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Trauma Surgeon Requirements
Summary
A.) Board certification
1.) Board certification (or Board Eligibility) is essential.
B.) Clinical involvement
1.) Trauma surgeons must be regularly involved in the care of all seriously injured
patients
a.) Must be present and assume care for Trauma Reds within 15 minutes of
patient arrival.
b.) Must evaluate Trauma Yellows before admission.
c.) Trauma surgeon is the leader of the trauma team and is responsible for
overall care of trauma patients including coordinating care with other
specialties and maintaining continuity of care.
i. Care of patients with multi-system injuries is supervised by
Trauma Surgeon.
ii. Interpret and reconcile recommendations of consultants in
overall care of patient
iii. Coordinate all aspects of treatment including resuscitation,
operation, critical care, recuperation and rehab or
discharge
iv. Remain in charge of the patient in the ICU.
v. Support from medical specialists is OK (internal medicine
and pulmonary medicine) but surgeons cannot relinquish
overall responsibility for patient care
d.) The core trauma group must take at least 60% of the call hours each
month.
2.) Must have full and unrestricted privileges
3.) Participate in the organization of trauma protocols.
4.) Participate in peer review meetings by attending at least 50%.
C.) Education
1.) All Trauma surgeons must have successfully completed ATLS course once.
2.) All Trauma surgeons must be knowledgeable and current in the care of injured
patients, this requirement may be met by:
a.) Documented acquisition of 16 hours of trauma-related external CME per
year on average
b.) Or by demonstrating participation in an internal education process
conducted by the trauma program based on the principles of practice
based learning and the PIPS program.
The following is excerpted from
Resources for Optimal Care of the Injured Patient 2006
These are the mandated requirements and responsibilities for a Trauma Surgeon.
1.) Qualified general surgeons must participate in major therapeutic decisions, be
present in the emergency departments for major resuscitations, be present at
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operative procedures, and be actively involved in the critical care of all seriously
injured patients. p19
2.) For Level II trauma centers, it is expected that the surgeon will be in the
emergency department on patient arrival, with adequate notification from the
field. The maximum acceptable response time is 15 minutes, tracked from the
patient arrival. The program must demonstrate that the surgeon’s presence is
in compliance at least 80% of the time. (CD 2-7) p19
3.) For some patients in stable condition who do not meet the criteria for the
immediate availability of the trauma surgeon, evaluation can be initiated
according to trauma team protocols by the attending emergency physician, and
the patient can be examined by the trauma surgeon before admission. p19
4.) The trauma surgeon on call must be dedicated to the trauma center while on
duty (CD2-8). In addition, a published backup call schedule for trauma surgery
must be available (CD2-9). p19
5.) Programs that admit more than 10% of injured patients to non-surgical services
must demonstrate the appropriateness of that practice through the performance
improvement and patient safety process (CD 5-11) p33
6.) In a Level I or II trauma center, seriously injured patients must be admitted to
or evaluated by an identifiable surgical service staffed by credentialed trauma
providers (CD 5-12). p33
7.) There must be a multidisciplinary peer review committee chaired by the trauma
medical director or designee, with representatives from neurosurgery,
orthopaedic surgery, emergency medicine and anesthesia (CD-5-18). The
purpose of the committee is to improve trauma care by reviewing selected
deaths, complications and sentinel events with objective identification of issues
and appropriate responses. The aforementioned representatives must attend at
least 50% of these multi disciplinary peer review committee meetings (CD 5-19).
p34
8.) At a minimum, the surgeons who constitute the core of trauma call coverage
must each attend at least 50% of these meetings (CD 5-19). This core group
must be defined by the trauma medical director (CD 5-20). This core group
must take at least 60% of the total trauma call hour’s each month (CD 5-21).
p34
9.) The general surgeon is the leader of the trauma team and is responsible for the
overall care of trauma patients, including coordinating care with other
specialties and maintaining continuity of care. The general surgeon is called on
not only to evaluate and treat the patient, but also to interpret and reconcile the
recommendations of team members and consultants to optimize patient care.
The general surgeon serves as the “captain” of the resuscitation team and is
expected to participate in the initial evaluation and resuscitation of seriously
injured patients. The care of the patients with multisystem injuries should be
supervised by the general surgeon. The general surgeon coordinates all aspects
of treatment, including resuscitation, operation, critical care, recuperation, and
rehabilitation or discharge. p37
10.) QUALIFICATIONS
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General surgeons caring for the trauma patients must meet certain requirements as
described herein. These requirements may be considered in 4 categories: board
certification, clinical involvement, education, and regional or national commitment
(Medical Director Only) p37
A.) Board Certification
Basic to qualification for trauma care for any surgeon is board certification in general
surgery by the American Board of Surgery, the Bureau of Osteopathic Specialists and
Boards of Certification, or the Royal College of Physicians and Surgeons of Canada.
Board certification is essential for general surgeons who take trauma call in Level I
and II trauma centers (CD 6-2). It is acknowledged that many boards require a
practice period and that complete certification may take 3-5 years after a residency
approved by the Accreditation Council for Graduate Medical Education (ACGME) or
the American Board of Osteopathic Specialties. If a physician has not been certified 5
years after successful completion of an ACGME or Canadian residency, the physician
usually is not eligible for inclusion on the trauma team. Such a physician may be
included when given recognition by a major professional organization in his or her
specialty (for example, the American College of Surgeons [ADS]. p37
B.) Clinical Involvement
In a hospital committed to trauma care, surgeons with special expertise in trauma
should be identified. Qualified surgeons should be regularly involved in the care of
injured patients. Participation in the organization of trauma protocols, trauma teams,
trauma call rosters, and trauma rounds are clear indicators of commitment to
excellence in trauma patient care. It is important for trauma surgeons to maintain
their surgical skills. Trauma surgeons must have privileges in general surgery (CD63). To maintain operative skills, general surgeons should participate in elective and
emergency general surgery.
In Level I and II trauma centers, the trauma surgeon on call must be dedicated to the
trauma center while on duty (CD 6-4). In addition, a published backup call schedule
for trauma surgery must be available (CD 6-5)
For Level I, II, and III trauma centers, it is expected the trauma surgeon be in the
emergency department on patient arrival, with adequate notification from the field.
For Level I and II trauma centers, the maximum acceptable response time is 15
minutes. Response time will be tracked from the patient arrival rather than from
notification or activation. An 80% attendance threshold must be met for the highest
level of activations (CD 6-6). The criteria for the highest level of activations must be
clearly defined by the trauma center and evaluated by the performance improvement
and patient safety program (CD 6-7). For Level I, II and III trauma centers, the trauma
surgeon is expected to be present in the operating room for all trauma operations. A
mechanism for documenting this presence is essential (CD 6-8). p38
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C.) Education
All general surgeons on the trauma team must have successfully completed the ACS
ATLS course at least once (CD 6-11) Active participation as an instructor for the ACS
ATLS course is desirable and should be encouraged.
It is important that all members of the trauma team are knowledgeable about current
practices in trauma care. In Level I and II trauma centers, external CME is the
recommended method of keeping current. The trauma medical director must accrue
an average of 16 hours annually or 48 hours in 3 years of verifiable external traumarelated CME (CD 6-12). Programs given by visiting professors or invited speakers and
teaching and ATLS course are considered outside education. It is important that other
general surgeons who take trauma call are knowledgeable and current in the care of
injured patients. In Level I and II trauma centers, this requirement must be met by
acquisition of 16 hours of CME per year on average or by demonstrating participation
in an internal educational process conducted by the trauma program based on the
principles of practice-based learning and the performance improvement and patient
safety program (CD 6-13). p39
11.) Physician Responsibility
The trauma service that assumes initial responsibility for the care of an injured patient
should maintain that responsibility throughout the acute care phase of
hospitalization. The trauma surgeon must remain in charge of the patient in the ICU
(CD 11-46). In all trauma centers, the trauma service must retain responsibility for
the patient and coordinate all therapeutic decisions (CD 11-53). Many of the daily
care requirements can be managed by a dedicated ICU team, but the trauma surgeon
must be kept informed and concur with major therapeutic and management decisions
made by the ICU team (CD 11-54). The structure designed for the care of critically ill
ICU patients may differ between hospitals, but the concept of the trauma surgeon
retaining overall responsibility for the patient is essential (CD 11-46)
The trauma surgeon in Level II trauma centers must also remain in control of the
surgical aspects of patient care, although it is recognized that the surgeon might seek
daily input from a physician with the critical care credentials consistent with the
medical staff privileging process of the institution (CD 11-53).
Trauma patients should not be admitted or transferred by the primary care physician
without the knowledge and consent of the trauma service. p66
12.) Medical Consultants
The complexity of the management of many seriously injured patients may require
support from medical specialists. However, surgeons should not relinquish the overall
responsibility for patient care. In a Level II facility, specialists from internal medicine
and pulmonary medicine must be available on staff (CD 11-67). In Level II facilities,
specialty consultation for problems related to internal medicine, pulmonary medicine,
cardiology, gastroenterology, and infectious disease must be available (CD 11-68). p67
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Reference:
1.) Resources for Optimal Care of the Injured Patient 2006. American College of Surgeons
Committee on Trauma.
Selected Data from the May 2006 ACS Consult visit.
A. Deficiencies:
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1.
2.
3.
4.
The trauma director does not have the authority to run the trauma program.
There is no published back-up schedule for the trauma surgeon.
There are inappropriate criteria for trauma team activation.
There are excessive admissions to non-surgical services for both adult and pediatric patients
without appropriate QA of these admissions. Refer each one – set guideline for consult.
5. There is no documentation that all of the emergency physicians or trauma surgeons on the trauma
panel have successfully completed ATLS at least once.
6. There is inadequate documentation on the trauma flowsheet of vital signs, physician response
times, and care outside of the emergency department.
7. The performance improvement program:
a. Is immature and is ineffective in identification and, therefore, correction of many
problems.
b. Does not adequately document loop closure or resolution of problems.
c. There is inadequate review of trauma deaths.
8. The trauma panel of surgeons does not attend 50% of the performance improvement peer review
committee meetings.
9. The neurosurgical representative or his alternate does not attend 50% of the performance
improvement peer review committee meetings.
10. There are no appropriate protocols for treatment of biological, chemical and nuclear hazardous
materials.
11. The neurosurgeon liaison and the emergency physician do not have adequate trauma related CME
documented for the past 3 years.
12.) The anesthesiology representative or his alternate does not attend 50% of the performance
improvement peer review committee meetings, this is a deficiency
Case Reviews done by the Consulting ACS Physicians.
Case 1. Potentially preventable death – ISS 26. Patient is a 40-year-old female who apparently has a
history of seizure disorders and had a seizure at home and was brought to the emergency department by
the pre-hospital personnel with stable vital signs, a GCS of 15. Patient underwent a CT scan of the
head, which showed intracranial hemorrhage and possible sheer injury. Patient had an abnormal pro
time with an INR of 3.2. The patient was admitted by the hospitalist and seen in consultation by
neurology and the neurosurgeon. Patient was admitted to the intensive care unit with no concentrated
effort to reverse her coagulapathy and she deteriorated approximately 8 hours after admission. The
neurosurgeon was notified and the patient did not have a repeat CT scan until the following morning and
was finally taken to the OR at 10:00 for marked deterioration in her CT scan and placement of a
ventriculostomy. Patient deteriorated in the Intensive Care Unit prior to the OR and was intubated by the
intensivist. She ultimately was pronounced brain dead and was an organ donor.
Critique: Patient was inappropriately admitted to the medical service with no attempt to reverse her
coagulapathy and delayed response to her neuro deterioration in the intensive care unit. PI did document
this death as potentially preventable but did not have any evidence of loop closure regarding admission to
a non-surgical service lack of appropriate care in the intensive care unit and delay of operative
intervention.
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Case 3. Transfer Out. Patient is a 46 year-old gentleman who arrived in the emergency department by
private vehicle and was hemodynamically stable with a GCS of 15. He had received a blow to the eye
and was sent to CT scan for a CT of his facial bones. Preliminary CT scan showed there was a
periorbital fracture but the emergency physician was concerned about entrapment. Patient was
appropriately evaluated and found to have a fracture of the orbit with impingement of the optic nerve and
was transferred to a Level I trauma center for treatment. This was after he had been admitted to
medicine and diagnosis of pneumocephalis was not appropriately evaluated.
Critique: There was a delay in evaluation and transfer of this patient to a higher level of care with a
potential injury to the optic nerve. Patient remained at the institution for 8 to 9 hours prior to transfer. PI
did not recognize or follow up on the miss read in radiology with potential injury to optic nerve.
Case 10. Admission to non-surgical service. Patient is a 13 year-old male who fell from a ladder striking
his head and neck. He was brought to the emergency department by paramedics and evaluated in the
ED with a CT scan of his cervical spine, which was negative; thoracic spine films showed a possible
compression fracture. A CT scan of T-3, T-4 and T-5 showed a compression fracture of T-4. He was
admitted to the pediatric service after the neurosurgeon was called; he said to admit the patient to peds
and he would see the patient on a non-emergent basis. Neurosurgery did see the patient 20 hours later
and ordered appropriate TSL brace. The patient did undergo the appropriate physical therapy.
Critique: Patient should have been appropriately admitted either to the trauma service or neurosurgical
service. PI did not identify this.
Chart 3 (Non-preventable death after head injury): This 89 year-old woman was next to the washing
machine when she cried, “Oh my God!” and fell backward hitting her head. There was no loss of
consciousness. She was helped up and brought to the hospital by ground EMS. She was stable during
transport. Shortly after arrival, she had nausea and vomiting followed by deterioration. She was rapidly
intubated. Imaging studies demonstrated bilateral, acute subdural hematomas. Past medical history
included atrial fibrillation for which she was receiving Coumadin. Her coagulopathy was reversed but she
continued to do poorly and died 7 hours following admission. Her death was declared non-preventable by
the trauma medical director but was never presented to the full trauma peer review committee.
Comment: This patient’s deterioration occurred before the diagnosis of possible subdural hematoma
could be made and before FFP was administered. This appeared to be a non-preventable death. The lack
of presenting this death to the peer review committee deprived the committee from discussing the recent
publications on the benefit of rapidly reversing the coagulopathy in patients with what appears to be a
minor closed head injury.
Chart 4 (Non-preventable death): This 86 year-old man was riding his lawn mower when he mistakenly
put the mower into reverse causing rapid downhill movement resulting in rollover of the mower and him
being thrown from the lawn mower onto the ground. He immediately complained of hip pain and was
unable to walk. Significant past history included COPD, atrial fibrillation for which he was receiving
Coumadin, carotid artery disease, chronic renal failure, secondary hyper-parathyroidism, hypertension,
and a probable right upper lobe lung cancer. He was stable when first seen and was brought in by
ground EMS. He arrived at 1350. He remained stable in the emergency department where he was seen
by the orthopaedic surgeon. He was admitted for pain control and subsequent ORIF. He was admitted
to one of the primary care physicians. He was seen by the cardiologist who recommended FFP therapy
and beta blockade in preparation for operation. The orthopaedic surgeon deferred ORIF on post injury
day one because of the rapid heart rate. He performed ORIF on post injury day two. Postoperatively,
the patient was noted to be “turbulent” and somewhat uncooperative. Subsequent postoperative
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problems included worsening of his renal failure so that hemodialysis was recommended. Hemoptysis
occurred and was thought to be due to lung cancer. The patient did not want to have any hemodialysis.
He gradually developed worsening respiratory failure and died. His case was reviewed by the trauma
medical director, who determined that this was a non-preventable death. This death was not presented
to the full peer review committee.
Comment: There was no flow sheet in the chart and there was no evidence of a trauma team activation.
There appears to be a number of cases in which trauma team activation is indicated but is not
implemented. By not presenting this death at the peer review conference, the trauma surgeons lost the
opportunity to identify how better postoperative care can be provided by a surgeon in comparison to a
non-surgeon
Chart 8 (Pelvic fracture): This 80 year-old woman fell on the steps at home and was brought by her
family members to the emergency department because of pain in the left groin. When first seen by the
emergency physician, she had stable vital signs. Imaging studies identified a pelvic fracture. She was
admitted to the hospital for observation. Orthopaedic consultation was provided in the emergency
department. Past medical history included tricuspid regurgitation, pulmonary hypertension, and atrial
fibrillation for which she was receiving Coumadin. She was observed gradually improved, and was
discharged on post-injury day ten. No performance improvement issues were identified.
Comments: The absence of a flow sheet was due to the fact that she was brought in by family
members to the emergency department. The reviewer emphasized that in-hospital observation by a
surgeon would have created more concern about the potential for intracerebral bleeding in a patient
receiving anticoagulation.
Reference:
2.) American College of Surgeons Committee on Trauma. Consult visit Aspirus Wausau Hospital
May 2005.
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