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April 1, 2013 Volume 77, Number 4
The Role of the Anesthesiologist in Management of Patients Following Traumatic Injury: Moving From Minimum Standards to Achieving the Status of Perioperative Physician Maureen McCunn, M.D., M.I.P.P., F.C.C.M.


Defining the Burden
Trauma is the third-leading cause of death in the U.S. and the leading cause of death in patients under the age of 44 years. The American College of Surgeons (ACS) Committee on Trauma defines minimum standards for anesthesiology in Level I ACS-verified trauma centers: anesthesiology services must be promptly available for emergency operations and for airway problems. These anesthesia services must be available in-house 24 hours a day; but this requirement can be met by senior residents and CRNAs – with faculty “promptly available and present for all operations.” This is clearly an opportunity to expand our scope of practice from O.R.-associated staff to a presence that includes the entire “chain of injury”: from pre-hospital through acute care, and on to rehabilitation.

Many patients have multiple trauma-related O.R. procedures during their initial hospitalization that are treated by the trauma service (e.g., “damage control,” with multiple returns to the O.R. for staged abdominal closure); while other patients have multiple procedures by different services, all related to their initial surgery (i.e., decompressive craniotomy or spinal stabilization, ocular repair for globe rupture, fasciotomy, fracture fixation, tracheostomy/percutaneous gastrostomy tube, skin grafts). Acute and chronic pain management expertise, including provision of regional anesthesia, has unique and clearly beneficial effects for patients following trauma. Many other trauma patients are readmitted for further procedures when swelling has decreased in the surgical field (i.e., pilon fracture repair or facial fracture repair). A trauma patient may require cardiopulmonary bypass (e.g., pulmonary vein injury) or ECMO (for severe pulmonary contusions/ARDS). Anesthesiologists care for these trauma patients at every stage of their resuscitation and recovery, and occasionally, care for patients who meet criteria for death by neurological criteria during organ procurement.

EACH of these patients requires anesthetic management during his or her operative case. Critically injured patients may also be cared for by anesthesiologists with certification in critical care and by anesthesiologists with certification in pain management, or those with additional training in regional anesthesia. These traditional roles of specialty and subspecialty trained anesthesiologists make us invaluable to the operation of any trauma center. But are we under-valued?

An Opportunity to Expand Our Role
ASA suggests that the “role of the anesthesiologist extends beyond the operating room.” Can we make this ideal a reality, given the current health care crisis and the competition from multiple specialties to provide care for patients?

An ASA survey with responses from >2,000 anesthesiologists who care for trauma patients demonstrated that only about one-half of anesthesiologists attend ED resuscitations (Figure 1) and only for airway management; they are not actively engaged in the resuscitation at all (Figure 2). Thirty-four percent of respondents do not ever go to the trauma bay – suggesting that emergency medicine physicians have demonstrated airway management competence for patients with acute airway compromise due to trauma: shock, facial fractures, severe traumatic brain injury, unstable cervical spine injury, penetrating trauma to the neck, etc. This is one example of our failure to engage with trauma surgeons, demonstrate our expertise and expand our scope of practice – based upon the expertise that we already possess.

Successful trauma anesthesiologists have demonstrated leadership roles in some “non-traditional” positions for our specialty: as directors of trauma center ICUs; quality management program directors; pre-hospital flight crew, with training of both ground and flight paramedics in airway and resuscitation skills; staffing pre-hospital emergency response teams to provide anesthesia during extrications or amputations; running trauma simulation-centers; heading up emergency preparedness/disaster management committees; and as directors of trauma rehabilitation ICUs. We can also play an active role in helping patients and families with end-of-life care in these tragic, unexpected situations where palliative care is beneficial. In the U.K. and in many European countries, anesthesiologists are the pre-hospital care providers and the trauma resuscitation leaders in the hospital, with total domain in the ICU.

The ACS has expanded its scope of practice – and its billing success – by developing the specialty of Acute Care Surgery; these practitioners are primarily trauma surgeons who also cover emergency surgeries (from the ED or for in-patients) thereby achieving two goals:
1. They are the experts in the management of hemodynamically compromised patients; and
2. Their presence in the hospital 24/7 allows the primary service to stay at home and to prepare for a busy elective O.R. schedule.

An Acute Care Anesthesiologist is an analogous clinician who could perfectly manage high-risk critically-ill patients with trauma, sepsis and massive transfusion/resuscitation needs.

Current trends to improve the hospital care of patients focus on outcomes not only related to physical well-being but also on patient and family satisfaction, with areas related to pain control, communication between physicians and patients, and coordination of care. How many of your trauma patients or their families know your name and understand your role in their care?

The ASA Committee on Trauma and Emergency Preparedness (COTEP) is committed to supporting all anesthesiologists in the current management strategies of trauma resuscitation, emergency preparedness and disaster management. A national survey of anesthesiologists who provide care to trauma patients demonstrated that most practitioners are not up to date on current practice guidelines for management of traumatic brain injury, preferred intubation techniques (in stable versus unstable patients), massive transfusion or educational initiatives (Figures 3-7). Many rely upon their training during residency – some as much as 20 years previously – to guide their care. Most of the respondents (71 percent) to this survey desire more ASA-sponsored trauma education. Many of these trauma-management guidelines have been developed with little input from anesthesiologists.

As anesthesiologists, we have unique skills in airway management, resuscitation, sedation, intensive care and pain management. Trauma patients need us, throughout their course of care. We should seek to be the perioperative physicians of choice for this complex patient population. We should aim to become the acute care, perioperative and trauma anesthesiologists who make a difference in the life or death of patients following traumatic injury. Our time is now.



Maureen McCunn, M.D., M.I.P.P., F.C.C.M. is an Assistant Professor, Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia.

References:
1. Trauma programs: consultation/verification programs. American College of Surgeons website. http://www.facs.org/trauma/verificationhosp.html. Revised June 6, 2012. Accessed February 26, 2013.
2. Napolitano LM, Fulda GJ, Davis KA, et al.; Critical Care Committee of the American Association for the Surgery of Trauma. Challenging issues in surgical critical care, trauma, and acute care surgery. J Trauma. 2010;69(6):1619-1633.
3. The Joint Commission website. http://www.jointcommission.org/. Accessed February 26, 2013.
4. American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness. Trauma and emergency preparedness. ASA website. http://www.asahq.org/for-members/about-asa/asa-committees/committee-on-trauma-and-emergency-preparedness.aspx. Accessed February 26, 2013.
5. Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 suppl 4):S333-S340.
6. Bratton SL, Chestnut RM, Ghajar J, et al.; Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma. 2007; 24(suppl 1):S87-S90.

7. McCunn M, Vavilala M, Speck RM, Dutton RP. ASA trauma care survey: anesthesiology practices demonstrate poor guidelines implementation and need for education [abstract A732]. Presented at: Anesthesiology 2011; October 15-19, 2011; Chicago, IL. http://www.asaabstracts.com/strands/asaabstracts/searchArticle.htm;jsessionid=3C9A4F66FCEE46E51B9F0C14F0CF2DA8?index=0&highlight=true&highlightcolor=0&bold=true&italic=false. Presented October 16, 2011. Accessed February 26, 2013.


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