The surgeon has no role in trauma resuscitation-
debate
Tony Smith
Outline
The surgeon has no role in trauma resuscitation in the ED -Debate
Tony Smith
Intensive Care Medicine Specialist
Auckland City Hospital
Medical Advisor, St John
Thanks a lot Ian…
• The conference equivalent of a rugby hospital pass
• An impossible task to successfully debate this topic in front of an audience containing significant numbers of surgeons with a strong interest in trauma
• I feel a bit like a sacrificial turkey…
I am always up for a challenge
• I am going to demonstrate that:
– There is nothing about trauma resuscitation that is specifically surgical
– Trauma is increasingly a non-surgical disease
– Surgeons are increasingly absenting themselves from trauma resuscitation
• I am going to show that:
– What evidence exists shows that having a surgeon present in ED makes no change to any important outcome markers
• Conclusion was easy – the surgeon has no role in trauma resuscitation in the ED
There is nothing about trauma resuscitation that is surgical
• Resuscitation
– Airway control
– Breathing support
– Circulatory support
– Some procedures
– Diagnosis of injuries
• Communication
• Forward planning
• Team approach
What is that surgeons actually do?
• They operate on patients
• They do long ward rounds with large numbers of trainees and students in tow
• They wear suits and ties
• They do outpatient clinics
• They very rarely turn up to trauma calls
– They have already decided they don’t have a role
– They have absented themselves
– The ‘odd exception’
• They don’t resuscitate patients
Anyway, what do we
mean by a surgeon?
• I am presuming we mean a general surgical specialist
• Specialist trauma surgeons do not exist in New Zealand
• The general surgeon is disappearing
• Sub-specialisation is increasingly the norm
– Hepatobiliary surgeon
– Head and neck surgeon
– Breast surgeon
– Vascular surgeon
– Colo-rectal surgeon
The surgeon who turns up could be a colo-rectal surgeon…
Trauma is increasingly a
non-surgical disease
• Most trauma patients do not need surgery
– DPL has been replaced by FAST
– Other resuscitation procedures do not need a surgeon
– CT imaging has replaced surgical decision making
– CT imaging increasingly results in non-operative approach
• When a patient requires surgery it is usually obvious and it does not require a surgeon to make the decision
Trauma is increasingly a non-surgical disease
• DCCM patient database
– Only 20% of trauma patients come to us from the resuscitation room via the operating theatre
• The types of surgery they had:
– Neurosurgery 50%
– Orthopaedic surgery 15%
– Other (thoracic, plastic, vascular) 15%
– Abdominal surgery 10%
• If you really want a surgeon in the ED then it should be a neurosurgeon
The evidence
• I was surprised at the number of studies looking at the impact of a surgeon on trauma resuscitation in the ED
– They are all published by surgeons
– The outcome differences reported are all surrogate
– None show a difference in important outcomes
• Conclusion: there is nothing in the evidence that supports the presence of a surgeon during trauma resuscitation in the ED
Surgeon in the resuscitation room #1
Trauma attending in the resuscitation room: does it affect outcome?
Porter JM, Ursic C. Am Surg. 2001 Jul;67(7):611-4.
• Retrospective, trauma database, six months
• Compared trauma calls that had surgeon either present or not present
– Patient demographics
– Time in resus room
– Time to CT scan
– Time to OR
– Hospital length of stay
– Complications
– Mortality
Surgeon in the resuscitation room #1
• They found no difference in
– Patient demographics
– Time in resus room
– Time to CT scan
– Hospital length of stay
– Complications
– Mortality
• They found a shorter time to OR and no missed injuries when surgeon was present
– No surprise
– Surrogate measure
Surgeon in the resuscitation room #2
Trauma faculty and trauma team activation: impact on trauma system function and patient outcome.
Khetarpal S, Steinbrunn BS, McGonigal MD, Stafford R, Ney AL, Kalb DC, West MA, Rodriguez JL.J Trauma. 1999 Sep;47(3):576-81.
• Comparative study of two trauma centres
– One with surgeon in hospital (IH)
– One with surgeon out of hospital (OH)
– 21 month period
• Results
– Time in resus was shorter in IH group
– Time to OR was shorter in IH group for penetrating trauma, but not for blunt trauma
– No difference in mortality
Surgeon in the resuscitation room #3
Impact of the in-house trauma surgeon on initial patient care, outcome, and cost.
Luchette F, Kelly B, Davis K, Johanningman J, Heink N, James L, Ottaway M, Hurst J.J Trauma. 1997 Mar;42(3):490-5; discussion 495-7.
• Retrospective review
– 16 months (1043 patients)
– 4 surgeons, 2 in hospital (IH) and 2 out of hospital (OH)
• Results
– Time in resus shorter in IH group
– Time to OR shorter in IH group
– No difference in mortality or hospital length of stay
Surgeon in the resuscitation room #4
The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients.
Helling TS, Nelson PW, Shook JW, Lainhart K, Kintigh D.J Trauma. 2003 Jul;55(1):20-5.
• Retrospective review (10 years) of in hospital (IH) vs out of hospital (OH) surgeon
• No difference in
– Time in resuscitation room
– Time to CT scanning
– Time to OR
– Hospital length of stay
– ICU length of stay
– Mortality
Surgeon in the resuscitation room #5
In-house trauma surgeons do not decrease mortality in a level I trauma center.
Fulda GJ, Tinkoff GH, Giberson F, Rhodes M.J Trauma. 2002 Sep;53(3):494-500; discussion 500-2.
• It is getting boring now…
• Yet another comparison of IH vs OH surgeon
• Yet more findings of no difference in any of the variables measured
The evidence is clear…
• The presence of the surgeon in the resuscitation room speeds time to the OR (these studies were all from the US with high rates of penetrating trauma)
• BUT - there was no difference in any meaningful outcomes like mortality, complications, hospital length of stay or ICU length of stay
• Surrogate outcomes are no longer acceptable
• It is meaningful outcomes that are important
• It is time to face the truth - there is no good evidence that the surgeon has a role in trauma resuscitation in the ED
I hope I have made you think about
what it is that is important…
I hope I have opened your eyes …
The surgeon has no role in trauma resuscitation in the ED
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Ministry of Health
