Trauma/original researchTrauma Management Outcomes Associated With Nonsurgeon Versus Surgeon Trauma Team Leaders
Introduction
In the United States, trauma care, particularly the resuscitative phase of care, has been traditionally considered an integral part of the domain of surgery. In 1999, the American College of Surgeons Committee on Trauma reported that “the active involvement of the trauma surgeon is crucial to the optimal care of the injured patient in all phases of resuscitation.”1 With ongoing evolution of care in trauma management and the training of nonsurgical specialties (such as emergency medicine) in trauma care, it is uncertain whether mandatory or even routine surgeon leadership in the resuscitative component of trauma care remains a necessity.
Objective evidence in favor of mandatory surgical leadership of trauma teams is lacking.2 In contrast with the requirements of the American College of Surgeons, the guidelines of the Trauma Association of Canada do not include that trauma team leaders must be surgeons.3 In fact, in many Canadian centers, including trauma centers in the province of Nova Scotia, nonsurgeons often lead trauma teams and manage the resuscitative care. Although trauma team leaders in Canada may be general or orthopedic surgeons, they may also be anesthesiologists, intensivists, or emergency physicians with an interest in trauma and with relevant experience and training. In Nova Scotia, our single site tertiary trauma center for adult patients is staffed continuously by dedicated, contracted trauma team leaders who are not on site (maximum 20-minute callback). Although advanced notice is given to trauma team leaders when possible, if a patient reaches the hospital before the trauma team leader, the patient’s resuscitative care is initially managed by a board-certified emergency physician (many of whom are trauma team leaders when not working as emergency physicians). Trauma team leaders are required to not be clinically working during their trauma call (ie, no operating room duties or emergency department shifts). Their primary role is to lead the resuscitative care of the major trauma patient. Subsequent inpatient care is managed by the staff of the appropriate clinical service.
Mandatory surgeon trauma management remains a controversial issue. Several recent studies have attempted to address this,2, 4, 5, 6, 7, 8, 9, 10, 11 but to date there have been no large outcome studies with direct comparisons between surgeon- and nonsurgeon-led trauma teams. Surrogates for direct comparison, such as differences in the timing of surgeon involvement, are inadequate to appropriately address the question.12, 13 Although direct comparison of surgeon- and nonsurgeon-led trauma teams is not currently possible in the United States because of the American College of Surgeons requirements, it can be explored in a Canadian context. In the present study, the Nova Scotia Trauma Registry (see Appendix E1 for registry inclusion criteria; available online at http://www.annemergmed.com)14 offers a unique opportunity to directly compare outcomes in surgeon- and nonsurgeon-led trauma teams.
The purpose of this study is to determine whether nonsurgeons are as effective as surgeons in leading trauma teams.
Section snippets
Study Design
This was a retrospective study using data from the Nova Scotia Trauma Registry database. Inclusion criteria for the registry14 are presented in Appendix E1 (available online at http://www.annemergmed.com). The data collected in the trauma registry database include facts related to the nature of the injury and trauma event, patient demographics, patient care, and patient outcomes.14, 15 Trauma registry data are collected by a team of health care professionals (nurses, paramedics, health records
Results
There were a total of 1,139 entries in the trauma registry during the period of interest. Of these, 306 did not meet the inclusion requirement of Injury Severity Score greater than or equal to 12 for blunt trauma or Injury Severity Score greater than or equal to 9 for penetrating trauma. Two records involved patients with severe burns, 15 records did not include trauma team leader identification, and 9 records did not include total length of stay; these were excluded from further analyses,
Limitations
One limitation of our study concerns the small number of penetrating trauma cases available. Although the pattern of results did not suggest a difference between surgeon versus nonsurgeon trauma team leader performance in penetrating trauma, the limited number of cases did not permit firm statistical conclusions in this regard. Further analysis in a larger setting with sufficient numbers of penetrating trauma cases would be appropriate.
A second limitation is related to the retrospective nature
Discussion
This study directly compares the outcomes of nonsurgeon- and surgeon-led trauma teams in a major trauma patient cohort in a Canadian tertiary trauma center. The findings suggest no clinical differences in terms of survival, length of stay in the hospital, or actual versus predicted survival for the patients of each group for blunt trauma cases. The number of cases of penetrating trauma was too low to allow meaningful group comparisons; however, there was no trend toward a difference between
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Supervising editor: Judd E. Hollander, MD
Author contributions: JMT conceived the study. JMA and JMT designed the study and obtained research funding. JMA completed the request for data through the trauma registry, and JMT supervised the data collection. JMA, JMT, and DAP provided data analysis advice. JMA and JMT provided statistical advice. JMA performed the statistical analyses. All authors contributed to the drafting of the article and to its revision. All authors saw and approved the final article. JMA takes responsibility for the paper as a whole.
Funding and support: JMA held a DMRF/Faculty of Medicine summer studentship with funding provided by a Dalhousie Medical Research Foundation Music-in-Medicine Studentship.
Available online November 15, 2006.
Reprints not available from the authors.