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In-depth with Dr. Barry McLellan

Barry McLellan

Illustration: Hang Yu Lin

Dr. Barry McLellan isn't only president and CEO of Sunnybrook. He's the hospital's former director of the trauma program, emergency services and trauma research; he was also a trauma team leader and trained in the field here. Later, he oversaw the base hospital (paramedicine) program. Oh, and somewhere in there he did a 10-year stint in the coroner’s office.

It's not hard to see why more than a few people refer to him as the father of trauma at Sunnybrook, though it's a moniker he likely would eschew, pointing instead to a legacy of pioneers that set the stage, including Al Harrison, Marv Tile and Bob McMurtry; and, above all, a highly enabling team environment. Here, he talks to Stephanie Roberts, editor of the SRI Magazine, reflecting on times past and relinquishing nothing about his future as his near-decade-long tenure at the helm at Sunnybrook comes to an end June 30, 2017.

Thank you for speaking with me. As I’ve developed this issue of the magazine, I’ve learned much about trauma at Sunnybrook. The work is extensive and extraordinary.

There are so many areas where we have made a big difference to the system of trauma care across the world. For example, take our blood bank. Prior to Jeannie Callum [director of the blood bank and transfusion medicine at Sunnybrook], Peter Pinkerton was the chief of clinical pathology, and he set that blood bank up to be the benchmark for making blood products available for trauma patients. As opposed to other organizations, where it was often an effort to try to get blood products for your trauma patients, the staff in our blood bank were reaching out to the resuscitation team to help make blood products available.

When people think of trauma care they often don’t realize there’s an entire organization that contributes to that care, including medical imaging, the labs, the blood bank—all of which are critical to ensuring the best outcome for patients.

When I think back to when I was a trauma team leader at Sunnybrook in the ‘80s and ‘90s, my job was made so much easier because of the leaders in medical imaging, the labs, the blood bank and other departments.

Trauma was the first program at Sunnybrook. By program, we mean bringing all of the services and resources together to provide care around a patient—and it was fantastic to have the support that came from everyone in this organization.

Trauma is all about the team. What is it about trauma that makes this so?

The question might be, what is it about Sunnybrook that makes this so? Sunnybrook as an organization has been built around team function. There is a culture of collegiality and cooperation. When the trauma program started in 1976, a lot of the building blocks were already in place. You had an organization that was already thinking about how to work together to advance patient care.

Through the ‘70s and ‘80s, it crystallized into a comprehensive program. It not only includes depth in specialty areas, but as we say, we have a care chain, and if you have a weak link anywhere in that chain, then care of the patient is going to suffer—so right from resuscitation in the field and the response of the paramedics, and the air ambulance transport, right through the trauma room, surgery and critical care—if any one of those is weak, right through rehabilitation and follow-up, then the outcome is less than optimal.

That thinking wasn’t in place to start with. It developed here. When we talk about the trauma system that’s in place more broadly, we have taken what was learned here and the creation of the program and disseminated it across the country and beyond. A lot of the trauma system thinking across the world came from some of the early work here. The impact of that team approach is amazing. It’s great for patients here, but it’s also affected patient care across the world.

Why did you choose trauma?

I trained here in the early ‘80s in emergency and critical care. Sometimes you get drawn in by what you see. I could see excellence in the work that was being done, and I could see great team function.

Mentorship is so important. When you start out in medicine, you are bombarded with choices. This can be wonderful. It also can be paralyzing.

It is. You are very much influenced by those who train you and what you see. I could see great care being provided and opportunities in research and education. The leaders that were around at that time in trauma were very much pioneers in their field.

You were involved early on with the base hospital and air ambulance program, which enjoy a high degree of collaboration with the trauma program. Is that unusual?

It was a natural evolution. The trauma program and the base hospital program developed at the same time. Helicopter transport was predominantly used for trauma patients when the program first started and was important in getting trauma patients to the trauma unit faster. Now helicopter transport is used much more broadly.

What was the hardest aspect of your work as a trauma physician?

Seeing injuries that were in large part preventable. Trauma patients are generally young, heavily skewed toward the male population. Early, much of it was related to motor vehicle [crashes], and much of that was preventable, whether it was because of alcohol, speed, other risk-taking behaviour or not wearing a seatbelt. You would be caring for someone who had a very bad head injury, had a spinal cord injury, and you would realize that a bad decision that was made would have an impact for the rest of their lives.

It’s one of the reasons that we became involved in injury prevention. It evolved from our early experience and research determining where prevention would be of most benefit in the system.

Not all trauma is preventable—but most of it is.

You’ve been here 10 years. When you look back at your accomplishments, of what are you most proud?

We’ve become more focused on a smaller number of areas—and you’re going to make the biggest impact if you select and grow a small number of specific areas of strength. I would say that’s one of the real strengths of our strategy: focus, and the impact comes out of that focus.

At Sunnybrook, there is TECC, which is broader than trauma.

It’s a really important distinction to make between the Tory Trauma Program and the trauma strategic priority. Each of the five strategic priorities at Sunnybrook has been very carefully defined around a clear grouping of patients and associated research and education, so when we talk about the trauma strategic priority we are speaking about those that have serious, life-threatening injuries and serious burns—that is really a relatively small subset of all the patients that go through TECC Program. When we’re talking about traumatic injury and burns and what’s made us internationally renowned, it’s around that subset. Bringing the other areas in, emergency and critical care, it’s a logical grouping, but it’s more than the trauma strategic priority.

Did it go by in a flash, the last 10 years?

Yes, but as you get older, Stephanie, all time goes by in a flash. It went by very, very quickly. When you reflect on what’s happened, you realize why it’s taken 10 years, but when you think back to 2007, it doesn’t seem that long ago.

There’s a long view behind you. How do you feel looking back?

I feel that the organization is poised for a great future, and when you are leaving and passing the baton, that’s what you would like to think is the case.

What remain some of the challenges?

Our biggest challenge is staying on focus at a time when there are so many demands on the total hospital. We don’t have a turnstile. We can’t control what comes in through the door. That relentless focus on making sure that we’re there when it matters most for patients is going to require ongoing attention to controlling volumes of activity and making sure the resources are selectively directed to strategic areas. If you come to Sunnybrook and you have an illness or injury that is diagnosed and requires scheduled care a few weeks or months down the road, it might not be provided here. We need to be there for those patients that really rely on Sunnybrook, when it matters most.

As chief coroner, what question did you get asked most often?

Probably the most common question was, ‘why would you ever do that?’ The answer is a pretty simple one. The coroner’s system is all about advancing public safety. It’s learning from individual deaths and the analysis of many deaths to make the province safer. It is very gratifying, because much of our policy, many of our safety initiatives, including in hospitals, have developed through the death investigation system. For me it was a natural segue from my interest in prevention, because much of it is about preventing injury and death.

What are some examples?

Many of the changes around the use of helmets and bicycle safety developed through coroners’ investigations. Much of the safety around school buses and children, and travel back and forth to school came through coroners’ investigations. Policy changes related to speed and design of motor vehicles came through death investigations. It’s a long list.

The magazine's theme is that trauma could happen to you. What is the single biggest misconception about trauma?

The biggest one is that it is an inevitable event and it was not likely preventable. Not all trauma is preventable—but most of it is. The other thing I think is a misconception is that when you have a serious injury there’s very little that can be done. In fact, there are great treatment advances, right from resuscitation through to surgery and critical care through to rehab. The outcomes from serious injury can be excellent. I also think many people don’t appreciate that in order to have that optimal outcome you need to be treated in a trauma centre.

Does the system know to get to a trauma centre?

Yes, and I will admit that I had something to do with that. If you’re picked up by paramedics anywhere in the GTA, the fact that you are taken to the nearest appropriate hospital—which means if it’s a serious injury to a trauma centre—is based on triage guidelines and protocols that were first developed years ago. There’s also a provincial distribution of trauma cases, so if someone has a serious injury anywhere in this province, it is clear as to where they should be sent.

It seems obvious that you should take people to where the expertise is. Why wasn’t that happening?

It wasn’t always appreciated for some injuries that outcomes would be better in a trauma centre. If someone had a serious head injury, then it might have been recognized. If they had a combination of less serious injuries without a bad head injury, however, then it wasn’t initially recognized that your outcome was that much better if you were sent to a trauma centre. It also wasn’t appreciated how important time to receiving life-saving care was, and that the time from injury until you get your emergent care is very important with respect to both survival and functional outcome.

What needs to happen now?

An important next step will be to conduct more research focused on functional outcome, to make sure that it’s about more than survival. It’s not that we have not paid any attention to this. We just haven’t paid as much attention as we could have. Total trauma care should be right through to that rehab and follow-up, and we are well poised at Sunnybrook to contribute here.

What would you say to a young you who was beginning his career in trauma?

First of all, I would say that it’s exciting work, it’s gratifying work, and there are great opportunities to continue to improve care. I would recommend focusing a research career on follow-up care and functional outcome.

Would you warn him of any pitfalls?

I wouldn’t. No.

Why not?

It’s hard work and much of that work takes place at night and on weekends—but you would know that before considering it as a career. I don’t think that there are any unique pitfalls. Anyone who’s entering into a research career needs to be aware of challenges around funding, but this is common to all areas of health care.

You are given a wonderful gift, untethered. You can do something toward fixing the health care system, and you can do something toward fixing the health research system. They’re not in competition. You have equal funds for each, let’s say $100 million.

I’m concerned that excellent research opportunities are being lost because they are not being funded. One hundred million dollars would go very quickly if it weren’t carefully allocated, so I would want to develop a clear investment strategy where you’d see the most impact. I’d have to think of exactly what that best allocation would be, because it’s too great a gift to waste with a quick answer!

What I would love to see at Sunnybrook, though, is a sustainable research operation that is not dependent on a range of uncertain funding sources as is the case at present.

What next?

You know what? I don’t know [laughs].

You’ve dedicated your life to health care in one form or another.

I have. You’re right.

I can’t imagine that would change.

I can’t either.

Is there anything else we should talk about?

Sunnybrook has had a very important role in shaping and developing the trauma system for patients that arrive here and around Ontario. We’ve exported that knowledge worldwide and made a difference in the care of patients with serious injuries across the globe. That’s something that as an organization Sunnybrook should take great pride in.

Researchers are working hard to get to a place where someone can be wheeled in, such that any number of “masters” in care can fix them, no matter what.

Any patient who arrives at Sunnybrook could not be in a better place. One of the great things about working in an organization like this is that you’re learning all the time. One should never take that for granted. Here, you’re constantly dealing with innovation and creativity—people always thinking about how to do things better. I never take it for granted that when I leave my office, I can turn left or right and within 30 seconds I will encounter a way smart person. Most people don’t experience that in their work environment.