Dr. Konstantinos Margetis, Chief of Neurosurgery at Mount Sinai Morningside (MSM), presents an overview of the neurotrauma program at MSM, including the hospital’s trauma activation criteria, scope of coverage, and patient volume.
Okay ready? So dr Margaret, this is the site chief at Mount Sinai Morningside and he's the director of the spine at Mount Sinai Union Square. He trained in Greece and then came to Cornell where I was a junior resident at the time and completed a pediatric fellowship and subsequently went to the Cleveland clinic to complete a spinal deformity fellowship. He brings a great deal of complex spine expertise to the department and I can speak for myself and saying that he has supported a number of my decisions on the management of spine related issues in pediatric patients and as well as being widely published and and an active member of our department. He also has a wife and a young family um that he gets that he spends his time with. He'll be presenting to us today on uh on the mount sunday morning side a spine experience I believe. Prom experience drama. Experience. My apologies. Thank you peter. Um can you see my screen? Um Yes, we see african. Okay, very good. Um so, good morning everybody today. We will discuss about the experience uh from Morningside, about uh the neuro trauma to treat over there. Uh on sunday morning side, these are departments trauma center in Manhattan. We also have health care located greens and we are all familiar with a great job that is being done over there. So let's start and uh with some slides. Uh, let's see whether you're a trauma or drama in general is an important problem whether we don't care about that. So, these are some data from the cbc and we can see that across all ages. Unintentional injury is the third leading uh, causes for years of potential life lost. and uh when we say younger ages below 65, that actually becomes the first cause for uh years, competition like lost. So it has a significant impact on our society. And some additional statistics also point to the same direction and we can see that especially younger ages. Unintentional injuries. The 1st 1st cause of death and even in other ages still remains like an important cause. And ah Uh in terms of the mortality uh their opportunity 60 deaths from unintentional injuries per 100,000 population. Uh In terms of your time, specifically the most uh widely cited statistics uh Come again from the CBc and there are more than two million people that visit the emergency department every year. For D. B. I. Uh 300,000 of them they get hospitalized and firstly across approximately 50,000 people die from TB. I. Every year. And in addition to the incidents of your family have Somewhere between 3-5 million people who survived the T. B. I. But they are living some disability caused by the traumatic brain injury. And of course it is it's not just a national problems and global problem. So there are multiple classifications of a traumatic brain injury because you know, although we would like to group these patients together but in reality there are many different pathologists that they're being classified at the traumatic brain injury. Uh this is a very good example where all these six patients they were uh in Coma. They had just less than eight and they were classified as Security B. I. But as we can see they have total different pathologies. Is basically the residual hematoma especially had confusions the I. S. D. Aids. Ah So they had authorities that are very different to treat and was totally different prognosis. So common classification is still classify the TB according to these six types of brain injury. Um I will start with some flights for the more junior members of our audience. So this is an individual uh hematoma and there are some specific criteria about want to operate. If the thickness is more than 15 millimeters, if there's more than five millimeters of uh midline seed, or if the volume is more than 30 CCs, usually uh is associated with a skull fracture that goes the knee during one of the arteries, uh usually the middle Manziel artery and is associated with the so called lucid intervals to the patient might lose questions at the time of the accident, he regained consciousness. And then as uh the hematoma continues to build up, then they might become from a dose again. And if they are not operated, then the usual outcome is actually, it's unfortunately there And uh, it has been well established in the, in the literature, you know, from the 70s that you need to operate uh really, really fast that any delay beyond two hours, it is unacceptable for this type of uh hematomas. We also have a low hematomas that they are under the dura in the sleep like potential space, which would go some girl space. And usually this is associated with underlying brain injuries or these bases. Uh we're usually became unconscious at the time of the injury. They remain unconscious. And there are also some specific criteria and guidelines that behemoth almost more than once that you need to speak. If it's causing more than five of midline shift or there's any particularly of probabilities, then you have to operate that Madonna And again, this well established the leadership from the 80s that you need to operate really, really fast. And they saw that if there is a delay of more than four hours and the mortality really increases. So in reality we tend to operate as soon as possible. But as you can see uh if there's a delay more than four hours, then the outcomes are really early effective. Then we also might operate for uh multiple confusions. And uh what we need to be aware about this type of pathology is that they're very likely to blossom uh basically increase in size and create mass effect and compress the brain. And again there's some specific idea that we use uh if there is a refractory SCP, If the volume is more than 5060s um and some other more specific criteria. So the types of operations that we do in neurosurgery for some of their, There are basically 3. 1 is the craniotomy where you can see here that there was a prior opening to the skull uh was evacuated and uh the bone was replaced with some plates and screws. So there's a craniotomy that we might open. Another option is to open a small hole and insert a catheter. This is an external particular drain that allows both the measurement of I speak, but also the Germans of CSF if we need to do that to control the I speak. And then we also have the big aggressive craniectomy where we opened the skull. We remove it from ultima, control the bleeding. But we did not replace the skull to allow for the brain to expand that you can see here and dr control the ice beam. But by the way, this craniectomy is not really perfect. I will probably have gone a little bit further back in this posterior margin, but this will be still sufficient for these patients. So, uh when we're managing the TB patients, we follow religiously. This publication by the American College of Surgeons and it is based on evidence but it's also based on the experience and the expert opinions of many people who are really experienced that we can, you know, drama. Some key points for the publication is that we use the classical coma scale to evaluate these patients. And it is important to write uh its components. So we don't use just the sum. Just Yes. 14 15, 13. I mean we use that but we also need to specify uh it's component, the eye response wherever response model response. That makes it easier for the next provider that will follow up to see. There was any change the neurological exam. Also, these publications specify some instructions for the american medical services that they should bring to a trauma center. Any patient with T. B. I. Yes, less than 14 or any deviation within this. Yes if they have an associate an additional extra cranial injury of uh specific severity grade and above the A. S. Uh s. Uh trouble free. That document also specifies that we should be monitoring the I. C. P. In patients who are in common with this year's basically less than eight and he hasn't had a brain damage of the city. And if it is the preferred method because it also allows for the Germans of CSF and that's a very very effective method to control the increased ice cream. Also we have three stages in regards to the management of increased intracranial pressure. First we start with elevating the head of bed. Actually it's more like it was also like a prevents prevention measures to prevent an increase. The I. C. E. With the data provides pain record control to the patient and there is a need it in place with rain CSF to control the elevated ICP. If these measures fail then we proceed with hyper smaller therapy. Either mannitol or hypersonic selling. Uh There's a lot of discussion which is better basically if you're dealing with a patient. Uh Actually I won't go into any details because it's a very long discussion. You can also try decreasing the P. A. N. C. 02 and you can also do a trial of paralysis and if there is a response to the city you can paralyze the patient and this can also have an effect on reducing the I. C. P. If these measures fail then we proceed with the most invasive options. Um decompress according to me is the number one option. But in some selected cases we might uh uh proceed with the arbitrator, propofol comma or some even most cases who might try hypothermia to see if it has an effect on the I. C. B. Also this document specifies that we should start early in Tehran nutrition. Uh If we think that the basic won't get excavated within the first week that would supersede with early tracheostomy. Uh We should avoid laparoscopic or any operation on the original anesthesia because this can increase the SCP uh If there is a stable city which will start loading up within three days. And another important point is that if we're dealing with a security by patient We should uh in most cases we should at least 72 hours of intensive care aggressive therapy before we proceed with the goals of care. Because it's very very easy to um To to be misguided by the by the findings and believe that this base has zero chance to survive. But there have been surprised mostly surprises that they survived and had a meaningful outcome. And in general unless we see something you know definitive on the city's kinda we should try to aim for 72 hours of therapy before any goals of care discussion. These are some physiological parameters that we try to uh in for basically we want good explanation. Could systolic blood pressure to maintain serval diffusion. We want to ask less than 2025. Uh The sodium needs to be within normal levels and the calculation functions will be optimized. Uh So these are simplified uh let's say image of how we to D. B. I. So we're in for a resuscitation and maintenance of uh normal physiology. We are always aware about the potential for unstable structures will maintain. Spy precautions, wait for an emergent brain decompression and control of the intracranial bleeding. And then we prevent and treat they present uh the secretary injury to the brain like such as uh mom seizures and etcetera. And rehabilitation is a very very important component of the overall care. So what we need to remember is it's like almost everything in neurosurgery, even like a smaller commission, a small mistake can have a devastating and catastrophic outcome. So even like a short period like a few minutes of increased I. C. P. Or human hypertension can lead to irreversible injury to the brain from ischemia. Or if we're dealing with an unstable structure around movement can cause irreversible paralysis. So attention to detail is paramount for the treatment of these patients. So what is the national authority that let's say monitors the development of the trauma patients? So american College of Surgeons has taken a leading role in that aspect. And they have some specific games on how to improve the care for the injured patients. And the two main instrument that they use is the verification of the trauma centers. So it's trauma center is being reviewed every three years by the american codes of service to make sure that they meet all the requirements of the A. C. S. And also the performance of its trauma center is actively monitored by the A. C. S. Which provides feedback to uh It's thomas said on how they can improve their performance and this is risk adjusted. They will see um uh some examples of these uh evaluation for for Morningside. So this is the document that basically defines uh what thomas center uh somehow in place. So what are the key components? So uh that's almost a little basically level on 11 tools to be ready at any time to treat uh a severely injured patients. Uh They have the ability to provide gravity emergency parent valuation availability, availability of blood. There is a trauma surgeon in house and ready to respond to any comma case in the city. They have a much more ideological capabilities and they are able to perform. Banks can immediately on transportations and neurosurgery orthopedic surgery and some other key surgical specialties are also readily available. Uh Obama said they're usually also has a surgical I. C. U. And they have rehabilitation care in house basically the form of pt OT access to rehabilitation doctors. And they'll have come a prevention and family research programs. They maintain the time of registering and probably the most important factories that they have a performance evaluation system in place. Uh So the travel centers, they're dividing level one to level four in terms of the care that they provide level on A. Level two are pretty much identical. And for us for neurosurgery there's no difference between a level one, level two, the requirements are basically the same and you're sending me needs to respond within 30 minutes and there needs to be to neurosurgeon on call one primary and one backup. The main difference for that. We make a promise is being level one. Is that they need to have a specific number of admissions and they need to have some additional requirements that we already have that over. More exciting. So uh keep concept is the activation. So we have the full activation which has a different name in different trauma centers over at more exciting. Call that trauma code over the elders, the goal that red drama. So we have the full activation. And there's some specific criteria for more decide these are our criteria. So we have the bamako code which is like the highest level of some activation. And we also have the time I learned for uh trauma patients that do not require the mobilization of all time or resources of the hospital. And uh in regards to the performance improvement. So as we said, there is a performance improvement system in place and uh put in some measures, evaluates improve, scare. And the key thing of the performance improvement program is that we're trying to find opportunities for improvement. So this is not about punishing people. Uh it's more about um learning from our mistakes and try to become better. And as you'll expect, there are some various in that process is so we need to be aware of what we prevent such a system to be effective. So these are regularly confrontational conversations and uh the goal against me on how, how we can become better. I think another thing, classification of the Colonel Sanders is uh Jeffrey Yang, who is an experienced thomas for Regina has reviewed many, many thomas Sanders, so he believes that definitely the best categories, the colonel said that they provide good care, but they believe that they provide some some Baltimore. The reason is that such a trauma center will actively trying to become even better. Then another category is that they provide good care and they believe that they provide good care. The problem with that is that people might, you know, might not try to become better, so there's more potential for improvement in titanium, an entire people. Then we have cases where they provides about health care and they know that they do that. So the good thing about that is even that they know about it, they're, they should be trying to become better. And the first category is that trump says that provides about amount of care but they provided, but they believe that they provide good. So this time I would not try to uh to get better. So that's the worst degree. So in Mahanta, therefore, trauma centers still level one to level two and somebody myself, why are there so many? There's a rule of thumb that trauma centers will cover approximately one million population. Um, and Manhattan has 1.6 million. So I are there so many times centers actually Manhattan to be considered more like a four million people city because there are so many people who commute here to work or to visit the city. So there's definitely like a role for for travel Sanders. And now let's go to mountain demonic side, which is located in the morning side Heights with allocation that has been considered as them academic progress of the city. Given that there are many higher education institutions, it carries uh the history of the ST luke's hospital with many innovations, including one of the first publications for HIV and dislocated in again Morningside. So a few things about, about the statics sense that is harmonic side. So most admissions go to drama. So even if the patient has, let's say an isolated brain injury, That patient would first be admitted to the trauma service for 24 hours. Uh and then that will be transferred to neurosurgery. This an agreement we have in place. And actually, I believe it's very convenient because trauma will take care of all the systemic issues. And then when the basic gets transferred to us, we only have to worry about the DB. And we don't have to worry about things that were not experts on. And uh in regards to the admissions, we can see that we uh into 2019 who met the goal for uh to become a level one trauma center In 2020. We came very, very close and it's a very, very good performance if we take into account that it was a covid here and make things change and we have very few transferred out. This is a quality basic that is actively being measured the pediatric transfers out there. Um, justifiable because we're not a pediatric trauma center, but any adult patient who was transferred out these cases get reviewed about what was the reason for that and whether it was justified or not. And as we can see over here, a significant proportion of our patients actually geriatric patients. And that seems to be the case in many other urban trauma centers in terms of the mechanism of injury force are by far the most common cause of uh of trauma that we see. And thankfully we don't see a lot of time of violence related trauma. And these are some more neurosurgery specific metrics. Uh These are the transfers uh that they come to our hostel because the neurosurgery is there the new york times disasters? Uh Beth Israel queens uh Brooklyn, we collaborate very closely with emergency departments of these hospitals and these transfers are coordinated by Nima and we really appreciate the help. And I'll say a few more things about being later. And we also keep track of uh some quality metaphor for your for neuro trauma. So as we discussed, any patient with tcs less than eight, so get a nice p monitor. So we measure that compliance and uh uh that that percentage is not because we're negligent. Uh there's usually a reason why you know we were in place and we want to make sure that in our notes destruction is documented so that there is no doubt about uh the quality of our work. And the same applies for initiating a video prophylaxis. There's usually a reason why we didn't initiate v deep reflection these patients. They might have located account unstable city or there's always a reason. And we actively monitoring these cases to make sure that there was no quality issues. Now let's see how we're doing college our performance. So again there's the risk of just mortality based on the data that are being collected by a dedicated person by trauma register. The trauma team has and these are reported to the American College of Surgeons. And these data are getting audited by the A. C. S. So our performance actually very very good. Um The alteration for patients security B. I. Uh to die in a hostel is almost half the national average. And ah this is a performance that has been um It's not just a snapshot. It seems to be like a pattern that would be able to really lower this uh This mortality we have always been doing probably really I mean around the average But all therefore that we have done in the last few years seems to be um you know to lead 2030. Another quality measures that we uh we keep track of is uh major hopeful events like I could give the injury of pneumonia take back to the or and um we are also performed very well in the security be, I mean the hostel is performed very well overall but insecurity B. I. Uh the performance really really good. And uh this is also something that we see a pattern uh not as convincing as well as with the modern mortality but there is a trend there that is getting really low. So we are five attendants that we take all and do Catanese our sites there who constantly supervises us. And uh rounds in person would review the cases in conferences and We're fortunate to have him available 24.70. There is a public space that we need his guidance or we need to help it or we really appreciate that. And as we said there is a primary neurosurgeon on call. There's a back a person and we need to be able to respond within 30 minutes. We closely collaborate with Nima both in the gas transport but also in rounding daily on the I. C. U. Basis. And we use this robot which can be um uh the the dilemma provider can can move it remotely and you can see and hear what the exam is so that this would be very very helpful and uh we really appreciate that limit equal because something was missing from Morningside. Uh And we're very thankful that we have access to the expertise of our neuro critical care team and we're very closely collaborated with the emergency department. Um I don't know whether burns trauma program director which is a very powerful position and trauma center. You have a very amazing collaboration with with him and we also work very closely with the rehab the team and we are fortunate to have in our system a model system for T. B. I. And the model system for spinal cord injuries. So this is these are very competitive um classifications for um for a rehabilitation department and we're very fortunate to have access to their expertise. And the last slides from the most important is the in house thing that make these great results happen. We have seven ft time, A Pds, Adonis, artsy Megan Alexandra laura and daniel, Rachel and Canadian our full time uh A PBS. Uh they're doing a great job and in trauma. Uh You need to you need to there sometimes they're very very dense and you need to be very fast and very effective and efficient with uh your decisions and your actions and uh this thing is definitely is definitely very very competent and we have per diem in months and the west A. PPS that they're helping us whenever we need them and we really appreciate that. And this year we started having pRS we had that georgians aka rotate with us doing both six and things will work but also doing clinical research that hopefully will be able to present review soon. Mhm. Something. We're good on time. Congratulations. Beautiful talk. Very interesting work, high quality work. Uh one question that I have for you, khan is with a big hospital system like we have now with expertise in various locations. What percentage of the cases that are transferred do you think could have been managed at another hospital or benefit from the transfer and the care the coordinated care that you give there? I know that sometimes we transfer someone based on a diagnosis such as a subdural but not a severity. And so do you have some way of understanding, you know where what sort of threshold uh in in severity is needed to really require the trauma center as opposed to the different diagnoses? Yes, question is clear. Yeah. So most of our transplants are from hospitals that they don't have neurosurgery or even neurology in house for example, Montana Brooklyn Montana queens. So um I mean in here some of these transfers who have stayed there. But having a patient with subdural hematoma being managing in General Medicine service when there is uh the option and there is access to uh neurosurgery service that they're able to intervene immediately. There's any deterioration is probably not optimal. And in the past, whenever we try to keep these patients at the refrain hospitals, the physicians over there definitely felt very, very uncomfortable with managing these patients. And uh there was a lot of pressure in making the transfer happened. Do I understand that about 15% of the cases are neuro, You had about 1100 Total and about €115. So it's about 15, on euro. And then the others are not neuro uh yes. So there were approximately 15% of our common measures are transfers for neurosurgery. The other admissions are patients who were admitted through the emergency department at Morningside or were transferred for general drama from other hospitals. So there's no trouble transfers. It's a small component but I think it's an important component because also for becoming 11 Long term Center we see that we're very close to that threshold that they C. S. Has played. So these transfers actually are helping us in meeting that requirement and uh I think that the current setting is is very good for the referring hospital because they don't have to worry about treating a pathology that are not familiar with. And I think that it probably offloads some other neurosurgery services in our system files on the west or on sunday hospital uh for having to deal with patients who they might have integrated pathology. But very often they are geriatric patients with many other comorbidities and having like a patient with medical disabilities in our service, it takes too much of our time that could be dedicated uh for patients with predominant uh you know, neurosurgery pathologies. Great, thank you so much. Yeah, very dark Constantinos. I think it uh is a great example and the data you showed really drives home the point that, you know, it's a dedicated trauma service and dedicated neurosurgeons with specialty and trauma that outcomes really improved in particular. You know, it's no it's no small feat to have a neurosurgeon available Within 30 minutes and a backup neurosurgeon that.
