For the Care of the Underserved

Thank you very much, and thank you Dr. Cioffi for that great introduction. I have to say, I did not expect in a million years to be standing up here, and it is an honor and rare privilege to be able to do so. The American Association for the Surgery of Trauma (AAST) has been part of my professional life and part of my culture since I was a young and very anxious junior resident presenting my first article here so many years ago. The title of an alternate subject that I had considered for this address was “The Company You Keep,” in reflection of the fact that there is not a day that goes by when I do not think about the value of the professional and personal relationships that exist among my colleagues and among so many people in this room. This community of surgeons that shares the same ideals, commitment, and dedication is extraordinary. I feel incredibly fortunate to have shared my professional life with so many special persons—those who have been a source of great support, encouragement, and camaraderie over the years. As a young medical student, I landed a summer job working for a group of surgeons here in San Francisco that included Bill Blaisdell, Don Trunkey, Frank Lewis, George Sheldon, Bob Lim, Art Thomas, Jack McAninch, and others who were or were to become household names in American surgery. Don Trunkey, with his “love of the sport,” humor, and quick wit, and Frank Lewis, with his piercing intellect and analytic approach to problems, helped to convince me that surgery is where I wanted to be. My “Forrest Gump” experience continued when I accepted my first faculty position with two young surgeons, Steve Shackford and David Hoyt, joined 2 years later by Jim Davis. You are all probably tired of looking at this picture (Fig. 1), as it has been shown so many times on occasions such as this. To the young persons in the room, this is what happens to trauma surgeons after 23 years (Fig. 2), a little heavier perhaps (except for Shackford), a little grayer, but still sharing the same ideals and aspirations and still lifelong colleagues and friends.FIGURE 1: From left to right: Drs. Mackersie, Hoyt, Shackford, Davis (1988).FIGURE 2: Twenty-three years later: Drs. Mackersie, Hoyt, Shackford, Davis (2011).Trauma of course is a team sport. We share the thrill of victory and the agony of defeat on a daily basis with other members of our clinical family. Our “family” at the San Francisco General Hospital (SFGH) includes Drs. Bill Schecter, Andre Campbell, Peggy Knudson, Mike West, Jan Horn, Mitch Cohen, Rochelle Dicker, Rachael Callcut, and Art Hill. I value their partnership and friendship greatly and appreciate their support (and patience) over the years. My wife Katherine is sitting here in the front row. She is the most important person and the best thing in my life. The importance of most everything else in our lives pales by comparison with someone who provides the love, support, and encouragement that is truly sustaining over a career and over a lifetime. Thank you Katherine so very, very much. The focus of the talk this morning is on the care of the underserved in relation to their needs for emergency surgical care (ESC). We have seen amazing advances in clinical science, practice models, and the effectiveness of care of the critically ill and injured. At the same time however, access to this care for a significant proportion of patients, the underserved, continues to be threatened. The basic premise of this discourse today is that improving timely access to a system of optimal trauma and ESC may be one of the most effective means of reducing the overall “burden of disease” for critical surgical illness in the United States. The basic message is that we are uniquely qualified and positioned to do this and it is an integral part of our academic and clinical future. Before discussing the underserved and on the occasion of the AAST’s 75th anniversary, it is worth reflecting briefly on some of the major developments and milestones we have seen in this eventful 75 years. Distilled from the milestones cited by the section authors of the AAST 75th anniversary commemorative book and from interviews with the AAST past presidents,1 I present to you an abbreviated listing of what are regarded as being some of the most important developments that have occurred during the last 75 years: □ Trauma systems: regional trauma performance improvement, large-scale trauma registries, risk-adjusted analytic techniques □ Imaging: computed tomography, computed tomography angiography, ultrasound □ Surgical critical care: specialty training, patterns of practice and staffing □ Critical care techniques: monitoring, management of organ failure, protocols and guidelines, goal-directed therapy □ Resuscitation: all aspects □ Selective operative management for solid organ injuries □ Damage-control surgery and delayed primary abdominal closure □ Intra-abdominal compartment syndrome and related pathophysiology □ Optimal resource standards for trauma centers and a formalized review process □ Primary and secondary injury prevention □ The concept of “acute care surgery” and the development of related training programs □ Endovascular techniques for trauma □ Improvement in nutritional support techniques □ Evidence-based practices and definitions of levels of evidence □ Expansion of clinical management guidelines and practice algorithms In a perfect world, every victim of injury and every patient experiencing acute surgical illness would be able to benefit from all that we have learned over these many years. In an imperfect world, there will be those groups whose demographic, geographic, or economic characteristics impede or prevent access to optimal trauma and ESC. In the context of our discussion today, these are the underserved. Geographic Factors in Access to Care The geographically underserved are people who do not have timely access to care by virtue of living in remote places. You have all seen the studies and diagrams from the American Trauma Society, illustrating populations that live within 1 hour of helicopter or ground access to designated trauma centers.2 Much of the United States remains outside this window even by helicopter, and if you look at 1-hour ground transport accessibility, the situation is even worse. Brent Eastman spoke about this in his Scudder Oration of 2009,3 with the idea of filling in all of these gaps in our trauma systems and improving access to care for everyone, regardless of geographic location. We forget sometimes that trauma systems are a relatively new development. Beginning with the first trauma centers in the early 1960s that provided reliable, timely access to surgical care, seminal work examining preventable deaths provided further impetus for the development of trauma centers and early trauma systems in the 1970s and 1980s.4,5 More formalized structures for trauma systems were provided through the American College of Surgeons’ optimal resources guide (1976), the Development of Trauma Systems (DOTS) course by the National Highway Traffic Safety Administration (1986), the Model Trauma Care Systems Plan by the Health Resources Services Administration (1992), and the initial Consultation for Trauma Systems by the ACS (1996). The ideal characteristics for trauma systems were subsequently defined and tabulated, and many in this room contributed to the 2006 Health Resources and Services Administration Model Trauma System Planning and Evaluation Guidelines6 and to the revised ACS “grey book” for trauma systems consultation.7 Despite the gradual but continuous growth of trauma systems in the United States, access to care is still far from perfect. In a 2004 study, Nathans et al.8 showed that more than one third of patients with major injury were not making it to a trauma center. Here in California, we seem to be doing a little bit better, with a steady increase in the number of high Injury Severity Score (ISS) patients reaching trauma centers to just less than 50% by 2006.9 Since 2006, we have seen a steady increase in the number of trauma centers filling in some geographic gaps, but the establishment of trauma centers in areas of need continues to present a challenge. The underserved in our trauma systems lack timely access for reasons beyond the simple lack of a local trauma center. These include the failure to use available trauma centers with more seriously injured patients being deliberately kept at nontrauma center facilities; delayed access caused by initial undertriage; delayed retriage (secondary triage) from a nontrauma center emergency department (ED), and delayed care caused by a failure to use management guidelines either in the field or at lower-level facilities. Protocol-driven care should begin at the scene, and basic prehospital practice management guidelines such as those for traumatic brain injury are often not being used at all or being delayed. We know how to reduce the number of underserved and expand emergency care systems access. We have the expertise, and we continue to work to do this with trauma. The key elements include upgrades in the level of care—from nontrauma centers to Level IV or Level III and from Level III to Level II, developing inclusivity in existing systems by promoting data sharing and participation in regional performance improvement, developing better triage and retriage (ED to ED) processes, and using outreach programs and regional education to promote protocol-driven management. In the context of a trauma system, the question has been raised: should regionalization similar to that for trauma be extended to include all critical surgical emergency care? It is a central question and one we are becoming positioned to address. A glimpse into what might be the magnitude of the problem is provided in a study by Santry et al.10 The authors compared the outcomes of patients with critical surgical illness who were transferred into a definitive acute care surgery center with a similar group of those who were admitted directly. Patients being transferred into an acute care surgery hospital had more than four times the mortality and a longer stay. While we do not have a definitive answer to the broader regionalization question yet, formulating a solution will be a recurring theme and a direction we will need to take. Let us say our next step will be to build a regionalized system of emergency surgical care—I will just call it ESC for short—that is not limited to emergency general surgery but includes other surgical as This ESC system would be on the of existing trauma systems and would the same elements used in a trauma ESC data registries, ESC ESC resources ESC triage and and ESC outcomes and analytic of this will we have to in this and limited ESC regionalization has to in a We should how to our existing trauma systems into systems for all critical surgical The This is the of as the the and the do we know about this In the of the This that trauma patients were less to be admitted to the had provided when were and had a mortality when compared with This was a very and the reasons for the were not My and Bill Schecter, of the of for this patient the of many and overall mortality the of in and to and with and other of and and the general lack of access to basic the A so. to be an for of patients and an lack of and the mortality from trauma even in the for those and a seen in even at a Level 1 trauma of us working in trauma with a all have that we are part of an that in or on and this to be the even for our most important are the for have a number of related to medical We know that this may be a significant a premise by one study an of on trauma outcomes in the in and that At one study that are for patients with This next one of for and patients sustaining is Dr. when we need for the is by a from the group that that patients seem to their trauma at with mortality is the or fact of being The seem to be and seem to be trauma is or should be the most of medical care and these are We the but of their □ The of □ medical □ □ in medical related to less time and less □ or □ on of benefit The for to or patients into or groups and on the of in benefit among these groups has been as part of a The to this is a in trauma remains to be but there is to we and the of and on these The The next group of underserved I will talk about is the is to be in this room at some and many of us are The of injury in the is in the of examining the and on life on these from a of to a of At the same injuries in from to and Care of the trauma patient is a growth is and there is are The for the injured is to the seem to be in and there is probably is a need for programs to better care for this To this last I Steve Shackford to a new on It is how and with what this group has The of optimal care to the underserved trauma is of great to this and a very important for development. the ACS and Trauma Improvement are working the same Despite the importance of as we might have it that the do not have the of access to trauma that we In a from California, et that was an for access to designated trauma center A similar was by et in a study of the trauma reasons for in trauma center access were further in two of of patients to designated trauma that lack of training related to the and may be important A study was one by et who that the of an where patients were more to be by care in the outcomes Access to with limited access to may be underserved In the injury prevention group at a study examining the outcomes from traumatic injury as a of patient The thing is the that the mortality for those patients to a even after for injury and was than for those or to a mortality for for This was a study and the for the the is that we are trauma in on the lack of or other of the for optimal therapy and optimal We seem to in the optimal care that we at our trauma centers by the lack of The of a has been by a number of other studies looking at the related to patients and those who are seem to be less in further the acute care In a study by et the authors even for were less to be to that brain injury is a primary of and in a of our trauma we the of for these patients and we know where these patients should their the fact to be that access to even for this may be for patients with traumatic brain the lack of is to their of these patients are not the of that studies that this is of is a critical part of our trauma system, but programs have been into the of care, for a of outcomes are a critical of overall systems but our existing systems structures are not by these clinical are not of Access to optimal in all to be to that may injury and other a and underserved The discussion far has on the underserved I to part of the that the work and that will be part of the solution to access to care for the underserved. of the key studies on surgical work from the George who did so to this important of our future. are with the of patients and the work this will In a study just this by Dr. and his a and was used to the surgical work with We are at a where the work has by since on and work growth it that we are in with the surgical work you the surgical critical care, and emergency general surgery work we the surgical critical care of trauma or acute care surgery is and The is the are with a 50% increase in since The is the of the and the of the in are not what need to It that we are not to be able to the work problem for ESC by in acute care surgery training This problem will a are not to be able to the work on a The through of and Health has for years the in patient access to in 2006 The of this is by a of and the number of surgeons by The has been used in a number of studies and and the message is the more surgeons there the the mortality the surgeons there the the mortality I would to briefly on what I think are a of important the general surgeons and a these surgeons as While the might be part of a in many are hospital From study by George there has been a increase in the in to in and the in the in to in At the same we job general surgeons to work in to some of these new or or not of the but the that there is a great for this group of general surgeons to ESC These are not acute care surgeons trauma and surgical critical care at Level 1 or Level 2 designated may not have the same of emergency practice that we however, a important part of the surgical work and we need to how to into our for ESC. As academic surgical our is to the and of emergency surgical and critical care training, within and for the general surgical As our is to and work within a system the level of ESC. the acute care surgery work as I is not to be to all trauma and emergency surgery. what other do we We new practice an use of and that most of us have to some into our We better our medical and as into for We how an general might be best used within a regional system to it more and ESC. We begin to these systems of ESC that are after and on our existing trauma While we do not have data that would the regionalization of all most of us in this room, on our with trauma and other critical surgical that there is a benefit to regionalization that to more or nontrauma surgical I would to of our AAST with to the of the trauma and the acute care Dr. in his AAST address in that the of trauma to a for the Surgery of and in the of a for the of the surgery of Dr. in his AAST address that the AAST’s was to the General Surgical in up a of high level of surgeons in the field of there was an AAST to do working with the American of was in this for a of We years with a work to an even number of underserved, the same The of the Safety Hospital the of and in the of the hospital was since all patients would have In his Dr. on the of these that there be those who have with access to care and that there is a need for that will for the patients and Dr. was many but not all but did so with that continue to the of a system of We have a of whose is with care the Care We are in the of care for of It is that as many as million persons will even with the that share is to by up to that will and that the of for the underserved and those with will a the the for trauma centers and trauma centers for their The to the in share for everything into it that will that the of care may have been and that the of trauma will be by The I to and is a a need for ESC and a of underserved. and it is a problem we have been to for in our work with trauma We are at a in this acute care surgery as a training we are to the next to acute care surgery emergency general surgical critical as an approach to a system of care that will these care of the advances in trauma care, so in the 75th anniversary commemorative and emergency surgery are not available to significant of our This situation will and the simple of improving access to care may be one of the most effective means of reducing the overall of for critical surgical illness and injury that we will in the years. should our be as an and as a community of We have our and learned in trauma to a broader of To extended systems of ESC and practice models, we need Surgical provides the of our trauma systems and the for a broader system all ESC. To for optimal care for all critical surgical we need with experience in doing this. I looking at in this room. To continue to outcomes and reduce we need and an data here today has their to and data and the These are part of the of the AAST and be to include emergency surgery. To the work we need and we need training and we need to the general into this work You are the group to do this. we have a to our in trauma surgery and trauma systems to a of emergency surgery. Trauma care and to ESC. Injury and trauma to ESC with Dr. AAST this The at some become or Optimal resource and process standards for and systems of care for trauma will expand to include a process Dr. of the on of for the AAST was last Dr. with the development of a for emergency surgery. At the same we continue to acute care surgery programs that will the next of that this of trauma to a broader of ESC. While we have these initial to expand our of and a new training it will be critical for us to that outcomes from nontrauma surgical will benefit from a similar of a systems approach to that used for trauma. I that most in this room this to be but that is not to be we did for we will need to the and outcomes effectiveness of a broader system of care for ESC. We have just the in of doing this. I think that it has become that the needs for ESC will not be within the of general surgery. on our part is a to data and outcomes for a to an system for ESC that and the of the general and a to training for the next of acute care care surgery surgical critical care, and emergency general is more than a training It is an of our an of our expertise, and an of our system of care that we have so over the last for trauma. at the AAST work and to the that will be at the We have to our and expertise, with a to a approach to needs for the underserved. This is our and we will be working to It has been such a privilege to as and an honor to be beyond Thank you for here to San thank you for me as and thank you for The of