Subacute Care Surgery (was trauma activation and stratification)

[Ronald Gross]

Tony, 
I am gonna have to agree with you here.  It does depend on where you
are.  Most important in your discussion, however, is the concept of the
multidisciplinary approach - and that should be the case regardless of
where you are and who is "in charge".
Ron

>>> Tony Joseph <tjoseph at ihug.com.au> 10/12/2006 9:33 AM >>>
Dear Ron
I guess it depends on where you are.
I agree that trauma is a surgical disease but the fact remains that
not
many of our surgeons see it as a viable career pathway related to
relatively
poor remuneration, lifestyle etc  and we have too many hospitals taking
too
few trauma patients in my state (which requires a political solution).
There is only 1 surgeon in Australasia that I am aware of who is
responsible
for patients in Intensive Care.
As a result the management of the trauma patient here is
multidisciplinary
and,  although there is always room for improvement, in the main our
outcomes are acceptable according to limited data from the
Australasian
National Trauma Registry ( NTR)
Regards
Tony   


On 12/10/06 10:30 PM, "Ronald Gross" <Rgross at harthosp.org> wrote:

> Hi Tony,
> lets make one thing clear here - Mattox is NEVER provocative.....
> YEAH, RIGHT!  ;-)
> All kidding aside, I think that we are relatively spoiled here at
> Hartford.  We still follow the "15 minute rule" - in fact we are in
> house and frequently beat the patient in the doors because of our
pager
> alert system.  We also stay with the patient from arrival to ICU to
> discharge, whether the patient gets an operation or not.  And unless
the
> patient really does have an isolated ortho or neurologic injury that
> requires surgery, the patients usually stay on our service for the
> duration.  So my comments are, clearly, coming from my point of
bias.
> On the other hand, if I did not believe that this is the way it
should
> be, I clearly would not have come here and stayed here........Now it
is
> my turn to be provocative as I afffirm my very strong conviction
that
> trauma is a surgical disease, and should be managed by surgeons.
> Best wishes,
> Ron
>>>> Tony Joseph <tjoseph at ihug.com.au> 10/10/2006 9:42 AM >>>
> Dear Ron
> I have only come into this late.
> No one is arguing that if the patient needs an urgent operation  ,
then
> the
> surgeon should be involved from time of arrival as there is good
> evidence
> that the presence of a surgeon in the resus room shortens the time
to
> OR
> significantly. In this country where the trauma laparotomy rate is <
> 5%, it
> is relatively easy to understand why Trauma surgeons are few and far
> between
> because they don;t get to operate. They don;t look after the patient
in
> the
> Intensive care unit and they don;t usually clear the cervical spine
(
> that
> is usually left to the Emergency , Orthopedics or Neurosurgical
docs).
> The trauma team leader is usually either the ER or Intensive care
doc,
> so
> the patient would be in deep trouble if we waved them "goodbye" on
> their way
> to ITU, OR or radiology. I am sure Ken was just being provocative in
> an
> earlier post
> Regards
> Tony Joseph
> Sydney, Australia
> 
> 
> On 10/10/06 10:50 PM, "Ronald Gross" <Rgross at harthosp.org> wrote:
> 
>> Ian,
>> 
>> With all due respect, as I remember it, surgeons operate, and that
>> operation is what the trauma patient needs when the bleeding is
> audible.
>>  Surgeons also provide critical care in the ICU; who better than
the
>> surgeon who has just done the case, or the surgeon who might do the
> case
>> in the near future, and who knows the patient intimately and
> understands
>> the physiology of the entire patient in front of him/her, to care
> for
>> that patient?  
>> 
>> As to your colleagues concept about who does trauma, I suggest that
> he
>> come on board here and see just how many of the surgeons on this
list
> DO
>> trauma - at the very least that fellow might have to alter his
> misguided
>> concept just a little bit.
>> 
>> Best wishes,
>> Ron
>> 
>>>>> "Ian Seppelt" <SeppelI at wahs.nsw.gov.au> 10/9/2006 12:20 AM >>>
>> Let me weight in to a CONSTRUCTIVE debate!
>> 
>> Karim has already highlighted the differences between trauma
surgery
>> in
>> the USA and elsewhere in the world, including the difficulty
getting
>> subspecialised surgeons interested in trauma.
>> 
>> I saw that first hand when I first bought Ken Mattox's book 'Top
>> Knife'. A senior Professor of Surgery (upper GI and oesophageal
>> surgery,
>> weekly oesophagectomy list, etc) came across me reading it, and I
>> described to him the 'Top Knife / Top Gun' analogy, for training
the
>> 'best of the best'. "BUT", he pointed out to me, "The BEST surgeons
>> don't DO trauma".
>> 
>> So given that in Australia / New Zealand / the UK etc it is
> difficult
>> to get senior surgeons interested in trauma (with notable
> exceptions),
>> for the most part it is Emergency Physicians, Intensivists and
>> Anaesthetists that take up the slack. I'm happy to accept that that
> is
>> substandard compared to having a highly trained 'Trauma Surgey
>> Attending' present when every seriously injured patient arrives,
but
>> as
>> Craig Ellis asked, where is the evidence that that is actually
>> correct?
>> 
>> 
>> What I need is something strong enough that even a senior Professor
> of
>> Surgery will agree that the evidence supports having trauma
surgeons
>> present in the emergency department when the patient arrives.
>> 
>> Or could it be that a well trained DOCTOR is what is needed,
>> regardless
>> of specialty, with the ability to activate emergency surgery for
the
>> minority of our (predominantly blunt) trauma patients who actually
>> need
>> an operation?
>> 
>> Cheers, Ian
>> 
>> Ian Seppelt FANZCA FJFICM
>> Senior Staff Specialist
>> Dept of Intensive Care Medicine
>> The Nepean Hospital, PO Box 63 Penrith NSW 2751
>> Clinical Lecturer, University of Sydney
>> 
>>>>> karim at trauma.org 5/10/2006 6:19am >>>
>> OK, it's possible I overstated the case for the sake of a little
>> argument
>> (the list has been rather quiet recently!) but there are trends
here
>> which I
>> believe are important.  First, clearly if you are a member of this
>> list,
>> attend trauma conferences, or are an attending at a level 1 trauma
>> centre,
>> chances are that you are committed to trauma/emergency care and you
>> are
>> not
>> the subject of my ranting.  However if you consider the whole body
> of
>> surgeons I think the picture looks less rosy - whether you are in
> the
>> UK,
>> South Africa, Australia or the US.  If you do not work in a Level
> 1/2
>> trauma
>> centre, if you are a resident planning on going straight in to
> private
>> practice, if you are a laparoscopic left adrenal surgeon, I don't
>> believe
>> the same zeal for trauma or emegency surgery is present.  If I am
>> totally
>> off base, then I happily stand corrected, and certainly I was
>> exaggerating
>> to make the point.  But the fact stands that emergency medicine
>> developed
>> (initially) to fill a vacuum left by surgery, and some specialties
>> (witness
>> cardiothoracics) are retreating to the operating room.  We need to
>> make
>> sure
>> trauma or acute care surgery doesn't go the same way.
>> 
>> Karim 
>> 
>> 
>> 
>> 
>
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