Acute Care Surgery: The Evolution of a Specialty

1. Acute Care Surgery:The Evolution of a Specialty Amy C. Sisley MD, MPH Banner University Medical Center Phoenix, Arizona

2. A Brief History ….

3. From Ancient Egypt 5000 Years Old Logical, systematic treatment of traumatic injuries Listed from head to toe The oldest known medical manuscript is a trauma textbook! Edwin Smith Papyrus3000 – 2500 BCE

4. Lessons Learned in the Past Trends of the Future

5. The “Golden Hour” ? “If you don’t operate within the first hour, you have probably lost the patient”

6. Who said that ? R Adams Cowley,M.D. Physician in Chief R Adams Cowley Shock Trauma Center Baltimore, MD Coined the phrase “the Golden Hour”

7. Who said that ? “If you don’t operate within the first hour, you have probably lost the patient” George Goodfellow, M.D. Tombstone, Arizona 1886

8. A little afternoon get together at the OK Corral in Tombstone, 1881.

9. Thoracic / Cardiac Pediatric Hand ENT / H&N Vascular Endovascular Colo-Rectal Endocrine MIS Transplant HBS Renal/Pancreas Bariatric Trauma / Critical Care The Sub-specialization of Surgery

10. Trauma Surgeons The Fighter Pilots Of The Surgical Profession

11. Trauma Care “We have a quote around here that trauma is for people for whom instant gratification isn’t fast enough. I love not knowing what I’m going to be doing 5 minutes from now” Deborah Stein, M.D. Shock Trauma Center Baltimore, MD

12. Modern Day Trauma Textbook Channeling Top Gun ???

13. Then What Happened? BLUNT TRAUMA • Significant decreases in injury severity Cars better built Highways engineered for safety “Traffic calming” strategies • Improved survival with non-operative management of Liver / spleen injuries J Trauma. 2001 Oct

14. Then What Happened? PENETRATING TRAUMA • Decreased penetrating violence End of the Crack Cocaine Epidemic • Widespread use of semi-automatic weapons increased on-scene mortality J Trauma. 2001 Oct

15. Is the Party Over? • This is a far cry from the “golden age of trauma surgery” • … a time when trauma surgeons were considered “master surgeons” who operated on the neck, chest , abdomen, and any injured vessel, and non-operative management was unusual Moore, EE. Trauma Surgery: Is it time for a facelift? Ann Surg. 2004;240:563-564

16. Challenges:Trauma/Critical Care • Increasingly non-operative: Resuscitation doctors? Babysitters? • Lifestyle Issues Long, unpredictable hours • Poor Reimbursement Uninsured and underinsured • Patient population (intoxicated, drug altered, violent)

17. Challenges:Trauma/Critical Care • Increasingly non-operative: Resuscitation doctors? Babysitters? • Lifestyle Issues Long, unpredictable hours • Poor Reimbursement Uninsured and underinsured • Patient population (intoxicated, drug altered, violent)

18. Non-operative Management

19. Non-operative Management

20. Resident Experience on Trauma: Declining Surgical Opportunities and Career Incentives? • 82 Trauma Centers • 2 year period • 247,00 Trauma admissions • Majority of trauma centers (65.9%) had >80% blunt trauma Fakhry S et. al. J Trauma 2003;54-1-8

21. Resident Experience on Trauma: Declining Surgical Opportunities and Career Incentives? Fakhry S et. al. J Trauma 2003;54-1-8

22. Gun Shot Wounds • Increased use of semi-automatic and automatic weapons • Increased on-scene mortality • Increased ED mortality • Fewer operations Carr BG et.al., 2008

23. Resident Experience on Trauma: Declining Surgical Opportunities and Career Incentives? Fakhry S et. al. J Trauma 2003;54-1-8

24. Resident Experience on Trauma: Declining Surgical Opportunities and Career Incentives? • Assuming 1 night in 4 on call • Potential participation in one year: • 15 trauma laparotomies • 6 DPLs • 45 Ultrasound examinations • Each resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair Fakhry S et. al. J Trauma 2003;54-1-8

25. Declining “Juice to Squeeze” Ratio Declining Interest In Trauma/Critical Care Amongst Surgical Residents

26. Challenges:Trauma/Critical Care • Increasingly non-operative: Resuscitation doctors? Babysitters? • Lifestyle Issues Long, unpredictable hours • Poor Reimbursement Uninsured and underinsured • Patient population (intoxicated, drug altered, violent)

27. Lifestyle Issues • Need to provide coverage 24-7-365 • Little attention and no regulation to attending hours • Significant deterrent to trainees • Recommendation of AAST is to adopt shiftwork. Where’s the $$$$?

28. Sleep deprivation is Dangerous

29. Trauma Surgery • The American Board of Surgery (ABS) does NOT recognize trauma surgery as a specialty • The ABS DOES recognize the (completely non-operative) field of Surgical Critical Care (SCC) as a subspecialty certification. Odd • There is no ACGME approved trauma fellowship training program • Trauma has no unified “voice”

30. Challenges:Trauma/Critical Care • Increasingly non-operative: Resuscitation doctors? Babysitters? • Lifestyle Issues Long, unpredictable hours • Poor Reimbursement Uninsured and underinsured • Patient population (intoxicated, drug altered, violent)

31. Poor payer mix EMTALA and Ethics Lack of ABS recognition or Trauma Surgery = no Trauma “voice” in CPT or RVU discussions Reimbursement Issues

32. Challenges:Trauma/Critical Care • Increasingly non-operative: Resuscitation doctors? Babysitters? • Lifestyle Issues Long, unpredictable hours • Poor Reimbursement Uninsured and underinsured • Patient population (intoxicated, drug altered, violent)

33. Intoxicated 73% with BAL> 0.8 Drug Altered 43% with + tox screen High risk of HIV, Hepatitis, other blood borne illnesses Violent? Perception of Trauma Patients Soderstrom C, et al. J Trauma

34. Perception of Trauma Surgeons Trauma Surgeons are the Lifeguards at the Shallow End of the Gene Pool Rick Dutton, MD, Anesthesiologist

35. 379 responses • Average age 49 • Male 88% • Critical Care Fellowship 73% • Time in Practice – average 15 years

36. Percentage of Respondents Answering: Agree/Strongly Agree Satisfied with Career Choice – 90% Trauma Surgeons are Undervalued by Society – 88% Trauma Surgery is a viable/sustainable practice – 35% Trauma Surgery can be designed to be viable/sustainable – 83%

40. Critical Care Workforce Shortage Currently 18 million ICU Days per year Exponential increase expected due to aging population Predicted : 35% shortage of intensivists by 2020 Health Resources and Service Administration report to Congress (Senate Report 108-81), January, 2009

41. Critical Care Fellowship Positions Filled: 2001 - 2009

42. Unmatched Critical Care Training Positions 2006-2010 Napolitano, et al. J Trauma, 2010

43. ED – full Increased ED wait times Lack of Hospital Beds Lack of Surgical Coverage Plastics, ENT, Neurosurgery, Hand, OB-GYN, General Surgery, Ophthalmology Trauma & Emergency Care

44. Why surgeons do not want to cover the ED • Increased liability • Poor reimbursement • Lack of hospital support • Lack of support from surgical subspecialties • Wreaks havoc on elective schedule

45. Mid-course Correction?

46. The Paradigm Shift: Acute Care Surgery: Trauma Surgical Critical Care Emergency General Surgery +/- Burn

47. Acute Care Surgery service: Combining Trauma and Emergency General Surgery • Operative volume comparable to GI/MIS • May actually underestimate trauma component of operative volume • Case variety excellent

48. ACS Rotation:Operative Experience