TRAUMA TEAM MEMBERS pose on the helipad atop the eight-story Heart Center at Holmes Regional Medical Center, which is home to the Trauma Center, Trauma Clinic and Emergency Department, all located on the first floor. The roof-top landing site was built with reinforcements that allow touchdowns by heavier military style helicopters used by NASA in the event of a shuttle launch pad emergency.

TRAUMA SURGEON Samuel Pellegrino has scrubbed in on a general surgery case at Holmes Regional Medical Center to remove scar tissue that’s a by-product of a patient’s prior rib injury. Suddenly, the doctor’s pager goes off, alerting him that a woman injured in a fall is on her way to the hospital via the First Flight air ambulance.

His colleague Dr. Edgar Figueroa finishes up the surgery case, while Dr. Pellegrino scrubs out and rushes down to one of five acute resuscitation rooms in The Trauma Center, located right next to the Emergency Department at HRMC.

TRAUMA SURGEON Samuel Pellegrino, MD tries to communicate with the patient, who is unsure of any details about her fall. He immediately orders x-rays, an ultrasound and other tests to determine what interventions might be needed.

“The first thing I try to do is put together the whole picture,” explains the 10-year trauma veteran, who leads the multi-disciplinary trauma team much like the quarterback in a football game – only here the split-second decisions potentially involve life or death.

“I have a woman lying there who has her eyes open but she’s not even trying to talk to me. Does she have a head injury? Is she unable to talk because she can’t breathe? Then I see her blood pressure is fine when taken from one arm, but not the other and I’m concerned because there’s a phenomenon that can occur if you tear your aorta (the largest artery from the heart). All those things are going though my mind and lead me to order the tests I do. That’s the stress of the job because I don’t want to miss something.”

This patient was lucky, as each life-threatening possibility is ruled out by diagnostic tests that take place either right in the trauma room or very nearby in the hospital, such as a CT scan to check for a head injury. What’s amazing is how quickly the decisions are made, the tests ordered and the results ready for Dr. Pellegrino’s review.

“We get priority,” he explains. “Our patients go to the head of the line when it comes to getting a CT scan things like that, same with the operating rooms. If I need an OR I don’t have to wait. It’s all part of that golden hour, that first resuscitation and an organizational structure that you don’t see in a place that is not a trauma center.”

Wide Reach
HRMC is home to one of just 22 trauma centers in Florida, a regional Level II center that opened almost ten years ago with a coverage area that now includes Brevard and Indian River counties, with patients coming from as far away as Okeechobee when needed.

HRMC had served all of St. Lucie County until May 1, when a provisional Trauma Center opened there that faces a yearlong review, with complex orthopedic trauma cases still coming to Holmes.  It’s an integrated statewide trauma system governed by Florida law, created starting in the early 1980s in an effort to save lives based on a simple premise: quickly get patients with severe injuries to a high-level, hospital-based care setting, staffed around-the-clock by specially trained trauma surgeons, critical care nurses and a host of other life-saving specialists.

“The sooner you get the people here the better,” says trauma surgeon Bartel Turk, who along with Dr. Pellegrino, is the co-medical director of The Trauma Center at HRMC. “When somebody’s bleeding, you only have so much time to get that bleeding under control. We will have people show up here basically pulseless, what we would call a trauma code and we can get them back if they get here soon enough.”

Dianna Liebnitzky

Experienced trauma/critical care nurse Dianna Liebnitzky was directing the trauma program at Orlando Regional Medical Center and was also president of the state Trauma Program Manager’s Association when the Department of Health asked her to assist the team at HRMC in applying for a Level II trauma center more than 10 years ago.

“It was to help them get the protocols and all of the care paths in place so they could have a smooth process to becoming a trauma center,” recalls Liebnitzky, who never imagined back then that in September 2007 she would come to work for HRMC as the Trauma Program Manager. “All trauma centers work together in unison to build this state system. We are not competitors.”

A Continuum of Care
Trauma care in Florida is a complex system in which trauma centers are just one step in what’s referred to as a continuum of care. It starts with the leadership of the Department of Health’s Office of Trauma, which administers and implements all matters involving trauma care in the state, right down to spelling out which physician specialists and equipment must be on stand by at trauma centers. The state also oversees the pre-hospital care component of trauma – that time period when paramedics are assessing a victim’s physical condition in the field to see if it meets the very specific state definition for trauma, which then requires transport to an official trauma center.

There’s a focus on injury prevention, with 180 programs in place around Florida such as prom night events designed to keep teens off the roads. Research to improve the quality of trauma care is a priority, especially at Level I trauma centers, which include pediatric trauma as a specialty and are often connected to a university-based medical center.

Integral to the trauma continuum of care are well-defined guidelines to ensure effective rehabilitation care for trauma victims and a trauma registry and evaluation system that tracks each patient’s care in an effort to improve quality.  Statewide collaborative educational and strategic programs related to disaster preparedness and response are also a primary focus of the HRMC Trauma team.

“Trauma has always been a continuum of care. It really came from the military world and was systemized during the Vietnam War era,” says Liebnitzky.

“Through the EMS system and the emergency department there are well thought out and set guidelines to get you channeled into the trauma pathway if that’s where you need to be,” adds Dr. Turk. “I think the most important thing for taking care of trauma patients is to have a unified system from beginning to end to get them through a very complex medical system as efficiently as possible.”

Since it starts with transport, helicopter ambulances are a key player, drastically cutting the time it takes to reach a trauma center. “A lot of the patients we have we pull from Interstate 95, either at the south or north end of the county so it really does make a difference getting them here by helicopter,” says First Flight paramedic Dave Segona, RN.

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HEALTH FIRST’s First Flight helicopter is responsible for saving thousands of lives when seconds count.

Treating the Whole Patient
Case management, the team that traditionally handles the planning for a patient’s hospital discharge and follow-up care, gets involved immediately in trauma cases. “We do a lot of crisis intervention right from the very beginning,” says Jerry Winter, RN, an HRMC case manager. “Families may have to travel to see the patient. We’re dealing with trying to return the patient back to their prior living condition which may not be Brevard County so it’s a little bit of a challenge trying to tap into resources.”

After their initial care in the trauma center, most patients are going to be transferred to the HRMC Surgical Intensive Care Unit or a customary medical/surgical patient care unit where the trauma surgeons, who are also critical care medicine experts, then become their attending physician, making daily rounds to supervise their care and rehabilitation needs.

The program is also blessed with very collaborative surgical and medical subspecialists in the community who contribute their respective expertise to the trauma team effort.

“Patients with a chest injury have a very high potential to get pneumonia and it could actually be the secondary disease process that takes their life,” points out Liebnitzky. That’s why trauma surgeons so carefully monitor the follow-up care, champion critical care protocol enhancements, such as pneumonia prevention, and also examine patients post-discharge in the center’s outpatient Trauma Clinic.

“If you get someone in here who’s really sick and you’re seeing the family everyday they know you’re fighting for them and their loved one and you really do make a very close bond,” says Dr. Pellegrino.

“I had a family member recently with a loved one who had a head injury and she was just so grateful he was alive she turned around and said ‘Can I give you a hug?’ That part makes it worth it.”

“We’ve had patients here over a year and you get attached. You can get attached to them if they stay a week,” adds Winter who says hospital staff have even been known to attend a former patient’s wedding. “These are families who are precious. They’ve had tragedy touch their lives and we just try to wrap our arms around them and plug them back into the community. Sometimes they leave with a new path. Sometimes they can’t return to the same pattern of living that they were accustomed to and we help them acclimate.”

It’s that potentially life-changing element of trauma that makes it so unique.  “Patients aren’t prepared to be here. It’s not like they’re scheduling their gallbladder to come out and they have everything arranged and someone’s going to feed the dog,” explains Dr. Pellegrino. “I always remind myself that these patients didn’t wake up this morning thinking I’m going to go to the hospital later today. It’s really given me an appreciation for how quickly things can change. Every single aspect of this affects their family, it affects their kids, it affects their work, everything.”

Specialized Care on Demand
Because of the complicated broken bones that often are part of a trauma injury, orthopedic surgeons are among those specialists required to be on call to support a trauma center program. At HRMC, three orthopedic trauma experts are among nine doctors employed by Health First Physicians as the center’s core physician team.

ORTHOPEDIC surgeons Dan Segina, left, and Ulises Militano perform reconstructive knee surgery following a hunting accident.

“There’s an inherent benefit of having a dedicated orthopedic service in place,” says Dr. Dan Segina, the board-certified orthopedic surgeon who’s Director of Orthopedic Trauma. “If you’re an orthopedic surgeon in the community, you may be in surgery doing a complex hip replacement and there’s nothing you can do about that. With our team, we have the capacity to have somebody available to be in the operating room on a moment’s notice.”

And it’s not just trauma patients who benefit from having high-level orthopedic experts on staff. “Not everyone who has a severe facture may be considered a trauma,” explains Dr. Segina.

“They may be sport fishing in the Keys and have a leg injury, but they return back to the Melbourne area and need some form of continued care. A lot of our geriatric patients may get into complex problems because of osteoporosis and poor bone quality. They require a higher level of expertise for some of their fractures and we can provide that as well. We can do that because we have a team approach where we can divide and conquer so we can see patients on referral, see patients in our offices and still make ourselves readily available for the traumas that will be coming in on a daily basis.”

Dr. Segina still has follow-up visits from patients he operated on in Jacksonville who now visit him at the Trauma Clinic in Melbourne. His team even operated on a patient who lived in Indian River County who’d been hit by a car while vacationing outside the country. Flown to the Melbourne airport by private air transport, the patient arrived suffering from a complex pelvic fracture that took a 12-hour surgery to repair.

Trauma nurse Liz Gray has worked at HRMC for 16 years, with six of those prior to The Trauma Center’s existence. She welcomes the addition of surgeons who can handle the extremely complex cases on site. “Before we were a trauma center we had to send pelvic fractures and any complex injuries to Orlando. You could bleed out during the transport because those injuries can be so serious,” she says.

A Focus on Prevention
Keeping people from becoming trauma victims is a top priority for everyone involved in Florida’s trauma system. From working with traffic engineers to improve safety at fatality-prone street intersections to influencing behavior, the trauma team is out there trying to make a difference.

“People who make bad decisions in life are more likely to show up in my trauma center than a well-rounded person who understands how the world works and makes good decisions,” says Dr. Turk.

PREVENTING INJURIES: Trauma Center staff dress up as Larry and Vince the “crash dummies” and attend community events to promote the center’s 3-D Program that aims to decrease drunk, drugged and distracted driving.

In an effort to encourage good decision-making, the HRMC Trauma Center has developed what’s called the “3-D Program” which aims to prevent drunk, drugged or distracted driving. For Dianna Liebnitzky the motivation behind its creation was very personal. A year ago her daughter wrecked a car that had been a gift following her graduation as class valedictorian, rolling the car in an accident that could have caused serious injuries but fortunately did not. After first telling her mom that an animal had run in front of the car, her daughter later told her that she’d looked down to check a text message on her cell phone. “She had her seatbelt on and except for that one split-second that she looked down, she did everything right. She knew not to hit the brakes. We practiced all those emergency events when I taught them to drive,” says Liebnitzky. “She told me not to ever stop talking to them about safety.”

Liebnitzky wants everyone to get involved in the conversation and has created what are called “Love Enough” cards that you fill out with your name and give to someone when you’ve taken their keys because they’re too impaired to drive.

The prevention component of trauma also includes preparing for mass casualty events, such as a bus crash, hurricanes, epidemics or even toxic contamination incidents. HRMC opened its current 43,000-square-foot Trauma Center/Emergency Department in the fall of 2006. It features an enhanced decontamination area with outside showers and a private entrance, just one of many patient safety features built into the all-new center.

“The benefit with the new trauma center is it was designed knowing that it would be a trauma center,” says Dr. Segina. “Where the helicopter pad is positioned, where elevator shafts are located, where the radiology and CT scanners are placed, where operating rooms are – all these things are taken into consideration so you would not be hamstrung or potentially put a patient at risk by saying they need a CT scan of their brain but that CT scan is on the other side of the hospital.”

True Team Approach

DR. BARTEL TURK checks on a patient in the Surgical Intensive Care Unit along with nurses Nancy Lefort, CCRN, ICU Manger and Pam Decelles, CCRN. The trauma surgeons make daily rounds to check on trauma patients who’ve been moved to the ICU or transferred to a regular room in what’s called a step-down unit. Documenting his follow-up care for patients admitted to the hospital is a big part of Dr. Turk’s job as the trauma service team tracks what are often multi-specialty treatments and an extensive rehabilitation program.

Disaster preparedness planning is an ongoing process that involves every department at HRMC. “With any true mass casualty the biggest thing you plan for is how you’re going to decrease the chaos to a manageable level,” explains Emergency Department Manager Nicki Andersen, RN, BSN. “We live for taking care of patients and saving lives and that’s where all of our energy lies. So planning for these things becomes relatively easy because everyone wants to be a part of it – they want to drill, they want to practice.”

Andersen also has emergency department nurses cross training in trauma care to increase the back up pool and with each trauma case, an emergency room physician reports to the trauma room with one primary mission: managing the patient’s airway and breathing and intervening if needed. It’s a true team approach that illustrates trauma manager Dianna Liebnitzky’s reminder that trauma care is not something that happens only within the walls of the trauma center.

“What a trauma program does is organize all the things you need to take care of these patients in the field and from the moment they hit the door, through rehabilitation,” adds Dr. Pellegrino. “It organizes that structure with all of the physical therapists, the orthopedic surgeons, the trauma surgeons, the social workers, case managers, respiratory therapists and others and it allows us to make that whole process more efficient and get the patient from this unexpected event back to their lives much easier than you can in a system without a trauma center.”

A Very Personal Calling
Dr. Turk compares the integrated trauma system and the high-level of constant readiness to the cardiology based system designed to handle heart attack patients and the neurology driven care protocols that kick in when someone suffers a stroke. In all three cases, timely intervention is what saves lives and preserves quality of life for those survivors. For the trauma team, that means routinely sleeping at the hospital when on call to ensure a quick response.

DR. BARTEL TURK takes a break from the day-to-day stresses of his job as Co-Medical Director of The Trauma Center at HRMC by attending a baseball game with his wife Lucille and 8-year-old son Joshua.

“My wife and I got married during my residency so she knows how it works and doesn’t give me too much grief when it seems like it’s been days and days and days and she hasn’t seen me,” says Dr. Turk. “It’s the profession I chose and I knew what it was like going into it and my family is very understanding.”

As Dr. Pellegrino wraps up his initial evaluation of the patient who fell, he says it’s the camaraderie between everyone involved in trauma care that makes the job easier. “Because we’re partners, if I had to call Dr. Turk, who’s not my official back up right now, he’d drop everything and come right away and that’s what’s important about having a team like this.”

Trauma Program Manager Dianna Liebnitzky says when the stress starts to pile up she thinks about a teenager who survived a horrific car crash and severe brain injury to then graduate high school with honors.

“I think about his success and how he would not have made it if a trauma system did not exist,” she says, getting choked up as she talks about her former patient. “This is our legacy. Someday when we’re gone we want this system to live on and be better because we were a part of it and we helped to design and develop and put things in place that impact multiple patients.”

THE TRUAMA CENTER at Holmes Regional Medical Center is prepared for trauma cases 24/7 because of the dedication of the core team of these nine surgeons whose expertise runs the gamut from general surgery, to complex reconstructive and orthopedic surgeries:

SAMUEL PELLEGRINO, MD, CO-MEDICAL DIRECTOR: Dr. Pellegrino first worked in marketing after college and was involved in advertising campaigns for the Orlando Magic basketball team when he decided to pursue his earlier desire to be a doctor. After receiving his medical degree from the University of Florida, he served his surgical internship and residency at Orlando Regional Medical Center, followed by a fellowship in Critical Care Medicine. He’s also an organ procurement specialist with TransLife, the federally designated organ and tissue transplant service for a 10-county area that includes Brevard.

BARTEL TURK, MD, CO-MEDICAL DIRECTOR: A University of North Carolina Medical School graduate, Dr. Turk then spent 10 years completing an internship, residency and fellowship that focused on surgery and critical care medicine. He and his wife are raising an 8-year-old son, a juggling act that he says his wife became familiar with during the rigors of medical school.

EDGAR FIGUEROA, MD, TRAUMA SURGEON: Dr. Figueroa completed medical school and his post-graduate specialty training in his native Puerto Rico before beginning a long career in general and trauma surgery in Florida. He’s also an expert in minimally invasive laparoscopic surgery and has been on staff at the Trauma Center at HRMC since 2000.

JON JOHNSON, MD, TRAUMA SURGEON: Dr. Johnson served as a Sergeant in the U.S. Army Reserves before graduating from Michigan State University’s Medical School. He’s had post-graduate training in general surgery, critical care and trauma surgery and also completed a fellowship in trauma cases involving children. In addition to his shifts at the Trauma Center, he works at Vital Watch, an electronic remote monitoring system for critically ill patients in Health First hospitals’ intensive care units.

PETER PAPPAS, MD, TRAUMA SURGEON: When Dr. Pappas got his medical degree from the University of Miami he was honored for his clinical research efforts. Miami’s Jackson Memorial Hospital, the third-largest teaching hospital in the country, was home during his general surgical residency, followed by fellowships in surgical critical care and trauma surgery in Orlando. As the University of Central Florida College of Medicine prepares for its first class of medical students this fall, Dr. Pappas is involved as an assistant professor of surgery.

DANIEL SEGINA, MD, ORTHOPEDIC DIRECTOR: After graduating with a genetics degree from the University of California at Berkeley, he moved to the University’s Irvine campus to earn his medical degree. He met his wife Kelly, an obstetrician/gynecologist, while both were in post-graduate training at Ohio State University Hospital. His residency in orthopedic surgery was followed by a specialized yearlong fellowship in orthopedic trauma at the University of Washington in Seattle and he spent three years at the University of Florida Health Sciences Center in Jacksonville before coming to HRMC in 2002.

ULISES MILITANO, MD, ORTHOPEDIC SURGEON: The State University of New York at Brooklyn, better known as SUNY Downstate Medical Center, was where Dr. Militano went to medical school and completed his five-year orthopedic surgery residency, followed by specialized training in orthopedic trauma cases. Born in the Bronx, he was a competitive swimmer while growing up and now likes to restore cars and motorcycles.

DANIEL BRANHAM, MD, ORTHOPEDIC SURGEON: Dr. Branham was the Alumni Scholar at the University of Tennessee’s College of Medicine before completing an internship in general surgery and an orthopedic surgery residency at the Medical College of Virginia. He’s also a specialist in hand and upper extremity traumas after a fellowship at the University of Florida and is a lieutenant in the U.S. Navy Reserves Medical Corps. Hobbies include hiking, fishing, surfing and playing guitar.

LEE THEOPHELIS, MD, RECONSTRUCTIVE PLASTIC SURGEON: Board-certified in both general and plastic surgery, Dr. Theophelis’ role on the trauma team ensures an early emphasis on setting the stage for reconstructive surgery. He graduated from the University of Michigan Medical School at Ann Arbor and then interned and served his residency in general surgery at Detroit’s Henry Ford Hospital. His fellowship in plastic surgery was at the University of Florida.

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