C. William Schwab, M.D.,...

Department of Surgery

Visiting Professor in Trauma Surgery University of Toronto

June 5 – 6, 2008

C. William Schwab, M.D., FACS

Professor of Surgery, University of Pennsylvania School of Medicine Chief, Division of Traumatology & Surgical Critical Care

University of Pennsylvania Medical Center

Dr. Schwab established the Division of Traumatology and Surgical Critical Care in 1987, including a Level I Regional Resource Trauma Center, Surgical Critical Care Service, the PennSTAR Flight Program, and the Communications Center at the University of Pennsylvania Medical Center. Dr. Schwab and his faculty of trauma surgeons are recognized worldwide for their surgical advancements of devastating gun injuries. The Trauma Center at Penn houses an international trauma and surgical critical care fellowship training program that provides trauma training for surgeons and surgical residents from around the globe. Many surgeons from the U.S. Air Force and Navy have completed Penn's fellowship program, and have used their expertise on the battlefields of Iraq and Afghanistan. Dr. Schwab has authored or co-authored more than 150 articles, editorials, and books on a wide variety of traumatology, surgical critical care, and firearm violence topics. He won the Curtis Artz award in 1997 for Injury Prevention of the American Trauma Society. The Royal College of Physicians and Surgeons of Canada also recognized his work when he gave the W.R. Ghent Lecture entitled "America's Uncivil War: Firearm Injury in America." In 2003, he was elected a fellow of the Royal College of Surgeons (Glasgow). ). In 2005 and 2006, he served as the President-Elect and President, respectively, of the American Association for the Surgery of Trauma and was a member of the Institute of Medicine’s Task Force on the Future of Emergency Care. Just recently, he was nominated as an Honorary Member of the Swedish Surgical Society.

University Rounds: Acute Care Surgery: “Where are we?”

Objectives:

1. Define Acute Care Surgery 2. Assess the need and implementation of the acute care surgery model 3. Review our experience

**This event is an accredited group learning activity as defined by the Maintenance of Certification Program of The Royal College of Physicians and Surgeons of Canada**

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Visiting Professor Program

Thursday, June 5th, 2008 Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto ON 13:00 – 14:00 Meet with Faculty - Sunnybrook Health Sciences Centre (Drs. Gordon

Rubenfeld, Sandro Rizoli, Homer Tien)

14:00 – 16:00 ICU Rounds – Sunnybrook Health Sciences Centre

18:00 – 20:00 City Wide Trauma Journal Club & Dinner

Rosewater Supper Club - By invitation only Journal Articles:

1. The OPALS Major Trauma Study: Impact of advanced life-support on survival and morbidity. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells GA for the OPALS Study Group. CMAJ 2008:178(9): 1141-52.

(Presenter: Dr. Shady Ashamalla – PGY III)

2. The U.S. Trauma Surgeon’s Current Scope of Practice: Can We Deliver Acute Care Surgery. Cothren CC, Moore EE, Hoyt DB. J Trauma 2008;64(4): 955-968.

(Presenter: Dr. Pavi Kundhal – PGY IV)

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Friday, June 6th, 2008 07:30 – 08:30 University Grand Rounds:

Paul Marshall Auditorium, St. Michael’s Hospital Dr. C. William Schwab Acute Care Surgery: “Where are we?”

09:00 – 10:30 Senior Resident Teaching The Banting Institute 100 College Street

11:00 – 11:20 Tour of the Surgical Skills Laboratory: Mount Sinai Hospital, 600 University Avenue

11:30 – 12:00 Meet with Faculty – St. Michael’s Hospital (Dr. Ori Rotstein 16CC 044) 12:00 – 12:30 Tour of the Simulation Lab – St. Michael’s Hospital – 5th Floor, Shuter Wing 12:30 – 13:30 Lunch with Faculty & Residents, St. Michael’s Hospital 13:30 – 15:00 Trauma / Critical Care Symposium,

St. Michael’s Hospital, 16 CC 101 Lecture Theatre • Epidemiology of trauma related death in Ontario

Dr. David Gomez • Paediatric Trauma Mortality in Ontario: A Population Based Study

Dr. Ivan Diamond • The use of Thromboelastography (TEG) in trauma Dr. Sandro Scarpelini • The Cost of Providing Health Care to Injured Soldiers in War

Dr. Dylan Pannell • The Survival Advantage in Trauma Centers: Expeditious Intervention or

Experience? Dr. Barbara Haas

• The role of ceramide in macrophage priming following oxidative stress Dr. Patrick Tawadros

• Determinants of access to care for pediatric trauma in sub-Saharan Africa Dr. Alex Mihailovic

15:15 Adjournment

Thank you to our Educational Partners

The Royal College of Physicians and Surgeons

Department of Surgery, University of Toronto Division of General Surgery, University of Toronto

Trauma Program, St. Michael’s Hospital

Trauma Program, Sunnybrook College Health Sciences Centre

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Thank you to our Industry Sponsors

Wyeth Pharmaceuticals

Novo Nordisk

Johnson & Johnson

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Trauma / Critical Care Research Symposium Abstracts

EPIDEMIOLOGY OF TRAUMA RELATED DEATH IN ONTARIO David Gomez, Myriam Berube*, Wei Xiong, Nadine Schuurman*, Avery B Nathens. Division of Trauma and the Department of Surgery, St. Michael's Hospital. *Department of Geography, Simon Fraser University Introduction

Trauma-related mortality has been shown to be higher in rural regions. While higher injury rates

might be responsible, a greater case fatality rate might also play an important role. To evaluate

whether there are opportunities for intervention, we set out to evaluate the epidemiology of

trauma-related death in Ontario.

Methods

Deaths were identified through a population-based registry of trauma-related deaths in the

province over the years 2002-2003. We excluded deaths due to asphyxiation, burns, drowning,

electrocution, intoxication and same level falls.

Age and gender-adjusted injury mortality rates were estimated at the census division and census

subdivision level, with each municipality categorized by their rurality (% of residents living in a

rural environment). Location of death as it relates to the provision of care (field, ED, OR, other

in-hospital) was evaluated as a function of

environment. ED deaths were considered

to be potentially salvageable patients. A

GIS vector-based network analysis was

used to model trauma center’s catchment

areas and its relationship with injury

mortality rates.

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Results

Rurality of municipality

50 - 100%

rural 1 - 49%

rural <1% rural p Value

N (Patients, municipalities) 447, 35 1691, 97 1348, 38 Cause of death

MVC 287 (64%) 970 (57%) 607 (45%) Penetrating 81 (18%) 282 (17%) 230 (17%) <0.0001

Falls 27 (6%) 237 (14%) 414 (31%) Other 52 (12%) 202 (12%) 97 (7%)

Site of death Field 347 (78%) 1000 (59%) 530 (39%)

OR 6 (1%) 36 (2%) 85 (6%) <0.0001ED 57 (13%) 348 (21%) 322 (24%)

Other in hospital 37 (8%) 307 (18%) 411 (31%)

Relative risk of ED death*

1.5 [1.2, 1.8]

1.3 [1.1, 1.4] Reference

Table 1. Cause and site of death by rurality*Among those surviving to reach ED

There were 3486 deaths over this time interval, yielding a mortality rate of 14.6 per 100,000

person-years. Adjusted mortality rates were almost 3-fold higher in rural municipalities (Figure

1). Patients were half as likely to die in the field in more urban environments (Table1 ). Among

those surviving to reach hospital, the relative risk of death in the emergency department (ED)

was 50% greater in the most rural

municipalities compared to the most urban.

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The context of death was explored as a

function of the travel time between trauma

center and location of injury among those

surviving to hospital. The relative risk of ED

death was 1.4 (CI 95% 1.2-1.7) times

greater among those who were injured beyond a 1

hour land transport time to a trauma center compared to those injured within this catchment area

(Map). Census divisions with the highest adjusted mortality rates lay outside a 1 hour land

transport time to a trauma center (Map).

Fig 1. Adjusted death rates and rurality

Conclusions

Improving trauma care in rural Ontario must become a

priority. The higher proportion of field deaths might be

amenable to primary prevention interventions or

advanced technologies (e.g. automatic crash

notification). There are opportunities for intervention

to reduce the rate of potentially preventable deaths in

the ED through focused education of rural providers

and greater access to transportation assets.

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PREVENTABLE PEDIATRIC TRAUMA DEATHS IN ONTARIO: A COMPARATIVE POPULATION BASED STUDY. Ivan R. Diamond MD1, Patricia C. Parkin MD1, Paul W. Wales MD1, Desmond Bohn MD1, Margaret Kreller CHIM1, Evelyn H. Dykes MBChB2, Barry A. McLellan MD3, David E. Wesson MD4

1The Hospital for Sick Children, Toronto, Canada. 2University of Aberdeen, Aberdeen, Scotland. 3Sunnybrook Health Sciences Center, Toronto, Canada. 4Texas Children’s Hospital, Houston, United States of America Introduction: In a previous study (1985-7) we found that 21% of pediatric (0-15 years) trauma deaths in the Province of Ontario were potentially preventable. Since then many trauma system changes have occurred including field triage, designation of trauma centers and improved injury prevention. This study aims to re-examine the preventable trauma death rate in our system using identical methodology to our previous study. Method: The records of all children (0 – 15 years) who died in Ontario (total pop. 11 million) from 2001 through 2003 following blunt or penetrating trauma were obtained from the Chief Coroner and compared to the those in our previous report. In both series we excluded cases where care was not sought (mainly homicides and suicides), and all deaths due to asphyxia and drowning. Deaths were considered preventable if the Injury Severity Score (ISS), based on AIS 1985, was < or = 59; all others were deemed unpreventable. Results: There has been a substantial reduction in both the number of pediatric trauma deaths and the proportion that were preventable [Relative Risk Reduction for preventable death: 69% (95% Confidence Interval: 43 – 83%); Number Needed to Treat: 7]. 2001-03 1985-87 Number of Deaths 211 378 Number of Cases with sufficient data to calculate ISS

168 317

Preventable deaths 11 67 Number of pre-hospital/in-hospital preventable deaths

7 / 4 34 / 33

Number of pre-hospital/in-hospital unpreventable deaths

113 / 44 140 / 110

Preventable death rate 7% 21% Conclusion: Aside from a marked decline in the overall number of pediatric trauma deaths in Ontario, there has been a 3-fold decline in the proportion of deaths from salvageable injuries (i.e., preventable deaths). It is highly likely that better primary and secondary prevention and improvements in trauma care contributed to these declines. We estimate that, for every 7 deaths from fatal injuries, system changes between the two study periods eliminated one preventable death.

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THROMBOELASTOGRAPHY (TEG®) IN TRAUMA: IDENTIFYING THE NEED FOR BLOOD TRANSFUSION S. Scarpelini 1,2,3*; H. Tien1*; V. Speers1; F. Spencer1*; S. Rizoli 1*

1. Sunnybrook Health Sciences Centre, University of Toronto. 2. University of Sao Paulo, Brazil. 3. Sponsored by CNPq, Brazil. Background:Coagulopathic bleeding remains a major cause of early death after trauma. Coagulation (coag) laboratory tests are occasionally inaccurate in diagnosing and ineffective in guiding its therapy. Thromboelastography (TEG) rapidly provides information about whole coagulation, but remains mostly untested in trauma. We investigated the role of TEG in identifying the need of blood transfusion in a cohort of trauma patients and compared to routine coag tests. Methods:All trauma patients admitted to Sunnybrook Hospital from February to October 2007 except those on anticoagulants and/or with incomplete data. TEG (citrated kaolin method) and routine coag tests were done upon arrival to Sunnybrook. Demographic and clinical data were prospectively collected. Hypocoagulability was defined as any abnormal TEG parameter (R, K, α, MA) or coag test (INR>1.4, PTT>45”, Fibrinogen<1.0g/L, Platelets<50x109/L). Results:547 patients met inclusion criteria. 72.4% were male, 83% suffered blunt trauma, average age was 39.7±18.8 years, transportation time 3.2±4.6 hours and ISS 21.5±13.1. TEG was abnormal in 105 patients and coag tests in 32, of which most (75%) also had abnormal TEG. In contrast only 22.9% of abnormal TEG also had abnormal coag tests. Over the first 24 hours 105 patients required red blood cell transfusion, 23 (4.2%) massively (>=10 units) and 82 (15%) between 1-9U. TEG was abnormal in 1.5 times as many patients requiring transfusion than routine coag tests, 60.9% versus 52.2% in massively transfused, 17.1% versus 11.0% among those transfused 1-9U. Conclusion:This preliminary analysis suggests that TEG has a higher yield in identifying trauma patients requiring early blood transfusion than routine coag tests.

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THE COST OF PROVIDING HEALTH CARE TO INJURED SOLDIERS IN WAR Pannell D Background: As the Global War on Terror progresses, the total health cost for treating wounded soldiers continues to rise. Although some reports have estimated the total cost of soldiers’ health care, no study has attempted to rigorously quantify this amount. We sought to quantify the cost of providing health care to soldiers injured while on duty in a conflict area. Methods: Retrospective study of all Canadian Forces soldiers injured in Afghanistan from 7 February 2006 to 6 February 2007. Canadian Forces trauma registry was used to identify all Canadian soldier injured and hospitalized at the military field hospital in Kandahar. Financial reports from the Canadian Forces Health Services were used to quantify the cost of providing care to these soldiers in Kandahar, at Landstuhl Regional Medical Center and during evacuation back to Canada. Insurance claims paid (as of Oct 15, 2007) to a third party insurer by the Canadian Forces were used to quantify the cost of health care in Canada. Results: During the one year period, 127 Canadian soldiers were injured and required admission to the field hospital in Kandahar. A total of 93 soldiers required evacuation to Landstuhl Regional Medical Center, and of these, 75 required further care at Canadian civilian hospitals. The Canadian Forces spent a total of $24.0 million to care for these 127 injured Canadian soldiers. The majority of these costs were associated with providing care in Afghanistan ($15.7 million). Caring for 93 wounded soldiers at Landstuhl Regional medical center cost approximately $2.0 million. Air evacuation costs of 75 wounded soldiers back to Canada cost $3.9 million. Further care in Canada for 75 severely wounded soldiers cost approximately $2.4 million. The average cost of caring for each severely wounded solider was approximately $230,000. Interpretation: Estimating the financial cost to properly care for soldiers wounded on overseas duty in conflict areas is critical for future planning and forecasting. We estimate on average, it costs approximately $230,000 to care for one severely injured soldier who requires repatriation back to a Canadian civilian hospital. Most of the costs are from establishing and staffing field hospitals in the conflict area.

THE SURVIVAL ADVANTAGE IN TRAUMA CENTERS: EXPEDITIOUS INTERVENTION OR EXPERIENCE? Barbara Haas Background: Trauma patients who receive care at designated trauma centers have a decreased risk of death. However, the processes of care that lead to these improved outcomes are unknown. We postulated that to a large extent, lower mortality is due to more rapid assessment and intervention, and set out with the objective of evaluating this aspect of care in a large cohort of patients with indications for immediate operative intervention. Methods: Data were collected from a multicenter (69 centers) prospective cohort study of 14,477 adult patients cared for in trauma centers (TC) and non-designated centers (NTC). From this cohort, we identified patients with two patterns of injury: hypotensive penetrating trauma (PT) and blunt traumatic brain injury (TBI) with mass effect (midline shift or pupillary abnormalities). Times from admission to relevant interventions (TBI - CT head, craniotomy; PT - major cavitary or vascular exploration) were assessed, as were the relative risks (RR) of in-hospital death in TC compared to NTC. RR were adjusted for differences in case mix using propensity analysis. Results: Among 1331 patients who met inclusion criteria, 23.5 % died in hospital. The relative risk of death was 0.61 (95% CI; 0.43-0.86) among patients managed at TC compared to those admitted to NTC. This survival advantage was seen both among hemodynamically unstable patients with penetrating injuries and patients with operable traumatic brain injury (table). Within the first 24h of admission, however, there was no statistically significant difference observed between the median times to radiographic assessment (CT head) or operative intervention at designated trauma centers as compared to other hospitals.

TBI PT TC NTC TC NTC Number of patients 634 132 490 75 Adjusted RR of death (95% CI) 0.72 (0.50-1.0) 1 0.43 (0.19-0.94) 1

CT head 0.80 1.11 N/A N/A Median time to (hrs) Operation 3.28 3.62 1.01 0.69

Conclusions: Risk of death is significantly lower among patients requiring early operative intervention if they are treated at a designated level 1 trauma center. This outcome is not due to more rapid assessment and intervention alone, and emphasizes the complex factors that contribute to the survival benefit of trauma center care.

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The Role of Ceramide in Macrophage Priming Following Oxidative Stress P.S. Tawadros, M. Ailenberg, M. Cantos, K. Szaszi, A. Kapus, J.C. Marshall, O.D. Rotstein. St. Michael’s Hospital, University of Toronto, Toronto, Ontario. Introduction: We have previously reported that oxidative stress contributes to priming of macrophages for increased LPS responsiveness through Src-dependent activation of the PI3 kinase/Akt pathway (J Biol Chem 2003). Recent studies have implicated the lipid ceramide, generated from sphingomyelin via acid sphingomyelinase (ASM), as an important upstream regulator of signaling in inflammation. Other recent reports have suggested that lipid mediators such as ceramide can activate Src kinases. Taken together, we hypothesized that lipid metabolites generated through the ASM pathway may play an important role in oxidant-induced activation of Akt and Src kinase in macrophages. Methods: RAW 264.7 macrophages were transfected in vitro with an ASM siRNA from Santa Cruz using Lipofectamine. A scrambled negative siRNA from Ambion was used as control. After 24hrs of transfection, cells were treated with 300uM hydrogen peroxide (H2O2) for 0-15mins. Western Blot analysis was performed using a phospho-Akt antibody (Ser 473) and a phospho-Src family antibody (Tyr 416). Changes were assessed by densitometry. Results: Molecular inhibition of ASM by siRNA was verified by PCR analysis of ASM mRNA levels compared to control housekeeping gene mRNA levels. Optimal knockdown conditions were found to be 40pmol of ASM siRNA for 24hrs. In the ASM knockdown group, H2O2-induced phosphorylation of Akt was reduced by over 95% at 5mins and 75% at 15mins compared to control. As well, H2O2-induced activation of Src kinase was reduced by over 95% at 5mins compared to control. These results support a role for ASM in generating early lipid mediators of oxidant priming in macrophages. Conclusion: Oxidant-induced activation of Akt and Src kinase is mediated in part by the ASM pathway. ASM and its lipid products may therefore represent upstream targets for modulating oxidant-induced cellular priming.

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DETERMINANTS OF ACCESS TO CARE FOR PEDIATRIC TRAUMA IN SUB-SAHARAN AFRICA A. Mihailovic 1, A. Howard 2, A. Willan 2, P. Coyte 3, A. Nathens 4, D. Urbach 1

1 Dept of Surgery, University of Toronto. 2 Hospital for Sick Children, Toronto, 3 Health Policy, Management and Evaluation, University of Toronto, 4 Dept of Surgery and Trauma Program, St. Michael’s Hospital, Toronto. Introduction: Timely surgical care for severe injury is the most significant determinant of both morbidity and mortality. Determinants of who ultimately receives care varies extensively across geopolitical and socioeconomic settings. The objective of this work was to identify these determinants, at the individual and community level, when children under the age of 14 are seriously injured in a low income country. Methods: 40 primary schools in a district of Kampala, Uganda were randomly selected. From these, 2500 homes were randomly selected in the community. Guardians were interviewed on all serious injuries, requiring at least 1 day from normal activity, in all children under their care in the past 12 months. Questions pertained to variables outlined in the “Andersen Model of Health Care Utilization” framework. Multilevel random effects analysis was used to determine the influence of individual, family and community level variables on a child access health services within 24 hour from injury Results: A child receiving surgical care within 24 hours was found to be predicted mainly by variables pertaining to their family’s demographic characteristics including belief systems, religion and ethnicity. Measures of monetary capital and social connectedness were also significant predictors. Receiving surgical care at any time for a specific injury was mainly predicted by the guardian’s perception of the progressive seriousness of the injury and to a very large extent, their social connectedness (social capital). Conclusions: Our results strongly support the need for local community involvement in addressing the large and growing issue of childhood injury and access to care. Parental representatives and community leaders should be actively engaged by researchers and policy makers, especially in low income countries.

City Wide Trauma Journal Club

Thursday, June 5th 6:00 PM

Rosewater Supper Club

19 Toronto St.

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E ach year in the United States, an estimated 500 000adult patients are transported to hospital after expe-riencing major trauma.1,2 Major trauma can be de-

scribed as life- or limb-threatening injury due to bluntforce, penetrating injury or burn injury. Considering bothfrequency and associated mortality, major trauma is thesecond most important condition for children and thefourth most important condition for adults treated byemergency medical service providers.2 About 20% of thesepatients die, and many survivors are left with permanentdisability.

Throughout most urban areas of the United States andCanada, paramedics provide prehospital advanced life-support to many of these critically injured patients. Ad-vanced life-support protocols include advanced airwaymanagement (endotracheal intubation) and intravenousfluid therapy. In contrast, basic life-support providers ad-minister oxygen, ventilate with a bag valve mask, and pro-vide immobilization and dressings. The relative effective-ness of community-based advanced life-support programsfor major trauma patients has not been clearly established,and there have been calls for larger and more rigorously de-signed studies.3–5

Endotracheal intubation in the field has not been provento reduce mortality and morbidity among severely injured pa-tients, and there are concerns that performing this difficulttask under trying conditions may cause harm.6,7 The value ofprehospital intravenous resuscitation has also been ques-tioned.8,9 In addition, there are concerns that the on-scenetime spent providing advanced life-support measures may ac-

ResearchD

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Ian G. Stiell MD MSc, Lisa P. Nesbitt MHA, William Pickett PhD, Douglas Munkley MD, Daniel W. Spaite MD, Jane Banek CHIM, Brian Field MBA EMCA, Lorraine Luinstra-Toohey BScN MHA,Justin Maloney MD, Jon Dreyer MD, Marion Lyver MD, Tony Campeau MAEd PhD,George A. Wells PhD, for the OPALS Study Group

@ See related article page 1171

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

Background: To date, the benefit of prehospital advancedlife-support programs on trauma-related mortality and mor-bidity has not been established

Methods: The Ontario Prehospital Advanced Life Support(OPALS) Major Trauma Study was a before–after systemwidecontrolled clinical trial conducted in 17 cities. We enrolled adultpatients who had experienced major trauma in a basic life-sup-port phase and a subsequent advanced life-support phase (dur-ing which paramedics were able to perform endotracheal intu-bation and administer fluids and drugs intravenously). Theprimary outcome was survival to hospital discharge.

Results: Among the 2867 patients enrolled in the basic life-support (n = 1373) and advanced life-support (n = 1494)phases, characteristics were similar, including mean age (44.8v. 47.5 years), frequency of blunt injury (92.0% v. 91.4%), me-dian injury severity score (24 v. 22) and percentage of patientswith Glasgow Coma Scale score less than 9 (27.2% v. 22.1%).Survival did not differ overall (81.1% among patients in the ad-vanced life-support phase v. 81.8% among those in the basiclife-support phase; p = 0.65). Among patients with GlasgowComa Scale score less than 9, survival was lower among thosein the advanced life-support phase (50.9% v. 60.0%; p = 0.02).The adjusted odds of death for the advanced life-support v.basic life-support phases were nonsignificant (1.2, 95% confi-dence interval 0.9–1.7; p = 0.16).

Interpretation: The OPALS Major Trauma Study showed thatsystemwide implementation of full advanced life-support pro-grams did not decrease mortality or morbidity for majortrauma patients. We also found that during the advanced life-support phase, mortality was greater among patients withGlasgow Coma Scale scores less than 9. We believe that emer-gency medical services should carefully re-evaluate the indica-tions for and application of prehospital advanced life-supportmeasures for patients who have experienced major trauma.

Abstract

CMAJ 2008;178(9):1141-52

From the Departments of Emergency Medicine (Stiell) and of Epidemiologyand Community Medicine (Wells), University of Ottawa, Ottawa, Ont.; theClinical Epidemiology Program, Ottawa Health Research Institute (Stiell,Nesbitt, Banek, Wells), Ottawa, Ont.; the Department of Emergency Medi-cine (Pickett), Queen’s University, Kingston, Ont.; Greater Niagara BaseHospital (Munkley, Luinstra-Toohey), Niagara Falls, Ont.; the Departmentof Emergency Medicine (Spaite), University of Arizona, Tucson, Ariz.; Inter-dev Technologies (Field), Toronto, Ont.; Ottawa Base Hospital Program(Maloney), Ottawa, Ont.; the Division of Emergency Medicine (Dreyer), Uni-versity of Western Ontario, London, Ont.; the Department of Family Medi-cine (Lyver), McMaster University, Hamilton, Ont.; and Emergency HealthServices (Campeau), Ontario Ministry of Health and Long-Term Care,Toronto, Ont.

CMAJ • April 22, 2008 • 178(9)© 2008 Canadian Medical Association or its licensors

11114411

Une version française de ce résumé est disponible à l’adressewww.cmaj.ca/cgi/content/full/178/9/1141/DC1

Research

tually delay life-saving expeditious transfer to the hospital andthe operating room.10 To date, no large controlled clinical tri-als have been conducted to evaluate the impact of prehospitaladvanced life-support programs on trauma-related mortalityand morbidity.3

As part of the Ontario Prehospital Advanced Life Support(OPALS) studies, we recently demonstrated that advancedlife-support programs had no impact on the outcomes of pa-tients who had experienced cardiac arrest, but they did lead

to significant improvement in survival among patients withrespiratory distress.11,12 The primary objective of the currentstudy, the OPALS Major Trauma Study, was to assess anychange in survival that might result from the systemwide in-troduction of prehospital advanced life-support programs inmultiple cities with existing basic life-support programs pro-vided through emergency medical services. We also evalu-ated the impact of advanced life-support on morbidity andprocesses of care.

CMAJ • April 22, 2008 • 178(9)11114422

Table 1: Characteristics of the 2867* study patients obtained from prehospital and on-scene records (part 1)

Phase of study; no. (%) of patients†

Characteristic Basic life-support phase

n = 1373 Advanced life-support phase

n = 1494 p value

Age, yr n = 1373 n = 1494

Mean (SD) 44.8 (20.9) 47.5 (21.8) 0.001

Min–max 16–97 16–98

Sex, no. (%) male n = 1373 n = 1494

1002 (73.0) 1065 (71.3) 0.33

Community population n = 1373 n = 1494 0.02

< 100 000 (n = 6) 164 (11.9) 147 (9.8) 0.07

100 000–200 000 (n = 5) 251 (18.3) 233 (15.6) 0.06

> 200 000 (n = 6) 958 (69.8) 1114 (74.6) 0.004

Case severity n = 1005 n = 1255 0.87

Minor 35 (3.5) 40 (3.2) 0.70

Moderate 214 (21.3) 277 (22.1) 0.66

Severe 374 (37.2) 486 (38.7) 0.46

Severe or life-threatening 366 (36.4) 433 (34.5) 0.34

Vital signs absent 16 (1.6) 19 (1.5) 0.88

Physiologic measures, mean (SD)

Diastolic blood pressure, mm Hg n = 280 n = 669

79.4 (17.2) 80.3 (38.0) 0.71

Systolic blood pressure, mm Hg n = 710 n = 1094

116.1 (45.3) 127.2 (39.9) 0.001

Respiratory rate, breaths/min n = 1014 n = 1256

20.5 (8.4) 19.1 (6.7) 0.001

Systolic blood pressure at scene n = 681 n = 1077 0.001

< 100 mm Hg 187 (26.3) 178 (16.3) 0.001

≥ 100 mm Hg 523 (73.7) 916 (83.7) 0.001

Glasgow Coma Scale score‡ n = 1340 n = 1450 0.003

Severe (< 9) 365 (27.2) 320 (22.1) 0.002

Moderate (9–12) 133 (9.9) 132 (9.1) 0.46

Minor (13–15) 842 (62.8) 998 (68.8) 0.001

Median (interquartile range) 14 (7–15) 14 (10–15) 0.008

Revised trauma score‡ n = 1227 n = 1341 0.001

0 to < 2 56 (4.6) 36 (2.7) 0.01

2 to < 4 64 (5.2) 42 (3.1) 0.008

4 to < 6 191 (15.6) 193 (14.4) 0.41

6 to 7.84 916 (74.7) 1070 (79.8) 0.002

Median (interquartile range) 7.84 (5.97–7.84) 7.84 (6.9–7.84) 0.001

Research

Methods

DesignWe conducted a systemwide before–after controlled clinicaltrial, the unit of study being individual eligible patients with ma-jor trauma seen during 2 distinct phases: the basic life-supportphase (36 months) and the advanced life-support phase (36months).13 Patient data were pooled across multiple study cities,but the start date for each phase differed, as each community re-

quired different periods to train paramedics to the advanced-life-support standard. The data-collection phases for each citywere separated by intervening run-in periods to allow for train-ing and system optimization. Detailed methods for the majortrauma portion of the OPALS Study were published previously.13

SettingWe conducted the study in 17 cities within the province of On-tario, Canada, with medical oversight for emergency medical

CMAJ • April 22, 2008 • 178(9) 11114433

Table 1: Characteristics of the 2867* study patients obtained from prehospital and on-scene records (part 2)




n = 1494 p value

Nature of injury n = 1371 n = 1494 0.94

Blunt 1262 (92.0) 1366 (91.4) 0.55

Penetrating 80 (5.8) 89 (6.0) 0.89

Burn 29 (2.1) 39 (2.6) 0.38

Extrication required n = 1329 n = 1472

234 (17.6) 303 (20.6) 0.05

Time intervals, min, median (interquartile range) n = 1373 n = 1494

Call received to crew notified 0.9 (0.5–1.4) 0.8 (0.5–1.6) 0.84

Crew notified to vehicle stops — basic life-support

6.0 (4.1–8.7) 6.9 (4.2–10.2) 0.001

Crew notified to vehicle stops — advanced life-support

— 6.5 (4.5–8.8) 0.10

Crew notified to vehicle stops — first 6.0 (4.0–8.7) 6.6 (4.5–9.1) 0.001

Vehicle stops to patient side 2.0 (1.0–2.0) 2.0 (2.0–2.0) 0.001

Patient side to depart scene 13.0 (9.0–18.5) 14.8 (10.6–20.6) 0.001

Depart scene to arrive hospital 6.1 (3.9–10.4) 7.2 (4.4–10.8) 0.001

Total time on scene 15.0 (10.0–20.5) 16.8 (12.6–22.6) 0.001

Total time, notified to arrive hospital 29.7 (23.0–40.1) 34.2 (26.5–43.9) 0.001

Prehospital interventions by emergency medical service n = 1373 n = 1494

Advanced life-support on scene 35 (2.5) 1082 (72.4) 0.001

Ventilation 137 (10.0) 180 (12.0) 0.10

Immobilization n = 1353 n = 1491

993 (73.4) 1120 (75.1) 0.29

Intubation n = 1373 n = 1494

All — 102 (6.8) —

Oral — 68 (4.6) —

Nasal — 34 (2.3) —

Intravenous line inserted n = 1236

— 779 (63.0) —

Intravenous fluid bolus n = 1236

— 144 (11.7) —

Intravenous morphine n = 1236

— 35 (2.8) —

Note: SD = standard deviation. *Some analyses are based on fewer observations than the total n for each phase because of missing data (indicated by n values in columns 2 and 3). †Unless stated otherwise. ‡Glasgow Coma Scale and revised trauma scores reflect the first available record, either prehospital or hospital.

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services provided by 11 provincial base-hospital programs. Thetotal population was 2.5 million, with the population of individ-ual cities varying from 20 000 to 750 000. Two large cities in thejurisdiction, Toronto and Hamilton, were not included becausethey both had pre-existing advanced life-support response sys-tems. Each of the participating centres was served by a provin-cial Central Ambulance Communications Centre, which pro-vided electronic and synchronized dispatch information. Theparamedics documented prehospital care on a standardizedprovincial ambulance call report form. During the basic life-support phase, each community provided a tiered response:firefighters first, followed by primary care paramedics who weretrained to provide all basic life-support measures.

PopulationThe study population consisted of all patients 16 years of ageor older who had been injured by any mechanism, whose in-jury severity score was more than 12, who had been trans-ported by land ambulance and who had been treated at one ofthe 13 lead trauma hospitals in Ontario. Patients could havebeen transferred from a primary hospital or taken directlyfrom the scene to the trauma hospital. Hospital and outcomedata were available from the Ontario Trauma Registry Com-prehensive Data Set.14 We abstracted prehospital informationfrom ambulance call reports and the database of the provin-cial dispatch centre. Excluded were patients younger than 16years, those whose injury had occurred more than 8 hours be-fore the call to emergency medical services and those whowere pronounced dead at the scene. The study received fullapproval by the Ottawa Hospital Research Ethics Board, andthe requirement for informed consent was waived.

InterventionThe study intervention consisted of an advanced life-supportprogram whereby 400 paramedics were trained to perform en-dotracheal intubation, insert intravenous lines and administermedications and fluids intravenously. The Ontario Ministry ofHealth and Long-Term Care funded this advanced life-supportprogram and has estimated that the total cost of training andoperational upgrades was $15.8 million. All of these para-medics had previously completed a 10-month community col-lege program and had several years of experience. For thestudy, the paramedics completed training to meet the Cana-dian Medical Association’s Emergency Medical TechnicianLevel III standards; this training involved 6 weeks of didacticinstruction, 6 weeks of clinical instruction and a 12-week pre-ceptorship (training in the field). To qualify for the advancedlife-support phase of the OPALS Study, each community hadto meet the following criteria for cardiac arrest patients: para-medics responded to 95% of cases, paramedics arrived at thescene within 11 minutes for 80% of cases, and paramedics suc-cessfully performed endotracheal intubation for 90% of cases.Of the original 20 communities considered for this study, 3did not meet these standards and were excluded.

Outcome measuresThe primary outcome, survival to hospital discharge, was de-fined as the patient leaving the hospital alive or being trans-

ferred to a long-term care facility; we obtained these datafrom hospital records. In addition, we measured disease-specific quality of life with the 7-level functional independ-ence measure for survivors.15

Data analysisThe sample size available for analyzing the primary outcome(survival to hospital discharge) was determined from thenumber of available cases in the study communities before(n = 1373) and after (n = 1494) introduction of advanced life-support services. Given a set of 4 assumptions (2-sided α =0.05, β = 0.20, baseline survival = 81.9%, and 1:1.09 ratio ofpatients in the 2 study phases), we estimated that the mini-mum absolute difference in the primary outcome that was de-tectable between the study phases was 3.8% (85.7% advancedlife-support v. 81.9% basic life-support). We tested the pri-mary hypothesis of improvement in survival rates from thebasic life-support phase to the advanced life-support phase byχ2 analysis techniques. All p values are 2-tailed.

We captured data for the following potential confounders:demographic characteristics (age, sex, community); prehos-pital variables (case severity, systolic and diastolic blood pres-sure, respiratory rate, Glasgow Coma Scale score, revisedtrauma score,16 nature of injury, requirement for extrication,the response-time intervals “crew notified to vehicle stops,”“vehicle stops to patient side,” “patient side to depart scene”and “depart scene to arrive hospital emergency department”);measures of specific advanced life-support interventions(ventilation, oral and nasal intubation, intravenous adminis-tration of fluids, administration of morphine); and hospitalvariables from the records of the lead trauma hospital (Glas-gow Coma Scale score, revised trauma score, injury severityscore, abbreviated injury score by body region,17 externalcause of injury code from the 9th revision of the InternationalClassification of Diseases, direct admission or transfer fromanother primary or secondary hospital, intensive care). Incases during the second phase of the study where basic life-support and advanced life-support crews were both sent tothe scene, the first response time or the shortest response in-terval was employed in analytical comparisons.

We assessed the match of injury severity between theOPALS Study patients and the reference group of the earlierMajor Traum Outcome Study by phase using the “M statis-tic,” as described in trauma score and injury severity scoremethodology.18,19 The M statistic ranges from 0 to 1, with avalue close to 1 indicating a good match and a value close to 0indicating a disparity in the injury severity match. We ex-pressed the clinical importance of the difference between theobserved (OPALS) and expected (Major Trauma OutcomeStudy) number of survivors as the “W statistic,” and we com-pared the mean increase or decrease in the number of sur-vivors per 100 patients treated with norm expectations. Weexpressed the statistical significance of the difference in sur-vival in the OPALS study population relative to the MajorTrauma Outcome Study population with the “Z statistic.” Ab-solute Z values exceeding 1.96 indicate a statistically signifi-cant difference in observed v. predicted survival rates.

We compared outcomes between phases for the following

CMAJ • April 22, 2008 • 178(9)11114444

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CMAJ • April 22, 2008 • 178(9) 11114455

Table 2: Characteristics of the 2867* study patients obtained from records of lead trauma hospital




n = 1494 p value

Clinical measures

Glasgow Coma Scale score‡ n = 1340 n = 1450 0.03

Severe (< 9) 344 (25.7) 328 (22.6) 0.06

Moderate (9–12) 110 (8.2) 96 (6.6) 0.11

Minor (13–15) 886 (66.1) 1026 (70.8) 0.008


Revised trauma score‡ n = 1227 n = 1341 0.02

0 to < 2 47 (3.8) 33 (2.5) 0.05

2 to < 4 57 (4.6) 38 (2.8) 0.02

4 to < 6 190 (15.5) 208 (15.5) 0.99

6 to 7.84 933 (76.0) 1062 (79.2) 0.06

Median (interquartile range) 7.84 (6.38–7.84) 7.84 (6.90–7.84) 0.001

Abbreviated injury score by body region, mean (SD) n = 1373 n = 1494

Head and neck 2.8 (2.2) 3.2 (2.5) 0.001

Face 0.3 (0.8) 0.4 (0.8) 0.41

Chest 2.1 (2.6) 2.1 (2.7) 0.70

Abdomen 0.8 (1.5) 0.9 (1.7) 0.20

Extremities and pelvic girdle 1.5 (1.9) 1.6 (2.1) 0.60

External 0.6 (0.9) 0.7 (1.0) 0.02

Injury severity score by category§ n = 1372 n = 1494 < 0.001

12–15 185 (13.5) 145 (9.7) 0.002

16–24 512 (37.3) 669 (44.8) 0.001

25–40 541 (39.4) 524 (35.1) 0.02

41–49 66 (4.8) 90 (6.0) 0.15

50–74 42 (3.1) 43 (2.9) 0.77

75 26 (1.9) 23 (1.5) 0.46


External cause of injury (ICD-9 code)§ n = 1328 n = 1494 0.001

Motor vehicle collision 697 (52.5) 675 (45.2) 0.001

Fall 334 (25.2) 440 (29.5) 0.01

Other road vehicle incident 29 (2.2) 30 (2.0) 0.75

Struck by or against object 21 (1.6) 38 (2.5) 0.08

Purposefully inflicted by other 103 (7.8) 144 (9.6) 0.08

Self-inflicted 62 (4.7) 53 (3.5) 0.13

Other or unknown 82 (6.2) 114 (7.6) 0.13

Care at lead trauma hospital n = 1373 n = 1494

Intubation 206 (15.1) 235 (15.9) 0.57

Admission

Transferred from primary hospital 411 (29.9) 380 (25.4) 0.007

Directly to lead trauma hospital only 962 (70.1) 1114 (74.6) 0.007

Specialized care unit 767 (55.9) 1036 (69.3) 0.001

Duration of medical care, d, mean (SD) n = 767 n = 1036

Specialized (e.g., intensive) care 8.5 (11.0) 7.6 (10.5) 0.08

Total hospital stay n = 1373 n = 1494

22.7 (35.8) 17.0 (21.8) 0.001

Note: ICD-9 = International Classification of Diseases, 9th revision. *Some analyses are based on fewer observations than the total n for each phase because of missing data (indicated by n values in columns 2 and 3). †Unless stated otherwise. ‡Glasgow Coma Scale and revised trauma scores reflect the lead hospital record or (if unavailable) the last prehospital or hospital record. §Classified according to levels in the Multiple Trauma Outcome Study.19

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a priori subgroups: community size, nature of injury, externalcause of injury, injury severity, Glasgow Coma Scale score,systolic blood pressure, abbreviated injury score and patientage. We also developed a series of multiple logistic regressionmodels to assess the effects of study interventions (studyphase, advanced life-support on site, and specific advancedlife-support interventions) on patient nonsurvival, while si-multaneously controlling for confounders indicated by thetrauma score and injury severity score methodology.

Results

A total of 2867 patients were enrolled during the basic life-support phase (n = 1373; total period July 1, 1992, to Feb. 28,1998) and advanced life-support phase (n = 1494; total pe-riod Feb. 1, 1998, and June 30, 2002) for all cities. Patients inthe 2 phases were similar for most characteristics obtainedfrom the prehospital (Table 1) and trauma hospital (Table 2)records. Compared with patients in the basic life-supportphase, those in the advanced life-support phase were slightlyolder and from larger communities, had higher mean sys-tolic blood pressure and lower respiratory rates, and had lesssevere injuries as indicated by Glasgow Coma Scale scoresand revised trauma scores. During the advanced life-support

phase, 6.8% of patients were intubated, which represents asuccess rate of 71.8% of cases in which intubation was at-tempted. In addition, intravenous access was established in63.0% of patients, which represents a success rate of 90.3%for all attempts. Overall, 11.7% of the patients received intra-venous fluid bolus therapy. According to hospital records(Table 2), patients in the advanced life-support phase hadless severe injuries (as indicated by Glasgow Coma Scalescore, revised trauma score, abbreviated injury scale and in-jury severity score), were more likely to have had a fall andless likely to have been involved in a motor vehicle collision,and were more likely to have been directly admitted to thelead trauma hospital compared with patients in the basiclife-support phase.

There was no substantial difference in overall survival tohospital discharge by study phase (81.8% for the basic life-support phase v. 81.1% for the advanced life-support phase;p = 0.65) (Table 3). In addition, the proportion of earlydeaths, within 24 hours, did not differ. More patients in theadvanced life-support phase than in the basic life-supportphase were judged by the paramedics to have “improved enroute to hospital” (5.3% v. 10.1%; p < 0.001). There were nodifferences in morbidity between the phases, as indicated bythe Glasgow outcome scale and functional independence

CMAJ • April 22, 2008 • 178(9)11114466

Table 3: Survival and other clinical outcomes during the 2 study phases*


Outcome Basic life-support phase


n = 1494 p value Absolute difference

(95% CI)

Primary n = 1373 n = 1494

Survival to hospital discharge 1123 (81.8) 1212 (81.1) 0.65 –0.7 (–3.6 to 2.2)

Death < 24 h n = 1330 n = 1439

93 (7.0) 103 (7.2) 0.86 0.2 (–1.7 to 2.1)

Secondary

Condition en route to hospital n = 1034 n = 1278

Improved 55 (5.3) 129 (10.1) 0.001 4.8 (2.6 to 7.0)

Worsened 841 (81.3) 1065 (83.3) 0.21 2.0 (–1.2 to 5.2)

No change 129 (12.5) 76 (5.9) 0.001 –6.5 (–9.0 to 4.1)

Vital signs absent 9 (0.9) 8 (0.6) 0.49 –0.2 (–1.0 to 0.5)

Glasgow outcome score at discharge n = 629 n = 598

Good recovery 271 (43.1) 234 (39.1) 0.16 –4.0 (–9.5 to 1.6)

Moderate disability 68 (10.8) 56 (9.4) 0.40 –1.5 (–4.9 to 2.0)

Severe disability 103 (16.4) 119 (19.9) 0.11 3.5 (–0.9 to 7.9)

Vegetative state 11 (1.7) 12 (2.0) 0.73 0.3 (–1.4 to 1.9)

Death 176 (28.0) 177 (29.6) 0.53 1.6 (–3.1 to 6.8)

Functional independence measure, mean (SD) n = 762 n = 990

At discharge 95.0 (28.6) 94.2 (28.2) 0.54 –0.8 (–3.5 to 1.9)

At 6 mo after discharge n = 455 n = 692

115.3 (21.0) 116.2 (20.2) 0.47 0.9 (–1.6 to 3.3)

Note: CI = confidence interval. *Some analyses are based on fewer observations than the total n for each phase because of missing data (indicated by n values in columns 2 and 3). †Unless stated otherwise.

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CMAJ • April 22, 2008 • 178(9) 11114477

Table 4: Survival to hospital discharge (primary outcome) among clinically important subgroups

Phase of study; % of patients discharged alive

Subgroup characteristic No. of patients

n = 2867 Basic life-support phase

(47.9% of total) Advanced life-support phase

(52.1% of total) p value

Community by population size 0.68

< 100 000 (n = 6) 311 90.2 85.7 0.22

100 000–200 000 (n = 5) 484 74.5 78.1 0.35

> 200 000 (n = 6) 2072 82.3 81.1 0.52

Nature of injury 0.73

Blunt 2628 82.7 81.5 0.41

Penetrating 169 73.8 78.7 0.45

Burn 68 62.1 74.4 0.28

External cause of injury (selected) NA

Motor vehicle collision 1372 84.8 84.6 0.92

Fall 774 78.4 73.4 0.11

Purposefully inflicted by other 247 87.4 87.5 0.98

Self-inflicted 115 67.7 66.0 0.85

Systolic blood pressure at scene, mm Hg 0.39

< 100 365 69.0 68.0 0.84

≥ 100 1439 87.6 85.7 0.32

Glasgow Coma Scale score 0.19

< 9 685 60.0 50.9 0.02

9–15 2105 90.5 90.1 0.83

Injury severity score 0.22

< 25 1511 95.8 94.3 0.18

≥ 25 1355 67.3 65.3 0.44

Patient age, yr 0.98

< 30 795 86.8 89.3 0.28

30–54 1104 87.2 87.1 0.97

≥ 55 965 70.5 68.8 0.57

Abbreviated injury score by body region

Score 1–3 NA

Head and neck 670 94.4 92.0 0.22

Face 521 84.0 84.1 0.98

Chest 583 90.0 86.2 0.16

Abdomen 472 87.0 90.1 0.29

Extremities or pelvic girdle 1077 87.5 86.2 0.52

External 1270 85.2 83.6 0.42

Score 4–5 NA

Head and neck 752 72.8 72.5 0.91

Face 2 100.0 NA NA

Chest 236 74.4 70.9 0.54

Abdomen 205 74.3 80.8 0.26

Extremities or pelvic girdle 66 66.7 83.3 0.12

External 58 60.7 76.7 0.19

Patient transport 0.69

Transferred from primary hospital 791 82.2 81.1 0.67

Direct from scene to lead trauma hospital 2076 81.6 81.1 0.79

Advanced life-support crew on scene*

No 412 NA 86.4 0.001

Yes 1082 NA 79.1

Note: NA = not applicable. *Comparison of survival between patients with and without advanced life-support crew on scene, for the advanced life-support phase only.

Research

measure at discharge and 6 months after discharge.For most of the a priori subgroups examined, there was

also no difference in survival to hospital discharge by studyphase (Table 4). The exception were the 598 cases with an ini-tial Glasgow Coma Scale score of less than 9, for whom sur-vival was lower in the advanced life-support phase than in thebasic life-support phase (60.1% v. 51.2%; p = 0.03). Withinthe advanced life-support phase, survival was lower for casesin which an advanced life-support crew attended the traumascene than for those attended by basic life-support crews only(86.4% for basic life-support v. 79.1% for advanced life-support; p < 0.001). The trauma cases in both phases of thisstudy were more severe than norms from the Major TraumaOutcome Study (M = 0.67 and 0.70 for basic and advancedlife-support phases, respectively). The number of survivors ineach phase of the OPALS Study was not substantially differentfrom that predicted by Major Trauma Outcome Study norms(Z = 0.72 for basic life-support phase, Z = –0.62 for advancedlife-support phase).

To better understand the factors influencing survival, wecompared survivors with nonsurvivors (Table 5) and thenconducted several logistic regression analyses to assess theeffects of study interventions on patient mortality while con-trolling for potential confounding variables (Figure 1, Figure2, Figure 3, Figure 4; Appendix 1, available online at www.cmaj.ca/cgi/content/full/178/9/1141/DC2). In all models,

poorer survival was associated with older age, higher injuryseverity score and lower revised trauma score (i.e., more se-vere). We found that the adjusted odds ratio (OR) for mortal-ity between the advanced life-support and basic life-supportphases was not significant when we used the revised traumascore obtained from the trauma hospital (adjusted OR 1.2,95% confidence interval [CI] 0.9–1.7; Figure 1), but it was sig-nificant when we used the prehospital revised trauma score(adjusted OR 1.4, 95% CI 1.0–1.9; Figure 2). The presence ofadvanced life-support providers at the scene was associatedwith increased mortality (adjusted OR 1.5, 95% CI 1.1–2.0;Figure 3). In addition, intubation in the field was associatedwith increased mortality (adjusted OR 2.8, 95% CI 1.6–5.0;Figure 4), and intravenous fluid therapy was associated withno benefit (adjusted OR 0.8, 95% CI 0.4–1.4).

Interpretation

In this controlled clinical trial, we found that the systemwideimplementation of prehospital advanced life-support did notdecrease mortality or morbidity among major trauma victims.Despite the large sample, controlled design and multiple ap-proaches to the analysis, we found no evidence of benefit inany clinically relevant subgroup of patients. To the contrary,the evidence suggested that patients with Glasgow ComaScale scores less than 9 had worse survival during the ad-

CMAJ • April 22, 2008 • 178(9)11114488

Table 5: Exploratory univariable association of patient and emergency medical services factors with survival to hospital discharge for 2866* patients with major trauma

Survival; median (interquartile range)†

Characteristic Survived n = 2334

Did not survive n = 532 p value

Patient n = 2334 n = 532

Age, yr, mean (SD) 43.8 (20.2) 56.6 (23.3) < 0.001

Sex, no. (%) males 1656 (71.0) 349 (65.6) 0.08

Initial injury severity score 20 (16–26) 26 (25–41) < 0.001

Glasgow Coma Scale score n = 2282 n = 508

Initial 15 (12–15) 6 (3–14) < 0.001

Final 15 (13–15) 5.5 (3–14) < 0.001

Revised trauma score n = 2148 n = 420

Initial 7.84 (6.90–7.84) 5.68 (3.29–7.84) < 0.001

Final 7.84 (7.11–7.84) 5.56 (3.38–7.55) < 0.001

Initial systolic blood pressure, mm Hg n = 2326 n = 514

128 (110–146) 120 (71–158) < 0.001

Emergency medical services n = 2334 n = 532

Time from receipt of call to patient side, min 9.3 (7.0–13.0) 8.8 (7.0–11.8) 0.008

Advanced life support phase of study, no. (%) 1212 (51.9) 282 (53.0) 0.67

Advanced life support at scene, no. (%) 876 (37.5) 233 (43.8) 0.008

Intubation in field, no. (%) 35 (1.5) 67 (12.6) < 0.001

Intravenous fluid bolus administered in field, no. (%) 107 (4.6) 37 (7.0) 0.03

*Some analyses are based on fewer observations because of missing data (indicated by n values in columns 2 and 3). †Unless stated otherwise.

Research

vanced life-support phase than during the basic life-supportphase. Our findings support those who believe that definitivetrauma care is best provided in the operating room and thatprehospital interventions may be associated with increasedcomplications or may delay transfer to hospital.

Controlled clinical trials of critically injured patients aredifficult to conduct, particularly in the out-of-hospital setting,and observers have called for better evidence from more rig-orous studies.3–5 Previous evaluations of advanced life-support programs have generally had small numbers or haveused observational methods.20–26 These studies generallyfound no support for prehospital advanced life-support

measures in major trauma. Although our study evaluated thepackage of interventions that is considered part of advancedlife-support protocols, endotracheal intubation and intra-venous fluid administration were the dominant elements ofthe protocols of care. We documented higher mortalityamong patients undergoing prehospital endotracheal intuba-tion even after controlling for age, injury severity and physio-logic measures. It seems intuitive that intubation would helpsome trauma patients in the field, but there is surprisingly lit-tle evidence to support aggressive airway management byparamedics. Multiple studies have found no benefit fromparamedic intubation of patients with head injury.23,27–30

CMAJ • April 22, 2008 • 178(9) 11114499

Increased riskof death

Decreased riskof deathOutcome OR (95% CI)

Adjusted OR (95% CI)

0 0.5 1.0 1.5 2.0 2.5

Age, per 10 yr 1.8 (1.7–2.0)

Injury severity score, per 10 units 1.9 (1.6–2.2)

Revised trauma score (final),* per unit 0.5 (0.4–0.5)

Call time,† per minute 1.0 (1.0–1.0)

Advanced v. basic life-support phase 1.2 (0.9–1.7)

Figure 1: Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) evaluating factors associated with mortality at hospital dis-charge. Model incorporates study phase and final (hospital) revised trauma score as predictors of mortality. Goodness-of-fit: p > 0.20.*Final assessment of revised trauma score represents value from lead trauma hospital; if missing, the value from the scene was used.†Time from call received to arrival of crew at patient side.


Age, per 10 yr 1.9 (1.8–2.1)


Revised trauma score (initial),* per unit 0.5 (0.4–0.5)


Advanced v. basic life-support phase 1.4 (1.0–1.9)

0 0.5 1.0 1.5 2.0 2.5

Outcome OR (95% CI)


Decreased riskof death

Figure 2: Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) evaluating factors associated with mortality at hospital dis-charge. Model incorporates study phase and initial (field) revised trauma score as predictors of mortality. Goodness-of-fit: p > 0.20.*Initial assessment of revised trauma score represents value from the scene; if missing, the value from the lead trauma hospital wasused. †Time from call received to arrival of crew at patient side.

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Other observational studies have suggested worse outcomesfor patients with head injury who are intubated in thefield.31,32 Rapid-sequence intubation techniques that employneuromuscular blockade are particularly controversial, andexpectations of benefit have not been confirmed by controlledstudies.6,7,33–38 Three retrospective studies suggested that fieldintubation by ground or aeromedical paramedics was associ-ated with better survival among patients with traumatic braininjury.33–35 These expectations of benefit have not been con-

firmed by controlled studies. In addition, ours was the firstlarge-scale controlled study to evaluate intravenous fluid ther-apy in patients with blunt trauma and head injury, but no ben-efit was observed. Lack of effectiveness of intravenous fluidtherapy has been previously demonstrated, especially for pa-tients with penetrating trauma to the torso.8,9,39,40

The strengths of our study include the large number of pa-tients, the involvement of communities of differing sizeacross a broad geographic area and a controlled design that

CMAJ • April 22, 2008 • 178(9)11115500


Age, per 10 yr 1.9 (1.8–2.1)


Revised trauma score (initial),* per unit 0.5 (0.4–0.5)


Advanced life-support at scene 1.5 (1.1–2.0)

0 0.5 1.0 1.5 2.0 2.5

Outcome OR (95% CI)



Figure 3: Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) evaluating factors associated with mortality at hospital dis-charge. Model incorporates advanced life-support provided at the scene as predictor of mortality. Goodness-of-fit: p > 0.20. *Initial as-sessment of revised trauma score represents value from the scene; if missing, the value from the lead trauma hospital was used. †Timefrom call received to arrival of crew at patient side.


Age, per 10 yr 1.8 (1.7–2.0)


Glasgow Coma Scale score (initial),* per unit 0.8 (0.8–0.8)

Systolic blood pressure (initial),* per unit 1.0 (1.0–1.0)

Call time, per minute 1.0 (1.0–1.0)

0 1.0 2.0 3.0 4.0 5.0 6.0

Intubation at scene 2.8 (1.6–5.0)

Intravenous fluid at scene 0.8 (0.4–1.4)

Outcome OR (95% CI)



Figure 4: Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) evaluating factors associated with mortality at hospital dis-charge. Model incorporates advanced life-support interventions as predictors of mortality. Goodness-of-fit: p > 0.20. *Initial assess-ments of Glasgow Coma Scale score and systolic blood pressure represent values from the scene; if missing, the value from the leadtrauma hospital was used. †Time from call received to arrival of crew at patient side.

Research

included a complete population-based sample. Training ofthe paramedics involved a standardized national curriculumand clinical training period. All trainees were experiencedemergency medical technicians and had the benefit of a 6- to36-month run-in period in which to perfect their skills. Theparamedics were skilful at performing procedures in thesedifficult cases; we previously demonstrated that, for patientswho had experienced cardiac arrest, these same paramedicswere able to successfully intubate in 93.7% of cases and tostart an intravenous line in 89.0%.11 The crews arrived atscene in a timely fashion (median 6.6 minutes).

An important potential limitation is that this study was de-signed as a before–after controlled trial, rather than as a ran-domized trial. However, we do not believe that this under-mines the validity of the findings. Randomization by patientwas not possible, because the paramedics considered it un-ethical to randomly withhold potentially life-saving proce-dures from patients. Selection bias was minimized by thepopulation-based approach, whereby all patients from thestudy communities who had been treated at the regionaltrauma centre were included. We are not aware of any impor-tant new therapies or any general societal increase in survivalrates among patients experiencing major trauma during thestudy period. Nevertheless, multiple statistical approacheswere taken to ensure the validity and robustness of our out-come measures.

The implications of this study are that community emer-gency medical services should carefully re-evaluate the use ofadvanced life-support measures for most trauma patients.Our data showed no benefit for any group of patients. Fur-thermore, we are concerned that the patients with head injurywho had a Glasgow Coma Scale score of less than 9 appearedto have higher mortality during the advanced life-supportphase than during the basic life-support phase. We note that,after controlling for age, injury severity and physiologic meas-ures, intubation in the field had an odds ratio for mortality of2.8. These data should lead to a re-evaluation of the indica-tions for and application of advanced life-support measuresin the field for trauma patients in urban areas. These findingscannot be extrapolated to either the care of trauma patients inrural settings or advanced life-support care for patients withnontraumatic conditions such as respiratory distress andchest pain. To prevent the deleterious effects of misplacedtubes, hypoxia and hypercapnea, prehospital intubation oftrauma patients should always be accompanied by continu-ous pulse oximetry as well as end-tidal carbon dioxide moni-toring and recording.

Conclusion

The implementation of full prehospital advanced life-supportby trained paramedics was not associated with lower mortal-ity rates relative to basic life-support measures for patientswith major trauma. Furthermore, our evidence indicates that,for patients with suspected head injuries and a GlasgowComa Scale score of less than 9, mortality was greater duringthe advanced life-support phase of the study than during thebasic life-support phase. On the basis of these findings, we

suggest that emergency medical services should carefully re-evaluate the indications for and application of prehospital ad-vanced life-support measures for patients with major trauma.

REFERENCES1. McCaig LF, Ly N. National Hospital Ambulatory Medical Care Survey: 2000 emer-

gency department summary. Adv Data 2002;(326):1-30. 2. Maio RF, Garrison HG, Spaite DW, et al. Emergency Medical Services Outcomes

Project I (EMSOP I): prioritizing conditions for outcomes research. Ann EmergMed 1999;33:423-32.

3. Spaite DW, Criss EA, Valenzuela TD, et al. Prehospital advanced life support formajor trauma: critical need for clinical trials. Ann Emerg Med 1998;32:480-9.

4. Carrico CJ, Holcomb JB, Chaudry IH; PULSE Trauma Work Group. Scientific prior-ities and strategic planning for resuscitation research and life saving therapy fol-lowing traumatic injury: report of the PULSE Trauma Work Group. Post Resuscita-tive and Initial Utility of Life Saving Efforts. Shock 2002;17:165-8.

5. Lewis RJ. Prehospital care of the multiply injured patient: the challenge of figuringout what works. JAMA 2004;291:1382-4.

6. Spaite DW, Criss EA. Out-of-hospital rapid sequence intubation: Are we helping orhurting our patients? Ann Emerg Med 2003;42:729-30.

7. Zink BJ, Maio RF. Out-of-hospital endotracheal intubation in traumatic brain in-jury: outcomes research provides us with an unexpected outcome. Ann Emerg Med2004;44:451-3.

8. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation forhypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-9.

9. Pepe PE. Controversies in resuscitation: to infuse or not to infuse (2). Resuscita-tion 1996;31:7-10.

10. Spaite DW, Tse DJ, Valenzuela TD, et al. The impact of injury severity and prehos-pital procedures on scene time in victims of major trauma. Ann Emerg Med 1991;20:1299-305.

CMAJ • April 22, 2008 • 178(9) 11115511

This article has been peer reviewed.

Competing interests: None declared.

Contributors: Ian Stiell and George Wells conceived the study, designed thetrial and obtained research funding. Ian Stiell and Lisa Nesbitt supervised theconduct of the trial and data collection. Ian Stiell, Lisa Lesbitt, William Pickett,Douglas Munkley, Daniel Spaite, Jane Banek, Brian Field, Lorraine Luinstra-Toohey, Justin Maloney, Joe Dreyer, Marion Lyver and Tony Campeau recruitedthe participating centres and managed the data, including quality control. IanStiell, Lisa Nesbitt, William Pickett and George Wells provided statistical adviceon study design and analyzed the data. Ian Stiell drafted the manuscript, and allof the authors contributed substantially to its revision and approved the finalversion. Ian Stiell takes responsibility for the paper as a whole.

Acknowledgements: We thank the OPALS Study Group investigators fromthe following network of Ontario base hospitals: Burlington: Matthew W.Stempien MD, Carrie I. Parkinson BScN; Cambridge: David Waldbillig MD,Kieran W. Ballah EMCA; Kingston: Gordon J. Jones MD, Mark R. HalladayEMCA; London: Kenneth A. Boyle EMCA; Ottawa: John P. Trickett BScN; Pe-terborough: Vincent Arcieri MD, John W. Fader BSc; Sarnia: Martin G.J. LeesMD, Dallas D. LaBarre EMCA; Sudbury: Robert S. Lepage MD, Sylvie Salmi-nen EMCA; Thunder Bay: Andrew W. Affleck MD, Tara A. Tyson BAdmin;Windsor: James C. Fedoruk MD, Meikel Gobet EMCA.

This study was funded by peer-reviewed grants from the EmergencyHealth Services Branch of the Ontario Ministry of Health and Long-TermCare and the Canadian Health Services Research Foundation. These govern-ment agencies had no role in the study design; the collection, analysis or in-terpretation of data; the writing of the report; or the decision to submit thepaper for publication.

We thank Julie Cummins for assistance with preparation of the manu-script. We also thank the other members of the OPALS Study CoordinatingCentre: David Brisson and Tammy Beaudoin (research staff), CatherineClement (editing), Irene Harris (administrative support), My-Linh Tran (pro-gramming) and Sheryl Domingo (data entry). We thank Cathy Francis of theOntario Ministry of Health and Long-Term Care for her support, contributingstaff members from our network of Ontario base hospitals and the many pri-mary care and advanced care paramedics who participated in the OPALS Study.

Ian Stiell holds a Distinguished Professorship and a University Health Re-search Chair from the University of Ottawa.

Disclaimer: George Wells is a coauthor of this article. As a biostatistics con-sultant of CMAJ, he was not involved in the vetting of the manuscript beforeits acceptance.

Research

11. Stiell IG, Wells GA, Field BJ, et al. Advanced cardiac life support in out-of-hospitalcardiac arrest. N Engl J Med 2004;351:647-56.

12. Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respi-ratory distress. N Engl J Med 2007;356:2156-64.

13. Stiell IG, Wells GA, Spaite DW, et al. The Ontario Prehospital Advanced Life Sup-port (OPALS) Study Part II: rationale and methodology for trauma and respiratorydistress patients. Ann Emerg Med 1999;34:256-62.

14. Pickett W, Simpson K, Brison RJ. Rates and external causes of head trauma inOntario: analysis and review of Ontario Trauma Registry datasets. Chronic Dis Can2004;25:32-41.

15. Stineman MG, Shea JA, Jette A, et al. The Functional Independence Measure: testsof scaling assumptions, structure and reliability across 20 diverse impairment cate-gories. Arch Phys Med Rehabil 1996;77:1101-8.

16. Champion HR, Sacco WJ, Copes WS, et al. A revision of the Trauma Score. JTrauma 1989;29:623-9.

17. MacKenzie EJ. Injury severity scales: overview and directions for future research.Am J Emerg Med 1984;2:537-49.

18. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method.Trauma Score and the Injury Severity Score. J Trauma 1987;27:370-7.

19. Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study:establishing national norms for trauma care. J Trauma 1990;30:1356-65.

20. Jacobs LM, Sinclair A, Beiser A, et al. Prehospital advanced life support: benefits intrauma. J Trauma 1984;24:8-13.

21. Potter D, Goldstein G, Fung SC, et al. A controlled trial of prehospital advanced lifesupport in trauma. Ann Emerg Med 1988;17:582-8.

22. Cayten CG, Murphy JG, Stahl WM. Basic life support versus advanced life supportfor injured patients with an injury severity score of 10 or more. J Trauma 1993;35:460-7.

23. Eckstein M, Chan L, Schneir A, et al. Effect of prehospital advanced life support onoutcomes of major trauma patients. J Trauma 2000;48:643-8.

24. Liberman M, Mulder D, Sampalis JS. Advanced or basic life support for trauma:meta-analysis and critical review of the literature. J Trauma 2000;49:584-99.

25. Liberman M, Mulder D, Lavoie A, et al. Multicenter Canadian study of prehospitaltrauma care. Ann Surg 2003;237:153-60.

26. Lee A, Garner A, Fearnside M, et al. Level of prehospital care and risk of mortalityin patients with and without severe blunt head injury. Injury 2003;34:815-9.

27. Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients withsevere head injury. J Trauma 2000;49:1065-70.

28. Bochicchio GV, Ilahi O, Joshi M, et al. Endotracheal intubation in the field does

not improve outcome in trauma patients who present without an acutely lethaltraumatic brain injury. J Trauma 2003;54:307-11.

29. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital endotracheal intubationon outcome in moderate to severe traumatic brain injury. J Trauma 2005;58:933-9.

30. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotra-cheal intubation on survival and neurological outcome: a controlled clinical trial.JAMA 2000;6:783-90.

31. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubationon outcome in patients with severe traumatic brain injury. J Trauma 2003;54:444-53.

32. Wang HE, Peitzman AB, Cassidy LD, et al. Out-of-hospital endotracheal intubationand outcome after traumatic brain injury. Ann Emerg Med 2004;44:439-50.

33. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in pa-tients with severe head injury. Trauma Research and Education Foundation of SanDiego. Arch Surg 1997;132:592-7.

34. Bulger EM, Copass MK, Sabath DR, et al. The use of neuromuscular blockingagents to facilitate prehospital intubation does not impair outcome after traumaticbrain injury. J Trauma 2005;58:718-24.

35. Davis DP, Peay J, Serrano JA, et al. The impact of aeromedical response to patientswith moderate to severe traumatic brain injury. Ann Emerg Med 2005;46:115-22.

36. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emer-gency medical services system. Ann Emerg Med 2001;37:32-7.

37. Dunford JV, Davis DP, Ochs M, et al. Incidence of transient hypoxia and pulse ratereactivity during paramedic rapid sequence intubation. Ann Emerg Med 2003;42:721-8.

38. Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventilationon outcome after paramedic rapid sequence intubation of severely head-injuredpatients. J Trauma 2004;57:1-10.

39. Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital fluids on survival intrauma patients. J Trauma 1990;30:1215-9.

40. Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscita-tion of patients with hypotension and severe traumatic brain injury: a randomizedcontrolled trial. JAMA 2004;291:1350-7.

CMAJ • April 22, 2008 • 178(9)11115522

Correspondence to: Dr. Ian G. Stiell, Clinical Epidemiology Unit,Rm. F657, Ottawa Health Research Institute, The OttawaHospital — Civic Campus, 1053 Carling Ave., Ottawa ONK1Y 4E9; fax 613 761-5351; [email protected]

The U.S. Trauma Surgeon’s Current Scope of Practice: CanWe Deliver Acute Care Surgery?C. Clay Cothren, MD, Ernest E. Moore, MD, and David B. Hoyt, MD

Background: The evolving disciplineof acute care surgery as an expansion oftrauma surgery is undergoing intense cri-tique. As we envision this new paradigmof surgical practice, an evaluation of ourcurrent status across the nation’s traumacenters is an essential step. The purpose ofthis study is to determine the practice pat-terns of trauma surgeons at major traumacenters throughout the United States.

Methods: A survey was sent to thetrauma directors of the 1,288 designatedtrauma centers in the United States, as listedby the American Trauma Society. As pro-posed, acute care surgery would encompassperforming emergent abdominal, vascular,and thoracic trauma procedures as well asproviding critical care. The addition of sim-

ple orthopedic and neurosurgical proce-dures has been considered.

Results: The survey response ratewas 72% among the Level I/II/III centers(n � 515) with 92% of Level I, 72% ofLevel II, and 59% of Level III centersresponding. Of the 169 Level I centers, 31(18%) reported their trauma surgeonsperform the full complement of thoracic,vascular, and abdominal cases. Traumasurgeons managed the full range of inju-ries at 11 (6%) of the 187 Level II centersand 7 (4%) of the 159 Level III centers. Atthese 49 centers, only 41% of surgeonsperform elective thoracic and vascularcases. The remaining 466 centers enlist acombination of vascular and thoracic sur-geons to manage trauma patients. Finally,

trauma surgeons performed cranial burrholes at eight trauma centers, placementof ICP monitors at four, and open frac-ture washout at three trauma centers.

Conclusions: The model of the acutecare surgeon is attractive and timely, butonly a limited number of trauma surgeonscurrently practice this proposed range ofoperative procedures; even fewer sur-geons have an elective surgical practice tomaintain key operative skills. Fellowshiptraining programs need to incorporatevascular and thoracic procedures to en-able the specialty of acute care surgery.

Key Words: Acute care surgery,Trauma, Emergency surgery, Vascular,Thoracic, Urgent surgery.

J Trauma. 2008;64:955–968.

To adapt to the changing forces in trauma surgery andpatient demand, an acute care surgery model, spanningtrauma and urgent surgery, is currently in evolution. The

development of acute care surgery is based on three broadconstructs: (1) patients continue to require emergent careduring an era of crisis in access to such care, (2) the societalcosts of maintaining a full registry of on-call physician cov-erage, and (3) maintaining trauma surgeons’ technical exper-tise and professional gratification, and promoting the field oftrauma as a viable career option for emerging surgical train-ees, hence ensuring availability of trauma surgeons in thefuture. The question becomes, could the current graduate of a5-year general surgery residency be comfortable and techni-cally competent to manage the following string of patients on

their call night: (a) a gunshot wound to the subclavian arterywith free intrathoracic bleeding, (b) an elderly patient withatrial fibrillation and 4 hours of acute ischemia of their leftlower extremity, (c) a young man thrown from his motorcyclein hemorrhagic shock with an open pelvic fracture and agrade 4 liver injury, and (d) a hospitalized medicine patientwith accelerating sepsis requiring open decortication of anempyema with partial lobar resection for necrotic lung?

The debate for a formal fellowship to expand traumasurgery training is not new. Prior American Association forthe Surgery of Trauma (AAST) Presidents Arthur R. Metz in1952, Leonard F. Peltier in 1980, and Ernest E. Moore in1995 encouraged a formal certificate of “Added Qualifica-tions in Trauma Surgery.”1,2 The AAST has recently pro-posed a curriculum for acute care surgery (ACS) that buildsupon the clinical and operative exposure of a 5-year generalsurgery residency.3 This curriculum contains designated ro-tations on thoracic, vascular, and hepatobiliary surgery topromote the acquisition of advanced surgical skills.4,5 The2-year program also requires formal surgical critical caretraining and provides additional operative experience withtrauma and elective surgery. Because the AAST-establishedad hoc committee4 as well as other authors3,6–12 have signi-fied the importance of including complex abdominal, vascular, andthoracic operative procedures in the emerging construct, wequestioned the following: (1) Whether current trauma sur-geons practice the model that is being developed for thefuture? (2) Are there existing acute care surgeons who can

Submitted for publication October 3, 2007.Accepted for publication November 9, 2007.Copyright © 2008 by Lippincott Williams & WilkinsFrom the Department of Surgery (C.C.C., E.E.M.), Denver Health

Medical Center and the University of Colorado School of Medicine, Denver,Colorado; and Department of Surgery (D.B.H.), University of California,Irvine, California.

Presented at the 66th Annual Meeting of the American Association forthe Surgery of Trauma, September 27–29, 2007, Las Vegas, Nevada.

Address for reprints: C. Clay Cothren, MD, Program Director, AcuteCare Surgery Fellowship, Department of Surgery, Denver Health MedicalCenter, Assistant Professor of Surgery, University of Colorado School ofMedicine, 777 Bannock Street, MC 0206, Denver, CO 80204; email: [email protected].

DOI: 10.1097/TA.0b013e3181692148

The Journal of TRAUMA� Injury, Infection, and Critical Care

Volume 64 • Number 4 955

serve as mentors for the upcoming generation of surgicaltrainees? Moreover, with a limited number of trauma opera-tions performed in the era of nonoperative management ofinjuries, performing elective surgical cases facilitates surgeonmaintenance of operative skills. (3) Have current traumasurgeons expanded their operative scope to include complexelective cases to prevent erosion of technical expertise? Thepurpose of this study is to determine the current practicepatterns of trauma surgeons in complex operative cases atinstitutions across the United States.

MATERIALS AND METHODSA survey was sent to the trauma directors of the 1,288

designated trauma centers in the United States, as listed bythe American Trauma Society (Appendix). Because acutecare surgery is defined as an extension of trauma surgery, theconstructed survey queried whether a trauma surgeon or aspecialty surgeon performed designated “index” cases. Forexample, does a trauma surgeon or a thoracic surgeon per-form pulmonary lobectomies for trauma, thoracotomies withwedge resection/pulmonotomy, or cardiorrhaphy? Similarly,does a trauma surgeon repair a subclavian artery or poplitealartery injury or do they call in a vascular surgeon after patientevaluation and definitive diagnosis? To be categorized as agroup doing “all” procedures, trauma surgeons had to per-form the full complement of index thoracic (pulmonary lo-bectomy, thoracotomy with pulmonotomy/wedge resectionand cardiorrhaphy), vascular (carotid artery repair, subclavianartery repair, superior mesenteric artery/vein repair, abdom-inal aortic/inferior vena cava repair, and popliteal artery re-pair), and abdominal procedures (hepatic lobectomy andtrauma Whipple); repair of descending thoracic aortic injurieswas considered as a surgical case separate from the vascularcomponent for analysis because of its unique nature.

To determine the qualifications of those surgeons sur-veyed, we also inquired whether the surgeons identified asthe “trauma surgery group” in their particular institution con-sisted only of trauma surgeons (ONLY group) or if the group

contained surgeons with added qualifications in vascular orthoracic surgery. With the consideration of adding simpleorthopedic and neurosurgical procedures to the acute caresurgeon’s realm, the survey also questioned hospital practicesregarding who places intracranial pressure (ICP) monitors andexternal fixators as well as who does open fracture washout.Finally, we questioned if the trauma group performed electivecases, focusing on cervical, thoracic, complex abdominal, andvascular surgery. Level IV and V trauma centers were excludedfrom the analysis because these facilities usually transfer patientswith major trauma.

RESULTSDemographics

Of the 714 Level I/II/III trauma centers, 515 completed thesurvey for an overall response rate of 72%. By trauma centerdesignation level, 92% of Level I, 72% of Level II, and 59% ofLevel III centers returned the survey. Self-reported demograph-ics for the trauma centers, including the number of traumaadmissions per year with an Injury Severity Score (ISS) greaterthan 15, were collected (Tables 1 and 2). The composition oftrauma groups, whether only trauma surgeons (ONLY group) ora combination of surgeons including those with added qualifi-cations in thoracic or vascular surgery is reported in Table 3. Thehighest preponderance of trauma groups containing only traumasurgeons was in Level I academic/university settings, with ap-proximately half of all Level I trauma centers reporting traumasurgeons only for their trauma group. In Level II and III traumacenters, the only institutions that approach the 50% mark in-cludes Level II academic/safety net hospitals and Level IIIacademic/university hospitals. Including all responding LevelI/II/III hospitals, 49 (9%) trauma centers report their traumasurgeons perform the full complement of thoracic, vascular, andabdominal cases (Fig. 1).

Trauma Surgeon’s Care of Specific InjuriesOf the 169 Level I centers, 31 (18%) reported their

trauma surgeons perform the full complement of thoracic,

Table 1 Demographics of Trauma Centers

Level No. Trauma CentersReturning the Survey

No. Academic/UniversityCenters

No. Academic/SafetyNet Centers

No. PrivateCenters

NondesignatedCenters

I 169 102 28 27 12II 187 14 9 128 36III 159 2 5 123 29ALL 515 118 42 278 77

Table 2 Trauma Admissions Per Year with an Injury Severity Score (ISS) Greater Than 15

Level I Level II Level III

AU ASN P ALL AU ASN P ALL AU ASN P ALL

Admits ISS �15 480 516 500 480 163 202 200 178 24 26.5 50.5 25

The median number of trauma admissions per year with an ISS greater than 15 was calculated for each category of trauma center.AU, academic/university centers; ASN, academic/safety net centers; P, private hospitals; ALL, all Hospitals.


956 April 2008

vascular, and abdominal cases (Table 4). These 31 centersinclude 20 academic/university institutions, 6 academic/safety net hospitals, 3 private hospitals, and 2 undesignatedgroups. Only 11 (7%) of the 31 centers reported traumasurgeons perform operative repair of descending torn aortas;this includes six academic/university centers, two academic/

safety net hospitals, one private hospital, and two undesig-nated groups. Of the 31 centers, five (16%) perform a rangeof elective thoracic and vascular cases, whereas two (6%)perform elective thoracic operations only (Table 5).

Of the 187 Level II centers that responded to the survey,trauma surgeons managed the full range of injuries at 11 (6%)facilities. These 11 centers include one academic/universityinstitution, one academic/safety net hospital, five private hos-pitals, and four undesignated groups. In one of these Level IItrauma centers, a private hospital, trauma surgeons repairedblunt thoracic aortic injuries. Ten (91%) of the 11 Level IIhospital’s groups perform elective thoracic and vascular op-erations (Table 5). Seven (4%) of the 159 Level III centersreported trauma surgeons perform the full complement ofcases, including repair of descending torn aortas. None of theseven Level III centers was designated as either academic/university or academic/safety net hospital. Of the seven cen-ters, five (71%) perform elective thoracic and vascular cases.

Of the 221 Level I/II/III hospitals reporting their traumagroups consists of trauma surgeons only, the individual com-plex trauma procedures performed by that trauma group isrepresented in Tables 6 and 7. Across all procedures, traumasurgeons performed less than 75% of these cases. Complexabdominal visceral operations, namely hepatic lobectomiesand trauma whipple procedures, were done by trauma sur-geons in 69% and 62% of hospitals. Within the thoracic casegrouping (Fig. 2), pulmonary lobectomy for trauma is doneby only one-half of the practicing trauma groups with theremainder calling in a thoracic surgeon for assistance. Theproportions for cardiac repair and thoracotomy with wedgeresection/pulmonotomy are slightly higher, with 62% and64% respectively of all trauma groups undertaking these. Ofall groups, those practicing at Level I centers or academic/university hospitals were more likely to perform the primarythoracic operation compared with other hospital-designationor hospital-affiliation classes.

The proportion of vascular trauma cases done by traumasurgeons was only marginally higher. Abdominal aortic andinferior vena cava injuries were repaired by 74% of practicingtrauma surgeons. For the remainder of vascular trauma cases,however, 60% or less are managed primarily by traumasurgeons (Fig. 3). Cumulatively, in all Level I/II/III traumacenters, trauma surgeons repair 55% of carotid artery injuries,48% of subclavian artery injuries, 61% of superior mesentericartery or vein injuries, and 48% of popliteal artery injuries.Compared with thoracic trauma cases, an opposite trend wasseen in the dispersion of cases by trauma center designationin some of the vascular cases. Although subclavian and ab-dominal vascular injuries are managed slightly more often byLevel I trauma surgeons, carotid and popliteal injuries weremore often repaired by Level III trauma surgeons. Interest-ingly, less than 40% of all Level I trauma surgeons repairpopliteal artery injuries. Perhaps not surprisingly, fewer than15% of all trauma surgery groups currently repair descendingtorn aortas.

Non-ACS Hospital Groups Level I Acute Care SurgeonsLevel II Acute Care Surgeons Level III Acute Care Surgeons-----------

Fig. 1. Trauma surgeons: acute care surgery.

Table 3 Composition of the Trauma Surgery TeamsStratified by Designated Hospital Affiliation Level

Hospitals with ONLY TraumaSurgery Teams

Level I (n � 169)Academic/University (n � 102) 69 (66%)Academic/Safety Net (n � 28) 15 (54%)Private (n � 27) 15 (56%)Not Designated (n � 12) 6 (50%)

Level II (n � 187)Academic/University (n � 14) 3 (21%)Academic/Safety Net (n � 9) 5 (56%)Private (n � 128) 42 (33%)Not Designated (n � 36) 11 (31%)

Level III (n � 159)Academic/University (n � 2) 1 (50%)Academic/Safety Net (n � 5) 2 (40%)Private (n � 123) 40 (33%)Not Designated (n � 29) 12 (41%)

ONLY trauma teams, survey answered “Our trauma group con-sists of only trauma surgeons.”

Table 4 Trauma Surgeons Perform the FullComplement of Index Procedures

Level No. RespondingTrauma Centers

No. Performing“All” Cases

No. PerformingDTA Repair

I 169 31 11II 187 11 1III 159 7 7ALL 515 49 19

By trauma center designation, total number of centers wheretrauma surgeons perform the full complement of index thoracic, vas-cular, and abdominal cases (“All”).

DTA, descending torn aorta.

U.S. Trauma Surgeon’s Scope of Practice


Elective Surgery CasesOf the 221 trauma surgery groups, 201 perform some

amount of elective surgery (Tables 8 and 9). The most com-mon elective case category reported was cervical operations,with more than 60% of trauma groups reporting they performthyroidectomies and parathyroidectomies (Fig. 4). The pre-ponderance of these cases, however, was performed in LevelII and III centers that were not academic/university institu-tions. Only 41% of Level I centers and 32% to 34% ofacademic/university hospitals performed elective endocrinecases. Abdominal operations were the next most commonelective surgery performed by trauma surgeons (Fig. 5), with53% of trauma surgeons performing hepatic lobectomies,

58% performing adrenalectomies, and 55% doing whippleprocedures and spine exposures. Aside from spine exposures,a similar trend to cervical cases was observed, with thepreponderance of cases done in non-academic/universityLevel II and III hospitals.

The amount of elective cases done by trauma surgeonsdecreased after the cervical and abdominal groupings. Only31% to 43% of trauma surgeons perform elective thoracicprocedures (Fig. 6). Proportions were slightly higher for de-cortication (43%) and pericardial windows (40%), cases thatmight be considered in the emergent or urgent case category,compared with the lower incidence of pulmonary lobectomy(31%) and esophagectomy (31%). Similarly, the proportion

Table 5 Elective Surgery Categories Performed by Trauma Surgeons

Level No. Centers Performing“All” Cases

No. Centers Performing ElectiveThoracic and Vascular

No. Centers Performing ElectiveThoracic Only

No. Centers Performing ElectiveVascular Only

I 31 5 2 0II 11 10 0 0III 7 5 0 0ALL 49 20 2 0

Adjunctive elective surgery categories performed by trauma surgeons who also perform the full complement of index thoracic, vascular, andabdominal cases.

Table 6 Trauma Procedures Performed by Trauma Surgeons Stratified by Hospital Designation

All Hospitals (n � 221) Level I (n � 105) Level II (n � 61) Level III (n � 55)

Pulmonary lobectomy 110 (50%) 62 (59%) 32 (54%) 27 (49%)Pulmonotomy 141 (64%) 74 (70%) 37 (61%) 27 (49%)Cardiac repair 136 (62%) 79 (75%) 37 (61%) 16 (29%)Hepatic lobectomy 152 (69%) 90 (86%) 50 (82%) 34 (62%)Trauma whipple 136 (62%) 85 (81%) 47 (77%) 25 (45%)Carotid artery 121 (55%) 57 (54%) 33 (54%) 36 (65%)Subclavian artery 105 (48%) 52 (50%) 28 (46%) 25 (45%)DTA 34 (15%) 15 (14%) 5 (8%) 14 (25%)SMA/SMV 135 (61%) 72 (69%) 40 (66%) 23 (42%)AA/IVC 163 (74%) 83 (79%) 50 (82%) 29 (53%)Popliteal artery 106 (48%) 40 (38%) 29 (53%) 37 (67%)

Proportion of trauma procedures performed by trauma surgeons, stratified by hospital designation, level I to III.DTA, descending torn aorta; SMA/SMV, superior mesenteric artery/superior mesenteric vein; AA/IVC, abdominal aorta/inferior vena cava.

Table 7 Trauma Procedures Performed by Trauma Surgeons, Stratified by Hospital Affiliation

All Hospitals(n � 221)

Academic/University(n � 73)

Academic/Safety Net(n � 22)

Private(n � 97)

Not Designated(n � 29)

Pulmonary lobectomy 110 (50%) 46 (63%) 11 (50%) 37 (38%) 16 (55%)Pulmonotomy 141 (64%) 63 (86%) 15 (68%) 46 (47%) 17 (59%)Cardiac repair 136 (62%) 64 (88%) 14 (64%) 37 (38%) 40 (45%)Hepatic lobectomy 152 (69%) 64 (88%) 18 (82%) 51 (53%) 19 (66%)Trauma whipple 136 (62%) 60 (82%) 18 (82%) 44 (45%) 14 (48%)Carotid artery 121 (55%) 38 (54%) 11 (50%) 59 (61%) 13 (45%)Subclavian artery 105 (48%) 35 (48%) 11 (50%) 48 (49%) 11 (38%)DTA 34 (15%) 10 (14%) 4 (18%) 17 (18%) 3 (10%)SMA/SMV 135 (61%) 46 (63%) 14 (64%) 61 (63%) 14 (48%)AA/IVC 163 (74%) 58 (80%) 16 (73%) 74 (76%) 15 (52%)Popliteal artery 106 (48%) 25 (34%) 9 (41%) 50 (52%) 22 (76%)

Proportion of trauma procedures performed by trauma surgeons, stratified by hospital affiliation.DTA, descending torn aorta; SMA/SMV, superior mesenteric artery/superior mesenteric vein; AA/IVC, abdominal aorta/inferior vena cava.


958 April 2008

0102030405060708090

100

Pulmonary Lobectomy Pulmonotomy Cardiorrhaphy

Academic/University (n=73) Academic/Safety Net (n=22)Private (n=97) Not Designated (n=29)

0

10

20

30

40

50

60

70

80

90

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Pulmonary Lobectomy Pulmonotomy Cardiorrhaphy

Perc

enta

ge o

f Tra

uma

Onl

y G

roup

s

Level I (n=105) Level II (n=61) Level III (n=55)A B

Fig. 2. Thoracic trauma procedures performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospitalaffiliation (B).

0

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Carotid Artery Subclavian Artery SMA/SMV Popliteal Artery

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Level I (n=105) Level II (n=61) Level III (n=55)

0102030405060708090

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Carotid Artery Subclavian Artery SMA/SMV Popliteal Artery


BA

Fig. 3. Vascular trauma procedures performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospitalaffiliation (B).

Table 8 Elective Surgery Cases Performed by Trauma Surgeons, Stratified by Hospital Designation

All Hospitals (n � 221) Level I (n � 105) Level II (n � 61) Level III (n � 55)

Thyroidectomy 141 (64%) 43 (41%) 51 (84%) 47 (85%)Parathyroidectomy 134 (61%) 41 (39%) 50 (82%) 43 (78%)Pulmonary lobectomy 69 (31%) 15 (14%) 23 (38%) 31 (56%)Decortication 95 (43%) 45 (43%) 23 (38%) 28 (51%)Pericardial window 88 (40%) 38 (36%) 24 (39%) 26 (47%)Esophagectomy 69 (31%) 23 (22%) 33 (54%) 23 (42%)Hepatic lobectomy 118 (53%) 50 (48%) 37 (61%) 31 (56%)Adrenalectomy 128 (58%) 45 (43%) 46 (75%) 37 (67%)Whipple 122 (55%) 47 (45%) 42 (69%) 33 (60%)Spine exposure 121 (55%) 62 (59%) 36 (59%) 23 (42%)Carotid endarterectomy 59 (27%) 7 (7%) 25 (41%) 27 (49%)Dialysis access 90 (41%) 23 (22%) 36 (59%) 31 (46%)Portocaval shunt 44 (20%) 14 (13%) 19 (31%) 11 (20%)AAA 54 (24%) 4 (4%) 25 (41%) 25 (45%)Peripheral bypass 54 (24%) 4 (4%) 26 (43%) 21 (38%)

Proportion of elective surgery cases performed by trauma surgeons, stratified by hospital designation level I to III.AAA, abdominal aortic aneurysm.



of cases done by trauma surgeons at Level I centers and atacademic/university hospitals approached the non-academic/university Level II and III hospitals for decortication andpericardial window cases.

Just as the minority of current trauma surgeons performelective thoracic surgery, few do elective vascular proce-dures. Although 41% of trauma surgeons were involved indialysis access operations, only 20% to 27% of trauma sur-geons undertook the remaining vascular case load includingcarotid endarterectomy, aortic aneurysms, and peripheral ar-terial bypasses (Fig. 7). Again, the proportion of electivevascular cases done by trauma surgeons at Level I centers andacademic/university hospitals was less than the nonacademic/university Level II and III hospitals. For all elective casesaside from decortications and spine exposures, the amountdone by Level II and III trauma surgeons was markedlyhigher than that done by Level I trauma surgeons. Of the 49

centers, Level I/II/III trauma centers reporting trauma sur-geons perform the full complement of procedures, 20 (41%)centers have surgeons that also perform a range of electivethoracic and vascular cases as part of their routine operativeexperience.

Neurosurgical and Orthopedic ProceduresThe neurosurgical and orthopedic procedures performed

by surgeons are summarized in Table 10. Of all hospitalssurveyed, trauma surgeons performed cranial burr holes ateight trauma centers, placement of ICP monitors at four, andopen fracture washout at three trauma centers. Of the 169Level I centers, trauma surgeons placed ICP monitors at four,washed out open fracture at three, performed cranial burrholes at one, and placed external fixators at one. Of the LevelII trauma centers, placement of ICP monitors, open fracturewashout, and cranial burr holes are always performed by

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ymotcedioryhtaraPymotcedioryhT


BA

Fig. 4. Elective cervical procedures performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospitalaffiliation (B).

Table 9 Elective Surgery Procedures Done by Trauma Surgeons, Stratified by Hospital Affiliation

All Hospitals(n � 221)

Academic/University(n � 73)

Academic/SafetyNet (n � 22)

Private(n � 97)

Nondesignated(n � 29)

Thyroidectomy 141 (64%) 25 (34%) 18 (82%) 77 (79%) 20 (69%)Parathyroidectomy 134 (61%) 23 (32%) 18 (82%) 51 (53%) 20 (69%)Pulmonary lobectomy 69 (31%) 4 (5%) 11 (50%) 41 (42%) 13 (45%)Decortication 95 (43%) 33 (45%) 11 (50%) 40 (41%) 11 (38%)Pericardial window 88 (40%) 29 (40%) 9 (41%) 38 (39%) 12 (41%)Esophagectomy 69 (31%) 14 (19%) 9 (41%) 35 (36%) 11 (38%)Hepatic lobectomy 118 (53%) 28 (38%) 14 (64%) 60 (62%) 16 (55%)Adrenalectomy 128 (58%) 28 (38%) 14 (64%) 69 (67%) 17 (59%)Whipple 122 (55%) 28 (38%) 15 (68%) 65 (67%) 14 (48%)Spine exposure 121 (55%) 44 (60%) 13 (59%) 53 (55%) 11 (38%)Carotid endarterectomy 59 (27%) 3 (4%) 4 (18%) 41 (42%) 11 (38%)Dialysis access 90 (41%) 12 (16%) 9 (41%) 55 (57%) 14 (48%)Portocaval shunt 44 (20%) 8 (11%) 4 (18%) 24 (25%) 8 (28%)AAA 54 (24%) 2 (3%) 2 (9%) 39 (40%) 11 (38%)Peripheral bypass 54 (24%) 2 (3%) 3 (14%) 40 (41%) 9 (31%)

Proportion of elective surgery cases performed by trauma surgeons, stratified by hospital affiliation.AAA, abdominal aortic aneurysm.


960 April 2008

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Hepatic Lobectomy Adrenalectomy Whipple Spine Exposure


Fig. 5. Elective abdominal procedures performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospitalaffiliation (B).

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Academic/University (n=73) Academic/Safety Net (n=22)

Private (n=97) Not Designated (n=29)A B

Fig. 6. Elective thoracic operations performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospitalaffiliation (B).

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PC Shunt AAA PeripheralBypass

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Fig. 7. Elective vascular cases performed by trauma surgeons, stratified by hospital designation, Level I to III (A) and hospital affiliation(B). CEA, carotid endarterectomy; PC Shunt, portocaval shunt; AAA, abdominal aortic aneurysm.



orthopedic surgeons or neurosurgeons rather than traumasurgeons. Of the 159 Level III centers, trauma surgeonsperformed cranial burr holes at seven, whereas ICP monitorplacement and open fracture washout was done by orthopedicsurgeons or neurosurgeons.

DISCUSSIONHistorically, today’s model of acute care surgery was

practiced by civilian trauma centers in the late 1960s to thelate 1980s during the golden age of trauma.7 A routine week-end of call would include pulmonary lobectomies, thoracicaortic repairs, hepatic lobectomies, reconstruction of poplitealarteries, and pancreaticoduodenectomies. The advent of com-puted tomographic scanning and a national emphasis on in-jury prevention resulted in a decrease in operative cases andan increase in nonoperative care responsibilities during theensuing two decades. The crisis of patient’s access to ade-quate health care and widespread economic impact of healthcare has paralleled the changes in the discipline of traumasurgery. These three forces have promulgated the adoption ofacute care surgery as the current paradigm of trauma andemergency care for the acutely ill as well as injured patient.

As proposed, acute care surgery would encompass per-forming emergent abdominal, vascular, and thoracic traumaprocedures as well as emergency general surgery.3–5 Aspectsof acute care surgery that set it apart from general surgery arethose noted in the developed training curriculum that requireadditional exposure in the ACS fellowship years, namelythoracic, vascular, complex hepatobiliary, and operativetrauma cases as well as surgical critical care. The focus of ourstudy was the procedures that set ACS training apart fromgeneral surgery training. As the persona and operative pur-view of the acute care surgeon develops, how does this differfrom the trauma surgeon’s current practice? What do currentpractitioners actually do? Are there acute care surgeons to actas mentors for young surgeons? Are there practicing traumasurgeons who embody the acute care surgery paradigm asenvisioned? To address these questions, we surveyed alltrauma directors across the United States to determine currentpractice patterns in complex operative trauma. Although sev-eral Level I trauma centers have followed the model of the“new” acute care surgery practice for the past 25 years,6,13 wehypothesized there would be few trauma surgery groups thatpracticed the full breadth of complex operative trauma cases.

By polling the trauma directors of Level I, II, and IIIcenters we queried who currently performs specific operativeprocedures at their institution. Were there still trauma sur-geons who are “master general surgeons”? Our results showthat few trauma surgeons currently practice the full range ofthoracic, vascular, and complex abdominal trauma cases.Only 9% of Level I/II/III trauma centers have trauma sur-geons that perform all the vascular, thoracic, and complexabdominal trauma cases, and only 25% of all trauma surgerygroups perform the full complement of operations, whereasthe remaining enlist a combination of vascular and thoracicsurgeons to manage specific injuries in their trauma patientpopulation. Less than one-half of trauma surgeons currentlyperform trauma pulmonary lobectomies, subclavian arteryinjury repairs, popliteal artery injury repairs, and descendingtorn aortic repairs. Additionally, the minority of hospitalshave groups treating the injured that are described as traumasurgeons, perhaps indicative of the waning interest in ourspecialty field.

The recognition that the discipline of trauma surgery isnear-extinction, at a crossroads, or in crisis has been reported formore than a decade.1–3,14–25 The many reasons leading to the“necessary creation” of acute care surgery as a defined specialtyhave been identified and expounded upon by numerous otherinvested authors. Patient care and trauma system driven aspectsinclude limited access to appropriate emergency care, lack ofsubspecialty coverage, transfer of patients to higher levels ofcare because of lack of such coverage, and hospital expenseof on-call coverage.26–34 Trauma surgeon related reasons in-clude but are not limited to the increasing percentage of non-operative trauma management, limited operative exposure,heavy inpatient census, in house call requirements, nocturnalduties, limited reimbursement for care, and consequently, lack ofinterest by residents.8,14,16,17,24,35–41 With the conclusion of the“golden age of surgery”7,8 and the limited exposure to operativetrauma, overall numbers of procedures performed by traumasurgeons has dropped substantially in the ensuing years.16,42–44

The proposal to incorporate emergency general surgery caseshopes to bolster these flagging numbers along with surgeons’career satisfaction. However, our survey suggests that the traumasurgeon’s trauma scope is currently narrow, with only approxi-mately half of trauma surgeons performing complex thoracic orvascular trauma cases. Often the acutely injured patient has beenevaluated, diagnosed, and effectively operated upon before a

Table 10 Trauma Surgeons Performing Specific Neurosurgical and Orthopedic Procedures

Level Responding TraumaCenters

Centers PlacingICP Monitors

Centers PerformingBurr Holes

Centers PerformingOpen Fx Washout

Centers ApplyingExternal Fixators

I 169 4 1 3 1II 187 0 0 0 0III 159 0 7 0 0ALL 515 4 8 3 1

The total number of hospitals where trauma surgeons perform specific procedures.ICP, intracranial pressure monitor; Fx, fracture.


962 April 2008

surgical subspecialist is able to come into the hospital fromhome. Why then have we as trauma surgeons abdicated suchcomponents of operative trauma care to the subspecialist?

One reason trauma surgeons may avoid such complextrauma cases is they think that their operative skills have notbeen maintained or were never developed. In even the busiesttrauma centers, the number of thoracic and vascular casesdone yearly for trauma and emergent indications by anysingle surgeon is marginal to maintain skills. Perhaps withoutelective cases to keep their technical skills current, surgeonshave a much more limited comfort zone. Although the ma-jority of trauma groups report they participate in electivesurgical care, an analysis of the case type and dispersion isquite revealing. Despite 60% of trauma groups performingelective endocrine/cervical cases, only 41% of Level I traumasurgeons comprise this demographic. In fact, it is seeminglya paradox that the large urban, academic training sites, wherethe need is most evident, do not perform complex traumaprocedures, whereas remote areas where the demand is muchless have a greater proportion of trauma surgeons doing thesecomplex cases. Approximately half of the surveyed traumasurgeons perform elective abdominal operations includinghepatic lobectomy, whipple procedures and spine exposure,but only 31% perform pulmonary lobectomy and esophage-ctomies and less than 27% perform elective vascular casessuch as carotid endarterectomy, AAA repair and peripheralarterial bypasses. For all elective cases aside from decortica-tions and spine exposures, the amount done by Level II andIII trauma surgeons was markedly higher than that done byLevel I trauma surgeons. These numbers are perhaps notsurprising because the majority of trauma groups defined astrauma surgeons practice at Level I hospitals, which presum-ably have associated subspecialty programs in thoracic sur-gery, vascular surgery, hepatobiliary/transplant surgery, andsurgical oncology. Recognition of the marked under-utilization ofthe trauma surgeon in the elective realm may provide an ave-nue to change the current structure of practice within hospi-tals. An added elective surgical practice would also increasethe appeal of such a career to residents and practicingsurgeons.13,14

The addition of simple orthopedic and neurosurgicalprocedures to the acute care surgery paradigm has been con-sidered; i.e., the European model.45–47 Currently, it is the rareoccasion when a surgeon other than an orthopedic surgeon ora neurosurgeon performs ICP monitor placement, cranial burrholes, open fracture washout, or external fixator placement.The inclusion of damage control orthopedics and simpleneurosurgical emergent procedures is appealing because ofinsufficient emergency department coverage by these subspe-cialties in many parts of the country.27–34,47 Despite suchshort-falls in the coverage of acutely ill and injured patients,and evidence that such procedures may be performed by thetrauma surgeon with appropriate training,48,49 the majority oforthopedic surgeons and neurosurgeons are unwilling to re-linquish emergent procedures.50–52 In fact, in many centers,

physician assistants place ICP monitors. Future conversationsbetween practicing acute care surgeons and subspecialtygroups will have to address these disparate vantage points,evaluate the effectiveness of their local trauma system, anddetermine the optimal delivery of care for the patient.

This survey did not address the coverage of emergencygeneral surgery cases by trauma surgeons. Several studieshave shown the feasibility of incorporating emergency gen-eral surgery cases into a trauma/critical care service, and itsassociated increase in the number of operative cases, in-creased use of operating room and ICU resources, improvedpatient outcomes, and physician satisfaction.53–58 However,the ability to apply such a working model in an individualhospital is determined by local hospital logistics, patientneeds, and politics. Such a shift in practice patterns does notalter the essential training of the surgeon in question, asemergency general surgery—typically consisting of appendi-citis, cholecystitis, soft tissue infections, and the occasionalperforated viscus—does not often require operative techniquesbeyond the scope of a general surgery residency-trained surgeon.The proposed model of the acute care surgeon, however, envi-sions a surgeon that could manage any patient, trauma ornon-trauma, with any surgical issue that requires operativemanagement within twenty-four hours.59 The acute care sur-geon would be a “go-to” surgeon.60 As mentioned previously,the question becomes, could the current graduate of a 5-yeargeneral surgery residency be comfortable and technicallycompetent to manage the following string of patients on theircall night: a gunshot wound to the subclavian artery withmassive hemothorax, an elderly patient with atrial fibrillationand 4 hours of acute ischemia of their right lower extremity,a young woman thrown from her motorcycle in hemorrhagicshock with an open pelvic fracture and a grade 4 liver injury,and a medicine patient with accelerating sepsis requiringopen decortication of an empyema with lobar resection fornecrotic lung?

Do emerging “master trauma surgeons” need additionaltraining beyond the scope of a general surgery residency?Can we train emerging acute care surgeons by mentorshipalone? Mentorship for emerging academic talent in the fieldof trauma surgery is sparse. Without numerous operativetrauma cases in residency,16,44,61,62 attending faculty maybegin jobs without having done more than one or two traumasplenectomies much less repaired a popliteal artery injury.Mentorship by a seasoned trauma surgeon, skilled at allaspects of operative and nonoperative care of the acutelyinjured is arguably the most critical component15,20 of thecurrent model of training for many emerging trauma/acutecare surgery/surgical critical care surgeons. This survey in-dicates, however, that the availability of such mentorship israre, with less than one-fifth of current Level I facilities andonly 9% of Level I/II/III hospitals employing a trauma surgeryteam facile in all aspects of thoracoabdominal and vascular trauma.The decades-old paradigm of training by mentorship, by



virtue of numbers alone, is unlikely to be capable of produc-ing the number of surgeons that will be necessary in thefuture.30 Currently the progressive specialization of residentsresults in the vast majority of graduates markedly narrowingtheir scope of daily practice; in contrast, acute care surgeryproposes expertise across a wide range of patient conditionsand surgical operations.

The current inception of acute care surgery and theassociated training paradigm was to address the emergingcrisis in access to health care and its associated economicburden, to provide optimal care of the acutely ill and injuredpatient, and to prevent the death of a “specialty currentlygasping for air”.24 Appropriate care of the injured and emergentsurgical patient, hospital economics, trauma system develop-ment, and physician availability, satisfaction, and competenceare at the crux of the development of this new specialty. Al-though the model of the acute care surgeon appears attractiveand timely, few hospitals currently employ this paradigm ofpractice. Training programs incorporating complex abdomi-nal, vascular, and thoracic procedures need to be developed toaddress the shortage of appropriately trained surgeons andenable the specialty of acute care surgery to serve society inthe coming decades.

ACKNOWLEDGMENTSWe thank Harry Teter and The American Trauma Society for providing

the addresses for our survey.

REFERENCES1. Peltier LF, Davis JH. A history of the American Association for the

Surgery of Trauma—the first 50 years. J Trauma. 1989;29:143.2. Moore EE. Trauma systems, trauma centers, and trauma surgeons:

opportunity in managed competition. J Trauma. 1995;39:1–11.3. Committee to Develop the Reorganized Specialty of Trauma,

Surgical Critical Care, and Emergency Surgery. Acute care surgery:trauma, critical care, and emergency surgery. J Trauma. 2005;58:614–616.

4. The Committee on Acute Care Surgery, American Association forthe Surgery of Trauma. The acute care surgery curriculum.J Trauma. 2007;62:553–556.

5. Britt LD. Acute care surgery: a proposed training curriculum.Surgery. 2007;141:304–305.

6. Moore EE. Acute care surgery: the safety net hospital model.Surgery. 2007;141:297–298.

7. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD. Acutecare surgery: Eraritjaritjaka. J Am Coll Surg. 2006;202:698–701.

8. Moore EE. Trauma Surgery: is it time for a facelift? Ann Surg.2004;240:563–564.

9. Spain DA, Richardson JD, Carrillo EH, Miller FB, Wilson MA, PolkHC Jr. Should trauma surgeons do general surgery? J Trauma. 2000;48:433–437; discussion 437–438.

10. Jurkovich GJ. Acute care surgery: the trauma surgeon’s perspective.Surgery. 2007;141:293–296.

11. Esposito TJ, Leon L, Jurkovich GJ. The shape of things to come:results from a national survey of trauma surgeons on issuesconcerning their future. J Trauma. 2006;60:8–16.

12. Spain DA, Miller FB. Education and training of the future traumasurgeon in acute care surgery: trauma, critical care, and emergencysurgery. Am J Surg. 2005;190:212–217.

13. Ciesla DJ, Moore EE, Moore JB, Johnson JL, Cothren CC, Burch JM.The academic trauma center is a model for the future trauma and acutecare surgeon. J Trauma. 2005;58:657–661; discussion 661–662.

14. Esposito TJ, Maier RV, Rivera FP, et al. Why surgeons prefer not tocare for trauma patients. Arch Surg. 1991;126:292–297.

15. Thal ER. Out of apathy. Bull Am Coll Surg. 1993;78:6–14.16. Fakhry SM, Watts DD, Michetti C, Hunt JP. EAST Multi-

Institutional Blunt Hollow Viscous Injury Research Group. Theresident experience on trauma: declining surgical opportunities andcareer incentives? Analysis of data from a large multi-institutionalstudy. J Trauma. 2003;54:1–7; discussion 7–8.

17. Richardson JD, Miller FB. Will future surgeons be interested intrauma care? Results of a resident survey. J Trauma. 1992;32:229–233; discussion 233–235.

18. Richardson JD. Trauma centers and trauma surgeons: have webecome too specialized? J Trauma. 2000;48:1–7.

19. Cryer HM III. The future of trauma care: at the crossroads.J Trauma. 2005;58:425–436.

20. Shackford SR, Gabran SGA, Rozycki GS, et al. On developingcareers in trauma and surgical care: report of the ad hoc committeeon careers in trauma surgery, Eastern Association for the Surgery ofTrauma. J Trauma. 1994;37:700–704.

21. Maier RV. Trauma: the paradigm for medical care in the 21stcentury. J Trauma. 2003;54:803–813.

22. Flint L. Achievements, present-day problems, and some solutions fortrauma care, surgical critical care, and surgical education.Am J Surg. 1991;161:207–212.

23. Engelhardt S, Hoyt D, Coimbra R, et al. The 15-year evolution of anurban trauma center: what does the future hold for the traumasurgeon? J Trauma. 2001;51:633–638.

24. Rodriguez JL, Christmas AB, Franklin GA, Miller FB, RichardsonJD. Trauma/critical care surgeon: a specialist gasping for air.J Trauma. 2005;59:1–5; discussion 5–7.

25. Shackford SR. The future of trauma surgery—a perspective.J Trauma. 2005;58:663–667.

26. Rotondo MF. At the center of the “perfect storm”: the patient.Surgery. 2007;141:291–292.

27. Gore L, Huges C. Two-thirds of emergency department directorsreport on-call specialty coverage problems. American College ofEmergency Physicians. Available at: http:/www.acep.org/1,34081.0.html.

28. The Lewin Group Analysis of AHA ED Hospital Capacity Survey.2002:7–18. Available at: http:/www.aha.org/ahapolicyforum/resources/EDdiversionsurvey0404.html.

29. The Schumacher Group. 2005 Hospital Emergency DepartmentAdministration Survey. Available at: http://www.tsged.com/survey2005.pdf.

30. The Division of Advocacy and Health Policy. A growing crisis in patientaccess to emergency surgical care. Bull Am Coll Surg. 2006;91:8–19.

31. Ciesla DJ. The acute care surgeon and emergency specialtyprocedures. J Am Coll Surg. 2007;205:187–189.

32. Spain DA, Bellino M, Kopelman A, et al. Requests for 692 transfersto an academic level I trauma center: implications of the emergencymedical treatment and active labor act. J Trauma. 2007;62:63–67.

33. Branas CC, MacKenzie EJ, Williams JC, et al. Access to traumacenters in the United States. JAMA. 2005;293:2626–2633.

34. Bosse MJ, Henley MB, Bray T, Vrahas MS. An AOA critical issue.Access to emergent musculoskeletal care: resuscitating orthopaedicemergency-department coverage. J Bone Joint Surg Am. 2006;88:1385–1394.

35. Richardson JD, Miller FB. Is there an ideal model for training thetrauma surgeons of the future? J Trauma. 2003;54:795–797.


964 April 2008

36. Trunkey DD. What’s wrong with trauma care? Bull Am Coll Surg.1990;75:10–15.

37. Esposito TJ. Rank and file weighs in on trauma and general surgeryissues: results from a survey of ACS fellows. Bull Am Coll Surg.2006;91:13–20.

38. Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD. Makingthe case for a paradigm shift in trauma surgery. J Am Coll Surg.2006;202:655–667.

39. Rodriguez JL, Polk HC Jr. Profitable versus unprofitable expansionof trauma and critical care surgery. Ann Surg. 2005;242:603–606;discussion 606–609.

40. Aucar JA, Hicks LL. Economic modeling comparing trauma andgeneral surgery reimbursement. Am J Surg. 2005;190:932–940.

41. Grossman MD, Schwab CW, Chu-Rodgers S, Kestner M. Time andmotion: a study of trauma surgeons’ work at the bedside during thefirst 24 hours of blunt trauma care. J Trauma. 1999;46:757–763;discussion 763–764.

42. Meredith JW, Miller P, Chang M. Operative experience at ACOSverified Level I trauma centers. Presented at Halstead Society,Cashiers, NC, 2002.

43. Richardson JD, Franklin GA, Lukan JK, et al. Evolution in themanagement of hepatic trauma: a 25-year perspective. Ann Surg.2000;232:324–330.

44. Bulinski P, Bachulis B, Naylor DF, Kam D, Carey M, Dean RE.The changing face of trauma management and its impact on surgicalresident training. J Trauma. 2003;54:161–163.

45. Stahel PF. Identity crisis in trauma surgery; Is the European model aviable option? J Am Coll Surg. 2007;204:723–724.

46. Oestern HJ, Probst J. Trauma Surgery in Germany: Balance andPerspectives [German]. Heidelberg, Germany: Springer; 1997:642.

47. Goslings JC, Ponsen KJ, Luitse JS, Jurkovich GJ. Trauma surgery inthe era of nonoperative management: the Dutch model. J Trauma.2006;61:111–114.

48. Kaups KL, Parks SN, Morris CL. Intracranial pressure monitorplacement by midlevel practitioners. J Trauma. 1998;45:884–886.

49. Treacy PJ, Reilly P, Brophy B. Emergency neurosurgery by generalsurgeons at a remote major hospital. ANZ J Surg. 2005;75:852–857.

50. Valadka AB, Timmons SD, Ellenbogen RG. Delivery of emergencyneurosurgical care. J Am Coll Surg. 2006;203:962–966.

51. Bosse MJ, Tornetta P, Sanders R, Swiontkowski MF, Russell TA.Acute care surgery. J Trauma. 2005;59:1035–1036.

52. Cohn J, Price MA, Stewart RM, et al. A crisis in the delivery ofcare to patients with brain injuries in South Texas. J Trauma. 2007;62:951–962; discussion 962–963.

53. Scherer LA, Battistella FD. Trauma and emergency surgery: anevolutionary direction for trauma surgeons. J Trauma. 2004;56:7–12.

54. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergencygeneral surgery service enhances the productivity of traumasurgeons, general surgeons and the hospital. J Trauma. 2005;58:906–910.

55. Kim PK, Dabrowski GP, Reilly PM, Auerbach S, Kauder DR,Schwab CW. Redefining the future of trauma surgery as acomprehensive trauma and emergency general surgery service.J Am Coll Surg. 2004;199:96–101.

56. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergencygeneral surgery with a trauma service: impact on the care of injuredpatients. J Trauma. 2004;57:467–471; discussion 471–473.

57. FitzPatrick MK, Reilly PM, Laborde A, et al. Maintaining patientthroughput on an evolving trauma/emergency surgery service.J Trauma. 2006;60:481–486; discussion 486–488.

58. Earley AS, Pryor JP, Kim PK, et al. An acute care surgery modelimproves outcomes in patients with appendicitis. Ann Surg. 2006;244:498–504.

59. Velmahos GC, Jurkovich GJ. The concept of acute care surgery:a vision for the not-so-distant future. Surgery. 2007;141:288–290.

60. Hoyt DB. Rock on—staying focused on our way to greatness.J Trauma. 2004;56:1–6.

61. Hawkins ML, Wynn JJ, Schmacht DC, Medeiros RS, Gadacz TR.Nonoperative management of liver and/or splenic injuries: effect onresident surgical experience. Am Surg. 1998;64:552–556; discussion556–557.

62. Boutros J, Sekhon MS, Webber EM, Sidhu RS. Vascular surgerytraining, exposure, and knowledge during general surgery residency:implications for the future. Am J Surg. 2007;193:561–566.

DISCUSSIONDr. L.D. Britt (Norfolk, Virginia): Yes, Dr. Trunkey had

a conflict and I’m not Dr. Trunkey but I am a proud south-erner. I commend the authors for their excellent work and foraddressing one of the most challenging issues in Americanmedicine today, the crisis in emergency care.

The stated aim of the study was to determine the practicepatterns of trauma surgeons at trauma centers throughout thecountry and to answer the question highlighted in their title,“Can We Deliver Acute Care Surgery.”

While this survey study will undoubtedly contribute tothe ongoing workforce analysis, the authors’ conclusion wasknown before one survey was ever returned.

Therefore, I would like to set the example and use mythree minutes and just acknowledge a couple of large ele-phants that are sitting in the middle of the living room that Iwant the authors to respond to.

With patient safety and access to emergency care asoverriding concerns in many of the trauma centers around thecountry, how can an acute care surgery model possibly workwith the documented absence – documented absence – ofconsistent subspecialty coverage and support being lack-ing, particularly neurosurgery and orthopedics which youdid not address?

Are we going to depend on the evolutionary process ofthis new specialty to address this concern?

Number 2, with regionalization less than optimalthroughout this country, how should, if at all, the acute Caremodel be applied in the rule setting?

Also, can the acute care surgery specialty coexist withgeneral surgery or will the acute care surgeon be the nextgeneration general surgeon?

Number 3, if the comprehensive acute care surgerymodel is adopted, what timetable would the authors proposewith respect to the specialty reaching a critical mass?

Going back to the authors’ title, “Can We Deliver AcuteCare Surgery”, where will the financial resources come fromfor the salary lines? Now, back to your paper.

If the fellowship training programs incorporate vascularand thoracic, I can’t help but ask this as the past, immediatepast president of the RRC, will this sort of vascular andthoracic procedures done by the fellow have a negative im-pact on the core general surgery residents with respect tothem meeting their minimum numbers?

If you could answer those question and address thoseelephants in the living room. Thank you.



Dr. Charles E. Lucas (Detroit, Michigan): Dr. HomerSmathers, the epitome of a master surgeon with acute caresurgical skills, is 91 years old and is missing his first AASTmeeting in 50 years because eight days ago he underwenta total gastroectomy with esophagojejunostomy for gastriccancer.

I spoke to him this morning at home where he is enjoyinghis soft-boiled egg in order to get a little protein. I said,“Homer, it’s okay if it goes by mouth but don’t take itintravenously.”

He extends his best wishes to the white-haired and no-haired surgeons here and advises the young surgeons toremember that you must first be the master surgeon and thendevelop your acute care surgical skills.

That’s why he chose to two white-haired old farts knownfor their trauma surgery to do his cancer surgery.

I think that any fellowship which is going to put outsurgeons in acute care surgery has to first remember to putout a master surgeon.

Dr. Gregory J. Jurkovich (Seattle, Washington): Thankyou. Let me just say for the audience that the Acute CareSurgery Committee is pleased to have this paper on thepreliminary session.

And that is the type of information that the committeewill look at carefully in the fostering and designing of futureplans for the fellowship training.

And I urge all members of the audience to participate inany way they can in either studies such as this or with help onthe committee as its structure proceeds.

To that end let me just focus on a couple of issues brieflyabout the paper. Number 1, the paradox, the seeming paradoxof Level III trauma surgeons doing more elective and moreextensive surgery than the Level I trauma center surgeons Ithink speaks to the wide applicability of the Acute CareSurgery fellowship model, not just for the Level I academictrauma center but for the entire spectrum of trauma care.

The question involved with this is, Clay, did you look atany age or training background of the surgeons which youqueried? In other words, were there any age-related charac-teristics of the surgeons who practiced in these differentenvironments?

Dr. Lawrence Lottenberg (Gainesville, Florida): Veryinteresting study. I actually was one of the responders and Idid have some questions when I was answering this.

Briefly, I find it hard to imagine that extra training inan acute care surgical fellowship will allow us to donon-invasive vascular surgery and endostent grafting, whichis one of the procedures that needs to be done if you’re goingto be able to cover the entire realm of these procedures.

And I was wondering whether or not you would look atthoracic training and vascular training as the ability to exposeand stop bleeding and then call a specialist if need be forthese complex procedures?

I just cannot imagine anybody being trained to do tho-racic procedures or complex vascular procedures in today’s

environment without taking a year or two in each one of thosedisciplines to be able to do the full realm.

Dr. Michael J. Sise (San Diego, California): Maybe Imissed something in my fellowship and my 30 years ofvascular practice but how can we possibly teach surgeonsvascular surgery and thoracic surgery without creating “de-lusions of adequacy?” I have grave concerns about this andI’d like the author to address it.

Dr. Anthony A. Meyer (Chapel Hill, North Carolina):Thank you. Similar to Michael’s comments. Obviously, thefocus of this is the patient and who can provide the best carefor a specific procedure.

You know, they talk about the question of Whipples. Ithink that is fine and not many people do, have to do manytrauma Whipples and not many surgical oncologists can dothose in the traumatic setting.

But the big question is for thoracic cases if you havethoracic surgeons immediately available or vascular surgeonswho do this in a daily basis, if you do five thoracostomies ayear are you the best person to be doing that thoracotomyrather than somebody who does five a week.

Dr. C. Clay Cothern (Denver, Colorado): So first I’dlike to address Dr. Britt’s questions and perhaps the “ele-phants in the room” as he so paraphrased. First was thequestion of whether or not the Acute Care Surgery modeladdresses the documented absence of subspecialty coverage.

Here I think specifically orthopedic and neurosurgicalrealms are what is at issue. And I think that there needs to bea conversation that despite such subspecialty coverage issuesthat these disciplines are unwilling to relinquish such proce-dures to the acute care surgeon.

I think that at each individual trauma system level andhospital level that this needs to be addressed to really addressthe appropriate care for the injured patient.

Regionalization is a question as far as optimal rural care.I think the acute care surgery model, as Dr. Jurkovich pointedout, that it’s really the Level II and III centers that are perhapsperforming some of the more complex procedures. And so Ithink that acute care surgery as a rural physician is perhaps anideal placement for this model.

Can this coexist with general surgery? I think that forthose of us, we already have an acute care surgery fellowshipand it exists quite nicely with our general surgery fellows.

We simply place our fellows in positions where they arenot in direct competition for cases with our general surgeryresidents.

Finally, a timetable as far as what will appreciate criticalmass. I think that is an excellent question but, unfortunately,not one that I can see into a crystal ball to determine what thecritical mass is and really what the need is for this type ofsurgery model.

Similarly, I know that Dr. Britt is interested in the finan-cial resources and salary lines, as he has spoken previously.And I think that there is some combination of hospital salarysupport as well as individual trauma surgeons generating their


966 April 2008

own salary that would really meet salary lines for each indi-vidual group.

And, finally, I think I addressed the impact as far asgeneral surgery cases and residents. Dr. Lucas, you men-tioned about the master surgeon and whether or not thefellowship could produce the master surgeon.

Again, having been mentored by a master surgeon inGene Moore I think that, again, the fellowship aimed toproduce fellows and, hence, practicing trauma surgeons thatreally are master surgeons and can address any operativecase, be it trauma or non-trauma, within the first 24-hours ofarrival into the hospital.

Dr. Jurkovich, you talked about the paradox that we seebetween Level I centers and Level II and III centers. Again,I think that it is an interesting paradox and perhaps it ad-dresses both the rural surgery element as well as broad-basedtraining for those that go out into more distant environmentsthat really address these on a more routine basis than perhapsthe Level I centers where we think the most important num-bers are.

And, finally, you asked about age-related characteristics.Unfortunately, our survey, for those of you who received itand responded, there was no either practice-based experienceor age-related characteristics in this survey.

The next question was asking about vascular surgery andendostents and that you can’t believe this exists. Again, we

are talking about a surgeon that can address any surgical issuewithin the first 24 hours.

And many of us have felt that endostents are somethingthat can be done acutely but it can also be, the patient can bemanaged non-operatively or essentially conservatively untilan endostent would need to be placed.

We have done them in our facility in a combination withinterventional radiologists and in our group of six acute caresurgeons at Denver Health.

Dr. Sise asked about how we can teach surgeons withoutgiving them delusions of adequacy, inadequacy or adequacy,excuse me.

I would say that that’s a difficult question to answer forthose of us that have been trained in this model andmentored in this model and feel that we are adequate acutecare surgeons.

The final question was who should be the best surgeon tooperate on these patients, should it be someone who is athoracic surgeon that operates every single week in the chestor should it be a surgeon that does five thoracostomies a year?

I think this is the element that speaks to elective casenumbers and really without maintenance of surgical skillsthat perhaps a trauma surgeon that only does one or two ofthese a year is not the person versus those that actuallymaintain their surgical skills with elective case numbers aregoing to feel more comfortable in the thoracic and vascularrealms on a daily basis.



APPENDIX: THE SURVEY DISTRIBUTED


968 April 2008

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