We often hear well-intended advice such as, "Don't sweat the details. Take care of the big things and the details will take care of themselves." General Surgery residency programs emphasize the opposite. They instill in us a compulsive attention to detail. Taking care of the details allows the big things to take care of themselves.
The ultimate goal of care for trauma patients is preservation of life and limb. To achieve the most desirable outcome, a keen and complete evaluation should be implemented at the earliest possible time. Suspicion of significant injury often arises from a subtle detail.
A significant portion of General Surgery residency involves resuscitation and care of the multitrauma patient. Critical skills, many of which must be performed or initiated simultaneously for optimal care, include the ability to quickly and effectively complete the primary and secondary surveys, establish an airway, direct fluid resuscitative measures and perform diagnostic and therapeutic interventions. These skills become routine by completion of a five-year training program.
Not only does a general surgery residency provide training in the diagnosis and treatment of trauma-related injuries, but it provides a useful insight into directing a trauma team. The resuscitative team, including emergency room nursing staff, respiratory therapists, EMT staff and radiology technicians, must deliver expedient resuscitative measures in an organized manner. Task assignment to each team member distributes responsibility such that lack of completion of one task does not impair subsequent maneuvers. Without task assignment, several members of the trauma team may become focused upon a single task such as starting a single IV access that could be attempted simultaneously on opposite extremities by more than one member. Task assignment allows evaluation and resuscitation to proceed in an organized and efficient manner.
Victims requiring multiple operative procedures must be managed by stratification of the severity and urgency of multiple injuries. Optimal care involves a well-planned, timely operative approach often requiring multiple specialists. An unstable patient may require emergent laparotomy allowing only an abbreviated or incomplete evaluation by other surgical specialists. Completion of these evaluations sometimes must be postponed but should never be omitted. Injury prioritization has recently been emphasized in the training of general surgeons. The general surgeon should be willing to take responsibility for organizing the operative approach and coordinating perioperative management.
Patients who lack injuries warranting operative intervention by the general surgeon also benefit from the involvement of a physician interested in the overall management. Initiation of deep vein thrombosis prophylaxis, ulcer prophylaxis or implementation of early nutrition requires keen attention to detail, yet may ultimately prevent complications.
Care for the multitrauma patient can easily become fragmented by involvement of multiple subspecialists. As the surgical generalist, the general surgeon is the logical coordinator for the multiply injured patient.
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