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Rock On???Staying Focused on Our Way to Greatness

2004; Lippincott Williams & Wilkins; Volume: 56; Issue: 1 Linguagem: Inglês

10.1097/01.ta.0000100172.39403.ec

1529-8809

David B. Hoyt,

Emergency and Acute Care Studies

The term "Rock On" is a current colloquialism used to imply "to move forward, to overcome resistance, to just get it done." The term characterizes for me how we need to address our current dilemma in medicine and in trauma. FIGUREFIGURE. David: B. Hoyt, MD, FACSRock 'n' Roll music originated from the fusion of Rhythm 'n' Blues, Swing, and Country music in the early 50s. It was based on a three-chord guitar progression, drums, and bass and required the development of the electric guitar, which, prior to their electrification, were inaudible in bands. The immediate response and popularity of Rock 'n' Roll music suggests that it must be close to the "beat" of our lives. It is often associated with people being unable to resist tapping their foot or dancing. It is certainly one of the social forces in the United States that has brought us together over the last 50 years. One might even argue that Abraham Lincoln was, in fact, responsible for the true origins of Rock 'n' Roll and that by liberating African-Americans and allowing the development of their music, from which rock ultimately developed, he started it all. In 1951, Alan Freed, the host of the classical radio station WJW in Cleveland, Ohio, had a luncheon meeting with Leo Mince, a record-store owner. Mince told Freed that Caucasian teenagers wanted to hear Rhythm 'n' Blues, and he asked Freed to start playing this music on the radio and told him that he would support advertising to do so. Freed started slowly and developed the "Moondog Rock 'n' Roll Party" at the end of the regular classic program. Soon it became a program of its own. He was noted for tapping the beat of the music on a Cleveland phone book with a golf glove that he kept at work to enhance the background beat. On March 21, 1952, they organized the Moondog Coronation Ball, and instead of advertising it as Rhythm 'n' Blues music, they called it Rock 'n' Roll to make it attractive to Caucasian teenagers whose parents would have been concerned if they were going to hear Rhythm 'n' Blues (African American) music. During a very short period of time, several bands reached national acclaim including: Bill Haley and the Comets, Little Richard, Chuck Berry, Jerry Lee Lewis, and Buddy Holly. Many features of these groups performances were defiant, the performers often climbing on their instruments or inventing signature movements, such as Chuck Berry's "Duck Walk." This new breed of music had grown up in a time following the largest war in our existence. During the same time that Rock 'n' Roll was maturing, we endured two more wars, Korea and Vietnam, which confronted America's youth with the realities of life and death. This was the time of greatest concern over the spread of communism internationally, and it lead to the Cold War and the era of McCarthyism. In stark contrast, as these concerns affected us, we were introduced to television programs like Father Knows Best—defining the American way of life. We watched events evolve such as the discussion of whether African Americans could sit on the bus. We saw heroes assassinated. The teen heroes of the time included contrasting characters such as: Marlon Brando or James Dean and Pat Boone or Dick Clarke. One of the greatest Broadway musical shows of the time, Westside Story, highlighted a story of racial contrasts and introduced the reality of inner city violence. The occurrence of Rock 'n' Roll, and particularly certain singers such as Elvis Presley, had unprecedented effects on American women in particular. Traditional society wanted to ban Rock 'n' Roll. It was characterized as a communicable disease and even proposed that it was a form of a neurological disorder likened to the medieval lunacy which takes on the name St. Vitas dance. There were many significant social changes over the 20-year period that followed the introduction of Rock 'n' Roll. These included: African-American liberation, women's liberation, sexual liberation, and a mentality amongst youth often attributed to the rock festival "Woodstock Nation." Great advances in science and technology occurred, such as landing on the Moon, while as a backdrop we fought the Korean War, the Vietnam War, and the nation debated over their appropriateness. We had campus riots, the Kent State tragedy, and ultimately loss of confidence in our leadership manifested by the Watergate break in. During this time, we watched the assassination of John F. Kennedy, Martin Luther King, and Bobby Kennedy. We experienced the dangers, social revolt, and our overall vulnerability, and we prevailed. Certainly these experiences had given us the fundamental character and perseverance we need to address the problems of today. ORIGINS OF TRAUMA CARE Just like Rock 'n' Roll's origins, the origins of trauma care were the result of fusion of practice: county hospitals, charity hospitals, and the military experience. The evolution of the trauma surgeon also broke with tradition. It started as a model of a special kind of surgeon who had a fighter pilot mentality—the "right stuff." This was a general surgeon who would operate on anything, was the "go to" surgeon for all real problems, approached problems with a "work with what you have" attitude, and had no concern for working in the middle of the night or worrying where the money came from. This surgeon thrived on excitement, per se, and loved every minute of it. What has happened to this identity as we go forward? Elvis Presley was driving a truck when he walked into Sun Records recording studio one day and recorded a couple of songs. The owner noted his talent and coupled him with three back up musicians and that's how it all started. Perhaps most notable was the phenomenal effect he had on a new musical genre. There is little question that his influence on music contributed to the major social revolution that occurred in the 50s and 60s. Ironically, he was unable to prevent himself from falling victim to its success. Elvis died dependent on drugs, he was overweight, and he had alienated most of the people around him. Despite this, his home in Graceland is visited by more Americans every year than any other building in the United States, except for the White House. In a sense, the 20-year lifespan of Elvis' entertainment career becomes a metaphor for the current dilemma we find ourselves in as trauma surgeons. Will we become victims of our own success and burn out, or will we evolve and "Rock On?" TIME TO DECIDE We are at a crossroads. Our patients should remain our priority. As such, there are three issues that will be critical to our success. These involve politics, science, and professionalism. Politics: Sit Ins Won't Work Are we effective? The political effectiveness of sit ins and rallies won't work today. The Woodstock Nation is now rich and fat, and some would question whether we still have the edge. Injury, accidental death, and disability were described as a neglected epidemic in 1966. 1 In a recent Institute of Medicine Report in 1999, our job to reduce the burden of injury was redefined. 2 In reality, though we have made significant changes, we have made less progress than we had hoped for 37 years ago. Significant accomplishments have been achieved through multiple organizations, including the American College of Surgeons Committee on Trauma, and other professional organizations. These accomplishments include: paramedic training, regional EMS systems, the development of 911 communication systems, the introduction of Advanced Trauma Life Support trauma care standards, the hospital verification program, and the National Trauma Data Bank. Trauma care is truly a disease-management model and it fits with our current perceptions of the way we should approach our patients. At the same time, we see an emerging epidemiologic peak of elderly trauma, yet our effectiveness in getting this message to the public has been minimal. 3 An important symposia, the Skamania Conference, developed consensus on the efficacy of mortality reduction following trauma system development. 4 We accept that an 8% to 10% mortality reduction can be realized. Despite this, we have great regional differences in trauma system development throughout the United States. When one looks at the effects of political intervention, the Trauma Systems Development Act of 1990 can be associated with increased trauma systems' development in the United States. Despite this, political will has not been sustained and federal reauthorization and re-appropriation is a battle every year. A recent trauma systems vision document with an eye toward 2010 re-articulates all the essential features that are needed to achieve success. 5 A recent Health Resources and Services Administration Report demonstrates inconsistent coverage of 911 services, inconsistent coverage by trained pre-hospital personnel, and incomplete coverage of helicopter ambulance services. 6 This report looks at the current status of states with a Strengths, Weaknesses, Opportunities, Threats analysis. Within this, states find system planning and operations as the greatest opportunity, but lack of finance and lack of human resources as the greatest weaknesses and threats. Further, although the ability to evaluate trauma system efficacy is one of the greatest weaknesses and threats identified, most also identified this as an opportunity. Combining the HRSA report with the recent profile of U.S. trauma centers suggests that much of the country is uncovered by trauma systems and is directly reflected in our readiness to deal with unconventional disasters. 7 We need to reaffirm our political influence to complete this job. One of the problems we face is that we are a "small player" in the overall picture of Washington politics. Further, going to Washington takes time and we are perhaps amongst the busiest group of practitioners in all of medicine. There are competing issues including bioterrorism, liability reform, and Medicare reform that compete for attention with our legislative needs. Nonetheless, by bonding together, the American Association for the Surgery of Trauma, the Coalition for Trauma Care, the American College of Surgeons Committee on Trauma, the American Trauma Society, and the National Foundation for Trauma Care can create a political agenda that will be very effective in getting our message across. In fact, we must work together and we must have a clear message. In the past year, a committee combining these groups has had regular telephone conference calls and has one primary goal for the next year. This is to preserve and reauthorize the Trauma Systems Development Act of 2003. This will likely finish the system. The status of the Trauma Systems Development Act of 2003 is favorable. It allows for substantially more money to develop state trauma systems and includes provisions to increase data collection, relieve state matching fund requirements, and calls for an Institute of Medicine study to study the state of trauma research and the role of federal agencies in supporting research. As a uniform message, trauma system development should be our first priority and we should emphasize that disaster preparedness will not be successful without a fully functioning trauma system in all states. What can you as an individual do? First and foremost, understand the challenge and support public advocacy by visiting the Capital and working with the political coalition that represents the American Association for the Surgery of Trauma and the American College of Surgeons. In addition, it is important for each and every one of us to work with local, city, county, and state governing bodies to get this message out and help push from the grassroots level. We need to emphasize this in the context of supporting the public health approach. Most healthcare planners today will respond to this message. We need to work for the development of trauma systems for our patients. Just as we had a recent indictment of the NASA Space Program, the public assumes we are on top of this problem in medicine even though we may not be. As frustrated as we may feel by what has occurred in Medicine over the last 10 years, our patients don't understand that we are not ready and we need to advocate for trauma systems on their behalf. Following the ability to inoculate for small pox, which preceded true vaccination, a great controversy arose in the United States. Benjamin and James Franklin opposed the inoculation publically in their newspaper, The New England Courant. Subsequently, Ben Franklin's son died of small pox in 1736. Following this he wrote: "A fine boy of four years old by the small pox taken in the common way. I long regretted bitterly and still regret I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation on the supposition that they should never forgive themselves if a child died under it. My example showing that the regret may be the same either way, and therefore, the safer should be chosen." We need to move trauma system development forward. Rock on. Science—The Path of Clinical Trials Just as with trauma system development, we have been concerned that we are less competitive for research funding and do not have an adequate infrastructure for clinical trials. Medicine followed the origin of organized civilization, which originated in the riverbeds of the Nile, the Euphrates and Tigres, and the Yellow River in China. The study of these cultures shows that politics and religion have influenced science and medicine and the scientific process since the beginning. For centuries physicians developed theories concerning spirits to explain disease. In early Egypt, the sun was thought to be a chariot driven by Apollo, or it was believed it was eaten and reborn each morning. Each of these theories were wrong, but you could still tell time by them, and as a result, the principle that false theories do not alter facts surfaced in early mankind. There was a fundamental flaw in logic that persisted until the late 19th Century when clinical experimentation really began to occur but which is still practiced too often today. The concept of "post hoc ergo propter hoc: therefore because of it," has guided medicine for thousands of years. In essence, if a man becomes sick and gets medicine and then gets well, then it might be concluded to be because of it. However, that something happened does not equal that it happened because of the first. In history, we are guilty of making this misjudgment time and time again. Much of what is written in the early Egyptian Papyrus suggests that some therapies were appropriately empiric such as the reduction of a dislocated mandible. This type of empiricism, evident even today, was clear almost 4,000 years ago. Greek science started in approximately 500 B.C. at a time when Greece was at peace and governance allowed thinking and time to think. It was during this time that Pharaohs described the eclipse, Pathagorus numbers, and the four elements, earth, wind, fire, and water, were defined. Hippocrates explained physiology in terms of four body fluids, blood, black bile, phlegm, and yellow bile, and started the process of examination of the sick and the recording of signs and symptoms. In his early writings, he describes "one must attend in medical practice not primarily to plausible theories but to experience combined with reason." This in fact, may be one of the first definitions of the clinical trial. The path of medicine changed shortly thereafter. Aristotle, a pupil of the naturalist movement in Athens, returned to Macedonia to serve his King: Philip, the Great Warrior. Aristotle returned to teach Philip's son Alexandrea. Macedonia attacked Athens and Philip was assassinated. Alexandrea was made King, started his conquest, and 13 years later he had developed one of the largest empires to date. One of the aspects of Alexandrea's conquests was to take scientists along to collect information for Aristotle's books of natural history. With this, the great Greek scholar's works in medicine spread as well. At its peak, Alexandrea had a vast library full of museums of all scholarship that included the origins of geometry, the principles of engineering, the first steam engine, and detailed dissections performed by Herophilus. Approximately 300 years later, the Romans began their conquests and ultimately overtook the Alexandrian Empire. The last ruler was Cleopatra. By 100 A.D., the Roman Empire essentially covered all civilized portions of the Earth. Galen, born a philosopher, moved to Alexandria and was educated and then returned home as a surgeon to the gladiators. He subsequently migrated to Rome where he did experiments that mixed animal and human observations. He gained popularity because he could give plausible explanations. He was positive and whereas Hippocrates would say, "observe and find out for yourself and prove it by many observations," Galen would say, " I will explain it to you." Thus medicine sustained Galen beliefs largely based on the force of personality. The Roman Empire died because it was an oppressive society. With the emergence of Christ and Christianity and the emphasis to love your enemies, the family of man shifted from the Empire of Rome to the Empire of God. About 200 years later, Constantine, who was the first emperor baptized Christian, transferred the capital of the Roman Empire to Constantinople (Istanbul). Romans were not seafaring and the trip down the length of what we now know as Italy slowed their army's ability to maintain central control. As a result of this shift to the East, Barbarians from the north (including areas that we now know as France, Spain, and England) invaded, Rome fell, and the Roman Empire divided. This left the Western Empire to speak Latin and fall into barbarism and the Eastern Empire to speak Greek and maintain the old Roman traditions. Learned men of the time were copyists, copying Galen verbatim. The love for learning persisted but the pursuit of the search for truth had died. In the sixth century, just 200 years later, in the cities of Medina and Mecca, Mohammed was born and the force of Arabic universe became religion. The Arabs stormed Syria and the Holy Land and soon Egypt, Armenia, North Africa, and Spain, and in the course of just 300 years, what had been known as the Roman Empire had essentially shifted to the Empire of Islam. The Arabs translated Latin into Arabic, and in doing so, kept Galen alive and continued teachings until the Renaissance Period. Since the center of the church remained in Rome, this gave the Pope the opportunity to consolidate Christianity as a force, and with religious unity grew political unity. Charlemange, crowned as King, was supervised by Pope Adrian I who essentially decreed "be Christian or die" and thus started The Crusades, which lasted for almost 300 years. Medicine and science were once again dead. Medicine returned to Europe through Constantine of Africa, who in 1010, after traveling to Arabia and India and learning medicine, tried to return to Carthage, his home town, only to be mistrusted. He escaped to Salerno to a monastery, and as a monk he translated his Arabic knowledge back into Latin. This reintroduced medicine into a language that could be understood. It was here, in Salerno, that the first medical school was started. Over the next several hundred years, medical schools began to emerge and the true renaissance physicians emerged introducing the foundations for medicine and clinical investigation as we know it today. Just as politics and religion have affected scientific thought during the last 3,000 years, today we have multiple pressures determining the structure and quality of patient care. These pressures have been heightened by Institute of Medicine Reports and it is in this context that we have been challenged to provide evidence-based medicine. In trauma however, we have a problem in that we have a very poor infrastructure for clinical trials. This is despite the fact that road traffic accidents will be second only to ischemic heart disease as causes of mortality for American males in the future. As well described by Don Trunkey two decades ago, the spending on trauma compared to cancer and diseases such as AIDS is disproportional. Trauma research has traditionally had an acute care focus that has been basic science. Outcomes, and process research (clinical research) has primarily been funded by drug company trials. A further problem, federal oversight, has been diffuse for trauma. We have neither a clinical trials network nor an integrated research network amongst the various public funding agencies. The National Institute of General Medical Science, where trauma has had most representation, was developed in 1962 and developed primarily as a basic science research focus. When one considers the variety of institutes that exist, a trauma institute might seem a logical way to fund basic and direct research. It is very unlikely there will be interest in establishing new institutes. Instead, we need to find a way to integrate existing resources in existing institutes and help foster the overall research agenda. There are many problems that confront us in our research agenda, and we have seen little progress regarding ways to control bleeding and affect Central Nervous System injury and little progress in the mechanisms of multiple organ failure. As we begin this discussion, academic practice is increasingly being pushed to be clinically active with less time to do research. Our "partners" in military practice lack a clinical experimental framework upon which to test hypotheses important to the battlefield, except during war. Recent events have made these problems less threatening. In July of 2000, the Post Resuscitative and Utility of Lifesaving Effort workshop was held to expand basic, translational, and applied research in cardiac arrest and trauma. This was a collaboration between multiple agencies. The Trauma Work Group, in a combined effort with the National Heart, Lung, and Blood Institute, Department of Defense, National Institute of Neurological Disease and Stroke, National Institute of General Medical Science, American College of Surgeons Committee on Trauma, American Association for the Surgery of Trauma, Center for Disease Control, Federal Drug Administration, and the National Institute for Childhood Diseases held a second trauma work group to explore the gaps/frontiers in basic research, areas ready for translational research, and to define the needs for a clinical consortium to do applied clinical research. This working group met in July of 2003 and identified a rich research agenda in cellular injury, clinical trials, endothelial changes in coagulopathy, traumatic brain injury, and multiple organ failure. Several recommendations occurred as a result of this conference. They include basic science recommendations, critical clinical research needs, clinical research opportunities and opportunities to facilitate trauma and resuscitation research. All of these will be published as a document in the next year. A clinical consortium RFA has been released to develop a trauma and cardiac arrest resuscitation clinical consortium for clinical trials. This being published is a good indication of what may come in the future if we are successful with this first effort. Further, a proposal to develop a "trans NIH" trauma/critical care work group sponsored by the National Institute of General Medical Science Program officer, Scott Somers, will attempt to explore additional opportunities to create inner agency collaboration. Our challenge is to put in grants and participate in this evolving process and not lose sight of this rich potential that can develop. It would appear that professional organizations working with public agencies can make a difference and we can remain competitive. We should take advantage of these opportunities and "Rock On." Professionalism—Are We Taking Care of Ourselves? We are having a debate about our future and whether we will die out or adapt and change. This is due to many problems including overspecialization of general surgery, general surgeons isolating their interests, pay, and malpractice. In addition, the efficacy of prevention has lead to less significant trauma and less operative trauma, as well as the evolution of operative protocols in our trauma centers, emphasizing nonoperative care. Pieces have been taken away by competing groups such as emergency medicine, intensivists, pulmonologists, and gastroenterologists or maybe we have let these prices go. People take bad jobs where they limit themselves to trauma and critical care with only little participation in emergency or elective surgery. In retrospect, it was probably a mistake to isolate ourselves within critical care. Increasingly, a critical care surgeon is viewed as being nonoperative and without the same respect as his operative colleagues. Finally, as people age, the call is harder, recovery is longer, and can be accompanied with general burn out. Resident's perceptions that trauma is an exciting career are not coupled with the reality of them pursuing this career. Even the recruitment process for general surgeons evaluates quality of life in association with the amount of trauma; low trauma—high quality of life. As we stand on this threshold, we need to ask ourselves, can we change? When one evaluates the process of change there are several components that need to be defined. First and foremost, we need to have a clear vision of what we want. Without a clear vision, there is a state of confusion; this is the state in which we currently stand. As a result of this realization, the American Association for the Surgery of Trauma and the American College of Surgeons Committee on Trauma convened a group of American surgical leaders in August, 2003, to create a visioning process and define the future of the trauma surgeon. Several assumptions were made with much input from Dr. Frank Lewis, Executive Director of the American Board of Surgery: Any change must work with the context of the American Board of Surgery, the Residency Review Committee, and the American Association of Program Directors. It must deal with the likelihood of increased work hour limitations and be attractive to young people. To qualify as a new specialty, it must satisfy major patient and public needs currently unmet and be broadly disease-management focused, not based on an operative or technology focus. It must create viable and attractive lifestyles appealing to students, consistent with the realities of current preferences. It must correct the present deficits that make trauma and critical care less attractive because of their nonoperative and night call requirements. It must not trespass on areas that will be defended by other Boards and should merge with other evolving specialties such as Emergency Medicine and medical hospitalist. It must incorporate the ACGME work hour limitations and the six core competencies. It should have as a major focus, how it will promote and enhance safety and quality of life. It should be structured to be financially viable and competitive with other comparable specialties. As a preliminary vision, this group defined a new specialty defined as a "surgical hospitalist" to include trauma, critical care, and emergency surgery of all types. Fundamental aspects of this vision are: Create a training program to achieve. Allow additional training in elective practice to maintain a balanced practice throughout the surgeon's life. Allow additional training in orthopedic or neurosurgery trauma as an option. Develop a comprehensive model for life-long learning to avoid practice isolation in the future. What will this look like? Surgeons would be broadly trained in disease management, they will be hospital based, and they would be able to preserve continuity by providing multidisciplinary care of multiple diseases through a comprehensive "team approach." Each of these is consistent with the current trauma service model in many institutions. The direction of the evolution of general surgeon training in the United States will have to be compatible with this. The specific steps for developing an advisory council status will have to be followed within the rules and regulations of the American Board of Surgery. We should make a goal to establish an advisory council within the American Board of Surgery with the American Association for the Surgery of Trauma as the lead organization. There are good models that already exist, and we will work toward this advisory council status as a major priority of the American Association for the Surgery of Trauma. Though we seem to be at a "critical threshold" with the potential to die out, this is instead an opportunity for us to move beyond and "Rock On."