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.
Reference: Successful placement of intracranial pressure monitors by trauma surgeons. J Trauma 76(2): 286-291, 2014.
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.
Reference: Unveiling posttraumatic stress disorder in trauma surgeons: A national survey. J Trauma 77(1):148-154, 2014.
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.