Trauma Triage

The Intersection of Epidemiology and Emergency Care

Dr. Tabitha Garwe is no stranger to interdisciplinary research. She is an associate professor of epidemiology at the Hudson College of Public Health. She also holds a joint faculty appointment with the Department of Surgery in the OU College of Medicine, where she is the director of surgical outcomes research. In this position, Garwe collaborates with the Department of Surgery faculty to design and analyze research studies. “They bring the clinical aspect of the research to the table,” she says, “and I help design the study, advise them how the data should be collected, analyze the data, and then discuss findings with the principal investigator.” This is a fantastic example of interdisciplinary research and collaboration. When prompted for her definition of interdisciplinary, Garwe responds, “It’s when people with different skills come together to do research.” She explains that interdisciplinary research is “more translational because it involves different aspects and opinions of people with unique skill sets trying to solve the same problem.” One of the many benefits is that this encourages diversity of thought, which generally results in the best solutions.

When Garwe joined the Department of Surgery, she mainly focused on trauma research. As the only level I trauma center in Oklahoma, OU Health is required to conduct research to maintain certification. In Oklahoma, hospitals are classified from level I through level IV, with level I providing the highest level of trauma care and level IV signifying more rural hospitals. The main difference between level I and level II trauma centers is that level I trauma centers are university teaching hospitals and are required to conduct research. In the Department of Surgery, Garwe’s primary role is to ensure residents and faculty conduct trauma research.

In addition to working with faculty and residents, Garwe also works as an independent researcher. For the past 15 years, she has researched trauma triage. Her interest in this field began with her doctoral dissertation and has continued with her current research. “My focus is on how injured patients are triaged and how it affects their health outcomes,” says Garwe. This includes triage from the scene of injury to the initial hospital and from the initial hospital to a higher level of trauma care. Garwe explains that when emergency medical personnel report to a scene with an injured person, the paramedics have to decide where to take the patient. “If all of the patients came to OU, it would overwhelm the system,” notes Garwe. “Since OU has the resources to treat the most severely injured, we want to ensure those resources are there when needed.” In essence, the trauma system aims to match the severity of a patient’s injury to the hospital with the appropriate level of trauma care. This ensures that the system functions efficiently and we don’t end up taking seriously injured patients to hospitals that don’t have the resources to care for them. It also means we don’t take patients with minor injuries to hospitals equipped to care for the severely injured. Garwe’s research aims to optimize this system. Oklahoma only has two level II trauma centers (both in Tulsa) along with the level I trauma center at OU Health. “That’s all we’ve got,” states Garwe. So, what happens if a patient needing level I or II trauma care is transported to a lower-level trauma center? According to Garwe, a delay of that nature is associated with an almost 200% increase in mortality.

Unfortunately, one of the groups often undertriaged to level I or II trauma centers is older people. With grant funding from the Oklahoma Center for the Advancement of Science and Technology, Garwe has researched geriatric trauma triage and how it impacts patient outcomes. She notes that “this is a nationwide problem where the same triage guidelines are used for everyone—from the healthy 18-year-old to a 95-year-old who may be on numerous medications.” This means that if you have two patients with the same injury, one young and the other old, the younger person is more likely to be taken to a higher-level trauma center. Why does this matter? Garwe says this “results in excess mortality in the older age group that could be prevented if they were taken to a level I or II trauma center.” When asked what ages qualify as geriatric, Garwe responds that the definition is 55 years and up. However, she remarks that studies have shown that under-triaging starts at 50 years old.

Garwe’s follow-up grant proposal focused on researching interfacility triage guidelines, which help physicians decide which patients need to be transferred to a center with a higher level of care. The reality is that most emergency department providers don’t stop to read and flip through the triage guidelines to see which ones apply to a patient; it simply isn’t practical. “Since emergency services can’t take every patient to a level I or II trauma center, we wanted to focus on the point that a patient gets to a hospital,” says Garwe. “Then we want to identify if the patient needs to be transferred and, if so, get them transferred as quickly as possible.” To decide which patients should be transferred to a level I or II trauma center, Garwe and her team used machine learning and artificial intelligence to develop a triage model to assist physicians. The main question was: “How can we identify patients who need to be moved to a higher level of trauma care quickly and objectively?” The model focused on several factors (such as vital signs, type of injury, etc.) related to the patient’s condition at the initial facility. Garwe then assigned different weights to each factor to identify patients at the highest risk for adverse outcomes. Instead of flipping through pages of triage guidelines, the physician can now use an app and answer yes or no questions about the patient. For example, “Do you suspect internal organ injury?” The physician answers yes or no, and the model combines the responses to predict the patient’s probability of dying and whether or not the patient should be transferred to a higher-level trauma center.

Garwe and her team have recruited three hospitals in the Oklahoma City metro area to test the model. They are currently in the testing phase to see if the app can be used in real-time or semi-real-time to influence decision-making on whether or not to transfer the patient. Garwe stresses, “Integrating artificial intelligence into decision-making is intended to help clinicians make the decision faster, not to take over or replace their role.” Her ultimate goal is to integrate this technology into the electronic health record system in the emergency department. “We wouldn’t be the first to do that,” notes Garwe. The hope is that this tool will help save lives by ensuring that patients who need to be transferred to a higher-level center are identified and moved quickly. Her research on automating triage guidelines has attracted quite a bit of attention. Garwe notes, “Sometimes people are afraid that artificial intelligence will take over everything, but we are just working with models.”

When asked about the challenges of interdisciplinary research, Garwe expresses that it can sometimes be difficult when team members aren’t open to the expertise others bring to the project. It makes her appreciate clinicians who are accepting and recognize her expertise in epidemiology and statistics. “Ideal interdisciplinary research is to feel like you’re a team,” Garwe says. “When people try to become involved beyond their discipline, it can break down the team.”

What she likes most about interdisciplinary research is the challenge that diverse topics provide. “I enjoy working on different topics, especially the work I do in the Department of Surgery,” states Garwe. Even though her primary focus is trauma, she also works in surgical oncology, pediatric surgery and other subspecialty research areas. “It encourages me to grow as a professional,” says Garwe.

Moreover, her interdisciplinary research laid the foundation for a course she developed in 2015 called Methods of Clinical Epidemiology. This class was inspired by her experiences working with residents in the Department of Surgery and the need to expand knowledge beyond what’s taught in traditional epidemiology courses. “Over time, I realized that we needed a course to tackle some of the methodology issues,” states Garwe. “When working in an interdisciplinary environment, you need certain additional skills.” Garwe uses numerous examples from her interdisciplinary research in her class, helping lead the way for students to conduct clinical research after graduation. Additionally, because of her interdisciplinary clinical research experience, Garwe was appointed as the statistical editor for the Journal of Trauma and Acute Care Surgery (the top journal in the field of trauma research) in 2022.

MORE ABOUT Dr. Tabitha Garwe Hobby

You might be surprised to learn that Garwe is a professional golfer. She toured with the Ladies Professional Golf Association Futures Tour while getting her doctoral degree and working as a trauma epidemiologist at the Oklahoma State Department of Health. “Whenever went to a tournament, people were always interested in how could do it all,” says Garwe. “I used to play every day except for Sunday.” Her Zoom background is the Augusta National Golf Club course. She explained that the image is of amen corner, aptly named because “it’s where you say your prayers before playing the holes with water and dune obstacles.” Garwe is a self-proclaimed sports junkie. She’s a fan of OU football and the Oklahoma City Thunder. “I like to see people perform under pressure; it’s fascinating to me— that’s probably why I like trauma,” she reflects.

Book Recommendation

“One of the books that changed how I look at things is The Celestine Prophecy by James Redfield,” says Garwe. This book helped her understand that there is a reason why things are happening and how interconnected events are. “You see how things tied together to get you where you are,” she remarks. Garwe also enjoys reading peak performance books. “I feel like, as human beings, we can be more efficient and do more with our time,” she says. “I started with golf, so one of my favorite books is Zen Golf: Mastering the Mental Game by Joseph Parent.”

Favorite Food

“I enjoy seafood even though it can be difficult to find here,” says Garwe. “I love lobster tail.” She especially enjoys the grilled lobster that her husband makes.

Inspiration

“My dad is a huge inspiration in my life,” she says. Garwe grew up in Zimbabwe, where her father is a Supreme Court Justice. “From an early age, he inspired me and made me believe that I could be whatever I wanted if I just put the work into it.”