Chapter 6: Acute Care Surgery

INTRODUCTION

Over the past decade the organization of a new paradigm in the management of acutely ill surgical patients has emerged, one emphasizing surgeons trained in trauma, emergency general surgery, and surgical critical care.¹ The need has been established for a specialized group of surgeons to care for patients with “time sensitive surgical disease” of high acuity, at any time of the day or night, regardless of the patients’ insurance or other social factors.² This comes at a time where we are experiencing an ever-increasing volume of emergency general surgery patients, with estimates revealing in excess of 27.6 million emergency general surgery hospital admission over the past decade.³ To address this need, the specialty of acute care surgery (ACS) was proposed by the American Association for the Surgery of Trauma (AAST). Acute care surgery as initially presented was comprised of trauma, surgical critical care, and emergency surgery. We have redefined the five components of ACS as trauma, surgical critical care, emergency surgery, elective general surgery, and surgical rescue (Fig. 6-1).

ORGANIZATION OF ACUTE CARE SURGERY

In recent years trauma surgery has undergone what some have referred to as an “identity crisis.”⁴ A prevalent opinion among those practicing the specialty was that it was not a sustainable practice model, with low operative volumes, decreasing the median trauma caseload per surgeon to approximately 50 per year.^5,6 Others lament that the days of the trauma surgeon as the master surgical technician have vanished.⁷ In addition to concerns regarding case volumes, the specialty has been plagued by issues with long, unpredictable work hours and high levels of stress, including the high-stake nature of the work.⁸ A 2006 survey of trauma surgeons revealed that 88% of respondents felt that their work caring for the injured was undervalued by society.^5,9 In summary, the majority of trauma surgeons surveyed felt that the specialty required a metamorphosis to remain viable as a career for future surgeons.⁵

Compounding the issue of this disenchantment was the lack of surgical resident interest in pursuing a career in trauma. A 2003 survey of general surgery residents reported that despite 83% of residents desiring fellowship training after residency, only 17% pursued a fellowship in surgical critical care.⁴ Even though the restriction of resident duty hours positively influenced recruitment into general surgery residencies, there clearly existed a need to then encourage these trainees to remain in the “business” of caring for general surgical emergencies. High levels of specialization among residents meant that only a minority of graduates from general surgery residency programs would remain in the true general surgery workforce, addressing the most common surgical emergencies.¹⁰ Overall, the number of general surgeons in the United States ...