracture in his left knee, two broken bones in his right arm, and a torn bladder. Dr. Maxson says he was able to avoid a life-altering brain injury because he was wearing a helmet.
“They really did a fantastic job. I was in a little bit of trouble, and they put me to sleep, and they took me to angiography and did a procedure to stop the bleeding in my pelvis,” Dr. Maxson said. Dr. Maxson underwent five operations in four days: the angioembolization to stop the pelvic hemorrhage, stabilization of his right femur with internal fixation, an almost 12-hour operation to correct his pelvic fractures and bladder rupture, internal fixation of the bone fracture in his right arm, and an operation to repair the lateral capsules, lateral ligaments, and fibial fracture in the left knee.
“Really, they marshalled all the troops. I had an unbelievable orthopaedic trauma team, a sports medicine trauma team, a trauma and critical care team, and a urology team,” he said. “I had almost no complications. I spent some time in the intensive care unit (ICU) and a week on the floor learning all the adaptive equipment, and then my wife, Amy, who is a nurse practitioner, was able to take me home within three weeks.”
After three more weeks, Dr. Maxson was able to resume his work as Chair of the ACS Committee on Trauma (COT) Verification Review Committee (VRC), conducting meetings by phone in preparation for the ACS Clinical Congress 2017, in San Diego, CA. “I really credit that with part of my recovery—at least in terms of my mental health. That helped me tremendously to focus on something else and keep me going,” he said.
“Probably a week after that, I was able to go in a wheelchair-accessible van back and forth to work to take on my administrative duties as chief of services at Children’s Hospital,” Dr. Maxson added. “In November, we had our site verification survey from the ACS COT, so I had a lot of preparation to do for that. My wife and colleagues were really helpful in terms of helping me get back and forth and to prepare for the site visit.”
By November 2017, he also was doing physical therapy and swimming to build his strength and cardiovascular reserves in preparation for walking. He had one more operation, removal of the pelvic stabilizing bar, in early December and began an intensive program of walking and physical therapy. He was able to travel to Chicago, IL, in January for the COT Executive Committee meeting.
Establishment of the Arkansas Trauma System
Odds are Dr. Maxson and many other trauma patients in Arkansas would have received less aggressive and less timely care in 2009 than in 2017. “In 2009, University Hospital was not a trauma center—not a state-designated or an ACS-verified trauma center. While the care was good, the resources absolutely were not in place to comply with the College’s verification,” he said, adding that he believes the outcome would have been dramatically different had he been involved in the collision at that time. “In our state, there were no real trauma teams. There were few physicians who were fellowship-trained in surgical critical care and trauma care. There was no orthopaedic traumatologist. There were no procedures or protocols in place to ensure that we got the right patient to the right place the first time. The preventable mortality rate was unacceptably high,” Dr. Maxson said.
The turning point for trauma care in Arkansas came in 2008, when Michael F. Rotondo, MD, FACS, then-Chair of the ACS COT, at the request of the ADH, offered a blunt assessment of the state’s preventable morbidity and mortality data. “He gave a comparative analysis on where Arkansas stood in comparison with the rest of the country, and I think it was shocking—shocking to the elected officials and shocking to the academics here in the state. But it was the final impetus that pushed the legislature and the governor in 2008 to set aside monies for the trauma system,” Dr. Maxson said.
“It was very powerful for us to have been able to point out how we compared with other states. I think before that, the elected officials and the public didn’t know exactly where we stood and how far we had to go,” Dr. Maxson said. “It wasn’t that Arkansans didn’t expect to be taken care of and the health care system didn’t believe its hospitals were doing a good job. They just didn’t have the comparative analysis. That’s one of the benefits of participation in the College: you get a national perspective.”
This analysis led to the enactment of the Arkansas Trauma System Act of 2009. Until that legislation was put in place, Arkansas was one of three states without a trauma system and the only state without a state-designated or ACS-verified trauma center. Injury was the number one killer of Arkansans between the ages of one and 44, and Arkansas’ overall injury fatality rate was 33 percent higher than the national average, according to a December 2017 ADH report. Moreover, the preventable death rate was 30 percent, according to a study published in the Journal of the American College of Surgeons (JACS).*
In fact, Arkansas had the highest injury mortality rate in the country before 2009, and preventable mortality was more than twice the national average, Dr. Maxson said.
In addition, the average time from injury to definitive care exceeded six hours, he said. A December 2008 report from the American College of Emergency Physicians cited Arkansas as having the worst system of emergency care in the nation, according to the ADH.
“So, we had a crisis in the state of Arkansas, and it was costing lives and it was costing money,” Dr. Maxson said. “It was really an unacceptably high public health burden.”
The ADH was charged with implementing the Trauma System Act of 2009 and, with UAMS, called upon Dr. Maxson to assist in establishing the trauma system in the state. Dr. Maxson had previous experience in trauma program development. He was responsible for starting the trauma program at Children’s Medical Center of Dallas, TX—the first ACS-verified Level I pediatric trauma program in the southwest U.S.—and for building the trauma services program at Dell Children’s Medical Center, Austin, TX, also an ACS-accredited Level I pediatric trauma center. He served for five years on the Governor’s Advisory Committee for the Texas trauma system and on the ACS COT.
“I came in 2009 as the medical director, and obviously, I was inextricably linked to the College and its resources. We availed ourselves very quickly of a systems consultation visit from the ACS, and that helped us get started on the right path,” Dr. Maxson said.
“We worked with the College to conduct a preventable mortality review, and we really were in touch with the College at every step. I know our system has been successful because of that,” Dr. Maxson said. “I think Arkansas is the poster child for what you’re supposed to do to establish a trauma system.”
Turning the situation around
In a six-year period, Arkansas was able to establish 57 state-designated or ACS-verified trauma centers, of which six are Level I, five are Level II, 16 are Level III, and 30 are Level IV. Although most of these trauma centers are in towns and cities throughout Arkansas, a few, including four Level I centers, are located in neighboring Springfield, MO; Memphis, TN; and Texarkana, TX, according to the ADH report.
The Arkansas Trauma System Act also established funding to improve emergency medical services (EMS), resulting in needed equipment purchases and personnel training. A total of 178 EMS agencies across the state participate in the trauma system, according to the ADH.
In addition, the state established the Arkansas Trauma Communications Center (ATCC) to ensure that traumatically injured patients are transported to the hospital best equipped to treat their specific injuries in the shortest amount of time. Call center operators are trained paramedics and nurses, and they triage and advise on transport of major and moderate trauma patients to hospitals that can provide optimal care.
According to the ADH, three major changes in the state’s medical delivery system were necessary to reduce transport to definitive care times: the creation of a trauma dashboard that provides real-time notification of a hospital’s capability and capacity; equipment of more than 500 ambulances with trauma radios so that EMS providers can call the ATCC from the scene of an accident; and a change in longstanding hospital policies to allow medical staff in the emergency department to accept patients rather than requiring an admitting specialist to be notified.
The state also put in place a quality improvement plan that encourages open discussion of outcomes, efforts to validate and analyze data related to each component of the trauma system, and use of the ACS Trauma Quality Improvement Program (TQIP) to benchmark Arkansas trauma centers against those in other states to identify opportunities for improvement. Arkansas is the first state to require all trauma centers to participate in TQIP, and it is the only state that requires trauma centers at all levels to submit data to the ACS National Trauma Data Bank.
The Arkansas Trauma System also provides funding for trauma education, including presentation of the Advanced Trauma Life Support® (ATLS®) course. The percentage of general surgeons and emergency physicians who are current in ATLS is 72 and 74 percent, respectively, both of which are above the national average, the ADH report indicates.
Another important development was the creation of a Trauma Image Repository (TIR). Because of the TIR, 84 hospitals across and outside the state can now send or receive radiological images for all types of traumatic injuries to a secure, centrally located repository. Any physician or specialist who provides care at the receiving facility can access these images, either through a web-based application or by having the images sent directly to the hospital, according to the ADH.
The JACS study mentioned previously showed that implementation of the Arkansas Trauma System cut the rate of preventable deaths due to injuries nearly in half over five years and saved 79 lives annually. The study investigators also determined that Arkansas saved $186 million annually, giving state taxpayers a roughly ninefold return on investment from the $20 million per year in public funding that the state has received.*
“So, from both a public health standpoint and a financial standpoint, establishment of the Arkansas Trauma System was a good thing for the state,” Dr. Maxson said.
Pointing to his own experience, he noted, “I’m going to go back to work. I’m going to go back to working for the College. I’m going to go back to work for my hospital. I’m going to continue to pay taxes in the state of Arkansas, and all of those things are because of the recent development of the trauma system in Arkansas. I’m alive and grateful for that—to be able to have made that change in our state,” Dr. Maxson said. “I was proud to be part of it—to be sort of the clinical architect of the system—and the irony is not lost on me that that same system was in place when I was injured, and I credit it with saving my life.”
Advice for surgeons in other states
Based on his experience with the development of the Arkansas Trauma System, Dr. Maxson encourages surgeons in other states that are looking to update, expand, or implement a trauma system to first seek external review. “You can’t get enough outside consultation, validation, and confirmation of your plan and your progress [internally]. State governments, state legislators, and the public value comparative analysis with other like states.”
Second, Dr. Maxson noted, “data is powerful.” He recommends the establishment of trauma registries and risk-adjusted benchmarking of the data, so that you can offer legislators and the public insights into what results they can expect from trauma system development.
Lastly, “you’ve got to tell your story frequently. State legislatures turn over, and if your funding comes from there, then you need an advocacy strategy to continue to let them know what’s being done with the taxpayer money and to be responsive to their questions and concerns. The College has the resources, including the State Affairs staff in the Division of Advocacy and Health Policy, to help you map those out. The message is that you need help, and it’s helpful to have the College and its resources to help you establish or update your trauma system. It pays dividends. It’s the right thing to do for your neighbors and the people of your community, and it’s the right thing to do financially,” he said.
Complete recovery in sight
Thanks to the Arkansas Trauma System, Dr. Maxson was on the road to a complete recovery at press time. He returned to clinical duty in the ICU on February 5 and was back to serving as the chair of the surgery service at Children’s Hospital of Arkansas. He planned to return to operating again in March.
When he returns to active practice this spring, Dr. Maxson anticipates being even more committed to his patients than before. “I learned a lot from this experience about what trauma patients go through. I think I’ll be a better trauma surgeon because of it. I’ve gained a lot of empathy for my patients.”
*Maxson T, Mabry CD, Sutherland MJ, et al. Does the institution of a statewide trauma system reduce preventable mortality and yield a positive return on investment for taxpayers? J Am Coll Surg. 2017;224(4):489-499.