Mountain Health Today

Welcome to Mountain Health Today, the show where we explore the people, the stories, and the innovations shaping health in the mountains. I’m Dr. Brian Evans, Chief Medical Officer of Tahoe Forest Health System.

From everyday wellness to the latest advances in medicine, our goal is very simple: to give you clear and trusted information that helps you and your family live well. Today, we’re going to be talking about the amazing trauma program that we have at our health system.

It’s just an astonishing group of resources that has been put together with some very smart people. We’re going to understand first what the heck is the trauma program, and we’re also going to be learning all about what it’s like to be a general surgeon.

In order to do that, I’ve got to bring in an expert, and I’ve got just the one — somebody who can tell us all about both those things. So, we’re very lucky to be joined by Dr. Ellen Cooper.

Dr. Cooper is a board-certified general surgeon and medical director of the trauma surgery program. She can do it all, from taking out your appendix to fixing you if you crash your ebike into a tree.

Dr. Cooper, welcome to Mountain Health Today. Thank you. I hope you can fix me if I crash my ebike into a tree, because it’s almost happened many times.

I’m going to do my best. And if I can’t, we’ll get you to where you can be fixed.

Okay, sounds good. I do wear my helmet — we’ll probably get to that later — but thank you for being here.

I really appreciate it. Let’s start with just general surgery and what a general surgeon is, because it has changed over the years, and you are a general surgeon first and foremost and also the head of our trauma program.

That’s correct. Yeah. So when I think about general surgery, I think about surgeons who take care of a variety of conditions and diseases.

We operate all over the body. Our focus is mainly on the abdomen and the chest, but we also take care of cancers across the body and really get to fix a lot of problems in patients.

Yeah, it’s a pretty broad area and it kind of covers the gamut from head to toe. It does. And sometimes we kind of define ourselves by what we aren’t — we don’t operate on the brain, we don’t operate on bones, but we operate almost everywhere else.

There are specialties for all that other stuff, and there’s been more of those specialties accumulating over the years. And one of the great things about practicing general surgery in Truckee is that because we’re a small town, we haven’t divided ourselves up into quite so many small pieces, so we really get to do a lot of different things.

Yeah, you really do. What’s the training process like? So if I wanted to become a general surgeon, how would I go about that?

I wouldn’t recommend it at your age, to be frank. After an undergraduate degree of your choosing, you spend four years in medical school and then at least five years in a general surgery residency, and that can increase depending on if you want to do research or an additional fellowship, but it’s a minimum of five years of surgical training after medical school.

Yeah, just full disclosure, I did think about becoming a general surgeon, but standing up for hours on end is not good for my ADHD, so it was not a fit. ER is much better for your ADHD.

Absolutely. All right, let’s talk about the trauma center, because we do now have a trauma center here at Tahoe Forest Health System.

So, what the heck is that, what does it mean, and specifically, maybe we can talk about the different levels — and we’re a level three. Yeah. So the concept of a trauma system has been around for decades.

The idea is that all injured patients can get to the right resources at the right time in the right place. And so we talk about centers, but what we’re really talking about is a whole continuum of care from pre-hospital to post-discharge where injured patients get exactly what they need in a planned, thoughtful way where we’ve thought about all the possibilities in advance.

There are essentially four levels of trauma centers. A level one is typically your big academic center, level twos are large community hospitals that may not do their research and surgical training but have all of the clinical resources, and then a level three, which is what we are, is really designed to provide resources as quickly as possible, especially in areas that may not be in those big cities.

And when you think about our community and all the activities going on in the North Lake Tahoe area, it really almost seems like a no-brainer that we have a trauma center here, getting close to where accidents and injuries may occur. Absolutely. I mean, if you think about the winter with I-80 being open or not open, it could basically be unreachable to get to the level two in Reno or the level one in Sacramento without a little bit of stabilization and care in Truckee itself.

The other thing we think a lot about is that if we can care for our community in a way that’s really meaningful and high quality and not have to send people out to those areas, that’s a real value for this area as well. Yeah.

But when you rewind the clock a little bit and think about what it was like here maybe 50 years ago, there was a hospital, we had an emergency department, we had some operating rooms, but we did not have a trauma center. We didn’t have this coordinated care effort, and so if people got hurt, what would happen to them? I mean, it was a lot more risky, wasn’t it?

I think it was a lot more risky. And I think it was also a lot more sort of, you know, who’s involved in the moment making those decisions — everybody was doing their best, but nobody had necessarily thought in advance, “Well, if this thing happens, this is our plan.”

If I-80 is closed, we have a plan to call our battalion chief at Truckee Fire to figure out how to get a patient out of Truckee if we need to. But we also have a whole set of plans for how to take care of patients in our community.

Yeah. Let’s talk a little bit more about the people you’re talking about, some of the folks on this broader team.

It’s not just the trauma surgeon — you’ve got a lot of folks who we think are the most important, but actually it’s really about a lot of people in this community coming together and using their expertise in their field to inform how we’re making decisions for injured patients. For sure. I mean, surgeons all agree that surgeons are the most important people in the hospital, right?

That is correct. That is correct. Yes. No dispute. Okay.

But you mentioned some of the folks who are outside in the environment, like out in EMS — emergency medical services — picking patients up and bringing them in, sometimes having to go find somebody to deal with a very difficult extraction. So who are those folks?

Well, I think that in the winter time, it starts with our local ski patrol, including our people who have wilderness medicine certifications. We have some ski patrol who have advanced training in first aid and ALS.

And then it moves on to our really valuable fire agencies that do all of our transportation for us. We think about pre-hospital communication between them and our nursing staff and the ER — our ER is a huge component of this.

And then you think about the OR, the ICU, and those places, and then post-discharge after injury. How do we get people back to doing exactly what they love as quickly as possible?

That includes rehab, physical therapy, home health — all of those people play a role in making sure we understand how to take care of these patients as successfully as possible. It’s amazing when you think about just the breadth of skills required in order to take care of a complicated trauma patient.

And all of this stuff has to be ready to deploy at a moment’s notice. That’s really the key — a trauma system has tried to anticipate everything in advance so that when a really sick trauma patient comes in, you don’t think, “Well, what do we do now?” You say, “Oh, we do what we do every time.”

So, you helped build this program, and I know that it was a team lift. But what did that require? Did you have to go out and make a case to the community or to the hospital or to others that we needed this, and what was the case that you made?

I think we were really at a moment as a health system where we were thinking about what’s our next step, what’s the next best thing that we can provide for our community, and everybody knew for I think 10 years or more that we should be a trauma system. And so I think everybody was ready at that moment, but it does take a lot of buy-in.

It takes asking a lot of people to change how they’ve done things historically and say, “Well, maybe we could do it this way — it’ll provide better care for people.” And what I love about working in this community is that if you are a good listener and you really understand where someone’s coming from and what their expertise is and then you work with them, they really want to do what’s best for a patient, so it was a really collaborative environment.

Yeah. What a great opportunity to seize, and I know it wouldn’t have happened without you, so thank you for that on behalf of the community.

I do want to ask this because you could almost imagine, “Oh, we’re just going to build a trauma center, we’re going to get all these positions in place and get the right equipment, and then it’s done.” But that is definitely not the case.

So tell us what goes into sustaining a trauma program and also continuously improving what we’re doing. Yeah. I think you make a really good point in that if we put a bunch of rules in place and said, “Okay, everybody follows these rules,” a couple of things can happen.

One, if the rules don’t make sense to people, we’ll never follow them. And so you have to be continually in dialogue with people about what your rules of the road are and why.

And then you really have to be a good listener when people come to you and say, “You know what, you made this set of rules, but in point of fact, Ellen, you are a member of the indoor team and you have never been on the side of a mountain trying to get someone out of a crevice, so your idea about how we’re going to do this doesn’t work.” And then I have to turn around and say, “Oh, you’re right about that — we need to change these rules.”

And the other thing you need to do is constantly look at how your care is performing — is the care that you’re delivering what you want to deliver? And if you’re varying from that, how do you bring people back and continually keep an eye on things so that you’re continuing to provide the highest level of care that you can?

I know that you’re very diligent about data and getting the right data about how this trauma program is performing. And then not just looking at it and going, “Okay, looks good,” but actually comparing how we’re doing at this trauma center nationally — what’s going on across the country and where do we stack up?

So what kinds of things are you looking at to show us that we’re either doing really well or maybe have an opportunity to improve some aspect of the care that’s delivered? Yeah. I think there’s a lot of data we look at, and one of the things we think a lot about is timely access to care.

If you show up at Tahoe Forest with a broken femur — the big main bone of your leg — how quickly should that be repaired, how quickly are we repairing it, and what are the barriers if we’re not matching up? And I’ll let you in on a little secret, Brian: our orthopedic surgeons destroy the national average on getting patients from the hospital into the operating room. They are amazing and deeply caring, and this is a high priority for them.

But you really have to be looking at all sorts of metrics, and the metrics can be kind of boring sometimes — but that’s where you start to see where quality could slip. Let’s say you’re supposed to get someone to the CT scanner within 30 minutes who’s significantly injured, and you’re watching it go to 45 minutes or an hour — well, you’ve got to pull that back in, because that’s where we diagnose life-threatening problems, and so if we delay that one piece, that could have a real consequence for the patient, even if on the outside it looks like a really boring thing.

Yeah. And we don’t just assume, “Okay, we like our data, we’re good” — you bring in a team of external experts to look at everything, look at our data, look at the care we provide, and then accredit our trauma center.

Absolutely. Who are those folks?

So that’s the American College of Surgeons. And if you’re a surgeon, you think that’s the most important governing body in the entire world.

General surgeons and trauma surgeons were the people who conceived of this idea of trauma systems and trauma care, and so they’ve built basically a very technical, very complicated checklist of what you need to do to provide care that’s appropriate to your community. It’s not really a secret, but it’s really technical and it can be really complicated, and sometimes you have to get creative in your community — if you’re, say, a rural hospital high in the Sierras — on how to meet what they expect of you.

The surgeons do a lot of that work, but the other staff in the trauma program are absolutely critical to making sure that we are dotting our i’s and crossing our t’s and doing what’s necessary to show the American College of Surgeons that we are where they want us to be. It’s almost like a continuous audit of our program — the program isn’t just rolling along doing what it does, it’s being looked at continuously, scrutinized, and improved upon.

Absolutely. And the other thing that you have to do is build a culture where people who are not totally immersed in this all the time feel really comfortable coming to the program and saying, “Hey, I have a question about this,” or, “Hey, I was involved in this patient and I didn’t think it went well — can you guys take a look at this?”

You really have to build a culture where you’re collaborating and people feel really safe and empowered to speak up, make changes, or ask us to review cases. Yeah.

And I know that a big component of all of this is your trauma conference — the case review conference that you host — and then there’s also a Winter Illness and Injury Symposium that we have once a year. So that seems to me to be a great opportunity to get the entire team together. How valuable is that?

It’s so valuable. And one of the things for me on a personal level, as someone who kind of lives and breathes trauma, there is nothing like listening to ski patrol or listening to our EMS partners talk about the challenges of mountain rescue and extrication in this environment.

And it just builds for me personally so much respect for what they deal with and how they solve problems. It really is remarkable when you think about the day-to-day job of ski patrol and EMS.

They are amazing, and what I have to admit — and people have heard me say this — is that when I stepped into this role in 2019, I was pretty sure I knew the answer to every question and how things should go. And really quickly, they very gently and without an ounce of rudeness educated me on what the realities were like for their jobs.

And so I always talk about the indoor team and the outdoor team, and I have such profound respect for our teammates who live outdoors with these patients with very minimal resources. They don’t check the weather and say, “Well, it’s raining, I don’t want to go outside” — they just go out, and I think they’re just amazing.

They really are. So, a lot of people have been watching this new show called The Pit.

How much is The Pit like what you do when there’s a trauma patient coming in and everybody gets the alert that they’ve got to go to the ER and take care of this patient — or maybe more than one? Are they getting it right in that show?

Have you seen the show? Yes, I’ve seen the show. And what I would say is that what happens in a day on The Pit would never happen in any hospital in one day.

But I actually struggled to watch it because it’s so emotionally resonant to me — it makes me a little anxious, it reminds me of situations I’ve been in where life is kind of on the line. And so I think it does a wonderful job of showing the team dynamic and the preparation that it takes to take care of these patients.

So we’re not endorsing the show, but if you were to watch it as a lay person, you’d see things that we do see and do take care of, a lot of the little details — just not all at once. Not all at once. Thank goodness. That would really be a problem.

Let’s talk a little bit about general surgery, because as we talked about, it’s kind of a full-spectrum sort of thing. So, what kinds of procedures do you do and like to do as a general surgeon at Tahoe Forest?

I feel really fortunate because I get to do a lot of different things at Tahoe Forest. As we talked about before, we’re not divided up into tiny little compartments.

I think other than trauma, the thing I love to do most is take care of women with breast cancer. With our cancer center, we are able to keep the majority of that care within our community, and I don’t know many general surgeons who wear two big hats of breast cancer and trauma, but I get to do that.

And then I also get to take care of people in emergency situations — take their appendixes out, fix their hernias, and solve a variety of other problems. You talked about your ADHD earlier, and small-town general surgery does allow you to switch gears a lot.

It really is interesting that your career has stuff that is routine — it can be scheduled, you can line it out like, “Okay, we’ll do that case in three weeks” — and then other stuff where you’ve just got to do it right now because there’s an emergency situation and it’s time to go. Absolutely.

And one of the things I think is challenging is that because of how our practice is built, you can do those same things within about 10 minutes of each other. And so you’re always switching gears and thinking about the long-term versus the short-term and how you’re going to prioritize care for patients.

You know, one of the things about our area is that there is a lot of cancer — it’s growing, and we have an older population that is getting older actually — so our cancer program is busy. And it’s also incredible, so say a little bit about how you interact with the oncology team at Tahoe Forest in just taking care of those patients.

Well, I think the first thing I’ll say is that our cancer center is also accredited by the American College of Surgeons — another situation where the surgeons think they’re the most important person in the room — but they have also built an incredibly high-quality program of care. And I think they do an amazing job at providing care that’s equivalent to the national standard, which is really spectacular.

And then what I think the real secret sauce is that we’re so small that you really get to treat every patient as an individual. Our nurses know everybody, they think about everybody, we’re on the phone or texting with each other all the time about patients to make sure that nobody slips through the cracks and that everybody is getting really personal, really emotionally centered care.

That’s also better than anywhere else. It is remarkable here — we’re so fortunate to have that team.

Okay, Ellen. So now we’re getting into the summer months, and trauma is relatively unpredictable in itself, but there are trends.

Here in our community, we’ve got the winter stuff and then we’ve got the summer stuff, and as it gets warmer, people start doing things like hitting the lake and firing up the ebikes. So what recommendations would you give to folks to avoid becoming a trauma patient of yours?

Well, not that we don’t want them — happy to take care of them — but you really don’t want to meet me on a Saturday afternoon. I think ebikes are really an emerging area of concern for trauma surgeons.

Many of us put our kids on ebikes to transport themselves across Truckee, including myself, but these are essentially motorcycles or mopeds. People need to respect the speed, they need to be thoughtful, they need to follow the law when it comes to right of way and yielding and those kinds of things.

And people need to remember that they go a lot faster than your body can power, so if you’re someone who hasn’t been on a bike in 20 years and you get on an ebike, your balance and your agility may not be the same. And so if you’re going 20 or 30 miles an hour, it can be really, really risky.

Always wear your helmet, and don’t drink and ebike. That is very good advice.

I am personally going to take your advice in an effort to avoid becoming a trauma patient. And I just want to say, this does wrap up our conversation on Mountain Health Today, but I want to thank you, Dr. Cooper, for sharing your insights, and I want to thank you, the audience, for spending part of your day with us.

I’m Dr. Brian Evans, chief medical officer at Tahoe Forest Health System. You can learn more about today’s topic or find resources and services at tfhd.com.

Until next time, take care of yourselves, take care of each other, and stay healthy here in the mountains.