- Email: [email protected]
Acute care surgery: Challenges and opportunities from the neurosurgical perspective
Acute care surgery: Challenges and opportunities from the neurosurgical perspective Alex B. Valadka, MD, FACS,a Richard G. Ellenbogen, MD, FACS,b Fremont P. Wirth, Jr, MD, FACS,c and Edward R. Laws, Jr, MD, FACS,d Houston, Tex, Seattle, Wash, Savannah, Ga, and Charlottesville, Va From the Department of Neurosurgery, University of Texas Medical School at Houston, Tex;a Department of Neurological Surgery, University of Washington School of Medicine, Seattle;b Neurological Institute of Savannah, Ga;c and the Department of Neurological Surgery, University of Virginia, Charlottesvilled
The field of trauma surgery faces a stormy future. Residents and other young surgeons have little interest in careers in trauma.1,2 Some surgical leaders have proposed the creation of a new specialty, tentatively named acute care surgery. Their vision is that its practitioners would enjoy a more controlled practice and lifestyle than many of the surgeons who have traditionally provided emergency care. They would also cast a wider net than traditional trauma surgeons. Their area of expertise would extend to all operative emergencies, not just trauma. A major flaw of this plan is the proposed scope of practice of these new specialists. Current proposals call for them to deliver large amounts of care that is provided currently by a variety of specialists. The following discussion focuses on the neurosurgical perspective on this new specialty, but many of these points also apply to these other specialties as well. Patient welfare is by far the most important reason why acute care surgeons need to avoid dabbling in subspecialty areas. The restricted work schedules of acute care surgeons, the broad scope of conditions that they plan on treating, and the relative rarity with which patients in the emergency department require invasive neurosurgical procedures all indicate that it will be difficult for these diversified specialists to acquire and maintain the technical expertise to carry out specialized procedures safely. This concern is magnified by the fact that only a small amount of an
Accepted for publication January 10, 2007. Reprint requests: George C. Velmahos, MD, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:321-3. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.009
acute care surgeon’s training, perhaps as few as 1 or 2 months, will be devoted to neurosurgery. Peer-reviewed articles in both neurosurgical and general trauma literature document the poor technical results and poor patient outcomes that occur when non-neurosurgeons attempt operative evacuation of traumatic intracranial mass lesions.3,4 Others have reported better results,5 but even in these cases, the operation consisted only of a burr hole; it was carried out in only 13% of cases; a neurosurgeon was involved heavily with the training and decision-making of the non-neurosurgeons; patients underwent immediate postoperative air evacuation to the neurosurgeon’s facility; and there is no certainty that the patients were better served by delaying their definitive care while non-neurosurgeons carried out procedures with which they had only minimal experience. Trauma meetings in the United States refer frequently to the “European model” of trauma care as some sort of goal toward which American trauma care should be moving. Supposedly, in this model, individuals receive broad training that enables them to provide a wide spectrum of trauma care. This model is a myth, however, at least as far as neurosurgery is concerned. Our European colleagues tell us that such a model exists at only a few centers, and it does not work well. Perhaps a more appropriate model is the United States’ military medical system. The United States military triage system must be especially efficient and sophisticated so that the wounded can be delivered to the evacuation hospital that has the most neurosurgical expertise. For this reason, neurosurgeons are co-located with specialized equipment and personnel at only a few locations— or even a single location—in a war zone. In places that are far more remote and isolated than those in rural America, telemedicine and teleradiology, often supplemented with live interaction with a centrally SURGERY 321
322 Valadka et al
located neurosurgeon, permit accurate initial assessment and stabilization. What about neurosurgical emergencies other than trauma? A great deal of emergency neurosurgical work involves ruptured cerebral aneurysms, intracerebral hemorrhages, ventriculoperitoneal shunt failures, spinal cord compression from tumor, pituitary apoplexy, and abscesses in the brain and spinal epidural space, to name just a few problems. Even if trauma were removed from the equation, neurosurgical expertise would still need to be available for this myriad of other emergencies. It would not make sense for these other patients to benefit from emergency care delivered by a neurosurgeon while, at the same time, trauma patients are denied access to neurosurgical expertise. Another practical question concerns the value of having a non-neurosurgeon carry out procedures or initiate treatment for problems that may rapidly escalate beyond his or her level of expertise. If an acute care surgeon were to place an intracranial pressure (ICP) monitor in a patient and then find that the ICP was quite high, what would the next step be? Would optimal management be medical or operative? What interventions might work best in that patient, and that might be contraindicated? These are complex situations that are difficult to manage even for experienced neurosurgeons. Fortunately, years of training, as well as ongoing experience throughout their careers, allow neurosurgeons to accumulate, maintain, and refine expertise in such situations. This experience cannot be acquired by a few months of postgraduate training followed by occasional exposure to patients with neurologic illnesses. Unfortunately, this emphasis on technical procedures without a thorough appreciation of the complex cognitive aspects of patient management characterizes much of the zeal of non-neurosurgeons to carry out neurosurgical procedures. A similar issue concerns the type of hospital at which such a patient should receive care. A smaller facility may not be the most appropriate place for management of a patient with severe traumatic brain injury. Most large hospitals and all Level I and II trauma centers already have neurosurgeons available to care for these patients, making it unnecessary to have other physicians carry out neurosurgical procedures. Will acute care surgery’s proposed scope of practice be effective in attracting students into this new field? Interestingly, in a survey of members of surgical trauma societies published recently, the lowest-ranked “ideal practice characteristic” was the potential opportunity to carry out neurosurgical
Surgery March 2007 and orthopedic procedures.6 Those who are promulgating the creation of this new field might wish to remember that the controversy that has been (and will be) caused by the proposed inclusion of subspecialty areas in the acute care surgery curriculum seems to be a waste of time and misguided effort because the very trainees who might choose to enter this field view the performance of orthopedic and neurosurgical procedures as a low priority. Of note, the proposal for creating a curriculum for training in acute care surgery went far down the pathway of development before orthopedic operation and neurosurgery were invited to participate in the process. That simple fact typifies the frequent state of emergency medical services in this country: the individual pieces are of high quality, but they are often not coordinated well. According to a January 2006 surveys by the American Association of Neurological Surgeons, more than 93% of neurosurgeons participate in their hospital’s call schedule, and more than 55% take call 2 or 3 times per week. However, fewer than half had been invited to participate in the formulation of their hospitals’ diversion policies or transfer policies. These results suggest that much of the “crisis” in the delivery of emergency neurosurgical care is overstated because most neurosurgeons are active participants in the system. Undoubtedly, there exist areas where neurosurgical emergency care is not optimal, just as there are also places where emergency medical care in general is not up to desirable levels. Rather than having non-neurosurgeons carry out procedures for which they are incompletely trained, a better solution is to improve the regional coordination not only of emergency neurosurgical care, but of all emergency medical care. Everyone agrees that a patient with a neurologic emergency is best served by going to a physician who specializes in the nervous system. The key is facilitation of the encounter between the patient and the physician by removing organizational barriers that prevent that encounter from taking place. At the very highest levels, the national neurosurgery organizations have been involved intimately in these discussions about the emergency neurosurgical workforce. Fruitful interactions have taken place both internally and with such organizations as the American College of Surgeons (ACS), the ACS Committee on Trauma (COT), and the American Medical Association. The biggest benefit from these discussions has been a renewed awareness that all the different specialties in medicine must work in concert if we are to solve the problems that plague this country’s
Valadka et al 323
Surgery Volume 141, Number 3
emergency medical care delivery system. ACS Executive Director, Tom Russell, speaks of the need for the “house of surgery” to come together during this crisis. Everyone involved in this issue wants to do what he or she thinks is best for patient care. Mutual respect and collegiality are essential if we hope to work together within the house of surgery. The ACS-COT has long been the recognized leader in identifying the criteria that a hospital must meet to be considered a trauma center. Several years ago, the COT created the Trauma System Planning and Evaluation Committee (TSPEC) to look beyond an individual hospital and, instead, to offer expert consultation on the organization and effectiveness of trauma care in an entire region. The creation of this committee was prescient. Most of the problems affecting emergency medical care arise from inadequacy of resources or poor coordination of existing resources. The TSPEC should position itself to be a major force as regionalization becomes accepted as an essential part of improving the emergency care delivery system. To fully realize this potential, the TSPEC should broaden its scope to look beyond trauma and, instead, offer consultation on all emergency services in a region. Another change that the TSPEC should adopt is the participation of a neurosurgeon and an orthopedic surgeon on each site visit. Given the importance of subspecialty availability to regional trauma systems, this change is logical. In fact, increasing the number of these specialists on the COT is another idea whose time has come. Most neurosurgeons have only minimal familiarity with the COT. Greater interaction and communication are essential if more neurosurgeons are to think of the COT as being “our” organization, as opposed to someone else’s. Improved interhospital cooperation is another necessary part of the solution. Because there exist fewer neurosurgeons than hospitals with emergency departments, it is physically impossible for every hospital that wants to have a neurosurgeon on call 24/7 to meet that goal. Instead, the goal should be maximizing patient benefit by ensuring that each region contains at least one hospital that has well-trained neurosurgeons with adequate equipment and other support to permit the delivery of consistently high-quality neurosurgical care, both operative and nonoperative, during the entire acute injury period. Written transfer agreements
and contingency plans are mentioned in the body of law spawned by the Emergency Medical Treatment and Labor Act (EMTALA), but few hospitals seem to have such agreements. Mandated cooperation through further refinements of EMTALA and through other regulatory bodies may improve the regional coordination of emergency medical care. A more collegial relationship between hospitals and their medical staffs is also sorely needed in many areas. Again, cooperation and mutual respect must characterize such interactions. Reasonable compensation for those who provide emergency services to a hospital would is a natural outgrowth of such relationships. Finally, tort reform is a basic step that would benefit all who provide emergency care. How could acute care surgery fit into such a system? One of the biggest neurosurgical needs is optimization of the resources available in a region. It is no longer possible to send every patient with a mild brain injury to the nearest Level I trauma center. Such transfers flood the major trauma centers with mildly injured patients, forcing the large hospitals to go on diversion and thereby making them unavailable for seriously ill patients who legitimately require care at these facilities. By gaining a greater appreciation of the relationship between systemic and neurological trauma, acute care surgeons might be able to communicate more effectively with neurosurgeons, thereby optimizing assessment and immediate treatment of patients and also promoting the most efficient utilization of a region’s emergency medical resources. The biggest winners will be our patients. REFERENCES 1. Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma 1992;32:229-35. 2. Maier RV. Trauma: the paradigm for medical care in the 21st century. J Trauma 2003;54:803-13. 3. Wester K. Decompressive surgery for “pure” epidural hematomas: does neurosurgical expertise improve the outcome? Neurosurgery 1999;44:495-500. 4. Wester T, Fevang LT, Wester K. Decompressive surgery in acute head injuries: where should it be performed? J Trauma 1999;46:914-9. 5. Rinker CF, McMurry FG, Groeneweg VR, et al. Emergency craniotomy in a rural Level III trauma center. J Trauma 1998;44:984-9. 6. Esposito T, Leon L, Jurkovich GJ. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006;60:8-16.
The field of trauma surgery faces a stormy future. Residents and other young surgeons have little interest in careers in trauma.1,2 Some surgical leaders have proposed the creation of a new specialty, tentatively named acute care surgery. Their vision is that its practitioners would enjoy a more controlled practice and lifestyle than many of the surgeons who have traditionally provided emergency care. They would also cast a wider net than traditional trauma surgeons. Their area of expertise would extend to all operative emergencies, not just trauma. A major flaw of this plan is the proposed scope of practice of these new specialists. Current proposals call for them to deliver large amounts of care that is provided currently by a variety of specialists. The following discussion focuses on the neurosurgical perspective on this new specialty, but many of these points also apply to these other specialties as well. Patient welfare is by far the most important reason why acute care surgeons need to avoid dabbling in subspecialty areas. The restricted work schedules of acute care surgeons, the broad scope of conditions that they plan on treating, and the relative rarity with which patients in the emergency department require invasive neurosurgical procedures all indicate that it will be difficult for these diversified specialists to acquire and maintain the technical expertise to carry out specialized procedures safely. This concern is magnified by the fact that only a small amount of an
Accepted for publication January 10, 2007. Reprint requests: George C. Velmahos, MD, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:321-3. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.009
acute care surgeon’s training, perhaps as few as 1 or 2 months, will be devoted to neurosurgery. Peer-reviewed articles in both neurosurgical and general trauma literature document the poor technical results and poor patient outcomes that occur when non-neurosurgeons attempt operative evacuation of traumatic intracranial mass lesions.3,4 Others have reported better results,5 but even in these cases, the operation consisted only of a burr hole; it was carried out in only 13% of cases; a neurosurgeon was involved heavily with the training and decision-making of the non-neurosurgeons; patients underwent immediate postoperative air evacuation to the neurosurgeon’s facility; and there is no certainty that the patients were better served by delaying their definitive care while non-neurosurgeons carried out procedures with which they had only minimal experience. Trauma meetings in the United States refer frequently to the “European model” of trauma care as some sort of goal toward which American trauma care should be moving. Supposedly, in this model, individuals receive broad training that enables them to provide a wide spectrum of trauma care. This model is a myth, however, at least as far as neurosurgery is concerned. Our European colleagues tell us that such a model exists at only a few centers, and it does not work well. Perhaps a more appropriate model is the United States’ military medical system. The United States military triage system must be especially efficient and sophisticated so that the wounded can be delivered to the evacuation hospital that has the most neurosurgical expertise. For this reason, neurosurgeons are co-located with specialized equipment and personnel at only a few locations— or even a single location—in a war zone. In places that are far more remote and isolated than those in rural America, telemedicine and teleradiology, often supplemented with live interaction with a centrally SURGERY 321
322 Valadka et al
located neurosurgeon, permit accurate initial assessment and stabilization. What about neurosurgical emergencies other than trauma? A great deal of emergency neurosurgical work involves ruptured cerebral aneurysms, intracerebral hemorrhages, ventriculoperitoneal shunt failures, spinal cord compression from tumor, pituitary apoplexy, and abscesses in the brain and spinal epidural space, to name just a few problems. Even if trauma were removed from the equation, neurosurgical expertise would still need to be available for this myriad of other emergencies. It would not make sense for these other patients to benefit from emergency care delivered by a neurosurgeon while, at the same time, trauma patients are denied access to neurosurgical expertise. Another practical question concerns the value of having a non-neurosurgeon carry out procedures or initiate treatment for problems that may rapidly escalate beyond his or her level of expertise. If an acute care surgeon were to place an intracranial pressure (ICP) monitor in a patient and then find that the ICP was quite high, what would the next step be? Would optimal management be medical or operative? What interventions might work best in that patient, and that might be contraindicated? These are complex situations that are difficult to manage even for experienced neurosurgeons. Fortunately, years of training, as well as ongoing experience throughout their careers, allow neurosurgeons to accumulate, maintain, and refine expertise in such situations. This experience cannot be acquired by a few months of postgraduate training followed by occasional exposure to patients with neurologic illnesses. Unfortunately, this emphasis on technical procedures without a thorough appreciation of the complex cognitive aspects of patient management characterizes much of the zeal of non-neurosurgeons to carry out neurosurgical procedures. A similar issue concerns the type of hospital at which such a patient should receive care. A smaller facility may not be the most appropriate place for management of a patient with severe traumatic brain injury. Most large hospitals and all Level I and II trauma centers already have neurosurgeons available to care for these patients, making it unnecessary to have other physicians carry out neurosurgical procedures. Will acute care surgery’s proposed scope of practice be effective in attracting students into this new field? Interestingly, in a survey of members of surgical trauma societies published recently, the lowest-ranked “ideal practice characteristic” was the potential opportunity to carry out neurosurgical
Surgery March 2007 and orthopedic procedures.6 Those who are promulgating the creation of this new field might wish to remember that the controversy that has been (and will be) caused by the proposed inclusion of subspecialty areas in the acute care surgery curriculum seems to be a waste of time and misguided effort because the very trainees who might choose to enter this field view the performance of orthopedic and neurosurgical procedures as a low priority. Of note, the proposal for creating a curriculum for training in acute care surgery went far down the pathway of development before orthopedic operation and neurosurgery were invited to participate in the process. That simple fact typifies the frequent state of emergency medical services in this country: the individual pieces are of high quality, but they are often not coordinated well. According to a January 2006 surveys by the American Association of Neurological Surgeons, more than 93% of neurosurgeons participate in their hospital’s call schedule, and more than 55% take call 2 or 3 times per week. However, fewer than half had been invited to participate in the formulation of their hospitals’ diversion policies or transfer policies. These results suggest that much of the “crisis” in the delivery of emergency neurosurgical care is overstated because most neurosurgeons are active participants in the system. Undoubtedly, there exist areas where neurosurgical emergency care is not optimal, just as there are also places where emergency medical care in general is not up to desirable levels. Rather than having non-neurosurgeons carry out procedures for which they are incompletely trained, a better solution is to improve the regional coordination not only of emergency neurosurgical care, but of all emergency medical care. Everyone agrees that a patient with a neurologic emergency is best served by going to a physician who specializes in the nervous system. The key is facilitation of the encounter between the patient and the physician by removing organizational barriers that prevent that encounter from taking place. At the very highest levels, the national neurosurgery organizations have been involved intimately in these discussions about the emergency neurosurgical workforce. Fruitful interactions have taken place both internally and with such organizations as the American College of Surgeons (ACS), the ACS Committee on Trauma (COT), and the American Medical Association. The biggest benefit from these discussions has been a renewed awareness that all the different specialties in medicine must work in concert if we are to solve the problems that plague this country’s
Valadka et al 323
Surgery Volume 141, Number 3
emergency medical care delivery system. ACS Executive Director, Tom Russell, speaks of the need for the “house of surgery” to come together during this crisis. Everyone involved in this issue wants to do what he or she thinks is best for patient care. Mutual respect and collegiality are essential if we hope to work together within the house of surgery. The ACS-COT has long been the recognized leader in identifying the criteria that a hospital must meet to be considered a trauma center. Several years ago, the COT created the Trauma System Planning and Evaluation Committee (TSPEC) to look beyond an individual hospital and, instead, to offer expert consultation on the organization and effectiveness of trauma care in an entire region. The creation of this committee was prescient. Most of the problems affecting emergency medical care arise from inadequacy of resources or poor coordination of existing resources. The TSPEC should position itself to be a major force as regionalization becomes accepted as an essential part of improving the emergency care delivery system. To fully realize this potential, the TSPEC should broaden its scope to look beyond trauma and, instead, offer consultation on all emergency services in a region. Another change that the TSPEC should adopt is the participation of a neurosurgeon and an orthopedic surgeon on each site visit. Given the importance of subspecialty availability to regional trauma systems, this change is logical. In fact, increasing the number of these specialists on the COT is another idea whose time has come. Most neurosurgeons have only minimal familiarity with the COT. Greater interaction and communication are essential if more neurosurgeons are to think of the COT as being “our” organization, as opposed to someone else’s. Improved interhospital cooperation is another necessary part of the solution. Because there exist fewer neurosurgeons than hospitals with emergency departments, it is physically impossible for every hospital that wants to have a neurosurgeon on call 24/7 to meet that goal. Instead, the goal should be maximizing patient benefit by ensuring that each region contains at least one hospital that has well-trained neurosurgeons with adequate equipment and other support to permit the delivery of consistently high-quality neurosurgical care, both operative and nonoperative, during the entire acute injury period. Written transfer agreements
and contingency plans are mentioned in the body of law spawned by the Emergency Medical Treatment and Labor Act (EMTALA), but few hospitals seem to have such agreements. Mandated cooperation through further refinements of EMTALA and through other regulatory bodies may improve the regional coordination of emergency medical care. A more collegial relationship between hospitals and their medical staffs is also sorely needed in many areas. Again, cooperation and mutual respect must characterize such interactions. Reasonable compensation for those who provide emergency services to a hospital would is a natural outgrowth of such relationships. Finally, tort reform is a basic step that would benefit all who provide emergency care. How could acute care surgery fit into such a system? One of the biggest neurosurgical needs is optimization of the resources available in a region. It is no longer possible to send every patient with a mild brain injury to the nearest Level I trauma center. Such transfers flood the major trauma centers with mildly injured patients, forcing the large hospitals to go on diversion and thereby making them unavailable for seriously ill patients who legitimately require care at these facilities. By gaining a greater appreciation of the relationship between systemic and neurological trauma, acute care surgeons might be able to communicate more effectively with neurosurgeons, thereby optimizing assessment and immediate treatment of patients and also promoting the most efficient utilization of a region’s emergency medical resources. The biggest winners will be our patients. REFERENCES 1. Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma 1992;32:229-35. 2. Maier RV. Trauma: the paradigm for medical care in the 21st century. J Trauma 2003;54:803-13. 3. Wester K. Decompressive surgery for “pure” epidural hematomas: does neurosurgical expertise improve the outcome? Neurosurgery 1999;44:495-500. 4. Wester T, Fevang LT, Wester K. Decompressive surgery in acute head injuries: where should it be performed? J Trauma 1999;46:914-9. 5. Rinker CF, McMurry FG, Groeneweg VR, et al. Emergency craniotomy in a rural Level III trauma center. J Trauma 1998;44:984-9. 6. Esposito T, Leon L, Jurkovich GJ. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006;60:8-16.