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W2088568856 abstract "The new 8th edition of the Advanced Trauma Life Support (ATLS) course manual1American College of Surgeons Committee on TraumaAdvanced Trauma Life Support for Doctors.Student course manual. 8th ed. American College of Surgeons, 2008Google Scholar contains a small but significant change. The phrase, “trauma is a surgical disease,” long a point of contention with other specialties caring for trauma patients, has been removed.Now used in over 50 countries as the basis for training in the initial assessment and management of trauma, this publication reflects the research and clinical experience of the American College of Surgeons (ACS) Committee on Trauma and expresses that organization's philosophy toward triage, diagnosis, and clinical care. Astute readers of the ATLS materials have noticed that a certain message is conspicuous by its absence. The preface to the 7th edition of the ATLS describes the ACS's role as follows:In accordance with that role, and recognizing that trauma is a surgical disease, the ACS Committee on Trauma (COT) has worked to establish guidelines for the care of the trauma patient.The 8th edition includes a substantially similar sentence, minus the crucial phrase on trauma as a “surgical disease.” John B. Kortbeek, MD, FACS, professor of surgery and critical care at the University of Alberta and a member of the COT who was instrumental in the revision process for the manual, confirms that the deletion is intentional.Dr. Kortbeek explains the change in historical terms. “The intent of making that statement,” he says, “was to emphasize that to have a successful trauma system and a successful trauma hospital, surgeons needed to be included in the management team and the care of the trauma patient. That remains true today. What changed over time is that that statement became a focal point and could be interpreted in varying ways, including in a negative, exclusive way, suggesting that only surgeons should be managing trauma patients, which is not correct and never was the intent of the statement.” The ATLS, he says, presents a “common language” for a safe and effective response to trauma, not a mandatory formula.Harmonious relations among the various specialties involved in trauma care–emergency physicians, trauma surgeons, emergency medical technicians (EMTs), blood bank personnel, anesthesiologists, radiologists (both interventional and purely diagnostic), orthopedists, intensivists, nurses, and others–would appear to be universally, non-controversially desirable. The implications of those critical 5 words, however, can extend beyond the laudable goal of teamwork.Some commentators inside and outside the surgical community, recalling trauma surgeons' historic role in developing and organizing the national institution of the trauma center, view the excision of the “surgical disease” statement in the context of a perception that this field is in crisis. If trauma triage and management have been evolving in ways that emphasize non-operative procedures, they have not done so without energetic opposition, at times strong enough to border on fighting words within and between specialties.Critical Time Wasted on No-Brainers?Norman E. McSwain, Jr., MD, FACS, NREMT-P, professor of surgery at Tulane School of Medicine and trauma director at the Spirit of Charity Trauma Center at the Interim LSU Public Hospital at New Orleans, stresses his specialty's traditional leadership emphatically.When he delivered the 31st Charles L. Scudder Oration on Trauma at the ACS's 2003 conference, he treated the statement “Trauma is a surgical disease from beginning to end” practically as a mantra, repeating it 15 times during his address; the published version italicizes each instance of it.2McSwain Jr, N.E. Prehospital care from Napoleon to Mars: The surgeon's role Charles L. Scudder Oration, 2003.J Am Coll Surg. 2005; 200: 487-504Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Recounting the history of surgical leadership in out-of-hospital care, and lamenting what he sees as fragmented, uncoordinated management in contemporary practice, Dr. McSwain challenged his colleagues to regain control of the full process, particularly through a component that he has personally pioneered, the training and supervision of EMTs and paramedics–“the eyes, ears, and hands of the surgeons” in the field–as well as decisionmaking once a trauma case reaches the hospital.“I was not part of the change” in the new ATLS, Dr. McSwain notes. “Nobody asked my opinion about it; if they did, I would have strongly objected to it, because I think [trauma] is truly a surgical disease.“That doesn't mean that there are not a lot of other people involved in it,” he adds, “but their role is only part of the picture. The surgeon is the only person that takes care of the trauma patient from the beginning of their illness until they're rehabbed and go home.”“R. A. Cowley, several years ago, developed the philosophy of the Golden Hour,” Dr. McSwain says. “That philosophy still holds absolutely true.”In situations where a surgeon is not clearly at the helm, Dr. McSwain says, valuable time within the Golden Hour is sometimes squandered on studies that may assist diagnostic precision but do not address the immediate priority: hemodynamic stability. “If they're bleeding from a gunshot aorta,” other penetrating injuries, pelvic fracture, or other severe conditions, “that hemorrhage can only be stopped in the operating room.”At Charity Hospital–where 65% of trauma cases are penetrating trauma, a proportion Dr. McSwain cites as the nation's highest–emergency physicians and trauma surgeons collaborate within well-defined roles. “There's an emergency physician standing at the head of the table, who's responsible for airway management and so forth, and there's a surgeon standing at the foot of the table, who's responsible for the overview of everything that happens … . You haven't got one group of people that's saying ‘No, I need to keep this patient in my own department for 2 or 3 hours until I get all the studies, and then if I think I need you I'll call you.'”The surgeon's pathophysiological and anatomical knowledge, Dr. McSwain says, makes him or her the logical coordinator of the full range of specialists whose different skills come into play.Crisis From One Angle, Evolution From AnotherSteven M. Green, MD, an emergency physician at California's Loma Linda University Medical Center who has participated in debates over the surgical role in trauma over the years, takes a position distinctly different from Dr. McSwain's. Time, technology, epidemiology,3Engelhardt S. Hoyt D. Coimbra R. et al.The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon?.J Trauma. 2001; 51: 633-638Crossref PubMed Scopus (62) Google Scholar and accumulated results, Dr. Green believes, have caught up to tradition, contributing to what he describes as a crisis for trauma surgery, with troubling implications for one of emergency medicine's key partner disciplines.4Green S.M. Trauma surgery: discipline in crisis.Ann Emerg Med. 2009; 53: 198-207Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar He interprets McSwain's vehement advocacy of surgical leadership as an indication that this “old school” philosophy is in trouble. “He would not have had to repeat that so many times in front of an audience of surgeons,” Dr. Green speculates, if the position were not in retreat: “Methinks he doth protest too much.”Particularly in clinical circumstances more ambiguous than penetrating trauma, a contemporary trauma surgeon spends surprisingly little time actually performing surgery: “only 1 per 83 adult blunt trauma activations and 1 of 1,111 pediatric blunt trauma activations,” by Dr. Green's research published in this journal.5Ibid.Google Scholar,6Steele R. Green S.M. Gill M. et al.Clinical decision rules for secondary trauma triage: predictors of emergent operative management.Ann Emerg Med. 2006; 47: 135-145Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The balance between the opportunities for dramatic interventions and this specialty's demanding conditions has shifted, resulting in what Dr. Green sees as “a big shortage of surgeons who are willing to take trauma call.”Mismatches between expertise and clinical needs, he finds, add up not only to what Ernest E. Moore, MD, FACS, has called “onerous nocturnal fire alarms in the ED without purpose,”7Moore E.E. Role of the acute care surgeon in the emergency department management of trauma.Ann Emerg Med. 2006; 47: 413-414Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar but to recruiting difficulties for trauma surgery, a trend toward part-time trauma surgeons or moonlighters taking trauma call (generating worse outcome data than full-timers), and ultimately the risk of a dangerous shortage of talent and experience in a setting where these qualities are urgently, if infrequently, needed.Dr. Green readily, repeatedly, and energetically acknowledges that surgeons for decades did “monumental and groundbreaking work in setting up our network of trauma centers and bringing hospitals up to the standard where they could provide a high level of trauma care.” Surgeons, he says, “were there when other specialties were not.”“In the 1970s, emergency medicine had not yet even really coalesced into a real specialty; there was no real leadership shown from us, because we didn't really exist.” Up through the 1980s, he adds, “the best and brightest surgeons wanted to do trauma, because it was the most prestigious, and it was quite lucrative then. Now it's the opposite.”He contrasts the field's post-Vietnam heyday–a period of rapid progress as surgeons, often with military backgrounds and training, made impressive strides against forms of trauma encountered in civilian life as well–with today's general reduction in invasive approaches.Fewer patients today need exploratory procedures, and the shift toward non-operative approaches leaves some surgeons frustrated. They may still exercise the holistic leadership that Dr. McSwain and others advocate, Dr. Green finds, but they are increasingly doing it outside the operating theater. Trauma surgeons are caught between the advances of competing approaches and evidence-based critiques from both the emergency medicine side (where “I've probably been the most vocal,” Dr. Green mentions) and the international community, where different allocations of specialists have produced comparable outcomes, calling into question the American assumption that surgeons are the natural and necessary captains of the trauma care team.For some physicians and surgeons, Drs. Green and McSwain both note, quality of life incentives and economics can weigh against the intuitive appeal of trauma work. Being on call at night, when most trauma cases come in, is a burden that not all bear gladly; 80-hour work weeks and scarce vacations, Dr. Green points out, appear to many contemporary medical students as more of a sign of professional and personal masochism than a point of pride.(The changing surgical culture, in this respect, leads Dr. McSwain to castigate some colleagues for losing interest in a core activity of their field. “I don't mind people not wanting to get up in the middle of the night to do surgery,” says Dr. McSwain, “but then if that's what your stance is going to be, step out of the way, don't block it.”)EM Surpasses Surgery as MED Student ChoiceEmergency medicine overtook surgery as American senior medical students' preferential specialty choice during the mid-1990s.8Association of American Medical CollegesMedical School Graduation Questionnaire All Schools Report, 1978-2007. Association of American Medical Colleges, Washington, DC2007Google ScholarWithin surgery as a whole, trauma surgery has also declined in popularity, Dr. Green finds, citing the American Board of Surgery's refusal to recognize it as a distinct subspecialty (in contrast to vascular, pediatric, hand, and other surgical domains) as an indicator of lack of prestige as well as a barrier to specific fellowship accreditation.A career as a general surgeon performing cholecystectomies and other largely elective procedures, Dr. Green suggests, offers a more regular schedule and more operating room time as well as steadier remuneration.“Back in the 1970s and ‘80s, when trauma surgeons really put [the trauma center system] together and trauma surgery was at its zenith, most Americans had health insurance,” he adds. “With the deterioration of health insurance coverage, trauma victims are disproportionately those without insurance. And so the reimbursement of a trauma surgeon based on their collections [is] poorer than the average surgeon, and so wages have fallen, and because of that, the interest in surgeons for making this their life–that among the other lifestyle factors–has definitely deteriorated.”A more direct problem is a growing discrepancy between indications for surgery and institutional requirements. Though ACS criteria for verifying a hospital as a trauma center mandate that surgeons be available on arrival of the sickest trauma patients, both the need for open procedures and their documented benefit are increasingly questioned. No hospital wants to lose its status as a trauma center, but surgeons remain on the sidelines in a majority of emergent cases, even some cases of penetrating trauma. A wagon circling response, Dr. Green finds, is natural: “Here's something that they have owned, they have been proud of, and now they see it slipping out of their grasp.”Part of this change, Drs. Green and Kortbeek both observe, stems from improvements in imaging, minimally invasive interventions, and other technologies, with the requisite skills now broadly distributed across the house of medicine's nonsurgical and surgical components. When hemorrhage is not apparent, as in some forms of truncal blunt trauma, computed axial tomography can identify a bleeding spleen or liver more rapidly than exploratory surgery.“In many ways nonoperative management is more difficult, because you have to be prepared to intervene, and you have to recognize when it's appropriate,” says Dr Kortbeek. “The other thing that's changed is the advent of interventional radiology, and specifically angioembolization, as a tool in the armamentarium of trauma systems. And that has converted many cases that previously were exclusively operative to either nonoperative or mixed operative/angioembolization cases. All those things are making a difference, and who performs and provides those services is evolving rapidly and varying across the country and countries.”The need for immediate laparotomy, Dr. Green finds, has become particularly rare in pediatric blunt trauma. Statistical analysis of admissions to major pediatric trauma centers shows “an amazingly low average of 1 laparotomy every 7 months per hospital, so that the Golden Hour concept “appears essentially nonapplicable to children suffering blunt trauma.”9Green S.M. Rothrock S.G. Is pediatric trauma really a surgical disease?.Ann Emerg Med. 2002; 39: 537-540Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Practice guidelines have accepted non-operative management as the norm in hemodynamically stable children and adults alike. The emergency and critical care specialties, Dr. Green finds, have evolved to the point that essentially all resuscitative and diagnostic measures short of surgery can take place outside the operating room.There is a meaningful distinction between a non-operative approach and a nonsurgical approach, Dr. Green allows, noting that surgeons remain the most reliable authorities on pathophysiology and surgical anatomy. But that specific knowledge differential, Dr. Green and co-author Steven Rothrock, MD, have written, does not affect the “exceedingly straightforward [management protocol] in the setting of blunt trauma: Observe with serial evaluations when hemodynamically stable; operate when not.”10Ibid.Google ScholarEmergency physicians and intensivists routinely and successfully assess hemodynamics in other settings, he notes, and have developed ample knowledge allowing them to decide which cases need a surgical approach. Surgeons themselves commonly refer to trauma as a non-operative specialty, says Dr. Green; he regards “multidisciplinary” as the preferable description.No Grounds for Relegation to “Ghosts”Non-surgeon-centered procedures, Dr. Green finds, offer advantages from several perspectives. Trauma surgeons relieved of obligatory calls that do not result in a need for their unique skills could apply them more efficiently, with a likely increase in professional satisfaction. “Most trauma surgeons,” he believes, “would be thrilled to get some help, to get their call burden reduced.” Emergency physicians and others could count on an undiluted talent pool in this critically important partner discipline.More important, the improvement in resource efficiency would involve no compromise in patient outcomes. Dr. Green has seen no evidence to date supporting better results when surgeons control the entire process.11Green S.M. Is there evidence to support the need for routine surgeon presence on trauma patient arrival?.Ann Emerg Med. 2006; 47: 405-411Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Findings of better outcomes in trauma centers than in hospitals lacking such accreditation, he believes, probably reflect other differences that have not been sorted out by specific regression analyses. “It is not just the surgeon in control,” he says; “it's having a big hospital with a lot of resources and organized protocols for care.”Dr. Green stresses the distinction between opposing the exclusivity implied by the “surgical disease” paradigm and recognizing the value of leadership and teamwork. He opposes “the inherent assumption that only a surgeon possesses the cognitive skills to do a trauma resuscitation … the implication there that if you don't have a surgery residency as your background and training, you cannot provide optimal early trauma care. I think almost all emergency physicians would strongly object to that. Because we like to think we're every bit as good in that first hour or two in resuscitating the trauma patient. Of course, in those unusual circumstances where the patient does need to go to the operating room, that is not our role and our training. So there does need to be continuity of care.”One source of unnecessary friction between fields, Dr. Green notes, is that the ATLS minimizes the role of emergency physicians and offers no explicit recognition of emergency medicine's expansion and maturation as a specialty over recent decades. “One thing that hasn't changed in the manual, which has always been kind of a source of irritation to emergency medicine, is throughout the entire ATLS student manual, a big thick book, the phrase ‘emergency physician’ never occurs. We are like the ghosts of trauma care. Everything is oriented around the surgeon. It's as if we don't exist.”If adherence to the traditional hierarchy implied in the previous ATLS reflects a concern that emergency medicine is encroaching beyond its appropriate domain, Dr. Green says, that perception is unfounded. “We as emergency physicians … do not provide care outside of the emergency department. There would need to be some other physician–whether it's surgeons or intensive care unit physicians or hospitalists with special training in trauma–there does need to be somebody to provide further care. And we as emergency physicians have never claimed that we could do or want to do that.” The removal of the exclusivist clause in the ATLS, he hopes, is a sign that a less dogmatic, less territorially minded generation of leadership may be ascendant at ACS.Emerging Global StandardsThe perception of a zeitgeist antithetical to the prestige of trauma surgery, one might note, has been current for some 2 decades12Richardson J.D. Miller F.B. Will future surgeons be interested in trauma care? Results of a resident survey.J Trauma. 1992; 32: 229-235Crossref PubMed Scopus (149) Google Scholar or longer. Reflecting on Dr. Green's publication describing trauma surgery as a discipline in crisis, Dr. Kortbeek comments, “I suspect you could have written that article 50 years ago and made the same comments about a different specialty.”He expresses no regrets about choosing a general surgical career with a substantial trauma and critical care component in his practice, and he has high praise for the young surgeons entering the field in his region. The important changes in the specialty, he finds, are an evolution toward efficient centralization in fewer but larger major trauma centers, a sharp rise in the volume of trauma cases paralleling population trends, and a shift toward a higher proportion of blunt trauma despite improvements in vehicular design: “We're seeing greater use of safety tools like restraints and airbags … but trauma hasn't gone away.”An important reason for relaxing the emphasis on surgical leadership, Dr. Kortbeek states, is that different nations' trauma care systems have allocated the various specialties' roles differently without a corresponding drop-off in clinical outcomes. Although surgeons are captains of the trauma care ship in the United States and Canada, and the ACS continues to support that role, the ATLS subcommittee is multidisciplinary, and its members recognize the variation in practices worldwide. European and Canadian hospitals, Dr. Green notes, do not require surgeons' routine presence when trauma patients arrive. Nonsurgical critical care physicians manage most European trauma resuscitations. In Germany, Dr. McSwain reports, orthopedic surgeons transported by helicopter provide much initial care in the field.Comparisons among the various systems are difficult because of confounding variables. France's high rates of motor vehicle injury and mortality, for example, complicate assessment of its out-of-hospital care-oriented Service d'Aide Médicale Urgente.13Nathens A.B. Brnet F.P. Maier R.V. Development of trauma systems and effect on outcomes after injury.Lancet. 2004; 363: 1794-1801Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar Death rates are highest, Dr. Kortbeek notes, “in sub-Saharan Africa and Russia, followed by the Middle East and India. Well, there are lots of reasons people die more frequently from trauma in those countries: most of them have to do with safety prevention and engineering processes, but they also have to do with access, standardized training, quality of training, and consistency of care. To pin it on whether an emergency doctor or a surgeon is running the trauma resuscitation would be impossible.”The essential principle that Dr. Kortbeek supports across the board is that some system coordinating prevention, acute care, rehabilitation, and reintegration must be in place. That someone knowledgeable is in charge is more important than that this person be a surgeon. “The worst sin,” he says, “is the sin of omission: not having a trauma system or a trauma plan.”The philosophical shift implicit in the revised preface is only one of many changes in the new ATLS. In an accompanying special report in the Journal of Trauma,14Kortbeek J.B. Al Turki S.A. Ali J. et al.Advanced trauma life support, 8th edition: the evidence for change.J Trauma. 2008; 64: 1638-1650Crossref PubMed Scopus (314) Google Scholar Dr. Kortbeek and 56 co-authors present 31 revised or new passages on topics ranging from familiar assessment procedures to new tools to disaster medicine, along with the research supporting each revision, organized under the 5-level evidence-classification system of Wright et al.15Bhandari M. Swiontkowski M.F. Einhorn T.A. et al.Interobserver agreement in the application of levels of evidence to scientific papers in the American volume of the Journal of Bone and Joint Surgery.J Bone Joint Surg Am. 2004; 86A: 1717-1720Google Scholar, 16Wright J.G. Revised grades of recommendation for summaries or reviews of orthopaedic surgical studies.J Bone Joint Surg Am. 2006; 88: 1161-1162PubMed Google Scholar, 17Wright J.G. Einhorn T.A. Heckman J.D. Grades of recommendation.J Bone Joint Surg Am. 2005; 76: 1909-1910Crossref Scopus (133) Google Scholar, 18Wright J.G. Swiontkowski M. Heckman J.D. Levels of evidence.J Bone Joint Surg Am. 2006; 88: 1264Google Scholar, 19Wright J.G. Swiontkowski M.F. Heckman J.D. Introducing levels of evidence to the journal.J Bone Joint Surg Am. 2003; 85A: 1-3Google Scholar Substantive changes from the 7th edition appear in algorithms for management of airways and pelvic fractures.By soliciting proposed changes and supporting evidence through the Web site trauma.org (with increased international participation in the ACS Committee on Trauma and ATLS Subcommittee, plus outreach to multiple stakeholder groups), connecting each topical revision to a ranked level of evidence (the lowest being “expert opinion” and the strongest being methodologically strong randomized controlled trials or systematic reviews of such trials), and acknowledging that evidence in some areas is lacking, the ATLS contributors were able to systematize and unify a body of international knowledge. They offer “one safe way of providing initial assessment and care for the injured” without making overreaching claims that this standardized approach is the only one acceptable in all clinical situations, or that the ATLS course occupies “the sharp edge of changes in trauma assessment, resuscitation, and adoption of new technology.”This balance between evidentiary grounding and philosophical circumspection, Dr. Kortbeek emphasizes, characterizes the allocation of responsibility among specialties as well. “I think the ACS believes,” he says, “that [surgical] involvement and leadership is essential. That doesn't mean that it's exclusive … . An exclusive system doesn't work for anybody or any specialty.”A More Inclusive Trauma ParadigmInsistence on exclusivity has hindered the acceptance of the ATLS overseas, and the change in the new preface is a move toward greater compatibility. “More than half the courses are now taught outside the United States and Canada,” Dr. Kortbeek notes. “The vision and mission of ATLS is to provide one safe way and one common language. There's a lot of support for that internationally, and a lot of good will.”Emphasizing the actions needed in trauma care rather than the specific professional roles of the personnel performing them does not imply an abandonment of certain core principles that everyone from Dr. McSwain to Dr. Green considers essential. As Dr. Green has written, “it should not be perceived as a personal affront to trauma surgeons that their dramatic success in maturing their subspecialty has rendered them less essential minute by minute.”20Green S.M. Ann Emerg Med. 2006; 47 (op. cit): 405-411Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar A timely, orderly response to trauma, with judicious rather than rote use of all relevant tools from ultrasonography to scalpels, remains indispensable, no matter who is at the helm. The new 8th edition of the Advanced Trauma Life Support (ATLS) course manual1American College of Surgeons Committee on TraumaAdvanced Trauma Life Support for Doctors.Student course manual. 8th ed. American College of Surgeons, 2008Google Scholar contains a small but significant change. The phrase, “trauma is a surgical disease,” long a point of contention with other specialties caring for trauma patients, has been removed. Now used in over 50 countries as the basis for training in the initial assessment and management of trauma, this publication reflects the research and clinical experience of the American College of Surgeons (ACS) Committee on Trauma and expresses that organization's philosophy toward triage, diagnosis, and clinical care. Astute readers of the ATLS materials have noticed that a certain message is conspicuous by its absence. The preface to the 7th edition of the ATLS describes the ACS's role as follows: In accordance with that role, and recognizing that trauma is a surgical disease, the ACS Committee on Trauma (COT) has worked to establish guidelines for the care of the trauma patient. The 8th edition includes a substantially similar sentence, minus the crucial phrase on trauma as a “surgical disease.” John B. Kortbeek, MD, FACS, professor of surgery and critical care at the University of Alberta and a member of the COT who was instrumental in the revision process for the manual, confirms that the deletion is intentional. Dr. Kortbeek explains the change in historical terms. “The intent of making that statement,” he says, “was to emphasize that to have a successful trauma system and a successful trauma hospital, surgeons needed to be included in the management team and the care of the trauma patient. That remains true today. What changed over time is that that statement became a focal point and could be interpreted in varying ways, including in a negative, exclusive way, suggesting that only surgeons should be managing trauma patients, which is not correct and never was the intent of the statement.” The ATLS, he says, presents a “common language” for a safe and effective response to trauma, not a mandatory formula. Harmonious relations among the various specialties involved in trauma care–emergency physicians, trauma surgeons, emergency medical technicians (EMTs), blood bank personnel, anesthesiologists, radiologists (both interventional and purely diagnostic), orthopedists, intensivists, nurses, and others–would appear to be universally, non-controversially desirable. The implications of those critical 5 words, however, can extend beyond the laudable goal of teamwork. Some commentators inside an" @default.
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