- Email: [email protected]
Acute care surgery from the orthopedic surgeon’s perspective: A lost opportunity
Acute care surgery from the orthopedic surgeon’s perspective: A lost opportunity Mark S. Vrahas, MD, Boston, Mass From the Department of Orthopedics, Division of Orthopedic Trauma, Massachusetts General Hospital and Brigham and Women’s Hospital, Harvard Medical School, Boston
The proposed specialty of Acute Care Surgery, including Trauma, Critical Care, and Emergency Surgery, is an important attempt to ensure that quality surgeons remain interested in trauma. Attracting the best, brightest, and most capable doctors to this specialty is of interest to all subspecialists who care for trauma patients. Nevertheless, there are critical issues regarding the specialty’s relationship to orthopedic surgery that must be addressed if the initiative is to succeed. In this regard, it is useful to examine some key questions in detail: Is there a need for trauma surgeons to provide orthopedic care? Can general surgeons, in a short period of time, learn the necessary skills to deliver this care? Will orthopedic surgeons agree to train acute care surgeons? Will these surgeons be able to receive hospital credentials? Unfortunately, I think an opportunity to enlist the help of sympathetic orthopedic trauma surgeons to address these issues has been lost due to the manner in which the specialty was conceived and introduced. IS THERE A NEED FOR TRAUMA SURGEONS TO PROVIDE ORTHOPEDIC CARE? Many emergency departments report difficulty getting orthopedic surgeons to cover call.1 In a survey of 1400 emergency departments, the American College of Emergency Physicians found that 2 of 3 departments did not have enough specialists for call; neurosurgeons, orthopedic surgeons, and
Accepted for publication January 10, 2007. Reprint requests: Mark S. Vrahas, MD, Yawkey Center For Outpatient Care, Massachusetts General Hospital, 32 Fruit Street, YAW 3-3C, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:317-20. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.003
obstetricians were at the top of the list of specialists who comprised the shortage.2 The proliferation of surgery centers not affiliated with hospitals has allowed orthopedic surgeons to perform elective procedures and so drop hospital affiliations and call responsibilities. Increasing subspecialization and the realization that difficult fracture problems are best managed by specialists have made general orthopedic surgeons less willing to deal with trauma patients. The general decrease in financial reimbursement, especially for emergency care, and the perception that emergency care can place surgeons in legal jeopardy have increased the desire of orthopedic surgeons to avoid emergency call and focus instead on elective procedures. The orthopedic surgeons remaining on call rosters are acutely aware of these issues. While the numbers of orthopedists on call rosters decrease, the burden increases for the remaining orthopedists. At some point, a crisis is reached and the hospital is forced to offer financial incentives to ensure orthopedic coverage. This extra financial burden has prompted hospitals to try and force orthopedic surgeons back to call rosters through modification of EMTALA laws.3 In brief, hospitals are acutely feeling the shortage of orthopedists willing to take on-call responsibilities. This lack implies a need for emergency orthopedic care. However, it is not clear that allowing acute care surgeons to provide a limited amount of orthopedic care would alleviate this shortage. Trauma surgeons potentially could provide emergency orthopedic trauma care; however, this would not obviate the need for orthopedists taking call. Several types of nontrauma orthopedic problems necessitate urgent care, and some mechanism would be required to designate an orthopedist for the continuing care of patients initially managed by acute care surgeons. Paradoxically, the Acute Care Surgery program might work best in trauma centers that have the SURGERY 317
318 Vrahas
least need for orthopedists. In trauma centers with a team of dedicated orthopedic trauma surgeons, all cases are generally turned over to the orthopedic trauma service for definitive care. Still, because no program can employ enough orthopedic traumatologists to cover all the call duties, other orthopedic subspecialists are forced to fill in frequently. This situation generates a great deal of controversy within orthopedic departments. Many orthopedic subspecialists resent taking call even though the obligation is usually minimal, and the orthopedic trauma service takes over the case the next day. It is conceivable that many orthopedic traumatologists would rather have the acute orthopedic problems cared for by an interested acute care surgeon than an uninterested orthopedist whose practice is based primarily on elective procedures. CAN ACUTE CARE SURGEONS BE APPROPRIATELY TRAINED IN A SHORT PERIOD OF TIME? If the goal of the Acute Care Surgery program is for acute care surgeons to provide emergency care, the answer is probably “yes.” However, if the goal is for acute care surgeons to provide definitive care, the answer is most assuredly “no.” There is a growing body of literature and a general belief among orthopedic surgeons that it is rarely appropriate to provide definitive care at night, on an emergency basis. Most orthopedic trauma surgeons advocate damage-control orthopedics.4,5 In other words, do what is necessary to stabilize the patient and save definitive reconstructions for specialists the next day. Currently, we ask our nontrauma orthopedic specialists taking call to deal with emergencies. Of course, compartment syndromes, vascular injuries, and overwhelming infections must be dealt with promptly. Clearly, acute care surgeons could deal with these problems. If bony stabilization is required, we ask only that an external fixitor be applied. Applying an external fixitor is not a complex procedure, and the skill could be taught easily to an experienced acute care surgeon. The most complex procedure we sometimes provide in a nighttime emergency is debridement of open fractures, which requires judgment and experience. In fact, studies undertaken in Europe6-8 suggest that debridement with early flap coverage by an experienced orthopedic trauma surgeon results in lower infection rates than the traditional protocol of urgent debridement by whoever is on call. Given these data, orthopedic surgeons on call often delay the debridement of open fractures until an experienced orthopedic trauma surgeon is available. Nev-
Surgery March 2007
ertheless, severe open fracture wounds sometimes must be handled immediately. Acute care surgeons could probably manage this task with little additional training. They could call upon their general experience with traumatic wounds to manage open fractures. In fact, one could argue that an experienced acute care surgeon would be more skilled at wound debridement than an orthopedic surgeon who has a practice limited to elective arthroscopy procedures. WILL ORTHOPEDIC SURGEONS AGREE TO TRAIN ACUTE CARE SURGEONS? In the current environment, the prospect of orthopedic surgeons agreeing to train acute care surgeon seems unlikely. The introduction of the proposed specialty has generated an extremely negative response from the Orthopedic Trauma Association (OTA) and the American Academy of Orthopedic Surgeons (AAOS). The assumption that the American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association would support the “Acute Surgeon” treatment of orthopedic trauma patients is wrong. A recent survey completed by 46% of the membership of the Orthopedic Trauma Association (OTA) and 48% of the American Orthopedic Association (AOA) showed that more than 95% of the respondents from both organizations were not in favor of general surgeons providing orthopedic care.9
Given this political backdrop, it will be difficult for orthopedic trauma surgeons to agree to provide training. Certainly, young orthopedic trauma surgeons interested in building their academic careers will be reluctant to buck the OTA. Even well-established senior orthopedic trauma surgeons sympathetic to the cause will have difficulty convincing their chairmen that it is a good idea to move counter to the stance taken by the AAOS. IF TRAINED, WILL THE ACUTE CARE SURGEONS BE CREDENTIALED TO PERFORM THESE PROCEDURES? It is conceivable that hospitals in need could force the orthopedic staff to accept the practice of acute care surgeons providing orthopedic care. However, this action would be extremely difficult if the orthopedic staff surgeons were opposed. Orthopedic surgeons could simply refuse to provide definitive care to patients initially treated by an acute care surgeon. Even if the hospital could somehow force orthopedic surgeons to accept these patients, the call problem would remain. Some kind of call system would have to be designed
Surgery Volume 141, Number 3
that would designate an orthopedic surgeon to be responsible for continuing care, and orthopedic surgeons would still be required to cover general call. Ultimately, the solution offered by the Acute Care Surgery program is most viable in hospitals with dedicated orthopedic trauma surgeons who see value in the additional help provided by acute care surgeons dedicated to trauma management. A LOST OPPORTUNITY The specialty of Acute Care Surgery seems like a viable option from the perspective of orthopedists. Orthopedic trauma surgeons should recognize that quality trauma surgeons are important and thus should have a vested interest in ensuring that the specialty remains viable. Although acute care surgeons may not resolve the shortage of orthopedists available for call, they could provide valuable manpower for trauma centers. In many cases, dedicated acute care surgeons who are interested in trauma would be a welcome addition to the field. Despite this, it is unlikely that the program will move forward without an improved buy-in from orthopedists. Unfortunately, the initial negative response from the AAOS and the OTA suggest that gaining this acceptance will be an uphill battle. A total of 19 members comprised the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.10 Unfortunately no orthopedic surgeons were included in this group. The committee did not reach out to the AAOS or the OTA for advice or support in trying to address the issues outlined above. Indeed, the committee did not even seek advice from the orthopedic members of the Committee on Trauma (COT). Moreover, orthopedic surgeons, especially orthopedic trauma surgeons, feel no responsibility for, or urgency to help resolve, the problems facing trauma surgery. Clearly, the collapse of trauma surgery as a specialty would greatly affect orthopedic traumatologists. However, some attempt to recruit orthopedic leaders to the cause should have been made before the specialty was introduced. This scenario speaks to a larger issue. Orthopedic trauma surgery has matured dramatically as a specialty. Interest in orthopedic trauma surgery and the demand for orthopedic traumatologists is high. Although no official records are available, fellowship directors from major orthopedic programs noted an unusually high number of quality applicants this past year. Moreover, orthopedic traumatologists are quite comfortable with the health of their specialty. The OTA and COT have worked hard to improve the quality of trauma care.
Vrahas 319
Unfortunately, these groups have been working in parallel directions with little cooperation. Orthopedic surgeons are members of COT, but these orthopedic surgeons do not speak officially for the OTA or the AAOS. In addition, membership in COT is not considered an important academic credential in the orthopedic community. Yet, at our institution, 48% of trauma patients require orthopedic procedures compared with 6% who require general surgical procedures. These percentages are typical of blunt trauma centers, but orthopedic surgeons comprise only 7% of COT membership. Given these factors, it is not surprising that orthopedic traumatologists feel they have little say in trauma center organization and so have little interest in issues facing COT. Similarly, COT has little knowledge of, or interest in, issues facing orthopedic trauma surgeons. Before orthopedic surgeons become interested in solving the issues facing trauma surgeons, they will need to feel that they have some stake in the system. Several trauma centers have bemoaned the fact that they have difficulty getting orthopedic surgeons involved in trauma care. Nevertheless, the OTA has never been asked to help address this issue in any official capacity. Dedicated orthopedic traumatologists are every bit as incensed by poor orthopedic care as general trauma surgeons, but they are not involved in official attempts to weed out inferior centers. Trauma center verification requires a site visit by 2 general trauma surgeons. Understandably, these surgeons focus on general surgical issues, and it is difficult for them to pick up subtle indicators of poor orthopedic care. As long as the center meets minimal orthopedic requirements, it passes. Dedicated orthopedic traumatologists are often angered when places they know have inferior orthopedic care are verified as trauma centers. Ultimately, if trauma surgeons expect orthopedic surgeons to assist in solving the problems facing trauma centers, orthopedic surgeons will have to feel a true personal or emotional interest, concern, or involvement in the process. The proposed specialty of Acute Care Surgery promises to help maintain the pool of quality trauma surgeons. However, solving the issues facing trauma centers and trauma surgeons may require more than a new specialty. It may necessitate a fresh look at how trauma centers are evaluated and managed with a view toward giving orthopedic traumatologists an expanded role in the process.
320 Vrahas
REFERENCES 1. Steiger B. ACEP poll: physician leaders distressed by specialist shortage; on call pay controversial. The Physician Executive 2005;May-June:14-8. 2. www.rwjf.org/newsroom/newsreleasedetail.jsp?id⫽10312 3. Report Number One to the U. S Department of Health and Human Services from the Inaugural Meeting of the Emergency Medical Treatment and Labor Act Technical Advisory Group. Bethesda (MD): Magnificent Publications; Appendix 7. 2003. 4. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopedics: evolving concepts in the treatment of patients who have sustained orthopedic trauma. [review]. Instruct Course Lect 2005;54: 447-62. 5. Hildebrand F, Giannoudis P, Kretteck C, Pape HC. Damage control: extremities. [review]. Injury 2004;35:678-89.
Surgery March 2007
6. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78:285-92. 7. Gopal S, Giannoudis PV, Murray A, Matthews SJ, Smith RM. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. J Bone Joint Surg Br 2004;86:861-7. 8. Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484-90. 9. Bosse MJ, Tornetta P, Sanders R, Swiontkowski MF, Russell, TA. [letter]. J Trauma 2005;59:1035-6. 10. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005;58:614-6.
The proposed specialty of Acute Care Surgery, including Trauma, Critical Care, and Emergency Surgery, is an important attempt to ensure that quality surgeons remain interested in trauma. Attracting the best, brightest, and most capable doctors to this specialty is of interest to all subspecialists who care for trauma patients. Nevertheless, there are critical issues regarding the specialty’s relationship to orthopedic surgery that must be addressed if the initiative is to succeed. In this regard, it is useful to examine some key questions in detail: Is there a need for trauma surgeons to provide orthopedic care? Can general surgeons, in a short period of time, learn the necessary skills to deliver this care? Will orthopedic surgeons agree to train acute care surgeons? Will these surgeons be able to receive hospital credentials? Unfortunately, I think an opportunity to enlist the help of sympathetic orthopedic trauma surgeons to address these issues has been lost due to the manner in which the specialty was conceived and introduced. IS THERE A NEED FOR TRAUMA SURGEONS TO PROVIDE ORTHOPEDIC CARE? Many emergency departments report difficulty getting orthopedic surgeons to cover call.1 In a survey of 1400 emergency departments, the American College of Emergency Physicians found that 2 of 3 departments did not have enough specialists for call; neurosurgeons, orthopedic surgeons, and
Accepted for publication January 10, 2007. Reprint requests: Mark S. Vrahas, MD, Yawkey Center For Outpatient Care, Massachusetts General Hospital, 32 Fruit Street, YAW 3-3C, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:317-20. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.003
obstetricians were at the top of the list of specialists who comprised the shortage.2 The proliferation of surgery centers not affiliated with hospitals has allowed orthopedic surgeons to perform elective procedures and so drop hospital affiliations and call responsibilities. Increasing subspecialization and the realization that difficult fracture problems are best managed by specialists have made general orthopedic surgeons less willing to deal with trauma patients. The general decrease in financial reimbursement, especially for emergency care, and the perception that emergency care can place surgeons in legal jeopardy have increased the desire of orthopedic surgeons to avoid emergency call and focus instead on elective procedures. The orthopedic surgeons remaining on call rosters are acutely aware of these issues. While the numbers of orthopedists on call rosters decrease, the burden increases for the remaining orthopedists. At some point, a crisis is reached and the hospital is forced to offer financial incentives to ensure orthopedic coverage. This extra financial burden has prompted hospitals to try and force orthopedic surgeons back to call rosters through modification of EMTALA laws.3 In brief, hospitals are acutely feeling the shortage of orthopedists willing to take on-call responsibilities. This lack implies a need for emergency orthopedic care. However, it is not clear that allowing acute care surgeons to provide a limited amount of orthopedic care would alleviate this shortage. Trauma surgeons potentially could provide emergency orthopedic trauma care; however, this would not obviate the need for orthopedists taking call. Several types of nontrauma orthopedic problems necessitate urgent care, and some mechanism would be required to designate an orthopedist for the continuing care of patients initially managed by acute care surgeons. Paradoxically, the Acute Care Surgery program might work best in trauma centers that have the SURGERY 317
318 Vrahas
least need for orthopedists. In trauma centers with a team of dedicated orthopedic trauma surgeons, all cases are generally turned over to the orthopedic trauma service for definitive care. Still, because no program can employ enough orthopedic traumatologists to cover all the call duties, other orthopedic subspecialists are forced to fill in frequently. This situation generates a great deal of controversy within orthopedic departments. Many orthopedic subspecialists resent taking call even though the obligation is usually minimal, and the orthopedic trauma service takes over the case the next day. It is conceivable that many orthopedic traumatologists would rather have the acute orthopedic problems cared for by an interested acute care surgeon than an uninterested orthopedist whose practice is based primarily on elective procedures. CAN ACUTE CARE SURGEONS BE APPROPRIATELY TRAINED IN A SHORT PERIOD OF TIME? If the goal of the Acute Care Surgery program is for acute care surgeons to provide emergency care, the answer is probably “yes.” However, if the goal is for acute care surgeons to provide definitive care, the answer is most assuredly “no.” There is a growing body of literature and a general belief among orthopedic surgeons that it is rarely appropriate to provide definitive care at night, on an emergency basis. Most orthopedic trauma surgeons advocate damage-control orthopedics.4,5 In other words, do what is necessary to stabilize the patient and save definitive reconstructions for specialists the next day. Currently, we ask our nontrauma orthopedic specialists taking call to deal with emergencies. Of course, compartment syndromes, vascular injuries, and overwhelming infections must be dealt with promptly. Clearly, acute care surgeons could deal with these problems. If bony stabilization is required, we ask only that an external fixitor be applied. Applying an external fixitor is not a complex procedure, and the skill could be taught easily to an experienced acute care surgeon. The most complex procedure we sometimes provide in a nighttime emergency is debridement of open fractures, which requires judgment and experience. In fact, studies undertaken in Europe6-8 suggest that debridement with early flap coverage by an experienced orthopedic trauma surgeon results in lower infection rates than the traditional protocol of urgent debridement by whoever is on call. Given these data, orthopedic surgeons on call often delay the debridement of open fractures until an experienced orthopedic trauma surgeon is available. Nev-
Surgery March 2007
ertheless, severe open fracture wounds sometimes must be handled immediately. Acute care surgeons could probably manage this task with little additional training. They could call upon their general experience with traumatic wounds to manage open fractures. In fact, one could argue that an experienced acute care surgeon would be more skilled at wound debridement than an orthopedic surgeon who has a practice limited to elective arthroscopy procedures. WILL ORTHOPEDIC SURGEONS AGREE TO TRAIN ACUTE CARE SURGEONS? In the current environment, the prospect of orthopedic surgeons agreeing to train acute care surgeon seems unlikely. The introduction of the proposed specialty has generated an extremely negative response from the Orthopedic Trauma Association (OTA) and the American Academy of Orthopedic Surgeons (AAOS). The assumption that the American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association would support the “Acute Surgeon” treatment of orthopedic trauma patients is wrong. A recent survey completed by 46% of the membership of the Orthopedic Trauma Association (OTA) and 48% of the American Orthopedic Association (AOA) showed that more than 95% of the respondents from both organizations were not in favor of general surgeons providing orthopedic care.9
Given this political backdrop, it will be difficult for orthopedic trauma surgeons to agree to provide training. Certainly, young orthopedic trauma surgeons interested in building their academic careers will be reluctant to buck the OTA. Even well-established senior orthopedic trauma surgeons sympathetic to the cause will have difficulty convincing their chairmen that it is a good idea to move counter to the stance taken by the AAOS. IF TRAINED, WILL THE ACUTE CARE SURGEONS BE CREDENTIALED TO PERFORM THESE PROCEDURES? It is conceivable that hospitals in need could force the orthopedic staff to accept the practice of acute care surgeons providing orthopedic care. However, this action would be extremely difficult if the orthopedic staff surgeons were opposed. Orthopedic surgeons could simply refuse to provide definitive care to patients initially treated by an acute care surgeon. Even if the hospital could somehow force orthopedic surgeons to accept these patients, the call problem would remain. Some kind of call system would have to be designed
Surgery Volume 141, Number 3
that would designate an orthopedic surgeon to be responsible for continuing care, and orthopedic surgeons would still be required to cover general call. Ultimately, the solution offered by the Acute Care Surgery program is most viable in hospitals with dedicated orthopedic trauma surgeons who see value in the additional help provided by acute care surgeons dedicated to trauma management. A LOST OPPORTUNITY The specialty of Acute Care Surgery seems like a viable option from the perspective of orthopedists. Orthopedic trauma surgeons should recognize that quality trauma surgeons are important and thus should have a vested interest in ensuring that the specialty remains viable. Although acute care surgeons may not resolve the shortage of orthopedists available for call, they could provide valuable manpower for trauma centers. In many cases, dedicated acute care surgeons who are interested in trauma would be a welcome addition to the field. Despite this, it is unlikely that the program will move forward without an improved buy-in from orthopedists. Unfortunately, the initial negative response from the AAOS and the OTA suggest that gaining this acceptance will be an uphill battle. A total of 19 members comprised the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.10 Unfortunately no orthopedic surgeons were included in this group. The committee did not reach out to the AAOS or the OTA for advice or support in trying to address the issues outlined above. Indeed, the committee did not even seek advice from the orthopedic members of the Committee on Trauma (COT). Moreover, orthopedic surgeons, especially orthopedic trauma surgeons, feel no responsibility for, or urgency to help resolve, the problems facing trauma surgery. Clearly, the collapse of trauma surgery as a specialty would greatly affect orthopedic traumatologists. However, some attempt to recruit orthopedic leaders to the cause should have been made before the specialty was introduced. This scenario speaks to a larger issue. Orthopedic trauma surgery has matured dramatically as a specialty. Interest in orthopedic trauma surgery and the demand for orthopedic traumatologists is high. Although no official records are available, fellowship directors from major orthopedic programs noted an unusually high number of quality applicants this past year. Moreover, orthopedic traumatologists are quite comfortable with the health of their specialty. The OTA and COT have worked hard to improve the quality of trauma care.
Vrahas 319
Unfortunately, these groups have been working in parallel directions with little cooperation. Orthopedic surgeons are members of COT, but these orthopedic surgeons do not speak officially for the OTA or the AAOS. In addition, membership in COT is not considered an important academic credential in the orthopedic community. Yet, at our institution, 48% of trauma patients require orthopedic procedures compared with 6% who require general surgical procedures. These percentages are typical of blunt trauma centers, but orthopedic surgeons comprise only 7% of COT membership. Given these factors, it is not surprising that orthopedic traumatologists feel they have little say in trauma center organization and so have little interest in issues facing COT. Similarly, COT has little knowledge of, or interest in, issues facing orthopedic trauma surgeons. Before orthopedic surgeons become interested in solving the issues facing trauma surgeons, they will need to feel that they have some stake in the system. Several trauma centers have bemoaned the fact that they have difficulty getting orthopedic surgeons involved in trauma care. Nevertheless, the OTA has never been asked to help address this issue in any official capacity. Dedicated orthopedic traumatologists are every bit as incensed by poor orthopedic care as general trauma surgeons, but they are not involved in official attempts to weed out inferior centers. Trauma center verification requires a site visit by 2 general trauma surgeons. Understandably, these surgeons focus on general surgical issues, and it is difficult for them to pick up subtle indicators of poor orthopedic care. As long as the center meets minimal orthopedic requirements, it passes. Dedicated orthopedic traumatologists are often angered when places they know have inferior orthopedic care are verified as trauma centers. Ultimately, if trauma surgeons expect orthopedic surgeons to assist in solving the problems facing trauma centers, orthopedic surgeons will have to feel a true personal or emotional interest, concern, or involvement in the process. The proposed specialty of Acute Care Surgery promises to help maintain the pool of quality trauma surgeons. However, solving the issues facing trauma centers and trauma surgeons may require more than a new specialty. It may necessitate a fresh look at how trauma centers are evaluated and managed with a view toward giving orthopedic traumatologists an expanded role in the process.
320 Vrahas
REFERENCES 1. Steiger B. ACEP poll: physician leaders distressed by specialist shortage; on call pay controversial. The Physician Executive 2005;May-June:14-8. 2. www.rwjf.org/newsroom/newsreleasedetail.jsp?id⫽10312 3. Report Number One to the U. S Department of Health and Human Services from the Inaugural Meeting of the Emergency Medical Treatment and Labor Act Technical Advisory Group. Bethesda (MD): Magnificent Publications; Appendix 7. 2003. 4. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopedics: evolving concepts in the treatment of patients who have sustained orthopedic trauma. [review]. Instruct Course Lect 2005;54: 447-62. 5. Hildebrand F, Giannoudis P, Kretteck C, Pape HC. Damage control: extremities. [review]. Injury 2004;35:678-89.
Surgery March 2007
6. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78:285-92. 7. Gopal S, Giannoudis PV, Murray A, Matthews SJ, Smith RM. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. J Bone Joint Surg Br 2004;86:861-7. 8. Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484-90. 9. Bosse MJ, Tornetta P, Sanders R, Swiontkowski MF, Russell, TA. [letter]. J Trauma 2005;59:1035-6. 10. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005;58:614-6.