WHAT CAN WE DO AS TRAUMA SURGEON

Ignatius RiwantoDep. of Surgery

Diponegoro Medical Faculty

WHAT IS TRAUMA SURGEON?

• A certificate of quality recognition is awarded to trauma surgeons, who have completed the whole program accredited by the European Board of Trauma Surgeons, and have attained a satisfactory standard.

The Trauma Surgeon Training Program

• surgical basis training (common trunk) – 2 years

• primary trauma training (part of common trunk) – 2 years

• advanced trauma training – 2 years

THE GOAL OF TRAINING

• Training in Trauma Surgery (EBTS) has the goal to enable surgeons to take care for all forms of trauma, including musculo-sceletal traumata, to get the responsibility for the coordination of all phases of traumatised patients, in diagnosis and treatment, including intensive care management and rehabilitation on a high standard level

MEMBERSHIP OF EUROPEAN BOARD

OF SURGERYOnly trauma surgeons with a special surgical training may have this competence. All surgeons with specialization for trauma surgery (like in Germany, Belgium, Netherlands, Switzerland or Czech Republic) or Trauma Surgeons (like Austria, Hungary, Spain) should join an European Board of Trauma Surgeons, Division of the European Board of Surgery.

BACKGROUND

• NEED REGIONAL MAJOR TRAUMA NETWORKS IN ENGLAND

• RCS MAJOR TRUMA WORKFORCE PROJECT TO DELIVER A SUSTAINABLE MAJOR TRAUMA WORKFORCE

• RECONSTRUCTIVE SERVICE IN ORTHOPAEDIC, PLASTIC AND MAXILLOFASCIAL ARE ALREADY MATURE

• 2 GAPS: 1. MAJOR TRAUMA CONSULTANT2. RESUSCITATIVE SURGEON

Major Trauma Consultant: coordinator, orchestrator and clinical leader for ongoing care for poly-trauma patients.

Resuscitative Surgeon: Surgical decision and management of life threatening torso hemorrhage and visceral trauma.

GENERAL SURGEON, VASCULAR SURGEON

RESUSCITATIVE SURGEON

ADDITIONAL TRAINING

HOW ABOUT INDONESIA IN MANAGING MAJOR POLY-TRAUMA?

• No certified trauma surgeon• No major trauma consultant, neither resuscitative

surgeon • Reconstructive service in orthopedic, plastic and

maxillofacial are already mature• Torso trauma already manage by digestive and

cardiothoracic surgery mostly in top referral hospital• Most hospital in district area only general surgeon

available with or without ATLS, DSTC, Peri-op Critically Ill course certificate.

WHAT CAN WE DO AS TRAUMA SURGEON

WHAT CAN WE DO AS GENERAL SURGEON IN MANAGING TRAUMA

• Does Indonesian general surgeon who already finished ATLS, DSTC and perioperative course have equivalent competence with trauma surgeon (Europe) or resuscitative surgeon (England) in managing major torso trauma?

• 100% ?, 75%?, 50%?, 25%? Should be studied• Should we have trauma surgeon? conflict with

orthopedic, plastic & maxillofacial surgeon• Should we have resuscitative surgeon who

capable manage major torso trauma? additional training for general surgeon (long term plan of Indonesian College of Surgeon ?)

SHORT TERM COURSE

• Identified the RCS curriculum for major trauma consultant and resuscitative surgery that not be trained yet in ATLS, DSTC and perioperative new topics.

• Training/ re-training for ATLS, DSTC, perioperative and new topics

• Certification based on course, experience and paper?

WHAT CAN WE DO AS GENERAL SURGEON WITH ADDITIONAL

COMPETENCE IN MANAGING TRAUMA?

WHAT SHOULD WE DO AS GENERAL SURGEON WITH ADDITIONAL

COMPETENCE IN MANAGING TRAUMA?

Nine RACS Competencies1. Collaboration and Teamwork2. Communication3. Health advocacy4. Judgement - clinical decision making5. Management and Leadership6. Medical expertise7. Professionalism and Ethics8. Scholarship and Teaching9. Technical expertise

https://www.surgeons.org/becoming-a-surgeon/surgical educationtraining/competencies/

KOMPETENSI BEDAH UMUM UNTUK TRAUMA TORAKO-ABDOMINAL

+ ATLS, DSTC, PERIOPERATIVE

General principles of good trauma management

The importance of injury as a public health issue. The importance of the injury mechanism in predicting actual injuries. The differing implications of blunt and penetrating injury. The importance of triage. The importance to the triage process of:

o injury mechanism, physiological status, evident injuries. The differing risk exposures and injury patterns in children, young

adults and the elderly. The patterns of associated injuries that are commonly observed. The commonly documented deficiencies in acute injury management. The importance of an integrated trauma treatment service in a hospital. The importance of a triage-based team approach to acute injury assessment. The value of a protocol-directed approach and practice guidelines to acute

injury assessment and management. The importance of regional trauma care systems that link injury prevention

activities, pre-hospital care, acute care hospitals with differing roles, and rehabilitation services.

http://www.surgwiki.com/wiki/Principles_of_trauma_managementhttp://www.anzjsurg.com/view/0/index.html

RESPONSIBILITY OF SURGEON ON TRAUMA CHAIN

ROLE OF SURGEON IN TRAUMA CHAIN

• Optimizing resuscitative strategy• Surgical technique• Logistic and resource allocation• Disaster management• Development of strategies in resources poor

location• Collecting, reporting and auditing data• Research

WHAT ARE USUALLY DONE BY INDONESIAN SURGEON IN MANAGING TRAUMA?

• Trauma team in hospital? No• Resuscitation (partly or

sometimes)• Surgery (always)• Collaboration for early

Rehabilitation• Others (???)

SURGEON ++

TRAIN & DO

DO

COLABORATION

• Optimizing resuscitative strategy• Surgical technique

A&E: Accident and Emergency

GENERAL SURGEON: ON CALL FOR ABDOMINAL TRAUMA

AFTER ABDOMINAL CT-SCAN

AFTER ABDOMINAL CT-SCAN

SURGEON ++

• Logistic and resource allocation

• Disaster management• Development of strategies

in resources poor location

• Optimizing resuscitative strategy• Surgical technique

TRAINTRAIN & DO

DO

COLABORATION

BNPBGovernment, NGO

collaboration

TRAIN-WORKSHOP

SURGEON ++

• Logistic and resource allocation

• Disaster management• Development of strategies

in resources poor location

STAKE HOLDER

• Optimizing resuscitative strategy• Surgical technique

TRAINTRAIN & DO

DO

COLABORATION

• Collecting, reporting and auditing data

• Research

CONTINUEUPDATING

• TRAINING/ RETRAINING• CONTINUING EDUCATION• READING

collaboration

Trauma Surgery to Acute Care Surgery: Defining the Paradigm ShiftThe Journal of Trauma: Injury, Infection, and Critical Care. 68(5):1024-1031, MAY 2010

• Trauma surgery is gradually evolving into acute care surgery (ACS)• Study compared averages for trauma surgeons with general, oncology,

and vascular surgeons of 85 institution, 2007-2008• Total procedures for each specialty were similar: trauma 660, general

surgery 715, surgical oncology 713, vascular 835• Cholecystectomy were comparable between trauma and general surgery

(388 vs. 452); both groups perform about 75% of the cholecystectomies laparoscopically

• Appendectomies, trauma surgeons (180) exceeded general surgeons (128). Each group performed approximately 65% laparoscopically.

NEXT IN INDONESIA

• GENERAL SURGEON + (ATLS,DSCTC,PERIOPERATIVE COURSE) + OTHERS ?

• TRAUMA SURGEON (AS IN EUROPE) ?• RESUSCITATIVE SURGEON (AS IN UK) ?• ACUTE CARE SURGEON (AS IN US) ?• OTHERS ?

SUMMARY• Trauma surgeon (Europe), major trauma consultant, resuscitative

surgeon (England), who manage major trauma patients need special training.

• In Indonesia there is no trauma surgeon, nor resuscitative surgeon, but only general surgeon with additional course regarding trauma (ATLS, DSTC, perioperative). Additional training to get equal competence in managing trauma may be needed.

• Surgeon should participate in every step of trauma chain; training for first aid, training and doing for BLS & ALS, doing resuscitative surgery and doing collaboration with medical rehabilitation.

• Surgeon should participate to be member of hospital trauma team, disaster hospital team and making coordination with other disaster team

• There is paradigm shift from trauma surgeon to acute care surgeon.