Abstract
Emergency medicine is a recognized medical specialty in many countries and most likely will also be in Finland in the near future. Emergency surgery on the other hand is not a widely recognized specialty in Europe, whereas in the United States a paradigm change of a trauma/critical care surgeon and an emergency general surgeon, respectively, has occurred in the last few years merging the two into acute care surgery (1). In most central and eastern European countries orthopaedic traumatologists are mainly responsible for the coordination of trauma care while general surgeons deal with acute non-trauma abdominal emergencies (2, 3). Other emergencies, such as vascular, cardiothoracic, urological and neurosurgical, for example, are managed by respective specialists. Even within the abdomen, some hospitals in the United Kingdom have divided the management of upper gastrointestinal and hepatobiliary surgical emergencies, and colorectal emergencies, respectively, into different hospitals and their specialists (4, 5).
Elective surgery and other interventions are more and more performed by super specialists concentrating in one organ or procedure. Pancreatic or oesophageal surgeons, interventional cardiologists, endoscopists etc. reach sufficient individual volumes that seem to produce better results, and the public expectations are also moving the pendulum towards super specialization. In addition to the problem of serving rural populations for elective procedures not discussed here, the organization of acute care for patients with injuries or acute disease processes is facing increasing challenges also in the developed countries due to aging populations, economic problems, and also because of the fragmentation of the medical profession. It is obvious that acute care can not be built around in-house one-organ specialists available round the clock, every day of the year. Someone has at least to make the assessment and coordinate the care in the front line, in the emergency departments.
One way of looking at acute care is to think it either as a longitudinal or a sequential process. In a longitudinal process, same person, team or specialty looks after the patient from the arrival to the emergency department thorough interventions, intensive care and all the way to discharging the patient from the ward. Major trauma care is a good example with trauma team members in the emergency department, trauma surgeons/intensivists and ward physicians being the same. In a purely sequential model, each crucial step of the treatment process (emergency department care, surgical or other interventions, intensive care) is managed by different persons with different training. Obviously, some form of hybrid model is closest to the existing models in most places.
The majority of patients in the emergency departments, at least in Finland, come either directly from home because of an acute symptom or injury, or from primary health care system where they have been seen by a general physician who has formulated a working diagnosis that presumably requires specialty care. The function of the emergency department is to transform the symptom into a diagnosis (if not already known) and organize the treatment accordingly. Some patients can be managed in the emergency department and discharged from there, others will be admitted to the hospital and the responsibility transferred to the treating clinician in an appropriate specialty.
A minority of patients arrive to the emergency department with abnormal physiology, sometimes in critical condition and usually transported by the emergency medical system. Simultaneous assessment and stabilizing treatment supporting vital organ functions, started already by the prehospital care providers continues in the emergency department. If the definitive care of the problem requires for example, emergency surgery or interventional radiology, the patient is directed to the care of those specialists.
Another factor that should be taken into account is that acute primary health care and hospital emergency services are at least in Finland increasingly being merged into joint or combined facilities where the patients can come “through one door” in with a symptom and will then be evaluated by an appropriate health care professional. Initial experiences from joint acute care services are overwhelmingly positive. Finally, many especially elderly people have multiple health problems, a magnitude of medications and often a combination of disorders that involve many of the organ- or discipline-based specialties. A properly trained physician can make a better judgment of the priorities, overall treatment strategy and goals than an anatomically-orientated specialist focusing only on the one, pressing target at hand.
Where's the beef then? Physicians interested, committed and specialized in the work carried out in the emergency departments are the best people to do it, both the diagnostic work out of the majority of patients as well as dealing with the initial response to the deranged physiology in critically ill or injured patients. A structured literature study identified 25 studies that assessed the effects of introducing a specialty in emergency medicine in comparison with emergency treatment provided by other doctors (6). Having emergency medical specialists improved the care for patients who needed life-saving interventions by safely performing procedures that have traditionally been considered exclusive parts of other specialties, e.g. intubation. Moreover, the admission process was more efficient leading to overall improvement of care for acutely ill patients.
Should surgeons work in the emergency department, and if so, what specialists? The majority of patients in emergency departments requiring surgical decision making and acute intervention have either musculoskeletal injuries or acute abdominal pain. Vascular and urological problems also increase with advancing age. However, it seems impractical to have orthopaedic surgeons, digestive surgeons, vascular surgeons, urologists etc. work in the emergency departments doing primary clinical examinations to patients, most of whom do not need acute surgical intervention. With the exception of trauma teams or extended acute surgical teams (trauma team concept extended to other life-threatening conditions such as ruptured abdominal aortic aneurysms), the best way to utilize the expertise of surgeons is to concentrate on the essence of what they are trained for: operate and care for surgical patients. This of course includes the decision making process of who and when to operate. For this they need to come to the emergency department when a consultation for a specific patient is needed, but not do the main bulk of their work there.
What kind of surgeons, then, should treat emergency surgery patients? Elective specialists claim to be experts in the surgical problems of “their” organs. However, evidence shows that properly trained emergency surgeons can perform emergency surgery as well as elective organ specialists (7). Besides, emergency surgeons are more familiar in dealing with acutely deranged physiology and have more experiences in applying principles of damage control surgery when needed. Furthermore, the majority of emergency surgical interventions are straight-forward, such as appendectomy, explorative laparotomy, management of ankle or hip fractures etc. Highly demanding interventions such as complex neuro- or cardiac surgery are not needed every day except in very large centres, and in most cases these specialists, who are mostly needed during day-time elective work, could be on-call at home with an obligation to be available at the hospital within 30 minutes, for example.
It has also been shown that following the model of regionalized trauma care, regionalizing care for non-traumatic surgical emergencies improves the quality of care and saves scarce resources (8 –10).
Do we need surgical specialists in-house? Absolutely, at least in specialties with large volumes. In-house attendings save money (11). Since it is not realistic to train one surgeon to manage all surgical emergencies, the natural dividing line goes between musculoskeletal and visceral surgery. An orthopaedic surgeon and a (visceral) emergency surgeon “hunting in pairs” would be the most functional combination. They could manage the bulk of emergency surgical interventions and start the life-saving surgery in those that need specialist help easily called from home, such as vascular surgeons, urologists, cardiothoracic or neurosurgeons.
Finally, all emergency surgical interventions need not be performed at night, and can safely be postponed to the next day (1, 12, 13). With proper urgency coding for emergency surgical patients and sufficient day-time emergency surgery table capacity, night-time work can be minimized. Extending the day into the evening can provide flexible working hours for staff and surgeons while avoiding non-essential work to performed at night because of capacity problems during the day. When the majority of emergency surgery is performed during office hours, surgeons specialized in emergency surgery can mainly work during day-time, provided that the number is sufficient and regionalized care produces enough patients (14).
In summary, the ingredients for a good beef are: regionalized acute care system, specialties in emergency medicine and emergency surgery, large volumes of both, one-door emergency departments, and well-running emergency surgical system with the majority of acute interventions performed outside the dark hours of the night.