When healing means more than stitching up wounds

SPONSORED: As the long-term impacts of trauma are better understood, providers in Alaska are working to adapt the way they treat trauma patients -- and to avoid seeing them in the first place.

SPONSORED: What’s the difference between saving a life and saving quality of life?

That’s the question at the heart of Dr. Elisha Brownson’s job.

Brownson is the trauma director at Alaska Native Medical Center. Technically, her professional discipline is all about taking care of severely injured patients. Once that might have meant simply managing a patient’s physical recovery, but today, Brownson and others in her field are taking an approach to trauma that pays attention to all aspects of recovery.

“As a trauma surgeon, I meet people at this critical point in their life, and the first thing that I’m responsible for treating is life-threatening injury,” Brownson said. “But what we’ve learned is that it takes a lot of time and effort and resources to not only sustain that life but lead to recovery.”

What is trauma?

When you use the word “trauma” in conversation, you’re probably talking about an experience that was stressful or upsetting in some way. In Brownson’s world, “trauma” refers to medical injuries -- broken bones, wounds, burns -- but those injuries are often caused by events that tend to leave invisible scars as well.

“When we think about trauma, I usually think about it as a rapid life-altering moment when something devastating happens to someone,” Brownson said. “Having a trauma happen to you is like getting struck by lightning. It happens in an instant, and it’s going to change your life forever.”

Patients receiving trauma care are often seriously injured and facing long recovery times. But it’s not enough, Brownson said, to focus on a patient’s medical recovery.

Take burns, for example. In general, according to Brownson, a burn patient can expect to spend one day in the hospital for every percent of their body that was burned. That can be a long hospitalization, but even after discharge, there’s more healing to be done, both physically and in terms of returning to day-to-day life.

“The other big part of that is integration back into your community,” Brownson said. “About two-thirds of the patients we see here in trauma are not from Anchorage. What I see is a really huge, often horrific event that has happened, and you’ve totally displaced the patient and their family from their community. That is a really big deal.”

Patients often want to get home as quickly as possible, sometimes before they’re truly ready to return. That’s why telemedicine has been a big factor in helping improve outcomes for rural trauma patients, she said. Providers are better able to keep patients “on the radar” for long-term follow-up even after they’ve returned to their home communities.

“It’s not just (about) getting your burn wound healed,” she said. “It’s what is your quality (of life) and function going to be? How can we improve your function along the way?”

To help answer those questions, ANMC has increased the amount of long-term follow-up with trauma patients to track recovery. The telemedicine program also helps make regional providers full partners in their patients’ care by keeping them connected with specialists. The result is a system in which patients get the best of both worlds -- advanced expertise from specialty doctors and the comfort and whole-person care of their local clinic.

“It’s a paradigm shift to say it doesn’t matter only that we can save more lives,” Brownson said. “It matters what the quality of those lives are.”

Seeking better outcomes

Trauma physicians are kept all too busy in Alaska, where the rate of death by injury is 50 percent higher than the national average. Among Alaska Native people, that figure jumps to three times the national average.

“Alaska is a pretty risky place to live, and Alaskans have higher rates of mortality related to trauma than other areas of the country,” Brownson said.

There’s good news, though: While unintentional injuries (such as falls, motor vehicle collisions, poisoning and drowning) are still a leading cause of death in Alaska, today unintentional injuries are less likely to be fatal for Alaska Native people than they were 30 years ago.

“Our mortality has improved,” Brownson said. “The advances that we’ve come up with for trauma care and resuscitation and prehospital care, getting people to the hospital sooner -- all of that has improved to better survival.”

Advances in blood replacement and surgery have played a role in that improvement as well. At ANMC, for example, trauma surgeons now work in a hybrid operating room where they can do open surgical procedures as well as interventional radiology -- using a catheter to find and stop internal bleeding.

ANMC was the very first hospital in the state to be verified as a Level II Trauma Center, a designation it has now held for 20 years. Last year its pediatric trauma program earned ANMC verification as a Level II Pediatric Trauma Center as well. These advancements arose out of necessity; ANMC’s emergency department treats and discharges 8,000 to 9,000 trauma patients annually, and another 900 to 950 from across the state are admitted for inpatient care. Over the years, the Tribal health care system has helped lead the way in improving Alaska’s statewide emergency medical structure.

“The great thing about Alaska is that we have a very inclusive trauma system,” Brownson said, adding that Alaska has been recognized nationally as having one of the country’s most comprehensive trauma systems. Alaska has 24 acute care hospitals, 17 of them trauma centers, and all required to report trauma data to the state. The medical community also collaborates on statewide initiatives, such as head injury guidelines, “so that everybody is sort of functioning on the same page,” she said.

That integration is critical in a state where emergency response can take much longer than is ideal. Trauma response has what’s known as a “golden hour” -- a window of time after injury during which critical care can significantly impact a patient’s chances of survival. In Alaska, that measure “is just totally thrown out the window,” Brownson said. That’s why rural providers, such as community health aides, are trained in common clinical guidelines that keep trauma patients stable and how to get them where they need to be for advanced care as quickly as possible.

Of course, in Alaska, many injuries occur far from a medical facility.

“One of the big focuses in the trauma world right now is teaching bystanders how to care for life-threatening hemorrhage,” Brownson said. “That’s really important in Alaska, because often if you’re out hiking or hunting and you have an injury, an EMS provider is not going to be your first responder. Your first responder is going to be your friend or your family or your neighbor.”

If that bystander knows how to apply pressure or use a tourniquet, it can be the difference between life and death. ANMC offers monthly Stop the Bleed classes that are free and open to the public.

“People actually run toward scenes of trauma and they want to do something to help,” said Brownson, who witnessed the phenomenon firsthand when she participated in the medical response to the 2013 Boston Marathon bombing. “I think that’s a really novel, new thing -- to have people be thinking about ways that they could help if someone that they encountered had a life-threatening injury.”

Considering culture in prevention and recovery

Even with the likelihood of a better outcome, no one wants to end up in surgery. Many accidental injuries could have been prevented in the first place -- and today’s trauma teams see that as part of their mission.

“The focus now is not only what do we do to keep that needle moving forward to better survival, but what do we do to better prevent injury and help people recover from injury?” Brownson said. “We’ve broadened the scope of our role.”

They’re supported in that by colleagues whose role it is to keep people out of the emergency room in the first place.

As ANTHC’s director of wellness and prevention, part of Dana Diehl’s job is to train care providers to help prevent and identify the effects of traumas of all kinds -- physical, emotional and mental. Diehl’s department also oversees outreach programs targeted at mitigating risk by educating Alaskans about boating safety, wearing helmets, fall prevention and poison prevention.

“We’re using cultural practices alongside best practices,” Diehl said.

At its heart, she said, it’s about recognizing patients as individuals who have unique experiences that impact how they will respond to medical care and how they will heal.

“What we’re seeing right now, since we’re really in the early stages of understanding how to put this into practice, is that our providers are being more compassionate and understanding about the person,” Diehl said. “I think that eventually will lead to better health for our people.”

Part of the reason injury rates are high among Alaska Native people is that there are certain risks inherent to the rural subsistence lifestyle. Boating and ATV riding, hunting and fishing can be risky activities, but they can also be made safer. Part of the Tribal health care system’s approach to trauma care is recognizing the importance of a patient’s lifestyle and culture -- both in minimizing the potential for injury and in making sure that plans for care and recovery keep an eye on returning to cultural activities.

“The goal no longer can be survival,” Brownson said. “We have to focus on function and quality of life and how that person is really going to contribute to their community and have a meaningful recovery.”

This story was sponsored by Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization working to meet the physical, behavioral, and environmental health needs of more than 175,000 Alaska Native and American Indian people living in Alaska so that they can fulfill the vision of being the healthiest people in the world.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Alaska Native Tribal Health Consortium. The ADN newsroom was not involved in its production.