Trauma surgery

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Trauma surgery is a surgical specialty that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. Trauma surgeons generally complete residency training in general surgery ^{[1] [2]} and often fellowship training in trauma or surgical critical care. The trauma surgeon is responsible for initially resuscitating and stabilizing and later evaluating and managing the patient. The attending trauma surgeon also leads the trauma team, which typically includes nurses and support staff, as well as resident physicians in teaching hospitals. ^[3]

Contents

• Training
• Responsibilities
• Acute care surgery
• History
• In the United Kingdom
• See also
• References
• External links

Training

Most United States trauma surgeons practice in larger centers and complete a 1- to 2-year trauma-surgery fellowship, which often includes a surgical critical-care fellowship. They may therefore sit for the American Board of Surgery (ABS) certifying examination in surgical critical care. National surgical boards usually supervise European training programs; they also certify for subspecialization in trauma surgery. An official European trauma surgical examination exists.^{[ citation needed ]}

Training for trauma surgeons is sometimes difficult to obtain. In the US, the Advanced Trauma Operative Management (ATOM) course and the Advanced Surgical Skills for Exposure in Trauma (ASSET) provide operative trauma training to surgeons and surgeons in training. The Advanced Trauma Life Support course (ATLS) is what most US practitioners who take care of trauma patients are required to take (emergency medicine, surgery, and trauma attending physicians, physician extenders, as well as trainees).

Responsibilities

The broad scope of their surgical critical care training enables trauma surgeons to address most injuries to the neck, chest, abdomen, and extremities. In large parts of Europe, trauma surgeons treat most of the musculoskeletal trauma, whereas injuries to the central nervous system are generally treated by neurosurgeons. In the US and Britain, skeletal injuries are treated by trauma orthopedic surgeons. Facial injuries are often treated by maxillofacial surgeons. Significant variation occurs across hospitals in the degree to which other specialists, such as cardiothoracic surgeons, plastic surgeons, vascular surgeons, and interventional radiologists are involved in treating trauma patients.

Trauma surgeons must be familiar with a large variety of general surgical, thoracic, and vascular procedures and must be able to make complex decisions, often with little time and incomplete information. Proficiency in all aspects of intensive care medicine/critical care is required. Hours are irregular with a considerable amount of night, weekend, and holiday work.

Most patients presenting to trauma centers have multiple injuries involving different organ systems, so the care of such patients often requires a significant number of diagnostic studies and operative procedures. The trauma surgeon is responsible for prioritizing such procedures and for designing the overall treatment plan. This process starts as soon as the patient arrives in the emergency department and continues to the operating room, intensive care unit, and hospital floor. In most settings, patients are evaluated according to a set of predetermined protocols (triage) designed to detect and treat life-threatening conditions as soon as possible. After such conditions have been addressed (or ruled out), nonlife-threatening injuries are addressed.

Acute care surgery

Over the last few decades, a large number of advances in trauma and critical care have led to an increasing frequency of non-operative care for injuries to the neck, chest, and abdomen. Most injuries requiring operative treatment are musculoskeletal. For this reason, part of US trauma surgeons devote at least some of their practice to general surgery. In most American university hospitals and medical centers, a significant portion of the emergency general surgery calls are taken by trauma surgeons. The field combining trauma surgery and emergency general surgery is often called acute care surgery.^{[ citation needed ]}

History

Dr. George E. Goodfellow is credited as the United States' first civilian trauma surgeon. ^[4] He opened a medical practice in the silver boom town of Tombstone, Arizona Territory, in November 1880, where he practiced for the next 11 years.

On July 2, 1881, U.S. President Garfield was shot in the abdomen by Charles J. Guiteau. Two days later, a miner was shot outside Tombstone. On July 13, 1881, Goodfellow performed the first recorded laparotomy to treat the miner's gunshot wound. The man had a perforated small intestine, large intestine, and bowel. Goodfellow sutured six holes in the man's organs. Similarly, President Garfield was thought later to have a bullet possibly lodged near his liver, but it could not be found. ^{[5] [6] : M-9} Sixteen doctors attended to Garfield and most probed the wound with their fingers or dirty instruments. ^[7] Unlike the President, the miner survived. ^{[8] [9]}

Goodfellow treated a number of notorious outlaw cowboys in Tombstone, Arizona, during the 1880s, ^[10] including Curly Bill Brocius. ^[11] During the gunfight at the O.K. Corral on October 26, 1881, Deputy U.S. Marshal Virgil Earp and his brother Assistant Deputy U.S. Marshal Morgan Earp were both seriously wounded. Goodfellow treated both men's injuries. ^{[12] : 27} Goodfellow treated Virgil Earp again two months later on December 28, 1881, after he was ambushed, removing 3 inches (76 mm) of bone from his humerus ^[13] and attended to Morgan Earp on March 18, 1882, when he was shot while playing a round of billiards at the Campbell and Hatch Billiard Parlor. Morgan died of his wounds. ^{[12] : 38}

Goodfellow once traveled to Bisbee, 30 miles (48 km) from Tombstone, to treat an abdominal gunshot wound. He operated on the patient stretched out on a billiard table. Goodfellow removed a .45-caliber bullet, washed out the cavity with hot water, folded the intestines back into position, stitched the wound closed with silk thread, and ordered the patient to take it to a hard bed for recovery. He wrote about the operation: "I was entirely alone having no skilled assistant of any sort, therefore was compelled to depend for aid upon willing friends who were present—these consisting mostly of hard-handed miners just from their work on account of the fight. The anesthetic was administered by a barber, lamps held, hot water brought, and other assistance rendered by others." ^[8]

Goodfellow pioneered the use of sterile techniques in treating gunshot wounds, ^[14] washing the patient's wound and his hands with lye soap or whisky. ^[8] He became America's leading authority on gunshot wounds ^[15] and was widely recognized for his skill as a surgeon.

By the late 1950s, mandatory laparotomy had become the standard of care for managing patients with abdominal penetrating trauma. ^[16] A laparotomy is still the standard procedure for treating abdominal gunshot wounds today. ^[16]

In the United Kingdom

In the United Kingdom, trauma surgery is now generally considered a subspeciality of general surgery. ^[17] However, at the Royal London Hospital, which is Britain's busiest major trauma centre and the busiest trauma unit in Europe, ^[18] their trauma surgeons come from backgrounds in vascular surgery.

Courses in the UK for aspiring trauma surgeons include the advanced trauma life support and Definitive Surgical Trauma Skills courses, both provided by the Royal College of Surgeons.

See also

• Transmediastinal gunshot wound
• Eastern Association for the Surgery of Trauma, is a major association of trauma surgeons in the US.

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names.

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. General surgeons also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions, to alter bodily functions, to reconstruct or improve aesthetics and appearance, or to remove unwanted tissues or foreign bodies. The subject receiving the surgery is typically a person, but can also be a non-human animal.

Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

An appendectomy or appendicectomy is a surgical operation in which the vermiform appendix is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appendicitis.

A trauma center, or trauma centre, is a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may also refer to an emergency department without the presence of specialized services to care for victims of major trauma.

A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid in the abdominal cavity.

A gunshot wound (GSW) is a penetrating injury caused by a projectile from a gun. Damage may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

Dietmar H. Wittmann is a German academic surgeon specializing in complex abdominal surgery. He was associated with the following medical schools: University of Hamburg, Germany, University of Düsseldorf, Germany, University of California San Francisco Medical School,USA, Hahnemann Medical School, Philadelphia,USA, Medical College of Wisconsin Milwaukee, USA. In addition to his clinical work, research, publications and teaching and lecturing worldwide, he is mostly known for his work relating to intra-abdominal infections, abdominal compartment syndrome abdominal compartment syndrome and staged abdominal repair STAR. Besides introducing the concept of calculated antimicrobial therapy Wittmann conceptualized the operative strategy of Staged Abdominal Repair (STAR) or the planned open abdomen to reverse the detrimental effects of the abdominal compartment syndrome and to treat imminent intra abdominal complications before they progress to life-threatening conditions. He is the inventor of a fascia prosthesis for temporary abdominal closure, the Artificial Bur Fascia Prosthesis (generic) or Wittmann Patch and Star Patch.

George Emory Goodfellow was a physician and naturalist in the 19th- and early 20th-century American Old West who developed a reputation as the United States' foremost expert in treating gunshot wounds. As a medical practitioner in Tombstone, Arizona Territory, Goodfellow treated numerous bullet wounds to both lawmen and outlaws. He recorded several significant medical firsts throughout his career, including performing the first documented laparotomy for treating an abdominal gunshot wound and the first perineal prostatectomy to remove an enlarged prostate. He also pioneered the use of spinal anesthesia and sterile techniques in treating gunshot wounds and is regarded as the first civilian trauma surgeon.

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

A pancreatic injury is some form of trauma sustained by the pancreas. The injury can be sustained through either blunt forces, such as a motor vehicle accident, or penetrative forces, such as that of a gunshot wound. The pancreas is one of the least commonly injured organs in abdominal trauma.

Damage control surgery is surgical intervention to keep the patient alive rather than correct the anatomy. It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis, hypothermia, and increased coagulopathy.

The 274th Forward Surgical Team (Airborne)—part of the 274th Forward Resuscitative and Surgical Detachment (Airborne)—is an airborne forward surgical team of the United States Army providing Level II care far forward on the battlefield. It was first constituted in 1944 and served in Europe during World War II. More recently it has been involved in relief operations following natural disasters and has undertaken several recent deployments to Iraq and Afghanistan. The 274th Forward Surgical Team was part of both the initial entry forces of Operation Enduring Freedom in 2001 and Operation Iraqi Freedom in 2003. Currently the unit falls under the command of the 28th Combat Support Hospital and is based at Fort Bragg, North Carolina.

References

External links

• Anaesthesia Trauma and Critical Care (ATACC)
• trauma.org Archived 2019-08-24 at the Wayback Machine a website dedicated to trauma
• National Foundation for Trauma Care