Subacute Care Surgery (was trauma activation and stratification)

[Karim Brohi]

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