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American Association for the Surgery of Trauma and the Clinical Congress of Acute Care Surgery 2011 Presidential Address

2012; Lippincott Williams & Wilkins; Volume: 72; Issue: 1 Linguagem: Inglês

10.1097/ta.0b013e31823fbda3

1529-8809

L. D. Britt,

Abdominal Trauma and Injuries

Let me first sincerely thank my colleague and dear friend, Dr. Wayne Meredith, for a very warm introduction and extremely kind remarks. We have truly traveled a long journey together. One could not ask for a better colleague and friend (Gail and Wayne are as close to the ideal couple as you can get). As I stand at this lectern as this organization's president, I remain under no illusion, for I fully realize that there are many in the audience today who could serve honorably in this capacity—a real testament to the depth of talent in this organization. When I reflect on the strong support that I have received over the years from so many of you, I realize that I could have a one-day symposium and still be unable to adequately recognize and thank the individuals who have been so instrumental in my professional development. Know that I have never once forgotten the words of support and the helping hands that assisted me in navigating this career path and ending up today at this podium. I would like to thank those faculty members who were directly involved in actually training me in my field of interest at Cook County Hospital and the Maryland Institute of Emergency Services Systems (or the "Shock Trauma Center"). Mentoring for me often extended beyond the walls of my particular alma mater, and I too want to recognize some of my most influential mentors. Standing here today, I would be remiss if I did not acknowledge and thank the excellent departmental faculty at Eastern Virginia Medical School. Without their tremendous talent and unselfish support, I would have never been able to devote the requisite time and effort that this and other positions dictate. Our graduates reflect the strength of our program. I particularly want to highlight those graduates during my tenure who have gone on to pursue careers in my specialty interest. Also, we all know that the underpinnings of any successful program are the gifted staff members. The Department of Surgery at Eastern Virginia Medical School is no exception. As an organization, we would have never been able to achieve all that we did this year without the superb expertise of Ms. Sharon Gautschy, our Executive Director, and Ms. Tamara Jenkins. I owe them a great debt. I too want to recognize Ms. Carol Williams, who is a stealth force that transcends organizational boundaries. She, along with Ms. Barbara Dean and Ms. Maxine Rogers, assisted me in balancing a year in which I was the elected leader of two major organizations at the exact same time. But make no mistake about it; the consistent and unconditional core support comes from my loving wife, Dr. Charlene Britt (the real doctor in the family). My daughter, Avery, has joined my wife in being a true anchor in my life. I would like to dedicate this address to our patients—often the most vulnerable population. It is a distinct honor for me to be able to preside over the inaugural Clinical Congress of Acute Care Surgery. It has been less than a year since I presided over the 100th anniversary of the Clinical Congress, which antedated the founding of the American College of Surgeons by three years. Curiously, that first clinical congress was also held in Chicago, similar to the inaugural Clinical Congress of Acute Care Surgery.1 It would, indeed, be difficult to overlook the historic significance of this meeting. The by-product of the Clinical Congress held in 1910 was the establishment of the American College of Surgeons. While no one can predict what the outgrowth of the Clinical Congress of Acute Care Surgery will be, it is quite evident that a new chapter is being written. Acute Care Surgery is a defined specialty that now has a permanent home. Similar to the Declaration of Independence, there have been many "founding fathers" (and mothers) who left their fingerprints on the inception and subsequent development of Acute Care Surgery. And many more fingerprints will be needed to continue the maturation process of a specialty that will help fill the void in the time-sensitive management of the acutely injured and critically ill patient population. As I read through the transactions of the early days of the Association, I was struck by the first presidential address by Kellogg Speed, MD, of Chicago. He stated, "In the rapidly expanding field of general surgery, schisms have occurred within the last thirty years, ending in a breaking off of certain specialties and narrowed fields, such as ear, nose, and throat surgery, genitourinary surgery, neurologic surgery, thoracic surgery, with others—and even one body devoted quite entirely to the surgery of goiter."2 Our first President of the Association went on to say, "It is not the primary desire or intention of the American Association for the Surgery of Trauma to cause the formation of an additional and possibly narrowed-vision group of surgeons under a different label, but to attempt an amalgamation and calling back to the fold of the well trained general surgeon of those interested in the maintenance of high surgical skill and scientific development in the phases of surgery which have to do with trauma, its immediate and distant effects and complications." Such commentary is relevant today as we broaden our profession. And I underscore the word "profession." In the book by Elliott A. Krause, Death of the Guild, it was highlighted that the professionals and the professions act with a "dual motive: to provide service and to use their knowledge for economic gain."3 It is a definition (or description) that a health care professional must reject, for strict adherence to such a concept could create settings in which the person, who actually needs the service, is no longer the first priority. As a specialty organization providing surgical care for the acutely injured and critically ill, such a "redefinition" of our profession is sacrosanct. The chief beneficiary should always be the patient. The Association's overarching mission is evidence-based, high-quality, cost-effective, consistent, and equitable health care. Unfortunately, equitable health care has not been achieved—neither nationally nor globally. Several books and periodicals have chronicled the worsening crisis in health care. An enlarging gap in emergency surgical care is, indeed, a major contributor to this crisis.4–6 As the premier organization in our profession, it is obligatory that we take a leadership role in definitively addressing the mounting challenges. Of course, no one organization can do it alone, but this association should be at the helm. This association has been invaluable in providing the cultural medium for the evolution of Acute Care Surgery, and its nourishment will need to continue in earnest. However, we now need to regain, reaffirm, or establish our leadership role on several fronts. This is imperative, for the health issues we face as an organization are many—and are at a national and global level. Sure, we could adopt a Calvinistic approach to the daunting challenges. Or as Rebecca Costa discusses in her recent book, The Watchman's Rattle, we could allow ourselves to be so overwhelmed by the problems of our era that we resort to instinctively reacting to symptoms and finding "quick fixes" in lieu of developing more definitive solutions.7 Costa states that "preparing the human mind for complex problem-solving offers the single greatest socioeconomic advantage possible across all fields and all industries." As we celebrate the 70th meeting of this association and as we officially broaden our scope, we may look back on an impressive and long list of achievements. Recently, a representative sample of the thought leaders of this organization was surveyed. Asked to highlight the Association's top achievements in contemporary times, the responders' unity in the selections was astonishing. Figure 1 depicts their common choices.Figure 1: American Association for the Surgery of Trauma (AAST) achievements.The publication organ of the Association, The Journal of Trauma (now the Journal of Trauma and Acute Care Surgery), has been immensely successful, irrespective of the metric used during the tenure of Dr. Pruitt as its editor-in-chief. The formal endorsement of the specialty, Acute Care Surgery, by this organization is one of our most seminal accomplishments. Starting from a simple concept and poised to fill an obvious void that has occurred with the timely management of the acutely injured and critically ill patient, this evolving specialty will be, perhaps, one of our greatest contributions to the optimal care of the patient. I am betting that at our 100th anniversary (and I plan on being in attendance!), there will be rousing applause for the direction that this organization took. The development and maturation of nonoperative and selective management, along with embracing the role of staged laparotomy or "damage control" surgery, reflect one of the main guiding principles in medicine: first do no harm. This organization has led the way in establishing related practice guidelines and algorithms, based on the best available evidence. The scientific programs held over the years and the surgeon scientists that I see scattered throughout this assembly reflect the wisdom of funding scholarships or fellowships. The steady infusion of advanced knowledge and new concepts or innovations is the blood supply that keeps this a viable organization. There is a time in any institution's or organization's growth that adjustments have to be made. Nostalgic inertia has to give way to progress if an organization is going to prosper and reach its potential. The development of a full-time administrative home and hiring an executive director were the right decisions at the right time, and this association was the beneficiary. With the increasing tentacles of this organization, along with the expansion of membership and the evolution of communication systems, the establishment of an effective communications network was essential. The Trauma, Burns, Critical Care Committee of the American Board of Surgery being formally recognized as a "sub-board" has reaching implications as the Acute Care Surgery specialty continues to mature. The wisdom of the American Board of Surgeons and the vision of its executive director, Dr. Frank Lewis, should not go overlooked. The currency for any academic society desiring to advance its discipline is research. The Multi-Institutional Trials Committee has the great potential of being the "research engine" for this association for years to come. Although the decision made by this association to broaden its membership still generates some discussion even in 2011, the advantages of expanding our base are quite evident. It has resulted in a more relevant and vibrant society. In fact, relevance is the fuel that keeps any organization vibrant. Figure 2 depicts how the perception of irrelevance can result in a precipitous decline in an association's members.Figure 2: American Medical Association (AMA) membership profile.Many of the greatest advances in our discipline were derived from our military experience. A close alliance with our military should always be a mainstay, for such a bond is natural. The impact of these achievements has bordered on being transformative, with respect to the actual metamorphosis of management paradigms resulting in optimal patient care and improved clinical outcomes. Appreciable scientific advancement is still needed to buttress our foundation. More translational and transformative research initiatives in our discipline are essential to the academic growth of this organization. On this day—the 70th meeting of this association—we have every right to be proud and even euphoric. However, we cannot rest on our laurels. On the contrary, the challenges we face today require organizational and individual leadership on a national and global level. As so eloquently highlighted by Dr. Brent Eastman in his 2010 Act Scudder Oration, our national trauma "system" is porous.8 With injuries still being the leading cause of death in people ages one to 44 years, and the fact that it is well documented that getting care at a Level I Trauma Center can lower the risk of death by at least 25% not having access to comprehensive trauma centers is unacceptable.9 In collaboration with other organizations, our association should be one of the principle architects for the development of a sweeping and comprehensive network that fully covers the country and provides health care personnel and other resources necessary to optimally manage acutely injured and critically ill patients. Figure 3 depicts our current medical landscape. When we drill down into the numbers, it becomes evident that while specialty shortages are widespread, one of the most impressive deficits is the inadequate surgical workforce in the acute care setting. That not only includes trauma or acute care surgeons but also trained general surgeons committed to quality care of the acutely injured or the critically ill.Figure 3: The medical landscape.The widespread specialty shortages are well-documented. However, if critical analyses of the workforce shortages in acute care settings were conducted, surgical intensivists would, undoubtedly, be at the top of the list. What has been unveiled is an alarming decline in the active involvement of surgeons in the intensive care units. Moreover, there has been increased delegation of care to nonsurgical specialists. This is not just a "turf battle" among the specialists. On the contrary, as underscored by Ivy et al.,10 "the presence of surgeons in the intensive care unit provides specific insights and perspectives to the care of the surgical patients, sometimes not fully appreciated by the nonsurgical practitioner caring for the same patients." Undoubtedly, this association has several members who are preeminent in this area. However, as an organization, could we be criticized for not weaving surgical critical care more into the fabric of our mission? Against a backdrop of an aging population with its associated comorbidities, tertiary and quaternary care facilities are enhancing their critical care capacity for current and future needs. Worldwide, surgical intensivists are practically extinct. Such an absence of this specialized workforce in this country is not an option. The earliest intensive care unit on record was a three-bed postoperative neurosurgical unit at Johns Hopkins Hospitals (1923). The adverse impact of the ongoing shortage of intensivists will be devastating and sustained. Surgical critical care being a key component and part of the definition of Acute Care Surgery was not serendipitous. Figures 4 and 5 put a spotlight on an ongoing challenge that this association must continue to address—suboptimal research funding. It is estimated that dedicated and funded research in trauma alone would likely result in the following annual benefits: (1) approximately 10,000 lives saved, (2) 1.5 million injuries prevented, and (3) $35 billion dollars in savings. There is a general consensus that there has been an inability to secure perpetual and major funding for trauma or acute care surgery research. The maturing of this organization's multi-institutional clinical trial initiatives will certainly assist in breaking ground in this area. However, there also needs to be a sustained thrust in basic science and translational research to provide the scientific foundation for continuing improvement in patient care.Figure 4: Dedicated and funded research in trauma.Figure 5: Comparative effectiveness research.Our association is national in name only. As the premier organization in our discipline, this association should strive to make an impact at home and abroad. When the worldwide scale of the problem is as pronounced as shown in Figures 6 and 7—with approximately 6 million people dying annually as a result of injuries alone—our charge as the lead organization in this field is to make a difference. Trauma alone is a major health problem throughout the world. In fact, the vast majority (90%) of trauma deaths occur in middle- and low-income countries.11 Insensitivity to global issues cannot be an accepted posture for this organization.Figure 6: Scale of the problem.Figure 7: Trauma as a global problem.There are a few members of this association who have not only appropriately framed the discussion on this topic but have demonstrated a commitment to address this problem. Past Presidents Ron Maier and Jerry Jurkovich, along with other members of the Seattle team, have had a sustained effort in this area and have reported their results to this assembly.12,13 Documenting that a seriously injured patient in a low-income environment is twice as likely to die as a similarly injured patient in a high-income environment, Mock et al.14 demonstrated a regional variation in mortality in the prehospital setting where the majority of the deaths occurred. I again commend past President Peitzman for selecting Dr. Charles Mock to be the FITTS Lecturer last year. His theme of "Strengthening Care for the Injured Globally" should still resonate with all of us.15 Especially when Dr. Mock emphasized that "if such an inequality could be addressed effectively, and fatality rates in low and middle-income countries could be reduced to those in high-income countries, more than two million lives per year could be saved." Worldwide, injuries and acute surgical illnesses, along with their associated morbidities and mortalities, are steadily increasing. Currently, as an association, we need, to do more with respect to providing expert consultation, along with helping to design low-budget practice guidelines that can be effectively used in austere environments. Hopefully, through our newly-established international committee, a more comprehensive strategy and an implementation plan can be developed. Finally, I would like to end my Presidential Address for the 70th meeting of the Association by "renewing our vows" and highlighting our professional responsibilities, as an organization (and as an individual). There are three paramount professional responsibilities: Excellent patient outcomes Wise resource allocation Effective self-regulation Also, while my presidential address has emphasized organizational accomplishments and challenges, it all starts with a commitment. For example, it took the selfless effort of a few individuals to change the entire management paradigm of a discipline. Dr. Walter Hoyt, an orthopedic surgeon from Akron, OH, along with a few of his colleagues wrote a pivotal document, Emergency Care and Transportation of the Sick and Injured, that became the underpinning for that specialty's committee on trauma.16 Irrespective of the authority of an organization, it will be individual effort that will be the driving force for better patient outcomes. With respect to resource allocation, all of us need to be better stewards of the health care expenditures that we control. Effective self-regulation is what this organization is all about. Currently, this association is its own regulatory agency, and we fully understand the big picture. Similar to the efforts of President Lyndon Johnson with establishment of the Medicare and Medicaid programs in the 1960s, this organization is continuing to design (and redesign) a health care system that provides a safety net for our most vulnerable population. The next chapter for this association is to critically analyze what we do, how it is done, and the impact that it has on the individual and the population. Comparative effectiveness research Figure 8 is this association's next major chapter. It is this type of process, with its derived benefits, that should be the hallmark of our self-regulation.Figure 8: Comparative effectiveness research pyramid.Again, it has been an incredible honor for me to have had the privilege to serve as your President. I cannot thank you enough for the support.