Why Am I Here?

Abstract

There are many important issues that constantly surround us, issues that we confront every day and night as we care for the injured. Most cannot be adequately addressed in a few minutes because of their scope and influence on our professional lives and the lives of our patients. None, however, are unimportant. Allow me to list a few of these:FIGUREFigure. David: B. Reath, MD, FACS President, Eastern Association for the Surgery of Trauma Solving the problem of alcohol as a trauma potentiator The importance of rehabilitation as the final pathway for our patients Profitability in trauma: how are we going to do more with less? Recognizing the importance of spirituality to us and our patients However, following the advice of one of my good friends and predecessors in EAST, I have decided to play from my strengths in this address. I will speak to you today as a surgical specialist, one who began his surgical career and training as a general surgery resident with an interest in trauma, and one who has been most fortunate to be asked by his colleagues to serve in various positions in this organization. In so doing, I hope to provide for you an answer to a simple question I have often posed for myself: Why am I here? I am sure many of you have been asking yourselves this same question. In fact, I have had some members come right up to me and ask me just how in the hell is it that I have come to be president of EAST? But because I hold this organization and this office in such great esteem, I have been thinking critically about this. Each morning and night when I sit at my desk at home with the EAST gavel in front of me, I am reminded that as a surgical specialist, my roots, like those of my specialty of plastic surgery, are in trauma. Furthermore, this may well be the reason that I am where I am today. It is not by a mistake or mere providence that we come to the positions we occupy in our professional and personal lives. We must all discern why we are where we are. In my case, I feel that there is something I have to contribute, and I must figure out what that is and thereby answer this question: why am I here? In my professional life, I frequently find myself wearing two hats, that of a plastic surgeon and that of a plastic surgical traumatologist. Perhaps a better metaphor would be to say that I often stand with one foot in the boat of trauma and one foot on the dock of plastic surgery. Generally, all seems well until the dock moves relative to the boat, or the boat begins to sail away from the dock. Either could produce a certain amount of personal discomfort. Fortunately, I have not yet had to jump onto to the dock or into the boat, and it is my intention not to do so. However curious I might find my position to be, it is clear to me that I should examine the important interdependence of trauma and the surgical specialist as we deliver care to our injured patients. To do this, I would like to address several questions: Is trauma care important to the surgical specialist? Are the surgical specialists important to trauma? What problems exist that may threaten our interdependence, and how do we solve them? IS TRAUMA IMPORTANT TO THE SURGICAL SPECIALITIES? Let us start by examining whether or not trauma care is important to the surgical specialists. In doing this, I would like to look at the specialties of plastic surgery, neurosurgery, and orthopedic surgery. However, let me hasten to acknowledge that there are numerous other specialties that also have important interdependent relationships with trauma. Their exclusion in this discussion is strictly editorial on my part because of the constraints of time. There is little doubt that this question is answered in the affirmative. But to understand why this is so, a brief review of the early years of these specialties may be instructive. Let us begin, then, by examining the history of plastic surgery, neurosurgery, and orthopedic surgery during their early years as independent specialties. It is important to remember that the emergence of these fields as independent fields of surgery came much later in history than did their presence and importance to surgery itself. Stated otherwise, these fields traditionally were within the purview of the general surgeon or physician, long before they emerged as specialties in themselves. Consider Ambroise Paré during the 16th century or Dominique Jean Larrey at the end of the 18th century, or our own Civil War surgeons in the last century. All were called into service of their fellow man on the battlefield to care for injuries to the torso, head, face, and extremities. Specialization as such did not exist. And yet each in their time contributed to these specialties without themselves being specialists. Furthermore, I would like to look at each of these specialties through the careers of surgeons who are arguably considered the fathers of these fields of modern surgical specialties: Sir Harold Delf Gillies, plastic surgeon; Harvey Cushing, neurosurgeon; and Sir Robert Jones, orthopedic surgeon. The time frame we will consider is the first part of this century, during World War I, at a time when trauma became a cornerstone of the foundation for each of these modern surgical specialties. With the assassination of Archduke Franz Ferdinand and Countess Sophie of Austria in Sarajevo, the “war to end all wars” broke out in Europe. This would be a war different in every regard to those that had preceded it, a conflict that was to present numerous heretofore unaddressed challenges to a medical community whose knowledge of military wounds was based on the Boer War fought on the South African desert terrain some 15 years earlier. In contrast, World War I was fought in trenches dug in the highly cultivated and manured fields of France, producing wounds richly contaminated by a variety of organisms. Rapid advances in weaponry and the introduction of heavy artillery produced wounds that differed from past conflicts in both quality and quantity. And because of the trench nature of this conflict, a disproportionate number of wounds were sustained to the head and face, because they were exposed above the parapets. 1 Sir Harold Delf Gillies The “father of plastic surgery” is said to have been Gaspar Tagliacozzi, who, in 1597, described a method of nasal reconstruction utilizing an arm flap. However, opposition by the Church to reconstructive surgery delayed the development of this field for the next 200 years. With the advent of general anesthesia in the mid 19th century, advances in surgery were largely directed at areas of the body that were formerly rather inaccessible. At the beginning of the 20th century, there existed neither separate divisions of plastic surgery, texts on plastic surgery, nor surgeons who were solely devoted to plastic surgery. 2,3 When war broke out on the continent of Europe, and casualties flowed across the channel to Britain, the figure who emerged to meet the challenges and to carry forward the field of plastic surgery was a British surgeon, Harold Delf Gillies. Gillies’ initial training and interest was centered on otolaryngology. With the outbreak of war in 1915, he traveled to France as a general surgeon with the British Red Cross. Because of the influences of Sir Charles Valadier, who established the first British plastic and jaw unit, and a book given to Gillies on the treatment of jaw fractures and wounds by the German doctor Lindermann, he became keenly interested plastic surgery. 4 On his return to England at the end of 1915, Gillies set up a plastic surgery unit at the Cambridge hospital at Aldershot. Although given little interest from the War Office, Gillies asked that all wounded face and jaw patients be sent to his unit and personally purchased labels to tag such patients; he then distributed these tags to the casualty-clearing stations in France. Soon a steady flow of patients began to arrive. During the battle of the Somme, from which he first anticipated 200 patients, over 2,000 arrived for care and treatment, all neatly tagged for him, both with the tags that he had had printed and with other tags that had been officially printed by the War Office. Because of the demand for plastic surgery, Gillies unit soon outgrew Aldershot, and, in 1917, he moved into the Queens Hospital at Sidcup, which eventually held more than 500 beds. This hospital included four separate units led by the British Gillies, the Canadian Risdon, the New Zealander Pickerill, and the Australian Colonel Newland. The competition and collaboration among these units was responsible for great progress in this surgical specialty. 4,5 Gillies’ contributions to the field of plastic surgery, which began with the treatment of World War I casualties, are profound. The use of local flaps, tube flaps, skin grafts, bone grafts, and the like were developed or advanced under his guidance. But what emerged most importantly from this early trauma experience were principles that are still followed today. Although these have been added to and altered by Millard, 6 the original16 principles bear repeating:4 Observation is the basis of surgical diagnosis Diagnose before you treat Make a plan and a pattern for this plan Make a record The lifeboat A good style will get you through Replace what is normal in normal position and retain it there Treat the primary defect first Losses must be replaced in kind Do something positive Never throw anything away Never let routine methods become your master Consult other specialists Speed in surgery consists of not doing the same thing twice The aftercare is as important as the planning Never do today what can honourably be put off till tomorrow Soon after the war had ended, Gillies and others struggled to have plastic surgery recognized as a specialty in itself. Had it not been for the work of Gillies and his colleagues caring for the war-injured, the emergence of my chosen field of plastic surgery would no doubt have been much longer delayed. Harvey Cushing At the beginning of this century, neurosurgery was, like plastic surgery, in its infancy as a surgical specialty. With the exception of a few general surgeons who had acquired a special interest and expertise in neurosurgery, most of the operations were being preformed by general surgeons under the direction of neurologists. 7 Neurosurgery was unprepared for the challenges of World War I. Mortality rates from earlier conflicts were staggering. During the Crimean War, McLeod reported mortality rates of 73.9% for penetrating injuries to the cranium. Similar rates were reported during the American Civil War. 8 Although some progress was made in the treatment of such injuries in the Boer War, mortality rates remained high (45.5%). 9 While, in the first part of this decade, great progress was being made with antisepsis and precision in neurosurgery, little attention was being paid to preparations for wounds produced by the type of warfare to be waged in 1914. Because of the nature of trench warfare and the absence of helmets (which were not introduced until later in the war), almost 25% of penetrating injuries involved the central nervous system. 9 This war caught Cushing, the leading neurosurgeon of his time, at the peak of his career. Having trained as a general surgeon with Halsted, he had been appointed as surgeon-in-chief of the Peter Bent Brigham Hospital, where his efforts continued the development of modern neurosurgery. In March of 1915, while still a civilian, he sailed with the Brigham unit to France for an intense 5-week visit. He traveled extensively and observed both the French and British medical systems in operation. During this visit Cushing became keenly aware of the need to prepare for American entry into this conflict: on his voyage home, the wreckage and bodies of the Lusitania, sunk several days earlier, were visible from the deck of his ship. 9 During the next 2 years, while Cushing was preparing for the United States entry into the war, conditions at the front remained chaotic. The belief that the head-injured patient did not tolerate transportation was axiomatic. Thus, limited surgery was performed close to the front, with secondary closure later, and extensive surgery to be done several days later at the base hospital. The injured were either receiving too little too soon or too much too late. Because of this, mortality rates in the French army were by Cushing to be about to 9 Cushing to France in and was soon at British at 9 from the the next during the of on of This experience with a to and on these patients. At the peak of Cushing on a He added a next to his where he could examine and the of his next for his in surgery, Cushing that it was better to one well and than to several In his own during this of time, Cushing, by his mortality rates from to 9 the battle of Cushing was to the at to several and to He was then to and was made the to the American He remained at that until the day of the During this he trained numerous surgeons in the care of head-injured patients, developed to and developed of He was as a Colonel 1 day after his and to an career. efforts during the war had a on trauma a of head he was to the of with He was to the care of these patients and was to Mortality rates were by through his of followed by and primary skin closure by and today. a of his as the leading neurosurgeon of his time, he established the care of the head-injured patient as a part of modern neurosurgery. Sir Robert surgery, was by the of World War I through the work of Robert Jones, considered by some to be the of modern orthopedic surgery. At the of the last century, was as a specialty was with bone 7 It was the general surgeon of this time that fractures and the of Robert Jones, was from a long of and this from his He is for his development of the which is still in use today. He was also in his Robert Jones, to medical and to with it was that in in began his medical career at the same time that he the care of fractures from his Although he became in he did not become a orthopedic surgeon until when he general surgery. In the of the which would the with the of was was appointed as the which to the first service in the caring for During the next 6 years, Jones, by surgeons and the this the to and treat of injured patients in his made numerous important contributions to the field of orthopedic surgery, and he over from his became recognized as the of orthopedic surgery by for 1 to for a the he is yet not the and his experience to do operations with a precision that is and is the man that he I of his great I must Robert as one of the surgeons it has be my good to But when the war broke Jones, then for the a he was sent to France, where he introduced the for the treatment of This the mortality rates of fractures from to Colonel to that that the more to from than other opposition from general he in his efforts to an orthopedic service and was made of the first orthopedic surgeon to sit on the of the War Office. at a hospital later to 500 and his and such with a of were eventually established by the end of the great in these In 1917, of the Hospital sailed for with surgeons to at British orthopedic after of the need of such the over American surgeons in these and trained under In before the American of that that there were than among wounded was to the methods of treatment of Sir Robert that surgeons orthopedic training under that they could not have acquired in a At the end of the war, Robert was years He was the United States by which is the a can career continued until his in In to being and given a he Surgery with Robert first in He was in the of the British Association and was by the American Association on the of his Each of these surgical began with in general surgery, as did the specialties they were in At the time when these specialties were as fields of surgery in trauma was both an important part and an important their it was, and that trauma is of importance to these surgical specialties. SURGICAL IMPORTANT TO This question will be answered more by the from the of in as a I trauma in the medical is for and has over a The trauma service is by trauma surgeons who are by the general surgical from the specialty is by orthopedic and plastic The specialty are surgery who work with the plastic and surgery on trauma. During the for which the most are patients were for trauma. other trauma patients were and from the a high of injuries that were either or for later Because of our trauma patients are of trauma, a of these patients are on by trauma patients with In contrast, however, the number of patients on by specialty surgeons is much the care of the trauma patient at such an is every as much on surgical specialists as a as on trauma We can feel then, in that the surgical specialist is of great importance to the field of trauma. Furthermore, we must acknowledge the interdependence of the fields of surgical and on its can deliver care to the injured and surgical specialists are like for a great Each must one next to the other to the one is or the is not the will and the themselves will be of little In such an the problems are to than the are to it is important that we this a good To do so, I have an of surgical specialists who are involved with trauma who are either members of EAST or are at trauma whose are members of EAST, to a simple that asked about their with trauma, their trauma, and the problems that they might with trauma care at their In of the of the the is The of these specialists have had extensive experience with specialty trauma both in of their years of and the of their devoted to trauma these surgeons that trauma was an important part of their specialty and that caring for the injured was both and a part to this several trauma that they were all either or with the trauma care by these specialists. where do the problems I have been to at or four areas of some of these are to the nature of trauma and are to and is that that the of trauma is and can with the care of other patients. This is and there seems to be little we can do about this until we are to our trauma patients to themselves in a with regard to the time of day and the of our However, of these patients to be for more would the time of specialty trauma care and to the of the of trauma. The of is the of for trauma we all to be in the same of to to a of patients who may be or at a time in which is many of the may that trauma care is However, when and are it is that trauma at in my is Thus, the of as many trauma patients as by such good from a special and should be with When such are the of the specialists and trauma surgeons must be well to an of for the care might be there are the of the medical of trauma or these are not from the of the trauma surgeons themselves. should be directed at the field of trauma. It would be that some of could be to all those who, by their with trauma must these patients and care for without regard to other quality is through the trauma and a of care is thereby it might be to or at these surgeons from as long as they with the quality should be at the through The last of is the of given to the surgical specialists when caring for the trauma patients. on such as time, and the given to specialty injuries must and do over all However, after these are the for the of the care for these injuries become and It would be my that the same in of the use of trauma and be given to the specialist, as to the trauma surgeon, in to the care of these patients, which may for many after the injuries have been addressed and the trauma surgeon has the a to the problems I have I would a of my the of surgical specialists in the of this In the first years of our an of of the involved the surgical specialties. I would out that some of the were not by the specialists rather by trauma However, in the last years this than of involved the surgical for one or two a There is no one reason nor a simple for this I would that this should not be considered to be a of our have for which we are all But as the quality of trauma has the of specialty has been us of our own this will not be and will a by our We must first surgical specialists to EAST and our we must our specialists to or with their trauma surgical colleagues in the of specialists should be included in and other of the in which their would be for their specialties and the of the trauma surgeon. Although trauma care may present certain problems for the surgical specialist, and there has been a in of the specialist with our EAST, as an the importance of the contributions of the surgical specialist to trauma. I that it is for this reason that I have been to have been involved with this organization and have been asked to be your president this It must be then that this is why I am I you my most and for this as a surgical specialist and for this