Talks of Emergency Surgery Specialty!

[Paulista]

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I was recently reading a neurotrauma surgery journal, and the president of this association was explaining the decreased interest in head trauma management by Neurosurgeons.

In some hospitals in Illinois, some neurosurgery group refused to keep head trauma surgery priviledges due to increased fear of malpractice.

The ACS and many trauma societies in North America are discussing the possibility of creating a subspecialty of surgery called "Emergency Surgery."

They were talking about surgeons trained in this specialty being capable of performing craniotomies without neurosurgeon on-call.

As you guys know even the busiest trauma center in the country such as USC in Los Angeles, trauma surgeons are not allowed to do burr holes without a presence of attending neurosurgeon in the OR...

It would be very interesting to know about the trend in this possible future specialty!

 

[DocM]

Paulista,

Can you please send the source (journal) where you learned this . It's sounds interesting.

Thank you.

 

[Docgeorge]

That sounds really interestig. I'm really interesed in trauma surg. It seems (in my very navie eyes) that that is someithing that a trauma surgeon should be able to do. Can they not teach a trauma surgeon how to do this safely during a trauma fellowship?

 

[Paulista]

I downloaded from the AANS website on neurotrauma committee report.
American Association of Neurosurgeons.

Neurosurgery became independent from becoming a subspecialty of general surgeon long ago with Cushing and others.

Since, the organization of neurosurgery specialty, they tried to keep a monopoly on cranial surgery including neurotrauma.

I even heard of patients dying because no neurosurgeons were willing to take the case.

Neurosurgery as a field can be boring with long surgeries!
But, If Trauma surgeons are allowed to do emergency cranial surgery independent from Neurosurgeon's oversight, then maybe many more lives can be saves specially rural areas.

Eventually, after the initial cranial emergency is stabilized then patient can be transferred to a tertiary center with full neuro team back up for continuity of care. This reform can only occur if there are enough mortalities for lack of neurosurgeons, and if there is a mandate from the federal government for reform.

I invite anyone to read on AANS article, pretty interesting indeed.

http://www.neurosurgery.org/sections/tr/newsletter/trauma0304.pdf

 

[Docgeorge]

What else would the emergency surgeons be able to do? Could they put a femur fxr in a traction splint. Could they repair an open book fxr of the pelvis?

I wonder if other countries have trauma surgeons that are able to do all these things? If we did get the specialty of emergency surgery who woud they be certified by the ACS, AANS, or the AAO? Or maby a comitee comprised of all three.

 

[droliver]

Reality check: I don't think there are a lot of general/trauma surgeons looking to let Neurosurgeons off the hook by adopting the high risk/low reward procedures & responsibilities that neurosurgeons have trained years to do.

 

[supercut]

Actually, I was at last year's AAST annual meeting.

A group from LA presented a paper about incorporating emergency surgery into trauma, and how it increased the trauma surgeon's operative experience and satisfaction. (Residents were happier with that arrangement too).

Then another speaker proposed that trauma should be expanded to include emergency surgery and could possibly be further extended to include emergency neurosurgery and ortho procedures.

I think there is an increasing trend to add emergency general surgery procedures to trauma. Surgeons who mainly do elective cases are often uncomfortable operating on the less than ideal circumstances of emergency cases (no bowel prep, coagulopathy, etc). In fact, both my med school and my current program include the gen surg ED consults in with the trauma service.

No gen surgeons are doing ortho/neuro stuff yet (not in the US, anyway). That will be some time in coming, if it ever does, and would require the cooperation of both the neurosurgery and ortho communities in order to provide proper training. Personally, I think it's a cool idea and I hope it can become a reality during my career.

 

[Docgeorge]

Do you know the name of the paper and where I can find it?

 

[droliver]

A group from LA presented a paper about incorporating emergency surgery into trauma, and how it increased the trauma surgeon's operative experience and satisfaction. (Residents were happier with that arrangement too).
.

We've done that for the last 30 years & its the situation that existed before the advent of the Trauma Surgeon Specialist era. I think a number of programs have started to go back to it to make work hour compliance issues easier (in that now you don't have seperate general, vascular, burn, or colorectal teams all on call simultaneously) as much as for keeping the skill set up to date. Dr. J. David Richardson has published a number of articles along these lines in recent years in TRAUMA and the Amer. Journal of Surgery

 

[surg]

A group from Penn presented a similar paper at the last ACS Clinical Congress meeting. It was published in July's Journal of the American College of Surgeons

http://www.journalacs.org/article/PIIS1072751504002911/abstract

Many centers have done this already prior to this obviously.

 

[LuckyMD2b]

I don't understand the distinction between Emergency Gen. surg and trauma surg. in that Penn article. Doesn't G surg cover both trauma and emergent surgery (e.g. appy's etc.)?

As for the craniotomy training for gen surgeons; it seems pretty irrelevent for those practicing in lsrge enough communities. Neurosx should always be doin those.

 

[droliver]

I don't understand the distinction between Emergency Gen. surg and trauma surg. in that Penn article. Doesn't G surg cover both trauma and emergent surgery (e.g. appy's etc.)

Actually at some places that would not necessarily be true & you'd have someone seperate on "general surgery" for those things with the trauma service just doing pure trauma admits.

 

[thenavysurgeon]

in training, and now in practice...i've seen two different perspectives of the 'emergency surgery' issue. Frankly, it would be a delightful thing to have some one, or a small group, on call for trauma and emergent cases. It would allow the general surgeon to pursue a totally elective practice, which would be pure bliss.

such a general surgeon would have to be willing to give up the income from an ER based referral (trauma or otherwise)....but the trade-off in life-style might outweigh any monetary loss.

will it happen?

not universally, and not soon. in larger, academic centers, its happening. in most cases, the hopsital will hire two 'emergency surgeons' that do all the non-elective cases out of the ER or consults, and split the call. they are usually paid well. most anticipate doing it for a couple of years, and then moving on.

as for general surgeons, or non-neurosurgeons doing burr holes and cranies in the middle of the night, i can tell you this. any surgeon that has trained in a large academic center with rotations in a level one center has been instructed to do burr holes. its not hard. should they do them? if the patient's life is threatened and one is unable to rule out a sub-dural or epidural hematoma, or suspects it strongly, then yes. its a justified procedure, if a neurosurgeon is not available. the transfer of such an obtunded and unstable pt to another facility without decompression would worsen outcome. its a total judgement call, and i think any surgeon would be challenged by this awful dilemma.

 

[Paulista]

Most General Surgery Residents may have assisted in Neurosurgical procedures some of them, but I really don't know of anyone actually getting involved with burr holes.

The only place I have heard Gen Surgeon doing it is in the academic trauma setting.
Like the well established programs such as USC trauma center, but even they do it under the presence of neurosurgeons.

Now, if you have worked in the military maybe that could be possible until transfer for definitive care.

My point is trauma surgeons should be allowed to do burr holes for emergencies as part of their common practice.

 

[thenavysurgeon]

well, drilling burr holes is not 'common practice'...i trained at a huge level one center, saw tons of poly-trauma pts with potential epi and subdurals, and drilled two patients myself, with the neurosurgery resident with me. its not going to happen in a common trauma practice....BUT you should learn how to do it. you should learn how to do everything you can, because a lot of technical moves are transferrable to your everyday surgical practice.