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Thu Oct 5 11:47:23 BST 2006

Well said, Bill.  Well said.

>>> "William Bromberg" <brombwi1 at memorialhealth.com> 10/4/2006 12:57 PM
>>>
This is clearly a case of two cultures speaking PAST each other. There
seems to be two major misunderstandings. Firstly is the design of the
trauma "system." From the little I know about trauma care in the UK
(please correct me if I err)  it is not really a "system" and indeed
surgeons are not at the helm. However in the US the trauma system was
sort of initiated (very broadly) by the American College of Surgeons. In
order to be a trauma center you have to have surgeons immediately
available (within 15 minutes). In order to be a Level I trauma center
you have to have either 1) an attending surgeon IN HOUSE 24/7/365 or 2)
a chief surgical resident in house 24/7/365 with attending backup
available within 15 minutes. 

The second misapprehension seems to be the qualifications of the trauma
surgeon. In the vast majority of Level I trauma centers the responsible
surgeons have completed a critical care fellowship (1-2 years) after
their 5-year general surgical residency. This prepares them to deal with
AMI + trauma, stroke + trauma, and etc and etc (the final common pathway
for many diseases seems to be a car crash on the way to the hospital or
"found down" with a contusion on the head * ergo trauma). While there
are indeed a number of non-trauma/CC trained surgeons taking trauma call
at a number of fine institutions, most of the patients in the ICU are
cared for by Trauma Surgeon Intensivists. 

I hope this serves to clear up some of the confusion. I also note that
calling people idiots or their comments "BS" rarely adds to the utility
of the conversation.

Bill Bromberg

William J. Bromberg
Savannah Surgical Group
912 350-7412

>>> JVARCELOTTI at mercy.pmhs.org 10/04/06 7:59 AM >>>
I cannot believe what I just read. It's total BS.

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Karim Brohi
Sent: Tuesday, October 03, 2006 4:36 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: Subacute Care Surgery (was trauma activation and
stratification)

Not a problem....................I think you have no clue what you are
talking about.........

Dell

__________

And you clearly have no clue how to positively contribute to a
discussion.

Ken et al.  There are two primary reasons why emergency physicians are
so
involved in today's care of trauma patients.

1. Because over the last 30 years surgeons have abdicated from the care
of
the emergency surgical patient.  &

2. Because it's cheaper to have one resuscitation area in a hospital.

Of these (1) is by far the most important and most disappointing - and
I see
little sign of it improving.  99% of all surgeons only want to see the
'good
stuff' ie. Patients who need an operation.  They only want to be
consulted
once a full work-up is complete (including a CT on all patients!!) and
even
then they'd ideally first meet the patient prepped and draped on the
operating room table.  Their only interest is in the technical aspects
of
the surgery, and would very much like to hand over care of the patient
to
internal medicine as the last stitch is placed.  They have minimal
knowledge
of perioperative critical care, limited to a few weeks in residency or
a
3-day critical care course they were made to go on.  For the trauma
patient
a quick feel of the abdomen and 'there's nothing surgical here' is
baseline
surgical resident response.

For trauma patients, a trauma team staffed by surgeons, anaesthetists
etc
but without an ED physician is still a fully competent trauma team. 
But if
the surgeons don't turn up because 'it's only a minor injury' or 'we're
in
theatre/clinic' - or the surgeons are incompetent - then an eager,
present
ED physician is the obvious person who is going to fill that vacuum -
at
least while the patient is in the ED.  Whether that management is
appropriate depends entirely on the trauma competency of that ED
physician -
but surgical absence, or absence of interest must be a more serious
issue.

How have we got here?  Primarily I believe that it's a lack of
education
about emergency surgery.  Without knowledge of the intricacies of
trauma
care, can you really be interested or enthused by it?  If your bosses
are
only interested in genetic markers of oesophageal cancer, or
increasing
survival of pancreatic cancer by 2 weeks with complex surgery, never
educate
you on emergency surgery and its imperatives, never teach emergency
surgical
technique, never enthuse you about perioperative care, never release
you
from elective surgery to even see the emergencies, the outcome is
inevitable.  Note there is nothing beyond ATLS in most surgeons'
trauma
education.

Unfortunately I see no answers in the new 'Acute Care Surgery'.  The
primary
motivator for this is supposed to be improved patient care.  But the
focus
is on increasing the number of operating cases for surgeons - not on
improving patient access to competent emergency surgeons.  Again -
surgeons
want to do more operating (and more billing) but less care.  Further,
the
older surgeon will withdraw from the on-call rota, have minimal
elective
practice, fall into management and simply not be around to educate
residents
and support junior colleagues.  

The patient of the future may see, in turn, ED physician - Surgical
technician - Critical care / Internal medicine.  Replace the surgeon
with an
interventional radiologist and you have the end of trauma surgery.

Karim

___________________________________________________
Karim Brohi FRCS FRCA
Consultant Trauma, Vascular & Critical Care Surgeon,
The Royal London Hospital 
Specialty Tutor in Trauma & Emergency Surgery,
The Royal College of Surgeons of England

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