Friday, December 8, 2023

Q&A with Stephen M. Cohn




Stephen M. Cohn, M.D., is the author of the new book All Bleeding Stops: Life and Death in the Trauma Unit. He is a trauma surgeon based in New York City.


Q: What inspired you to write All Bleeding Stops?


A: I often get asked what we do, and my wife urged me to use my many trauma stories to illuminate the public.


Trauma surgeons are general surgeons who typically do an extra year or two of fellowship after their five-year surgical residency and then specialize in emergency surgery, critical care, and trauma.


We are not emergency room doctors who spend their time in the ER exclusively and manage all sorts of medical issues. We focus on the patients with severe injuries, or who have illnesses requiring operations (like appendicitis, gallbladder inflammation, or anything bleeding, obstructed, or perforated).


We also deliver most of the ICU care in the sickest surgical patients. Think of the trauma surgeons as experts in dealing with medical catastrophe.

Q: Why did you decide to become a trauma surgeon?


A: It’s funny, but the field sort of chose me. Throughout med school, the faculty always asked me what area of “surgery” I was going into. I always answered that I was planning to be a family practitioner like my father. They would always respond “no, you will be a surgeon.”


Three days into my first surgical clerkship as a junior med student I realized they were correct. I always enjoyed the general surgery and trauma field because the patients were so sick and seemed the most challenging.


Later, I found I gravitated to this area in regard to my joy in educating trainees and performing scientific investigations.


Q: What would you say are some of the most common perceptions and misconceptions about a trauma surgeon’s work?


A: The public perception of trauma care is often based upon what they see on TV and in the movies.


It is hard for me to watch any show where they include trauma care, as they always speed up the process and make it very theatrical, obviously related to limited time and the need to elevate the entertainment value.


So, diagnoses are made instantaneously, and interventions are accomplished in no time. And everyone is running around like chickens with their heads cut off.


In reality, the trauma process is very controlled, methodical, and the sicker the patients are, the calmer we must be. This is in both the emergency room and in the operating room. There is simply zero room for anxious, excitable, loud people.


Also, we never try to fish out a bullet! This act only leads to unnecessary additional operative time and results in tissue injury and blood loss. And bullets are rarely a source of infection or late complications.


Q: How was the book’s title chosen, and what does it signify for you?


A: The title pertains to the inevitability of the termination of bleeding, and the challenge to us in trauma to stop the hemorrhage before the patient succumbs. I suppose it is a bit of gallows humor.


Q: What are you working on now?


A: I have another surgical textbook coming out next year and am contemplating writing another book for the general public which will focus on the changes in the surgical approach to disease over the last few hundred years.


Q: Anything else we should know?


A: I would be remiss if I did not urge your readers to strive to avoid injury, both as individuals and as a society. We need to aim to reduce the number of avoidable injuries and an improve our delivery of high-quality trauma care.


To accomplish this, we must as a society recognize the consequences of our cultural norms and institute creative measures which reduce the likelihood of trauma.


It would be great if we could regionalize trauma centers so that we have the appropriate number and geographic distribution to deliver optimal care to the population.


In Maryland, for example (with over 6 million inhabitants), all significant trauma victims are flown to a single adult or solitary pediatric Level I trauma center in Baltimore. The state also has a few Level II trauma centers. 1 This is an ideal concentration of resources.


This contrasts with Boston, where there are six Level I and one Level II adult trauma centers for a population of under 700,000 in the city proper and 8.5 million in the metro area.


Other US states have no grand plan and little statewide governance. I believe that the regionalization of trauma care in fewer, higher-quality centers would lead to better outcomes and lower costs.

I believe it is time to use some innovations to help reduce risky behavior.


For example, cars could all require a breathalyzer to start their ignition, potentially reducing the incidence of drunk driving. A federal law could require motorcycle helmet use, as is mandated in many developed countries. Strict enforcement of gun regulation could dramatically reduce the number of mass shootings.


And research must be funded to investigate the benefits of the changes that I just suggested. Otherwise, we are destined to have “Groundhog Day” in regard to trauma, for the indefinite future.


--Interview with Deborah Kalb

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