Velmahos Acute Care Surgery, An Issue of Surgical Clinics, E-Book

1. Auflage 2014
ISBN: 978-0-323-26683-3
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 100 Seiten

Editor George Velmahos and authors highlight every important area in Acute Care Surgery for all general surgeons. Topics include obstruction, perforation, bleeding, acute inflammation, hernia emergencies, the open abdomen, necrotizing soft tissue infections, vascular emergencies, thoracic emergencies, and much more!

Autoren/Hrsg.

Velmahos, George

Leseproben

Preface
Acute Care Surgery: From De Novo to De Facto
George C. Velmahos, MD, PhD, [e-mail],     Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA George C. Velmahos, MD, PhD, MSEd, Editor There is little debate anymore about the need for Acute Care Surgery (ACS). It seems like yesterday—and it is indeed less than 10 years ago—that general surgeons, trauma surgeons, neurosurgeons, orthopedic surgeons, and administrators alike were entangled in confusing and often contradicting arguments about ACS. Like every change, this particular one was not to be accepted without resistance and disbelief. Eventually, it was put to the unmistaken test of public use. It was tried in various hospitals and left to succeed or fail according to its ability to improve the process and outcomes of care. Now, in 2014, as most hospitals around the country have developed or are in the process of developing ACS programs, we can confirm that the model was a success. The need for ACS was born out of the discrepancy between the care delivered to trauma and nontrauma emergency patients. Over nearly five decades, our country developed an enviable system for the care of the injured. Trauma teams, trauma centers, and trauma protocols were created to ensure that trauma patients are managed in an organized and comprehensive manner. Regionalization of trauma care allowed interconnectivity between centers, delivery of patients to the right place according to resources and commitment, and transfer of care from lower to higher levels of trauma centers, when the need arises. The American College of Surgeons directed and supported this effort in numerous ways through its Committee on Trauma. None of these existed for nontraumatic surgical emergencies. Unlike trauma, the care provided to patients with a surgical disease of nontraumatic cause was often fragmented and possibly inadequate. There were no dedicated teams and no well-planned systems for these patients who arrived in the middle of the night with a perforated diverticulum, a bleeding ulcer, or an obstructed bowel. To complicate things further, the increasing trend of subspecialization among US surgical residency graduates was leaving a huge void in call coverage. Particularly in tertiary centers, surgeons had become masters of one specific body region or even one specific organ. Often by mandate from the institution, they were focused on the practice of breast, endocrine, colorectal, foregut, or pancreatobiliary surgery. When night came, they were asked to revert to broad-based general surgery and, as a matter of fact, under the most adverse conditions on the most unstable patients. It was not always easy, particularly when a full elective operative schedule or clinic was waiting the next morning. Nontraumatic emergency surgical disease was not always managed in the best possible way or by the most qualified person. As a young trauma surgeon, I can vividly remember the trauma bay bustling with the activities of our robust trauma team, spread around the bed of a patient with critical injuries. Too many people in the room was the typical problem. In the next bay, a patient with peritonitis and sepsis received only a fraction of this activity and often in the absence of a surgical team. The room was often quite empty. Following deliberations with multiple interested stakeholders, the American Association for the Surgery of Trauma established in 2003 the ad-hoc Committee to Develop the Re-organized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.1 Eventually, this became the standing Acute Care Surgery Committee and led the effort of developing a curriculum for ACS fellowship and defining the scope of practice of ACS.2 With the understanding that one size does not fit all, the leaders of this effort balanced the need for standardization with the flexibility to conform to local standards. Initially, a few academic institutions explored the benefits of an ACS team. Based on early positive feedback, more institutions followed and quite rapidly the concept spread in academia and community practice alike. I can remember only a few examples of explosive expansion of a new concept in my career and ACS is one of them. From a debated and mistrusted novelty it became a fact of surgical practice within only a few years. No doubt exists that there is a lot of work to be done. The initial intent of including orthopedic and neurosurgical procedures in the ACS surgeon’s gamut was met with resistance by the relevant subspecialty societies, and to a great extent, abandoned.3,4 The overlap with the general surgeon’s practice is still significant. The boundaries of ACS need to be refined according to the basic rule of delivering care to the right person at the right place at the right time (by the right surgeons, I might add). Different institutions have different needs. We should allow the flexibility to apply slightly different ACS models in academic versus community hospitals and in large versus small centers. Training goals and methods must be better defined. We have come a long distance. ACS now encompasses trauma, surgical critical care, and emergency nontraumatic surgery.5 The scope of practice in emergency surgery is increasingly understood. For me it is defined by four simple words: bleeding, obstruction, perforation, and inflammation (acute). The American Association for the Surgery of Trauma has described it in greater detail by a list of relevant ICD-9 codes.6 There are 16 ACS fellowship programs that produce trained and committed ACS surgeons every year. Many more are prepared to follow. The training in general surgery has been enhanced after the creation of ACS teams.7 Academic scholarship on ACS is ramping up and the trauma community, which has traditionally excelled in the research of injury and resuscitation, is applying its research infrastructure in emergency surgical diseases.8 Finances improve, and departments with ACS teams have realized increased revenues at the ACS division without compromising the profit of general surgeons.9 Quality control and productivity initiatives from the well-oiled trauma QA machine have fertilized the emergency nontraumatic surgery world.10,11 Finally, not to be minimized, the perceptions of young trainees, who were recently ranking trauma surgery low in their preferences, have now changed and ACS is considered a desirable career goal.12 With all this in mind, the current issue of the Surgical Clinics of North America presents a compilation of nontraumatic emergency surgery diseases that are frequently managed by ACS teams. Most of them are confined to the abdomen. Some are extra-abdominal and universally within the purview of the ACS surgeon (eg, necrotizing fasciitis). Others depend on local standards, expertise, and culture (eg, thoracic or vascular emergencies). The collaboration with subspecialists should only be viewed in a positive light as a way to enhance patient care, never as a turf war. The ACS model should be based on inclusion not exclusion. The experts who authored the articles are nationally recognized authorities, who have devoted their professional lives to the care of the patient in need. They write from experience, knowledge, and the heart. References
1. Committee to Develop the Reorganized Specialty of Trauma Surgical Critical Care and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005; 58:614–616. 2. The Acute Care Surgery Committee of the American Association for the Surgery of Trauma. The Acute Care Surgery curriculum. J Trauma. 2007; 62:553–556. 3. Vrahas, M.S. Acute care surgery from the orthopedic surgeon’s perspective: a lost opportunity. Surgery. 2007; 141:317–320. 4. Byrne, R.W., Bagan, B.T., Bingaman, W., et al. Emergency neurosurgical care solutions: Acute Care Surgery, regionalization, and the neurosurgeon: results of the 2008 CNS consensus sessions. Neurosurgery. 2011; 68:1063–1067. 5. Velmahos, G.C., Jurkovich, J.G. The concept of Acute Care Surgery: a vision for the not-so-distant future. Surgery. 2007; 141:288–289. 6. Shafi, S., Aboutanos, M., Agarwal, S., Jr., et al. Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg. 2013; 74:1092–1097. 7. Stanley, M.D., Davenport, D.L., Procter, L.D., et al. An Acute Care Surgery rotation contributes significant general surgical operative volume to residency training compared to other rotations. J Trauma. 2011; 70:590–594. 8. Early, B.J., Huang, D.T., Callaway, C.W., et al. Multidisciplinary acute care research organization (MACRO): if you build it, they will come. J Trauma Acute Care Surg. 2013; 75:106–109. 9. Miller, P.R., Wildman, E.A., Chang, M.C., et al. Acute care surgery: impact on practice and economics of elective surgeons. J Am Coll Surg. 2012; 214:531–535. 10. Barnes, S.L., Cooper, C.J., Coughenour, J.P., et al. Impact of acute care surgery to departmental productivity. J Trauma. 2011; 71:1027–1032. 11. Ingraham,...