Who should perform vascular surgery for trauma?

[Sise, Mike MD]

Rick,
 
Well stated from someone who has helped define the proper treatment of vascular injuries. The problem often seems to center around the high risk nature of these injuries and the tendency to blame technical failures on the patient's severity of injury. Frequently the experienced vascular surgeon with trauma expertise is the only one who really knows if things were done appropriately and if failure was inevitable. I suspect we have some work to do here to define expected outcomes and to assess the appropriateness of management.
 
MJS

  _____  

From: docrickfry at aol.com [mailto:docrickfry at aol.com]
Sent: Sun 8/6/2006 2:26 AM
To: trauma-list at trauma.org
Subject: Re: Who should perform vascular surgery for trauma?



Mike--
Whoever can do vascualr trauma shouold do it.  It must be someone who is familiar with the basic principles of vascular diagnosis and surgical approaches, as well as someone who is familiar with the application of these precepts in the setting of trauma, which is quite different than elective vascular surgery.  My experience is like yours, that those vascular surgeons who do not do trauma are usually at sea on a major vascualr injury peripherally, and this is no different from general surgeons, urologists, cardiac surgeons, etc who do not do trauma.  General surgeons have the working familiarity with vascualr surgey from their residency, but generally do not do this surgery in practice.  I think all trauma services should train their fellows in vascualr trauma--there is no one good answer here, as it is difficult for any surgeon to do a case that he/she has not done in awhile, but I agree that they are well equipped to try in the field as they have the basic traiing to make a
  good shot if there is no one else
ERF


-----Original Message-----
From: Sise.Mike at scrippshealth.org
To: trauma-list at trauma.org
Sent: Fri, 4 Aug 2006 10:52 AM
Subject: Who should perform vascular surgery for trauma?


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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