Contemporary Surgery

Is acute-care surgery the answer
for trauma call?

Department of Surgery, Medical University of South Carolina, Charleston

Who should take trauma call? In the age of specialization and outcome-driven evaluation of care, the answer seems obvious. Certain diseases have seen improved outcomes and reduced complications at high-volume “centers of excellence”, where surgeons are familiar with complex procedures and specialized perioperative care.^1-9 Translation of these findings suggests that trauma-trained specialists would best handle trauma patients.

Our institution, the Medical University of South Carolina Hospital, is the only Level I trauma center in a 100-mile radius. Three trauma/critical care-trained surgeons share most of the coverage to treat more than 2500 trauma patients a year. Every fifth evening, other subspecialty department members chip in. As in most trauma centers, the volume is simply too great for the few specialists to manage alone.

  A hybrid acute-care specialty

About 70% of the 1000 annual graduates of general surgery residencies pursue subspecialty training.¹⁰ Fewer choose trauma/critical care. Only 66 positions (48%) in the surgical critical care specialty match filled in 2008 (BOX).¹¹

Most academic trauma centers have developed a hybrid of acute-care surgery, trauma surgery, and critical care to try to broaden the scope of practice for the trauma surgeon and attract more candidates.^13,14  The American Association for the Surgery of Trauma (AAST) has proposed an acute care surgical fellowship curriculum.¹⁵

The problem with specialization

Surgical specialization has created a new problem: Surgeons who complete fellowships become compartmentalized—they no longer feel comfortable treating trauma patients, nor do they want to.

In a recent study, 85% of British general surgeons said major trauma should only be directed to trauma centers. While 90% had confidence in their ability to manage trauma, that number dropped when asked about these specific injuries:¹⁶

• Vascular (51%).

• Retroperitoneal (49%).

• Cardiothoracic (20%).

We suspect similar trends would be seen in a survey of specialty-trained surgeons in the United States.

  Not enough coverage

The low number of trauma/critical-care specialists has created a significant problem: Many hospitals cannot provide 24-hour coverage. The National Trauma Institute estimated 160,000 trauma-related deaths occurred in the United States in 2007.¹⁷

Unintentional injuries are the fifth leading cause of death, and the leading cause of young patient deaths.¹⁸ In 2003, 40 million people were treated in emergency departments. Almost 3 million were hospitalized for unintentional injuries.¹⁹ These numbers will likely rise as the population grows, further exacerbating coverage issues.²⁰

  Regionalize trauma care?

The National Study on the Costs and Outcomes of Trauma (NSCOT) identified differences in treatment at Level I trauma centers versus non-trauma centers.²¹ Risk of death was 25% lower in the most severely injured younger patients treated at trauma centers. Better outcomes were shown in patients with major lower-limb trauma treated at a Level I trauma center.²²

Level I trauma centers had a lower mortality in patients with cardiovascular and severe liver injuries (grades IV and V, AAST liver injury scale), and a lower disability rate in patients with complex pelvic fractures compared with Level II centers.²³

This suggests a trend toward improved outcomes in other trauma patient subsets: high-energy neuro-trauma, upper-extremity trauma, cardiothoracic, and vascular injuries. Variables that influenced good outcomes are:

• Quantity. Improvements in mortality and length of stay in shock and coma patients occurred in centers with more than 650 trauma admissions a year.²⁴ The number of trauma patients a center treated was the only variable linked to improved outcomes. Level of accreditation, presence of an “in-house” trauma attending, surgical residency, or medical school affiliation were not.²⁵

• Type of injury. High-volume centers showed a higher survival rate for 7 of 9 injury types compared with the predicted value defined by a severity characterization of trauma score (ASCOT).²⁵ This suggests severely injured patients in shock benefit from trauma center treatment.

• Specialty. Higher mortality was shown in injured patients treated by general surgeons taking trauma call than by a full-time trauma group.²⁶

Contradictory findings

These findings, however, cloud the picture:

• Volume. No difference was found in mortality and length of stay between high- and low-volume Level I and II trauma centers.²⁷ Mortality rates of trauma patients with injury severity scores (ISS) greater than 15 were no different between high- and low-volume centers (Levels I, II, III).²⁸ Neither study accounted for physiologic parameters in mortality and length of stay.

• Caseload. A negative correlation was found between trauma center volume and survival. Surgeon caseload had no effect on survival rates.²⁹

Mortality rates in patients with a similar ISS were no different if treated by high-volume trauma surgeons or low-volume specialists.³⁰ High-volume trauma surgeons were defined as treating more than 35 patients per year with an ISS greater than 15.³¹

  Improving survival

Improved survival and outcomes for severely injured, critically ill patients treated at high-volume Level I trauma centers is likely multifactorial. The trend may depend on intrinsic support systems within academic trauma centers as well as trauma surgeons’ increased experience.

Trauma surgeons can take heart that their specialized care and 40-plus years of research have led to improved survival and functional outcomes. This, however, does not mandate that trauma care must be the exclusive responsibility of trauma surgeons.

Collaboration needed

Although trauma is a universal problem, few physicians are trained to care for critically injured patients. The growing trauma coverage crisis requires a collaborative effort among the following groups:

• Physicians and staff. Trauma, general, and subspecialty surgeons must continue to cooperate in a team approach to provide excellent care.

• Institutions. Institutional commitment is critical to successful care. Hospitals must develop and maintain the necessary infrastructure and staff to support surgeons taking call.

• Government. Improved state and federal funding are needed to ensure adequate resources and coverage.

Disclosure

The authors did not disclose any relationships.

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