Why We Speak Up

We are sure that, at least once in your medical life, you’ve found yourself in an Emergency Department with a critical surgical patient asking “what the heck should I do?!”
Well, welcome to Acute Care Surgery! But, what is it exactly?

You may think ACS is elective surgery speeded up to the extreme, well, it’s nothing like that!

ACS is a whole new way of thinking surgery! We are used to elective surgery, in which our first aim is to sort out the problem and to rebuild the patient’s anatomy. In elective surgery you have a prepared patient, who has been visited by each needed specialist; you have X-Rays and CTs, you schedule the procedure and have a clear view of what you’ll face. Moreover, the patients are also ready for your surgery: they slept at best, they are physically and mentally ready!

On the other hand, when you face a critical patient everything you’ve learned so far in university falls apart. Your priorities crash due to his/her conditions and the anesthetist screams at you that you cannot schedule a patient with 70/30 mmHg and 150 bpm for a 5 hrs complex operation!

Here is where your entire mindset needs to change to reorganize priorities, starting with physiology!

Physiology is your first and main goal in ACS. After that, anatomy can have some space!

In critical situations the patient doesn’t need a fancy operation, he/she needs a well done surgical cleanup and a bed in the Intensive Care Unit. 

Let’s say it one more time, only after having restored physiology, start thinking about anatomy. 

Now, think about a 75 yo male with septic shock from perforated diverticulitis with free abdominal bowel content, medical history of hypertension, and a couple of previous minor operations. The situation is critical thanks to a 75/32 mmHg, 137 R bpm (beats per minute), and Lactate levels of 12 mmol/L. You rush to the Operating Room! But then, what to do?

Your first choice is surely to resect the perforated sigma, do a nice and clean Knight-Griffen stapled anastomosis, and leave no drainage! Operating time 4.5 hrs, even better than your Chief! 

If your choice is this, we really have to work hard on you…

Your patient needs to survive the sepsis or your anastomosis won’t have enough blood and oxygen supply to heal, so he needs to have the infection source controlled, antibiotics, inotropes, and fluids. Among this list, your role as a surgeon is to control the infection source and then you have to collaborate with the intensivists to bring the patient out alive from the ICU, and the hospital.

Your surgical option is to resect the sigma and clean up the abdomen, then, what to do with the colonic stump? One option is to complete the operation with a terminal colostomy like a Hartmann procedure. On the other hand, you can decide to leave the abdomen open, let the patient regain his entire physiology (or at least a part of it), and then, after a while, do a nice and neat anastomosis. An even better solution!

As you can see by our suggestion, surgery is not the main part of the plan. When you face a really critical patient you have to step down by your purely surgical podium, start knowing of intensive care and collaborate with the intensivists, for the sake of patients. Intensivists are part of the ACS Team, not enemies!

Another thing you always have to bear in mind is that your emergency patients won’t come to the Emergency Department prepared for you. They will have a full stomach, anticoagulants on board and their physical status won’t be at its best (on the contrary, it will be drained by the pathology). So, as we already established, it is a cornerstone to restore his/her physiology. This should be done before and during surgery.

Bear also in mind to reduce the surgical insult to the minimum (as time and cuts) and let the patient regain strength, before definitive management!

We are sure you heard about the ABCDE approach to critical patients, but do you know why it is so widely used? The core principle is very simple: “treat first what kills you first!”

A patient with an inability to inhale would be lost before a patient with respiratory failure, who would even die before the one bleeding and so on! The same mindset must be incorporated in your way of evaluating a critical surgical patient as in the ED as in the OR. 

Restore physiology and then anatomy!

Now that we explained why ACS is so important let’s see also if it is so frequent or not!

In 2016 Eurostat standardized the causes of death in Europe for 100.000 inhabitants. As you can notice in the figure, accidents are the fifth cause of death in the male population and the sixth for women. 

Not so uncommon as you can see!

But there’s more… In the analysis conducted by the CDC on the leading causes of death in the States, trauma appeared the main cause of death among the population between 1 and 44 years old. Considering all age groups, it is the third cause in men and the sixth among women.

Moreover, a very interesting article by Becher et al. created a perfect snapshot of the present situation in which Emergency General Surgery (EGS) is still not considered as a proper subspecialty of general surgery but just something with no father or mother. 

In the same article, the authors underline the burden of EGS diseases as a cause of hospital admission. The surprising fact is that it outnumbers “giants” such as diabetes, coronary heart disease, and cancer. The question now is why it doesn’t need a specialized doctor, as we need the diabetologist for diabetes or a knee specialized orthopedic!

So, now we hope we have created a bit of interest in your mind!

We don’t know if you’re a medical student, a resident, or a consultant, but you’re more than welcome to Surgical Pizza!

References

1. https://ec.europa.eu/eurostat/
2. Heron M. Deaths: leading causes for 2017. National Vital Statistics Reports 2019;68.
3. Becher RD, et al. Ongoing evolution of emergency general surgery as a surgical subspecialty. J Am Coll Surg 2018;226:194–200. 
4. Gale SC, et al. The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample – 2001 to 2010. J Trauma Acute Care Surg 2014;77:202-8.