Trauma remains a surgical disease from cradle to grave

ORIGINAL ARTICLE

Trauma remains a surgical disease from cradle to grave Shannon N. Acker, MD, Robert T. Stovall, MD, Ernest E. Moore, MD, David A. Partrick, MD, Clay Cothren Burlew, MD, and Denis D. Bensard, MD, Aurora, Colorado

A dramatic rise in nonoperative management of many blunt and some penetrating traumatic injuries has occurred during the past four decades. This trend has lead some to suggest that trauma is no longer a surgical disease. We questioned what role the trauma surgeon plays in the care of the injured patient. We hypothesized that surgical intervention and judgment are still often required in both injured children and adults. METHODS: We queried the trauma databases at two academic Level I trauma centers (adult and pediatric) for all patients admitted for trauma who underwent an inpatient operation between July 1, 2009, and June, 31, 2013, as well as those patients with ‘‘potentially operative injury.’’ Potentially operative injury was defined as the presence of liver or splenic laceration of any grade or hemothorax in patients who did not undergo an inpatient operation. For analysis, we divided patients into groups based on age. We differentiated infants (0Y1 years), toddlers (2Y5 years), school-aged children (6Y12 years), adolescents (13Y15 years), young adults (16Y21 years), adults (22Y40 years), middle-aged adults (41Y50 years), late middle-aged adults (51Y64 years), and elderly (965 years). Data collected included demographic information and number of operations performed in each patient based on surgical service (neurosurgery, trauma surgery, orthopedic surgery, and other surgical services). RESULTS: During this 4-year study period, 11,611 patients were admitted to the trauma service, 6,334 (54.6%) of whom underwent an inpatient operation and another 492 (4.2%) of whom had potentially operative injury. Across all age groups, orthopedic procedures accounted for the greatest percentage of inpatient procedures (970% of inpatient operations performed). Neurosurgical intervention accounted for less than 10% of inpatient surgical interventions, and general surgical procedures performed by trauma surgeons accounted for 17.1%. More than half of all general surgical procedures were performed in the patients who required a hospital stay of more than 7 days (67.2% among all patients). CONCLUSION: More than half of patients admitted following traumatic injury require operative intervention. This rate remains stable across all age groups. Our data emphasize the continued need for surgeons to stay engaged in the care of the trauma patient, particularly those most critically injured patients who will require prolonged hospital stay. (J Trauma Acute Care Surg. 2014;77: 219Y225. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. Care management study, level IV. KEY WORDS: Operative trauma; demographics; trauma surgeon. BACKGROUND:

A

dramatic rise in nonoperative management of many blunt and some penetrating traumatic injuries has occurred during the past four decades, including management of liver and spleen injury. This is exemplified by the publication of more than 2,000 articles on ‘‘nonoperative management trauma’’ during this time. This trend has lead some to suggest that trauma is no longer a surgical disease.1,2 This sentiment seems to be conveyed most strongly in the emergency medicine literature,1,2 in which one can find articles titled ‘‘Trauma is Not a Surgical Disease’’ and ‘‘Is Pediatric Trauma Really a Surgical Disease?’’ Some groups have even gone as far as to promote the elimination of surgeons from the evaluation of the injured patient or even of the need to transfer a patient to a trauma center.2,3 Green and Rothrock2 argue that the only unique role of the surgeon is to operate, and the decision of whether to operate ‘‘remains exceedingly straightforward I Observe with serial evaluations when hemodynamically stable; operate when not.’’2 Given the growing school of thought that says that the role of the surgeon in trauma Submitted: March 7, 2014, Revised: April 24, 2014, Accepted: May 6, 2014. From the Department of Pediatric Surgery (S.N.A., D.A.P.), Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora; and Department of Surgery (R.T.S., E.E.M., C.C.B., D.D.B.), Denver Health Medical Center, Denver, Colorado. Address for reprints: Shannon N. Acker, MD, University of Colorado School of Medicine, 12631 E 17th Ave, C302, Aurora, CO 80045; email: shannon.acker@ ucdenver.edu. DOI: 10.1097/TA.0000000000000363

can be relegated to emergency medicine providers, hospitalists, and intensivists, with consultation of subspecialists when necessary, we questioned what role the trauma surgeon plays in the care of the injured patient. We hypothesized that surgical intervention and judgment are still often required in both injured children and adults.

PATIENTS AND METHODS Following approval of the Colorado Multiple Institutional Review Board, we queried the trauma databases at two academic Level I trauma centers (Children’s Hospital Colorado, American College of SurgeonsYcertified Level I pediatric trauma center, and Denver Health Medical Center, American College of SurgeonsYcertified Level I adult/Level II pediatric trauma center). These two centers serve as referral trauma centers for a multistate region. We reviewed all patients admitted for trauma at either institution who underwent an inpatient operation that was performed in the operating room between July 1, 2009, and June 31, 2013, as well as those patients with ‘‘potentially operative injury.’’ Potentially operative injury was defined as the presence of liver or splenic laceration of any grade or hemothorax in patients who did not undergo an inpatient operation. In most cases, patients were admitted to the trauma service under the care of an acute care or pediatric

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G0.0001 G0.0001 G0.0001 G0.0001 52.6 (288) 11.4 319 (61.6%) 94.5 (518) 27.6 (234) 12.8 206 (25.2%) 96.2 (817) 25.60 12.1 96 (13.9%) 97 (690) *Percentage based on those who survived to hospital discharge; comparisons between groups were performed with one-way ANOVA.

22.5 (353) 11.8 162 (10.6%) 97.8 (1,535) 22.9 (136) 13.4 62 (10.7%) 97.1 (578) 22.3 (63) 9.1 9 (3.2%) 99.3 (281) 37.2 (337) 8.6 9 (1%) 99.5 (900) 44.5 (297) 6.4 16 (2.4%) 99.4 (663) 43.7 (90) 10.1 14 (7.0%) 97.6 (201) 31.3 (1,982) 10.6 974 (15.7%) 97.6 (6,183)

0.61 0.79 0.78 0.76 0.87 0.61 0.72 0.72 0.41 0.73

1,160 47.2 (548) 1,590 53.4 (849) 1,338 53.1 (711) 2,972 52.8 (1,570) 1,092 54.5 (595) 548 51.6 (283) 1,348 67.1 (905) 997 66.9 (667) 566 36.4 (206) 11,611 54.6 (6,334)

Age 6Y12 Age 2Y5 Age 0Y1 All Patients

TABLE 1. Demographic Characteristics by Age Group

During this 4-year study period, 11,611 patients were admitted to the trauma service, 6,334 (54.6%) of whom underwent an inpatient operation and an additional 492 patients (4.2%) of whom had a potentially operative injury. A total of 8,472 inpatient procedures were performed, for a mean of 1.3 inpatient operations per patient undergoing intervention. Demographic characteristics of the patients who required an inpatient operation for all age groups are summarized in Table 1. The median age of the patients requiring an inpatient operation was 27 years (range, 0Y102 years), and a total of 4,352 (68.7%) were male. The mean (SD) ISS was 10.6 (10.0). Survival to hospital discharge was 97.6%. The female patients made up less than 30% of operative trauma patients in all age groups except for the very young (G12 years) and the elderly. ISS also varied on the basis of age; the lowest mean ISS was seen among children younger than 15 years. Correspondingly, the highest survival rates were also seen among the patients younger than 15 years (999%). The proportion of patients requiring discharge to a rehabilitation center also increased with age, with less than 10% of the children requiring rehabilitation, while 61.6% of the elderly patients who survived to hospital discharge required rehabilitation. The percentage of patients admitted to the trauma service who required an inpatient operation remained fairly consistent at approximately 50% for all age groups, except for infants (36.4%) as well as toddlers and school aged children (66.9% and 67.1%, respectively). Data regarding trends in hospitalization with respect to age are presented in Table 2. The median length of hospital stay increased with age, from a median of 1 day among infants,

Age 13Y15

RESULTS

Total patients admitted Patients requiring an operation, % (n) Operations performed per admitted patient Female, % (n) ISS Discharge to rehabilitation* Survival to hospital discharge, % (n)

Age 16Y21

Age 22Y40

Age 41Y50

Age 51Y64

Age 9 65

p

surgeon. Data were obtained from the prospective trauma databases maintained at each institution. At our institution, it is standard practice to perform elective tracheostomies, placement of gastrostomy tubes, intracranial pressure monitoring, and placement of external ventricular drains at the bedside in the intensive care unit (ICU) and not in the operating room. For this reason, our data exclude most of these ‘‘bedside’’ procedures. For analysis, we divided the patients into groups based on age. We differentiated infants (0Y1 years), toddlers (2Y5 years), school-aged children (6Y12 years), adolescents (13Y15 years), young adults (16Y21 years), adults (22Y40 years), middle-aged adults (41Y50 years), late middle-aged adults (51Y64 years), and elderly (965 years). Data collected included number of operations performed in each patient based on surgical service (neurosurgery, trauma surgery [labeled as general surgical procedures including thoracic, abdominal, or vascular procedures], orthopedic surgery, and other surgical services), age, sex, Injury Severity Score (ISS), hospital and ICU length of stay (LOS), discharge disposition, and mortality rate. Statistical comparisons were made between age groups using one-way analysis of variance (ANOVA) where appropriate to compare continuous variables. Adjustment for multiple comparisons was used. A p value of less than 0.05 was considered statistically significant.

G0.0001

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Hospital LOS, median (range), d LOS 9 7 d, % (n) ICU LOS, median (range), d No. OR visits, mean Requiring 91 operation, %

*Comparisons between groups were performed with one-way ANOVA. OR, operating room.

1 (1Y88) 5 (33) 5 (1Y67) 1.16 5.80

1 (1Y67) 6.2 (56) 2 (1Y39) 1.08 3.30

1 (1Y32) 12 (34) 3 (1Y29) 1.08 4.20

2 (1Y88) 27.6 (164) 2 (1Y29) 1.18 9.50

4 (1Y158) 27.8 (437) 2 (1Y36) 1.59 24.40

4 (1Y113) 31.5 (224) 3 (1Y52) 1.44 20.80

5 (1Y107) 41.3 (351) 3 (1Y56) 1.46 22.20

6 (1Y128) 41.6 (228) 3 (1Y45) 1.48 21.30

6 (1Y85) 24.7 (1567) 3 (1Y45) 1.3 13.70

G0.0001 G0.0001 0.004 G0.0001 G0.0001

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3 (1Y158) 19.4 (40) 3 (1Y67) 1.3 15.4 (976)

Age 0Y1 All Patients

TABLE 2. Trends in Hospital Course by Age Group

Age 2Y5

Age 6Y12

Age 13Y15

Age 16Y21

Age 22Y40

Age 41Y50

Age 51Y64

Age 9 65

p*

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toddlers, and school-aged children to a median of 6 days among late middle-aged and elderly patients (p G 0.0001). Similarly, the percentage of patients requiring a hospital stay of more than 7 days increased with age, from a low of 5% among infants to 41.6% among patients aged 51 years to 64 years (p G 0.0001). Of note, only 24.7% of the elderly operative trauma patients required an inpatient stay of more than 7 days. However, this trend was not seen with median ICU LOS, which ranged from 2 days to 3 days in all groups except for infants (median ICU LOS, 5 days). Also increasing with age was the mean number of inpatient operations per operative trauma patient, which remained less than 1.2 operations per patient for children younger than 15 years and ranged from 1.3 to 1.6 for adults (p G 0.0001). Correspondingly, the percentage of patients requiring more than one operation during their hospitalization increased with age. Less than 10% of all children required more than one operation, while this remained greater than 20% for all adults except the elderly (13.7%) (p G 0.0001). The number of operations performed by each surgical subspecialty by age group and the relative proportion of inpatient operations performed by each specialty in each age group are depicted in Table 3. These trends in relative contribution to inpatient operations by surgical specialty based on patient age group are shown in Figure 1. Across all age groups, orthopedic procedures accounted for the greatest percentage of inpatient procedures, with peaks among toddlers and school-aged children as well as the elderly (970% of inpatient operations performed). Neurosurgical intervention remained fairly constant across all age groups, accounting for less than 10% of inpatient surgical interventions. The highest rates of neurosurgical intervention were seen at the extremes of age (infants and the elderly, 99% of all inpatient procedures). General surgical procedures performed by trauma surgeons accounted for 17.1% of all inpatient operative trauma procedures. Trauma surgical intervention was highest among infants and adults, with few toddlers, children, adolescents, and elderly requiring general surgical intervention. Procedures performed by other surgical subspecialists such as plastic surgeons; ear, nose, and throat specialists; or oral maxillofacial surgeons were grouped together and account for 14.5% of all inpatient surgical procedures. These interventions decreased steadily with age from approximately 20% of all procedures between ages 0 years and 15 years to only 6.1% of procedures in the elderly. Figure 2 demonstrates rates of operative intervention among the patients who required hospital LOS of more than 7 days with regard to patient age. More than half of all general surgical procedures were performed in the patients who required a hospital stay of more than 7 days among all age groups (67.2% among all patients). Rates were highest at the extremes of age, with more than 80% of trauma surgical procedures in infants and adults older than 51 years, occurring in the patients with hospital LOS of more than 7 days. Similar trends were seen for neurosurgical procedures. More than 50% of all neurosurgical procedures were performed in patients with hospital LOS of more than 7 days for all age groups except for toddlers (48.6%) (73.2% among all patients). Rates remained greater than 70% for infants and all

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TABLE 3. Rate of Operative Intervention by Surgical Subspecialty and Age Group All Patients

Age 0Y1

Age 2Y5

Age 22Y40

Age 41Y50 Age 51Y64

Age 9 65

Total no. operations performed 8,839 All operations that were GS 17.1 (1,507) operations, % (n) All operations that were NS 7.1 (623) operations, % (n) All operations that were 61.4 (5,424) orthopedic operations, % (n) All operations that were 14.5 (1,285) performed by other surgical services, % (n)

243 18.5 (45)

781 6.3 (49)

989 6.3 (63)

343 8.8 (30)

1,024 21.6 (221)

2,413 26.4 (637)

1,079 20.3 (219)

1,336 16.2 (217)

725 10.8 (78)

11.5 (28)

4.7 (37)

2.3 (23)

6.4 (22)

7.5 (77)

7.4 (178)

8.2 (88)

7.6 (101)

9.5 (69)

49.4 (120) 71.8 (561) 72.4 (716)

63.6 (218)

56.4 (577)

52.0 (1,255)

57.5 (620)

64.8 (865)

73.7 (534)

20.6 (50)

21.3 (73)

14.6 (149)

14.2 (343)

14.1 (152)

11.5 (153)

6.1 (44)

Age 6Y12 Age 13Y15 Age 16Y21

17.2 (134) 18.9 (187)

GS, general surgery; NS, neurosurgery.

age groups older than 16 years. The proportion of orthopedic operations performed in the patients with hospital LOS of more than 7 days ranged from 4.5% to 51% and increased steadily with age (34.8% among all patients). Similarly, the proportion of surgical procedures performed by other specialists was only 32.1%, ranging from less than 30% among groups younger than 21 years and increased steadily to 75% in the elderly.

Figure 1. Percentage of all operations performed in the cohort of admitted trauma patients in terms of surgical subspecialty. The figure demonstrates that, across all age groups, orthopedic procedures accounted for the greatest percentage of inpatient procedures, with peaks among toddlers and school-aged children as well as the elderly (970% of inpatient operations performed) (shown in blue). Neurosurgical intervention remained fairly constant, with peaks at the extremes of age (infants and the elderly, 99% of all inpatient procedures), across all age groups. Neurosurgical procedures are shown in red and account for less than 10% of all inpatient procedures. General surgery procedures accounted for 17.1% of all inpatient operative trauma procedures. General surgical intervention was highest among infants and adults, with few toddlers, children, and adolescents requiring general surgical intervention (shown in orange). Procedures performed by other surgical subspecialists were grouped together (shown in green) and account for 14.5% of inpatient surgical procedures. These interventions decreased steadily with age from approximately 20% of all procedures from age 0 years to 15 years to only 6.1% of procedures in the elderly. 222

Within the trauma database, every coded procedure is listed. A total of 1,507 separate general surgical operations were performed with 2,458 separate procedures documented. Of these 3,278 procedures, 93 (2.8%) were gastrostomy tube placement and 146 were chest tube placement (4.5%). A total of 1,099 involved thoracotomy, thoracoscopy, or median sternotomy (33.5%); 450 were vascular procedures (13.7%); and 1,353 (41.2%) involved laparotomy or laparoscopy. The remaining procedures included bronchoscopy, endoscopy, or esophageal procedures. Six hundred twenty-three neurosurgical operations were performed with 1,884 separate

Figure 2. Variation in proportion of inpatient operations by surgical specialty among patients with hospital LOS of more than 7 days. The figure demonstrates the relative proportion of operations by each surgical subspecialty that are performed in patients who require more than 7 days of hospital stay. This figure demonstrates that more than 50% of general (shown in orange) and neurosurgical (shown in red) procedures are performed in patients who require more than 7 days of hospital LOS among all age groups. Fewer than 10% of orthopedic operations are performed in children (G12 years) with a hospital stay of more than 7 days. The relative proportion of orthopedic procedures performed in patients with hospital LOS of more than 7 days increases with age, which may be reflective of the fact that the number of patients requiring more than 7 days of hospital stay also increases with age. The same can be said for procedures performed by other surgical specialties (shown in green). * 2014 Lippincott Williams & Wilkins

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*Percentage based on those who survived to hospital discharge; comparisons between groups were performed with one-way ANOVA. IQR, interquartile range.

612

28 (4.6) 17 (60.7) 19.4 13 (46.4) [2] 9 (32.1) [2] 13 (46.4) 4.5 (1Y8.75) 3 (1.5Y4) 6 (21.4) 17 (60.7) 51 (6.9) 41 (80.4) 24.8 19 (37.3) [2] 23 (45.1) [2] 16 (31.3) 2 (1Y5) 1 (1Y3) 0 (0) 37 (72.5) 54 (10.9) 148 (10.6) 47 (7.5) 41 (75.9) 115 (77.7) 39 (83.0) 20.1 21.1 26.5 31 (57.4) [3] 83 (56.1) [2] 24 (51.1) [2] 22 (40.7) [2.5] 51 (34.5) [2] 19 (40.4) [3] 9 (16.7) 37 (25.0) 19 (40.4) 2 (1Y4) 2 (1Y4) 2 (1Y4) 2 (1Y2) 2 (1Y3) 2 (2Y3) 2 (3.7) 2 (1.4) 1 (2.1) 44 (82.5) 109 (73.6) 30 (63.8) 39 (14.7) 30 (76.9) 13.4 13 (33.3) [2] 28 (71.8) [3] 1 (2.6) 2 (2Y4) 1 (1Y2) 1 (2.6) 37 (94.9) 75 (16.9) 51 (68.0) 12.8 39 (52.0) [3] 40 (53.3) [3] 0 (0) 3 (2Y4) 1 (1Y1) 2 (2.7) 74 (98.7) 492 (9.3) 14 (3.9) 36 (10.9) 365 (74.2) 9 (64.3) 22 (61.1) 19.8 20.8 19.7 256 (52.0) [2] 11 (78.6) [2] 23 (63.9) [3] 216 (43.9) [2] 7 (50) [2] 17 (47.2) [3] 96 (19.5) 0 (0) 1 (2.3) 2 (1Y4) 4 (2Y11.5) 3 (2Y4) 2 (1Y3) 2 (1Y6.5) 1 (1Y3) 18 (3.7) 1 (7.7) 3 (8.3) 395 (80.3) 13 (93) 34 (94.4)

Age 51Y64

741 627

Age 41Y50 Age 22Y40

1,402 497

Age 16Y21 Age 13Y15

265 443

Age 6Y12 Age 2Y5

330 360

Age 0Y1 All Patients

TABLE 4. Characteristics of Potentially Operative Trauma Patients by Age

Our aim was to describe the trends in operative interventions performed throughout a patient’s life span and to document the role of the trauma surgeon in the care of the injured patient. Our data indicate that more than one half of the patients admitted to trauma centers following acute injury required at least one inpatient surgical procedure and another 10% of the patients had a potentially operative injury requiring ongoing monitoring by a trauma surgeon. These rates remained stable across all age groups. Orthopedic procedures accounted for greater than 50% of inpatient procedures among all age groups, except infants. This trend changed markedly when considering only the patients who required at least a 7-day hospital stay. More than 50% of all general and neurosurgical procedures were performed among this group of patients, another trend that was consistent across all age groups. More importantly, these data underscore the essential role of the trauma surgeon in the care of the injured patient, as more than half of all admitted patients required at least one inpatient operation. The patients with potentially operative injuries, which require ongoing monitoring by the trauma surgeon, made up nearly 10% of the admitted trauma patients who did not require an operation. While most operations are performed by orthopedic surgeons, that is not the case when considering the most severely injured patients with a hospital stay of more than 7 days, in whom most of the general and neurosurgical procedures were performed. These data highlight the fact that the role of the trauma surgeon is not limited to the initial evaluation in the emergency department but extends throughout the hospital stay. The input of the trauma surgeon is essential to determining the optimal time for operative intervention based on the patient’s complete constellation of injuries. Our data highlight that, in the most severely injured trauma patients, identified here as those requiring more than 7 days of hospital stay, the role of the trauma surgeon, as well as the neurosurgeon, should not be underscored. The most consistent trend demonstrated is that length of hospital stay and number of operative interventions increased with increasing patient age. This corresponded to a small decrease in survival to hospital discharge that was seen

5,277

DISCUSSION

Total patients admitted who did not undergo operation Patients with potentially operable injury, n (%) Male, n (%) ISS, mean Liver injury, n (%) [median grade] Spleen injury, n (%) [median grade] Hemothorax, n (%) LOS, median (IQR) Length of ICU stay, median (IQR) Discharge to rehabilitation,* n (%) Survival to hospital discharge, n (%)

Age 9 65

p

procedures documented, 115 of which were intracranial pressure or external ventricular drain placement (6.1%). A total of 1,222 procedures involved craniotomy or craniectomy (64.9%), 334 were spinal procedures (17.8%), 191 involved peripheral nerve repair (10.1%), and the remaining procedures included ventriculoperitoneal shunt or needle biopsy procedures. Descriptive characteristics of the patients with potentially operable injury are shown in Table 4. These patients made up 9.3% of all admitted trauma patients who did not undergo an operation. These patients had higher ISS (19.8 potentially operative vs. 10.6 operative; p G 0.0001) and lower overall survival (80.3% potentially operative vs. 97.6% operative; p G 0.001). Survival among the potentially operative patients decreased with increasing patient age, from greater than 90% among children down to only 60.7% among the elderly.

G0.0001 0.2 G0.0001 0.26 0.02 G0.0001 0.08 G0.001 G0.0001 G0.0001

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with increasing age and increasing need for inpatient rehabilitation among those who survived to hospital discharge. While it should be emphasized that overall survival for all trauma patients requiring an inpatient operation was excellent (97.6% overall), our data demonstrate that, as patients age, the LOS and the number of operations increase among those patients requiring at least one inpatient operation. Increasing LOS with age was also seen among the patients with potentially operative injury. This is consistent with previous data, which demonstrated an increased mortality rate and worse short- and long-term prognosis among elderly patients following trauma.4,5 Interestingly, the rate of operative intervention was highest among young children and actually decreased slightly as patients aged. These data highlight the fact that the care of the trauma patient extends far beyond the initial evaluation that occurs in the emergency department, with most of the trauma patients requiring operative intervention. These patients often require prolonged hospital stay with multiple operative interventions. Another 10% of patients who do not require operative intervention have potentially operative injuries that require ongoing monitoring. While some suggest that the surgical care of the injured patient is important only at the time of presentation to determine whether a patient requires an operation,2 our data demonstrate that this is not accurate. The current data add to the growing literature demonstrating the unique and irreplaceable role of the surgeon in caring for the injured patient.6Y8 The presence of an attending trauma surgeon has been shown to reduce resuscitation time and time to incision for emergent operations8 as well as decreased hospital costs when a trauma surgeon is in-house.9,10 Published data have also indicated the benefit of general surgery resident involvement in trauma care, leading to improved efficiency of trauma care delivery.11 In addition, Leeper et al.6 recently found that there was an increased rate of missed injury when the trauma team leader is from a nonsurgical background. Although cause could not be delineated from their data, these authors speculate that the lack of dedicated trauma training that includes both inpatient and follow-up care of the injured patient accounts for the differences.6 Our data provide further evidence that the role of the trauma surgeon is not limited to the initial evaluation and resuscitation but extends throughout the patient’s hospitalization. This point warrants emphasis because most of the general and neurosurgical procedures described here were not emergent procedures performed on patient arrival. Most were performed in the patients who required prolonged hospitalization. These data highlight the fact that surgical judgment is an overarching component of surgical care that extends throughout the hospital stay. This judgment begins with management of the patient’s initial sympathetic response to injury at presentation and is needed throughout the patient’s hospital stay. As with all data collected in a retrospective fashion, our data are inherently limited. We did not differentiate between procedures performed emergently and those that were performed nonemergently. For this reason, conclusions regarding rates of emergent operative intervention cannot be made. In addition, procedures performed by each surgical subspecialist were not differentiated but were instead grouped as a whole. We chose to include all procedures performed in the 224

operating room, which did include a small number of relatively minor procedures, such as gastrostomy or chest tube placement. While these procedures do not require trauma surgeon expertise, they make up a small percentage of the procedures reported here and do not detract from the overall trends documented by the data. Additional limitations include the fact that it is difficult to account for the value of surgical monitoring among patients who do not require operative intervention. We have attempted to account for this by including those patients with potentially operative injury. Despite these limitations, our data remain valuable in their unique description of the demographics of operative trauma. More than half of patients admitted following traumatic injury require operative intervention, and another 10% of those not requiring operative intervention have potentially operative injury requiring ongoing monitoring. These rates remain stable across all age groups. The specific interventions performed vary with patient age, with the need for general surgical intervention peaking among adults aged 22 years to 40 years. In addition, most of the general and neurosurgical procedures were performed in the patients with hospital LOS of more than 7 days, while most of the orthopedic procedures, particularly in children, were performed in the patients with a hospital LOS of less than 7 days. Trauma remains a surgical disease with frequent surgical intervention and excellent survival regardless of age. Our data emphasize the continued need for surgeons to stay engaged in the care of the trauma patient, particularly those most critically injured patients who will require prolonged hospital stay. AUTHORSHIP S.N.A., R.T.S., and D.D.B. contributed to conception and design of research. S.N.A. collected the data. S.N.A., R.T.S., and D.D.B. analyzed the data. S.N.A., R.T.S., and D.D.B. interpreted the results. S.N.A. drafted the manuscript. S.N.A., R.T.S., E.E.M., D.A.P., C.C.B., and D.D.B. edited and revised the manuscript.

ACKNOWLEDGMENT We thank Lucinda Giblin, RN; Stephanie Harrison, RN, MBA; and Kristine Hansen, RN, from the Children’s Hospital Colorado and Craig Gravitz, RN, from Denver Health Medical Center for their help in obtaining trauma registry data.

DISCLOSURE The authors declare no conflicts of interest.

REFERENCES 1. Lane P. Trauma is not a surgical disease. Arch Emerg Med. 1989;6(2):85Y89. 2. Green SM, Rothrock SG. Is pediatric trauma really a surgical disease? Ann Emerg Med. 2002;39(5):537Y540. 3. Ahmed JM, Tallon JM, Petrie DA. Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders. Ann Emerg Med. 2007;50(1):7Y12. 4. Grossman MD, Miller D, Scaff DW, Arcona S. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma. 2002;52(2):242Y246. 5. Innocenti F, Coppa A, Del Taglia B, Trausi F, Conti A, Zanobetti M, Pini R. Prognosis and health-related quality of life in elderly patients after a mild to moderate trauma. Intern Emerg Med. 2014; 9(4):467Y474.

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6. Leeper WR, Leeper TJ, Vogt KN, Charyk-Stewart T, Gray DK, Parry NG. The role of trauma team leaders in missed injuries: does specialty matter? J Trauma Acute Care Surg. 2013;75(3):387Y390. 7. Tepas JJ, Frykberg ER, DiScala C. Pediatric trauma is very much a surgical disease. Ann Surg. 2003;237(6):775Y781. 8. Khetarpal S, Steinbrunn BS, McGonigal MD, Stafford R, Ney AL, Kalb DC, et al. Trauma faculty and trauma team activation: impact on trauma system function and patient outcomes. J Trauma. 1999;47(3):576Y581.

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9. Luchette F, Kelly B, Davis K, Johanningman J, Heink N, James L, et al. Impact of the in-house trauma surgeon on initial patient care, outcome, and cost. J Trauma. 1997;42(3):490Y495. 10. Porter JM, Ursic C. Trauma attending in the resuscitation room: does it affect outcome? Am Surg. 2001;67:611Y614. 11. Offner PJ, Hawkes A, Madayag R, Seale F, Maines C. General surgery residents improve efficiency but not outcome of trauma care. J Trauma. 2003;55:14Y19.

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