STYLE Media and Design

Trauma is the leading cause of death for ages one to 44 in Larimer County and in the United States. Trauma Center of the Rockies is a Level II trauma center that provides comprehensive care for critically injured patients in Northern Colorado, southern Wyoming, and western Nebraska.

Motorcycle and automobile accidents accounted for 43 percent of the traumatic injuries treated at the Trauma Center at Medical Center of the Rockies (MCR) last year. Injuries from falls comprised another 32 percent.

Most of these injuries are fairly innocuous, according to Rob Baer, M.D., orthopaedic trauma surgeon with the Orthopaedic Center of the Rockies. “The most common injury we see at the Orthopaedic Center is a wrist fracture caused by falling on an outstretched hand. Ankle and leg injuries are a close second. Unless, of course, you are talking about motorcycles; I think they are dangerous and anybody who decides to ride one has to understand, sooner or later, they’ll probably crash.”

“During the summer months we see a life- or limb-threatening injury daily,” adds Dr. Baer. He notes that it is important to remember not all of these injuries occur in the immediate area. “We have a large catchment area. We get patients, by ambulance or helicopter, from northern Denver, Wyoming, Nebraska, and even South Dakota.

Sometimes, life-threatening injuries are not caused by something as dramatic as a motor vehicle accident or a fall while rock climbing. Sometimes they are just due to an unlucky circumstance or a lapse in judgment. That is what happened to Carlos Toca, a teenager from Loveland, in August 2008.

“Carlos did what the majority of under-21-year-olds with cervical spine injuries have done,” explains Dr. Timothy Wirt, M.D., a neurosurgeon with the Front Range Center for Brain & Spine Surgery, P.C. “He wasn’t drinking. He wasn’t doing anything any other normal 15-year-old boy wouldn’t do.”

It all happened last summer on a sweltering hot day up the Big Thompson Canyon. Dripping with sweat, Carlos and his friends decided to take a dip in the river. One by one, they jumped into the cool mountain water. And one by one they surfaced, refreshed. All except Carlos.

A local emergency medical services (EMS) team was called to the scene. The paramedics quickly assessed the situation and determined, based on his injuries and lack of sensation in his legs, that Carlos needed to be transported to a Level II Trauma Center. He was airlifted to MCR. “He came within millimeters of being a quadriplegic,” says Dr. Wirt, the neurosurgeon on Carlos’ trauma team. “He got very lucky.”

Luckier still, Carlos had his near-fatal mishap in an area with a regional, Level II trauma center. A hospital that was in constant communication with the ambulance crew and had already begun assembling a team of specialists and sub-specialists. A hospital that was already developing an action plan while Carlos was still en route.

Chris Cribari, M.D., Medical Director of Trauma for MCR's Trauma Center of the Rockies

The Process

As the Trauma Surgeon, Dr. Cribari leads a team of specialists like Dr. Wirt and Dr. Baer that are all part of a coordinated on-call system. “We have to be available to be at the hospital within a half an hour,” adds Dr. Wirt. It is a system that works.

“I think (Poudre Valley Health System’s Trauma Program) has unified what used to be a very fragmented approach to treating multiple-injury patients,” says Dr. Wirt. “Before, we would all come in and parcel out our care. There was no coordinated effort. I don’t think there is any question that with this system in place there are improved outcomes.”

Poudre Valley Health System (PVHS) began its trauma program at Poudre Valley Hospital in the early 1990s, building the PVH program into a Level II trauma center.

Rob Baer, M.D., and Orthopaedic Trauma Surgeon with the Orthopaedic Center of the Rockies

“When we were considering building a new hospital, one of the driving decisions was being able to offer these top-level trauma services regionally,” explains Lori McDonald, a registered nurse and PVHS’s trauma program director. “We also realized that we couldn’t take trauma resources out of the city – we needed to make sure that PVH would still be capable of handling some trauma.”

Ultimately, PVHS decided to move the Level II services to MCR, while maintaining basic essential services at PVH at a Level III designation.

Dr. Cribari describes the process: “Upon arrival, the patient is met by a team of specialists who work in concert to quickly identify and treat all of the injuries.” Trauma patients are whisked into a state-of-the-art emergency department (ED) with dedicated trauma rooms where the team’s first task is to stabilize the patient, getting blood pressure and bleeding under control, and resuscitating them if necessary. Once stabilized, the patient is evaluated from head to toe.

Timothy Wirt, M.D., Neurosurgeon with Front Range Center for Brain & Spine Surgery, P.C.

“The trauma patient undergoes a rapid assessment and diagnostic workup while undergoing resuscitation,” says Dr. Cribari. “This begins in the ED trauma bay and continues in the adjacent CT scanner, the OR (operating room), or the surgical intensive care unit. When you have someone with multiple injuries, there may be injuries that are not as obvious as others, but equally important to identify immediately.”

MCR’s trauma team works closely together, says McDonald, who describes the intricate dance that takes place in the trauma room.

“Besides the trauma surgeon, anesthesiologist, and ED physician, there are two ED nurses, a critical care nurse, and an OR nurse. There’s also a phlebotomist from the lab, a radiology tech, and a respiratory therapist. We have a couple of other people who may respond, including a nursing supervisor, security, and a social worker who will notify and assist the family. So it’s a pretty big group of people in the room. Sometimes it may look like chaos, but it is organized chaos because everybody has a specific job to do.”

Daniel Asadi, D.O., Medical Director of the Northern Colorado Long Term Acute Hospital

Recent advances in technology have also enhanced the diagnostic and treatment process. “What is now a critical link is remote digital imaging,” explains Dr. Wirt. “I can read CT scans and X-rays from the office, home, or any of the hospitals. Within 60 seconds, I can tell the trauma surgeon at the other end of the phone whether the patient needs to go to the OR right away or whether it is something that can wait. We couldn’t do the coordination we do without the current technology and system in place.”

According to McDonald, many people misconstrue trauma as ER care. “They don’t understand it is an entire continuum that includes pre-hospital care, in-hospital care, and post-hospital care.”

After the trauma patient is stabilized and evaluated at MCR, he or she will either go to the operating room or to the surgical intensive care unit (SICU). In Carlos Toca’s case, the trauma team determined that he had broken his neck and bruised his spinal cord. He was taken into surgery where Dr. Wirt inserted a plate and fused his spine.

Joseph Jacob, M.D., Medical Director of the Northern Colorado Rehabilitation Hospital

Once patients get to the SICU, whether they come directly from the ED or from the OR, they are carefully followed by their trauma team. “Trauma patients have a potential for fragmented care,” says McDonald. This can happen, she explains, because of the different specialists who may be involved in their care.

The trauma center employs trauma case managers - nurses specially trained in the care of the injured patient - who work closely with the trauma surgeon. Case managers serve as a liaison for the patient, family, trauma team, and specialists, says McDonald.

“We do multi-disciplinary rounds every morning where the trauma surgeons and care providers come to the patient room to review the plan of care with each other and the patient,” she says. Besides the trauma surgeons and case managers, the team includes primary care nurses, a physical therapist, pharmacist, and discharge planner.

Sam Laney, M.D., Associate Medical Director of the Northern Colorado Rehabilitation Hospital

Once patients are ready to leave the SICU, they are moved to the post-trauma unit. “One of the scariest times for families is when the patient is ready to leave the ICU,” says McDonald. “Again, the case manager is available to the patient and family. Because they see the same person throughout, it reassures the patient and their family and provides continuity of care.”

Simultaneously, the team is getting the patient ready to leave the hospital. “Our rehabilitation therapists are integrated from the get-go,” says McDonald. “They’re already doing things while the patient is still in bed and do a lot of therapy with the patient in the room.”

Medical Center of the Rockies' Trauma Center of the Rockies team works to stabilize a patient.

What Happens After The Hospital

Trauma care doesn’t end when patients are ready to be discharged. The continuum of care includes making sure the patient gets the post-hospital care they need. The trauma team works with the patient and family to find the best fit for their rehab needs, which may include the PVH Life Skills Rehab facility or one of the other local or regional rehabilitation facilities.

Two other local options include The Northern Colorado Rehabilitation Hospital (NCRH) and the Northern Colorado Long Term Acute Hospital (NCLTAH), both of which share a campus not far from MCR.

Decisions regarding post-hospital care are made based on the individual needs of the patient. For example, Carlos went to Craig Hospital in Englewood where he would meet and be treated with other young patients with spinal cord injuries.

“If a patient has enough injuries that they can’t go home safely and they need a doctor to manage their medical issues, then such a patient is more appropriate for an acute rehabilitation hospital like NCRH,” says Sam Laney, M.D., Associate Medical Director of NCRH. “We actively look at patients who have multiple injuries and require multiple avenues of care to recover. The goal, which is accomplished as a team, is to medically optimize them, make them stronger, and enable them to do more for themselves. We call that maximizing independence. We train them safely how to use devices like walkers, power wheelchairs, and even train the family to take care of their loved one in the home environment.”

NCRH was recently rated in the 10 percent of inpatient rehabilitation facilities in the United States. “This hospital is the only freestanding rehabilitation hospital north of Denver and into Wyoming,” adds Joseph Jacob, M.D., NCRH’s Medical Director. “We provide physical rehabilitation for individuals with arthroscopic, neurologic, or musculoskeletal disease or trauma. In this hospital, we can admit patients over the age of 14 from a variety of settings.”

For patients who are very sick, have a great preponderance of medical issues, and require constant monitoring, NCLTAH might be a more appropriate choice. “If a patient is too sick to actively participate in rehabilitation, the NCLTAH would be an option,” says Daniel Asadi, D.O., NCLTAH’s Medical Director. “At our facility, we have pulmonologists, nephrologists, and infectious disease doctors. It is a level of care that is more intense. All the rooms are able to have a cardiac monitor.”

Dr. Timothy Wirt with Carlos Toca minutes before he removed the hardware from Carlos' neck. Thanks to Dr. Wirt and the Trauma Center of the Rockies team, Carlos has recovered significantly from his accident in August 2008, where he broke his neck and bruised his spine.

“NCLTAH is for patients who need an ICU level of care,” adds Dr. Laney, who often consults with Dr. Asadi on an as-needed basis.

Such collaboration is one of the many positive aspects of a joint campus. “It’s just a wonderful situation because, even though we are two separate entities, the doctors at NCRH and NCLTAH can help each other,” explains Dr. Asadi. “The medical and therapy related strengths of each facility complements the other,” adds Dr. Laney, “It makes the medical campus better able to meet the needs of the complex patient.”

Once NCLTAH patients are more stable, it also provides a continuity of care when they transfer to NCRH. “A good portion of our patients go to the rehabilitation facility,” agrees Dr. Asadi.

Once patients are released from whatever rehabilitation setting deemed appropriate and go home or into a skilled nursing facility, the continuum of care goes on and the circle closes. Patients continue to meet, on an outpatient basis, with specialists like Dr. Wirt and Dr. Baer, who manage their care as long as such oversight is necessary.

“It is a trauma system that works,” says Dr. Wirt, who thinks more communities need to adopt a similar model. “Nationally we need to have highly efficient, good trauma centers that work with trauma patients. If we don’t promote (our success) other systems will never evolve to where they need to be.” And in the end it will be the patients and their communities who are short-changed.

For Carols Toca, the outcome is a happy one. This month, Dr. Wirt removed the hardware in Carlos’ neck. Besides some limitations in his hands, he is almost back to normal and, with a few restrictions, Carlos is able to participate in most activities with other teens his age. +

The Five Levels of Trauma Care: What They Mean

There are five levels of trauma care a hospital or other facility can choose to provide, according to Lori McDonald, Poudre Valley Health System’s Trauma Program Director. They are as follows:

Level V → Indicates a minimum level of care and is generally assigned to ski clinics.

Level IV → Indicates a small community hospital where physicians are available, but general surgeons may not be available 24/7. In a trauma situation, their role is to stabilize the patient and get him or her ready for transfer to a trauma center.

Level III → Indicates the hospital has a trauma center. In addition to the anesthesiologists, there are general, trauma, and orthopedic surgeons at the ready. Other sub-specialists, like neurosurgeons and facial-trauma surgical specialists, may not be available. Poudre Valley Hospital is a Level III trauma center.

Level II & Level I → Indicates a hospital that offers what is considered upper-level care. This hospital can take care of the full spectrum of clinical needs. Sub-specialists are on-call, ready to respond as needed. The only difference between a Level II and a Level I is that Level I is affiliated with post-graduate Residency programs and has a trauma research program. Medical Center of the Rockies is a Level II trauma center.