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Wed Oct 11 00:10:54 BST 2006

Ron, I'm not disputing that in any way, for the USA [trying not to go
around in circles!]. But what you describe is NOT the reality elsewhere
in the world for a whole lot of reasons previously articulated.

So my question (and Craig Ellis's question) - please help us with
published evidence that we can put under our surgeons' noses, that what
we currently offer is substandard care leading to poorer patient
outcomes.

Joke: The only 'critical care' I generally see surgeons provide in the
ICU is when they come in with large retinue and 'criticise' [again, with
notable uncommon exceptions]

You make the point the patients need surgeons to operate when the
bleeding is audible --- of course, that goes without saying. But IN MY
ENVIRONMENT with predominantly blunt trauma, with very few knife and gun
injuries, the majority of trauma patients in fact do not need an
operation, nor do they ever get one. The most recent report from NSW
(state) Institute of Trauma and Injury Management documents 2407 severe
traumas in 2004, including 18 shootings and 54 stabbings (about 3%). The
remaining 97% of severe traumas were BLUNT injury, predominantly car
crashes and falls.

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> Rgross at harthosp.org 10/10/2006 10:50pm >>>
Ian,

With all due respect, as I remember it, surgeons operate, and that
operation is what the trauma patient needs when the bleeding is
audible.
 Surgeons also provide critical care in the ICU; who better than the
surgeon who has just done the case, or the surgeon who might do the
case
in the near future, and who knows the patient intimately and
understands
the physiology of the entire patient in front of him/her, to care for
that patient?  

As to your colleagues concept about who does trauma, I suggest that he
come on board here and see just how many of the surgeons on this list
DO
trauma - at the very least that fellow might have to alter his
misguided
concept just a little bit.

Best wishes,
Ron

>>> "Ian Seppelt" <SeppelI at wahs.nsw.gov.au> 10/9/2006 12:20 AM >>>
Let me weight in to a CONSTRUCTIVE debate!

Karim has already highlighted the differences between trauma surgery
in
the USA and elsewhere in the world, including the difficulty getting
subspecialised surgeons interested in trauma.

I saw that first hand when I first bought Ken Mattox's book 'Top
Knife'. A senior Professor of Surgery (upper GI and oesophageal
surgery,
weekly oesophagectomy list, etc) came across me reading it, and I
described to him the 'Top Knife / Top Gun' analogy, for training the
'best of the best'. "BUT", he pointed out to me, "The BEST surgeons
don't DO trauma".

So given that in Australia / New Zealand / the UK etc it is difficult
to get senior surgeons interested in trauma (with notable exceptions),
for the most part it is Emergency Physicians, Intensivists and
Anaesthetists that take up the slack. I'm happy to accept that that is
substandard compared to having a highly trained 'Trauma Surgey
Attending' present when every seriously injured patient arrives, but
as
Craig Ellis asked, where is the evidence that that is actually
correct?

What I need is something strong enough that even a senior Professor of
Surgery will agree that the evidence supports having trauma surgeons
present in the emergency department when the patient arrives.

Or could it be that a well trained DOCTOR is what is needed,
regardless
of specialty, with the ability to activate emergency surgery for the
minority of our (predominantly blunt) trauma patients who actually
need
an operation?

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> karim at trauma.org 5/10/2006 6:19am >>>
OK, it's possible I overstated the case for the sake of a little
argument
(the list has been rather quiet recently!) but there are trends here
which I
believe are important.  First, clearly if you are a member of this
list,
attend trauma conferences, or are an attending at a level 1 trauma
centre,
chances are that you are committed to trauma/emergency care and you
are
not
the subject of my ranting.  However if you consider the whole body of
surgeons I think the picture looks less rosy - whether you are in the
UK,
South Africa, Australia or the US.  If you do not work in a Level 1/2
trauma
centre, if you are a resident planning on going straight in to private
practice, if you are a laparoscopic left adrenal surgeon, I don't
believe
the same zeal for trauma or emegency surgery is present.  If I am
totally
off base, then I happily stand corrected, and certainly I was
exaggerating
to make the point.  But the fact stands that emergency medicine
developed
(initially) to fill a vacuum left by surgery, and some specialties
(witness
cardiothoracics) are retreating to the operating room.  We need to
make
sure
trauma or acute care surgery doesn't go the same way.

Karim 

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