Surgical Rescue: An Essential Component of Acute Care Surgery

The "General Surgery" we have known for decades is rapidly dying, at least in the developed countries.A major paradigm shift has occurred, yielding an increasing number of narrowly and subspecialty focused surgical graduates and practicing surgeons, leading to organ-or procedure-specific practices (1).Concomitantly, the proportion of our populations who are elderly and more likely than the younger age group to require surgery has increased.The demand for care has outstripped the supply of general surgeons willing and able to provide the care for these patients (2-4).Acute Care Surgery (ACS), as it is called in the United States, and Emergency Surgery, as titled in Europe and elsewhere, has developed to address this public need.Trauma surgeons in the United States and the "visceral" trauma and emergency general surgeons of Europe have embraced this specialty.Although the terminology is new, the practice of ACS is not.The majority of us, in fact, have been "Acute Care Surgeons" for years.As originally described in the United States, ACS consists of Trauma, Emergency Surgery, and Surgical Critical Care.Ten of the 29 most common hospital discharge diagnosis in the United States are those seen daily on any inpatient list of the ACS team, including but not limited to pancreatitis, appendicitis, colitis, soft-tissue infection, cholecystitis, injury, and bowel obstruction (2-4).It is this disease process of the ACS patient that distinguishes the acute care surgeon, from the general surgeon and elective surgical pathology.Elective surgery focuses on full understanding of the anatomy and pathology of the disease.Although equally fundamental for ACS, there is the additional critical need to address the abnormal physiology in the emergency surgery or trauma patient.This involves prompt source control, whether from a perforated duodenal ulcer or gunshot wound to the duodenum.The primary disease is a hole in a hollow viscus, and the physiologic response and need for immediate surgical intervention are the same.It has become clear to us that patients who have developed complications of medical or surgical care may be the most vulnerable of all patients.Referring again to US hospital discharge data (2), Complication of Medical or Surgical Care is as frequent as appendicitis, acute cholecystitis, and small bowel obstruction combined.These patients comprise approximately 20% of our inpatient General Surgery service at the Pittsburgh