Acute care surgery is a relatively new surgical specialty that continues to evolve in scope. At this time, it consists of the care of trauma, emergency general surgery, and critically ill surgical patients. A discussion of the evolution of this shift in clinical service is worthwhile not only to capture the historical perspective of these changes but also to shine a spotlight on surgical principles that maximize the success of surgical intervention in acutely ill or injured patients.
The formation of acute care surgery has been shaped and promoted by several powerful forces in surgery and health care in general. Over the last 30–40 years, trauma surgery had developed as its own subspecialty, particularly at large urban trauma centers. In many institutions, trauma surgeons have become the primary surgeons providing trauma care, and general surgeons have concentrated on elective surgeries, often in narrow fields of expertise. This transition has occurred more slowly in other urban medical centers, and even today in smaller suburban and rural hospitals, general surgeons continue to provide care for trauma victims as well as maintaining busy elective practices. Concurrently over the last 20 years, the volume of penetrating trauma, and with it the concomitant surgical case volume, has declined in all but a very few of our country’s largest trauma centers. Additionally, new evidence-based practice guidelines for blunt abdominal trauma have evolved with the result that there are fewer operative interventions. Over this same time frame, trauma surgeons have also assumed the role of surgical intensivists and have taken over managing and providing much of the care to patients in our surgical intensive care units (ICUs). Some of this was driven by the fact that a large proportion of ICU patients in our major trauma centers consisted of trauma patients. Given that trauma-related surgical case volume was in decline, coupled with the fact that most nontrauma surgeons developed an ever-increasing elective practice, these surgeons specializing in trauma care sought ways to adapt their skill set to the surgical needs of patients that would enhance care delivery. Hence the evolution of acute care surgery.
Because trauma surgeons are present in the hospital 24 hours a day in verified Level I and II trauma centers, it was natural for these surgeons to begin managing patients with other emergent and urgent general surgical diseases. Thus emergency general surgery became part of the responsibility of trauma surgeons. In many institutions, the volume of operative cases of patients with emergency general surgical diseases far exceeded the case volume of trauma patients. The combination of all three of these entities—trauma, emergency general surgery, and surgical critical care—has been labeled as acute care surgery.
But what about the general surgeons who used to care for many of these patients? Over the same time frame that acute care surgery was developing, other forces were at play drawing general surgeons away from the full breadth of ...