Tag Archives: operating room

Trends In Resident Trauma Operative Experience

Even though it’s called trauma surgery, the operative experience in trauma tends to be somewhat limited. This is due mostly to the fact that most trauma centers see predominantly blunt trauma. Yes, there are hospitals around the world where the penetrating injury load remains high and there is operative experience aplenty.

But in the US, the vast majority of trauma centers see mostly blunt trauma. Surgical residents in the US are required to log 10 operative and 20 nonoperative cases to successfully meet residency completion requirements. And blunt trauma is tending to get less and less operative in nature. A good example is the evolution of blunt solid organ injury to mostly nonoperative management.

So what is happening with surgical resident operative trauma experience? And has there been any impact from the work hour restrictions that have gone into effect in the US? A study from Harborview, Denver Health and Seattle Children’s looked at the ACGME operative logs for surgical residents annually from 1989 to 2010. They combined the data into 5 year blocks, with the last two having work hour restrictions in place.

Some interesting findings:

  • Overall mean caseload of major cases (all types) remained steady at about 925 per resident
  • Mean trauma operative caseload decreased from 76 to 39 (beginning of work hour restrictions)
  • Mean trauma operative caseload remained steady at 39 for the 7 years in which work hour restrictions were in effect
  • The number of intra-abdominal trauma operations decreased from 31 to 17, and the number of liver/spleen operations decreased from 5 and 4 to 3 and 2

Bottom line: Resident trauma operative experience has declined and stabilized in the US. This is due to the evolution of our management of blunt trauma. Unfortunately, this decline will reflect on how well prepared surgeons at outlying hospitals are, and in the quality of emergency surgery they may provide. The impact will be felt most by seriously injured patients who cannot be taken to a high level trauma center initially. We need creative solutions to address this issue, such as mini-clerkships in trauma or structured experiences at high level trauma centers for surgeons in outlying hospitals.

Related post: ED at the busiest hospital in the world!

Reference: ACGME case logs: surgery resident experience in operative trauma for two decades. J Trauma 73(6):1500-1506, 2012.

Pelvic Fractures: OR vs Angio In The Unstable Patient

One of the cardinal rules of trauma care is that hemodynamically unstable patients can only go the the operating room from the ED. No trips to CT, xray, etc. Trauma professionals occasionally try to make exceptions to the rule, but it usually doesn’t work out.

Well, what about the patient with severe pelvic fractures who is or becomes unstable? Pelvic fracture bleeding is not always easy or even possible to control in the OR, and angiography offers a way to identify and stop the bleeding, right?

The trauma group at Ryder in Miami did a lengthy (13 year) retrospective review of their experience with these patients. They looked at every patient who underwent angiography, then identified the subset that went to the OR followed by angiography. There were 134 angio patients and 49 OR to angio patients on whom they based their analysis. Obviously, there is plenty of opportunity for bias in this study, and many of the study patients identified had to be excluded due to incomplete records.

Patients who went to the OR first tended to have similar injury severity but were sicker than the angio alone group. Crystalloid and blood resuscitation volumes were significantly higher in the OR group as well. Most of these patients underwent a laparotomy, and 64% had active intra-abdominal bleeding. None died in OR, and most were left with a damage control abdominal closure.

In the angio group, there were really 2 subsets: angio alone, and angio followed by OR. Mortality in the angio alone group was similar to the OR-angio group. But deaths skyrocketed in those who went from angio to OR (67% vs 20%). This is likely due to them failing angiographic management of bleeding. Three patients died in the angio suite.

Bottom line: There’s a lot of data in this paper, and some of the results can be explained by selection bias. However, they appear to support algorithms released by EAST and the WTA (see diagram above). In general, a trauma patient with severe pelvic fractures and hemodynamic instability needs to go to OR to identify and treat any source of intra-abdominal bleeding. If pelvic bleeding remains a problem, preperitoneal packing may be considered, followed by a trip to angio at that point. The rule that unstable patients should only go to OR (or an ambulance bound for a trauma center if there is no OR) still holds!

Reference: Operating room or angiography suite for hemodynamically unstable pelvic fractures? J Trauma 72(2):364-372, 2012.

Quiz: There is just one extremely rare reason that I know of to move to CT with a hemodynamically unstable trauma patient. Leave a comment with your guess.