1. The Traumatic Injury Spectrum: A Novel Primary Care Perspective for Training, Education, and Practice Steven A. Hankins, MD, MPH

2. Disclosures A portion of my salary is provided by a Hawaii Department of Health Grant for the development of a trauma curriculum for the UH Family Medicine Residency Program. That grant has made possible the work that resulted in this presentation. I have no other financial or ethical disclosures. I will not be discussing any off label use of any FDA approved medications or devices.

3. Objectives By the end of this session participants will: 1)be familiar with the local burden of disease related to traumatic injury and its impact on primary care 2)be able to describe "the spectrum of traumatic injury intervention" as it relates to the practice of primary care 3)be able to identify two or more opportunities to personally engage in traumatic injury prevention at the local level.

4. Hidden Objectives To convince you that primary care truly provides the bulk of traumatic injury care To convince you that through effective partnering, coalition building, advocacy, community outreach, and clinical care we can significantly reduce the burden of disease related to traumatic injury

5. Bottom Line Up Front Traumatic injury is a leading cause of morbidity, mortality, disability, and loss of quality of life Traumatic injury represents a huge spectrum of disease, the majority of care for which happens in the primary care setting There are many opportunities for primary care providers to effectively intervene in the prevention, management, rehabilitation, and long term follow up of traumatic injuries

6. Bottom Line Up Front Changing our perspective of traumatic injury allows us to better train and educate primary care physicians to practice more effective interventions in their local communities Actively engaging in effective prevention through education, advocacy, and outreach will enable primary care physicians to have a far greater impact on reducing the burden of disease related to traumatic injury.

7. Hawaii DOH Trauma Curriculum Development Grant $200,000 Grant to UCERA for the Department of Family Medicine to Develop Trauma Curriculum for the Family Medicine Physicians 2 years (Feb 2012 – Feb 2014); 1 yr $100,000 Feb 2014-2015, and again Feb 2015-2016. Funds both faculty and administrative support staff positions, training, and materials Curriculum must address trauma prevention, management, and rehabilitation

9. Tip of the Iceberg “BACK SYMPTOMS” “KNEE SYMPTOMS” UNCODED “LOW BACK SYMPTOMS” “LEG SYMPTOMS” “SHOULDER SYMPTOMS” “NECK SYMPTOMS” “ARM SYMPTOMS” CHRONIC PAIN “COMPLEX REGIONAL PAIN SYNDROME” DISABILITY EVALUATIONS

10. Defining “Traumatic Injury” Proposed working definition - Disruption in structure or function of a bodily tissue/organ caused by kinetic, chemical, thermal, or radiological energy transfer from an exogenous force, object, or entity, exclusive of infectious agents. May be “intentional”, “unintentional,” or of “undetermined intent.” Specifically does not include emotional or psychiatric distress

11. Spectrum of Traumatic Injury MINOR INJURIES INCIDENTAL TO REASON FOR VISIT MINOR INJURIES PROMPTING VISIT MODERATE INJURIES MANAGED IN CLINIC MODERATELY-SEVERE REFERRED TO SPECIALTY PROVIDER INJURIES REFERRED TO ER/HOSPITAL INJURIES FOLLOWING UP FROM ER/HOSPITAL DEBILITATING INJURIES IN REHABILITATION DEBILITATING INJURIES WITH SEQUELAE

12. Spectrum of Intervention MVA EtOH Built Environment Vehicle Speeding Injuries Disability Pain Rehab DME Pre-hospital Mgmt In-patient Care ED Care Breathalyzer lockout Tx ReferralCounseling Reflectors Lighting Impact Absorption Traffic Calming Speed Governor Laws & Enforcement Equipment Care Coordination Out-Pt Care

13. Current Educational Approach Limited exposure in medical school and for primary care residents Focus is on acute management of severely injured Mostly done through short focused highly focused courses such as ATLS – known to be effective for short term knowledge retention Focus on stabilization & operative management Little formal curriculum on prevention, non-surgical definitive management, or long-term follow up

14. A Better Way Injury Prevention training for health care professions known to be efficacious in changing behaviors and attitudes Systemic and structural interventions known to lower morbidity and mortality due to injury Training health care professionals to intervene in traumatic injury across the spectrum affords more opportunity to reduce the injury burden

15. JABSOM FM Residency Program Specific Needs and Opportunities Recent removal of trauma surgery rotation from curriculum Need for focus on prevention Need for focus on management of long- term sequelae State funded grant supporting systems wide approach to reduction of traumatic injury related morbidity and mortality

16. The objective of the UH DFMCH Trauma Curriculum Development Grant is to “develop a cadre of family medicine physicians who are literate, articulate, and active in the areas of traumatic injury prevention, management, and rehabilitation.”

19. Specific Respondent Suggestions Population focused prevention for the young Individualized prevention for the elderly – falls, medications, abuse Focus on primary prevention strategies (workshops?) Addressing emotional/psychiatric issues in follow up Sports related trauma Management of common uncomplicated fractures Joint injuries – especially the knee ATLS Guidelines based PTSD training Wound Care Child safety Domestic /Family violence Acute and chronic pain management Traumatic Brain Injury Common injury patterns Appropriate referral PT/OT modalities and resources

20. Needs Assessment Conclusions Traumatic injury prevention, management, and follow up are important areas for curriculum development at the UH FMRP There is a need for greater emphasis on prevention, lower acuity non-operative management, and management of long-term sequelae. Residents and faculty generally feel that these issues are important components of primary care education There is good evidence that injury prevention training and trauma management trainings can be effective.

21. Traumatic Injury Curriculum Development Advisory Committee Provided initial project guidance and feedback Representatives from: –Pre-hospital/EMS –Emergency Medicine –Rehabilitation –Family Medicine

22. Proposed Traumatic Injury Curriculum ContentMethod of InstructionEvaluation Method Epidemiology Burden of Disease Didactics Resident Research Projects Written Examination Project Review Prevention Teaching Patient Education Systems and Structural Interventions Disaster Preparedness Work Shops Community Projects Didactics Participation in Preparedness and Planning activities Pre-post training assessments Project outcomes data Examination performance Event Feedback Acute Management Subacute Management Non-surgical Definitive Care ATLS Didactics Workshops PT/OT observational experiences Table tops/Exercises Skills Demonstration Performance Written Examination Pre-post assessments Exercise Feedback Follow up/Rehabilitation Management of Sequelae Case Presentations Didactics Exposure experiences in rehab care facility Oral Presentation Assessment Written Examination

23. Focus Areas Identified Residents and faculty reviewed current epidemiologic trends Reviewed the Hawaii Injury Prevention Plan 2012-2017 Selected Top 3 Focus Areas via the Nominal Group Technique –Falls –Suicide –Violence and Abuse

24. Unique Curricular Elements Public Health Advocacy –Didactic sessions –STFM On-line Modules –Resident self-selected injury related issue for submission of testimony to legislature for or against Community Outreach –Partnering with Homeless Outreach Clinic –Residents will provide injury prevention educational activities to residents at homeless shelters Structured experiences in rehabilitation medicine

25. Opportunities for Further Research and Development Curriculum efficacy and outcomes –Knowledge assessments –Self-efficacy ratings by residents –Community Outreach Site Impact Community Primary Care CME Development and Implementation

26. Ways you too can help reduce the burden of injury for your patients and community: Get engaged in advocacy around injury prevention at the local and state level Join and support injury prevention and care provision coalitions such as the Hawaii Statewide Fall Prevention Consortium, etc. Familiarize yourself with the relevant injury epidemiology in your community Participate in injury prevention community education activities Remember to counsel patients on relevant injury prevention topics

27. Summary Traumatic injury is a leading cause of morbidity, mortality, disability, and loss of quality of life Traumatic injury represents a huge spectrum of disease, the majority of care for which happens in the primary care setting There are many opportunities for primary care providers to effectively intervene in the prevention, management, rehabilitation, and long term follow up of traumatic injuries

28. Summary Changing our perspective of traumatic injury allows us to better train and educate primary care physicians to practice more effective interventions in their local communities Actively engaging in effective prevention through education, advocacy, and outreach will enable primary care physicians to have a far greater impact on reducing the burden of disease related to traumatic injury.

29. Questions? Comments? hankinss@hawaii.edu