When every second counts

Razek’s passion on the subject is easy to understand. As chief of one of only four tertiary trauma centres in Quebec, Razek is responsible for making sure that victims of the most devastating car crashes on the island of Montreal immediately receive top-notch care from a coordinated team of specialists. In total, more than 9,000 major and minor trauma patients — victims not only of crashes but of falls, workplace accidents, assaults and anything else that results in severe injury — pass through the MUHC’s Emergency Department at the General each year, with more than 1,600 admissions. According to Razek, this makes the MUHC one of the busiest trauma centres in the country (the Montreal Children’s Hospital of the MUHC has it’s own world-class child and adolescent trauma centre).

“Most people don’t realize how damaging trauma is,” he says. “To put it in perspective, trauma is the number one cause of death for people under 45 in Canada, and is by far the leading cause of death in children. In the population as a whole, it’s the cause of the most years of life lost, more than cancer, heart disease or any other condition. With those statistics, it’s incredibly important that we offer world-class trauma care and that we keep working to find more effective ways of treating, and preventing multi-system injuries.”

A huge step forward in trauma treatment took place in 1993, when a major reorganization in the way serious injuries were treated in Quebec led to the creation of four tertiary trauma centres. Before then, trauma victims were simply taken to the nearest emergency room, regardless of how well or poorly equipped that hospital might be to treat them. “Most trauma victims require well-stocked blood banks and experts in orthopedics, neurosurgery, plastics and just about every other specialty you can imagine,” Razek says. “In the old days, not many places had access to a neurosurgeon at 3 a.m., making it very difficult to deal with cases that arrived in the middle of the night. Not having the right people in place put a huge burden on emergency room staff and facilities.”

In the 1980s, physicians and surgeons across North America began to reevaluate how the most severe traumas were triaged and treated, using as their model the experiences of army medics and surgeons who had worked on the battlefields of Vietnam and Korea. They soon realized that trauma victims had the best chance of survival if they were treated at a specialized trauma centre, even if this meant being transported a short or long distance away. In Montreal, it was surgeons at the Montreal General Hospital who were at the vanguard of bringing this important movement to Quebec. “The General had a long history of expertise in treating severe traumatic injury,” Razek says. “Following on this tradition, Dr. David Mulder was instrumental in establishing Quebec’s four tertiary trauma centres and ensuring that the General, which later became part of the MUHC, was one of them.”

Today, as soon as emergency responders arrive at the scene of a major trauma, the victims are evaluated according to an objective scale to determine if their injuries warrant transport to a tertiary trauma centre. If they do, the responders call the nearest centre and ask that the trauma team be assembled. In a significant number of cases, it is Dr. Razek and his colleagues at the MUHC who receive the call. “The most important member of the trauma team — the quarterback, as it were — is the Trauma Team Leader (TTL),” Razek explains. “The TTL is paged by the ER staff when a trauma is on the way, and it’s his or her responsibility to arrive at the hospital in no more than 20 minutes. The TTL is an expert in trauma resuscitation and can be a surgeon, emergency physician or anaesthesiologist.

Once at the hospital, the TTL notifies the blood bank and assembles an interdisciplinary team that includes nurses, senior surgical residents, respiratory therapists and social workers. In most cases, all of this takes place before the patient arrives. “Having a specialized team means that even the most complex trauma case won’t deplete the resources we have to deal with our normal emergency caseload,” Razek says. With the arrival of the patient, the TTL evaluates and prioritizes his or her injuries and pages the necessary additional specialists (plastic surgeons, neurosurgeons, orthopedic surgeons and so on) in the appropriate sequence. “It isn’t unusual for trauma patients to have injuries to every major system in their body,” Razek says. “According to protocol, the TTL decides what needs to be done first and also performs resuscitation and emergency procedures to manage patients as they await further treatment.”

How well does this system work? Razek is visibly enthusiastic as he cites the statistics. “In 1993, before the trauma centres were up and running, studies showed that the mortality rate from the most severe types of traumas was 50 percent, in other words, one in two of those patients didn’t survive.” In 1998, the studies were repeated and the figure had dropped to 18 percent, and by 2002, once the system had matured even further, mortality had dropped to an astonishing 8.9 percent. “This kind of radical improvement is almost unheard of in medicine,” Razek says. “The only explanation is that specialized trauma centres like ours at the MUHC make an incredible difference in how well we can treat the most severely injured patients.”

The key to a trauma centre’s success is a well-orchestrated multidisciplinary team that is able to respond quickly. Every member must be highly qualified not just in her own specialty, but in the particulars of trauma care. According to Razek, the MUHC is in many ways an ideal environment for this system. “We have an excellent group of specialists who are used to working in a collaborative and cross-disciplinary environment,” he says. “Our surgical residents are very well trained and our nurses are skilled and dedicated. Trauma care uses a lot of resources at every level, from the specialized neurosurgeon on call nights and weekends to the housekeeping staff that makes sure we have sterile places to work. We’re very lucky to have all of the pieces in this complicated puzzle in place.” The addition of two new surgical recruits, Dr. Paola Fata and Dr. Kosar Khwaja, to this team means that we will have assembled one of the strongest groups in the country. “When the redevelopment is complete, we’ll see a smoother flow of patients through all of the service areas, from radiology and intensive care to operating rooms and recovery areas.”

Asked what the MUHC trauma team does best, Razek grins, “Actually, we’re pretty good at just about everything.” In fact, the MUHC’s trauma team is so respected that they are currently partnering with non-government organizations (NGOs) to train doctors and nurses in Ethiopia, Tanzania and Uganda. “I just got back from a trip to Sudan, and next week I’m going to Germany to receive training from a Red Cross disaster relief organization,” Razek says. In an interesting reversal of learning from Vietnam medics whose experiences in battle informed modern trauma care, the MUHC also trains medics in the Canadian military in how best to treat traumatic battlefield injuries.

With such a successful track record, how do Razek and his colleagues plan to improve trauma care at the MUHC? First, he is enthusiastic about the improvements to the ER and trauma facilities that will come with the redevelopment of the MUHC’s Mountain campus. “We’re already thrilled with the recent renovations to our emergency room,” he says, referring to improvements that were funded in large part through gifts to the Best Care for Life campaign. “When the redevelopment is complete, we’ll see a smoother flow of patients through all of the service areas, from radiology and intensive care to operating rooms and recovery areas.”

To achieve this flow, trauma and emergency services will be moved from their present location on the first floor of the Mountain campus to the sixth floor, where complementary services such as medical imaging, intensivc care and operating rooms will also be located. In the current configuration, these functions are spread across four floors and three wings of the hospital, meaning that even the most critical and unstable trauma patients often need to undergo a considerable amount of transportation during diagnosis and treatment. The redesigned trauma and ER wing will make such logistical difficulties a thing of the past, with all of these complementary units located side by side and within easy access of both the Cedar entrance and a proposed helipad on the roof of the building.

Razek would also like to see improvements in the way patients are treated before they arrive at the hospital. “We’d prefer to have a lot more paramedics in the field,” he says. “Our emergency responders do excellent work, but a fully trained paramedic can administer more sophisticated care in those critical first hours before a patient gets to the hospital.” Razek is equally keen to see the MUHC and its sister trauma centres have access to a helicopter to transport patients whose injuries occur far from the downtown core. “Imagine that you’ve been in a car crash somewhere on Highway 40 during rush hour. Those minutes spent sitting in an ambulance in traffic might make the difference between life and death. We know that coming to a trauma centre improves outcome, but not everyone gets to us in time or at all.” Redevelopment plans at the Mountain campus include the addition of a helipad for just this reason.

Finally, Razek wants to expand the Trauma Division’s educational and community outreach mandate to include working with community leaders, schools, fire departments and police officers to promote injury prevention programs and teach life-saving skills like CPR. “The most effective interventions in the world are those that prevent an injury from happening in the first place. Every trauma is a tragedy, but those that didn’t need to happen are particularly poignant.”

Which brings us back to car crashes. Accidental or not, patients unfortunate enough to find themselves in Dr. Razek’s trauma bay can at least be assured that they are in very good hands indeed.