Tag Archives: trauma surgeon

When Should You Activate Your Backup Trauma Surgeon?

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

In-House Trauma Attendings: A New Financial Benefit for Hospitals?

Many trauma hospitals provide in-house trauma attendings to improve the timeliness of care and to provide housestaff supervision. In many centers, this is required in order to meet the surgeon response requirements for trauma activations. Frequently, this involves some expense for the hospital if they provide an on-call stipend. A study in the Journal of Trauma examined the financial impact housing the surgeons in the hospital at an urban Level I trauma center.

Bellevue Hospital in New York City implemented an in-house attending policy in October of 2007. The study looked at the year prior to and the year after implementation. It focused primarily on the number of operative cases performed during nights and on weekends. The biggest changed noted was a four-fold increase in the number of cholecystectomies performed and 1.2 day decrease in the length of stay for those patients.

Using several financial approximations, they concluded that the hospital received an increased revenue of $854K, while the in-house attending program cost the hospital $750K during the year. The study raises a number of questions, though. The average length of stay, even after in-house attending presence, was 5 days! It would seem that additional savings could be accrued by working on LOS for these patients, as well as other surgical groups. There were other procedures that were done at night that were not analyzed, so there are probably more benefits to be accrued.

The downside of the in-house attendings performing these acute care surgery cases was that their availability for incoming trauma patients was reduced. There were also questions about the possibility of errors when performing surgery at 4AM.

Bottom line: This study shows evidence that there is a financial benefit to having an in-house surgeon. This will be important to hospital administrators who must grapple with the cost of moving to this type of coverage. However, higher quality financial research of this type is also needed.

Reference: In-house trauma attendings: A new financial benefit for hospitals. Pachter, Simon et al. J Trauma 2010;68(5) 1032-1037.

Can You Teach A Trauma Surgeon To Insert An ICP Monitor?

You’ve heard the statistics about the graying of our society. The proportion of older people is growing rapidly. Well, there are only about 4400 neurosurgeons in the US, and they are aging as well. Nearly a third are older than 55 years.

This leaves a relatively small number of neurosurgeons tasked with helping to take care of trauma patients. Many Level II centers are hard pressed to maintain their neurotrauma services. Even basic procedures like ICP monitor placement may require transfer to another center.

The group at Miami Valley Hospital in Dayton looked at their experience with training surgeons to insert intraparenchymal ICP monitors (not EVD devices) over a 6 year period. Their trauma surgeons, as well as surgical residents were trained by watching a video, practicing in a cadaver lab under the supervision of a neurosurgeon, and being proctored by a neurosurgeon while placing them in three patients. Surgical residents could place the monitor if directly supervised by a surgeon.

Here are the factoids:

  • Of 410 monitors placed, 298 were placed by surgeons and 112 by neurosurgeons
  • The surgeons placed 188 Licox monitors and 91 Caminos. The type was not recorded in 19.
  • Surgeon complication rate was 3% (9 patients), and the neurosurgeon rate was 0.8% (1 patient). None were major of life-threatening.
  • Most of the complications were malfunction of the device. There were 2 dislodgements in the surgical group, and 1 in the neurosurgeon group.

Bottom line: This one’s a little tough to interpret. Yes, the number of complications (malfunction) is higher with the surgeons. But the numbers are small, and this difference does not reach statistical significance. I do worry that the training is a bit too sketchy. But I think that this procedure will soon enter the skillset of many acute care surgeons, especially those working at hospitals in more rural settings. This will be the quickest way to begin high quality neurotrauma care for patients who are injured in areas not served by highest level trauma centers.

Related post:

Reference: Successful placement of intracranial pressure monitors by trauma surgeons. J Trauma 76(2): 286-291, 2014.

Trauma Surgeons And PTSD??

A number of studies have documented post-traumatic stress disorder in our trauma patients, pre-hospital providers, and combat veterans. A new study now suggests that PTSD symptoms are present in 41% of trauma surgeons(!). Can it be true??

The study was carried out using an email questionnaire that was sent to all EAST and AAST members. Respondents were directed to an online questionnaire that polled them for basic demographics, as well as a series of questions using a well-established PTSD checklist scale, the PCL-C.

Here are the factoids:

  • 1104 questionnaires were distributed, and 453 were complete enough for analysis (41%)
  • Respondents tended to be younger (68% < 50 years old), male (76%) and white (80%)
  • The majority worked in Level I (71%) urban (90%) academic centers (81%) with resident coverage (83%)
  • 85% took at least 4 in-house calls each month, 27% had 2 weeks or less of vacation each year (!), and 81% believed that trauma surgery was more stressful than other surgical subspecialties
  • 40% of respondents had PCL scores consistent with PTSD (!)
  • The only independent predictor of having PTSD symptoms was managing 5 or more critical cases while on call

Bottom line: Hmm, be skeptical of this one. Yes, it does seem to show some possible issues with PTSD in a select group of trauma surgeons. However, I don’t believe this is easily generalized, and my personal contact with surgeons around the country does not really bear this out. The survey methodology, response rate, and the skewed demographics raise some serious questions about the quality of this data. And can self-reporting of PTSD symptoms from a group of trauma surgeons really be reliable?? It does appear that a subset of surgeons who work at very busy urban centers may be at risk, and this certainly deserves further scrutiny. But this study does not really apply to the majority of surgeons practicing trauma care in this country, who don’t work in that kind of environment.

Related posts:

Reference: Unveiling posttraumatic stress disorder in trauma surgeons: A national survey. J Trauma 77(1):148-154, 2014.

Again? Trauma Surgeon In-House vs At Home

Here we go again. Yet another paper debating whether we really need to have a trauma surgeon in-house at high level trauma centers. A paper published in December 2013 looks at this topic, and is a perfect illustration of why you need to read the whole article, not just the abstract!

This retrospective study primarily examined patient mortality, as well as a few other LOS indicators. They compared their results as they changed from having trauma surgeons who took call from home to taking in-house call. It involves only one trauma center in Lexington, Kentucky and covers two 21 month periods. 

Here are the factoids:

  • There were roughly 5000 patients each in the at-home and in-house groups
  • Overall demographics looked identical, even though the authors thought they detected differences in age and ISS
  • Time in ED, ICU LOS, hospital LOS decreased significantly, and percent taken to OR increased in the in-house group. There was no change in mortality.
  • These patterns were the same in trauma activation patients, who were obviously more seriously injured.
  • The authors conclude that having an in-house surgeon does not impact survival, but can speed things up for patients throughout their hospital stay.

I have many problems with this study:

  • The statistical results are weird. Many of the allegedly significant differences appear to be identical (e.g. mean age 44+/-19 vs 45+/-19, hospital LOS 3 days vs 3 days). And even if the authors found a test that makes them look statistically significant, they are clinically insignificant. ICU LOS differences were measured in hours, and 25 hours was significant? 
  • Attending presence “improved” from 51% to 88%. This means that they were not present in 1 of 5 trauma activations. This can easily overshadow any positive effect their presence may have had.
  • Mortality is too crude an indicator to judge the value of surgeon presence.
  • Lengths of stay can be due to so many other factors, it is not a valid measure either.
  • A retrospective, registry study has too few of the really critical data points

Bottom line: This paper is the poster child for why you MUST read the full paper, not just the abstract. If you had done the latter, you may believe that having an in-house surgeon is not necessary. Many papers (of variable quality) have looked at this (poorly) and there is no consensus yet. But it is a requirement for ACS verification if the surgeon can’t make it to the bedside of a seriously injured patients within 15 minutes. 

After observing trauma activations for 32 years, I know there is value in having an experienced surgeon present at the bedside during them. However, this value is very hard to quantify and every paper that has tried has not looked at the right variables. And these variables cannot be assessed in a retrospective, registry type study. 

Yes, there is no good, hard evidence of the value of the in-house surgeon. But it is there. Let’s stop publishing (and not critically reading) this kind of junk and confusing the issue!

Reference: Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency. J Am College Surg 281(4):734-738, 2013.