A Chance to Cut is a Chance to Cure

It's March 1979, and you're a senior surgery resident. You've just spent 30 straight hours at the hospital, mostly in the OR working on one case after another, including a hepatic lobectomy on a woman who was shot in a domestic violence incident and a splenectomy on a car crash victim.

You're tired, you wouldn't mind seeing your wife and kids at least once this week and you really need a place to lie down, but you've got six more hours to go. The first patient waiting for you is a kid with a stab wound in his abdomen. Still, you count your blessings for the umpteenth time that you've decided to pursue this line of work. You're every inch the "master surgeon," having operated on every part of the body, with some vascular and orthopedic surgery thrown in for good measure. If only the legendary Dr. Red Duke were in town to see you work.

Fast forward 25 years to a senior resident today. You're leaving the hospital after a 24-hour stint, ready to go home for a nap before taking your family to your parents' place for the traditional Sunday night supper date. As chief resident, you've had the usual string of cases, including many CTs and a few focused abdominal sonograms for trauma (FASTs) on patients who fell or were in car crashes. It's been several shifts since you've seen a serious gunshot or stabbing victim. You'd like to stay and help the attending with an exploratory laparotomy case left over after he took call with you last night, but it's simply against the rules. You're starting to get really worried about him, actually: he is distressed over the number of cases being foisted on him. You're thinking for the 10th time this week that you should have heeded your medical school friends' advice and forgone trauma surgery for something with much better pay and hours, like bariatrics or colorectal surgery.

"When I was growing up, we did lots of gunshot wounds, stabbings, all kinds of trauma cases," said H. David Reines, MD, vice chair, Department of Surgery, Inova Fairfax Hospital, Falls Church, Va. "The hours were horrendous, divorce rates were terrible, but it was exciting: you spent your life in the hospital taking care of folks. And you didn't care if you got paid or not because you were on salary. Plus, no one was too worried about malpractice. It was fun and everybody did everything."

The advent of peritoneal lavage and a decrease in violent crime leading to fewer penetrating injuries, along with other major developments in the nonoperative management of trauma cases, have put a new face on critical care surgery.

These changes have been so dramatic, and the culture of medicine has changed so much in recent years, that time appears to have nearly run out on the survival of the traditional trauma surgeon.

"We have this new thing where trauma centers don't make money, people want to go home at night, we don't operate very much, no one wants to take trauma call at night, and no one's reimbursing us for all the uninsured," Dr. Reines said. "The majority of the time, the trauma surgeon is babysitting. Most of my residents want to operate; they don't want to babysit."

A paper last year documented that more than 80% of trauma admissions are for blunt injuries, and that residents have to care for an average of 500 blunt trauma patients before getting to do a splenectomy or liver repair (Fakhry et al. J Trauma 2003;54:1-8).

Trauma centers around the country are trying to solve the crisis besetting today's trauma surgeons. The most common way is by creating an acute care service or emergency general surgery service, in the attempt to significantly increase both operative volume and revenue for trauma surgeons and their institutions.

In fact, emergency general surgery, which encompasses emergency trauma surgery, general surgery and critical care, has become so popular nationwide that a joint ad hoc committee of the American Association for the Surgery of Trauma (AAST) and the American College of Surgeons' Committee on Trauma is considering it as a potential subspecialty, an approach that has the makings of being a good fit for the academic, financial and lifestyle needs of the younger generations, and may subsequently attract future attendings and residents alike.

However, the success of acute care surgery services---and hence the enthusiasm with which trauma surgeons are embracing them---varies widely among regions and between hospitals.

"The concept of an emergency surgical hospitalist is anathema to those of us over 40, but may be the reality for the future. It's the only way to maintain our surgical skills," observed H. David Reines, MD, vice chair, Department of Surgery, Inova Fairfax Hospital, Falls Church, Va., where the creation of a full-time trauma service is being evaluated. "But the workload will be tremendous, and I think the most dangerous aspect is that the colorectal surgeons, the vascular surgeons, the orthopedic surgeons and the neurosurgeons aren't going to feel like they have to do trauma surgery. They of course prefer to see patients and operate during the day."

At the Denver Health Medical Center's Rocky Mountain Regional Trauma Center, which in 1979 created one of the first acute care surgery services in the country, six full-time trauma surgeons manage all of the institution's general, noncardiac thoracic and vascular surgical trauma cases, as well as all critical care, nontrauma emergency, urgent and elective surgery cases. Trauma and critical care call is divided equally between the six members of the team.

Fully 41% of the 4,082 cases performed by the acute care surgery service members from 2002 to 2003 were elective, according to a review presented by David Ciesla, MD, assistant professor of surgery at Rocky Mountain, at the AAST 2004 annual meeting. Another 40% were urgent cases and 11% were emergencies. Only 332 cases (8%) were trauma operations. Among the nonelective operations, 53% were abdominal or alimentary procedures, 22% were vascular, 14% were thoracic and 9% were head and neck cases. Moreover, while the trauma cases tended to come into the hospital on weekends, other emergency surgery cases were spread evenly throughout the week, with urgent cases usually cropping up before 6:00 p.m. on weekdays.

"Our data have shown that in this environment, trauma surgeons can provide high-quality thoracic and vascular operative care," Dr. Ciesla said. "The broad range of operative procedures managed by our service is facilitated by not having to actively compete for cases with specialty services. This is a solid first step towards reclaiming the trauma surgeon's operative potential."

He added that they are considering tacking on the emergency procedures of specialty services such as neurosurgery, including placement of intracranial pressure monitors and performing decompressive craniotomies.

In yet another model, surgeons at the Vanderbilt University Medical Center in Nashville created a separate, nontrauma, emergency general surgery service in 2000. At their institution, surgeons perform both emergency and elective general surgery, also exclusive of vascular or other emergencies now outside the purview of most general surgeons. There is one surgeon dedicated to all emergency department surgeries 24 hours a day, with seven attendings staffing the emergency surgery and trauma services. A chief resident-run team of residents and a number of physician extenders, such as acute care nurse practitioners, lend support to the surgeons.

The analyses by Virginia Commonwealth and Vanderbilt also indicate that adopting an emergency general surgery service means that surgeons not only perform a greater number of the more "desirable" operations but also take on a growing proportion of the unglamourous tasks, such as drainage of perirectal or intra-abdominal abscesses, as well as other "pitfalls," like routine appendectomies and cholecystectomies, according to Dr. Reines and other opinion leaders in the field.

"Initial enthusiasm for the solution of adding nontrauma emergency surgery responsibilities has the potential to be short-lived, because the majority of these surgical emergencies consist of draining soft-tissue infections and excising necrotic gastrointestinal structures," said Denver's Dr. Ciesla. "Indeed, it can be argued that coverage of these surgical emergencies has a greater effect on the job satisfaction of the somnolent elective surgeon---whether he be a general surgeon or a subspecialist---who is relieved of these responsibilities."(emphasis mine)

The attendings have had to absorb the majority of the blow, as the 80-hour workweek shelters the residents. Attendings now work an average of 87 hours a week and have about five in-house calls monthly, with a sixth night backing up a fellow. Each of the in-house calls averages 34 hours when surgeons are on service, and at least 26 hours when they are not.

"When you look at this, and present this to a resident and say, 'How would you like to work more hours than your residents, operate a lot postcall, work on your postcall day, have your academic time consumed doing elective cases instead of pursuing research interests or traveling to meetings? Doesn't that sound like a good career to you?' they'd say, 'Not a chance!'" said Lewis Kaplan, MD, director of Yale's Surgical Emergencies service, after presenting the information at the AAST's 2004 annual meeting. "I'm not sure this is really the model we wish to pursue in order to attract residents and keep trauma surgery alive."

Labels: Future of Surgery