Well formed trauma systems more important than surgeon’s experience for survival
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Well formed trauma systems more important than surgeon’s experience for survival
We take our trauma systems for granted for the most part. What trauma systems are all about is a subject most would never consider important nor is it something the average person even wants to think about. What I call the “rhythm of trauma” is evident every day. The local news is plenty of evidence of that. Every single day there is at least one or two stories directly involving trauma injury and/or death. Car accidents, shootings, stabbings, horrendous work injury, the list goes on and on.
Spend much time at a trauma center and that rhythm becomes more and more evident. Daily you hear the choppers landing, daily there is evidence of the ICU clearing out some and accepting others, daily there are the discharge of trauma survivors with balloons, cards, well wishes and as I like to put it… “good luck with all that!”.
In the midst of this rhythm, there is the trauma system which is so key to those so seriously injured surviving their injuries or not surviving according to a recent study. Seems in this one exception to the general rule of “your surgeon makes all the difference” for trauma systems, seems its the system itself that means more in the difference between surviving and death.
The study, conducted at Johns Hopkins University, Looked at the patriarch of trauma centers, the R Adams Cowley Shock Trauma Center which is a level 1 trauma center and the true innovator in the early days where they stepped forward and took trauma injury out of the emergency room and put it in its own environment, which as been proven over and again to be the right way to treat trauma injury. Innovators of core trauma injury treatment concepts such as the “golden hour”, they were the first such hospital to use helicopters to ferry the most critically injured to their facility, both innovations now used in every state in the nation regardless of how well their trauma system is formed, if at all.
The research centered around the fact that the trauma center relied on first year attending surgeons in the trauma center until 1998 when a trauma director who had a 10 year fellowship under his belt was hired to initiate changes. Examples of changes included having an attending trauma surgeon present 24 hours a day, using written evidence-based algorithms, protocols, and guidelines for patient management, and creating a dedicated trauma admitting unit.
Many of those changes made in the trauma center are now part of the requirements for level 1 trauma center certification by the College of Surgeons; the body that certifies trauma centers today.
In this article, they state the following about the study criteria and result:
To analyze the effect of surgeon experience on mortality, the researchers looked at survival rates in the trauma unit before and after the hiring of the trauma director, who performed surgery in addition to overseeing the entire unit.
In the three-and-a-half-year period before his hiring, 4,499 patients were treated by novice trauma surgeons.
In the six-and-a-half-year period following his hiring, 5,783 patients were treated by novice surgeons and 3,612 were treated by the trauma director.
In the latter time period, there was no significant difference in the mortality rate in patients treated by the less-experienced surgeons or the trauma director.
Among patients treated by the novice surgeons, those who underwent surgery after the trauma director was hired were 44% less likely to die than those treated in the early period (OR 0.56, 95% CI 0.37 to 0.85).
After excluding deaths in the emergency department, which includes many patients dead on arrival, mortality dropped from 1.8% to 1.2% after the hiring of the trauma director (P=0.01).
“Although the survival improvement … may seem small,” the researchers said, “this decrease in mortality represents a large number of lives saved.”
The authors acknowledged some limitations of the study, including the retrospective design and the use of a single center, historical controls for the comparison of novice surgeons over time, a single experienced trauma surgeon, and mortality as the only clinical outcome.
So at least according to the results as stated here, those very few that actually have a vital concern about trauma care in their area should look to how well your local trauma system is formed, rather than worrying about the experience.
One thing this study shows is that trauma research, while the most poorly funded of all diseases is in some amazingly capable hands, our job as citizens is to be trauma system centered. We will always encourage people to be involved in their states efforts with respect to trauma care. Like so many things, this is a states responsibility, so it falls upon us to hold our states accountable.
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The R Adams Cowley Shock Trauma Center is in fact, part of the University of Maryland Medical Center and the University of Maryland School of Medicine.
You are quite right, sorry for the confusion. I’ll correct the article forthwith! Thanks for the input!