The requirement for a surgical attending presence during initial resuscitation by the Committee on Trauma of the American College of Surgeons has been challenged lately and is the subj ect of intense debate at different levels. Most experts in the field postulate that there is a relationship between trauma center patient volume and mortality reduction.⁴ Furthermore, it has been shown that outcomes are directly related to institutional commitment, and not just the individual surgeon’s experience.⁵ Prehospital hypotension has been questioned as an indicator of severity of injury or poor outcome.⁶ It is the philosophy of most units, including ours, to have a trauma attending present or within an immediate response for those patients with the following physiologic findings: (i) a systolic blood pressure <90 mm Hg; (ii) a Glasgow Coma Score (GCS) <8, (iii) need for endotracheal intubations, and (iv) penetrating injuries to the neck and/or torso.⁷ There is no data to support that in-house attending presence decreases mortality. However, patient disposition, coordination with other specialists, and perhaps increased reimbursement are associated with an in-house presence. Durham et al.,⁸ recently examined outcomes of injured patients who met prehospital criteria for trauma team activation before and after instituting a system of in-house trauma surgeon attending presence. Preventable deaths, as defined by review of each death by a multidisciplinary panel, were reduced from 8% to 1% after provision of in-house attending coverage.

Tertiary hospitals must provide specialty coverage or risk a loss of substantial federal and state subsidies for their trauma centers. Furthermore, the lack of proper ER coverage can result in violation of the Emergency Medical Treatment and Labor Act (EMTALA). This has the potential to incur hefty fines or termination of agreements for Medicaid and Medicare reimbursement. The increase in the number of hospitals using hospitalists to relieve primary doctors of admissions, as well as alternative practice venues that have made outpatient surgeries common practice, has encouraged some surgical specialists to reduce or drop their clinical privileges including ER availability.

During the 2005 Spring Meeting of the American College of Surgeons in Washington, D.C., Dr. J. Wayne Meredith, Chairman of the Committee on Trauma, reported that the current yearly expenditure by hospitals to outsource ER call coverage is close to $1 billion annually. As a matter of fact, the difficulties with ER call coverage by specialists has been the number one complaint in a recent survey among physician executives.⁹ This impact has been felt particularly in community-based trauma centers. Another significant contributing factor for the lack of a timely response to the ER was a result of the 2003 decision by the Centers for Medicare and Medicaid Services to ease the 1985 EMTALA rules, permitting specialists to schedule elective surgeries while on-call provided the hospital is able to show that “their coverage was reasonable.” Multiple efforts are under way to improve the ER coverage by specialists. However, most experts in the field believe that ER coverage by surgical specialists will remain a problem unless radical changes are made (see Table 1).

The American Medical Association states that physicians have a “moral responsibility” to provide emergency care to any patient regardless of their ability to pay. That principle is not currently followed, and it is not uncommon that physicians change their hospital privileges from “active” to “courtesy” to avoid ER coverage. An alternative to this dilemma is to secure locum tenens physicians. The caveat of this arrangement is the lack of continuity of care by the same physician, which is one of the fundamental goals of surgical care put forth by the American College of Surgeons since the time of its inception in 1912. The lack of consistent ER coverage is problematic for trauma centers for the specialties of neurosurgery, orthopaedic surgery, plastic surgery, and ophthalmology. Changes in the practice structure for these specialties have had the unintended consequence of
worsening the problem of emergency specialist availability. Neurosurgical practice has moved away from intracranial surgery and neurocritical care toward spine surgery. Orthopaedic surgery is a highly compartmentalized specialty with narrow clinical focus for many specialists, which leads to a lack of confidence to manage acute musculoskeletal injuries. Plastic surgery and ophthalmology have moved increasingly to outpatient practice sites with many specialists practicing without active staff hospital privileges. Lack of proper specialist coverage causes delays in patient treatment and increases patient transfers between hospitals, with EMTALA violations. During the 2005 meeting of the Department of Health and Human Services, the EMTALA laws dominated the agenda. After extensive discussions, no recommendations were issued at the meeting other than the panel will try to meet at least twice a year.¹⁰

Clearly, the most common stated reason physicians drop ER coverage is because professional liability expenditures have risen. There is also a related increase of specialty consultation requests as defensive medicine practices increase. The scenario worsens as the number of ER patients continues to rise as the number of emergency department facilities diminishes. In 2004, the Centers for Disease Control and Prevention (CDC) reported that the number of emergency facilities decreased approximately 15% between 1992 and 2002. This is exacerbated by a recent report by the ACGME predicting that there would be a shortage of approximately 85,000 physicians by 2020. The end result, in trauma centers, is that trauma surgeons provide the overwhelming majority of day-to-day care for injured patients regardless of the fact that many of these patients have single system injuries that are within the scope of practice of a surgical specialist.

We have found that the best incentive to motivate orthopaedic and neurosurgical participation for patient care is to maintain the care of their patients under the trauma service. A strong case can be made that furnishing specialty care to an emergency patient leads to deferral or cancellation of elective surgery and office patients, which results in lost income. It is fitting that, in recognition of this lost revenue, a financial stipend for ER coverage is used as an effective means of increasing participation in the ER call schedule and responsiveness to trauma consultations. Instituting contractual agreements between the hospital and designated specialty groups is another alternative avenue that allows responsive care and, because the specialists practice together in focused groups, continuity of care is maintained. The complexity of ER coverage is such that on June 14, 2006, the Institute of Medicine (IOM) released three reports in Washington, D.C. where they addressed the future of emergency care in the United States Health System. The core of this study by the IOM addressed three key areas: 1) prehospital, 2) hospital based, and 3) adult and pediatric emergency and trauma care. They also provided an overview of the emergency care system in the United States.

Although multiple specialists are usually required to care for complex trauma patients, the basic principle of a “captain of the ship” remains as true now as when it was initially coined in the late 1970s. This term implies the clear need of a general surgeon with a strong trauma background as the responsible person to lead the team.

Since the early 1990s, trauma has been recognized as a discipline. Most new trauma surgeons complete formal preparation in an approved training center with the ultimate goal of obtaining a certification in Surgical Critical Care by the American Board of Surgery (ABS). Under a newly conceived early specialization program of the ABS, core training in general surgery may be reduced to 4 years. Specialization will consist of 2 additional years to achieve certification in both general surgery and surgical critical care. This concept is envisioned to further expand a potential concept for an “emergency care surgeon” that would incorporate trauma, surgical critical care, and emergency general surgery.²,¹² This work is in progress, with major changes anticipated in the way that trauma surgeons are trained and the boundaries of their specialty.

With the amended working hours and the use of physician extenders to provide first-line care for trauma patients, the concept of a team approach is better illustrated now than ever before. The need for continuous communication and well-organized “checkout” rounds between coming and going members of the team is crucial to avoid potential complications, missed injuries, and eventually missed patients altogether.

It has become evident in the last decade that with the multiple options available to care for some specific injuries (minimally invasive surgery, observation, selective angiography, and embolization, etc), it is paramount to have a strong leadership in trauma services at this point in time. It is apparent that with the accepted philosophic approach for nonoperative management, and the desire to “push the envelope” potentially exposing patients to
unnecessary risks, a dedicated leadership by an experienced trauma surgeon is important.