WHAT IS TRAUMATOLOGY Faye Chiou Tan MD Chief

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

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 – 2 nd century, BC Hippocrates – “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 – 5 th 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 (15 th century), hospitals, nursing care, compassionate care.

History 17 th and 18 th centuries • De Motu Cordis – William Harvey, circulation of blood • 1666 – Lower – blood transfusions

Kinematics of Trauma • Cavitation – like a game of pool or bowling (Norman Mc. Swaim, Jr in Textbook Trauma) • Permanent cavity and temporary one • Muscle spread without tearing • Liver and spleen inelastic and rupture

Kinematics of Trauma Bullet bow shock wave – Shadowgraph or Schlieren images

Types of Traumatologists Orthopedic 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

Types of Traumatologists General Trauma Surgeons Textbook “TRAUMA” 4 th edition, Mattox, Feliciano, Moore Fluids, nutrition, organ repair, swelling, fasciotomy, DIC

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 Academy Stages of help Wave I (Day 1 -10) – Crisis stabilization Wave II (Day 5 -15) – Stress management, social support Wave III (Day 10 -20) – Training, referrals, resources Wave 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)

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

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

Types of Physical. Traumatologists 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

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 reports J Computerized Axial Tomography – Anatomic series Electrodiagnostic medicine in trauma rehabilitation in EMG Secrets, Tan, editor.

Training of NIDRR- ARRT research fellows (2002 -2014) • Two tracks – SCI and TBI • Two year research program with up to 20% clinical 5 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

Education component • Dr. Pandit – Education Director • Resident Traumatology Program and Rotation • Traumatology Journal Club • Traumatology Fellowship Program Application

Rehabilitation Traumatology Fellowship funding • Texas Higher Education Coordinating Board • Emergency and Trauma Care Education Partnership Program • Baylor receives $475 K 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 mm. Hg (NL < 15 mm. Hg). What is the most common traumatic nerve injury? Radial nerve

Suggested References Traumatology Journal of Traumatology Orthopaedic and Trauma Surgery Orthopaedics and Traumatology TRAUMA – Mattox et al. Trauma rehabilitation – Robinson, Larry

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