Helling Thomas S, Nelson Paul W, Shook John W, Lainhart Kathy, Kintigh Denise
Department of Surgery, Saint Luke's Hospital of Kansas City, Kansas City, Missouri, USA.
J Trauma. 2003 Jul;55(1):20-5. doi: 10.1097/01.TA.0000071621.39088.7B.
The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients.
This retrospective study assessed patient care parameters over the past 10 years on critically injured patients to detect any difference in outcome whether the surgeon was IH or OH at the time of the trauma team activation (cardiopulmonary instability, Glasgow Coma Scale [GCS] score < 9, penetrating truncal injury). Patients were subcategorized into blunt/penetrating, shock (systolic blood pressure < 90 mm Hg) on arrival, GCS score < 9, Injury Severity Score (ISS) > 15, or ISS > 25. Response was examined from 8 am to 6 pm weekdays (IH) or 6 pm to 8 am weekdays and all weekends (OH). Patient care parameters examined were mortality, complications, time in the emergency department, time to the operating room, time to computed tomographic scanning, intensive care unit length of stay (LOS), and hospital LOS.
For all patients (n = 766), there was no significant difference in any parameters except intensive care unit LOS (IH, 4.90 +/- 7.96 days; OH, 3.58 +/- 7.69 days; p < 0.05). For blunt trauma (n = 369), emergency department time was shorter (99.71 +/- 88.26 minutes vs. 126.51 +/- 96.68 minutes, p < 0.01) and hospital LOS was shorter (8.04 +/- 1.02 days vs. 11.08 +/- 1.15 days, p < 0.05) for OH response. For penetrating trauma (n = 377), shock (n = 187), GCS score < 9 (n = 248), ISS > 15 (n = 363), and ISS > 25 (n = 230), there were no statistically significant differences in any patient care parameter between IH and OH response. For those in most need of urgent operation-penetrating injuries and shock-there were no differences in time to operating room or mortality for OH or IH response.
As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.
外科医生参与创伤患者的初始评估和治疗一直是创伤中心认定的重点。然而，对于一级创伤中心的认证，美国外科医师学会创伤委员会目前并不要求医院内有主治创伤外科医生在场，前提是高级外科住院医师能随叫随到。同样，密苏里州并未强制要求主治创伤外科医生必须在医院，但要求高级（研究生四年级或五年级）外科住院医师能立即做出响应，若主治医生不在医院，则要求其在20分钟内做出响应。然而，一些人认为主治医生在医院值班能为重伤患者提供更好的治疗。
这项回顾性研究评估了过去10年中重伤患者的治疗参数，以检测在创伤团队启动时（心肺功能不稳定、格拉斯哥昏迷量表[GCS]评分<9、穿透性躯干损伤）外科医生在医院内或不在医院时患者的治疗结果是否存在差异。患者被分为钝器伤/穿透伤、入院时休克（收缩压<90mmHg）、GCS评分<9、损伤严重程度评分（ISS）>15或ISS>25。响应时间为工作日上午8点至下午6点（医院内）或工作日下午6点至上午8点以及所有周末（医院外）。所检查的患者治疗参数包括死亡率、并发症发生率、在急诊科的时间、进入手术室的时间、进行计算机断层扫描的时间、重症监护病房住院时间（LOS）以及住院总时间。
对于所有患者（n = 766），除了重症监护病房住院时间外，其他参数均无显著差异（医院内，4.90±7.96天；医院外，3.58±7.69天；p<0.05）。对于钝器伤患者（n = 369），医院外响应时在急诊科的时间更短（99.71±88.26分钟对126.51±96.68分钟，p<0.01），住院总时间也更短（8.04±1.02天对11.08±1.15天，p<0.05）。对于穿透伤患者（n = 377）、休克患者（n = 187）、GCS评分<9的患者（n = 248）、ISS>15的患者（n = 363）以及ISS>25的患者（n = 230），医院内和医院外响应在任何患者治疗参数上均无统计学显著差异。对于那些最需要紧急手术的患者——穿透伤和休克患者——医院外或医院内响应在进入手术室的时间或死亡率方面没有差异。
只要由高级别的医院内外科住院医师进行初始评估和治疗，并且只要主治医生在规定时间内（若在医院外）做出响应以指导关键决策，在这项回顾性研究中并未显示医院内有主治医生能改善重伤患者的治疗效果。
