- Email: [email protected]
Trauma Surgery Crisis
Correspondence Michael Levine, MD Anne-Michelle Ruha, MD Department of Medical Toxicology Banner Good Samaritan Medical Center Phoenix, AZ Department of Medical Toxicology Phoenix Children’s Hospital Phoenix, AZ doi:10.1016/j.annemergmed.2009.03.032
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Marquet P, Chevrel J, Lavignasse P, et al. Buprenorphine withdrawal syndrome in a newborn. Clin Pharmacol Ther. 1997;62:569-571.
Aris K. Exadaktylos, MD University Department of Emergency Medicine Inselspital Bern University Hospital Bern, Switzerland doi:10.1016/j.annemergmed.2008.06.475
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Green S.Trauma surgery: discipline in crisis. Ann Emerg Med. 2009:53:198-207. 2. Exadaktylos A, Velmahos GC. Emergency medicine and acute care surgery: a modern “Hansel and Gretel” fairytale? Emerg Med J. 2008;25:321-322.
Full Life Support for Acute Care Surgery
Trauma Surgery Crisis
To the Editor: We thank Dr. Green for his interesting article on the emerging surgical discipline of acute care surgery and his perspective on the decline of trauma surgery.1 His article does describe the challenges of general trauma surgery and the unfortunate schism between the existing acute care specialties very nicely. Over the last decades we have seen the rise of emergency medicine from a sidelined specialty to an equally recognized board certified specialty in the US, Canada, UK and Australasia. On its rise emergency medicine has faced significant challenges from its inception to its successful establishment in these and many more countries. Although some of trauma surgeons’ diagnostic and therapeutic duties have been taken over by emergency physicians, one of the most consistent frustrations of emergency physicians remains: the inability to receive expeditious help from surgical subspecialists, when it comes to interventions and admissions. The trend towards training of subspecialized subspecialists is worsening the situation. Because of this trend we strongly believe that acute care surgery is a brave move towards a new direction and culture in patient care and can help to solve some of our problems.2 We should respect and support this newborn specialty with all means, and provide advanced life support through all stages until proven that acute care surgery is not our sister specialty we ever looked for. We should remind ourselves how emergency medicine got up to its feet many years ago. We should not miss this unique opportunity to develop our relationship with acute care surgery but we should assist in shaping acute care surgery for the good of our patients.
To the Editor: As a physician for 33 years, a member of the American College of Emergency Physicians, and practitioner of trauma surgery/emergency medicine, I read Dr. Green’s article1 with a turmoil of emotions and thoughts. Dr. Green has done an admirable job of outlining the crisis, the factors leading to it, and some of the fallout as its result. But I am saddened, confused, and angered at his underlying theme, conclusions, and implications. The leaders of trauma surgery (Shires, Shaftan, West, Trunkey, Mattox, Moore, Cleveland, Maull, Schwab, Feliciano, Champion, Lewis, and McSwain to name a few) responded to a need with research, innovation, and collaboration. But the underlying object was always to get the trauma patient to the right level of care in the right time with the right resources for recovery. That meant a system! EMS, emergency department (ED), ICU, rehab, OR, and specialty care integrated and coordinated. The trauma surgeon was the team leader, the facilitator for that integration. It was more than the initial evaluation, resuscitation, and treatment. Dr. Green states that the paradigm of “trauma as a surgical disease” is dead because many trauma patients don’t need surgery, can be handled by non-surgeons during their initial evaluation, and trauma surgery isn’t a recognized “subspecialty” among surgeons. This is getting old. We heard these same arguments 20 years ago when trauma surgery was infantile. Why? Turf? More importantly, there are still compelling reasons why care of the injured remains a surgical disease. Many of Dr. Green’s colleagues in Level II, III, and IV trauma centers do not or cannot place chest tubes, start central venous pressure lines, repair complex lacerations, and, if the ED
478 Annals of Emergency Medicine
Volume , . : September
Correspondence is busy, do not wish to remain with the trauma patient during his ED course. I am familiar with many surgical ICUs run by non-surgeons. Seems fragmented to call a surgeon urgently at 2 AM for a delayed bleed if the surgeon has never been involved with the patient prior. And who is the facilitator/coordinator when the patient goes to rehab with his trach and chest tube? In my opinion it isn’t about the initial ED course or golden hour. It is about a team leader for a continuum of care from time of EMS response to the time of complete recovery. Despite Dr. Green’s plea to “preserve the career of trauma surgeons for the benefit of our patients” I find personality profiling an unusual approach. I will not regurgitate the profiles offered for emergency physicians. Surgery has always been more demanding training because of the nature of the specialty. As a result it attracted quick thinking, compulsive, and extrovertive personalities. Bad? I don’t think so but I do know the “old blood-and-guts surgeons” of yesterday are gone. As one of my mentors said, “I can train a monkey to operate, but it takes six years to train a surgeon to know when to operate, what operation to do, and how to get out of trouble.” Despite the decline in operative trauma surgery the underlying principle still holds true for the non-operative care of the trauma patient. Dr. Green has implied trauma surgeons aren’t really necessary, emergency physicians/primary care physicians can do the initial care, the specialty shouldn’t and doesn’t exist, and surgeons should concentrate on lifestyle changes. I would state a large number of rural hospitals do not have adequate trauma systems and have less than state-of-the-art EMS capabilities. Emergency medicine-trained physicians tend to concentrate in metropolitan centers yet are more needed in rural settings. Many emergency medicine-trained physicians lose their trauma skills or prefer not to care for trauma patients. Emergency services as a whole in this country is rated C-. Health care is in crisis. It is not a trauma surgery crisis. It is a trauma, EMS, health care crisis. And just as trauma care is a coordinated continuum so is the answer to the crisis. I would suggest Dr. Green not advocate and officiate but rather motivate and collaborate until there is evidence-based data to support a nontrauma surgeon system of care from time of injury to recovery. James R. Stone, MD, MBA Southwest Iowa Surgery Atlantic, IA doi:10.1016/j.annemergmed.2009.02.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Green SM. Trauma surgery: discipline in crisis. Ann Emerg Med. 2009;54:198-207.
Volume , . : September
The Future of Trauma Surgery To the Editor: We read with interest the article by Green in the February 2009 issue of Annals of Emergency Medicine. As strong advocates of the role of emergency physicians in trauma care and program directors of a trauma/critical fellowship for emergency medicine trainees, the article has relevance to our professional interests.1 Unfortunately, the article does little to advance the cause of emergency physicians who seek a broader role in the administrative design and clinical implementation of trauma systems. Instead, the article focuses on the collapse of general and trauma surgery, issues related to “surgical personalities,” and the changing demographics of the trauma patient population that make trauma surgeons extraneous in the majority of cases. While some of these arguments may be valid, they are highly complex issues and evidence presented to support them is often anecdotal, oversimplified, or inaccurate. Examples include the suggestion that trauma surgery was born out of concepts generated during the past quarter century; in fact, trauma surgery and much of surgery in general is rooted in military medicine dating back many centuries. The strong linkage between trauma and surgical care is also evident in the bedrock of basic research on shock, blood banking and infection that grew out of the experience of surgeons in military conflicts. Trauma systems designed to facilitate optimal care for trauma patients in the early 1970s had less to do with the dominance of surgical personalities and more to do with triage networks (including aero medical transport) developed in Korea and Vietnam. Reference to the American College of Surgeons Committee on Trauma (ACS-COT) suggests that the organization began the process of studying and organizing trauma systems in the 1970’s and utilized this information to construct a paradigm that served the interests of surgeons. In fact, the ACS-COT has it’s origins in the American College of Surgeons Fracture Committee and its initial report to the College in 1920. This report, and the committee itself, focused on improving accurate recordkeeping in fracture treatment (prior to the development of an orthopedic specialty board) and the committee evolved more naturally in its role as the lead organization for trauma care than the article suggests. The trauma resource document “Optimal Care of the Trauma Patient” published by the Committee on Trauma and used as a template for trauma center verification deals with multiple phases of care from out-of-hospital through rehabilitation and includes standards that go far beyond the emergency or resuscitative phase of care.2 Dr. Green’s article omits discussion of the continuum of trauma care beyond the resuscitative phase. This is particularly true of the complex critical care environment and coordination of competing algorithms that characterize this phase of care. For example, optimal management of blunt solid organ injury in the ICU is trivialized as evidence that surgical care is always operative care and therefore increasingly unnecessary. Annals of Emergency Medicine 479
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Marquet P, Chevrel J, Lavignasse P, et al. Buprenorphine withdrawal syndrome in a newborn. Clin Pharmacol Ther. 1997;62:569-571.
Aris K. Exadaktylos, MD University Department of Emergency Medicine Inselspital Bern University Hospital Bern, Switzerland doi:10.1016/j.annemergmed.2008.06.475
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Green S.Trauma surgery: discipline in crisis. Ann Emerg Med. 2009:53:198-207. 2. Exadaktylos A, Velmahos GC. Emergency medicine and acute care surgery: a modern “Hansel and Gretel” fairytale? Emerg Med J. 2008;25:321-322.
Full Life Support for Acute Care Surgery
Trauma Surgery Crisis
To the Editor: We thank Dr. Green for his interesting article on the emerging surgical discipline of acute care surgery and his perspective on the decline of trauma surgery.1 His article does describe the challenges of general trauma surgery and the unfortunate schism between the existing acute care specialties very nicely. Over the last decades we have seen the rise of emergency medicine from a sidelined specialty to an equally recognized board certified specialty in the US, Canada, UK and Australasia. On its rise emergency medicine has faced significant challenges from its inception to its successful establishment in these and many more countries. Although some of trauma surgeons’ diagnostic and therapeutic duties have been taken over by emergency physicians, one of the most consistent frustrations of emergency physicians remains: the inability to receive expeditious help from surgical subspecialists, when it comes to interventions and admissions. The trend towards training of subspecialized subspecialists is worsening the situation. Because of this trend we strongly believe that acute care surgery is a brave move towards a new direction and culture in patient care and can help to solve some of our problems.2 We should respect and support this newborn specialty with all means, and provide advanced life support through all stages until proven that acute care surgery is not our sister specialty we ever looked for. We should remind ourselves how emergency medicine got up to its feet many years ago. We should not miss this unique opportunity to develop our relationship with acute care surgery but we should assist in shaping acute care surgery for the good of our patients.
To the Editor: As a physician for 33 years, a member of the American College of Emergency Physicians, and practitioner of trauma surgery/emergency medicine, I read Dr. Green’s article1 with a turmoil of emotions and thoughts. Dr. Green has done an admirable job of outlining the crisis, the factors leading to it, and some of the fallout as its result. But I am saddened, confused, and angered at his underlying theme, conclusions, and implications. The leaders of trauma surgery (Shires, Shaftan, West, Trunkey, Mattox, Moore, Cleveland, Maull, Schwab, Feliciano, Champion, Lewis, and McSwain to name a few) responded to a need with research, innovation, and collaboration. But the underlying object was always to get the trauma patient to the right level of care in the right time with the right resources for recovery. That meant a system! EMS, emergency department (ED), ICU, rehab, OR, and specialty care integrated and coordinated. The trauma surgeon was the team leader, the facilitator for that integration. It was more than the initial evaluation, resuscitation, and treatment. Dr. Green states that the paradigm of “trauma as a surgical disease” is dead because many trauma patients don’t need surgery, can be handled by non-surgeons during their initial evaluation, and trauma surgery isn’t a recognized “subspecialty” among surgeons. This is getting old. We heard these same arguments 20 years ago when trauma surgery was infantile. Why? Turf? More importantly, there are still compelling reasons why care of the injured remains a surgical disease. Many of Dr. Green’s colleagues in Level II, III, and IV trauma centers do not or cannot place chest tubes, start central venous pressure lines, repair complex lacerations, and, if the ED
478 Annals of Emergency Medicine
Volume , . : September
Correspondence is busy, do not wish to remain with the trauma patient during his ED course. I am familiar with many surgical ICUs run by non-surgeons. Seems fragmented to call a surgeon urgently at 2 AM for a delayed bleed if the surgeon has never been involved with the patient prior. And who is the facilitator/coordinator when the patient goes to rehab with his trach and chest tube? In my opinion it isn’t about the initial ED course or golden hour. It is about a team leader for a continuum of care from time of EMS response to the time of complete recovery. Despite Dr. Green’s plea to “preserve the career of trauma surgeons for the benefit of our patients” I find personality profiling an unusual approach. I will not regurgitate the profiles offered for emergency physicians. Surgery has always been more demanding training because of the nature of the specialty. As a result it attracted quick thinking, compulsive, and extrovertive personalities. Bad? I don’t think so but I do know the “old blood-and-guts surgeons” of yesterday are gone. As one of my mentors said, “I can train a monkey to operate, but it takes six years to train a surgeon to know when to operate, what operation to do, and how to get out of trouble.” Despite the decline in operative trauma surgery the underlying principle still holds true for the non-operative care of the trauma patient. Dr. Green has implied trauma surgeons aren’t really necessary, emergency physicians/primary care physicians can do the initial care, the specialty shouldn’t and doesn’t exist, and surgeons should concentrate on lifestyle changes. I would state a large number of rural hospitals do not have adequate trauma systems and have less than state-of-the-art EMS capabilities. Emergency medicine-trained physicians tend to concentrate in metropolitan centers yet are more needed in rural settings. Many emergency medicine-trained physicians lose their trauma skills or prefer not to care for trauma patients. Emergency services as a whole in this country is rated C-. Health care is in crisis. It is not a trauma surgery crisis. It is a trauma, EMS, health care crisis. And just as trauma care is a coordinated continuum so is the answer to the crisis. I would suggest Dr. Green not advocate and officiate but rather motivate and collaborate until there is evidence-based data to support a nontrauma surgeon system of care from time of injury to recovery. James R. Stone, MD, MBA Southwest Iowa Surgery Atlantic, IA doi:10.1016/j.annemergmed.2009.02.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Green SM. Trauma surgery: discipline in crisis. Ann Emerg Med. 2009;54:198-207.
Volume , . : September
The Future of Trauma Surgery To the Editor: We read with interest the article by Green in the February 2009 issue of Annals of Emergency Medicine. As strong advocates of the role of emergency physicians in trauma care and program directors of a trauma/critical fellowship for emergency medicine trainees, the article has relevance to our professional interests.1 Unfortunately, the article does little to advance the cause of emergency physicians who seek a broader role in the administrative design and clinical implementation of trauma systems. Instead, the article focuses on the collapse of general and trauma surgery, issues related to “surgical personalities,” and the changing demographics of the trauma patient population that make trauma surgeons extraneous in the majority of cases. While some of these arguments may be valid, they are highly complex issues and evidence presented to support them is often anecdotal, oversimplified, or inaccurate. Examples include the suggestion that trauma surgery was born out of concepts generated during the past quarter century; in fact, trauma surgery and much of surgery in general is rooted in military medicine dating back many centuries. The strong linkage between trauma and surgical care is also evident in the bedrock of basic research on shock, blood banking and infection that grew out of the experience of surgeons in military conflicts. Trauma systems designed to facilitate optimal care for trauma patients in the early 1970s had less to do with the dominance of surgical personalities and more to do with triage networks (including aero medical transport) developed in Korea and Vietnam. Reference to the American College of Surgeons Committee on Trauma (ACS-COT) suggests that the organization began the process of studying and organizing trauma systems in the 1970’s and utilized this information to construct a paradigm that served the interests of surgeons. In fact, the ACS-COT has it’s origins in the American College of Surgeons Fracture Committee and its initial report to the College in 1920. This report, and the committee itself, focused on improving accurate recordkeeping in fracture treatment (prior to the development of an orthopedic specialty board) and the committee evolved more naturally in its role as the lead organization for trauma care than the article suggests. The trauma resource document “Optimal Care of the Trauma Patient” published by the Committee on Trauma and used as a template for trauma center verification deals with multiple phases of care from out-of-hospital through rehabilitation and includes standards that go far beyond the emergency or resuscitative phase of care.2 Dr. Green’s article omits discussion of the continuum of trauma care beyond the resuscitative phase. This is particularly true of the complex critical care environment and coordination of competing algorithms that characterize this phase of care. For example, optimal management of blunt solid organ injury in the ICU is trivialized as evidence that surgical care is always operative care and therefore increasingly unnecessary. Annals of Emergency Medicine 479