Subacute Care Surgery (was trauma activation and stratification)

[Jane Harper]

Except for those trauma centers that HAVE no residents ...

Jane Harper, MS, RN, CCNS, ACNP
--------------
"The trained nurse is one of the greatest blessings of humanity, taking a
place beside the physician and the priest, and not inferior to either in her
mission."  -- Sir William Osler, MD 

> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
> bounces at trauma.org] On Behalf Of E Edhayan
> Sent: Tuesday, October 03, 2006 19:13
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Subacute Care Surgery (was trauma activation and
> stratification)
> 
> Dr. Brohi,
> 
>   This is not the experience in the US.
> 
>   In Trauma Centers across the US the Trauma patient is cared for on the
> Trauma Service staffed by Trauma Surgeons and Surgical Residents from the
> ED to the time of discharge.
> 
>   Trauma is a big part of surgical training in the US. In fact, on the
> oral boards one room is dedicated to Trauma and Critical Care.
> 
>   E. Edhayan M.D., FACS
> Trauma Medical Director
>   St. John Hospital
>   Detroit - Mi 48236
> 
> Karim Brohi <karim at trauma.org> wrote:
> 
> 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
> 
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> 
> 
> E. Edhayan M.D., FACS
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