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Join Stephen Cohn, a trauma surgeon, and the author of All Bleeding Stops: Life and Death in the Trauma Unit. In this conversation, Stephen shares his experiences and insights into the complex world of trauma surgery, where life and death decisions are made every day. Tune in as he discusses the challenges of navigating critical care, family dynamics, and ethical dilemmas while providing invaluable care to patients.

Stephen Cohn is a trauma surgeon.

He discusses his book, All Bleeding Stops: Life and Death in the Trauma Unit.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Stephen Cohn. He’s a trauma surgeon and the author of the book All Bleeding Stops: Life and Death in the Trauma Unit. Stephen, welcome to the show.

Stephen Cohn: Thank you very much, Kevin. Nice to meet you.

Kevin Pho: So we’ll get into your book in a little bit. I know you have an excerpt on KevinMD, and we’ll talk about that, but just briefly share your story and journey to where you are today.

Stephen Cohn: Sure. For the past 40 years or so, I’ve been actively involved in general surgery and trauma, and I’ve been fortunate enough to run or work in a number of large trauma centers and large surgery departments. Over that time, I’ve accumulated significant experience. What you often find is that when you’re trying to explain to a resident or a medical student the importance of doing this or not doing that, you like to give them an illustrative example of what happens when you don’t follow that protocol, let’s say. Over the years, I accumulated quite a few of these illustrative stories, and a couple of years ago, at the request of my wife, I sat down and wrote them down. I aimed them at the lay public as much as the medical community. Obviously there’s a certain interest in the medical community also, but I made them understandable, hopefully, to everyone.

Kevin Pho: So you’ve been involved in the trauma surgery space for decades now. Tell me about the evolution of trauma surgery and some of the observations you’ve made over your decades-long experience.

Stephen Cohn: Sure. Much of what we do in the care of an injured individual was derived from the military experience. The experiences in combat in World War II, Korea and Vietnam informed civilian surgeons. They would come back from their wartime experience and apply those techniques to the civilian population. One of their observations was that more rapid transport of an injured individual to definitive care improved outcomes. So better ambulance and EMS systems were devised, and air transport was employed to move people over long distances, or where there was a lot of obstruction to moving the patient to the trauma center.

The second thing that has evolved over the last 40 years is the development and regionalization of trauma centers, so that now, rather than every hospital trying to manage complex injured patients who have been hit by a car, fallen from a height, suffered work injuries or whatever, they’re brought to regional centers where there’s a level of expertise on the part of the entire staff and resources that can be applied.

The other thing that’s occurred is a series of observations by a lot of very smart people that certain things work in the civilian sector and certain things don’t. With the experiences in Vietnam, Afghanistan and Iraq, more and more of what used to be done simply based on the experience of the person with the most gray hair has moved to evidence-based medicine, which I’m sure you talk about routinely on your podcast, where we try to base more and more of our trauma care on scientific data. So there’s been improved allocation of resources, regionalization and expertise, both at the point of injury and in the hospital.

I want to make one other point. The role of the so-called trauma surgeon is quite a bit different now. Forty years ago, general surgeons, any kind of surgeon, would do trauma care. Now there’s more and more specialization, where a group of individuals, usually with what we call a surgical critical care fellowship, specialize in the management of trauma patients, people with bad emergency general surgical issues, and also the ICU. Those three things are aligned, and we’ve been seeing a lot of our young surgeons move to that area of the field.

Kevin Pho: Your book is called All Bleeding Stops: Life and Death in the Trauma Unit. You have an excerpt from that book on KevinMD about navigating complex ICU conversations from a trauma surgeon’s perspective. Talk a little bit about that excerpt.

Stephen Cohn: Sure. This little mini-chapter, or subchapter, was put in because of the frustration that we intensivists deal with on an almost daily basis. We have patients with complex injuries who arrive in our ICU for our care, but our care, or our persons, are foisted on a family that was not at all prepared for the fact that Grandma or Grandpa fell down a set of stairs and has a terrible head injury. So we’re not the well-known, trusted advisor to the family who’s been caring for them for 30 or 40 years. Rather, we’re just some person in a white coat who is in their face telling them that Grandpa looks bad and that we need to turn off the ventilator or something. So there is almost an immediate distancing of the family from trusting us. In what we call the trust Olympics, we’re losing.

So we spend a lot of time trying to get to know the families, but this is time-consuming, and we have a limited amount of resources in ourselves. In big ICUs in particular, but any ICU, it’s a real challenge. And of course, everyone’s heard of someone who had a miracle, and everyone’s heard of medical error leading to bad outcomes. I’ve had that in my own family. So there’s an intrinsic wariness in families toward these shiny-faced people who just appear with no warning and ask them either to withdraw care or to consider that Grandma, Grandpa, a daughter or a son could in fact not have a good outcome. It’s very challenging. I don’t believe this is as much of a problem in Canada, Denmark or France as it is here. I think we’ve not done a good job of informing the public that we are doing everything we can, but that there are limits to what we can do, and there are limited resources.

In the excerpt, I give an example of an elderly man who came in after a big stroke. He was seen, appropriately, by the neurosurgical service and the neurology service, and they elected to attempt to dissolve the clot in his brain. He was in his 80s, and one of the known complications, which happens rarely but did happen to him, is a bleed: The clot-dissolving agent led to a major bleed, and he had a massive hemorrhagic stroke. After a week, he was doing basically nothing but triggering the ventilator. So we went to the family and said, “Look, we’ve done everything. We really need to do one of two things: Either we do a tracheostomy and move him to some type of nursing home situation, because he’s basically vegetative, in a coma, or we withdraw care.” Those are the two options. There really aren’t any other options in that situation, and nobody would suggest that there are.

The family said, “Well, we know he wouldn’t want to be trached and vegetative, but we’re not comfortable with withdrawing care.” So for the next two weeks, we had frequent family meetings, basically trying to convince them that they had to make a choice one way or the other. Eventually they decided to withdraw care, but he’d been in the ICU for maybe three weeks. This is very unfortunate. If he were the only person on the planet, or the only one in our hospital like this, that’s one thing, but we had a half-dozen people in the same situation. The negative consequence is that patients were unable to get into the ICU for ICU care and were essentially in a holding pattern in the ER and the recovery room, and we know that being unable to access the ICU actually worsens outcomes. So it’s a frustration, but it’s also a challenge on our side, and I think the more the public understands what our challenges are, maybe the better they’ll understand that we’re not running around turning everybody’s ventilator off because we’re tired of taking care of their grandmother or something.

Kevin Pho: You mentioned earlier that a situation like this would be less common in other countries like Canada and Denmark. What exactly are they doing differently to educate and inform the public so that they encounter those situations less frequently?

Stephen Cohn: I’ll give you my impression. This is not factual; it’s just a gestalt impression I get. Of course, in the United States, it’s a privilege to be healthy; it’s not a right. In all these other First World countries, it’s a right. If you’re a French citizen, you have the right to health care. I think people there have a certain belief in their health care system that Americans don’t, at least in my impression, a belief that people are trying to do the best they can with the resources they have, and that there aren’t unlimited resources. The attitude here is more that there are unlimited resources, so why would I consider that it’s otherwise? I think that’s the crux of it, along with the belief that we’re not necessarily thinking of the patient first, which is not at all the case. I think it’s a cultural thing. Basically, Canadians believe that people are trying to do their best.

Kevin Pho: So you have a platform here. What message would you like to share with potential patients and families that could perhaps mitigate the situations you described?

Stephen Cohn: Right. On an individual basis, I don’t think there’s an easy solution in America. I think the solution in America is to have a system where everyone has health care, where we’re not spending fantastic sums of money on the last few months of life. Once it became a system where everyone had health care, I think people would look at the totality of our resources and consider that we’re doing the best we can, that the people caring for their loved ones are well trained, and that while they should have high expectations, we’re not going to be perfect. Like I said, I’ve had a personal experience with medical error leading to the demise of one of my family members, and it’s always hard to swallow. But I do believe that everybody was trying to do the best they could, and that medications are sometimes mistakenly given or omitted. Judgments are difficult in the ill.

Kevin Pho: So let’s zoom out a little bit. Your book is called All Bleeding Stops: Life and Death in the Trauma Unit, and that anecdote is just a small part of it. Tell us some of the other main messages you want readers to come away with after reading your book.

Stephen Cohn: OK. One message is what exactly trauma surgeons do: that we’re not emergency room doctors. Emergency room doctors are certainly necessary, essential individuals, but trauma surgeons are in the operating room, and they’re managing the most complex general surgery and ICU patients. That would be one objective. Another would be that this is a very difficult, very challenging area, and that’s why I love it, because every day there are new major challenges. The book delineates a lot of different kinds of injuries and a lot of different management of injuries, and it has a lot of stories, some of which are amusing and some of which are tragic.

One of the underlying themes is that so many of the injuries we take care of are completely avoidable. That leads us to the little op-ed that I know you had on your site: things like seat belts, motorcycle helmets and drunk driving. There may be ways that we as a society can institute some simple things, such as helmet laws, that would dramatically lower the incidence of head injuries after motorcycle crashes and reduce the huge cost burden that is medical care. In many countries, you can’t ride a motorcycle without a helmet. In this country it’s commonly done, and it leads to a much higher death rate and a much higher number of patients. You don’t just die when you fall off a motorcycle; you end up in a coma with a tracheostomy, getting tube-fed for the rest of your days. That’s something people don’t realize, and they also don’t realize that the cost of that is borne mostly by the taxpayers, not by the individual or insurance.

I don’t want this to be about finance, but a lot of this injury stuff is avoidable. The most dramatic example I’ve seen over the last couple of months is that I live in New York City, and we have all these people riding around on electric bikes and electric mopeds that go about 40 miles an hour, and only a minority have helmets on. My ICU right now is filled with people with devastating head injuries from moped-versus-car crashes, and they’re in really bad shape. This is a fairly simple thing: Require helmets. It lowers the incidence of devastating brain injury dramatically. That’s been shown, and it’s not like helmets are unaffordable. So I think much of what we care for is avoidable.

The other message in the book is that people who do trauma also do a lot of emergency general surgery, and that’s most of the operating we do: all the appendectomies, gallbladders, bowel obstructions and people who are bleeding to death. At most major trauma centers, the person in the hospital who holds a lot of the catastrophe stuff is the trauma surgeon. They’re the ones in the hospital, kind of like a surgical hospitalist. So it’s a challenging job, and it’s very enjoyable, but it can be hard to do.

Kevin Pho: Now, are there any misperceptions about the field of trauma surgery that you would like to clear up?

Stephen Cohn: Well, we mentioned the whole idea that we spend all our time in the ER. Within the field of surgery, or let’s say among medical students, people often feel that trauma surgeons are masters of nothing, that they’re sort of generalists, when in fact the way we think of it is that we’re the experts in dealing with catastrophe. When someone loses an airway on the floor somewhere, or when someone is bleeding to death in the operating room and they need someone to come and bail them out, that’s who they call: They call the trauma surgeons to come do that. So I think we’re pretty proficient at dealing with catastrophic problems, and I think that goes with the whole critical care and ICU thing. But that’s probably the main misperception: what exactly we do.

In terms of training, we generally go through four years of medical school and five years of residency, and then most of us typically do a year or two of critical care or trauma critical care fellowship, and then it’s just a matter of gaining experience. Many trauma surgeons and general surgeons have military experience, as I do, and that just gives us a little different perspective. It doesn’t mean you can’t be a perfectly competent or excellent general and trauma surgeon without military experience; it just gives you a little different perspective.

Kevin Pho: Now, for those medical students who may be interested in trauma surgery, what kinds of questions should they ask themselves to make sure they’re the right fit for the field?

Stephen Cohn: Right. I think, just like any area of medicine, the first thing you have to decide is whether you are temperamentally equipped to be in this area. One of the things we talk about a little bit in the book is that there are people who are absolutely essential who do inguinal hernia surgery over and over again, all day long, and they do an excellent job. They’re very competent, and they have great results. That’s a completely controlled environment where you know what you’re dealing with, you know the operation, and it’s standardized. With a trauma patient, I always tell people: After a car crash, imagine this patient was stuffed into a burlap bag and struck by five guys with baseball bats, then pulled out of the bag, put on a stretcher and rolled in the door. What’s their injury? No idea. So you have to be pretty nimble, methodical but nimble, and recognize that the unexpected is just that.

I had a patient years ago who arrived by helicopter from a car crash. The story was that he was driving a car and crashed it on the freeway. They brought him in, he had low blood pressure, and we gave him a bunch of fluid, and all of a sudden he started to bleed like a shower nozzle out of his neck and his head. We thought, “Oh my God, what’s going on?” It turned out that while this man was driving, the front passenger seat was occupied by the wife of a man sitting in the back seat, and the man in the back thought the two people in the front seat were having an affair. So at 60 miles an hour, he decided to pull out a knife and stab the driver in the neck, breaking the knife off in the driver’s head. Obviously, who can plan for something like that, where you’ve got a knife blade snapped off in someone’s neck?

Things are very chaotic, or potentially chaotic, and we always say that the sicker the person is and the more chaotic it appears, the calmer we as trauma surgeons need to be, because the entire team takes its cues from the leader. If we remain calm and methodical and deal with the problems that arise without becoming anxious, the outcome is better for the patient. So you have to make sure that you’re the right psychological fit for the job, the same as with any position in medicine. It is a pretty fast-moving position. I always say it’s sort of like being Captain Sully landing a plane on the Hudson, except we have three of them at once sometimes, and you have to maintain your cool, try to follow your training and have good instincts. That’s something not everybody enjoys, but if you are a student who enjoys dealing with catastrophe and can keep your cool, then you might consider it. As a general surgeon you’ll have lots of exposure to it, and people naturally either have an affinity for it or they don’t.

Kevin Pho: Now, you’ve been a trauma surgeon for decades, and you have experience in the military. Have you really seen it all? Do you think there’s any situation in the hospital setting that could surprise you?

Stephen Cohn: Well, it’s a matter of degree. Maybe 20 years ago, I had the opportunity to train many of the trauma surgeons who run trauma centers in the Middle East: Beirut, Cairo, Riyadh, and multiple cities in Israel. After the recent events, one of the trauma surgeons there told me that they had received 100 casualties in 36 hours. Sometimes it’s a matter of volume. Have I taken care of a hundred critical people in a day? That’s a level that I haven’t seen. Obviously you do have times when you have a huge volume.

I’m sort of not answering your question, but I’m going to say this: It’s interesting that sometimes it’s not so much about the number as the intensity of a single person, which can keep you doggedly taking care of someone for a long period of time. I’m not trying to bring this back to my book, but it makes me think of one particular person we took care of. We spent the whole afternoon with 20 people working on this kid, and he amazingly survived. It really was an enormous team, giving him massive amounts of blood and everything else to try to get him through a devastating injury. So it’s not so much the volume. But getting back to your question, I think I’ve seen most of the things that folks see. There’s always the occasional unique experience, but I don’t think I’m looking to be surprised at this point. I think you want to calmly deal with whatever comes through the door.

Kevin Pho: We’re talking to Stephen Cohn. He’s a trauma surgeon and the author of the book All Bleeding Stops: Life and Death in the Trauma Unit. Stephen, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Stephen Cohn: I guess it’s all about injury prevention. That’s my take-home message. Wear a helmet when you ride a motorcycle or a bicycle. Wear your seat belt. Don’t drink and drive. One of my colleagues likes to have an occasional drink, and he has a Breathalyzer in his car. If he gets in the car and he’s had some drinks, he checks it, and if it’s near the limit, he calls an Uber. Don’t drink and drive. We still have the same per capita loss now that we did 35 years ago. It’s crazy. Try to prevent injuries.

And then, if someone has the misfortune to have a bad outcome and end up in the intensive care unit, please try to remember that these folks are doing the best they can to keep your loved one alive. Try to give them your trust, and realize they’re not the enemy. They’re doing absolutely everything they can to sustain your loved one.

Kevin Pho: Stephen, thank you so much for sharing your stories, time, and insight, and thanks again for coming on the show.

Stephen Cohn: Thank you, Kevin. I appreciate the opportunity.