The American Association for the Surgery of Trauma—Through the Looking Glass: Déjà vu All Over Again
2009; Lippincott Williams & Wilkins; Volume: 66; Issue: 1 Linguagem: Inglês
10.1097/ta.0b013e3181953bc4
ISSN1529-8809
Autores Tópico(s)History of Medical Practice
ResumoThere are several themes chosen for presidential addresses of academic organizations including scientific, motivational, and historic messages. I did not want to make this scientific because I'm not smart enough. Nor did I want to make it motivational because I'm not charming enough. An historic motif was chosen because I believe I am old enough. The title was chosen to put the material into context from two sources. Louis Carroll wrote “Through the Looking Glass and What Alice Found There” as a follow-up to the classic “Alice in Wonderland.” The looking glass is a mirror through which Carroll chose to look and I fixed on that theme in an attempt to scan back through American Association for the Surgery of Trauma (AAST) history to frame the organization from where we've been. Hopefully that will shine some light on where we are going. I stole “déjà vu all over again” from the great American philosopher and baseball Hall of Famer, Number 8 Yogi Berra. Through the course of this address, I hope to demonstrate that a lot of the issues that we grapple with today have really been with us for a long time, many from the inception of our great organization. I hope this will provide a perspective on the importance of several of the issues and also help direct us toward resolution. I would like to begin by making several acknowledgments. First, thank to our new President, Jerry Jurkovich, for his more than kind and generous introduction. Furthermore, in the spirit of déjà vu all over again, I was able to locate this picture of Jerry that was provided for his application to AAST in 1987. You will note a striking resemblance to one of the great comedians of the 20th Century—déjà vu all over again, President-Elect Groucho Jurkovich!! Sorry, Jerry, but anticipating the baby pictures, I just couldn't help it. I have had the great good fortune to attract an outstanding faculty in the Division of Trauma. Under the leadership of Martin Croce, a stellar group of young trauma surgeons has evolved including Gayle Minard, Tiffany Bee, Lou Magnotti, George Maish, Ben Zarzaur, and Tom Schroeppel. They continue to provide exceptional clinical care and produce a high volume of research. Ramona Pipkin has been my Administrative Assistant for the past 19 years, and without her I couldn't tie my shoes. She tries to keep me in the middle of the road and provides an excellent face for the department through her kindness and intelligence. Finally I would like to acknowledge family. I was fortunate to come from a blue-collar background in Ohio. Both paternal and maternal grandparents were of German heritage and several generations have come from Central and Southern Ohio. My maternal grandparents Floyd and Maggie Graff were salt of the earth, hard-working, and very kind people. After the great depression, most of the men became railroaders. My paternal grandparents, William and Flossie Fabian came from agrarian stock. They were proud and family oriented, and they became successful neighborhood grocers. This brings me to my parents Joe and Katie Fabian. I don't believe there are any harder working, self-sacrificing people. Forget about the 80-hour work week! For many years, they ran a neighborhood grocery store from 8:00 am to 10:00 pm 6 days a week. They would slack off on Sunday by closing at 6 o'clock—so they were only 94 hour-a-week workers. Through their enterprise, they were able to send my brother Jack, a gastroenterologist in Florida, and my sister, Cindy, a nurse in Ohio, and me to college. Turning to my direct family, Denise and I have been blessed to have five healthy and intelligent children. Matt, John, Kathryn, Rachel, and James. All have gone to excellent universities and have been successful in making me a poor man. This brings me to Denise. We have been together for 39 years. She has done an exceptional job of raising our children and tolerating me. We have had the greatest times together. We take great joy in traveling the world and will continue to experience the joys and wonders of different places and different people. Denise you're terrific! The seeds of this address were sewn back in March when Denise and I went to the AAST archives at the National Library of Medicine. The leadership made a wise decision to institute these archives back in 1983. The Conservation Program provides protective housing and storage for these historic materials. They are stored in an about a dozen large acid free boxes. We spent one entire day reviewing the documents. These archives establish a legacy and tradition that is critical for the long-term identity of the organization. To do justice to our archives, one could easily spend two full days. In the last hour and a half, I found myself shuffling through the records much more quickly than I wanted. An AAST Strategic Planning Meeting was held January 11–12, 2007 at which four initiatives were chosen for the organization to focus on over the next 5 years (Fig. 1). The trip to Bethesda allowed me to contemplate again on that Strategic Planning Meeting and helped to frame a vision for those initiatives. I think you will find those initiatives are indeed a reflection of the AAST Looking Glass. Thus, the remainder of this address will focus on “Where We've Been, Where We Are, and Where We're Going … I think!”Fig. 1.: AAST strategic planning meeting initiatives.The Beginning … A group of six surgeons from across the country met in 1937 at the meeting of the Western Surgical Association in Indianapolis. It included Edgar Gilcreest from San Francisco, Eslie Asbury and Ralph Carothers from Cincinnati, and three Chicago surgeons Arthur Metz, William Cubbins, and Kellogg Speed. At that meeting, they discussed the importance of the provision of trauma care for the well being of the population. Although they noted that care for injury constituted nearly half portion of surgical practice at that time, they felt that trauma was neglected relative to the scientific and educational components in that area of practice. Consequently, they decided additional consideration was warranted and elected to have further discussion a couple of months later at the Southern Surgical Association meeting in Birmingham. This gave them the opportunity to involve other respected surgeons from around the United States. Drs. Gilcreest, Carothers, and Asbury sat down with seven Southern surgeons to discuss the issues further. Those included Frank Strickler and Arnold Griswold from Louisville, Ross Woolsey from St. Louis, W. P. Herbert from Asheville, Charles Green from Houston, William Estes from Bethlehem, and Isidore Cohn from New Orleans. As a result of those two meetings, the group decided to form a new organization dedicated to care of the injured. On May 14, 1938, an announcement was sent out by Edgar Gilcreest as the Chairman of the Committee for the Organization of the American Association of Traumatic Surgeons. I actually held in my hands the original letter that was sent to Dr. John Raff, a prominent neurosurgeon from Portland, OR inviting him to a Founder's Meeting (Figs. 2 and 3). Holding that historic document sent a chill up my spine. To think that this letter had been sent some 70 years ago to establish the Founder's meeting for what would eventually become the AAST was nearly a spiritual experience. In fact, going through the entire archives, the smell of the pages of the many documents was ethereal. It made me feel like I was almost there, a fly on the wall—déjà vu all over again. Sorting through the correspondence, I ran across many pages of onion-skin paper. I had not seen onion skin for nearly 30 years. For the younger among us, I should mention that this kind of paper was used in the days before word processing as an aid in making multiples copies of typewriter produced documents. It also reminded me of how much more difficult it used to be to both correspond and construct articles before email and word processing. However, it also made me consider that perhaps the joy of accomplishment of completing a finished article under those circumstances was in some ways more gratifying than it is today. But, I digress …Fig. 2.: Page one of announcement of AAST founder's meeting.Fig. 3.: Page two of announcement of AAST founder's meeting.Thus, the Founder's meeting was held June 14, 1938 at the San Francisco County Medical Society. That meeting was held in conjunction with the American Medical Association as were most of the early meetings of our organization—my, how times have changed. There were a couple of interesting discussion points in the minutes of the Founder's meeting that have bearing on current issues. Dr. Charles Venable questioned the advisability of a 200-membership limit and also that the proportion of 85% general surgeons and 15% specialists might be unwise. Today, we discuss how to increase involvement and representation by many of our nongeneral surgical colleagues including orthopedic surgery, neurosurgery, and pediatric surgery, as well as others. Dr. Frank Boland from Atlanta inquired if it were necessary to define the term “general surgery”; the Advisory Council for General Surgery of the American College of Surgeons is addressing the definition of general surgery this year—déjà vu! Both of those important issues were extensively discussed at the AAST Strategic Planning Meeting in January and one of our four major initiatives was Branding/Identity (Fig. 1). At the 1938 meeting, Dr. Gilcreest said “It is interesting to note that half of the patients who are admitted to hospitals are cases of trauma, and that 90% of the doctors who treat these patients are not interested particularly in trauma.” Has anyone heard those sentiments expressed in a more recent time? In the archives, I found interviews that Dr. Don Trunkey had conducted for our 50th Anniversary in 1988. One was an interview with Dr. C. Mathewson regarding the origins of AAST—Trunkey: “In 1988 it is very difficult to get the private doctors to support trauma centers as well. It doesn't really seem like it has changed very much in 50 years.” Mathewson: “I can recall considerable debates concerning the fragmentation of general surgery into specialties. One surgeon was so adamant in his opposition that he proposed that there should be a society devoted to surgery of the umbilicus. There was also a strong feeling that the orthopedists were stealing the treatment of fractures from the general surgeons.” Premonition of issues surrounding the development of Acute Care Surgery? Another of our AAST Strategic Planning Issues—Acute Care Surgery. The category of Honorary Membership has been reserved for those who have made remarkable contributions to the trauma field. Testimony to the high esteem for which that category is held is that there have only been 49 honorary members elected over the 70-year lifespan of this organization. It is noteworthy that our first Elected Honorary AAST Fellow was Ernest Emory Codman (Fig. 4). E. A. Codman was the first surgeon in this country to stress the principles and practice of evidence-based medicine. In 1918, he stated “The really difficult thing about the End Result System is to induce the staff in any hospital to be willing to make a truthful acknowledgment of the personal part which contributes to the success or failure of the cases.” He could have made that statement today. Codman had been on the staff of the Massachusetts General Hospital but was removed because of his promotion of the controversial nature of outcomes-based practice and research. He then established his own hospital called The End Results Hospital and became a leading voice in the development of The American College of Surgeons. Fortunately, Harvard and Massachusetts General Hospital have recently established the Codman Center for Clinical Effectiveness in Surgery.Fig. 4.: Picture of Ernest A. Codman, MD.Another short biography to mention is that of Kellogg Speed (1879–1955), the first President of the AAST (Fig. 5). Like many trauma surgeons throughout history, he served in wartime, being active in World War I at the front at Ypres and France. After the war, he became a Professor at Rush Medical College and established the Fracture Clinic at Cook County Hospital. It is important for us to recognize that at the inception of our organization the care of fractures occupied a major portion of the work of trauma surgeons. Dr. Speed published 195 articles and 124 of those were on fractures and tetanus. He became a founding member of the American Board of Surgery and the American Board of Orthopedic Surgery. It is also noteworthy that in 1900 he was the Captain of the University of Chicago football team led by the famed Amos Alonzo Stagg. At that period in history, the University of Chicago was a national football powerhouse.Fig. 5.: Picture of Kellogg Speed, MD.The Early Years … The minutes of the first Annual Meeting that was held in May 8, 1939 at The Homestead at Hot Springs, VA were reviewed. Figures 6 and 7 illustrate the original opening minutes of the meeting as well as the first two articles of the Constitution established at that meeting. Article I states: “The name of this Association shall be the American association for traumatic surgery.” It is interesting to note that by the time of the second meeting that was held in 1940 in Atlantic City, the name had been changed to the AAST. I struggled through the archives to find discussion regarding the changing of the name but could find none. I can only imagine that the founding members had taken a lot of grief from their colleagues around the issue of “traumatic surgery.” There were 199 Fellows elected at the inaugural meeting. These included eight Honorary Fellows and it was stated: “… this classification should be reserved for those who have appeared at one or more of our meetings.” Many of the eight were indeed giants in the field of surgery in the first half of the 20th century: J. M. T. Finney, Rudolf Matas, William Mayo, Robert Carothers, Surgeon General C. R. Reynolds and Colonel J. L. Magee of the U.S. Army, Surgeon General Ross T. Meintids of the U.S. Navy, and Colonel J. L. Potter of the Canadian Army. The organization didn't just let anybody in for honorary membership. The minutes of the 1941 meeting stated “… there was considerable discussion over Dr. George Crile, Dr. Charles Scudder … in as much as they had never attended a meeting, the matter was deferred.” Clearly, our organization has always made an effort to follow the rules. Both men were subsequently elected to honorary membership—after attending a meeting. Further consideration of our active fellowship category demonstrates that we have gone from being a fairly exclusive organization to being relatively inclusive. In 1946, the constitution was amended to increase the active membership to 250, in 1961 an amendment to 300, in 1970 to 350, and in 1983 the limitation on number of active members was discontinued. Currently, AAST membership consists of 49 honorary fellows, 295 seniors, 723 active, and 8 contributing scientists for a total membership of 1,075.Fig. 6.: Minutes from first AAST meeting in 1939.Fig. 7.: First constitution established in 1939.Let us turn briefly to finances. Figure 8 is a copy of Dr. Morrison' treasurer's report from the first annual meeting in 1939. To have a meaningful comparison of finances from the time of our origin to today, the fiscal milieus were compared using the Consumer Price Index. That comparison is shown in Table 1.Fig. 8.: First treasurer's report.Table 1: Comparison of AAST Financial Statements of 1939 to Today with Adjustment by the Consumer Price IndexIn actuality, although there has been a dues increase, that increase is much less striking than the difference in cash on hand. We will return to that number in a few minutes. To maintain the talk in the historical context of the times, we will consider what else was happening in the world at the times of some of our national meetings. The front page stories from the Wisconsin State Journal on May 5, 1939 had several articles of local interest but also demonstrated that the winds of war were blowing (Fig. 9).Fig. 9.: Frontpage of The Wisconsin State Journal newspaper dated May 5, 1939.At the second annual meeting in 1940, there was an interesting section from the Secretary-Treasurer report, which I have dubbed “The Hotel California Rule”: “Dr. Metz further reported that Dr. ___ of Detroit had not paid his dues for 2 years, and read a letter in which he stated that he wishes to resign. It was the feeling of the council that the secretary write him a letter, quoting the by-laws on this point, and accept his resignation, if and when his dues were paid.” As mentioned previously, our group has always been a stickler for the rules! Dr. Gilcreest was our second President. His Presidential Address was entitled “The Progress of the Surgery of Trauma.”1 There were some premonitory statements made in his address: “It is to be expected that the trend today in everything is toward specialism and this is certainly true in the rapidly expanding field of general surgery; but this can be carried too far … we should strive to get the cooperation of administrative staffs of hospitals, large and small, to recognize the importance of being equipped at a moment's notice to adequately care for the seriously injured. They should realize that the first hour of injury is the most important one.” Thus, he addressed the continuing controversy over specialization as well as organizing hospitals into trauma centers with emphasis on organization, equipment, and perhaps being the first to recognize the first hour of injury—“The Golden Hour.” As I went through our archives, it became increasingly clear how wise and forward thinking our forefathers were. I am remiss to not already have mentioned that our Canadian brethren have been coconspirators from the inception of the AAST. The third annual meeting in 1941 was held at the Seigniory Club at Montebello, Canada. This site remains today a lovely meeting lodge near Montreal with a fascinating historical register of international meetings. A portion of the minutes from that meeting provides somewhat of a déjà vu moment for acute care surgery: “Clay Ray Murray discussed the situation in which many men thoroughly trained in trauma find themselves in regards to the surgical boards. They are not accepted by the Orthopedic Board nor accepted by the Board of General Surgery. Dr. Murray believed that something should be done about this. He moved that a committee be appointed to investigate this matter.” At this suggestion, there was a Council Meeting in Boston in 1941 at which the minutes reflect a first attempt at certification: “Secretary directed to obtain legal counsel regarding copyrighting name of association” American Board of Surgery of Trauma. Robert T. Bushnell, Attorney General of Massachusetts consulted. He reported: “Cannot be done now.” Some things are timeless—lawyers can always tell you how something can't be done, but have a great deal of difficulty telling you how to get something done. The fourth annual meeting was held at the Copley Plaza Hotel in Boston June 4 to 6, 1942. A significant amount of that scientific program was devoted to orthopedic injury. Sadly, although orthopedics was the cornerstone of our organization, over the years it has dwindled to the point recently of total absence of orthopedic contributions. However, I am very happy and encouraged to note two excellent orthopedic articles on this year's program—article #25 “Skeletal Traction versus External Fixation in the Initial Temporization of Femoral Shaft Fractures in Severely Injured Patients” from Carolinas Medical Center, and article #26 “Early Total Care of Borderline Physiology Patients with Femur Fracture is Superior to Damage Control Orthopedics” from John Hunter Hospital of the University of Newcastle. It is imperative that we join once again more closely with our colleagues in orthopedics and promote that representation in the AAST. That would clearly benefit education and research in our field and, most importantly, will promote optimal trauma care for our patients. The following announcement was in a preface of the minutes of fifth annual meeting: “Due to the Difficulty of Transportation and at THE Request of the Government no Meeting was Held in Nineteen Hundred Forty-Three.” On June 9 and 10, 1944, the meeting was held at the Edgewater Beach Hotel in Chicago. The historic postcard of the Edgewater Beach belies the times (Fig. 10). We were in the throes of World War II. The Association Banquet was held on Friday evening, June 9, 1944 and the address was “Experiences in England, Russia, and Africa” by Colonel Loyal Davis. Loyal Davis was a very prominent neurosurgeon of the day and became one of the most successful executive directors of the American College of Surgeons. (Incidentally, he was also the stepfather of Nancy Reagan, former President Ronald Reagan's wife.) Only 3 days before the Association banquet, the allies invaded Europe at Normandy (Fig. 11). I located the frontpage stories from an extraprinted by The Marion Star, the local newspaper in the small town in which I grew up (Fig. 12). Portions of the stories in that extra are as follows: “London, June 6—The Berlin Radio” said today that “combined British American landing operations against the western coast of Europe from the sea and air are stretching over the entire area between Cherbourg and LeHavre”—“Supreme Headquarters, Allied Expeditionary Force, June 6—American, British, and Canadian troops landed in northern France this morning, launching the greatest overseas military operation in history with word from their supreme commander, Gen. Dwight D. Eisenhower, that” we will accept nothing except full victory “over the German masters of the continent.”Fig. 10.: Contemporary postcard of Edgewater Beach in Chicago, IL.Fig. 11.: Photograph of allied invasion at Normandy June 6, 1944.Fig. 12.: Frontpage Extra of The Marion Star newspaper dated June 6, 1944.There were several important motions made at the business meeting in 1944. Committee responsible for coordination and cooperation of various boards. Send transactions, if available, to 65 university libraries (this may prove impractical, considering the limited balance available). Appoint educational committee—for teaching and study of trauma. Committee to encourage colleges to teach more trauma. Further, schools be kept abreast of what this association is doing. Those motions made some 64 years ago once again point to very important issues that we continue to deal with which were identified at the AAST Strategic Planning Meeting—Advocacy, Branding/Identity (Fig. 1). “Due to War Time Emergencies no Meeting was held in Nineteen Hundred Forty-Five.” The third and only other cancellation was Seattle September 2001. The sixth annual meeting was held in San Antonio. It is interesting to note from a contemporary postcard that the River Walk has hardly changed (Fig. 13). The program demonstrated social events for the meeting that included floats along the river and the banquet was with Mexican entertainment—sounds like a banquet we would have today. Motions at the Business Meeting in 1946 were:Fig. 13.: Contemporary postcard of San Antonio's River Walk. Dues increase from $10.00 to $15.00. Active fellowship increase from 200 to 250—adhere to by-laws requiring at least 10 years practical experience. Dues increase in 1947 to $25.00 (San Antonio deficit). We returned to San Antonio in 2000 for our sixtieth annual meeting, a joint meeting with the Orthopedic Trauma Association. I think it is about time that we again have a joint meeting and request that the Board of Managers investigate the possibility. The Road to Certification … The various surgical boards were established between 1934 and 1948 (Fig. 14). In 1951, the Board of Managers passed a resolution to sponsor a Board for the Surgery of Trauma. It is interesting to note that the American Board of Orthopedic Surgery had a concomitant consideration at that time. From the minutes of the 13th Annual Meeting held at The Drake in Chicago: “A most significant report then was heard from Dr. Warren Cole who is our representative on the Joint Committee with the American Board of Surgery for the establishment of the subsidiary Board of Surgery of Trauma.” Interestingly, politics developed that silenced those efforts for a separate board. But, I could not find documentation anywhere in the minutes what the maneuvering was by which board certification was blocked. However, as I get older it becomes more clear that political machinations and backroom lobbying are usually involved with these sorts of efforts. I was admitted to fellowship in the AAST in 1985 and since that time, there has been low-level discussion many times about pursuit of a board. But, it seems to me that a time might be coming in the not terribly distant future when a board will indeed be established. There are good arguments to prevent superspecialization but it appears to me that the tide is becoming too great to stop the trend of surgical specialization in many areas. The world of vascular surgery has been involved in a tug of war for the past decade and the Vascular Surgery Board was recently established. The number of certifications for surgical critical care is essentially the same as for vascular surgery. There is great pressure from surgical oncology for a similar board and assuming that will come to pass, it is hard for me to imaging a board in trauma will not occur as well. Although there are many reasons to keep general surgery “general,” I believe specialty knowledge bases, practice patterns, and healthcare demands will usher in those specialties in a similar fashion to the development of the surgical boards in the 1930s and 1940s. Indeed, in 2007, the American Board of Surgery established the Trauma, Burns, and Critical Care Advisory Council. In 2008, the AAST established the Acute Care Surgery Fellowship to which several programs are now applying. I believe that this fellowship with defined curriculum, goals, and objectives will further the road to the board in concert with ACGME recognition and certification.Fig. 14.: Dates of origination of the surgical boards.The Scientific Program … I would like to spend a few minutes reviewing some highlights of scientific programs over the years for both historic and scientific interest. A valuable document was recently given to the Association by Dr. Lew Flint. It is the Transactions of the AAST meetings from 1938 through 1943 (Fig. 15). It will be noted that in our early years, articles were published by the American Journal of Surgery. For the first decade, we had 18 to 24 articles presented annually and in the 1950s it went up to around 50 articles, up to 60 in the 1970s, and quite miraculously at our current combined meeting with our colleagues in the Japanese Association for Acute Medicine there are a phenomenal 86 papers being presented here in Maui. Parenthetically, it should be noted that the quality is outstanding and L. D. Britt and the Program Committee deserve congratulations for putting together the excellent work of our membership for this 67th Annual Meeting. For the first 24 years, the Secretary of the association chose the articles from submitted abstracts. From 1963 to present, the Program Committee with the Recorder as Chairman has selected the articles. This important change was made by one of the most illustrious members in the history of the organization, William T. Fitts, for whom the Fitts Lectureship has been dedicated and which Dr. Charles Lucas will be delivering tomorrow.Fig. 15.: Front cover of “Transactions of The American Association for the Surgery of Trauma” 1938–1943 published in The American Journal of Surgery, Inc., NY City.Now I would just like to reflect on a few select articles. At the Ninth Annual Meeting in Atlantic City in 1949, Truman G. Blocker Jr, and Virginia Blocker (by invitation) gave “article 31: The Texas City Disaster: A Survey of 3,000 Casualties.” This was a report on a disaster that occurred April 16, 1947 in Galveston Bay. A French ship loaded with ammonium nitrate exploded causing the huge catastrophe that killed 567 people (Fig. 16). Sadly, Galveston has been the site of other horrific tragedies. The Hurricane of 1,900 killed between 6,000 and 12,000 people—the deadliest natural disaster that has ever struck the United States. Hurricane Ike wreaked terrible havoc once again on the town 2 weeks ago. Galveston has shown it's resilience and I am confident that it will resurrect again. We should offer a prayer for Galveston.Fig. 16.: Frontpage of The Galveston Daily News dated April 16, 1947.The climate in the post-World War II era lead to a couple of interesting banquet addresses on topics that were current as the Cold War was ushered in. At the annual banquet of 1948, guest speaker Dr. Austin M. Brues, Medical Director of the Argonne Medical Laboratory delivered the address: “Nature of Trauma in Atomic Warfare.” At the banquet of 1952 at the Biltmore Hotel, the guest speaker was William C. Bullitt, former Ambassador to Russia and France, who delivered the address: “The World Situation and the Probabilities of American Survival.” The nation was justifiably preoccupied with the threat of mass extinction. The early 1950s were times of backyard family bomb shelters that were established by the U.S. population to retreat to at the time of nuclear war (Fig. 17). I have clear memories seeing these in my childhood. Families supplied their shelters with canned goods and water in hopes of surviving nuclear holocaust. As is typical in America, to cope with extremely difficult issues, our catastrophes are satirized. A great example of that time is the movie by Stanley Kubrick, “Dr. Strangelove, or How I Learned to Sto
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