Confessions of a dual-trained, dual-practicing vascular-trauma surgeon

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Joseph DuBose

Like most of the other readers of Vascular Specialist, I look forward to perusing each release for not just useful information but also insightful editorials that frame ongoing issues in thoughtful and entertaining ways. I personally find that I am rarely disappointed in what I find in this newspaper in this regard, and the recent article by our medical editor, Dr. Malachi Sheahan III, titled “A modest proposal: Let’s eat the trauma surgeons” was no exception. It left me with many things to think about… including how I would season the half of my body that Dr. Sheahan satirically suggested I should cannabilize. 

Let me explain. I am a dual-trained trauma and vascular surgeon who continues to fight to maintain a balanced practice in both fields. For six years after completing a surgical critical care/trauma two-year fellowship, I worked as an academic military trauma surgeon. I confess I am one of those slightly deranged individuals who actually enjoys the struggle of creating order from chaos at times when most sane individuals would probably rather be in bed. For me clinically, there is simply nothing like the adrenaline and reward that can be found trying to save a trauma victim from bleeding to death at midnight on a Saturday. 

Ask any busy trauma surgeon what their most interesting recent case was and I would be willing to bet some vascular injury is a common response. I relished these challenges perhaps more than most of my trauma colleagues. It was not hard to appreciate, however, that I had some gaps in my training that limited my ability to care for many of these challenges. Endovascular technologies were already emerging as effective solutions to vascular injuries at some anatomical locations and improving outcomes as they did so. In the open surgical realm, I found it challenging to find avenues by which I could consistently maintain my skillsets in exposure, control and repair of blood vessels. More military deployments or trauma call were not going to fix these deficiencies very efficiently. 

Joseph DuBose responds to criticism over his comments regarding vascular surgery’s place in the management of vascular injury—and his coining of the term “lesion vision”

And so, with the support of my military leadership and some respected trauma mentors, I self-demoted from mid-level trauma attending to vascular fellow. It was at times a humbling experience. But now, seven years into a dual practice, I can honestly say that I have found the clinical niche that I find most personally rewarding. I take as much trauma call as any of my trauma partners, and also have a busy vascular practice treating the full spectrum of elective and emergent vascular disease. It makes for a very busy workload for sure, but an advanced vascular skillset has empowered me to be clinically happy in my interest area—and even to expand into areas that one would not typically associate with traditional vascular or trauma surgery practice. For example, my current vascular group performs the majority of the solid organ and hemorrhage control embolization interventions for our trauma program. 

Despite my contentment with my dual practice, I must confess it often presents me with interesting dilemmas. I do sometimes find myself asking existential questions related to my professional identity. Am I a trauma surgeon with a passion for vascular injury? Or, rather, am I a vascular surgeon with an interest in vascular trauma? The answer is sometimes complex and dependent upon the context. When my two training background split personalities converge in the deciding of how to manage a complex vascular injury, the real quandaries can begin. In these moments, all the debates regarding the future of vascular trauma and optimal vascular injury treatment in the endovascular era, that rage across the “Twittersphere,” become my internal dialogue. 

In attempting to make sense of these often dueling perspectives, I worked with a group of vascular and trauma surgeons as lead author on an editorial called “Beyond the crossroads: Who will be the caretakers of vascular injury management?” for Annals of Surgery. The intent was to outline the challenges all stakeholders face as changes in technology, training and trauma center organization influence the ongoing evolution in vascular injury care. It was my attempt to highlight for consideration the potential potholes on this road that both vascular and trauma surgeons must travel together. As one who will readily “nerd out” about vascular trauma, this publication was a way of giving voice to the debating portions of my overly trained mind. 

The response? Well, let’s just say it was not necessarily warmly received in all sectors. Many trauma surgeons criticized me for suggesting they are no longer capable of caring for vascular injury in the era of endovascular technologies. Some vascular colleagues perceived that I was implying they fail to understand the nuances of vascular injury management in the context of the severely injured trauma patient. My well-intentioned highlight of potential present and future challenges had backfired to some degree. The article left me best known in some circles as the evil spirit who coined the term “lesion vision,” thereby arming some of my fellow trauma surgeons with a war cry against further encroachment of vascular surgeons into their cherished vascular injury excitement. 

By way of apology, I offer as backstory that the first time I ever used “lesion vision” was in presenting one of my own morbidities where I had clearly let focus sharpen too narrowly on the hybrid operating room (OR) screen, and missed important changing physiology of a bleeding trauma patient under my own care. As such, if I coined the term in later self-deprecation at our M&M meeting, then I am also the first documented victim of this malady. As I genuflect remorsefully in your collective directions, I hope that you will forgive me and let me return from the outcast lunch table at the annual vascular community picnic. 

It is also my fervent hope that you will help me make room at that table for others like me. When I started down this pathway of dual training, I could count on one hand the individuals that I knew of working as true dual-practicing vascular and trauma surgeons in the U.S. Now, however, this pathway seems to be making some small gains, and our numbers are growing. At present, these individuals seem to cluster at major high-volume trauma centers around the U.S. Baltimore, Denver and Austin all harbor collections of dual-practicing vascular/trauma surgeons. A more substantial number of dual-trained surgeons primarily practice more exclusively in vascular surgery but serve as exceptional ambassadors to vascular injury care, and outstanding resources to their trauma partners at their trauma centers. At least monthly, I get a call from a surgical resident or trauma fellow to talk about the benefits of pursuing dual training in the context of changes in vascular injury care. It may not be a massive movement, but it does seem to be a potential “thing.” 

The question remains, however: Is there a real role for this sort of a training pathway? There is clearly a need for more vascular surgeons to support trauma, as has been discussed on the pages of this periodical very effectively. No rational individual would argue that vascular surgeons are not an absolutely necessary part of the endovascular advancement of vascular injury care. The days of open blunt aortic repair have given way to thoracic endovascular aneurysm repair (TEVAR). Other anatomic locations are following suit. Only the vascular community is uniquely positioned to effectively guide this evolution. Open vascular repair skills will almost certainly continue to be required for vascular trauma management, but no one has the ability to develop and maintain this skillset like the modern vascular surgeon. The role of the vascular surgeon in trauma is secured for those that are interested in incorporating it into their practice. 

But there is also a clear and present interest among trauma surgeons in remaining engaged in vascular injury care. In a recent survey of both vascular and trauma surgeons, it was noted that, despite significant interest in vascular injury by practicing trauma surgeons, most feel unprepared to do so. The most commonly cited reasons for this discomfort were inability to maintain the skillset and unfamiliarity with techniques. Can my own unique breed of dual-trained surgeons, and the numerous vascular surgeons who are also interested in trauma, be of service in this regard? Can we, in the least, do a better job of educating the next generation of trauma trainees in the capabilities we have to offer that might augment the care of the most challenging of the patients they are called upon to care for? I hope the answer is “Yes”… or I will have to figure out yet another new career plan. 

In my own vision of a future utopia, I can see a time when there may be at least one dual-practicing trauma and vascular surgeon at most of the leading trauma centers in the U.S. In this ideal world, these individuals could serve as ambassadors between their vascular and trauma divisions. They will be valuable in improving the knowledge base and skillset of their trauma colleagues and their trainees, and finding ways to empower trauma surgeons to engage actively and productively in the vascular injury care evolution. They will also free their vascular partners to focus their energies more actively on the unique vascular practice models they are passionate about—be they aortic, peripheral, cerebrovascular or venous in nature. They might be “odd ducks” like myself, but they have the potential to be valuable resources to both disciplines they have pursued. And in this utopian future, no one will remember what “lesion vision” means. 

Joseph DuBose, MD, is a professor of surgery in the University of Texas at Austin’s Dell Medical School in Austin, Texas. 

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