WESTERN SURGICAL ASSOCIATION PRESIDENTIAL ADDRESS
Contributions of Public Hospitals to Surgery in the United States Steven C Stain,
MD, FACS
surgeons volunteering their time to teach and care for patients at Los Angeles County Medical Center. I was trained by three WSA Presidents: Drs Mikkelsen, Arthur Donovan (WSA President, 1992), and Thomas V Berne (WSA President, 1999). Claude Organ (WSA President, 1993) once said that he “had the privilege of a Jesuit education.” Well, I had the privilege of a public education, completing high school, college, medical school, residency, and fellowships at public institutions. Since then, I have worked at 3 private institutions, University of Southern California, Meharry Medical College, and Albany Medical College. The last 2 are distinguished by the fact they are 2 of the 3 private medical schools in the continental United States that are not associated with an undergraduate school, the other is Rush Medical College. The topic of my Presidential address is the contribution of public hospitals to surgery in the United States. This selection was inspired by Raymond Joehl’s 2012 WSA Presidential Address, “The VA: A Precious Resource.”4 Public hospitals serve a vital purpose for our country. We take for granted the immense burden they shoulder by caring for the less fortunate in our society, and providing training to tomorrow’s surgeons, and we often forget the significant scientific contributions that came out of public hospitals. According to the American Hospital Association, there are 5,732 hospitals in the United States, and 1,037 are listed as being state- or local governmentrun facilities.5 Pennsylvania Hospital, founded in 1751 by Benjamin Franklin and Dr Thomas Bond, is generally acknowledged as the first hospital in the United States.6 It opened its doors to patients in 1752, and is still a vibrant 520-bed acute care hospital that is part of the University of Pennsylvania system. Bellevue Hospital in New York, opened on March 31, 1736, two weeks ahead of Charity Hospital in New Orleans, might in fact be the oldest hospital in the country.7 Bellevue might not be acknowledged as the first hospital, as often facilities were built by charities as almshouses to care for the aged or infirmed poor rather than formal hospitals. Bellevue is described as the first public hospital in the United States, and has been the site of many milestones in US history, including establishment of the first ambulance service and first maternity award, and development of the techniques of measurement of cardiac
The Western Surgical Association was formed as the Western Association of Obstetricians and Gynecologists in 1891.1 The first president, Dr Milo Ward, a gynecologist from Topeka, Kansas, sent out a call for a meeting to be held in at the Copeland Hotel in Topeka for the purpose of organizing the Association. The most important business transaction of the 1895 meeting was the name change to the Western Surgical and Gynecological Association, a name that remained until 1909, when it became the Western Surgical Association. The association was originally limited to specialists residing in the Missouri River cities of Iowa and Missouri and the states of Kansas, Nebraska, and Colorado. Eventually, the membership criteria were interpreted to include members from states bordering on and west of the Ohio and Mississippi Rivers and their major tributaries2 (Fig. 1). In his Presidential Address in 1926, Robert C Coffey pointed out that “The West is not a mere geographic term, a personality if you wish, which has fled from a cramped social environment to the great open spaces where men may think and act independently, untrammeled by precedent and tradition.”3 The Western Surgical Association (WSA) is now a national surgical society, evidenced by the fact that 3 of the last 11 presidents elected have been from New York, that is, Fabrizio Michelassi, Merril Dayton, and myself. I am proud to be the 6th WSA President associated with Los Angeles County þ USC Medical Center. Lawrence Chaffin (WSA President, 1953) was a Massachusetts General Hospital-trained surgeon, and during his career he served as Chief of Surgery at Good Samaritan Hospital, Children’s Hospital of Los Angeles, and Los Angeles County Medical Center, and was vice president of the American Surgical Association. Dr Chaffin, Arthur Pattison (WSA President, 1969), and William P Mikkelsen (WSA President, 1976) were part of the tradition of community
Disclosure Information: Nothing to disclose. Presented at the Western Surgical Association 122nd Scientific Session, Indian Wells, CA, November 2014. Received December 16, 2014; Accepted December 22, 2014. From the Department of Surgery, Albany Medical College, Albany, NY. Correspondence address: Steven C Stain, MD, FACS, Department of Surgery, Albany Medical College, 50 New Scotland Ave, MC 194, Albany, NY 12208. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
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http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.060 ISSN 1072-7515/15
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Contributions of Public Hospitals to US Surgery
Figure 1. Western Surgical Association original states (blue).
output by right cardiac catheterization in 1945.8 These investigations in cardiac physiology ultimately led to the Nobel Prize being awarded to Andre Cournard, Dickinson Richards, and Werner Forssmann in 1956.9 I have chosen to highlight some of the scientific achievements from 8 public hospitals selected from the original geographic distribution of the WSA. These 8 hospitals have much in common. Each has a long and colorful history, with roots in the 19th century. All are associated with medical schools and surgical training programs, and are stalwart pillars of their communities, both for their role as academic trauma centers, safety-net institutions for the underserved, and the unique roles in the training of surgeons. But most importantly, they have an incredible cadre of committed surgeons, most of whom have spent their entire career at public hospitals. My research into these hospitals was facilitated by discussions with several surgeons who had trained at or worked at these hospitals (Table 1). Not surprisingly, none of them added any of their own discoveries to the list. My first contribution to surgery, really to medicine in general, is by Sidney Garfield, a name very few of you know. Sidney Garfield grew up in New Jersey, started at Rutgers University and transferred to University of Southern California, and graduated in 1924. He attended medical school at University of Iowa and, after an internship at Michael Reese Hospital, he started surgical training at LA County General Hospital in 1933. Midway through his
residency, he borrowed $2,250 from his father to open Los Angeles Contractor’s General Hospital in the Mojave Desert east of Los Angeles. This hospital was set up to provide health care for the 5,000 employees of the Metropolitan Water District of Southern California who were working on an aqueduct to bring water from the Colorado River to Los Angeles.10 The hospital started as fee-forservice, but insurance companies were slow to pay, and frequently did not pay at all. Ingeniously, Garfield arranged with the largest insurer on the project, Industrial Indemnity Exchange, for “prepayment” of a nickel per day to the hospital for any hospitalizations required for the 5,000 workers. It was hugely successful, so then employees were offered the option of receiving total medical care for an additional nickel per day. As Garfield completed his general surgery residency training at LA County General Hospital in 1939, the owners of Indemnity Industry Exchange contacted him to see if he could provide similar health care services for a project being run by their colleague, Edgar Kaiser. His company, Kaiser Enterprises had won the bid to build Coulee Dam over the Columbia River in the state of Washington, which at the time was the largest man-made structure ever built. Kaiser then used Garfield to support the Kaiser West Coast Shipyards project in the San Francisco Bay area. This was a critical time of support, as the Kaiser West Coast Shipyards was launching a ship a day, and needed to maintain the health of its workers. With a $250,000 loan from Kaiser’s
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Table 1.
Contributions of Public Hospitals to US Surgery
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Contributions of US Public Hospitals
Hospital
Charity Hospital San Francisco General Hospital Cook County Hospital Denver General Hospital Harborview Medical Center Los Angeles County General Hospital Parkland Memorial Hospital Detroit Receiving Hospitals
Year founded
Scientific contribution
1736 1857 1858 1860 1877 1878
Association of tobacco smoking and lung cancer Trauma system developments, response to AIDS epidemic First blood bank in the United States Trauma-associated coagulopathy Closed intramedullary nailing of femur fractures Integrated managed health care system
1894 1915
Burn injury resuscitation Crystalloid vs colloid resuscitation
banker, AP Giannini of Bank of America, Garfield built the modern 54-bed Permanente Foundation Hospital in Oakland, which was owned by the Foundation and leased by Garfield and Associates. This relationship between Kaiser and Garfield was the basis for what would become Kaiser Permanente, which, as an integrated managed care consortium, is the largest HMO in the country, and some would say a model for how to deliver high-quality care effectively. Although not created specifically at a public hospital, the LA County historians still take credit for the fact that it was cocreated by an LA County General Hospital-trained resident. The second accomplishment of establishing the first blood bank in the United States comes from Cook County Hospital in Chicago. This life-saving therapy has progressed from direct transfusion to sophisticated component blood therapy. Blood transfusion occurs daily in most hospitals, and the process of collection, storage, and administration is often taken for granted. The term blood bank typically refers to a hospital division where blood products are stored and where proper testing is performed to reduce the risk of transfusion-related adverse events. Storing blood in a refrigerator became possible through the introduction of sodium citrate as an anticoagulant in 1915 and by the addition of sugars in 1916, which allowed preservation.11 Because of the large volume of this anticoagulation storage mixture, it was not initially popular. Bernard Fantus of Cook County Hospital is credited with the establishment of the first blood bank in the United States. In the Therapeutics Section in the back of a 1937 issue of Journal of the American Medical Association, he described the “The Therapy of the Cook County Hospital.”12 His “Notice to Medical Staff” announced the effort to preserve blood by refrigeration to be used for blood transfusion. He listed rules for depositing blood, keeping the blood, drawing on the “blood bank,” cross-matching before injecting, administration,
Sources of information
Jon Hunt William Schecter Kim Joseph, LD Britt Ernest Moore, G Jerry Jurkovich Ron Maier Arthur Donovan, Thomas Berne, Albert Yellin James Valentine Charles Lucas, Ana Ledgerwood
and dosage. He said that it was obvious that one cannot obtain blood unless one has deposited blood. Staff physicians would obtain chilled 500-mL flasks and two 5-mL test tubes for typing, and the date, name of the intern, and his service. If blood is needed, the house physician should secure 5 mL from the patient and have it cross matched by the resident who supervises the transfusion. There is some dispute about who is responsible for the organization of blood banks in the United States. John S Lundy of the Mayo Clinic organized a similar service, and described it in the proceedings of the staff meetings of the Mayo Clinic.13 The term blood bank, however, is ascribed to Bernard Fantus from Cook County Hospital, and the Bernard Fantus Lifetime Achievement Award is a distinguished service honor given by the American Association of Blood Banks. There is no doubt now that smoking is associated with lung cancer, but what is not commonly known is that this relationship was first suggested by observations made at another public hospital, Charity Hospital of New Orleans. In 1933, Ewarts Graham and JJ Singer, from Washington University, reported the first successful case of pneumonectomy for lung cancer.14 Michael Debakey wrote: “Accordingly, my chief, Dr Alton Ochsner, like a few other pioneering thoracic surgeons, immediately developed an intense interest in this problem. We began a systematic search in the wards and clinics at the Charity Hospital in New Orleans for possible candidates.”15 In 1939, Alton Ochsner and Michael Debakey published their series of pneumonectomy for the treatment of primary pulmonary malignancy.16 The article analyzed a series of 70 collected cases with 7 of their own. It should be noted that 5 of their 7 patients died postoperatively (mortality 71%). But in the Discussion section, the authors state: “In our opinion the increase in smoking with the universal custom of inhalation is probably a responsible factor, since inhaled smoke, constantly repeated over a
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long period of time, undoubtedly is a source of chronic irritation to the bronchial mucosa.” In addition, they referenced the fact that during World War I, the tobacco companies made packages of cigarettes freely available to soldiers, and tobacco products rapidly became fashionable. With two decades of widespread smoking in the population, the chronic irritation of the tracheobronchial mucosa had an oncogenic effect. It took a long time for this association to become accepted. In 1999, Dr DeBakey noted that it was gratifying to have their conviction of the causal relationship between tobacco smoking and cancer vindicated by the Surgeon General’s Report in 1964, some 25 years after they published their report.15 The association of smoking and lung cancer is another contribution from a public hospital, Charity Hospital of New Orleans. Seminal contributions for resuscitation of injured patients came out of public hospitals, and I will highlight 3 institutions: Parkland Memorial Hospital, Detroit Receiving Hospital, and Denver General Hospital. In 1968, Charles Baxter and Tom Shires published an article that included experiments on rhesus monkeys, splenectomized mongrel dogs, and patients treated at the Parkland Burn Center.17 Isotope studies in rhesus monkeys showed that extracellular fluid decreased by 38% to 50% after burn injury. The cardiac output was corrected after burn injury with the balanced salt solution, Lactated Ringers. The optimal regimen for IV fluid was determined by a pilot project of 11 patients with burns varying from 30% to 85%, and was calculated to be 4 mL Lactated Ringers/percent burn/kg body weight given over 24 hours. A recent survey of burn centers found that 69.3% of burn centers use the Parkland Formula for initial resuscitation.18 During my training in the 1980s, it was common to use albumin for resuscitation. I do not recall the last time that I ordered it. Despite the fact that the 1998 Cochrane review concluded “albumin should not be used outside the context of a properly conceived and rigorously controlled trial with mortality as the endpoint,” there are still randomized trials comparing the effects of colloids with crystalloid resuscitation, even as recently as last year.19,20 In his 2000 Scudder Oration entitled “The Water of Life: A Century of Confusion,” Charles Lucas detailed Starling’s Law of the Capillary, the pathophysiology of hemorrhagic shock and the colloid/crystalloid controversy.21 In a series of randomized trials, the group from Detroit Receiving Hospital showed that albumin had a negative inotropic effect, a detrimental effect on respiratory function, and altered coagulation.22-24 Altered coagulation is often the result of injury, and no institution has studied that issue more than Denver
J Am Coll Surg
General Hospital.25 Coagulopathy was noted in battle casualties from the Korean and Vietnam War, and Richard Simmons (as a Captain in the US Army) noted that this consumptive state, which occurred within 2 hours of injury, was consistent with disseminated intravascular coagulopathy.26 In 1982, Ernest Moore and his coauthors termed this phenomenon the bloody vicious cycle, which has subsequently been referred by others as the lethal triad, and most recently as iatrogenic trauma coagulopathy.25 This concept led to the fundamental basis of “damage control surgery,” introduced in 1983 by Harlan Stone in an article from Grady Memorial Hospital entitled “Management of the Major Coagulopathy with Onset during Laparotomy.”27 In a series of articles, the Denver General Hospital group described acidosisinduced coagulopathy, platelet abnormalities associated with massive transfusion, and hypothermia-induced coagulopathy. In their 2004 Lancet article with Fred Moore, they wrote: “we are challenged to think of the next generation of resuscitation; and then over the last decade have studied how to best improve our resuscitation techniques.”28 Along with others, they have prospectively studied optimal fresh frozen plasma to RBC transfusion ratio, point of care use of thromboelastography, and the role of primary fibrinolysis in the acute coagulopathy of trauma.29-31 If we are to wonder where our scientific understanding of resuscitation and coagulation comes from, we should look no farther than our public hospitals. The first of the West Coast hospitals with scientific contributions to highlight comes from Harborview Medical Center in Seattle. Unless you are from Seattle, you might not have ever heard the name Sigvard T Hansen. What would be the treatment of a patient who came into your hospital with an isolated femur fracture? Forty years ago, he would have likely been treated with 6 weeks of skeletal traction. In 1968, a multi-organeinjured patient came to Harborview Medical Center in a coma with a fractured femur after a motor-vehicle accident. Hansen, the chief resident on call, proposed to his attending that he wanted to rod the femur so they could get her out of bed sooner to recover from her other injuries. The attending said, “if you do that, then don’t tell me about it” and stomped off.31,32 The patient recovered completely. Hansen finished the residency and eventually became the chief of orthopaedics at Harborview in 1981 and chair at University of Washington in 1985. Although the practice had been applied in Europe, Hansen published his first series in 1979 and, when his series of 520 femoral fractures was presented in 1984, he was roundly criticized and threatened with expulsion from orthopaedic associations. This year, he received the
Vol. 221, No. 1, July 2015
Award for Distinguished Contributions to Orthopaedics from the American Orthopaedic Association. The Harborview Medical Center Trauma Division, led by Ron Maier, has been a leader in multicenter trials that have changed the way we take care of trauma and critical care patients. To name a few: the ARDSNet consortium that proved low-volume, low-pressure ventilation decreased mortality for ARDS; the New England Journal of Medicine study that showed a 25% decrease in mortality when trauma patients were cared for in Level I trauma centers vs community hospitals; and, most recently, accrued the most patients in the Glue Grant that studied the entire human genome response to injury up to 28 days.33-35 There are many claims to the development of the first trauma system in the United States, but my research suggests that the first trauma system was developed at San Francisco General Hospital, under the direction of William Blaisdell. In 1968, the “gold service” was converted to an exclusive trauma service.36 Federal recognition of trauma centers began in 1971 to 1972, and San Francisco General Hospital was one of the first so designated. However, in 1971, the California Legislature passed the Paramedic Act, and the plan was “the nearest ambulance to the nearest hospital.” Dr Blaisdell changed that practice for trauma, in part, by volunteering to spend his sabbatical in 1977 as acting Medical Director of the San Francisco Department of Public Health. He spent time in the Aid Stations, rode the ambulances, and compiled a report to the Department that outlined the system of caring for trauma patients in the city and county of San Francisco. John West, a 1973 graduate of the University of CaliforniaeSan Francisco surgery and Don Trunkey compared the results of trauma care in San Francisco County, a region where all patients are brought to a single trauma center, with the results of care in Orange County, where patients are brought to the closest receiving facility, and proved that a dedicated trauma system resulted in lower mortality.37 San Francisco was also the epicenter of the AIDS epidemic in the 1980s, and San Francisco General Hospital serves as an example of how to best care for these patients. In the spring of 1981, a San Francisco General Hospital surgeon, William Schecter, was called to the Respiratory ICU on ward 5R.38 There, he saw a 33year-old gay man dying of hypoxia due to an unknown disease causing bilateral interstitial pulmonary infiltrates. Schecter was unenthusiastic about an open lung biopsy because of the high risk, but agreed to proceed. To everyone’s amazement, this young manddespite the fact that
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he did not have lymphoma and had no history of organ transplantation or immunosuppressive drugsdhad Pneumocystis carinii pneumonia. In the same year, outbreaks of Kaposi’s sarcoma and P carinii pneumonia also appeared in Los Angeles and New York. On July 25, 1983, the country’s first AIDS ward opened, and San Francisco General received one of the first grants, and San Francisco General Hospital, another public hospital, took the lead in establishing protocols for treating AIDS patients. For the last public hospital, I return to my roots, Los Angeles County, or General Hospital. It is not a single disease, or specific therapy, but an approach to the care of patients. As a resident, we were well versed in the “selective management” of patients. In 1958, William Mikkelsen and CJ Berne suggested that most patients with perforated duodenal ulcers, if they were sealed by water-soluble contrast, could be treated nonoperatively.39 By legend, there were so many patients with perforations in the 1960s awaiting surgery that, by the next day, their peritonitis had resolved. Although Charity Hospital was arguably the first hospital to treat abdominal stab wounds by observation and serial examination, selective management became the dominant approach to treating stable patients with stab wounds, then posterior gunshot wounds, kidney injuries, and even all gunshot wounds at LA County.40-43 The principal of selective management was that careful examination and serial re-examination, combined with diagnostic tests when necessary, could select patients that could be treated nonoperatively. This discussion of public hospitals reminds us of some of the contributions that have come out of these storied institutions. At a time when health care reform proposes to improve patient experience of care (including quality and satisfaction) and population health, and reduce the per capita cost of health care, it is important to recognize that public hospitals are a precious national resource that must be supported and maintained.
REFERENCES 1. Mills WM. Early days of the Western Surgical Association. Arch Surg 1948;56:563e569. 2. Jurkovich GJ. Regionalized health care and the trauma system model. J Am Coll Surg 2012;215:1e11. 3. Jordan GL. The presidential address. Arch Surg 1985;120: 525e529. 4. Joehl RJ. The VA: a precious resource. J Am Coll Surg 2013; 217:1e6.
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5. American Hospital Association, Fast facts on US hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fastfacts.shtml#community. Accessed November 5, 2014. 6. Williams WH. The early days of Anglo-America’s first hospital. The Pennsylvania Hospital, 1751-1775. JAMA 1972;220: 115e119. 7. Hoover EL. Charity hospital: from the beginning to either a new beginning or the end. J Natl Med Assoc 2007;99:578e579. 8. Bellevue Hospital Center, NYU Langone Medical Center. Available at: http://www.med.nyu.edu/patients-visitors/ourhospitals/bellevue-hospital-center. Accessed November 5, 2014. 9. Cournand A, Riley RL, Breed ES, et al. Measurement of cardiac output in man using the technique of catheterization of the right auricle or ventricle. J Clin Invest 1945;24: 106e116. 10. Debley T, Stewart J, eds. The Story of Dr. Sidney R. Garfield: The Visionary Who Turned Sick Care into Health Care. Oakland: The Permanente Press; 2009:1e33. 11. Diamond LK. The history of blood banking in the United States. JAMA 1965;193:128e132. 12. Fantus B. The therapy of the Cook County Hospital. JAMA 1937;109:128e131. 13. Moore SB. A brief history of the early years of blood transfusion at the Mayo Clinic: the first blood bank in the United States (1935). Transfusion Med Rev 2005;19:241e245. 14. Graham EA, Singer JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA 1933;101:1371e1374. 15. Debakey M. Carcinoma of the lung and tobacco smoking: a historical perspective. Ochsner J 1999;1:106e108. 16. Ochsner A, DeBakey M. Primary pulmonary malignancy: treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. Surg Gynecol Obstet 1939;48:433e451. 17. Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci 1968;150:874e894. 18. Greenhalgh DG. Burn resuscitation: the results of the ISBI/ ABA survey. Burns 2010;36:176e182. 19. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317:235e240. 20. Annane D, Siami S, Jaber S, et al; CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013;310:1809e1817. 21. Lucas CE. The water of life: a century of confusion. J Am Coll Surg 2001;192:86e93. 22. Weaver DW, Ledgerwood AM, Lucas CE, et al. Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 1978;113:387e392. 23. Johnson SD, Lucas CE, Gerrick SJ, et al. Altered coagulation after albumin supplements for treatment of oligemic shock. Arch Surg 1979;114:379e383. 24. Dahn MS, Lucas CE, Ledgerwood AM, Higgins RF. Negative inotropic effect of albumin resuscitation for shock. Surgery 1979;86:235e241. 25. Gonzalez E, Moore EE, Moore HB, et al. Trauma-induced coagulopathy: an institution’s 35 year perspective on practice and research. Scand J Surg 2014;103:89e103.
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26. Simmons RL, Collins JA, Heisterkamp CA, et al. Coagulation disorders in combat casualties. I. Acute changes after wounding. II. Effects of massive transfusion. 3. Post-resuscitative changes. Ann Surg 1969;169:455e482. 27. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg 1983; 197:532e535. 28. Moore FA, McKinley BA, Moore EE. The next generation in shock resuscitation. Lancet 2004;363:1988e1996. 29. Sperry JL, Ochoa JB, Gunn SR, et al. Inflammation the Host Response to Injury Investigators. An FFP: PRBC transfusion ratio >/¼1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma 2008;65:986e993. 30. Kashuk JL, Moore EE, Wohlauer M, et al. Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy. Transfusion 2012; 52:23e33. 31. Kashuk JL, Moore EE, Sawyer M, et al. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg 2010;252:434e442. 32. Revolutionizing Trauma Care: The Sigvard T. Hansen Jr., MD story. Available at: https://www.youtube.com/watch? v¼9lpmFfHtE-w. Accessed November 5, 2014. 33. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301e1308. 34. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366e378. 35. Rajicic N, Cuschieri J, Finkelstein DM, et al. Inflammation and the Host Response to Injury Large Scale Collaborative Research Program. Identification and interpretation of longitudinal gene expression changes in trauma. PLoS One 2010;5:e14380. 36. Lim R, Sheldon G. The Blaisdell years. In: Schecter W, Lim R, Sheldon G, et al, eds. The History of the Surgical Service at San Francisco General Hospital. San Francisco, CA; 2007: 77e149. 37. West JG, Trunkey DD, Lim RC. Systems of trauma care: a study of two counties. Arch Surg 1979;114:455e460. 38. Schecter W. The Trunkey years. In: Schecter W, Lim R, Sheldon G, et al, eds. The History of the Surgical Service at San Francisco General Hospital. San Francisco, CA; 2007:150e184. 39. Berne CJ, Mikkelsen WP. Management of perforated peptic ulcer. Surgery 1958;44:591e603. 40. Shorr RM, Gottlieb MM, Webb K, et al. Selective management of abdominal stab wounds. Importance of the physical examination. Arch Surg 1988;123:1141e1145. 41. Velmahos GC, Demetriades D, Foianini E, et al. A selective approach to the management of gunshot wounds to the back. Am J Surg 1997;174:342e346. 42. Velmahos GC, Demetriades D, Cornwell EE 3rd, et al. Selective management of renal gunshot wounds. Br J Surg 1998;85: 1121e1124. 43. Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234:395e402.
Contributions of Public Hospitals to Surgery in the United States Steven C Stain,
MD, FACS
surgeons volunteering their time to teach and care for patients at Los Angeles County Medical Center. I was trained by three WSA Presidents: Drs Mikkelsen, Arthur Donovan (WSA President, 1992), and Thomas V Berne (WSA President, 1999). Claude Organ (WSA President, 1993) once said that he “had the privilege of a Jesuit education.” Well, I had the privilege of a public education, completing high school, college, medical school, residency, and fellowships at public institutions. Since then, I have worked at 3 private institutions, University of Southern California, Meharry Medical College, and Albany Medical College. The last 2 are distinguished by the fact they are 2 of the 3 private medical schools in the continental United States that are not associated with an undergraduate school, the other is Rush Medical College. The topic of my Presidential address is the contribution of public hospitals to surgery in the United States. This selection was inspired by Raymond Joehl’s 2012 WSA Presidential Address, “The VA: A Precious Resource.”4 Public hospitals serve a vital purpose for our country. We take for granted the immense burden they shoulder by caring for the less fortunate in our society, and providing training to tomorrow’s surgeons, and we often forget the significant scientific contributions that came out of public hospitals. According to the American Hospital Association, there are 5,732 hospitals in the United States, and 1,037 are listed as being state- or local governmentrun facilities.5 Pennsylvania Hospital, founded in 1751 by Benjamin Franklin and Dr Thomas Bond, is generally acknowledged as the first hospital in the United States.6 It opened its doors to patients in 1752, and is still a vibrant 520-bed acute care hospital that is part of the University of Pennsylvania system. Bellevue Hospital in New York, opened on March 31, 1736, two weeks ahead of Charity Hospital in New Orleans, might in fact be the oldest hospital in the country.7 Bellevue might not be acknowledged as the first hospital, as often facilities were built by charities as almshouses to care for the aged or infirmed poor rather than formal hospitals. Bellevue is described as the first public hospital in the United States, and has been the site of many milestones in US history, including establishment of the first ambulance service and first maternity award, and development of the techniques of measurement of cardiac
The Western Surgical Association was formed as the Western Association of Obstetricians and Gynecologists in 1891.1 The first president, Dr Milo Ward, a gynecologist from Topeka, Kansas, sent out a call for a meeting to be held in at the Copeland Hotel in Topeka for the purpose of organizing the Association. The most important business transaction of the 1895 meeting was the name change to the Western Surgical and Gynecological Association, a name that remained until 1909, when it became the Western Surgical Association. The association was originally limited to specialists residing in the Missouri River cities of Iowa and Missouri and the states of Kansas, Nebraska, and Colorado. Eventually, the membership criteria were interpreted to include members from states bordering on and west of the Ohio and Mississippi Rivers and their major tributaries2 (Fig. 1). In his Presidential Address in 1926, Robert C Coffey pointed out that “The West is not a mere geographic term, a personality if you wish, which has fled from a cramped social environment to the great open spaces where men may think and act independently, untrammeled by precedent and tradition.”3 The Western Surgical Association (WSA) is now a national surgical society, evidenced by the fact that 3 of the last 11 presidents elected have been from New York, that is, Fabrizio Michelassi, Merril Dayton, and myself. I am proud to be the 6th WSA President associated with Los Angeles County þ USC Medical Center. Lawrence Chaffin (WSA President, 1953) was a Massachusetts General Hospital-trained surgeon, and during his career he served as Chief of Surgery at Good Samaritan Hospital, Children’s Hospital of Los Angeles, and Los Angeles County Medical Center, and was vice president of the American Surgical Association. Dr Chaffin, Arthur Pattison (WSA President, 1969), and William P Mikkelsen (WSA President, 1976) were part of the tradition of community
Disclosure Information: Nothing to disclose. Presented at the Western Surgical Association 122nd Scientific Session, Indian Wells, CA, November 2014. Received December 16, 2014; Accepted December 22, 2014. From the Department of Surgery, Albany Medical College, Albany, NY. Correspondence address: Steven C Stain, MD, FACS, Department of Surgery, Albany Medical College, 50 New Scotland Ave, MC 194, Albany, NY 12208. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
1
http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.060 ISSN 1072-7515/15
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Contributions of Public Hospitals to US Surgery
Figure 1. Western Surgical Association original states (blue).
output by right cardiac catheterization in 1945.8 These investigations in cardiac physiology ultimately led to the Nobel Prize being awarded to Andre Cournard, Dickinson Richards, and Werner Forssmann in 1956.9 I have chosen to highlight some of the scientific achievements from 8 public hospitals selected from the original geographic distribution of the WSA. These 8 hospitals have much in common. Each has a long and colorful history, with roots in the 19th century. All are associated with medical schools and surgical training programs, and are stalwart pillars of their communities, both for their role as academic trauma centers, safety-net institutions for the underserved, and the unique roles in the training of surgeons. But most importantly, they have an incredible cadre of committed surgeons, most of whom have spent their entire career at public hospitals. My research into these hospitals was facilitated by discussions with several surgeons who had trained at or worked at these hospitals (Table 1). Not surprisingly, none of them added any of their own discoveries to the list. My first contribution to surgery, really to medicine in general, is by Sidney Garfield, a name very few of you know. Sidney Garfield grew up in New Jersey, started at Rutgers University and transferred to University of Southern California, and graduated in 1924. He attended medical school at University of Iowa and, after an internship at Michael Reese Hospital, he started surgical training at LA County General Hospital in 1933. Midway through his
residency, he borrowed $2,250 from his father to open Los Angeles Contractor’s General Hospital in the Mojave Desert east of Los Angeles. This hospital was set up to provide health care for the 5,000 employees of the Metropolitan Water District of Southern California who were working on an aqueduct to bring water from the Colorado River to Los Angeles.10 The hospital started as fee-forservice, but insurance companies were slow to pay, and frequently did not pay at all. Ingeniously, Garfield arranged with the largest insurer on the project, Industrial Indemnity Exchange, for “prepayment” of a nickel per day to the hospital for any hospitalizations required for the 5,000 workers. It was hugely successful, so then employees were offered the option of receiving total medical care for an additional nickel per day. As Garfield completed his general surgery residency training at LA County General Hospital in 1939, the owners of Indemnity Industry Exchange contacted him to see if he could provide similar health care services for a project being run by their colleague, Edgar Kaiser. His company, Kaiser Enterprises had won the bid to build Coulee Dam over the Columbia River in the state of Washington, which at the time was the largest man-made structure ever built. Kaiser then used Garfield to support the Kaiser West Coast Shipyards project in the San Francisco Bay area. This was a critical time of support, as the Kaiser West Coast Shipyards was launching a ship a day, and needed to maintain the health of its workers. With a $250,000 loan from Kaiser’s
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Table 1.
Contributions of Public Hospitals to US Surgery
3
Contributions of US Public Hospitals
Hospital
Charity Hospital San Francisco General Hospital Cook County Hospital Denver General Hospital Harborview Medical Center Los Angeles County General Hospital Parkland Memorial Hospital Detroit Receiving Hospitals
Year founded
Scientific contribution
1736 1857 1858 1860 1877 1878
Association of tobacco smoking and lung cancer Trauma system developments, response to AIDS epidemic First blood bank in the United States Trauma-associated coagulopathy Closed intramedullary nailing of femur fractures Integrated managed health care system
1894 1915
Burn injury resuscitation Crystalloid vs colloid resuscitation
banker, AP Giannini of Bank of America, Garfield built the modern 54-bed Permanente Foundation Hospital in Oakland, which was owned by the Foundation and leased by Garfield and Associates. This relationship between Kaiser and Garfield was the basis for what would become Kaiser Permanente, which, as an integrated managed care consortium, is the largest HMO in the country, and some would say a model for how to deliver high-quality care effectively. Although not created specifically at a public hospital, the LA County historians still take credit for the fact that it was cocreated by an LA County General Hospital-trained resident. The second accomplishment of establishing the first blood bank in the United States comes from Cook County Hospital in Chicago. This life-saving therapy has progressed from direct transfusion to sophisticated component blood therapy. Blood transfusion occurs daily in most hospitals, and the process of collection, storage, and administration is often taken for granted. The term blood bank typically refers to a hospital division where blood products are stored and where proper testing is performed to reduce the risk of transfusion-related adverse events. Storing blood in a refrigerator became possible through the introduction of sodium citrate as an anticoagulant in 1915 and by the addition of sugars in 1916, which allowed preservation.11 Because of the large volume of this anticoagulation storage mixture, it was not initially popular. Bernard Fantus of Cook County Hospital is credited with the establishment of the first blood bank in the United States. In the Therapeutics Section in the back of a 1937 issue of Journal of the American Medical Association, he described the “The Therapy of the Cook County Hospital.”12 His “Notice to Medical Staff” announced the effort to preserve blood by refrigeration to be used for blood transfusion. He listed rules for depositing blood, keeping the blood, drawing on the “blood bank,” cross-matching before injecting, administration,
Sources of information
Jon Hunt William Schecter Kim Joseph, LD Britt Ernest Moore, G Jerry Jurkovich Ron Maier Arthur Donovan, Thomas Berne, Albert Yellin James Valentine Charles Lucas, Ana Ledgerwood
and dosage. He said that it was obvious that one cannot obtain blood unless one has deposited blood. Staff physicians would obtain chilled 500-mL flasks and two 5-mL test tubes for typing, and the date, name of the intern, and his service. If blood is needed, the house physician should secure 5 mL from the patient and have it cross matched by the resident who supervises the transfusion. There is some dispute about who is responsible for the organization of blood banks in the United States. John S Lundy of the Mayo Clinic organized a similar service, and described it in the proceedings of the staff meetings of the Mayo Clinic.13 The term blood bank, however, is ascribed to Bernard Fantus from Cook County Hospital, and the Bernard Fantus Lifetime Achievement Award is a distinguished service honor given by the American Association of Blood Banks. There is no doubt now that smoking is associated with lung cancer, but what is not commonly known is that this relationship was first suggested by observations made at another public hospital, Charity Hospital of New Orleans. In 1933, Ewarts Graham and JJ Singer, from Washington University, reported the first successful case of pneumonectomy for lung cancer.14 Michael Debakey wrote: “Accordingly, my chief, Dr Alton Ochsner, like a few other pioneering thoracic surgeons, immediately developed an intense interest in this problem. We began a systematic search in the wards and clinics at the Charity Hospital in New Orleans for possible candidates.”15 In 1939, Alton Ochsner and Michael Debakey published their series of pneumonectomy for the treatment of primary pulmonary malignancy.16 The article analyzed a series of 70 collected cases with 7 of their own. It should be noted that 5 of their 7 patients died postoperatively (mortality 71%). But in the Discussion section, the authors state: “In our opinion the increase in smoking with the universal custom of inhalation is probably a responsible factor, since inhaled smoke, constantly repeated over a
4
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Contributions of Public Hospitals to US Surgery
long period of time, undoubtedly is a source of chronic irritation to the bronchial mucosa.” In addition, they referenced the fact that during World War I, the tobacco companies made packages of cigarettes freely available to soldiers, and tobacco products rapidly became fashionable. With two decades of widespread smoking in the population, the chronic irritation of the tracheobronchial mucosa had an oncogenic effect. It took a long time for this association to become accepted. In 1999, Dr DeBakey noted that it was gratifying to have their conviction of the causal relationship between tobacco smoking and cancer vindicated by the Surgeon General’s Report in 1964, some 25 years after they published their report.15 The association of smoking and lung cancer is another contribution from a public hospital, Charity Hospital of New Orleans. Seminal contributions for resuscitation of injured patients came out of public hospitals, and I will highlight 3 institutions: Parkland Memorial Hospital, Detroit Receiving Hospital, and Denver General Hospital. In 1968, Charles Baxter and Tom Shires published an article that included experiments on rhesus monkeys, splenectomized mongrel dogs, and patients treated at the Parkland Burn Center.17 Isotope studies in rhesus monkeys showed that extracellular fluid decreased by 38% to 50% after burn injury. The cardiac output was corrected after burn injury with the balanced salt solution, Lactated Ringers. The optimal regimen for IV fluid was determined by a pilot project of 11 patients with burns varying from 30% to 85%, and was calculated to be 4 mL Lactated Ringers/percent burn/kg body weight given over 24 hours. A recent survey of burn centers found that 69.3% of burn centers use the Parkland Formula for initial resuscitation.18 During my training in the 1980s, it was common to use albumin for resuscitation. I do not recall the last time that I ordered it. Despite the fact that the 1998 Cochrane review concluded “albumin should not be used outside the context of a properly conceived and rigorously controlled trial with mortality as the endpoint,” there are still randomized trials comparing the effects of colloids with crystalloid resuscitation, even as recently as last year.19,20 In his 2000 Scudder Oration entitled “The Water of Life: A Century of Confusion,” Charles Lucas detailed Starling’s Law of the Capillary, the pathophysiology of hemorrhagic shock and the colloid/crystalloid controversy.21 In a series of randomized trials, the group from Detroit Receiving Hospital showed that albumin had a negative inotropic effect, a detrimental effect on respiratory function, and altered coagulation.22-24 Altered coagulation is often the result of injury, and no institution has studied that issue more than Denver
J Am Coll Surg
General Hospital.25 Coagulopathy was noted in battle casualties from the Korean and Vietnam War, and Richard Simmons (as a Captain in the US Army) noted that this consumptive state, which occurred within 2 hours of injury, was consistent with disseminated intravascular coagulopathy.26 In 1982, Ernest Moore and his coauthors termed this phenomenon the bloody vicious cycle, which has subsequently been referred by others as the lethal triad, and most recently as iatrogenic trauma coagulopathy.25 This concept led to the fundamental basis of “damage control surgery,” introduced in 1983 by Harlan Stone in an article from Grady Memorial Hospital entitled “Management of the Major Coagulopathy with Onset during Laparotomy.”27 In a series of articles, the Denver General Hospital group described acidosisinduced coagulopathy, platelet abnormalities associated with massive transfusion, and hypothermia-induced coagulopathy. In their 2004 Lancet article with Fred Moore, they wrote: “we are challenged to think of the next generation of resuscitation; and then over the last decade have studied how to best improve our resuscitation techniques.”28 Along with others, they have prospectively studied optimal fresh frozen plasma to RBC transfusion ratio, point of care use of thromboelastography, and the role of primary fibrinolysis in the acute coagulopathy of trauma.29-31 If we are to wonder where our scientific understanding of resuscitation and coagulation comes from, we should look no farther than our public hospitals. The first of the West Coast hospitals with scientific contributions to highlight comes from Harborview Medical Center in Seattle. Unless you are from Seattle, you might not have ever heard the name Sigvard T Hansen. What would be the treatment of a patient who came into your hospital with an isolated femur fracture? Forty years ago, he would have likely been treated with 6 weeks of skeletal traction. In 1968, a multi-organeinjured patient came to Harborview Medical Center in a coma with a fractured femur after a motor-vehicle accident. Hansen, the chief resident on call, proposed to his attending that he wanted to rod the femur so they could get her out of bed sooner to recover from her other injuries. The attending said, “if you do that, then don’t tell me about it” and stomped off.31,32 The patient recovered completely. Hansen finished the residency and eventually became the chief of orthopaedics at Harborview in 1981 and chair at University of Washington in 1985. Although the practice had been applied in Europe, Hansen published his first series in 1979 and, when his series of 520 femoral fractures was presented in 1984, he was roundly criticized and threatened with expulsion from orthopaedic associations. This year, he received the
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Award for Distinguished Contributions to Orthopaedics from the American Orthopaedic Association. The Harborview Medical Center Trauma Division, led by Ron Maier, has been a leader in multicenter trials that have changed the way we take care of trauma and critical care patients. To name a few: the ARDSNet consortium that proved low-volume, low-pressure ventilation decreased mortality for ARDS; the New England Journal of Medicine study that showed a 25% decrease in mortality when trauma patients were cared for in Level I trauma centers vs community hospitals; and, most recently, accrued the most patients in the Glue Grant that studied the entire human genome response to injury up to 28 days.33-35 There are many claims to the development of the first trauma system in the United States, but my research suggests that the first trauma system was developed at San Francisco General Hospital, under the direction of William Blaisdell. In 1968, the “gold service” was converted to an exclusive trauma service.36 Federal recognition of trauma centers began in 1971 to 1972, and San Francisco General Hospital was one of the first so designated. However, in 1971, the California Legislature passed the Paramedic Act, and the plan was “the nearest ambulance to the nearest hospital.” Dr Blaisdell changed that practice for trauma, in part, by volunteering to spend his sabbatical in 1977 as acting Medical Director of the San Francisco Department of Public Health. He spent time in the Aid Stations, rode the ambulances, and compiled a report to the Department that outlined the system of caring for trauma patients in the city and county of San Francisco. John West, a 1973 graduate of the University of CaliforniaeSan Francisco surgery and Don Trunkey compared the results of trauma care in San Francisco County, a region where all patients are brought to a single trauma center, with the results of care in Orange County, where patients are brought to the closest receiving facility, and proved that a dedicated trauma system resulted in lower mortality.37 San Francisco was also the epicenter of the AIDS epidemic in the 1980s, and San Francisco General Hospital serves as an example of how to best care for these patients. In the spring of 1981, a San Francisco General Hospital surgeon, William Schecter, was called to the Respiratory ICU on ward 5R.38 There, he saw a 33year-old gay man dying of hypoxia due to an unknown disease causing bilateral interstitial pulmonary infiltrates. Schecter was unenthusiastic about an open lung biopsy because of the high risk, but agreed to proceed. To everyone’s amazement, this young manddespite the fact that
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he did not have lymphoma and had no history of organ transplantation or immunosuppressive drugsdhad Pneumocystis carinii pneumonia. In the same year, outbreaks of Kaposi’s sarcoma and P carinii pneumonia also appeared in Los Angeles and New York. On July 25, 1983, the country’s first AIDS ward opened, and San Francisco General received one of the first grants, and San Francisco General Hospital, another public hospital, took the lead in establishing protocols for treating AIDS patients. For the last public hospital, I return to my roots, Los Angeles County, or General Hospital. It is not a single disease, or specific therapy, but an approach to the care of patients. As a resident, we were well versed in the “selective management” of patients. In 1958, William Mikkelsen and CJ Berne suggested that most patients with perforated duodenal ulcers, if they were sealed by water-soluble contrast, could be treated nonoperatively.39 By legend, there were so many patients with perforations in the 1960s awaiting surgery that, by the next day, their peritonitis had resolved. Although Charity Hospital was arguably the first hospital to treat abdominal stab wounds by observation and serial examination, selective management became the dominant approach to treating stable patients with stab wounds, then posterior gunshot wounds, kidney injuries, and even all gunshot wounds at LA County.40-43 The principal of selective management was that careful examination and serial re-examination, combined with diagnostic tests when necessary, could select patients that could be treated nonoperatively. This discussion of public hospitals reminds us of some of the contributions that have come out of these storied institutions. At a time when health care reform proposes to improve patient experience of care (including quality and satisfaction) and population health, and reduce the per capita cost of health care, it is important to recognize that public hospitals are a precious national resource that must be supported and maintained.
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5. American Hospital Association, Fast facts on US hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fastfacts.shtml#community. Accessed November 5, 2014. 6. Williams WH. The early days of Anglo-America’s first hospital. The Pennsylvania Hospital, 1751-1775. JAMA 1972;220: 115e119. 7. Hoover EL. Charity hospital: from the beginning to either a new beginning or the end. J Natl Med Assoc 2007;99:578e579. 8. Bellevue Hospital Center, NYU Langone Medical Center. Available at: http://www.med.nyu.edu/patients-visitors/ourhospitals/bellevue-hospital-center. Accessed November 5, 2014. 9. Cournand A, Riley RL, Breed ES, et al. Measurement of cardiac output in man using the technique of catheterization of the right auricle or ventricle. J Clin Invest 1945;24: 106e116. 10. Debley T, Stewart J, eds. The Story of Dr. Sidney R. Garfield: The Visionary Who Turned Sick Care into Health Care. Oakland: The Permanente Press; 2009:1e33. 11. Diamond LK. The history of blood banking in the United States. JAMA 1965;193:128e132. 12. Fantus B. The therapy of the Cook County Hospital. JAMA 1937;109:128e131. 13. Moore SB. A brief history of the early years of blood transfusion at the Mayo Clinic: the first blood bank in the United States (1935). Transfusion Med Rev 2005;19:241e245. 14. Graham EA, Singer JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA 1933;101:1371e1374. 15. Debakey M. Carcinoma of the lung and tobacco smoking: a historical perspective. Ochsner J 1999;1:106e108. 16. Ochsner A, DeBakey M. Primary pulmonary malignancy: treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. Surg Gynecol Obstet 1939;48:433e451. 17. Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci 1968;150:874e894. 18. Greenhalgh DG. Burn resuscitation: the results of the ISBI/ ABA survey. Burns 2010;36:176e182. 19. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317:235e240. 20. Annane D, Siami S, Jaber S, et al; CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013;310:1809e1817. 21. Lucas CE. The water of life: a century of confusion. J Am Coll Surg 2001;192:86e93. 22. Weaver DW, Ledgerwood AM, Lucas CE, et al. Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 1978;113:387e392. 23. Johnson SD, Lucas CE, Gerrick SJ, et al. Altered coagulation after albumin supplements for treatment of oligemic shock. Arch Surg 1979;114:379e383. 24. Dahn MS, Lucas CE, Ledgerwood AM, Higgins RF. Negative inotropic effect of albumin resuscitation for shock. Surgery 1979;86:235e241. 25. Gonzalez E, Moore EE, Moore HB, et al. Trauma-induced coagulopathy: an institution’s 35 year perspective on practice and research. Scand J Surg 2014;103:89e103.
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26. Simmons RL, Collins JA, Heisterkamp CA, et al. Coagulation disorders in combat casualties. I. Acute changes after wounding. II. Effects of massive transfusion. 3. Post-resuscitative changes. Ann Surg 1969;169:455e482. 27. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg 1983; 197:532e535. 28. Moore FA, McKinley BA, Moore EE. The next generation in shock resuscitation. Lancet 2004;363:1988e1996. 29. Sperry JL, Ochoa JB, Gunn SR, et al. Inflammation the Host Response to Injury Investigators. An FFP: PRBC transfusion ratio >/¼1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma 2008;65:986e993. 30. Kashuk JL, Moore EE, Wohlauer M, et al. Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy. Transfusion 2012; 52:23e33. 31. Kashuk JL, Moore EE, Sawyer M, et al. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg 2010;252:434e442. 32. Revolutionizing Trauma Care: The Sigvard T. Hansen Jr., MD story. Available at: https://www.youtube.com/watch? v¼9lpmFfHtE-w. Accessed November 5, 2014. 33. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301e1308. 34. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366e378. 35. Rajicic N, Cuschieri J, Finkelstein DM, et al. Inflammation and the Host Response to Injury Large Scale Collaborative Research Program. Identification and interpretation of longitudinal gene expression changes in trauma. PLoS One 2010;5:e14380. 36. Lim R, Sheldon G. The Blaisdell years. In: Schecter W, Lim R, Sheldon G, et al, eds. The History of the Surgical Service at San Francisco General Hospital. San Francisco, CA; 2007: 77e149. 37. West JG, Trunkey DD, Lim RC. Systems of trauma care: a study of two counties. Arch Surg 1979;114:455e460. 38. Schecter W. The Trunkey years. In: Schecter W, Lim R, Sheldon G, et al, eds. The History of the Surgical Service at San Francisco General Hospital. San Francisco, CA; 2007:150e184. 39. Berne CJ, Mikkelsen WP. Management of perforated peptic ulcer. Surgery 1958;44:591e603. 40. Shorr RM, Gottlieb MM, Webb K, et al. Selective management of abdominal stab wounds. Importance of the physical examination. Arch Surg 1988;123:1141e1145. 41. Velmahos GC, Demetriades D, Foianini E, et al. A selective approach to the management of gunshot wounds to the back. Am J Surg 1997;174:342e346. 42. Velmahos GC, Demetriades D, Cornwell EE 3rd, et al. Selective management of renal gunshot wounds. Br J Surg 1998;85: 1121e1124. 43. Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234:395e402.
