Trauma Surgery

Interview #1 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. Charles J. Yowler, Assistant Professor of Surgery at Case Western Reserve University and Director of the Surgical Critical Care Fellowship at MetroHealth Medical Center in Cleveland, Ohio. Dr. Yowler works as a trauma surgeon, burn surgeon and surgical intensivist.

Biography: Dr. Yowler received a B.S. in Chemistry from Michigan State University and went to medical school at Creighton University. He then did a surgical residency and trauma/surgical critical care fellowship at Walter Reed Army Medical Center in Washington, D.C. While in the service, Dr. Yowler served as the director of the SICU at Walter Reed, the chief of the burn study group at The U.S. Army Institute of Surgical Research, and deployed to Iraq to take care of casualties during Desert Shield and Desert Storm. Our Pediatric and Trauma Surgery Divisions Director Erik Glassman has had the opportunity to work with Dr. Yowler at Metro. Erik says "He is an excellent surgeon and an amazing teacher."

What attracted you to trauma surgery/surgical critical care? I have always been interested in the intellectual challenge of the critically ill patient. I do not like clinic visits and routine postop care. Throughout your entire career (including training), what has been the most difficult thing to deal with? Death of children following trauma--these are healthy children who lose their lives usually through no fault of their own (i.e., they aren't driving the car). If you could pick the three most important characteristics for a trauma surgeon, what would they be? Decisive-decisions must be made quickly often with incomplete database. You do not have the surgical oncologists' luxury of a MEDLINE search. Tolerant-we deal with a patient population that may be difficult, psych disorders, substance abuse) "We are all God's children" (from my personal experience, you hear this a lot at 2 am when you are being puked on by a drunk person) Supportive-trauma/critical care is a team effort. A good ICU nurse will save more patients than the M.D. Do you have any advice for medical students considering a career as a trauma surgeon/surgical intensivist? Must enjoy his work to make up for the bad hours-trauma is a nighttime game. On the other hand, other problems are reduced. Surgical oncologists have more lawsuits and the majority of our patients are truly appreciative of our work. How would you assess the competitiveness of obtaining one of the trauma/surgical critical care fellowship spots? Only 70 percent of the current positions fill annually. There is a recognized shortage of trauma surgeons. Do you have any insight for a resident looking to obtain one of the fellowship spots? All applicants obtain a position. This is in sharp contrast to Peds, Vascular, and Surg Onc fellowships. What do you see as the three most important advances in trauma/surgical critical care over the past 15 years? Trauma systems- designation of certain hospitals as trauma centers of excellence(Level I) Improvement in survival following burn injury. Increased staffing of ICU's with full-time intensivists. What do you see as the three most important advances in trauma/surgical critical care over the next 15 years? Septic Shock--we are getting closer to pharmacologically manipulating septic shock and preventing multiple organ dysfunction syndrome. Nonoperative and minimally invasive treatment of traumatic injuries. Hepatic failure--we will have an artificial liver that can temporarily function (such as dialysis with renal failure). Considering the continuously evolving nature of healthcare, where do you see the subspecialty of trauma surgery in 15 years? Explosive growth--"as long as we have handguns and motorcycles, there will be plenty of business for trauma surgeons." There is no effective preventive strategy in trauma medicine since so many of our patients are irresponsible. (substance abuse, spousal/child abuse, habitual bad drivers, and criminal activity). Do you have any suggestions for educational references for students to reference? The American College of Surgeons has a trauma resource aimed at the medical student audience. (The resource is ATLS TEAM)

INTERVIEW #2 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Norman McSwain, Jr., M.D., FACS, Professor of Surgery and Director of Trauma at Tulane University Medical Center.

Biography: Dr. McSwain graduated from the University of the South (majoring in Biology) and attended medical school at the University of Alabama. He completed his residency at Grady Hospital and served in the military as a physician.

Did you find your military training useful in your civilian career as a trauma surgeon? As a surgeon-yes, as a trauma surgeon-no. What attracted you to trauma surgery/surgical critical care? The fun of working on the edge. Throughout your entire career, what has been the most difficult thing to deal with? Medical students and residents more interested in themselves than the patient. Medical students who are more interested in playing than learning about patient care. If you could pick the three most important characteristics for a trauma surgeon, what would they be? Enjoy working Enjoy Anatomy Enjoy physiology Do you have any advice for medical students considering a career as a trauma surgeon/surgical intensivist? Do not do it unless the patient ALWAYS comes first. How would you assess the competitiveness of obtaining one of the trauma/surgical critical care fellowship spots? Moderately competitive. Do you have any insight for a resident looking to obtain one of the fellowship spots? Concentrate on patient care. What do you see as the three most important advances in trauma/surgical critical care over the past 15 years? Autotransfusion CT scan Understanding Shock What do you see as the three most important advances in trauma/surgical critical care over the next 15 years? Blood substitutes Better understanding of multiple system organ failure Identification of the end point of shock resuscitation Considering the continuously evolving nature of healthcare, where do you see the sub-specialty of trauma surgery in 15 years? Less interest in trauma by politicians and health care providers. Less trauma surgeons, therefore less available good trauma care. Do you have suggestions for educational resources for students to reference? Good background in surgery. TRAUMA COMES AFER THE BASICS.

INTERVIEW #3 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. Kennan J. Buechter, M.D., Professor, Chief of Surgery and Trauma Program Director, Medical Center of Louisiana (affiliated with LSU).

Biography: Dr. Buechter attended Drury College where he majored in Chemistry and German. He did his residency at LSU-New Orleans and did his Trauma/Surgical Critical Care fellowship at LSU-New Orleans. University Attended: Drury College

What attracted you to trauma surgery/surgical critical care? Complexity of patients, intensity of care, rapidity of decision making and intervention. Throughout your entire career (including training), what has been the most difficult thing to deal with? 24 hour call schedule followed by an elective schedule and or clinic-utter exhaustion after 36-40 hours up. Young assault victims, particularly victims of beatings, rapes, etc. If you could pick the three most important characteristics for a trauma surgeon, what would they be? Stamina Confidence Ability to maintain composure, relax under stress. Do you have any advice for medical students considering a career as a trauma surgeon/surgical intensivist? Be sure it's what you want, as it becomes all encompassing. There are many unique sacrifices that surgeons make. e.g., I know of very few female surgeons with a "normal" life. How would you assess the competitiveness of obtaining one of the trauma/surgical critical care fellowship spots? Not that competitive if one does reasonably well in residency. Many spots available and unfilled. What do you see as the three most important advances in trauma/surgical critical care over the past 15 years? Improvements in ventilator management Development of trauma systems and centers nation wide Identification of trauma as a unique aspect of surgery. What do you see as the three most important advances in trauma/surgical critical care over the next 15 years? Hopefully continued trauma system development in the US. Liquid ventilation Brain rescue and rehabilitation Considering the continuously evolving nature of healthcare, where do you see the subspecialty of trauma surgery in the next 15 years? Trauma surgeons staffing designated trauma centers with major trauma bypassing non-trauma centers. Most major trauma out of the routine practice of general surgery. Trauma surgery more recognized as its own discipline. Do you have a case report that you can share with me that would be of particular educational benefit to the other students? See "Trauma Rounds" published every month in the Southern Medical Journal (comes in the handy pdf format off the website http://www.sma.org/smj). Do you have suggestions for educational resources for students to reference? American Association for the Surgery of Trauma Website (http://www.aast.org) and American College of Surgeons website (http://www.facs.org).

INTERVIEW #4 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. D. Demetriades, M.D., Ph.D., Professor of Surgery and Director of Trauma/Critical Care, LAC and USC Medical Center, USC University.

Biography: Dr. Demetriades attended Athens Medical School and did his residency and trauma fellowship in South Africa. In addition to his medical degree, he holds a Ph.D. in Surgery.

What attracted you to trauma/surgical critical care? Fast evaluation, fast decisions, fast action, fast and sometimes dramatic results. Throughout your entire career (including training), what has been the hardest thing to deal with? Fatal injuries to children are difficult to accept. If you could pick the three most important characteristics for a trauma surgeon, what would they be? Fast thinking Fast decision making Fast action Do you have any advice medical students considering a career as a trauma surgeon/surgical intensivist? This job is only for people who thrive on fast pace and excitement. How would you assess the competitiveness of obtaining one of the trauma surgical critical care fellowship spots? In our center, (USC) it is really competitive. It is much easier in most other centers. Do you have any insight for a resident looking to obtain one of the fellowship spots? Look for size of the trauma center. Look for the volume on penetrating trauma for the center. Do a Medline search for articles published by the center. What do you see as the three most important advances in trauma/surgical critical care in the past 15 years? Challenging all unscientific dogma with good studies. Technology The work by the committee on trauma of the ACS. What do you see as the three most important advances in trauma surgery/ surgical critical care in the next 15 years? Technology for early and easy diagnosis of abdominal injuries Advances in the care of head trauma Advances in the care of ARDS

INTERVIEW #5 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. Kenneth L. Mattox, M.D., Professor and Vice Chairman of the Dept. of Surgery, Baylor College of Medicine. Hospital Affiliation: Ben Taub General Hospital.

Biography: Dr. Mattox attended Wayside Baptist University and majored in Biology. He completed medical school and residency training at Baylor College of Medicine. He served in the military as a physician. He has additional training in Thoracic Surgery.

What attracted you to trauma surgery/surgical critical care? The challenge of hard work, sickest of the sick surgical patients, gratification, patient need. Throughout your entire career (including training), what has been the most difficult thing to deal with? Regulating industrial complex, managed care, clock punching lifestyle issues on the part of other physicians. If you could pick the three most important characteristics for a trauma surgeon, what would they be? Attention to detail Passion for excellence Mastery of complex situations Do you have any advice for medical students considering a career as a trauma surgeon? Take the hardest courses, drive your work. Do you have any insight for a resident looking to obtain one of the fellowship spots? Be the best of breed and it will never be difficult. What do you see as the three most important advances in trauma/surgical critical care over the next 15 years? Technology Integration Point of service Imaging/Lab/QA Virtual reality simulations in surgery Do you have suggestions for educational resources for students to reference? My textbook "Trauma 4th edition" McGraw Hill 2000, Mattox, Feliciano, Moore.

INTERVIEW #6 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. John A. Morris is a Professor of Surgery at Vanderbilt University and Director of Trauma at Vanderbilt.

Biography: Dr. Morris went to Trinity University in Hartford where he majored in English. He then attended medical school at the University of Kentucky. Dr. Morris then also completed his surgical residency there. Dr. Morris then went to the University of California at San Francisco to complete a trauma surgery/surgical critical care fellowship.

What attracted you to trauma surgery/surgical critical care? I am a coutrarim--No one else was interested in a major disease process. Throughout your entire career (including training), what has been the most difficult thing to deal with? Time management and an ungrateful "system" political, professional, hospital If you could pick the three most important characteristics for a trauma surgeon, what would they be? Sick analysis Leadership Stamina How would you assess the competitiveness of obtaining one of the trauma/surgical critical care fellowship spots? High What do you see as the three most important advances in trauma/surgical critical care over the past 15 years? Trauma Systems Development Damage Control Concepts What do you see as the three most important advances in trauma/surgical critical care over the next 15 years? Control of Second Degree Brain Injury Spinal cord regeneration/repair Understanding of the inflammatory response Considering the continuously evolving nature of healthcare, where do you see the subspecialty of trauma surgery in 15 years? hospital: integrated systems of prehospital, acute care, rehab and sub-acute care M.D.: small groups of specialists: general surgeons/ortho/face in an integrated fashion of care for patients. Dr. Morris adds that when it comes to trauma, he doesn't think about individual cases but instead thinks about populations of patients.

INTERVIEW #7 Conducted by 2000-01 Division Coordinator, Erik Glassman (Boston U.) Dr. Virginia Eddy, MD is the Director of the Surgical Intensive Care Unit at Vanderbilt University Medical Center.
Biography: Dr. Eddy graduated Magna Cum Laude with a double major in Psychology and Chemistry from the University of South Carolina. She received her M.D. degree from the University of South Carolina, where she graduated first in her class. After an Internship in Surgery at the Geisinger Medical Center, Danville, Pennsylvania, she returned to the University of South Carolina School of Medicine for a year in a surgical research fellowship followed by her surgical residency. After a fellowship in Critical Care and Trauma at Vanderbilt, she was appointed Instructor in Surgery at Vanderbilt in 1992. She was promoted to Assistant professor in 1993 and to Associate Professor in 1997. She served as Director of the Surgical Intensive Care unit at the Nashville Veterans Administration Hospital from 1994 to 1997 and since 1997 has been Director of the Surgical Intensive Care Unit at Vanderbilt University Medical Center. Dr. Eddy currently serves as the Course Director for the Third Year Core Clerkship in Surgery. This biography was provided for the Surgery Interest Group by Dr. Eddy and was done by Vanderbuilt University
Why Trauma Surgery? I think most people think trauma surgery is about adrenaline and heroism. The big save, the high drama. For me, trauma surgery is about grace, courage and beauty. I am as in love with my job today as the first day I started it. I will try to explain what I mean in the following paragraphs. First, generalism. When I went to medical school, it was with the intent of being a complete physician, one who was equipped to manage any problem. While that may not be a completely realistic aspiration in this day and age, trauma surgery allows me to come as close as possible to that dream. I get to take care of the whole patient, not just one organ system. I manage my patients' medical issues, and if they need surgery, I operate on them. Although I certainly do consult my specialist colleagues for particularly complex problems, it is my responsibility to know enough about the whole patient to wisely use the information my consultants give me, and to incorporate their recommendations into a coherent treatment plan that keeps the whole patient in mind. I like this generalist approach. Second, ownership. I see the patient from the start of their disease process through their convalescence and after their discharge to home. I take care of them when they come to the ER, in OR, in the ICU, on the ward, and in the clinic. This allows me to have a sense of really being the patient's doctor, not just another consulting superspecialist in the crowd. It is incredibly rewarding to see these patients who were once on death's door when they are recovering and reintegrating back into their community. Third, relationships. I like the interpersonal aspects of trauma surgery. This may be counterintuitive, but the relationships I develop with my patients and their families are important to me. In fact, this is why I decided against family medicine as a career ? I wanted a specialty where I could spend as much time as I wished talking with my patients. My hours are certainly long, but they are mine; I don't have to work under the pressure of needing to see a certain number of patients in clinic each day in order to stay financially viable. Primary care specialties usually don't have this freedom. Forth, operating. I love surgery as a discipline. The human body is breathtakingly beautiful. Sometimes when I am operating, I am so awestruck by the beauty in front of me that I just want to cheer. (I do manage to keep my enthusiasm under sufficient control so that we can operate successfully.) I think it must be like being an art collector who gets to work in an art museum everyday. Fifth, teamwork. I enjoy being part of a team whose goal is to use our collected talents to heal these terribly injured patients. As the trauma surgeon, I am the team leader, but it is a team nonetheless, and the patient's outcome depends on the functioning of each member of the team. I try to make sure that everyone knows this, including the patients, families, and the team members. I also try to make sure that each member of the team shares in the credit for our successes. And let me emphasize that the team includes attendings, residents, students, nurses, respiratory therapists, radiology technicians, physical therapists, etc. It isn't just about doctors. Sixth, perspective. I mean this in a special way. We often think of medicine as a life-saving discipline. In fact, what we often ought to be about is quality of life rather than length of life. A lot of my job deals with making people comfortable, whether it is managing postoperative pain, or allowing someone to die in comfort and dignity. And sometimes this means helping the family cope with the horror of seeing their loved one hurt or dying. Sometimes my job is to ease the family's pain. It is hard to describe the incredible personal courage I have seen patients and their families exhibit under the worst possible circumstances. It is a privilege to be entrusted with the care of these folks. Seventh, teaching. By teaching, I can have the biggest influence on the greatest number of patients. And, best of all, I get to see my students grow into fine doctors, and they force me to be intellectually precise and meticulous in my reasoning as part of the bargain. Do you have any advice for medical students considering a career in Trauma? There are a lot of smart doctors out there who are good with their hands. That isn't what being an excellent doctor is about. Those are only the starting points. The thing that distinguishes the excellent from the adequate doctor is not intellect, or the ability to quote a bunch of obscure articles, or technical ability. The quality that will make you an excellent instead of an average doctor is to treat your patients and their families with genuine respect, interest, compassion, and gentleness. A medical student who is considering a career in trauma surgery must first decide that they will be an excellent doctor. Trauma surgery requires a residency in general surgery which includes five clinical years and often one or two research years. After surgery residency, there is a one or two year long fellowship in trauma and critical care. So, that's a seven to nine year commitment after medical school. Thus, a medical student who is considering a career in trauma surgery must be patient and perseverant. As a corollary to this, there is a bunch of joy to be had during that long training process, if a person is able to perceive it. Those who can't have fun during the training process ought to pick another career.