Trauma—Twenty years and after

The

American VOLUME

PRESIDENTIAL

T raumaS

95

Journal APRIL

1958

NUMBER

of Surgery FOUR

ADDRESS

Years and After

Twenty

HORT

scientific development in the phases of surgery which have to do with trauma, its immediate and distant effects and complications.” We have fuIfiIIed this concept we11 in that our programs have been of a genera1 nature, embodying topics of basic importance as we11 as technical detai1. Our membership consists of outstanding individuaIs whose interest is Iimited to specia1 fieIds as we11 as those with more genera1 interest. Trauma being no respector of anatomical boundaries, our Association has been and continues to be a common meeting ground for those interested in trauma without regard to Board designation. It is not my purpose now to review our fruitfu1 past, but rather to consider additiona and present probIems and future goals. Two objectives appear strongIy before us if we are to continue to make contributions to the progress in the fieId of trauma. The first of these is to give thought to the extension of our educationa opportunities for training and research in trauma, and the second is to Iend our efforts toward decreasing the number and severity of accidents. The origina interest in trauma was centered in surgeons; in fact trauma was the primary reason for the existence of surgeons. One has onIy to peruse the works of Parit, Heister and Baron de Larrey, in fact the works of any of the earIy surgeons, to note that trauma formed the basis of our art. Even more recentIy, great and obvious strides were made in surgery during and after each of our wars. Trauma always was and stiI1 is basicaIIy a surgica1 probIem,

of twenty years ago this Association was formed “. . . for the cuItivation and improvement of the science and art of the surgery of Trauma and allied sciences, the eIevation of the medical profession and the consideration of such other matters as may properly come within its sphere.” It wouId be presumptuous to assume that we couId assess accurateIy the success which has attended our activity, or determine how we11 we have approached the goaI as set forth in our articIes of organization. Since 1938 there has been an increased interest in the probIems of trauma, not 0nIy in most segments of our profession but aIso by the pubIic at Iarge. We have progressed beyond expectation toward the attainment of our goal. In his organizationa1 address, Dr. Edgar GiIcreest pointed out that the subject of trauma was rareIy discussed at meetings of the major surgica1 societies of this country. Today the subject of trauma is wideIy discussed in other surgica1 associations and the American Board of Surgery reguIarIy incIudes probIems of trauma in their examinations. In the first presidentia1 address presented here at Hot Springs, Dr. KeIIogg Speed pointed out that it was not the primary desire or intention of The American Association for the Surgery of Trauma to add to the schisms in surgery with an organization of Iimited scope or viewpoint, but rather “. . . to attempt an amaIgamation and caIIing back into the foId of the we11 trained genera1 surgeon of those interested in the maintenance of high surgica1 ski11 and 489

American Journal of Surgery.

Volume 03, April. 1958

Johnston traumatizing machinery is provided the public, we are the first to learn of the new danger. In fact, such mechanisms are likely promptI\- to become :I part of our nomenclnturc, such as “bumper fracture,” the now forgotten “crank and more lately fracture,” “ do it yourself” “Iahvn mower injuries.” We cannot help but Iook beyond the machines to their eff‘ect on our patients. We have much to offer the mechanical engineer in the way of suggestions for safetv factors and the safety engineer in regard to the mechanisms of injury, even if the accomplishment of most of these must be Icft to proper experts. The use of advertising media has done much to bring before the public a mass consciousness of the importance of injuries. hlass consciou+ ness about safet,y is unfortunatcl?. not nec‘e.ssariI>, transposed into personal carclulness. All too often this is considered as atl’ecting other people. The relationship bctwccsn the doctor and his patient offers a means 01’tlcxloping R personal sense of safety. Concerted efforts at control of cancer and heart disease, as well as problems of numerically less important concern \uch as poliomyelitis and tubercuIosis, have been made. In the fight against tubercuIosis, in which so much progress has been made, the cooperative effort of lay and medica groups working together as one team was essential. Tuberculbsis is still a problem but it h as been whittled to size. Those in the medica profession most interested in trauma do little about prevention; and those interested in the prevention of accidents make little use of the help which can be obtained from the medical profession, nor do the>, help much in deveIopment of better care of the injured. WhiIe it is understandable how these two separate and divergent attacks on this probIem came about, combined efforts could yield better resuIts. Time was when there was concern about the speciaI,ty to which trauma rightfully- beIonged. Since InJuries are not always limited to anatomical areas, and since even m-hen they are the whoIe patient suffers, it is ohviousIy impossibIe to consider this problem wit,h a Iimited viewpoint. Jurisdictional disputes are not Iikely to contribute to advances, and with a problem so great the combined efforts of the entire medica profession and the pubIic are required. We must extend our activities toward encompassing the whoIe problem of trauma.

and trauma has always meant more than surgical tec.hnic, for no surgeon who deals with the effects of trauma can heIp but recognize that most injuries should not have occurred and that prevention is important. Trauma is today our greatest pubIic heaIth probkm. It is the leading cause of death in the j-ounger age group (one to thirty-five years) [r], an d in addition accounts for most of the crippling of our popuIation. Our saIvage rate in terms of life and function depends not onIy on the degree of skill we exercise but aIso on the severit; of the injury. We have, however, recognized that, as in the case of any disease entity, severity is not a cause for hopeIessness hut rather is a stimulus for our best efforts. As in any pubIic heaIth probIem, the efforts of the entire medica profession are required as well as the cooperation of the pubIic. Disconcerted and unassociated programs of effort to control trauma have hardIy permitted us to keep up with the probIem. It brings to mind the remark of the red Queen to AIice, “Now here you see it takes a11 the running you can do to keep in the same place. If you want to get somewhere eIse, you must run at Ieast twice as fast as that.” U’e have made progress when we consider the increase in traumatizing agents but not in reIation to the tota number of deaths. The Detroit PoIice Department has made a good record in reducing trafic deaths in the City of Detroit, showing a decrease in fataIities where the number of deaths is considered in relation to the increase in the city’s trafbc. Statistics must be weighted with popuIation, with numbers of traffk miIes and many other factors, but the fact remains that we have not reduced the terrific to11 of Iife and Iimb due to trauma. It does, however, intimate a certain pride in “running fast enough to keep in the same place.” There is no reason why it shouId continue so to be. Despite the surgeons’ inherent interest in the probIem of prevention, we haxe done very Iittle about it. We do not have the engineering information or authority to change design of machinery, nor do we have the facility or means of impIementation for making the pubIic aware of this grim probIem through modern mass media. We do have first hand information as to how accidents occur and what mechanisms are invoIved; and when new 1MCFAKLAND, R. A. The roIe of human factors in accidental trauma. Am. J. hf. SC., 234: I, 1957. 490

PresidentiaI We cannot be interested in reparative aspects alone, for the saIvage rate wiII never suffice to decrease the death rate adequateIy, no matter how accompIished we become. The National Safety Council has been activeIy engaged in attempts to prevent accidents since 1913 and this alone has not proved to be the whole answer. We must combine our inffuence, our interest and our abiIities with those of important Iay groups in combatting the trauma problem if proper progress is to be made. Education in trauma presents a chaIIenge. This Association has had great concern about adequate training for the care of patients suffering from the effects of trauma. Repeatedly during our meetings there have been discussions concerning the educational opportunities not only m our medIca schooIs but also for residency training in trauma. We have decried the Iack of adequate programs for training in trauma. With the development of speciaIty training programs, opportunities for broad and genera1 training in the fieId of trauma have been more difficult to obtain. Many recognized general surgica1 programs have become Iimited to narrow fieIds; and if any attention is paid to training in tra,uma, it is through the farming out of residents to other services where they serve for short periods in effect as interns and the training vaIue is negIigibIe. It wouId be a most impractica1 person who wouId suggest going back to the good oId days when genera1 surgical services cared for a11 surgica1 problems, with the surgica1 trainee in hospitaIs handIing a11 types of surgica1 cases incIuding a11 of the trauma. It is important that we aIso deveIop surgeons who centraIize their interest in special fields. It wouId be best if the centraIization of interest came after a broad training in genera1 surgery, but even so, speciaIty training wouId be necessary. Our present system was not pIanned; it just deveIoped. Persona1 interests as we11 as probIems of organization (the better and more effIcientIy to get the day’s work done), pIayed the dominant roIe rather than sound educationa1 phiIosophy. In many hospitaIs patients suffering trauma are not weIcome because they have a tendency to disrupt orderIy scheduIes of work and appointments. In addition, the patient brought into the hospita1 from an accident causes diffIcuIty in determination of financial responsibiIity beforehand. With Iimited budgets in most hospitaIs, one finds it

Address dificult to criticize the Iack of enthusiasm of many hospitals for admission of accident victims. The Iack of opportunity for training in trauma does not excuse those in charge of training programs for not attempting to SO that their trainees remedy the situation might have we11 rounded training. Many have tried to remedy this through an attempt to send their residents to city, county or other hospitals where large numbers of trauma cases are seen, This is usuaIIy d&uIt to arrange effectively because the worthwhiIe hospitaIs of this sort have their own we11 organized residency programs and adequate numbers of residents. It is diffIcuIt to see how such institutions could ask their own residents to step aside to provide opportunities for trainees from other hospitals. hlost we11 run city institutions can provide opportunities for men we11 quaIified in basic surgical principles by a good surgica1 residency, as junior staff men, for a period after their residency. Funds, interest in education and proper pIanning must be avaiIabIe. Men who have just finished a good residency would not require too extended training in trauma and need not interfere with, but might rather enhance, the surgica1 training programs in many of our hospitals where Iarge numbers of injured patients are treated. Better programs for training in trauma are essential and a stimuIus for the estabIishment of other programs is necessary. A separate board of trauma is not the answer, for there are certainI? enough boards to divide our surgical farnIl?;. Recognition of exceIIence of ability in trauma care under existing boards, or by other means, wouId offer a stimulus without adding additiona probIems. This Association, as we11 as the Committee on Trauma of the American CoIIege of Surgeons, has had interest in the many short courses which have been conducted by many institutions. These are effective means of bringing the principles of trauma care to those interested. Our own Michigan Committee has been active in presenting the probIems of the care of trauma throughout the state by frequent conferences, not onIg in our universities and at our state medical society meetings but aIso in smaII communities throughout the state. This Iatter type’yof effort is carried on by other committees on trauma and is of advantage,

491

Johnston for accidents are important in small communities as well as Iarger ones. Furthermore, trauma is a problem in which a11 segments of our profession become involved. Therefore it becomes necessary that information about the best methods of care of the injured be presented to all segments of our profession. I have mentioned the excellent programs presented before this Association and those sponsored by the Trauma Committee of the American CoIIege of Surgeons. Much of the material presented has been concerned with origina work and has been presented to those whose interest and concepts about trauma are well developed. AI1 too frequentIy we find ourselves talking to those who need it Ieast. Injuries do not occur only where there are we11 trained experts. They occur here, there and everywhere, and I dare say that the majority of injuries must he cared for by those Ieast

492

quahtied by training and interest to do so. Many of these people have of necessity learned by experience, the dear teacher, to do a re:rsonabIe and acceptable job; others do not do so we11 and lvork at great expense in lift or limb to their patients. The development of better training facilities and a closer Iiaison with those most active in the prevention of accidents is our problem and we cannot avoid it if \ve are to maintain our position of leadership in trauma. Let us then rededicate ourselves to those principles for which this Association \vas founded. The challenge is great, for trauma is as a pestilence in our land and a scourge to our people. Let us then carefully plan our attack on all fronts, for we cannot win by skirmishes in limited sectors. CHAKLES G. SOHKSTON, M.D., Detroit, Michigan