Foreword

It is said that where one stands depends upon where one sits. This is particularly true in the care of the traumatized patient. I can think of no other aspect of medical care that so well illustrates the problems of the modern meta-stable industry of health care delivery. To me the fundamental question of modern medicine in the United States is whether we are a private industry or a public utility—maybe even a fundamental right. I do not consider myself an ardent socialist or capitalist, although my participation in our profession most likely means I am a little of both. I do, however, very much consider myself a realist. And the realistic and pragmatic side of me is quite convinced that our current system of trauma care is unsustainable.

Society has an expectation that medical care for traumatic events will be available by some means. And it is expected that this situation will exist independent of society's ability to underwrite the cost of its care either privately or by third party payers. This expectation of course extends to all persons who become acutely ill but it is somewhat more dramatically displayed in the trauma population. Society has some fundamentally sound reasons to maintain this belief. Taxpayers and their elected governments provide prehospital emergency medical services, equipment, and personnel. Communities may have responders of varying levels of training and expertise; they may use full-time, part-time or volunteer personnel, and may have shared arrangements for the use of equipment. Certainly all the prehospital care services provided, independent of level of sophistication, will likely fall short without hospitals to accept the injured patients.

Although hospitals do derive some economic support and service benefit from communities and various levels of government, the support is generally far short of the costs incurred by these institutions. There are some situations in which trauma care is profitable to the institution but there are many whereby the cost is an enormous strain on its financial survival.

The American College of Surgeons, through its commendable support of Advanced Trauma Life Support training efforts and its verified trauma center review process, has made tremendous strides in improving the care delivered to our injured fellow citizens. The American College of Surgeons, though however important, is not an elected body by the people and is not an established organ of government. Neither fellowship in the college nor participation in any of its programs is mandatory for any surgeon, let alone any trauma surgeon. And whereas voluntary acceptance and adherence to the espoused principles of the American College of Surgeons committee on trauma has improved trauma care substantially, it will unlikely carry us the rest of the distance.

Our current model of trauma care and interfacility transfer patterns by necessity requires more people to be available to handle surge capacity than one can optimally employ during more average workloads. When the percentage difference in resource requirements between peak surge and optimal efficiency is low, most systems can absorb the economic impact. As that percentage increases, the impact varies from detrimental to unsustainable. In part this is because trauma care at the physician and hospital level is reimbursed on a piecework basis whereas the readiness requirement follows a “firefighter” model. Firefighters are not paid to put out fires so much as they are compensated for their availability and willingness to put out fires. If we were to develop the practice of paying firefighters only to put fires out, we would run the risks of encouraging arson or inhibiting fire prevention, or possibly have inadequate numbers of people available to fight fires. (Let me state that by no means do I wish to suggest that firefighters would do any such thing. I have the utmost respect and admiration for their profession and use this example for the sole purpose of metaphor. Also, in many places fire and rescue responders are the prehospital trauma care support personnel—another reason to include them in this discussion). Because injury prevention and community education are part of our overall trauma project—another largely nonreimbursed effort—we find ourselves, rightfully, trying to put ourselves out of business. Ironically, we serve the public's interest to the degree to which we can keep ourselves unemployed.

The financial strains of trauma care systems coupled with the success in improvements in care of the traumatized patient have created a new—though maybe not so terribly new—problem for us as surgeons: the surgeon who feels that his operative volume and experience is suboptimal to maintain proficiency. One report suggested that many “trauma surgeons” working in level I trauma centers performed less than one laparotomy per week. This volume of operative experience was thought to be suboptimal for maintenance of technical proficiency. I agree. One solution is the development or widespread adoption of the “acute care surgery” model. There are certainly pros and cons to that approach. On the pro side it would likely yield a greater operative volume to the surgeon in question. On the con side it would not yield a higher volume of trauma-related cases. Furthermore because the science of trauma is really about the applied knowledge of the consequences of damaging levels of kinetic energy being transmitted to an unsuspecting patient, there is not necessarily a reason to believe that the acute care surgeon would have particular adeptness at managing nontraumatic acute care problems. Simply because a patient presents nonelectively does not imply what type of specialty trained physician the patient would benefit from most. It may be possible to suggest that if the modern trauma surgeon does so few laparotomies that he or she is volume-deficient for operative proficiency. Then, perhaps, we should have “abdominal surgeons” consulted for operative care of these patients as we frequently do for patients requiring the expertise of orthopedic surgeons, neurosurgeons, plastic and reconstructive surgeons, and so forth.

The modern era has also added a new wrinkle to the debate of emergency service—disaster preparedness. We have addressed this topic in some detail in our June 2006 issue of the Surgical Clinics of North America. Certainly the kind of surge capacity needed to manage a large-scale disaster could potentially dwarf any of the aforementioned concerns, yet the components of the dilemma are identical: resource allocation, surge capacity, and availability of expertise. Declared disasters are generally accompanied by some governmental or societal funding to help mitigate the costs of response, but the ongoing “slow disaster” that has evolved in terms of trauma and emergent care will unlikely be recognized in such terms by the public or their duly elected and appointed officials.

As I conclude this foreword I realize that its content may well irritate, if not infuriate, some of our colleagues. I would like to think that it will be read as a call to collectively address a huge societal problem rather than an attempt to fuel an already bitter “turf war.” You, the reader, will have to decide how you see it. I have had the opportunity to care for traumatized patients both as attending of record and consultant, as private solo practitioner and as a member of a large group, as well as chief of surgery of a Combat Support Hospital in an active shooting war; the problems and the issues have always been similar in each of those environments: difficult systems issues, appropriate matching of skill sets to problems, distribution of finances and resources, and integration of new technology and understanding. Dr Maier and his colleagues have done an outstanding job of summarizing the scientific basis of trauma care and the concept of systems. We as general surgeons need to address these issues among ourselves and force hospital systems and government as well as third party payers to address the logistical and financial considerations previously alluded to. This topic is too important to leave unresolved. We need to definitively establish whether we are a private industry, a public utility, or a right or entitlement. Internal cost shifting and turf battles are analogous to the rearranging of deck chairs on the Titanic. The future of the rest of medical care may depend upon how this debate is conducted and resolved. Each of us should try our best to get it right.