Claim emerging vascular surgeons ‘less well prepared to rapidly achieve open exposure’ in trauma setting draws scorn

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A recent perspective published in the Annals of Surgery—which argued the shift toward endovascular care had led to a deficit in open surgical experience among the emerging cadres of trainees, impacting the treatment of vascular trauma injuries—has drawn broad censure from within the ranks of vascular surgery.

Vascular and general surgery graduates, as well as already practicing vascular surgeons, “are increasingly less well prepared to rapidly achieve open exposure and control of injured vessels,” the paper claims. Meanwhile, trauma surgeons at major civilian trauma centers “also have increasingly limited experience with open vascular repair relative to even two decades ago, when trauma surgeons did most emergent vascular surgery.”

The arguments—contained in a piece entitled “Beyond the crossroads: Who will be the caretakers of vascular injury management?”—come from Joseph J. DuBose, MD, a clinical professor of surgery at the University of Maryland’s R. Adams Cowley Shock Trauma Center in Baltimore who is also affiliated with the Uniformed Services University of the Health Sciences in Washington, D.C, et al. The authorship also included Todd E. Rasmussen, MD, attending vascular surgeon in the Military Health System and a professor of surgery at the Uniformed Services University of the Health Sciences.

In recent days, many vascular surgeons responded to the perspective in a robust discussion via social media.

“We need to dispel a myth,” wrote Joseph Mills, MD, professor and chief of vascular and endovascular surgery at Baylor College of Medicine in Houston, on Twitter. “Although our #VascularSurgery trainees get abundant endovascular experience, they still obtain substantial experience in open surgery.”

As they outlined their rationale, DuBose et al made the case that the “significant morbidity and mortality” of relatively uncommon vascular injuries require a level of open surgical skills and proficiency that are “increasingly difficult to acquire and maintain.”

The use of endovascular technologies for select trauma applications “show promise,” the authors write, “but the majority of contemporary vascular injuries continue to require open treatment.”

They argue: “There is a crossroads where we must choose to either abdicate all vascular trauma care to vascular surgeons or maintain vascular skills within the group of surgeons called on to provide trauma care. One could argue each path has merits. We are now beyond that crossroads and have failed to design a system that meets the need.”

HISTORY

Responses were brisk. Some members of the vascular surgery community sought to place into context their involvement in vascular trauma care.

Patrick Geraghty, MD, of Washington University School of Medicine in St. Louis, reasoned: “While I agree with the dream (fully vascular-capable trauma surgeons), dreamers seem to be in short supply. I’ve done hundreds of vascular trauma repairs—when we show up, the trauma team scrubs out. Which is fine—the 1970s aren’t coming back. But if the trauma community wants to try to build a cadre of co-trained surgeons, the military would seem to offer the best starting point.”

Ben Colvard, MD, a vascular surgeon in Cleveland, added:  “Regardless of what a minority of vocal trauma surgeons say about managing vascular traumas on their own, when it comes down to brass tacks in the OR [operating room], the majority of trauma surgeons will #callvascular for a serious vascular injury at major trauma centers.”

Elsewhere in the perspective piece, DuBose and colleagues touched on how they see “this loss of skill in open vascular management” as potentially of most concern in rural and military environments “where endovascular options for trauma are not as readily available.”

Tahlia Weis, MD, a vascular surgeon in Marshfield, Wisconsin, drew attention to the example of a rural level two trauma center in her state for which the nearest level one facility is at a distant remove. “Most of our incoming traumas are coming from > 100 miles from us,” she tweeted. “Our trauma surgeons consult us for major vascular injuries. We acknowledge this is a standard of care. This is what we teach our [general surgery] residents.”

Sherene Shalhub, MD, associate professor of surgery in the division of vascular surgery at the University of Washington in Seattle, commented: “Since ideal multidisciplinary care is available only in larger hospitals, a minimal set of competencies for those serving rural communities should be the focus during training.”

Sharmila Dissanaike, MD, chair of surgery at Texas Tech University in Lubbock, Texas, agreed that there was a need for minimal competency in vascular care for rural practice: “I see the consequences when this isn’t available in rural towns in my region. Not sure how best to do that though; exposure to vascular trauma and emergency revascularizarion would be key.”

TRAINING

Others indicated a problem with the paper’s starting point.

“This whole argument exhausts me, the abdication of the majority of vascular injuries to [vascular surgery] already happened, years ago, at least at many places on the East Coast,” opined Reid Ravin, a vascular surgeon at Mount Sinai in New York, via Twitter. “Training paradigms are only serving to reinforce the trend that stated decades ago.”

At the core of their perspective, DuBose and colleagues make a call for change within trauma training. “Limited course offerings for trauma/acute care surgeons must be followed by more substantial changes in both training and guidelines for referrals within trauma systems,” they write in the paper.

Meanwhile, in another Twitter response Guillermo Escobar, MD, program director for the Emory University vascular surgery fellowship and residency in Atlanta, stated: “The problem is that modern vascular management relies on access to endo [and] modern trauma relies on access to vascular. Rural and military don’t have either.”

He added: “Do something proactive. Make an ESP [early specialization program] like we have in vascular.”

Escobar went further. “Outcomes improve with subspecialists’ involvement, yet subspecialists are not always available [especially in rural areas and in the military],” he explained. “Open surgery experience lower for [all because of] laparoscopy, endo, [interventional radiology]. Some trauma surgeons want [to be] ‘surgeon totalis’ after a [one-year fellowship]. We went to [two years] in 2002!”

One passage from the perspective saw the authors write that vascular surgeons can develop a form of tunnel vision—”lesion vision”—amid what they term an increasing focus on endovascular modes of care. This drew particular ire.

“It essentially accuses an entire specialty of performing inappropriate surgery,” noted Karen Woo, MD, associate professor of vascular surgery at University of California, Los Angeles (UCLA). “Fellow surgeons no less. This demands a response.”

REBUTTAL

The prospect of a rebuttal piece penned by vascular surgeons has already been raised. Nicolas Mouawad, MD, chief of vascular and endovascular surgery in the McLaren Health System-Bay Region in Bay City, Michigan, was among those to volunteer as a possible co-author.

“The use of endovascular therapy in the setting of trauma has increased dramatically in the last few decades with studies demonstrating improved in-hospital mortality and decreased rates of sepsis,” he told Vascular Specialist. “Vascular surgeons realized the importance and advantages of endovascular interventions, even in the non-trauma setting, and have since doubled the training of vascular surgeons from one year to two years in the early 2000s to dedicate and refine expertise in these particular skills.

“It is a worthy discussion and should be a collaborative one. The goal is patient care, and it is more than just open or endovascular skills; but rather, it involves vascular decision-making, things that vascular surgeons do every day, which is reinforced by a busy elective practice. Vascular surgeons should bridge the gap.”

Mouawad ended on a conciliatory note: “This paper does offer perspective on changes in trauma practice but should also allow the counterpoint from the vascular surgery community who routinely, and for the most part, are called to deal with vascular traumatic injuries that require endovascular reconstructions.”

SOURCE: doi:10.1097/SLA.0000000000003912

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