Acute Care Surgery: The Evolution of a Specialty Amy C. Sisley MD, MPH Banner University Medical Center Phoenix, Arizona

Acute Care Surgery:Acute Care Surgery:The Evolution of a The Evolution of a

SpecialtySpecialty

Amy C. Sisley MD, MPHAmy C. Sisley MD, MPH

Banner University Medical CenterBanner University Medical Center

Phoenix, ArizonaPhoenix, Arizona

A Brief History ….A Brief History ….

Edwin Smith PapyrusEdwin Smith Papyrus3000 – 2500 BCE3000 – 2500 BCE

From Ancient EgyptFrom Ancient Egypt

5000 Years Old 5000 Years Old

Logical, systematic Logical, systematic treatment of traumatic treatment of traumatic injuriesinjuries

Listed from head to Listed from head to toetoe

The oldest known The oldest known medical manuscript medical manuscript is a trauma is a trauma textbook!textbook!

Lessons Learned in the

Past

Trendsof the

Future

The “Golden Hour” ?The “Golden Hour” ?

““If you don’t operate within the If you don’t operate within the

first hour, you have probably first hour, you have probably

lost the patient”lost the patient”

Who said that ?Who said that ?

R Adams Cowley,M.D.R Adams Cowley,M.D.Physician in ChiefPhysician in Chief

R Adams Cowley R Adams Cowley

Shock Trauma CenterShock Trauma Center

Baltimore, MDBaltimore, MD

Coined the phraseCoined the phrase

““the Golden Hour”the Golden Hour”

Who said Who said that ?that ?

““If you don’t operate If you don’t operate within the first within the first hour, you have hour, you have probably lost the probably lost the patient”patient”

George Goodfellow, M.D.Tombstone, Arizona

1886

A little afternoon get together at the OK Corral

in Tombstone, 1881.

The Sub-specialization of SurgeryThe Sub-specialization of Surgery

Thoracic / CardiacThoracic / Cardiac

PediatricPediatric

HandHand

ENT / H&NENT / H&N

VascularVascular– EndovascularEndovascular

Colo-RectalColo-Rectal

EndocrineEndocrine

MISMIS

TransplantTransplant– HBSHBS– Renal/PancreasRenal/Pancreas

BariatricBariatric

Trauma / Critical CareTrauma / Critical Care

Trauma

SurgeonsThe

Fighter Pilots

Of The

Surgical Profession

Trauma CareTrauma Care

““We have a quote around We have a quote around here that trauma is for here that trauma is for people for whom people for whom instant gratification instant gratification isn’t fast enough. I isn’t fast enough. I love not knowing what love not knowing what I’m going to be doing 5 I’m going to be doing 5 minutes from now”minutes from now”

Deborah Stein, M.D.Deborah Stein, M.D.Shock Trauma CenterShock Trauma CenterBaltimore, MDBaltimore, MD

Modern Day

Trauma Textbook

Channeling Top Gun ???

Then What Happened?Then What Happened?

Significant decreases in injury severitySignificant decreases in injury severity

Cars better built Cars better built Highways engineered for safety Highways engineered for safety ““Traffic calming” strategies Traffic calming” strategies

Improved survival with non-operative Improved survival with non-operative management of Liver / spleen injuriesmanagement of Liver / spleen injuries

J Trauma. 2001 OctJ Trauma. 2001 Oct

BLUNT TRAUMA

Then What Happened?Then What Happened?

Decreased penetrating violenceDecreased penetrating violenceEnd of the Crack Cocaine EpidemicEnd of the Crack Cocaine Epidemic

Widespread use of semi-automatic Widespread use of semi-automatic weapons increased on-scene mortalityweapons increased on-scene mortality

J Trauma. 2001 OctJ Trauma. 2001 Oct

PENETRATING TRAUMA

Is the Party Over?Is the Party Over?

This is a far cry from the “This is a far cry from the “golden age of golden age of trauma surgery”trauma surgery”

… … a time when trauma surgeons were a time when trauma surgeons were considered “considered “master surgeonsmaster surgeons” who ” who operated on the neck, chest , abdomen, operated on the neck, chest , abdomen, and any injured vessel, and non-operative and any injured vessel, and non-operative management was unusualmanagement was unusual

Moore, EE. Trauma Surgery: Is it time for a facelift?Ann Surg. 2004;240:563-564

Challenges:Challenges:Trauma/Critical CareTrauma/Critical Care

Increasingly non-operative:Increasingly non-operative:Resuscitation doctors?Resuscitation doctors?Babysitters?Babysitters?

Lifestyle IssuesLifestyle IssuesLong, unpredictable hoursLong, unpredictable hours

Poor ReimbursementPoor Reimbursement Uninsured and underinsuredUninsured and underinsured

Patient population (intoxicated, drug Patient population (intoxicated, drug altered, violent)altered, violent)






Non-operative ManagementNon-operative Management

Non-operative ManagementNon-operative Management

Resident Experience on Trauma: Declining Resident Experience on Trauma: Declining Surgical Opportunities and Career Incentives?Surgical Opportunities and Career Incentives?

82 Trauma Centers82 Trauma Centers 2 year period2 year period 247,00 Trauma admissions247,00 Trauma admissions Majority of trauma centers (65.9%) Majority of trauma centers (65.9%)

had >80% blunt trauma had >80% blunt trauma

Fakhry S et. al. J Trauma 2003;54-1-8



Gun Shot WoundsGun Shot Wounds

Increased use of Increased use of semi-automatic and semi-automatic and automatic weaponsautomatic weapons

Increased on-scene Increased on-scene mortalitymortality

Increased ED Increased ED mortalitymortality

Fewer operationsFewer operations

Carr BG et.al., 2008




Assuming 1 night in 4 on callAssuming 1 night in 4 on call

Potential participation in one year:Potential participation in one year: 15 trauma laparotomies15 trauma laparotomies 6 DPLs6 DPLs 45 Ultrasound examinations45 Ultrasound examinations

Each resident will care for an average of Each resident will care for an average of 500 blunt trauma patients before 500 blunt trauma patients before performing a splenectomy or liver repairperforming a splenectomy or liver repair


Declining “Juice to Squeeze” Ratio

Declining Interest In Trauma/Critical Care Amongst Surgical Residents






Lifestyle IssuesLifestyle Issues

Need to provide coverageNeed to provide coverage 24-7-36524-7-365

Little attention and Little attention and no no regulation to attending hoursregulation to attending hours

Significant deterrent to Significant deterrent to traineestrainees

Recommendation of AAST is Recommendation of AAST is to adopt shiftwork. Where’s the to adopt shiftwork. Where’s the $$$$?$$$$?

Sleep deprivation is DangerousSleep deprivation is Dangerous

Trauma SurgeryTrauma Surgery

The American Board of Surgery (ABS) does The American Board of Surgery (ABS) does NOT recognize trauma surgery as a specialtyNOT recognize trauma surgery as a specialty

The ABS DOES recognize the (completely non-The ABS DOES recognize the (completely non-operative) field of Surgical Critical Care (SCC) operative) field of Surgical Critical Care (SCC) as a subspecialty certification. Oddas a subspecialty certification. Odd

There is no ACGME approved trauma fellowship There is no ACGME approved trauma fellowship training programtraining program

Trauma has no unified “voice”Trauma has no unified “voice”






Reimbursement IssuesReimbursement Issues

Poor payer mixPoor payer mix

EMTALA and EthicsEMTALA and Ethics

Lack of ABS Lack of ABS recognition or Trauma recognition or Trauma Surgery = no Trauma Surgery = no Trauma “voice” in CPT or “voice” in CPT or RVU discussionsRVU discussions






Perception of Trauma PatientsPerception of Trauma Patients

IntoxicatedIntoxicated 73% with BAL> 0.873% with BAL> 0.8

Drug AlteredDrug Altered 43% with + tox screen43% with + tox screen

High risk of HIV, Hepatitis, High risk of HIV, Hepatitis, other blood borne illnessesother blood borne illnesses

Violent?Violent?

Soderstrom C, et al. J Trauma

Perception of Trauma Surgeons Perception of Trauma Surgeons

Trauma Surgeons Trauma Surgeons are the are the

LifeguardsLifeguards

at the at the

Shallow End Shallow End

of theof the

Gene PoolGene Pool

Rick Dutton, MD, Anesthesiologist

379 responses

Average age 49

Male 88%

Critical Care Fellowship 73%

Time in Practice – average 15 years

Percentage of Respondents Answering: Agree/Strongly Agree

Satisfied with Career Choice – 90%

Trauma Surgeons are Undervalued by Society – 88%

Trauma Surgery is a viable/sustainable practice – 35%

Trauma Surgery can be designed to be viable/sustainable – 83%

Critical Care Workforce Critical Care Workforce ShortageShortage

Currently 18 million Currently 18 million ICU Days per yearICU Days per year

Exponential Exponential increase expected increase expected due to aging due to aging populationpopulation

Predicted : 35% Predicted : 35% shortage of shortage of intensivists by intensivists by 20202020

Health Resources and Service Administration report to Congress (Senate Report 108-81), January, 2009

Critical Care Fellowship Positions Filled:

2001 - 2009

Napolitano, et al. J Trauma, 2010

Unmatched Critical Care Training Positions2006-2010

Trauma & Emergency CareTrauma & Emergency Care

ED – fullED – full

Increased ED wait Increased ED wait timestimes

Lack of Hospital BedsLack of Hospital Beds

Lack of Surgical Lack of Surgical CoverageCoverage– Plastics, ENT, Plastics, ENT,

Neurosurgery, Hand, Neurosurgery, Hand, OB-GYN, OB-GYN, General General SurgerySurgery, Ophthalmology , Ophthalmology

Why surgeons do not want to cover Why surgeons do not want to cover the EDthe ED

Increased liabilityIncreased liability

Poor reimbursementPoor reimbursement

Lack of hospital Lack of hospital supportsupport

Lack of support from Lack of support from surgical surgical subspecialtiessubspecialties

Wreaks havoc on Wreaks havoc on elective scheduleelective schedule

Mid-course Correction?Mid-course Correction?

The Paradigm Shift:The Paradigm Shift:

Acute Care Surgery:Acute Care Surgery:

TraumaTrauma

Surgical Critical CareSurgical Critical Care

Emergency General SurgeryEmergency General Surgery

+/- Burn+/- Burn

Acute Care Surgery service:Combining Trauma and Emergency General Surgery

Operative volume comparable to GI/MIS

May actually underestimate trauma component of operative volume

Case variety excellent

ACS Rotation:ACS Rotation:Operative ExperienceOperative Experience

Departmental Impact of Initiating an

Acute Care Surgery Practice Model

Barnes et al. J Trauma;71(4):2011

Development of A New ParadigmDevelopment of A New Paradigm

2004 2004 The Committee to Develop the The Committee to Develop the Reorganized Specialty of Trauma, Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgical Critical Care, and Emergency Surgery formsSurgery forms

20062006 Present curriculum outline to AAST Present curriculum outline to AAST

20072007 Retreat with ABS and AAST to Retreat with ABS and AAST to present curriculum, develop competency present curriculum, develop competency verification toolsverification tools

Development of A New ParadigmDevelopment of A New Paradigm

Spring 2007Spring 2007 First site visits for ACS First site visits for ACS fellowshipfellowship

Fall 2007Fall 2007 First ACS fellowship interviews First ACS fellowship interviews

July 2008July 2008 First year of formal AAST-ACS First year of formal AAST-ACS fellowshipsfellowships

Acute Care SurgeryAcute Care Surgery

Trauma and general surgery should together Trauma and general surgery should together create a specialist that has broad training in create a specialist that has broad training in elective and emergency general surgeryelective and emergency general surgery

A graduate of this training paradigm would be A graduate of this training paradigm would be responsible for managing acute general surgical responsible for managing acute general surgical problems, providing surgical critical care and problems, providing surgical critical care and managing acute traumamanaging acute trauma

This specialist should do “shift” work, not unlike This specialist should do “shift” work, not unlike the emergency physicians, the emergency physicians, if local practice if local practice patterns support this approachpatterns support this approach

Acute Care Surgery FellowshipAcute Care Surgery Fellowship

AAST Recommendations:AAST Recommendations:2-Year fellowship training2-Year fellowship training9 – 12 months of Surgical Critical Care9 – 12 months of Surgical Critical Care12-15 months Trauma and Advanced 12-15 months Trauma and Advanced SurgerySurgeryOriginally Included Specialty TrainingOriginally Included Specialty Training

NeurosurgeryNeurosurgeryOrthopedic SurgeryOrthopedic Surgery

J Trauma, 2005;58-614-616

ACUTE CARE SURGERYACUTE CARE SURGERY

RequiredRequired

Elective General SurgeryElective General Surgery

Emergency Surgery CallEmergency Surgery Call

Trauma CallTrauma Call

Surgical Critical CareSurgical Critical Care

Trauma System DesignTrauma System Design

Disaster ManagementDisaster Management

Management of surgical Management of surgical emergenciesemergencies

Not Quite RequiredNot Quite Required““Expected”Expected”

ThoracicThoracic

VascularVascular

HepatobiliaryHepatobiliary

““Encouraged”Encouraged”

NeurosurgeryNeurosurgery

Orthopedic SurgeryOrthopedic Surgery

IRIR

Acute Care Surgery FellowshipAcute Care Surgery Fellowship

July 2008 – First year July 2008 – First year formal AAST fellowship formal AAST fellowship availableavailable

Currently 14 accredited Currently 14 accredited ACS fellowships ACS fellowships (including Banner UMC-(including Banner UMC-Tucson)Tucson)

No ABS Board No ABS Board examination yetexamination yet

Acute Care Surgery:Acute Care Surgery:Unresolved IssuesUnresolved Issues

Reimbursement Reimbursement Good News – ACS model tends to result in improved Good News – ACS model tends to result in improved

payor mixpayor mixBad News – Recession/UnemploymentBad News – Recession/UnemploymentUnclear – Health Care Reform?Unclear – Health Care Reform?

TerritoryTerritoryGeneral SurgeonsGeneral SurgeonsColorectal SurgeonsColorectal Surgeons

Lifestyle IssuesLifestyle Issues

Acute Care Surgery:Acute Care Surgery:Unresolved Issues – Identity Unresolved Issues – Identity

CrisisCrisisWill other surgeons Will other surgeons take call at all?take call at all?

Are we the doctors Are we the doctors who take care of the who take care of the patients no one else patients no one else wants?wants?

Are we fighter Are we fighter pilots/master pilots/master surgeons?surgeons?

Acute Care Surgery: Still Evolving, but here to Stay!

Where Are We Going?

Hey “Fighter Pilots”Keep Looking AHEAD

Documents

Acute Care Surgery: The Evolution of a Specialty Amy C. Sisley MD, MPH Banner University Medical Center Phoenix, Arizona