Breaking Barriers in Rural Trauma Medicine

Ever wondered how trauma care can reach the most remote corners of our country? Joining us today is Dr. John Hill, the brilliant mind alongside Dr. Bill Long, who pioneered the Mobile Surgical Transport Team (MSTT) in Oregon. Discover how their innovative approach has revolutionized trauma care by bringing critical surgical interventions directly to rural hospitals, drastically improving survival rates. You'll hear about the origins and impact of the MSTT and how this life-saving initiative has reshaped emergency medical response since its inception in 1983.

Managing logistics and legal considerations for a mobile surgical team is no small feat. In this episode, Dr. Long and Dr. Hill break down the complexities of rapid coordination and the critical importance of obtaining emergency privileges from rural hospitals. Learn how a 15-minute window can make all the difference in assembling and transporting essential surgical instruments, monitoring equipment, and blood supplies. They also highlight the collaborative spirit required to operate across diverse regions, ensuring seamless and lawful operations.

Effective collaboration between urban and rural medical professionals is crucial for success. Dr. Long and Dr. Hill emphasize the value of respectful communication and teamwork, outlining the roles of various medical specialists from OR to trauma nurse supervisors. The episode also delves into specialized skills needed for urgent situations, the role of perfusionists, and the logistical challenges of medical transport. Through heartening stories and practical insights, we celebrate the relentless dedication and specialized skills of medical teams committed to saving lives and transforming trauma care in rural settings.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.  

Follow us on Twitter @DrLongPodcast 
Producer: Esther McDonald 
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast 

© Flatline to Lifeline 2025

Transcript

Speaker 1 0:01

Welcome to Flatline to Lifeline with Dr Bill Long. This podcast explores the very real potential for survival within the medical field of trauma. My name is Will Oman. Dr Long is both my uncle and a hero to many in the state of Oregon and beyond for radically altering the approach and adaptation to trauma care by applying simple principles in profound ways. Trauma care by applying simple principles in profound ways. Here we will discuss the innovations and adaptations that Dr Long and his team of nurses and surgeons employed over his almost 50-year career. The near-death experiences that we discuss here showcase the ability to achieve and to repeat unexpected survival outcomes. Patients that would normally be deemed dead on arrival were now being treated with techniques previously only available within an operating room. We hope to educate those listening from any walk of life and to inspire those in medical professions to consider and adopt the life-saving techniques and approach to trauma care, because when the need is greatest for the patient, saving time saves lives.

Speaker 1 1:11

Welcome back to Flatline to Lifeline with Dr Bill Long.

Speaker 1 1:14

We are ecstatic to have his cohort in crime, part two, part 1B, whatever you want to call him, but definitely refer to him as Dr Dr John Hill, part two of the cardiac cowboys here in the studio with us again.

Speaker 1 1:31

We're going to take a summary review of the mobile surgical transport team what we refer to here as the MSTT and the logistics not only of just getting that group together but also making the addition of the portable cardiopulmonary bypass or CPB. Cps and what it took to get it on a plane, what it took to have multiple teams in geographic locations working in concert, the things that if you had a lens focused in and you only saw one part, you wouldn't understand the breadth and scope of what it actually took to make these stories that we've told here in season three even possible. So enough from me. I'm going to turn it over to the two experts here and we've talked a lot about the historical perspective of different things and timelines of the availability ofT and then, ultimately, the portable CPB. It started with an act of Dr Hill's favorite word serendipity.

Speaker 2 3:17

You were at Emanuel Hospital in Oregon and spend time with his dying mother in San Francisco, and would I mind taking over his responsibilities as the life flight medical director Concurrently? At the same time, the chief of surgery announced that he was going in a different direction with his life and he was going to be absent in that position. And would I take over the training of the residencies general surgical residency of the program and help? At the same time I was trying to develop a trauma program. So those things happened and both these people were gone three to four months. That created opportunities.

Speaker 2 3:56

In the meantime, both John and I noticed that patients were coming in in a very rural state such as Oregon, bringing patients in who either were dying en route or dying from delays at the hospital, and said you know, and this didn't make any sense, why are they dying? So the idea came up well, if we can't get these patients alive to the hospital because to send the helicopter out to pick them up at a base 100 miles away or even 50 miles away and bring them back took up another hour of time Suppose we could fly out to that hospital and help resuscitate the patient there. Once they get them stabilized, then bring them back and we had a much higher survival rate once we were able to do that. That was the genesis of the mobile surgical transport team.

Speaker 1 4:46

And so we've talked. You know we have a tagline that we've been using for three seasons now, that saving time saves lives. Right, and we've adapted it to different stories. You know, saving time saves limbs and things like that. Or now, with the portable CPB, you're buying time to save lives.

Speaker 1 5:08

Essentially, what would happen according to protocol from the Emergency Board of Surgeons I can't remember the acronym because there's so many of them ideally it was to stabilize the patient once they were into a hospital. But a lot of these rural hospitals that were not level one trauma centers didn't have the capability to stabilize and people were to your point they were expiring before they got the attention they needed, simply by the capability of the facility they were at, not the know-how or the talent of the doctors on site, but simply by not having the equipment necessary. And you're now talking about taking this whole, basically a traveling army mash unit, and dunking it in wherever Oregon and saying, hey, we're going to do what's needed right now to get them stabilized and by time, and then take them back to the place where we can actually treat them Correct.

Speaker 2 6:16

That's correct. Again, we're going back to 1983. And at that time, you know, in rural areas the dogma that was coming out was stabilize and transfer, and if it can't be stabilized, well, they were going to die anyway and there was no point in trying to transfer. So that was the message that went out in the advanced trauma life support courses and a number of the textbooks that were written stabilize and transfer.

Speaker 2 6:46

With someone bleeding to death from a ruptured spleen, it's going to continue to bleed and the longer it takes to be able to send a helicopter out from an urban area or trauma center to go down and pick them up, put them in the helicopter and bring them back. Many times they would bleed to death in the helicopter or by the floor of the helicopter, could even land. So the question of is can you bring a blood bank which the rural, many rural hospitals don't have, with essential components of blood with you and plus surgical instruments instruments they are not likely to have because they don't do that kind of surgery, like vascular instruments, thoracic instruments Can you bring that with you with a trained nursing group, that OR nurse and an ICU nurse who has been trained to deal with trauma resuscitation, with you to help their team coordinate with our team to stabilize, give them blood and basically operate on there and to stop the bleeding and bring them back. That was the concept.

Speaker 1 7:50

And that kind of dovetails nicely, because it starts to add to the breadth and scope of what we're actually talking about, because it seems horrible to put this into financial terms, but it costs money to have a helicopter lift off and go out somewhere.

Speaker 1 8:09

And if you to steal a phrase from Dr Hill, where he had a patient and he knew all the outcomes if he didn't do something different, and then that was the moment he decided well, hey, I have this machine, what do you think about trying this? So in a sense you're doing the same thing like, hey, if we're going to spend the money to send a helicopter out there and this person's going to die anyway because they can't be stabilized, let me give you another option. Check out door number two here, where that helicopter takes off, but it's actually got the right people and the right equipment on it to do the job necessary. And so you can then make almost a financial argument and say, if we're going to spend the money, let's actually spend the money and do something with it, otherwise we might as well light it on fire.

Speaker 2 9:02

Well, there was a recurring theme that I heard over and over for the next 25 years about the stabilize and transfer. And I had one highly notable trauma surgeon say I don't care if the patient got shot on the door of my house, at the doors of the entrance of my hospital. That patient would stay at my hospital until and before I would ever transpire. If I can't stabilize him, he would die anyway. That lasted, that thinking lasted for 30 years and they were vehement about it.

Speaker 2 9:36

There was basically no one to stop this from happening in Oregon because there was no recognized opposition other than habit people what they were traditionally doing and that's how we were able to do it. We were ready to say we're offering the service, all you have to do is call and we will come. Habit had been set up so that we can mobilize these resources. Instead of putting an hour to load the helicopter and get it going in that direction, another half an hour to get the helicopter down there and then load the patient to bring them back. We brought the whole thing there to stabilize, stop the bleeding there, not back at Emanuel, dr Hill.

Speaker 1 10:12

I think you had something to add there.

Speaker 3 10:14

Yeah, I think that part and parcel with this is also the evolution over time of the Emanuel trauma group, providing and teaching trauma courses for the rural hospital so that they could also be more successful even when the MSTT showed up. Education was a huge part of this, for the rural portion of Oregon was allowing those surgeons new skills, new thoughts, so that patients might in fact be in better condition by the time the MSTT got there. So I think that that also just the outreach that was performed by Emanuel Hospital helped immeasurably in making this whole process a better process for the state.

Speaker 1 11:10

That's awesome. And Emanuel itself is not a teaching hospital, right Like Oregon Health Science.

Speaker 2 11:17

Well, we had. At the time when I arrived they had already had a general surgical residency program at Emanuel Hospital. They didn't have an emergency medical training program there. But they did have a general surgical residency program at Emanuel Hospital.

Speaker 2 11:25

They didn't have an emergency medical training program there but they did have a general surgical training program and so from that standpoint it was, and the pediatrics had a pediatric program for teaching pediatric residents. But to a large degree we were having other academic institutions send us some of their residents and medical students to Emanuel so they would get the experience that they were not getting able to get at their own hospital.

Speaker 1 11:51

Okay, so this is to use Dr Hill's language, this is an outreach program.

Speaker 3 11:58

This is benevolence, in a way, where you're saying we have something to provide and we want to better equip you so that when you do call us, we can better equip you to handle things in such a fashion that we've already jumped over steps one, two and three because you know what to do and they still need us, but you can prepare a place for us almost, and I think a key to this also wasn't just teaching physicians, it was the trauma nurses, taking their time, taking their skills, taking their ability and going out and teaching as well, teaching as well, teaching their peers, their cohorts, so that when those trauma came in, traumas came in to the ER, because that's generally where they would occur in the rural ERs no-transcript what was happening at Emanuel getting unexpected survivors.

Speaker 2 13:33

Before we even started the mobile surgical transport team, they went out to nursing conferences for ICU, er nurses OR nurses all over the state Pacific Northwest talking about what is possible, and their enthusiasm got the local nurses interested in finding out how they could participate and do something more for the patient, because in many ways the nurses are more connected with the patient than a lot of the doctors are, and that changed a lot of things. And then, once that built up, it was the nurses that were suggesting in some of these hospitals that called us why don't you call the mobile surgical transport team? We've heard what they're doing there and we don't want this patient to die. And it was their local pressure to get the calls being made to ask for us to come.

Speaker 1 14:30

That's awesome and you've said that from moment one. When we talked about just setting up the geographically centered area within your brick and mortar hospital, based on its military roots of the MASH unit, you said that the driving force behind this was not necessarily the idea that you had for the team to work in concert and that pit crew approach. It was the pit crew itself and it was driven by the nurses. And time and time again you have stressed the importance of the nurses being on board and that that was really the glue that kept this together. What's great about what you're both saying is that you're shifting the hierarchy and the paradigm that the doctors sit on top and the nurses are below or beneath. Doctors sit on top and the nurses are below or beneath, and you've now elevated the nurse and given them a voice in the post-operative meetings and you've seen the connection that they have with the patients.

Speaker 1 15:38

And at one point, I believe, dr Long, you said something that the nurses were grieving, that the nurses themselves were bleeding along with the patients. They were hurting, and it was that emotional connection and a very human connection that you were tapping into as well. So this outreach, this benevolence, this teaching, it's all very grassroots and you're saying something that I started to say over the course of the three seasons is that the patient's life has value. It's not just X's and O's, it's not a spreadsheet, it's. This is a person, this is a human being who has a life. Who's going to go stop, you know Dr Hill at McMinimins eight years later and grab his hand and say, hey, I remember you, do you remember me? And there's that bond between people instead of a very sterile environment where somebody's hurt and we fixed him or we weren't able to fix him, and then life goes on.

Speaker 2 16:46

So the issue I think is important To get the nurses buy-in. They had to see with their own eyes People survive, patients survive that normally they knew would have died. So they once, once they started having personal experience with seeing people survive injuries that previously would have been declared, uh, uniformly fatal, they became believers. And, like in almost in everything, once a group of people begin to believe in what you're trying to do, you get their support. They want to make that available for anybody who comes through who is in danger of dying. That's the power. If we just came in there and talked theory to them, it would never have worked. We had to show that these people could survive. So many doctors say, well, there's nothing more I can do. I mean, the patient's going to die anyway. They heard that most of their professional careers Until we started doing this. Then they became believers.

Mobile Surgical Transport Team Logistics

Speaker 1 17:48

What you're describing is truly amazing. Let's shift now into really the nuts and bolts of what it takes to have this mobile surgical transport team work. There are myriad variables going on and a whole host of people all working in concert. And, Dr Long, what do you think is the beginning portion of this, Especially with the CPS unit? I think you spoke of size and the portion of this Especially with the CPS unit? I think you spoke of size and the weight of it being the first logistical hurdle.

Speaker 2 18:24

Well, long before the CPS was even imagined being the deal list we had to deal with, how quickly could you respond to a call for help? Remember, in many of these rural hospitals who operate, basically you had to call in a team from home or from way from their office, or they're already in the operating room. You had to call an anesthesiologist in. You had to call or nurse anesthetist in. You had to call an OR team in because, you know, outside of the normal operating hours they weren't on the premise, so they were losing time at these places and they didn't, as we mentioned before, have the blood bank support to do that In addition to the technical equipment and the expertise to use that equipment appropriately. They might do a major rupture spleen once a month, just to put it into perspective. Consequently, you had to sit there and mobilize a team within minutes, and so the standard we set the helicopter if we're going out by helicopter within a surgical transport team had to be available within 15 minutes. Well, what do you do to make that happen? Well, you can't have one person trying to do all this. We sent, basically the OR nurse who was going to go on the mobile surgical transport team to get the surgical instruments that we would possibly need thoracic and vascular. We had them sterilized and packed in a suitcase to go with it. That was in the IOR. She would go and run and grab that, bring it to the helicopter. The ICU nurse would bring the monitors in the IOR. She would go and run and grab that, bring it to the helicopter. The ICU nurse would bring the monitors and equipment and all the attachments that need to go with the monitor. The ER nurse would go to the hospital blood bank and get the blood bank. And again, the blood bank was tuned in with the idea they had so many units of fresh frozen plasma, so many units of packed red blood cells, so much cryoprecipitate, so much platelets because most rural hospitals did not have platelets and have that all ready to go. And that would go into a portable cooler made of styrofoam with a thermometer in it, with ice, and that was all loaded up.

Speaker 2 20:32

And in the meantime that combination could be changed if we had the blood type from the rural hospital of the patient that they wanted us to come and take care of. And that's where the rural hospital had to play a role. They had to give us the blood type. So we did not have to use all of the universal donor blood going out on these trips. We could bring type-specific blood, and all that basically was happening concurrently. The Life Flight nurse basically was charged with getting the critical information about the patient comorbid diseases, antibiotic sensitivities, allergies and stuff like that. That was her job. And then, lastly, the trauma OR nurse supervisor had to make sure that the rural hospital would grant emergency privileges. Even though we had our things on file, you just can't take off and land and start doing surgery someplace. You have to have a grant from the hospital administration and the hospital medical director for us to have a team come in and do something.

Speaker 1 21:34

So the cardiac cowboys can't just show up, kick in the door and say we're here.

Speaker 2 21:39

Not, if you want to live.

Speaker 1 21:41

Okay, fair enough. So now you have infighting between the doctors if you take that approach, and you've always taken a very concerted and sensitive approach to the fact that specialists are, by nature, very protective of their turf and their knowledge, so it's completely understandable. But you listed something which is interesting and, dr Hill, you have something to say so I definitely want to hear. But what's crazy is you just listed off five different nurses right after we discussed the importance of nurses five different nurses all doing a job within 15 minutes, just to get this helicopter or fixed wing aircraft off the ground. So where did you want to go with this, dr Hill?

Speaker 3 22:25

Well, I was just going to say, you know, there is the, frankly, the legal aspect, which is really the medical staff and you being granted emergency privileges to go function as part of their temporary medical staff, because if you don't have that, then from a legal standpoint you have significant issues, particularly if something goes awry. You can't just barge in. That never works, I think that. But because of that that was a lot of pre-planning went into the legal aspects from Emanuel Hospital as to be able to have those documents ready to roll and they could then say, okay, who's going, which doctor, which nurses are going on this particular mission, and have that ready and available once they came in the door of that rural hospital. So that was just another piece of the logistics that had to occur every single time and that's huge, particularly when, ultimately, in this day and age, you're going to or have been to so many hospitals, not only in Oregon but in the Pacific Northwest and the state of Alaska. That's always a dance that happens to occur.

Speaker 2 23:53

I think the other thing that John is possibly referring to about kicking the door in, if there's one thing that basically sets people's teeth on edge is being talked down to and there's no more. I mean, it doesn't take a PhD to pick up on that tone. That is set by the person who is talking down to the other person. That is set by the person who is talking down to the other person. I heard, when I first arrived in Oregon, doctors telling rural doctors you shouldn't be doing that, you're not qualified to do it. Send us a patient. That's arrogance plus it's demeaning and consequently a lot of rural doctors were basically conditioned to have a negative attitude toward a lot of the urban doctors because of this way of communication. That's why the asking permission can we come and do this? Can we come and help you? Changes that whole dynamic to where they are part of the team and not basically observers standing in the corner of the room while we do our thing. They have to be a part of the team.

Speaker 1 24:58

That's absolutely fantastic. So thus far, what we've got is not only just a professional approach, as you said, where you're not kicking in the door, you're working in concert with these people. You're saying, hey, you're part of this, you've given us permission on the legal side of things. You've also given TASA permission to work alongside you. You have an expertise. They've called for help, but it's an agreement on that.

Speaker 1 25:29

Then you have five nurses inside of 15 minutes that are all gathering the necessary supplies. You have size configurations for just the machine itself, the additional tools, the battery supply, the ventilator that needs to be portable, all the instruments, monitors, blood bank, all of these things. Everybody's got their assigned duties. But when you go to that list of the five nurses that you talked about the OR, the ICU, the ER, the life flight and the trauma nurse supervisor those are all specially and highly trained people as well. So you have to go through, let's predate this event and you have to go back to the educational aspect of it, and those people have had to be brought along and taught something, educated to a certain level to even perform, to get to the spot where, in 15 minutes, they can go grab the right things.

Speaker 2 26:31

Well, you have to remember that, in the environment that John and I encountered at Emanuel is after a few months of seeing these unexpected survivors. When we asked them to help us to put the mobile surgical transport team together, they wanted to. I mean, that's a difference being told to do. They wanted to be a part of that and the energy that comes from people who want to be a part of something and willing to sacrifice to be a part of it. It's unmeasurable.

Speaker 1 27:01

And we'll get to. We'll get to to Dr Hill's point on that in just a minute. Just the willingness. But there's another, there's. There's one more person that we need to recognize, or one more role, and that is the role of the perfusionist. And that person transports the CPS or ECMO machine and the cannulas for loading it onto the land or air ambulance. And we've spoken of perfusionists and you both have done it in very revered terms, reverent terms. So, dr Hill, can you explain whata perfusionist actually is?

Speaker 3 27:42

Sure, a perfusionist is a highly trained professional who runs the heart-lung machine, and the heart-lung machine isn't just a dial you get to just turn and go have coffee. They are having to constantly monitor temperatures, ph, blood gases, blood volumes, how much flow a patient needs to survive, and so that's just in the standard open-heart operating room. I mean, that's, that's what they do, and as a cardiac surgeon, you are totally dependent on their abilities to make sure that the patient upon whom you are operating is going to going to be viable and alive, and at the end of the surgery they are basically the patient's lifeline. During that whole period of time, the anesthesiologist can go read the Wall Street Journal, the surgeon can just focus on doing the procedure, but the perfusionist is making sure they have a viable patient during that period that the patient's on bypass.

Speaker 1 29:07

Then that very much explains the reverent terms that this is basically the patient's that you're talking about. Yeah, this is, this is the, the actual living version of the patient, making sure that the one who is operating, who is being operated on, is, as you said, viable, then, okay, that gives a lot of scope and understanding for that and it and it, and it goes back to this pit crew approach that Dr Long has said for all three seasons, that all of this is happening, you know, not sequentially, but concurrently. Dr Long, you had something to add.

Critical Considerations in Trauma Transport

Speaker 2 29:51

Just to add to what John was saying. But the value of the perfusion is that you as a surgeon can focus technically on doing the operation stopping the bleeding, all the things that need to be done inside the patient because you're not having to sit there and make all the decisions for running that machine. He does it for you because you can't do major operation in critical situations under the stress of time and get good outcomes if you're distracted by multiple things or people interrupting your train of thought.

Speaker 3 30:26

That's why the perfusions are so essential Once you get into transport. That adds a whole new dimension to what they are responsible for, because you know when you are loading and unloading patients who are now hooked to a bunch of tubes and a device, then that all has to be done safely because that you know one of those tubes comes unconnected, you're done. Kinked. One of those things kinks, you're done so that the perfusionist in our scenarios is always the one who is directing, starting and stopping the transport process to make sure that all of those lines and all of those devices are going to stay functional during the movement between ground to the transport system, back to the ground, back to the OR, back to the CAT scanner, back to the. Wherever you happen to be going, the perfusionist has really kind of got the helm in many of those cases.

Speaker 1 31:44

Okay, and then you know, going kind of down the list of things running concurrently and the educational aspect and just the logistics.

Speaker 1 31:55

You know it starts with a having a team that's there on site, site, ready to go as Dr Long has mentioned numerous times that there's people ready surgeon to cover for him at home base at, in your case, emanuel Hospital, because now you're taking the guts of your trauma ICU team, putting them on a helicopter or plane and sending them out. So now you have, ostensibly you have two different teams in two geographic locations and they're both working together on the same case Because they're just as the rural hospital that you've worked in concert with is kind of preparing a place for you guys to land, for you guys to operate and then work with you On the back end on the return flight. You have to have a place prepared as well for them to re-accept this patient once stabilized. So now you have a vast amount of people involved that are just actively working on the case itself and, as Dr Long has said, it's all happening concurrently for you guys to leave and be out on the road within 15 minutes, which is an incredible response time. Yes, dr Hill.

Speaker 3 33:32

Well, you also have to remember if you're going to take people away, you have to have people staying home, because the next trauma patient might come into the ER at a manual Right, so that those people have to be there and committed.

Speaker 3 33:49

And during this whole process then you have to remember you can't take all those bodies with you, right Patients. It becomes very selective who can go and whose skills are needed, because there are only three seats in that helicopter. There may be four in a fixed wing and you already have one for surgeon and one for perfusionist if you're taking the CPS device. If you're not, that gives you a little bit more leeway. But you have to then decide who are you going to need and what's that patient going to need the most when you get there, and so that you have to make that decision up front and it depends on which transport you're going to use. Are you going to use a helicopter, are you going to use a fixed wing or are you going to use ground ambulance and time and distance plays a role in each of those choices as well and weather.

Speaker 2 34:54

And weather.

Speaker 3 34:55

Weather is a big, that's a good point.

Speaker 1 34:57

That's a good point and we haven't even discussed what you said, dr Hill, which I love. You know we're talking about the human aspect of things and the value of a human life. Well, there's value, obviously, in all the human lives that have to board this transport. So Dr Long had mentioned, you know, the willingness of these nurses and they wanted to do these things and they wanted to push this program forward. But you also have to have between three and four people that actually want to get loaded onto the aircraft to begin with, or get in the land ambulance and travel a long distance there, ambulance and travel a long distance there. So you have to consider that these people also have families and they're putting themselves in harm's way just to get on a plane. You limit your chances of getting in a plane crash to about 0% by never getting on a plane there is risk involved.

Speaker 3 36:04

A plane there is risk involved and particularly when there's weather in the winter, there is risk involved. There's risk involved and it's a bright, sunny day and every year in this country there are accidents with medical, ambulance transports accidents with medical ambulance transports, which is terrible to think about. It's a very real issue that people have to make a decision.

Speaker 1 36:35

They are willing to do this because they think there's value in it.

Speaker 2 36:42

And then there we go back to value again. Dr Long, you had something Well. The other thing we'll talk more about this later when we get down to specific areas like brain injuries, spinal cord injury and so on, where I begged surgical specialists to go with us on a mobile surgical transport team, especially if the patient had an epidural or subdural hematoma, which is a blood clot either on the surface of the brain or inside the brain and that needed to be drained.

Speaker 2 37:06

Because, again, time is of the essence, and not one neurosurgeon in 33 years thought I would even suggest it. I knew it could happen because there was a neurosurgeon that John Hill and I knew in the San Diego area. He was in the community's neurosurgeon. He taught the emergency physicians at a hospital called Oceanside Hospital how to do a burr hole, one of the simplest. I mean, even the Cro-Magnon people and the Aztecs and the Incas were doing burr holes, but he taught them how to do it and he would then drive over and clean up the mess and whatever by the time he got there, but at least the pressure in the brain had been resolved. But in the neurosurgeon's thought I thought I was crazy. So you don't get buy-in from a lot of the different people who know what the potential risks are.

Speaker 1 38:00

So you have to plan around that you can't force somebody on the plane or in the ambulance who don't want to go, and then the last thing that is mentioned here by Dr Hill and I kind of hinted to it before, but it's all of the things that occur prior to moment zero, where the MSTT gets the call.

Speaker 1 38:26

It's the training, it's the technique, it's the proficiency and the planning that goes into this in all the different specialties, and then training as a team, and then training as a team. And you talked about that, dr Long, in one of our first two episodes of season one, where you were talking about just the need for these people not only to be into the idea and bought in on this idea of working as a pit crew, but then training for it too. You know, because when the situation arises, you need people to know exactly what to do. Practice makes perfect on an athletic team. You run drills, you do practice plays before you actually get to the game and for for you guys, you actually had to drill this. Can you kind of expound upon what training looked like for this group of people?

Team Approach to Transforming Trauma Care

Speaker 2 39:26

Well, the ideal training would be basically like they do in football, probably in baseball and basketball you take videos of the game and the coaches and the players review the films. And the coaches and the players review the films because in football if you miss a block, you know no one gets beyond the line of scrimmage or the quarterback gets sacked. So the training you know. There we tried to accomplish that at UC San Diego. John Fortune, one of our trauma fellows, later became a trauma attending surgeon. He brought video there and we used to watch the videos and that would give you an idea so that you could play it back and say this is where we can improve on something and improve the timeline of care and the accuracy of care. But that we couldn't. I could not get that to work at a manual. People would unplug the video, they would, the tape would disappear, stuff like that because they did not want to be embarrassed on, you know, among their peers. And that's another factor that you have to consider in today's health care and the health care that we were evolving there. You know how do you train the ideal. You take them to the laboratory and take an anesthetized dog or a pig and you would create injuries and then the team would basically learn how to do it. Well, you could teach certain techniques that would, by it's called.

Speaker 2 40:48

One of the courses was called the advanced trauma operations manual, where you taught them how to tell a soap a stab wound of the inferior vena cava. You showed them how to solve a stab wound to the heart or gunshot wound to the heart. You know and goes, and it goes on and on. But we found that running that course it wasn't just teaching the surgeon. You had to bring from the rural hospital, for example, the scrub nurse so that they could anticipate what the surgeon would need to be able to do this procedure. So that was a different concept, bringing the scrub nurse from the hospital. But the hospital administrator of the rural hospital had to agree to finance the nurse to come to Portland for a day so that we could do that kind of training. I mean, there's so many opportunities to really upgrade the care of patients. When under great stress, it's not only stress upon the patient but it's stress on the rest of the team when somebody is faltering in their ability to do something.

Speaker 1 41:46

Yeah, you're only as good as your weakest link. So we've talked about the logistical aspect of this and the physical nature, the performance on the field, so to speak. We've talked about the training nature. This all happens from this serendipitous, or or providential, moment of you absorbing, uh, responsibilities of, of two roles that had kind of vacated their responsibilities. It opens up this conversation, uh, between you and hospital administration of what can, what can we do more? If we're going to take the flight out, we might as well bring back a live patient, someone to work on, a life to save that has value, and then that ultimately becomes an administrative task of the legal paperwork, the finances for it, the absorption of extra cost to train the team to do all of those things. And so now, behind the scenes, what the family of the patient is seeing is people actively working, but the number of people and the number of jobs and responsibilities that take place just in order for patient zero to be patient zero is vast. You have so much that has to occur just to even allow this to happen. You had kind of gotten into it with the rural hospitals where you have to have permission to go work there and you have to have a relationship with those hospitals.

Speaker 1 43:23

I kind of liken it to to you know, my area of expertise a baseball game and you see nine players out on the field, but it took about 500 people all working jobs, maybe 750 if you can consider the minor league players just to get those nine people on the field to play a singular game, because you have to consider coaching staff on that field.

Speaker 1 43:52

Then you consider the minor league players filtering up to be one of those nine. You consider all the coaches and support staff for that. Then you have a medical department. Then you have a scouting department who are trying to find the best players so that they can accelerate through the minor leagues to get to that spot. They've had to train to do that. Then you're talking about your strength and conditioning department. Then you talk about the front office, who is making economic decisions, and the next thing you know is that nine people on the field was impacted by 700 people. That had to do a bunch of things for that even to occur. And that's how I see you guys explaining this, at least through my lens. Is that an accurate picture for what you experienced?

Speaker 3 44:41

Is that an accurate picture for what you experienced? Yes, I mean. I think that you have to have clearly a whole support group nursing techs administration legal. For an idea like the MSTT to come to fruition, you have to have that support or else you simply can't do those things. You can't do it. It will fail If any of those pieces are not in play and intact and if any of those pieces are not wanting to play the game, Pun intended.

Speaker 1 45:25

if none of these things happen, the MSGT doesn't get off the ground.

Speaker 2 45:32

Well, that's basically a metaphor for the MSGT taking off either in a fixed-wing aircraft or a helicopter, but if you're going by a land ambulance, you don't need to get off the ground.

Speaker 1 45:43

Okay, so you've now wrecked my pun and I appreciate that about you and that's what a good person does. As you said at 6'4", you're talking down to me, so I feel better about myself at this point, joking aside. Joking aside, this is a vast concerted effort to create this program and value the life of a singular patient, and it happened numerous times. It really goes back to this idea that it takes a team, it takes a group of people to have a collective mission and you need to put value on the patient to create unexpected outcomes. So you're using what's readily available and it's the utilization of the equipment and the technique and adapting it to a new situation that is revolutionary. It's not the technique or the equipment that itself that is revolutionary. It's just thinking outside the box and it ultimately goes back to does the patient's life have value? And if we save some time, we can save a life.

Speaker 3 47:02

We were driven by experience where we didn't succeed.

Speaker 3 47:11

If you look at the evolution of how we developed, the reason we developed being able to put the bypass device on the helicopter, adapt it to the helicopter, was really driven by trying to use a big old device and not being successful and we needed a new way of looking at things. The Carmita to me. You know that having that drove the ability to use it in trauma, that drove the ability to use it in trauma, so that it is none of that was new. It was available technologies that developed better, but it was really the team saying you know, we could, next time we can do this better, next time we can adapt, we can maybe have a better outcome. And I think that's what drove. Everyone was really saying we got to do better because we're going to see this patient different name, same problem, we're going to see him again in the future and we need to be better prepared for that.

Speaker 1 48:43

That's fantastic. That's fantastic that the cardiac cowboys, the high flyers, the specialists are really saying that it is the team approach. Once again, you guys keep going to this team. It's a mission statement, it's this ideology that you got to get better and it's even from your aspect. It's learning from failure. Failure is only failure if you fail to learn from it. Dr Long, you had something to add.

Speaker 2 49:15

Well, I think John Hill and I both had the experience, both in our general surgery or trauma days and as well as in our cardiac surgical days. We had leaders in that field Not all the cardiac surgeons, not all the trauma surgeons, but the ones in charge believed in quality assurance and they would go through failure and success, detail by detail, to find out how we can improve the delivery of care. Success, detail by detail, to find out how we can improve the delivery of care. And that was basically our model, for which we built our trauma program at Emanuel and our mobile surgical transport team at Emanuel. How, every time we did a mission, we would have a sit down period with everybody fresh in their mind and go over, you know, phase by phase, time by time, to see how we could improve the efficiency and the quality of the care we provided. That was key. You can't make progress without that.

Speaker 1 50:09

And it takes a lot of energy to do that, because then you have to relive something and go through it step by step, and that truly is a difficult thing. I remember sitting in clubhouses after tough losses and going through it with the guys and the same thing I mean obviously very different, very different scenario. Nobody's life was on the line, livelihood perhaps. But you look at it and it's not fun to admit your mistakes, it's not fun to relive a group failure, but it's necessary to push forward. So with that I'll say this thank you both. Thank you both for your um you know the, the serendipity and the providence of your longstanding friendship, but for being available and telling these stories and putting them out there so that they can perhaps inspire other people to group together and come together with a mission statement to help save lives, to save time and save lives.

Speaker 1 51:22

This has been highly educational for me. I'm deeply grateful to be a part of it and I just thank you and I'm sure the many people that you've treated also are grateful, not only for your expertise but for going back and sharing this, because you did learn from your collective failures and were willing to say what can we do better. Dr Long. As you've said many, many times, you can always quit. It takes energy to try, and that's what we, the general public, want. We want our doctors, we want the team of nurses, we want the hospital administration to try to give us all a chance in the worst of circumstances, and I think we'll close with that.

Speaker 1 52:12

We hope you enjoyed this episode. To learn more about the MSTT, the portable CPB and any of the case studies that we've discussed this season and the strategies for lifesaving that we've discussed as well, you can check out the show notes and Dr Long's upcoming book entitled Flatline to Lifeline. As we close, we remind you to imagine a world where dead isn't actually dead. We remind you that there are places and people who value the patient over the system. Flatline is not the end. A lifeline exists. Saving time saves lives. Thank you for joining us here on Flatline to Lifeline with Dr Bill Long and special guest Dr John Hill. We'll see you again soon in season four.