Trauma surgery

Editor-In-Chief: Niral Shah, M.D. [mailto:nashah@bidmc.harvard.edu]

Trauma surgeons are physicians that have completed residency training in general surgery and have concentrated their practice on the care of injured and critically ill patients. In the United States, trauma surgeons generally work in hospitals specifically designated as trauma centers by the American College of Surgeons (ACS) or by individual states.

When a patient with significant injuries is identified by prehospital personnel, the trauma center is notified and a designated trauma team is activated. The team typically includes nurses, resident physicians, and a variety of support staff and is led by the attending trauma surgeon. The trauma surgeon is responsible for the initial and ongoing evaluation and resuscitation of the injured patient. In most settings this follows a rigorous set of predetermined protocols designed to detect and treat life threatening conditions as soon as possible. After such conditions have been treated (or ruled out), non-life threatening injuries are addressed.

The majority of trauma surgeons practicing in larger centres are certified in general surgery by the American Board of Surgery (ABS) and have completed a 1-2 year fellowship in Surgical Critical Care. This allows the surgeons to sit for the ABS certifying examination in Surgical Critical Care. If this is passed then the examinee is recognized as having additional qualification in Surgical Critical Care. There is no separate Board or examination for 'trauma surgery'.

The broad scope of this training enables the trauma surgeon to address most injuries to the neck, chest, abdomen, and extremities (other than fractures). Injuries to the central nervous system are generally treated by neurosurgeons. Musculoskeletal injuries are treated by orthopaedic surgeons. Facial injuries are often treated by maxillofacial surgeons. There is significant interhospital variation in the degree to which other specialists, such as cardiothoracic surgeons, plastic surgeons, vascular surgeons, and interventional radiologists are involved. Most patients presenting to trauma centres have multiple injuries involving different organ systems, and 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 on to the operating room, intensive care unit, and hospital floor.

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 orthopedic or neurosurgical in nature. For this reason, most trauma surgeons devote at least some of their practice to general surgery. In most U.S. university medical centers, a significant portion of emergency general surgery call is taken by trauma surgeons. This increases the operative case load for trauma surgeons and allows other general surgical specialists (such as gastrointestinal surgeons, surgical oncologists, and vascular surgeons) to focus on their own respective areas.

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 critical care is required. Hours are irregular and there is a considerable amount of night, weekend, and holiday work. Salaries for trauma surgeons are comparable to those for general surgeons.

Training for Trauma Surgeons

Training for trauma surgeons is sometimes difficult to come by. The Royal College of Surgeons of England is responsible for training consultants via the Definitive Surgical Trauma Skills course, or the 'DSTS'. It remains the only course of its kind in the United Kingdom.

Originally designed to teach the military, the course now teaches both the military and civilian surgeons and teaches delegates how to repair vascular, cardiothoracic and general surgery injuries that are becoming increasingly prevalent in today's society.