A needs assessment of Canadian general surgery postgraduate trauma training

BackgroundClinical exposure to operative trauma cases for general surgery residents has decreased over recent decades. However, trainees are still expected to demonstrate competency in trauma care and injury management.MethodsA prospective survey based on preliminary qualitative analysis and a trauma education conceptual framework was distributed to general surgery educators, trauma surgeons, and general surgery residents across the country. Participants were asked to describe their trauma training experience, the educational resources available at their training programs, and their level of support for potential curriculum components.Results45% (31/69) of educators and 14% (58/405) of trainees responded to the survey. Perceived deficiencies were identified in the operative management of thoracic (educators 13%, trainees 28%), mediastinal (3%, 14%), neck (16%, 33%), and vascular (26%, 47%) injuries. Additional educational deficiencies were also identified in the domains of trauma systems and epidemiology, research and quality improvement, and injury prevention. Educators identified more inadequacies in training than trainees. Both groups supported participation in radiology (77%, 85%) and guideline (74%, 90%) reviews, journal clubs (84%, 81%), education rounds (90%, 88%), leading trauma resuscitations (94%, 98%), and trauma resuscitation simulations (90%, 95%) as valuable educational initiatives.ConclusionsTrauma training in Canada is currently perceived to be inadequate to support resident education. The development and implementation of competency-based curricular components will be essential to address the identified deficiencies. This data will be used to inform the development of a national trauma training curriculum and initiatives to enhance resident education.     

Development of a statewide trauma registry

In October 1986, the Pennsylvania Trauma Systems Foundation (PTSF) developed a statewide registry. Development concentrated on four major issues: 1) data elements; 2) patient selection; 3) confidential mandatory involvement for trauma centers; and 4) reporting/analysis. The overall compliance of the trauma centers was 81.5%. Documentation of prehospital run times and admission trauma scores were 21% and 70%, respectively. PTSF patients 55 years or older (27.9%) had twice the mortality as younger patients. Falls accounted for 76% of injuries to elderly patients. Finally, 42.6% of survivors had moderate to severe disabilities. Defining the "major trauma patient" is extremely difficult. A registry must have uniform quality data without undue costs. To obtain such data, maintenance of an active registry must be viewed as important as medical care, if organized trauma systems are to remain cost effective.     

Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service

BACKGROUND: Dwindling operative opportunities in trauma care may have a detrimental impact on career satisfaction among trauma surgeons and on career attractiveness to surgical trainees. Addition of emergency general surgery may alleviate some of these concerns. STUDY DESIGN: The trauma service at our institution incorporated nontrauma emergency general surgery over a 3-year period. The institution's trauma registry and hospital perioperative database were queried. The changes in operative caseload are described. Current trauma faculty anonymously completed a Web-based questionnaire about the addition of emergency general surgery to the trauma service. RESULTS: Operations for trauma decreased in 2002 compared with 1999, despite a higher number of penetrating injuries and total trauma contacts. Nontrauma general surgery operations performed by trauma faculty increased in proportion to coverage provided by the trauma service. In 2002, 57% of all cases performed by trauma surgeons were emergency general surgery, which accounted for 32% to 74% of an individual surgeon's caseload. In anonymously completed Web-based questionnaires, current trauma faculty expressed satisfaction with the combined trauma and emergency general surgery model. CONCLUSIONS: The combined trauma and nontrauma surgery service increased operative caseloads and improved satisfaction of trauma surgeons. A comprehensive trauma and emergency general surgery service may be an attractive model for the future of trauma surgery and provide logistical and medical advantages to the emergency general surgery patient population.     

Autopsy in general surgery practice.

This study evaluates the impact of the autopsy on a general surgical training program from 1984 through 1988. We have retrospectively examined the charts of all patients who died during this period. Included in this analysis are the records of patients from the general, cardiac, pediatric, and transplant surgery departments during this 5-year period. In all, 628 patients were evaluated. The overall autopsy rate was 73%. The clinical impressions prior to death are correlated with the anatomic diagnoses found during autopsy. Significant diagnostic discrepancies (errors unrecognized and directly related to or associated with the cause of death) were determined. On a yearly basis, diagnostic discrepancies range between 23% to 39%. Gross and histologic examination of surgical patients reveals significant information concerning the cause of death. These data confirm the educational benefit of autopsy despite escalating utilization of sophisticated, noninvasive diagnostic modalities. It is our opinion that the mortality conference, with formal autopsy presentation, is a vital forum for the discussion of patient care and quality assurance issues. Autopsy remains the most specific indicator of errors in diagnosis, management, judgment, and technique in surgical practice today.     

Economic modeling comparing trauma and general surgery reimbursement

BACKGROUND: The viability of trauma care as a surgical subspecialty is continually challenged by economic pressures related to reimbursement and opportunity costs. METHODS: The literature was examined for articles focused on economic implications of a trauma focused surgical practice. Economic forecasting techniques were applied using a recalculating spreadsheet to examine charge and revenue generation comparing the effects of numerous variables affecting a trauma or general surgical service. RESULTS: Elective general surgery practices derive the majority of revenues from procedural services, whereas trauma practices derive the majority of revenues from evaluation and management. Only centers with high admission volume can expect trauma surgeons to cover salary and expenses, predictably in association with high opportunity costs. CONCLUSION: The differences in time, effort, and patient volume required for a trauma surgeon to generate revenues comparable to an elective practice are dramatic. The current system creates disincentives for surgeons to participate in trauma care.     

The importance of vascular surgery training in a general surgery practice

The aim of this report was to document the practice of vascular surgery for graduates of 4 general surgery training programs.Graduating residents from 1991 to 1995 were surveyed by phone to document the number of reconstructive vascular and dialysis access procedures that they performed during the most recent 12 months. Those who pursued additional training beyond general surgery or who did not successfully complete the certifying examination of the American Board of Surgery (ABS) were excluded. In addition, the Resident Review Committee for Surgery (RRC-S) defined category report for these same general surgeons during their residency was examined.Fifty-five percent (26 of 47) of the board-certified general surgeons do either reconstructive or dialysis access vascular surgery. The average number of procedures in the RRC-S defined category for this cohort was 76. During the focused 12 months, 1986 vascular procedures were done by these 26 surgeons (76 cases per surgeon).In certain regions of this country, a significant volume of vascular surgery is done by general surgeons who have an ABS primary certificate alone. The technique of control and repair of major arteries and veins, the consequences of distal organ ischemia, reperfusion injury, thrombosis, and embolization are important anatomic and physiologic principles that must be taught in the curriculum to general surgeons, regardless of their future surgical careers. (Curr Surg 57:381-383. Copyright 2000 by the Association of Program Directors in Surgery.)     

Impact of acute care general surgery coverage by trauma surgeons on the trauma patient

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days (P < 0.0001), intensive care unit length of stay (P < 0.0001), and hospital length of stay (P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.     

A profile of urban adult pedestrian trauma

The interaction between the pedestrians, drivers, and vehicles involved in pedestrian trauma often receives less attention than motor vehicle occupant accidents. To better define these factors, records of 161 pedestrians admitted to two urban university hospitals were reviewed. There were 87 females and 74 males. Females were older, with a median age of 62 years, compared to 43 years for males. Alcohol was a factor in 39 (52%) males and ten (12%) females. The mean Injury Severity Score (ISS) was 14.6, with injuries most commonly to the extremities in 135 (84%), external surfaces in 103 (64%), and the head and neck in 71 (44%). There were 18 deaths (11.2%) with a mean ISS of 40.3. Of the 143 survivors, 18 (12.5%) with a mean age of 68.4 years required placement in long-term care facilities. Elderly survivors also had longer hospital stays, consuming 51% of all hospital days. Driver information from the governmental universal automobile insurance agency was available for 134 accidents. Drivers failed to yield the right of way in 31 instances (23%). Fifteen (11%) were driving without due care and five (4%) at an unsafe speed. Nine (7%) had documented alcohol involvement. Forty drivers (30%) incurred a total of 50 traffic charges. Previous driving records were available for 109. Forty-six (42%) had been involved in two or more previous accidents and 40 (37%) had five or more previous citations for moving violations. Pedestrian action at road intersections was recorded in 75 accidents.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluating performance of statewide regionalized systems of trauma care

A new methodology is presented for evaluating the extent to which patients within regionalized systems of trauma care are treated at the appropriate hospitals. Criteria are proposed for retrospectively classifying trauma patients as to whether they should have been treated at a trauma center. The criteria were developed by a panel of nationally recognized trauma experts and are based on the age of the patient and the type and AIS severity of injuries sustained. The criteria were then applied to uniformly collected data available for all trauma discharges in 1988 from acute care hospitals in a state with a well developed system of regionalized trauma care. According to the criteria, 19% of all trauma discharges in 1988 should have been treated at a trauma centers. Of those who should have been treated at a trauma center according to criteria, 66% actually received treatment at a center. Of those who were classified not to have required care at a trauma center, 62% actually were treated at non-trauma center hospitals. The congruence between where patients should have been treated and the actual level of hospital care received varied by the type and severity of the traumatic injuries sustained. The results of the analysis provide insights into the characteristics of trauma patients at higher risk of not getting the appropriate level of trauma care and should assist in improving guidelines for triage and transfer within a regionalized system of care.     

A profile of general practitioner obstetrics

The pattern of obstetrics as practised by general practitioners in a small country town over a period of 22 years is reviewed. The importance of dedicated nursing staff is emphasized, and an appeal is made for the establishment of maternity units distinctly separate from general hospitals.     

Endoscopic retrograde cholangiopancreatography in a general surgery practice

Endoscopic retrograde cholangiopancreatography (ERCP) is performed for the diagnosis and therapy of benign and malignant biliary and pancreatic disease. There are few reports in the literature regarding the incorporation of this procedure into a general surgery practice. One hundred seven consecutive ERCPs performed by the same surgeon over a two-year period were reviewed. The most frequent indications for ERCP were jaundice, suspected common bile duct stones, and a history of pancreatitis. Successful cannulation of the ampulla of Vater was achieved in 97 per cent of the cases with the desired duct being adequately visualized in 90 per cent of the cases. Sphincterotomy was performed in 42 per cent of the procedures and common bile duct stones were removed with a balloon or basket catheter. The overall complication rate was seven per cent with no mortality. ERCP accounted for 20 per cent of all endoscopies and 12 per cent of all procedures performed by the surgeon. Twelve per cent of these patients were subsequently operated upon by the surgeon while another 16 per cent requiring surgery were returned to the referring physician. This study supports the feasibility of the incorporation of ERCP into a general surgery practice.     

The present and future role of general practice surgery

In the RSA a general practitioner may perform any operation he feels competent to do. This contention is discussed, the type and frequency of operations performed by GPs is described, and the changing role of general practice surgery, its medicolegal implications, and the experience and training needed are outlined.