 Good afternoon. On behalf of the McLean Center for Clinical and Medical Ethics and the University of Chicago Trauma Center, I welcome you to the 17th lecture in our 2017-2018 lecture series on ethical issues in violence, trauma, and trauma surgery. It is indeed my pleasure to introduce today's speaker, who is also a trauma surgeon and friend, Dr. Manta Swarub, who I met pretty much upon arrival to Chicago over 13 months ago. Dr. Swarub is an associate professor of surgery at Northwestern University, the Feinberg School of Medicine. He's also the program director of the Global Surgery Fellowship in the Division of Trauma and Critical Care at Northwestern and an attending surgeon at Northwestern Memorial Hospital. Dr. Swarub attended medical school at the University of Texas at Houston, where her mom still lives, and continued her training in general surgery at Washington Hospital Center in DC and at the University of South Florida. She then completed a critical care fellowship that brought her here to the City of Chicago at Northwestern and has been trapped in the orbit of Chicago ever since. She's a fellow of the American College of Surgeons as well as the International College of Surgeons and a founding member of the Board of Governors of the Academic College of Academic International Medicine. Dr. Swarub has won multiple procedures awards for her outstanding teaching and was also recently featured in Oprah O' Magazine. Dr. Swarub has developed the Northwestern Trauma and Surgical Initiative, an international program involving residents, medical students, and multidisciplinary fellows of which two are here, that aim to improve trauma surgical care in low and middle income countries throughout the world and in low income settings. More recently, she has also developed an important initiative on the South Side, the Chicago Trauma First Responders Course in collaboration with Ceasefire Chicago, which is an attempt to empower community providers and community members in the art of tourniquet and bleeding control. This course intended to teach community and layperson first responders simple skills to arrest bleeding with items found at the site of traumatic injury. You'll hear more about this and other initiatives largely around the concept of empowerment and ethical dilemma. Please join me in welcoming Dr. Swarub. Thank you guys so much. Thank you, Dr. Rogers, for that wonderful introduction. And I'd like to thank the McLean Center for Clinical Ethics for inviting me to give you all a talk on this series. My talk is actually on ethical dilemma of empowerment in the creation of a trauma care system. And although it may seem strange because how can there be a dilemma when you're trying to become stronger and more confident, especially in controlling one's life, how there's a dilemma in that. But there is, because with empowerment comes expectation. So I have no disclosures that are relevant to this presentation. But before we start, I want us to play a game. So the person next to you, I want you to link up with them and get in an arm wrestling position. Seriously. Your job is to get your arm down as many times as possible in 30 seconds. Ready? Go. All right. Good. So who got more than one? More than 10? Awesome. You guys got 55. So what was the key to this? What was key to success, someone? What was key to success, Dr. Siegler? Okay. And how about those of you who weren't able to get the other person's arm down? What was the issue there? All right. Well, in theory, if we work against one another, all right, then we're not going to achieve what we need to achieve. If we are working together, let's say Selwyn and I are playing this game, then we will have an optimum assessment of what our goals are and we'll both be able to achieve our goals. So this becomes important when we look at a box and a cone. All right. Let's say Selwyn is only able to look through P poll A. What do you guys think he's going to see? A triangle. Now let's say I'm only allowed to look through P poll B. I'm going to see a circle. Without the realization of what's being seen, we can't actually realize what's inside of the box, the actual object. If we don't take into consideration each other's perspective, we will never realize what is the truth. And so as we're planning any intervention, we must work together as a team. Otherwise, we all suffer. So to empower any one particular mouse may actually be very detrimental to all of the parties involved. And in our conversation today in ethics and trauma care, the ones who will suffer in this case would be our patients. So a brief journey. Here's an outline of our journey. A brief evaluation on the burden of trauma. Then we'll discuss empowerment and then how it relates to the global burden of trauma. First in first responders training and then in actual trauma systems development. And then how a bidirectional approach keeps us all out of the mousetrap. Before we actually evaluate the burden of trauma, I think it's important to delineate what's actually meant by trauma. So the word injury is oftentimes used in place of the word trauma. And injury is usually caused by something, some kind of massive force. Okay. And it can be intentional or unintentional. But when we think about what trauma actually is, it can include the above. It can include the actual injury to the self. But it also includes the mental health issues. And it is comprehensively involves trauma systems and care pre-hospital in hospital and after hospital. The trauma burden by definition is actually injury burden, right? Because we don't actually define what the mental health aspects of what we are looking at. So in 2013 globally, there were 4.8 million deaths of unintentional and intentional injury worldwide. And approximately 10% of the global burden of disease. What's interesting is that more than 90% of all of these injury related deaths occur in low and middle income countries. Now, I'm a very simple surgeon. So I like things delineated clearly, pictorially. So if you think about death from injury, it's almost 6 million people with another 30 million people disabled. Versus AIDS, malaria, and tuberculosis combined. And this is only going to get worse. If we look at years of life lost, okay, in the 1990s, this includes high income countries and low income countries. Road traffic incidents were only the ninth most common cause of death. And as industrialization has happened and the economies of low and middle income countries have improved, it's predicted that in 2020, road traffic incidences will be number three in the causes of death. So now what? How do we lessen this burden? How do we make this better for our patients? How do we improve outcomes and improve access to trauma care? Well, going back to our cube, we want to be able to see the comb. We want to be able to use the correct tools for the job by knowing all the different perspectives, by taking into account and gaining the buy-in from the screws, from the nails, from the hammer, and from the wrench. So how do we do this in a group, in a country? How do we make sure we're in sync with one another? Yes, the dilemma. So first, to engage in this conversation about the ethical dilemma, let's talk about empowerment. Empowerment for an individual refers to a process where an individual understands the process and results of an action and the ability to exert influence and control over that action. In a community, we strengthen experiences and proficiency. We strengthen the actual community framework and capacity. We remove barriers and we strengthen assets and resources. And with our goal in community empowerment, we are trying to reach equality and health promotion. But as you can see, strengthening individuals' communities is only a part of health promotion. So how do we achieve that? And ideal development can only happen when the interests of all of the stakeholders and beneficiaries align. So the screws, the wrenches, the hammers, the nails. And here is where we have a problem. How does one engage and assure that each stakeholder and beneficiary knows that the goals that we set will actually come to fruition? These aspirations are based upon ideals that are based upon mutual acquiescence. How can one promise an empowered community of better outcomes if they are involved in a road traffic incident without improving the environment or writing legislation to ensure that trauma care actually exists? As one develops ideas and thinks through how to develop and implement a trauma system to create a sustainable and contextualized solution, we must work from both directions. Our team at Northwestern Trauma Surgical Initiative realized the importance of working both ways up, from the top down and from the bottom up. Involving citizens in trauma management in a grassroots fashion encompasses the first two steps of empowerment. Developing this trauma system applies to the third and fourth. We propose a systemic way of approaching this dilemma from the bottom up via a first responders training course and from a top down by establishment of a trauma care system. And the synergistic benefit from this bi-directional approach reaches health equity, not equality. And this is a very important and definite difference that we need to be more precise. So our first intervention that we discuss is our first responders training. But first and foremost, will it actually even help to empower lay first responders? Is there a need for it? Is there a desire for it? So there's evidence that very simple things and empowering people at the lay first responder level can actually make a difference in people's lives. Even in complex medical systems, empowering lay people is very important. There is scant evidence that shows that advanced and costly approaches to emergency medical services actually improves outcomes. And in low and middle income countries, first responders may be the only or first tier of emergency responders in resource limited settings in high income countries, sorry. And when I say resource limited, I mean those who are disenfranchised, those who may not have a trauma center nearby, those who may due to economic variables be overburdened, and those communities that are indeed overburdened by high violent level of crime, or even communities that feel socially disempowered. And as per the Hartford consensus, which came out in September of 2015, it can be the difference between life and death. And they can turn bystanders into immediate responders, and we can prevent exsanguination. Having presence and participation of community members allows each individual to take on a role as both a provider and a beneficiary. In addition, the first responder can be a valuable resource and an active investigator in injury surveillance. As a person is in direct contact with those involved in the incident, first responders can provide and collect data in regards to prevention initiatives in the future. So involving community members in trauma care transforms passivity into active ownership of healthcare and allows the ability to control in a situation that is normally chaotic. Empowering individual members and eventually the community is a fundamental step in mobilizing society towards health equity. Empowering those at risk to participate in and care for and help save individual lives may actually keep them from taking a life. However, this approach alone cannot tackle the issue of trauma care, where the system has not even begun to catch up with what's actually going on. Without hospitals in the vicinity of a community or the modality of transportation to the hospital, the efforts of bystanders are hopeless. So we develop systems of care from the top down. And a trauma system we know consists of pre-hospital, hospital, and post-hospital care. And broken down further, there are even more arms that need to be developed. And extrapolating U.S. data for low and middle income countries, we know that in states that have trauma systems, there's actually a 9% less mortality rate compared to those without. We also know that the risk of death is significantly lower when patients are provided care in a trauma center. The value of a trauma center is cost effective, as resources are allocated based upon what is actually treated at the hospital. So combined with the recognition of trauma as a major burden in low and middle income countries and the success of utilizing trauma systems in high income countries, the World Health Organization and the International Association for the Surgery of Trauma and Surgical Intensive Care spearheaded the development of essential trauma care project. It was launched in 2004 and certain low and middle income countries such as India, Vietnam, Ghana, Sri Lanka, Botswana, and Mexico participated. The evaluations determined that basic resources and training were what was most critically needed at the level of the district or primary hospitals, which reached the highest volumes of trauma. Essential services are those that are high yield but low cost and which realistically could be assured to almost everyone in a given population. There is often a misperception that improvements in trauma care would be expensive and inappropriate in low and middle income countries. However, disease control priorities project has shown that several interventions that need to be promoted to improve trauma care are among the most cost effective in a healthcare armamentarium. So the goals, what were the goals of the essential trauma care? They were to identify and promote inexpensive ways of reinforcing trauma treatment worldwide. They wanted to work within the system of the actual low and middle income country and use all of the stakeholders at play because you can't implement a high income country system in LMICs. It doesn't work. It's very important to engage the stakeholders to train pre-hospital trauma providers and hospital based trauma providers and develop a trauma registry to evaluate how we make change. However, this too, this top down approach is not sustainable model by itself. Without proper trust of the community and buy-in into the system, the system is inoperable. So a bi-directional approach must be taken. And the things that we look at for a successful trauma system are systems based needs assessment to start off to evaluate the system and then coordination of all different branches. We then develop targeted corrective action and develop an appropriate model. The Northwestern trauma and surgical initiative aims to improve access to surgery and trauma care through education and research to low resource areas. NTSI implemented a trauma first responders training course in Chicago, first by performing a thorough needs assessment with focus groups and then we constantly elicit feedback and change the course as is needed. The course was founded in response to the high death toll that was seen from gun violence at Northwestern, even though there are six level one trauma centers in the Chicago city limits. Since its inception in January 2017, the instructors have trained more than 340 community members. The course focuses on pre-hospital care and pre-ambulance care in resource limited settings. Participants have shown that they actually feel more empowered even at six months after being given the course. And these efforts are not without saying that a trauma system does not need to be in place. And it's guided under that assumption that patients will eventually be transported to a level one trauma center where they will receive appropriate care. So NTSI also attempted the implementation of a trauma first responder course in Santa Cruz de la Sierra Bolivia with the same goal to reduce pre-hospital mortality. But it soon became evident that other than failing miserably, we had people who were very interested in becoming trauma informed and to receive training. But there wasn't any semblance of a trauma system to receive these potential patients. So even though tourniquet application may stabilize a bleeding patient at the scene, it won't save a patient's life eventually if there is no way to get to the hospital. Since then, we've redirected our efforts towards writing legislation to implement programmatic development that focuses on education. For example, ATLS, Advanced Trauma Life Support. The pass rate was almost 10%. It's about it. And we implemented a ATLS preparatory course which allowed our participants to actually improve the outcomes of passing the course and becoming ATLS certified. We're also working on a central dispatch system and an emergency medical technician training program that is to include first responders, chauffeurs, and emergency medical providers. There is no one size fits all approach in the trauma system development world in low and middle income countries. And this is even more important and more evident when you strain to put a high income country model into an LMIC. So in order to minimize the likelihood of a true ethical dilemma and a failure of a system, educational initiatives, public announcement of initiatives by all stakeholders should be ongoing. And there should be transparency in the work so as to build trust between parties and facilitate information transfer and assure the identification of the cone in the box. Thank you. Thank you for that expansive review both local and world, especially in Bolivia. And I want to explore a little bit more around the genesis of Bolivia and the pivot towards advocacy. Because in the space of advocacy, it's almost like in at least in medical school, I'm going to go from medical school perspective, it's something that gets beaten out of us. Some of us actually come with a strong advocacy bent and that somehow through all of the biomedical training that we do, we lose that. And I see some medical students in the room who may or may not agree. But if you can share a little bit about that transition realizing that you could transfer some of the knowledge around tourniquets and temporary hemorrhage control, but realizing that there was this big gap on the trauma system side. So as we started teaching in La Paz, it was a very interesting, that's the first place that we taught. And what we noticed was that there was no language that was spoken that was similar even amongst the hospital providers. So the head of trauma in La Paz, when he came in to sit on this course, sit in on this course, he's like, oh, you know, this is so good. Because even I don't remember some of these things. Even when I take care of some trauma patients, I won't put a C collar on them. And I was a little bit devastated at that moment in time. But those things kind of build up in your mind about what is actually lacking. And it's not because people don't want to take care of people well. It's because they don't know. And not knowing is not, you know, is not their fault per say. Does that make sense? You know. And so as we empowered people, we noticed that, you know, the community was very receptive. But these patients would arrive to the hospital and they wouldn't have anybody to care for them. So in the Yungas jungle, it's an eight-hour roundtrip basically from the hospital, the nearest level one trauma center there. And these patients would come with their, you know, let's say they did get their pelvis is bound. What then? What would actually happen to them? So without actually, you know, stepping up the system and laying the foundation properly at the hospital level, we didn't feel that it would be appropriate to go into the community and start working there first. So that's how the, you know, the angle changed. We were lucky enough that we had contacts into the government. And so my Bolivian fellow or my fellow who lives in Bolivia currently, he's a resident at Northwestern. This is his second year there. He was actually able to garner a seat in government. And so he created, he actually created a sector that deals just with trauma care. So that's pretty, pretty cool, I think, where we've actually written legislation for a 911 system, a dispatch center, and actually, you know, worked on that level. And as we are, you know, getting to the point where we're going to start the paramedic school, the paramedic school is modular so that it can be, it can be, you know, simplified for a layperson as well as, you know, complex so that if physicians wanted to take the course, they could as well. I'm going to open up the floor at the stage. There are questions. Mention was made of ceasefire and project on the south side. Could you say something about that? Sure. So as we were developing the idea of having a course in the community, we knew that we would need strong community-based partners. Northwestern has had a relationship with ceasefire since 2009. And as we went forward and, you know, thinking about it, we thought that it would be an appropriate combination to work with ceasefire Chicago. And so what we've done is ceasefire has helped us with validity. So if I have a patient who comes in and tells me how exactly I should do an operation, that usually doesn't work out really well. So what ceasefire has done for us is actually allowed us to have some validity to access patients that we normally wouldn't be able to access. And so we've been able to be in communities that normally would never have the opportunity to either come to Northwestern and take the course or be, you know, around medical professionals that, you know, might be able to give them more access to healthcare. I think, like, you addressed sort of on a systems level and as a trauma center, like, what the expectations become. Does that also apply to, like, the community? Like, when you empower people on a community level, like, what the expectations then look like for them? It's a great question. I think that it's really interesting to see, and so I'm going to refer back to some work that I did in Bangladesh. So there is a group called, or there is a group called Operation Smile, right? Op Smile. So Operation Smile has a group out of it called, there are the special courses in trauma care. And so we did first responder courses in Cambodia and in Bangladesh. And in Bangladesh, we partnered again with a community of young activists. So when we were teaching, we had to, you know, bridge this barrier that was, you know, in a very predominantly Muslim country, you know, men and women touching one another if there was an accident that happened. And in low and middle income countries, like, when I've been in India, my mother, like, will not let me go anywhere near an accident when it happens. Because of all of the different things that are, you know, you can be implicated in the accident itself. You can then be taken to the police station. There's so many different things. So as we broke that barrier, right? And, you know, since then, Critical Link has started in Bangladesh, which is a mobile application that, you know, takes care of the first responders that are in the area. And the community's expectations have increased because of that. Because now, if there is a incident that occurs, the community knows that there's a group of first responders out there who are notified based on location. So I think both ways there is expectation that occurs. I know you mentioned, like, men touching women and women touching men and, you know, whatever gender identified in certain places. I'm also wondering specifically because Chicago has so much gang violence and so much like segregation between different communities. How did you overcome that barrier? And also, how did you choose who would become a, like, first responder in Chicago? Was it self-selecting? Do you do it by geographic area? Great questions. So for me, it started off as a, this is a journey of passion, okay? So seeing my patients dying in my trauma bay made me focus on the community that is served by Northwestern. So that's how we started, okay? We talked to Ceasefire, first and foremost, after we did our focus groups with different communities throughout the South Side of Chicago, and then talked to them about who would be the most powerful to be play first responders, as well as during our focus groups we asked who would be interested in learning this kind of information. And what we found was that, you know, the violence interrupters were very interested. We're doing a big teaching in a couple of weeks with Ceasefire. We also found that, you know, people who go to the church and are in the community, not an active part of street organizations, but are affected by street organizations, wanted to learn this information. So a lot of times, the way that we run the courses, we have organizations that can contact us, churches, Ceasefire, et cetera, urban youth outreach, all sorts of different organizations that reach out to us to say, hey, can you do a training for us? And then we have open trainings, so social media, right? So we post them on Facebook, we tweet them out, and that's how people come and take the class itself. I'm sorry? Yes, sir. Urban youth outreach has in Inglewood. We've been teaching at six different schools. So we've taught at Dunbar Vocational School, at the Peace Center in Doulton. We've taught at Crane Medical Preparatory School. I've taught all the football players at Julian High School, which was very interesting class. And we've taught just community members who've been parts of different organizations. So we've taught also on the West Side. So the course has been taught in Spanish and in English, obviously in English, but also in Spanish. And we're actually creating a team so that we can target specifically to have more access to people who are Spanish-speaking only. Sure. So for the actual patient, there's the Good Samaritan law that protects the person. What is the law in regards to the first responder getting hurt? Well, there's no law specifically that addresses a first responder getting injured, but right. So no, if you're not a medical person and you're trying to help and do the best of your abilities and not actively trying to hurt somebody at the scene, there's no repercussions. Illinois has a really great Good Samaritan law. You've left people without any questions, although there's a follow-up question. I was just asking about the emotional impact of trauma and how much a physical injury can either be a physical injury or a long-term issue of PTSD. How do you train people in that? Sure. So it's not perfect, right? However, we do address emotions, self-emotions. You're, you know, being able to deal with your own emotions and also dealing with emotions at the scene and how you deal with conflict. Like by giving other people jobs, by calming the situation, using a calm voice, not, you know, escalating a situation. We also even address, you know, taking photography and how there's actually no need to take photography after an incident has happened. However, not to get into a verbal conflict again with an individual if that individual is trying to, you know, film the situation and doesn't put their phone away or doesn't do a job like calling 911 since they have their phone out. So we also, okay, so I also carry a phone that I give the phone number with a key chain to everybody so that if they use their skills, they can call me, right? And in addition to that, if they need to debrief about the situation, they can call me. And the third part of that is having resources. So Brightstar has just started having a hotline for mental health services a few times a week. And so I've given patient or I've given people that particular phone number because it's very jarring when you hear, you know, these stories that these kids tell you. So you mentioned a couple of religious organizations that have been helpful or sort of in the circuit with you. Have you run into any religious institutions, traditions that have been a hindrance to your work? Not as yet. Okay. I can't say, I can't say that in the future that I won't come across somebody religiously that would be a hindrance, but as of yet, no one has hindered the work we're trying to do. It's always great about, you know, taking care of, you know, treat, treat others how you would want them to treat you. So thank you. So like we're talking about training people at the point that violence has already occurred. So is there something apart of this process that you can use the experiences to kind of systematically go back and understand why the violence is happening and like not just in a, you know, oh, we started to understand it because we've been a part of this, but like, I don't know, not turning it into research, but just like some form of knowledge gaining that we're getting from the process. So we're going back and evaluating the people that we taught last year in the actual, you know, calendar year to evaluate how they've used and what violent situations they've actually seen, et cetera. But, you know, more to your question, I feel, you know, yeah, this has already happened now. Trauma has already happened. Violence has already happened. Whatever has already happened. The incident has happened. But these kids, we started a club, a true communities club, because we changed the name of the course. We call it trauma responders unify to empower communities. True communities is the name of the course now. And we started a club at one of the high schools called the True Communities Club. And these kids are advocates in their community. So it may, it's not trying to figure out why the violence has happened, but hearing their stories and then seeing their desire to be advocates into the community and advocating for their community, it'll be amazing to see how this process, where this process leads to. When we were teaching at the Peace Center in Dalton, one of the kids asked one of my fellows about becoming a neurosurgeon and just a simple like, you think I could actually do that? You know, having access to people who can show a different side of the world is a totally different experience for a lot of people. I'm fascinated by this model of community involvement, you know, really getting out there in the neighborhoods and involving lay people. And I wonder if you've thought at all about expanding that beyond trauma care. No, not yet. We've been working fairly vigorously and tirelessly in getting this training out there. And we've been partnering, we're just started conversations with some people who do psychologic, you know, the psychologic aspect of how to deal with trauma and bringing that training maybe to the teachers and to others. In Dalton, as far as we've expanded, we did a three-tiered type of system. So all of the teachers, we taught them the American College of Surgeons Stop the Bleed course. We then taught the curriculum of true communities, which includes making makeshift tourniquets and dealing with the airway over a five-day period. And then the third part and the fourth part of that is actually holding a session for community members where they learned how to place combat application tourniquets and make makeshift tourniquets. And then actually putting up Stop the Bleed kits in the school itself. And we created these makeshift kits. So that's as far as we've expanded so far outside of the actual teaching of community members. But we're working on it. If you have any ideas, let me know. Well, I was just thinking that there's so many other areas of medicine that could benefit from that. I mean, I'm picturing, you know, like kids, high school kids being trained to teach their parents how to care for their diabetes or, you know, things that are very wide spread that, I mean, it's just the enthusiasm and the focus of adolescents in particular. To harness that for medical good would be amazing. There's actually an organization that teaches diabetes and hypertension management to high school students. And I believe the program or the, they're in 10 schools right now. I can't remember the name of the organization, but I could look it up for you and let you know. But there are people who are working on different aspects of it. So the example that you gave with the top down bottom up approach in Bolivia, I believe, and kind of strengthening the infrastructure of the trauma systems, I really liked. And I wondered how you think about that here in a place like Chicago where a top down approach might include things like advocating for gun violence prevention and changing the law or changing kind of policy and how you balance like how much to put it in that pot versus kind of a bottom up approach of teaching people how to respond to something once it's happened. Sure. So the only way that I know how to do things is by getting in it, right? So if you are trying to work on a top down approach or a bottom up approach, just do it and to actually be in it. So I think that part of what I've tried to do personally is get involved with the Illinois Department of Public Health and the Chicago Department of Public Health. And so as those connections are being made and joining committees and trying to be a part of the knowledge and community committee so that we can bring more awareness to this. And as well as advocating for gun, I mean for, not for gun violence, against gun violence and against gun laws. So I think that you know personally we definitely you know do that but I don't specifically you know and tell my students and residents to you know go to certain locations or it's I'll tell them if there's like we're holding a march on March 14th at Northwestern a walkout and so you know we'll tell everybody about that but I don't particularly put any pressure on anybody to attend such things. I wanted to thank you so much for coming the long distance of eight miles from Northwestern. I'm ensuring your perspectives and I look forward to ongoing partnerships and as we see how our joint work evolves. But thank you.