Is Trauma Really a Surgical Disease
Tony Joseph
Outline
Is Trauma Really a Surgical Disease?
Tony Joseph
Auckland Trauma Service 10th Annual Conference
August 2005
Reflections of a Non -surgeon
Surgery is one part of the definitive care for victims of Trauma
Escaping Trauma?
Trauma in evolution ?
What do I mean?
• Are Surgeons still the leaders in Australasian Trauma Management?
• Do they want to be?
• Is there enough Surgical interest in trauma at postgraduate level?
• Is Trauma training / exposure adequate?
• Are Trauma victims requiring less operative intervention?
• Is Trauma decreasing in incidence ?
Australasian Initiatives
• Trauma Verification
• EMST
• CCrISP
• DSTC
• Trauma Fellowships
• Is this enough?
Question?
• Are you comfortable with your PGY3 registrar starting the surgery on a Whipple’s procedure at 0800 hrs ?
• Are you comfortable with the same person operating on a Trauma patient with a major Liver injury at 0300 hrs?
• Is there a difference in the level of seniority required for each operation?
Is there less trauma?
• USA –decrease in violent crime parallels decrease in surgical cases
• Decrease in surgical involvement in blunt trauma
– Non-operative?
– Injury prevention
– Increase in Neuro and spinal-orthopaedic Trauma
Gordon Trinca 1970
• Goal to “ensure adequate numbers of qualified staff available to CARE for and treat ..trauma patients”
– Trauma Team approach
• Trauma Care implies longitudinal involvement and “laying” of hands
– Rather than Horizontal
Preventable deaths
A study of 2 counties ( 1974)
• MVA deaths after arrival at hospital Orange (90) and San Francisco County(92)
• Orange County-Preventable
– 2/3 Non –CNS related deaths (30)
– 1/3 CNS-related deaths (60)
• San Francisco- 1 death ( Missed TAI)
• This comparison “emphasises benefits of aggressive, experienced management of Trauma victims …in trauma centres”.
Why the need for Trauma Surgeons?
• Well documented improved chance of survival for patients with major trauma treated in specialised trauma centre within a regionalised system of Trauma care
West et al Arch Surgery 1983
McDermott at al Aust NZ J Surg 1997
What does the data show?
How many Australasian Trauma Centres have a Trauma Admitting Bed card ?
Who takes responsibility?
Surgical involvement in Trauma
• Resuscitation
• Operation / Non-operation
• Post-operation
• Intensive care
• Rehabilitation
• Prevention
• Education
• Research
24 Yr male
• MBA V Car at 1800 Hrs
• Chest Injuries / unconscious / shocked at scene
• Arrives Trauma Centre 1900 Hrs
• Intubated / L ICC –2 L blood
• FAST positive haemo-pericardium / haemo-peritoneum
• S/B Gen Surg Reg and Cardiothoracic Reg
• Cardiothoracic Surgical Consultant notified
• Transfer to OT: T= 70 mins
• Commenced Thoracotomy: T= 95 mins
• Lacerated heart x 2 / repaired
• Unable to restart heart
• Died 2130 hrs
Issues
• Would presence of Experienced Surgeon on site have altered outcome?
• Does need for Immediate Surgery require in-house Surgical expertise ?
• Is this cost-effective?
• Are the numbers too small to justify the cost ( or are they?)
Trauma can be an attractive career Option ( or not)
• Low Operative case load : Admissions
• Heavy after – hours workload
• Less Senior Surgical interest / Increased sub-specialisation
• (Re) Defining training and career development
• Increasing non-surgical management
• Poor Remuneration
Wong and Levy. ANZ J Surg 2004
Survey of Trauma Fellows Aust / NZ July 2005
• 25 Major Trauma Centres ( Adult and Paediatric)
• 7 Positions filled ( 28%)
Survey of Advanced Surgical Trainees 2001
• Evaluate attitudes and experience
• 272 / 587 ( 46%) response
– 85% consider future in Trauma care
• 48% attended > 5 Trauma resuscitations in last 6/12
• 22% Team leader at > 5 resuscitations last 6/12
• 4% Yr 1 Adv Trainees had Surgical Consultant supervision > 5 resuscitations last 6/12
B Thomson and I Civil. ANZ J Surg 2001
Survey of Advanced Surgical Trainees 2001
• Final yr Gen Surgery Training ( 4th year) total Trauma operations = 36.6 ( 10.4 cases / yr)
- 22.2 laparotomies
– 2.9 Thoracotomies
– 1.7 craniotomies
Survey of Advanced Surgical Trainees 2001
• Average no Trauma operations / Yr
– General Surgery: 12.3 ( 7 laparotomies)
– Cardiothoracic: 20.3 ( 1.8 thoracotomies)
– Neurosurgery: 40.6 ( 35.7 craniotomies)
– Orthopaedics: 223 ( 221 orthopaedic)
What did they think re training?
• Adequacy of exposure to Operations
– General surgery 32%
– Neurosurgery 72%
– Orthopaedic 86%
• Adequacy of Operating supervision
– General Surgery 70%
– Neurosurgery 59%
– Orthopaedic 46%
How much operative Experience is necessary?
• US Trauma Fellowship guidelines
– > 50 patients with major torso / vascular injury
– Require laparotomy, thoracotomy, vascular repair
– Or care in ICU > 48 hrs
• RACS trauma committee
– Minimum 30 trauma laparotomies during advanced training
Conclusions from survey
• Increased consultant supervision at Trauma resuscitations
• Surgical rotations need to be planned to cater for Trauma Training
• Further assessment in changing climate of trauma management
Thomson, Civil, Danne, Deane, McGrath
ANZ J Surg 2001
What does the future hold?
L D Britt 2002
• The Emergency Surgeon?
• One stop shopping
– ALL Emergency Surgical Care including trauma
• Very few General Surgeons in current practice
What is optimal Trauma experience for Surgeons?
• Improved survival for seriously injured patients in high volume centres
• Management of
– < 35 seriously injured patients / yr unlikely to have unexpected survivors
– > 125 patients / yr should be at least 2 unexpected survivors
Konvolinka et al Am J Surg 1995
What is the answer?
• Keep Trauma surgery and general surgery together
• Need to train general surgeons in acute torso surgery as well as neurosurgery and orthopaedic surgery
– Rural advantages / European model
• Trauma surgery and emergency surgery should co-exist
• Non-trauma surgery should also be part of the repetoire ( exit strategy)
Acute Care Surgery ( USA Model)
• Trauma, Critical Care and Emergency Surgery
• Post graduate Trauma Training Fellowship should be built on General Surgery Foundation
• Future of Trauma Surgery Committee (AAST)
D Spain. Am J Surg 2005, 190 (2)
Acute Care Surgery Fellowship Training (USA)
• Surgical Critical Care ( min 6 months)
• Hepatobiliary
• Neurosurgery
• Thoracic
• Vascular
• Orthopaedic
• ENT
How to do it ?
• Paradigm shift in Training
– Undergraduate and post graduate level
• Concentrate resources
– Surgery, Emergency, Intensive Care, Radiology, Step down wards, Rehabilitation, Research and Prevention
• Remuneration
– Relative value
Canadian Model
S Hamilton: Fraser Gurd Lecture Trauma 2005 Whistler
• Develop the interdisciplinary Trauma Team
• Streamline the “Emergency Surgical Training” program for Surgical Trainees
• Develop Surgical Critical Care programs across disciplines
• Vertical rather than horizontal integration of the Trauma Team
Challenge?
• Integration of disciplines to provide comprehensive care
• Minimal cross specialty exposure in surgery, emergency medicine and medicine
• Is there a role for an emergency physician that extends into the trauma unit/critical care unit…a vertically integrated acute “medicine” stream?
• What is the role of clinical assistants, advanced nurse practitioners and related disciplines?
The Trauma Team:
The Question is..
• Why is it that in both postgraduate medical education and the education of the other health science disciplines, training occurs in isolation:
Minimal cross specialty exposure in surgery, emergency medicine and medicine;
There is virtually no interdisciplinary education, other than the important ‘on the job training’ that is a part of every institution;
• What is it about the health care disciplines that they have not recognized the importance of cross functional training in solving complex problems?
A new Paradigm
• Evolution of the interdisciplinary team:
Acute Care Specialist (s)
Generalist surgeon / Emergency Physician
Intensivist / Anaesthetist
Clinical assistant
Trauma nurse
Advanced nurse practitioner
Physiotherapist
Clinical psychologist
One of the Models
( S Hamilton)
Appeal of Trauma is a Horizontal Sub-specialty with Components from both Medicine and Surgery
A proposed course of action?
• Political acknowledgement re the problem
• Introduce cross- and inter-disciplinary training concepts at undergraduate level
• Interdisciplinary training and career choice at Postgraduate and College level
• Less Pressure to sub-specialise and allow more general training in early years
• Develop “Trauma and Acute Surgical Centres”
– With “acute medical centres”
• Appropriate remuneration and “lifestyle” opportunity ( Generations X, Y and Z )
Recognition of Trauma as a Public Health Issue
• Along with cardiovascular disease and Cancer
• Train adequate numbers clinicians
– Medical / nursing / allied health
• Resource the areas where they work
• Make it sustainable
What is the ideal?
• Min > 400 major trauma patients
• Trauma Service has admitting “bed” card
• In-house
– Trauma / Acute care Surgeon ( ALL Trauma Surgery)
– Trauma Critical care Specialist
– Emergency Physicians / Anaesthetics
– Dedicated Trauma Nurses / advanced practitioners
• Need for active buy-in from all other Subspecialty units eg Orthopaedics
• Out patient and F/U clinic
Local Interdisciplinary Training
International Interdisciplinary Training
Thank You
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Ministry of Health
