Charles H. Nicholson, MD Clinical Tour

1. Charles H. Nicholson, MDClinical Tour Levi Procter, MD

2. Objectives • Who was Dr. Nicholson? • What is this clinical tour? • Why did I apply? • Where did I go? • What I learned? • How can you apply?

3. Charles H. Nicholson, MD

4. Who was Dr. Nicholson • Born in Harlan, Ky 2/28/31 • Graduated HS at 16 • Received BA and MD from Vanderbilt • Residency in GS at Strong Memorial in NY • Deployed to Weisbaden, Germany 1960-63 • Clinical instructor at Strong Mem in 1963 • Cardiothoracic surgery fellowship at U Florida 1964

5. Established a general and thoracic practice in 1965 via the Lexington Clinic at St. Joes • Broad practice including: • esophageal, vascular, hepatic, endocrine and pediatric surgery

6. Educator • Most respected for his teaching • “Charles Nicholson (and Richard Floyd, his clinic partner) probably had as much impact on my career as about anyone, in that they gave me a direction to follow in my clinical training and practice.” • Dr. David Richardson

7. What is this tour? • Opportunity to visit other program(s) • Scholars are selected based upon:-accomplishments-career goals-and the manner in which the tour is expected to impact their career

8. Founders • William Walton, MD • Edwin Nighbert, MD • Tom Daugherty, MD

9. Past Recipients • Tom Connally, MD (Strong Memorial, NY) • Phillip Chang, MD (Vancouver Gen, BC, CA)

10. Goals for tour • See a diverse group of trauma programs • Visit leaders in trauma care • Get a first hand look at how they run the show • Witness their infrastructure • Give other residents interested in a trauma fellowship a taste of what’s out there

12. My Tour • Hermann Memorial Hospital, Houston, TX • Univ California at San Diego, CA • Denver Health, Denver, CO • Emory University, Atlanta, GA • Ryder Trauma Center, Miami, FL

13. Memorial Hermann Hospital

14. Memorial Hermann Hospital • One of two level I trauma center’s in Houston, Tx • Approximately 6,000 admissions a year • 800-bed hospital • 25 bed Shock-Trauma ICU (STICU) • ~975 admissions/yr to STICU

20. Leading Figures of Trauma Care

21. Trauma Research Powerhouse • Research staff present 24 hours/day • At all trauma activations • Logs every intervention- including fluids, amount, time- blood- imaging- OR/intervention- etc

22. Center for Translational Injury Research (CeTIR) • Profound research infrastructure • Self fulfilling entity consisting of:- Free standing structure- Staffed with PhDs in: Statistics, Public Health, epidemiology- Editors, grant and manuscript writers- Research fellows - Medical students- Database collators • All located on one floor in a circular layout

23. Current Research

24. Rehabilitation • Specializing in trauma rehabilitation: • Brain injury • Stroke • Spinal cord injury • Poly-trauma and amputation

25. Fellowship • 1 year SCC fellowship • Optional ACS year • (3) fellows/yr for SCC (applied for 6) • (3) research fellows • 1-2 Trauma Clinical instructors • Primarily an ICU year • Some operative time on EGS/Trauma call and at neighboring hospital (in first year)

26. Trauma Care • AM rounding on all new admissions/consults like we do • Large focus on protocol care • All attendings have agreed to follow all protocols • If disagreement arises they all meet, review literature, and decide on a new consensus at a monthly “Practice Management Guideline Meeting”

27. University of California at San Diego

28. UCSD • One of first trauma systems in the country, 1976 • One of the most efficiently triaged trauma systems in US • Trauma mortality cut from 21% to <1% • A person who sustained a life-threatening injury in San Diego County stands twice the chance of surviving than if the injury had occurred in nearly any other part of the United States • Coordinated by the EMS reporting

29. UCSD • ~2500-3000 trauma admissions/yr • One of 6 trauma centers • 3 EMS systems • UCSD has smallest catchment area but densest population

30. UCSD • Triage based on: • Physiologic criteria - low blood pressure, ↓Glasgow coma score, ↑respiratory rate • Anatomic criteria including penetrating wounds to the torso, amputations, and major facial injuries

31. UCSD • Trauma patients go to 1 of 2 places: • Three Bed Resuscitation room • OR • Notice that NONE of that patients are seen in ER

32. Resuscitation Room • Located on 2nd floor • Adjacent to Shock/Trauma ICU • Resuscitation nurses are the nurses working in STICU • They assume care of that patient when they go to ICU

33. OR Resuscitation • If major penetrating thoracic/abdominal trauma, hemorrhagic shock, loss of pulse en-route • Patient brought straight to the OR • All resuscitation performed in OR • Hemorrhage control time ~18 minutes from arriving in OR • Halved their mortality in these patients

34. SICU • 20 bed ICU • 1,600 admissions/yr • Cares for trauma, neurosurgery, cardiothoracic surgery, transplant (heart, lung, liver, and pancreas), ortho-spine, ENT, plastics, vascular surgery, general surgery, and high risk obstetrics

35. Regional Burn Center • ~450 admissions/yr • 8 ICU beds • 10 step-down beds • American Burn Association and the American College of Surgeons, Committee on Trauma (ACS-COT), 1 of 58 centers

36. Raul Comibra, MD, PhD, FACS • Monroe E. Trout Endowed Chair • Chief of Trauma • Internationally renowned authority on trauma and trauma system development

37. ATOM and ASSET course and become instructor • Cadaver lab for vascular exposures • Impressive multimedia group for education • Massive database run by PhD in statistics and MPH (all he does is trauma stats/epidemiology) • Large lab run by PhD that does trauma research and large supply of post-docs

38. Benefits of this program • Education on setting up a trauma system • Learn how to run a trauma program • 3 fellows/yr • Optional second year to get:- MPH- Trauma system development- Research in lab- completely customizable 2nd year

40. Denver Health • One of best trauma centers in the nation • Lowest mortality of 110 academic centers • 1 of 7 acute care surgery fellowships accredited by the AAST • ~2500 trauma admissions/yr • True ACS service • Trauma orthopedics • Severe pelvic trauma (they write the papers on preperitoneal packing) • ~90 Grade IV/V liver injuries/yr

41. Trauma and Acute Care Surgery Fellowship (TACS) • 2 years • 9 months SCC • 15 months of ACS • Rotations on thoracic, vascular, interventional radiology, hepatobiliary, neurosurgery

42. Protocolized ICU Care • Much of their care follows protocols that all attendings agree on • Monthly meetings to discuss issues with protocols, review of literature on protocols, agreement that everyone follows

43. One of the few true ACS models left • Manages all general surgery including: • Surgical oncology (pancreatic cancer, thyroid, etc) • Colorectal • Pancreatic disease • Vascular • Thoracic

44. Grady Memorial

45. 953 beds • 17 ORs • 55 ICU beds • 3000 trauma admissions/yr • ~27% penetrating

46. Fellowship Details • 3 board-eligible surgeons/yr • 2-year fellowship • 1st year is Trauma/Emergency Surgery • 2nd year is Critical Care • Largely resident run hospital • Fellow runs clinic and responsible for trauma/EGS service • 2nd year allows pure focus on ICU care

48. Ryder Trauma Center • Jackson Memorial Hospital (3rd largest teaching hospital in US) • 1558 beds • 17 Trauma/EGS attendings • ~6,000 trauma admissions/yr • 40% penetrating trauma • Only level I trauma center in South Florida (covers south Florida, South America and Caribbean) • Accredited by ABA, Burn Center (1 of 3 in Fl) • All EGS performed by them

49. Benefits to this program • 1st year is surgical critical care, 2nd year is mainly operative year (EGS/Trauma) • Significant volume (trauma and EGS) • Significant penetrating trauma volume • Six fellows in the first year • Free standing research institute • Free standing trauma center

50. Ryder Trauma Center • All the forward surgical teams for the United States Military are trained here • 6 Trauma ORs • Trauma Anesthesiologists • Trauma Neurosurgeons • 25 Bed ICU • ATOM and ATLS course instructor training