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Sat Apr 22 15:59:12 BST 2006

First:  

Are there surgeons who are completely uncomfortable and inadequate in  
treating trauma patients?  Are there cardiologist who are technically  extremely 
adept?  Are there paramedics who can intubate even the most  difficult airway?  
Are there surgeons who can read an EKG?  Are there  emergency physicians who 
are a trauma surgeons dream as an associate and  partner?  Are there 
cardiologist who always misread an  echocardiogram?  Are there interventional radiologist 
who never take care  of their hematoma and infectious complications?  Are 
there trauma surgeons,  neurosurgeons, and orthopedic surgeons who almost never 
come in to the hospital  when called by an emergency physician, although they 
are getting paid to be on  call?   Are there emergency physicians who continue 
to use cyclic  hyper resuscitation and are very very slow to call a surgeon 
even on a "bleeding  to death" patient until they have satisfied their ego?  Are 
there surgeons  whose hands do not seem to be connected to their brain?  

The answer to these questions is a resounding YES.   

Second:

The response to the articles in both system, management, EM, trauma, and  
surgical journals is that we should provide to any emergency patient the very  
best that we have available at any particular time.  It is no secret that  the 
majority of the trauma surgeons from the famous Denver General Hospital  Trauma 
Service were away at the national meeting at the time of the Columbine  
School shootings a few years ago, and most of the in juried were taken to the  
areas non-level I trauma center.    

Third:

In just what percent of the total trauma load of population catchment, does  
a trauma system, a trauma center, and a trauma surgeon make a  difference.   
Depending on how you define effectiveness, it may be  somewhere between 2% and 
8%.  Without question, most injured patients  do not need a trauma center, 
trauma surgeon, and maybe not even a surgeon.   I remember the days when 
emergency physicians reduced and splinted a  Collies Fracture very well, and sent the 
patient on their way.     Code I trauma (the minor injuries) in Houston are 
encouraged to be taken by  ambulance or private car to NON-Level I emergency 
centers.  It is  the patient with a high injury severity score, altered 
physiology, and need  for immediate surgery or surgical intensive care that benefits 
from the trauma  system.   Only 6-8% of a catchments trauma patients are 
hypotensive  and 1/3 of these hypotensive patients have fatal and irreversible  
non-survivable injuries.   In another 1/3 of the patients their  hypotension is due 
to NON-blood loss causes, such as pneumothorax, a stomach  full of air, 
drugs, etc.   A trauma surgeons presence is not  going to have ANY impact on 
outcome in this 2/3 of post traumatic hypotensive  patients.    It is in the other 
1/3 (2-3% of the total  trauma load) that the trauma surgeon can and does make 
a significant difference  because of their availability, presence, technical 
skill, decision making,  discipline, and down stream effects.   

FInally:

For the post traumatic hypotensive patient with a survivable injury, the  
purpose of the emergency center and the emergency physician is to wave to the  
patient as they go from the ambulance dock to the ICU, interventional suite, or  
operating room.   There is very little that needs or can be done  to alter 
outcome, except increase the time, increase the cyclic crystalloid  hyper 
resuscitation, increase the complications, increase the mortality by  treatment in 
the emergency center.   It is in these cases that  the acute care surgeons 
presence is essential, and the trauma system  is at its best.   Can other 
specialist in health care be  essential parts of this team, led by evidence based 
principles.  Of course  they can and do.   Can an ill informed surgeon harm 
patients in  this group with immediate life threatening injuries.  Of course they  
can, by not being available, by popping the clot, by activating cytokines,  by 
temporizing definitive therapy, by over treating, etc. etc.    

I still take Acute Care Surgery (formerly known as Trauma) in-hospital  call 
several times a month.   And I am much older than Dr.  Gross.   Do I make a 
difference when I am on call.  I tend to  think that I do, for the kind of 
patient I have identified who needs to  not stay in the EC for unnecessary tests, 
or to document by innumerable CT  scans, what is already known by physical exam 
or simple tests, most of which can  be performed in the OR or ICU.    

Are there a list of Acute Care Surgery conditions which every  emergency 
physician, intensivist, and surgeon in the world would agree need  urgent and 
rapid surgical mentality and technical intervention.  Of  course such a list can 
and has been constructed.    

Remember that being a surgeon is not just a technical, non-cognitive  feat.   
Being a surgeon is a philosophy of life, an approach to  problem solving, 
which on occasion involves an operation.   In today's  world many emergency 
physicians, intervenional pulmonologists,  cardiologist, gastroenteriologists, 
interventional radiologists and others  are "surgeons" from a psychomotor 
standpoint.   Likewise there are  "surgeons" who are almost afraid to make a decision 
or appear afraid to operate  on the big bad acute care surgical case and from 
a psychomotor  standpoint are more like the internist of the 1950s.    This is 
 not a criticism of career choice, it is just recognizing that the cognitive  
proceduralists of today function in numerous venues of the  hospital.    

Yes, each of us can find one or two articles which fluff our specialty ego,  
but it is the standardized system approach to major health problems and  
challenges ( such as disasters, evacuations, bird flu, trauma,  cancer, clean air, 
immunizations, vascular disease, futility, medical  economics, etc) the 
require for us to collectively apply our judgement,  energies, and discipline.   To 
do otherwise converts us from a  professional guild to simple governmental 
employed tradesmen and  tradeswomen.    

Let us together preserve the guild.  

Kenneth L. Mattox, M.D.  

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