A Perfect Storm: 2019 Scudder Oration on Trauma

A perfect storm: a particularly violent storm arising from a rare combination of adverse meteorological phenomena.Wikipedia (accessed August 2, 2019) Thank you, Drs Bulger, Stewart, and Hoyt, for this extraordinary honor of delivering the 2019 Scudder Oration on Trauma. I would also like to take this opportunity to welcome all of you to San Francisco. Just 3 miles south of here is the San Francisco General Hospital/Zuckerberg Trauma Center (SFGH), where I have worked for the past 30 years and been supported by an outstanding group of faculty members, trauma/critical care fellows, and University of California San Francisco surgery residents. I follow in the footsteps of 4 previous Scudder Orators from the SFGH including:1.1982–FW Blaisdell: “The Nature and Consequences of Traumatic Shock”1Blaisdell F.W. Traumatic shock: the search for a toxic factor.Bull Am Coll Surg. 1982; 68: 1-10Google Scholar2.1989–DD Trunkey: “What Is Wrong with Trauma Care”?2Trunkey D.D. What’s wrong with trauma care?.Bull Am Coll Surg. 1990; 75: 10-15PubMed Google Scholar31991–GF Sheldon: “Trauma Manpower in the Decade of Aftershock”3Sheldon G.F. Trauma manpower in the decade of aftershock.Bull Am Coll Surg. 1992; 77: 6-12PubMed Google Scholar4.2006–FR Lewis: “Physiology for the 21st Century: Cardiopulmonary Function in Sepsis” (unpublished) (Fig. 1) It was Dr Blaisdell who provided me with the title for this talk when he described for me the perfect storm that occurred in San Francisco in the 1960s. It started with the hippie phenomenon originating in the Haight-Ashbury district of San Francisco, a neighborhood that would become the setting for the “Summer of Love” in 1967. Idealistic youth from across the nation flocked to Haight-Ashbury to participate in the counterculture, where LSD, marijuana, and methamphetamine dominated the scene.4Howard J.R. The flowering of the hippie movement.Ann Am Academy of Political and Social Science. 1969; 382: 43-55Crossref Scopus (14) Google Scholar Meanwhile, over in Berkeley, political activism was thriving, and violent protests against the Vietnam War eventually crossed over the San Francisco Bay as well.5Gales K.E. A campus revolution.Br J Sociology. 1996; 17: 1-19Crossref Google Scholar Coupled with the release of a large number of previously incarcerated mentally ill patients into the streets on the antipsychotic drug chlorpromazine, San Francisco was converted from the “City of Love” to a “City of Crime and Violence.”6Fakhourya W. Priebea S. Deinstitionalization and reinstitutionalization: major changes in the provision of mental healthcare.Psychiatry. 2007; 6: 313-316Abstract Full Text Full Text PDF Scopus (81) Google Scholar In response, Dr Blaisdell redesigned the surgical service at SFGH such that there was a dedicated trauma surgical team in house 24/7. Because SFGH was owned by the city and county of San Francisco, as was the ambulance service, it was easy to direct all injured patients into the newly organized trauma center.7Schecter W. Lim R. Sheldon G. Christensen N. The Blaisdell Years in The History of the Surgical Service at San Francisco General Hospital. UCSF Press, San Francisco CA2007: 102-108Google Scholar Therefore, SFGH became the second major trauma center in the US (with Cook County hospital in Chicago being the first) and it became the first city in the nation with an organized trauma system.8Blaisdell F.W. 1991 AAST Presidential Address: The pre-medical role of city/county hospitals in education and healthcare.J Trauma. 1992; 32: 217-228Crossref PubMed Scopus (14) Google Scholar As a result, the number of patients with penetrating injuries treated at SFGH rose from the steady rate of 100 annually up until 1964 to almost 400 in 1969.7Schecter W. Lim R. Sheldon G. Christensen N. The Blaisdell Years in The History of the Surgical Service at San Francisco General Hospital. UCSF Press, San Francisco CA2007: 102-108Google Scholar Surgeons in a current war never begin where the surgeons in the previous war left off: they always go through another learning period. All military medicine, insofar as civilians are concerned, is a discontinuous specialty. Consequently, in every new war the same stupid mistakes are made again and soldiers lose their lives or limbs because the doctor was ignorant of past experience. I cannot overemphasize the need to study military medicine and surgery.Col Edward D Churchill, MD, 19519Churchill E.D. Address to the Army Medical Graduate School in Washington D.C., February 11 1951. Hall, RM. Armed forces consultants remembered at 50.Bull Amer Coll Surg June. 1966; 81: 47-53Google Scholar A perfect storm can exist only with the right levels of humidity, ionic charge, and temperature. That said, the term perfect storm does have a rather negative connotation. On a more positive note, a similar paradigm flows from the discipline of public policy, the Punctuated Equilibrium Theory, which states that policy change can occur rapidly when there is a convergence of interest groups, policy makers, and an opportunity window.10Cairney P. Understanding public policy: theories and issues. Palgrave Macmillan pub, 2011http://www.palgrave.com/products/title.aspz?pio=360100Date accessed: July 31, 2019Google Scholar In 2014, David Hoyt, MD, FACS, who has had a lifetime interest in military surgery, was at the helm of the American College of Surgeons (ACS) as the executive director. COL (ret) Norman Rich, MD, FACS, USA and Captain Eric Elster, MD, FACS, USN, both decorated military surgeons, were directing the Department of Surgery at the Uniformed Services University for the Health Sciences, and Brig Gen Jonathan Woodson, MD, FACS, USAR, was serving as the undersecretary of defense for health affairs. These 4 individuals represented the interest group that had strong connections with the policy makers, and the window of opportunity was the beginning of the withdrawal of US troops from Iraq and Afghanistan, with the accompanying fear that Churchill's prophecy would repeat itself. By 2014, the US had been at war for more than a decade (our longest war in history), during which a comprehensive trauma system (the Joint Theater Trauma System, JTTS) had been built up to include combat casualty treatment centers in Iraq and Afghanistan, Landstuhl Regional Medical Center (Germany), and the military receiving hospitals in the US (Walter Reed Army Medical Center and the National Naval Hospital in Bethesda, and Brooke Army Medical Center in San Antonio). This elaborate trauma system was modeled after the civilian trauma system in the US, which, in turn, was on military during the and Vietnam S. system in a of from and Trauma. PubMed Scopus Google Scholar This in a steady in combat injuries by of the for combat casualty Trauma Surg. PubMed Scopus Google go from Trauma Surg. 75: PubMed Scopus Google of a policy on the and of combat Surg. 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