Who should perform vascular surgery for trauma?

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To my colleagues,
 
I help teach TRACS, a refresher advanced trauma surgery course for Navy Surgeons headed to Iraq and Afghanistan. Many of the attendees have already done  a tour there and I always learn from their experience. This week we had an interesting discussion on vascular repairs. All have and will have to treat complex vascular injuries. They have taught us much about damage control and evacuation with the use of shunts. However, there is a basic question always faced by the combat surgeon who hasn't done an unsupervised vascular repair since his or her residency - What should I take on? 
 
I've recommended two somewhat conflicting suggestions. 1. Try to do only what you are comfortable and capable of doing - fix 'em if you can, shunt 'em if you can't - and - 2. Dirty Harry's law - A man's (women's) got to know his (her) limitations - with Sise's corollary - When you're all alone, the sky's the limit - take your best shot.
 
In our civilian trauma centers in our community and, I suspect, around the US there is no standard approach to who should repair injured vessels. Two of us on our trauma panel are also board certified vascular surgeons with a small elective practice and we cover all of our center's vascular injuries. At the same time, some of the worst errors I'm asked to review from out of town are the tragedies perpetrated by "elective" vascular or cardiovascular surgeons. Some of the best work is by general surgery trained trauma surgeons with an interest is vascular.
 
Who should perform vascular surgery for trauma and how do we insure quality coverage for our patients?
 
Mike Sise
Scripps Mercy Trauma

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