Trauma Surgeons' Impactful Last Half Century

Over the past 50 years, trauma care overall has advanced dramatically, with major reductions in mortality and morbidity. As a result of this, trauma care also includes focusing on our trauma survivors and their quality of life, even beyond hospitalization. Despite many advances and massive progress, the global burden of trauma is still increasing particularly in Low- and Middle-Income Countries. A large proportion is due to the inequity and disparity of resources, funding and their distribution, but also related to the lack of education and training in many regions and countries across the globe. This editorial article spotlights the contributions and impact of surgeons and trauma specialists and the collaborative work of professional organizations on these important improvements in trauma care. The authors, senior trauma surgeons, identified five areas of major advances in trauma care: initial management with crucial changes in resuscitation and surgical tactics, known as damage-control surgery, advances in medical imaging supporting decision-making and treatment during early stages of resuscitation and beyond, changes to less invasive and minimally invasive techniques in trauma surgery and interventional radiology, enhancements and progresses in trauma education and training as well as developments of integrated and coordinated trauma systems along the entire patient journey. The “Damage-Control” concept has been employed in trauma surgery for more than 100 years, when liver injuries were packed by Pringle. However, the underlying physiological principles were not well understood, results were unacceptable and the procedure was abandoned. In 1983, Stone [1] described an alternative approach to definitive trauma laparotomy in the presence of coagulopathy. This consisted of abbreviating the procedure and controlling the bleeding with packing, followed by resuscitative measures to achieve physiological normalcy; once the patient had been resuscitated in the intensive care unit environment, then proceeding to definitive (completion) surgery [2]. This staged approach resulted in much better survival rates. At that time, damage control procedures were confined to abdominal injuries only. As the physiological abnormalities were better studied and understood, in particular the concept of the “Triad of Death” with acidosis, coagulopathy and hypothermia, the practise of abbreviated laparotomy was widely adopted by surgeons. In 1993, Rotando et al. coined the term “Damage-Control Surgery” (DCS) [3, 4]. and this principle is well-established and define as control of bleeding followed by control of contamination, followed by temporary abdominal closure. In the early 2000s, the concept of Damage-Control Resuscitation (DCR) was formulated, consisting of several strategies which were directed towards achieving a better outcome during resuscitation [5]. These included: early, aggressive hemorrhage control, a blood-first resuscitation strategy, and permissive hypotension (when appropriate). DCR works synergistically with DCS to improve physiology [6]. As the knowledge and the experience of this concept expanded, the tenets of this approach were extended to other anatomic regions beyond the abdomen as well as non-traumatic conditions [7-9]. Damage-Control Orthopedics, Vascular Surgery, Neurosurgery and Thoracic Surgery are among them. Damage-Control Orthopedics (DCO) became well established where patient with multisystem injury in extremis would benefit from a DCO approach [8, 9]. After initial resuscitation, traction or external fixators and debridement are frequently employed. In orthopedic trauma, the DCO method has been contrasted to early total care as in the other specialties as well; more recently the overall principle has been defined as early appropriate care [10, 11]. The concept of damage-control has also been adopted into neurosurgical practise; in 1998, Rinker et al. [12] introduced this principle for severe traumatic brain injury; Rubiano et al. [13] and later on Rosenfeld [14] described damage-control for severe brain injuries; however, it took some time for this concept to move out of the military context into the wider neurosurgical community. The damage-control concept was also introduced into penetrating neurotrauma patients, as well as into low-resource environments, using non-invasive neuro-monitoring [15]. Other important applications of DCS have been described for resource-constrained environments including outlying or rural/regional hospitals, as well as in mass-casualty situations [16]. Imaging for trauma patients has radically transformed over the past five decades, shifting from invasive diagnostic techniques to rapid, non-invasive modalities that now guide modern trauma care. In 1965, the landmark article by Root and colleagues introduced diagnostic peritoneal lavage (DPL) for evaluation of potential abdominal injury in trauma patients [17, 18]. Offering a more objective evaluation tool, DPL became the gold standard for the next 20 years, while recognizing that it was non-specific, at times overly sensitive and had the potential to cause injury. Over the next several decades, ultrasound was recognized as a valuable diagnostic tool in Europe and Japan, and in 1992 Tso published the first US series, followed by a series of 476 patients by Rozycki and colleagues in 1993 [19, 20]. The “Focused Assessment with Sonography for Trauma” (FAST) acronym was published in 1996 [21, 22]. An international consensus conference, led by Scalea, served to establish the FAST exam in trauma management algorithms. Ultrasound is mainly useful for identifying the presence of intra-abdominal and pericardial fluid, most frequently blood, in trauma patients. Bedside ultrasound offers widely available, rapid and non-invasive imaging without radiation exposure, or injury risk to the patient, and is easily repeatable. Subsequently, the extended FAST (eFAST) has expanded the exam to include thoracic views, allowing rapid detection of pneumothorax and hemothorax with sensitivities superior to supine chest radiography [23]. Despite limitations in detecting retroperitoneal or hollow viscus injuries, FAST/eFAST remains important in early trauma evaluation [24, 25]. The introduction of computed tomography (CT) in the late 1970s revolutionized trauma care. Early CT scanners provided cross-sectional imaging, that although with limited resolution and time-consuming, was superior to plain radiography. As technology improved, CT was even more widely adopted by the late 1980s. Notable advances in helical and multidetector CT during the 1990s and 2000s improved speed and resolution, enabling whole-body trauma scans within minutes [26]. High-resolution CT allowed accurate grading of splenic, hepatic, and renal injuries, facilitating the transition to non-operative management (NOM) for hemodynamically stable patients. Large multicenter studies confirmed NOM as safe and effective, reducing unnecessary laparotomies and preserving organ function [27, 28]. Organ-injury scales were first published by the American Association for the Surgery of Trauma in 1989 but later revised to include CT scan evaluation. Use of the CT scan has revolutionized the diagnosis, management and understanding of traumatic brain injury. From reliance on clinical exam, plain radiographs of the skull and invasive, potentially dangerous studies including ventriculography, imaging is now rapidly obtained demonstrating size, location and consistency of blood, but also the presence of edema and ischemia. The ability to obtain repeated imaging to follow injuries or change in clinical status further increases the value of this modality. The introduction of CT-angiography (CTA) has become the gold standard for diagnosing vascular injuries. In thoracic aortic trauma, CTA allows rapid, highly sensitive visualization of intimal tears, pseudoaneurysms, and mediastinal hematomas [29]. Similarly, blunt cerebrovascular injury (BCVI) such as carotid or vertebral artery trauma, was often occult yet devastating. This has been increasingly recognized and guides clinical and prophylactic management. Screening protocols using CTA allow early detection of injuries and therefore initiation of antithrombotic therapy, reducing stroke risk [30, 31]. Peripheral vascular injuries, once reliant on invasive angiography, are now routinely evaluated with CTA, both ruling and ruling out the presence of injury and allowing more expeditious intervention. Collectively, CTA has replaced conventional angiography in most trauma centers. Over the past five decades, most surgical disciplines—including traumatology—have progressively transitioned toward minimally invasive techniques, which by 2026 have become integral to both the diagnostic evaluation and therapeutic management of trauma patients. This evolution has been driven by the aim of reducing the systemic inflammatory response, shortening hospital length of stay, and decreasing the overall morbidity associated with conventional open surgical procedures. Advances in percutaneous endovascular techniques have significantly reshaped the diagnostic and therapeutic approach to the injured patient, enabling rapid vascular intervention across a wide range of traumatic hemorrhage scenarios. Non-operative management of hemodynamically stable trauma patients with solid-organ injuries has become the standard of care over the past several decades, substantially reducing the need for trauma laparotomies and organ resection [32-34]. This paradigm shift has been strongly supported by the widespread availability of high-resolution computed tomography and angiography with transcatheter embolization. Embolization enables targeted, organ-preserving control of arterial hemorrhage and is particularly advantageous for managing bleeding in anatomically challenging regions, such as the pelvis and liver [35]. The use of endovascular techniques in penetrating trauma involving anatomically challenging vessels, such as the subclavian or axillary arteries, is also promising and raising in their applications. Stent-graft placement is emerging as a viable therapeutic option in hemodynamically stable or stabilized patients [36], and significantly reducing morbidities as compared to open surgical approaches. The first documented use of laparoscopy in the evaluation of traumatic injury was reported as early as 1925 [37]. Nearly a century later, in the early 21st century, laparoscopy gained more formal recognition in the management of hemodynamically stable trauma patients. Initially, it was primarily employed as a diagnostic modality to assess peritoneal violation in cases of penetrating abdominal trauma [38]. In recent years, however, its use has expanded to include therapeutic interventions for selected injuries, such as diaphragmatic lacerations and hollow-viscus lesions [39]. Although most literature describes its application in penetrating trauma, its utility in blunt trauma is increasingly being explored [40]. The World Health Organization (WHO) estimates a global health workforce that includes over 70 million people; approximately 12.7 million are doctors and 30 million are nurses and midwives. The model to manage the trauma patient requires a multi-disciplinary approach [41]. The number of medical and nursing schools in some countries has increased, but unfortunately fewer professionals have dedicated their careers to emergency and trauma care. It is necessary to consider civilian trauma patients, with different specialties, but include military's surgical workforce [42]. In the surgical and emergency care areas, there are no doubts that the best way to prepare a competent and well-trained doctor is through dedicated residency programs. Few medical schools have disciplines dedicated to trauma care and it is not uncommon for surgery residents to have a limited experience and training in trauma care [43]. The Acute Care Surgery program developed by the American Association for the Surgery of Trauma (AAST) in 2005, including trauma and general surgery, training in elective and emergency surgery, in trauma surgery and surgical critical care, was a good solution to attract surgical trainees and fellows, very similar to the model created in Brazil in the 1990s. Many larger hospital systems have successfully implemented acute care surgery including the knowledge base of trauma surgery and surgical critical care to meet the changing needs of the healthcare system in different continents [44, 45]. Trauma education through the professional societies is absolutely crucial, and building on the experience with international colleagues who have extraordinary clinical volume in certain countries is so important to train the next generations [46, 47]. The Advanced Trauma Life Support (ATLS) course is the strongest program to teach trauma care to physicians [43, 48]. The program organized by the American College of Surgeons (ACS) Committee on Trauma (COT) has worked to establish guidelines for the care of injured patients worldwide with 1.5 million healthcare providers who have taken the course; more than 60% of ATLS courses are now taught outside North America. The Definitive Surgical Trauma Care course (DSTC) was developed on the initiative of six international surgeons in 1993 and was launched by the International Association for Trauma Surgery and Intensive Care (IATSIC) in 1996, in Sydney. Participants learn about damage control principles in major trauma, prioritize investigations and procedures discussing cases, and demonstrate teamwork and effective communication during trauma management skills. The Definitive Anesthesia Trauma Care (DATC) course and the Definitive Perioperative Nurse Trauma Care (DPNTC) course can run simultaneously with the DSTC course to provide anesthesiologists and perioperative nurses with knowledge and skills in damage control resuscitation, anesthesia and nursing care [48, 49]. The European Trauma Course (ETC), promoted by European Resuscitation Council (ERC) with support from the European Society of Anaesthesiology (ESA), the European Society for Trauma and Emergency Surgery (ESTES), and the European Society for Emergency Medicine (EuSEM), was the first course to address non-technical skills in trauma resuscitation and was launched in 2008, in Belgium. Since then, the ETC has experienced substantial growth, expanding to more than 80 centers across 25 countries, teaching with simulation-based training, focusing on teamwork and non-technical skills in dynamic team-based scenarios [50]. Telemedicine technology is an important tool in trauma education for newer generations of young surgeons and medical students and has been used across the world to facilitate communication with learning paths for unusual cases or reinforcement of routine cases discussed with experienced surgeons. Trauma Tele-Grand Rounds promoted since 2010 through the University of Miami, and more recently organized by the Panamerican Trauma Society (PTS), connects multiple remote institutions simultaneously to discuss trauma cases presented by one institution on a rotating basis. This is a successful example of medical education training participants to improve care for trauma patients [47]. Another successful experience on trauma education is the Academic Leagues, which consist of groups of medical or nurse students that voluntarily congregate in extracurricular activities under the supervision of a surgeon. The first Trauma League in Brazil was founded at University of Campinas, in 1992, and has attracted many medical students to their activities, providing students with teaching, research, and practical activities. Trauma Leagues have been demonstrated to bring the students to their activities and to attract new general surgeons [51, 52]. From a global healthcare perspective, trauma care has immensely evolved into a holistic approach to the trauma patient's entire journey with coordination and integration of all specialties and multidisciplinary teams. A large focus of trauma specialists has been in the development, implementation and verification of trauma systems on a local, regional, national and international collaborative level [53]. The ultimate goal of any trauma system is to provide high-standard care for the best possible outcome to the individual patient as well as to the entire trauma population. In other words, to transport any trauma patient in a timely fashion to definitive care, ideally a high-level trauma center. Although, in many high-income countries, trauma systems are recognized for their organized structures and their governance, many countries are still facing large challenges. These include the implementation and standardization of trauma pathways as a result of infrastructure and logistical problems, enormous resource constraints as well as underdeveloped education and training in trauma and across the health sector. Many initiatives and partnerships have been launched to advocate, support and build trauma systems in such resource-constrained regions. In recent years, several Middle Eastern (Saudi Arabia, Qatar) and Asian countries have started to focus and implement trauma system structures with dedicated resources and experts involved. Asian countries have strengthened their systems out of Singapore with international collaboration and founded the Asian Collaboration for Trauma to broaden and strengthen their advocacy for trauma care in their region. For many years, Pan-American trauma societies have supported the development of trauma systems, and on the African continent, a number of countries are supported by organized partnerships, global health support as well as local and NGO support, with organizations from Europe, the US, Canada, Australia and other regions. Trauma system development includes clear trauma center designation and referral pathways, data monitoring through registries and data utilization for quality improvement programs (TQIPs) [54], Trauma prevention initiatives, in collaboration with various agencies, organizations and governments to implement regulations and legislation, are another essential component of trauma systems. Trauma Verification programs of several national Trauma committees have been instrumental to model and monitor trauma systems with great success [55]. Trauma registries have been developed across the globe, though comparability is difficult, and standardization is an ongoing challenge. A major improvement to clinical practice and patient outcomes has been the development and roll-out of numerous clinical practice guidelines and protocols (including the WHO Trauma checklist released in 2016). A comprehensive summary was published by the ACS COT in 2023 [56]. 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