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Although it may be apocryphal, it is said that the Chinese have a curse that states, “May you live in interesting times.” We live in interesting times. Hospitals across the country are facing financial difficulty and trauma centers are the first area examined for closure. Trauma centers in Pennsylvania, West Virginia, and Las Vegas have closed, at least temporarily, because of problems with specialist coverage. The insurance crisis in many of our states has created a situation where even physicians who are willing to care for trauma patients cannot get professional liability coverage, forcing them to either move to more physician friendly states, to come up with new alternatives such as physician or specialty owned carriers, or even to go bare. A flaw in the Medicare reimbursement formula has lead to a 10% decrease in physician payments over two years. And, even though Medicare does not pay a large role in trauma reimbursement, we all know that as Medicare does, other carriers rapidly follow. Leapfrog and other consumer groups are demanding “quality care” and are determining what that quality is, whether we agree with it or not. This quest for quality has lead to the 80 hour workweek for residents, which leads us to wonder how we will do the work we need to do and says nothing of how we will educate residents with these limitations. Finally, despite these restrictions, we still face the issue that medical students are not choosing surgical residencies as they did before, and surgical residents are not choosing trauma fellowships for training. How can trauma surgery and trauma surgeons survive in the current economic environment of medicine? Surely there have never been such interesting (and dangerous) times for our field? As most presidents do in preparing their presidential addresses, I went back and reviewed the addresses of my predecessors to gain historical perspective and to reexamine their wisdom. In doing that, I learned once again that there are no new problems in medicine—whatever problems appear new at the time have almost certainly been considered in the past, even if the tools were not available to address them. This also applies to the problems I am considering today. Our first president, Kimball Maull, talked about the disconnect between the public perception of trauma and the actual problem that trauma presents to society. Our second president, Burton Harris, talked about the problems of the redefinition of surgery and the surgical specialties, the lack of interest of many surgeons in doing trauma, and most fearsome of all, the evil effects of business on the field of medicine. Len Jacobs talked about the forces of diversification and specialization which were affecting trauma care and noted that “Uncompensated trauma care and maldistribution of trauma centers Submitted for publication May 7, 2003. Accepted for publication May 12, 2003. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Division of Trauma/Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee. Presidential address presented at the 16th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15–18, 2003, Ft. Myers, Florida. Address for correspondence: Blaine L. Enderson, MD, MBA, FACS, FCCM, Professor of Surgery and Chief, Division of Trauma/Critical Care, University of Tennessee Medical Center at Knoxville, Department of Surgery, University Memorial Hospital, 1924 Alcoa Highway, Knoxville, Tennessee, 37920-6999; email: benderso@utk.edu.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Background: Proinflammatory eicosanoids formed from arachidonic acid (AA) by lipoxygenase (LO) and cyclooxygenase (COX) pathways have been shown to inhibit apoptosis in certain cell types. This study determined whether inhibition of LO and COX increased apoptosis in AA-treated HL-60 cells in vitro. Methods: HL-60 cells were incubated with 50 μmol/L AA and an enzyme inhibitor (1-10 μmol/L) for COX, LO, 12-LO, and 5-LO for 12 hours. Flow cytometry was used to assess viability, apoptosis, and necrosis. Apoptosis was further assessed using terminal dUTP nick end-labeling and DNA fragmentation. Results: The highest concentration of LO inhibitors, but not COX inhibitors, decreased viability and increased apoptosis and necrosis in the presence of exogenous AA. Conclusion: These results suggest that disruption of the metabolism of AA by LO, in particular 5-LO, decreases cell survival and increases apoptosis. Thus, downstream metabolic processing of AA by LO but not COX plays a critical role in the regulation of HL-60 cell apoptosis.

Background: The differentiation of duodenal perforation from duodenal hematoma is not always possible with computed tomography (CT). Our diagnostic guideline has included duodenography to investigate CT findings of periduodenal fluid or wall thickening. However, the utility of duodenography as a diagnostic study in blunt abdominal trauma is not defined. We evaluated duodenography as a diagnostic test in patients with suspected blunt duodenal injuries (BDIs). Methods: During a 10-year period, 96 patients out of 25,608 trauma admissions had CT findings of possible BDI and underwent duodenography. Demographic and clinical data, diagnostic methods, and management were derived from prospectively collected data. CT and duodenography studies were reviewed and correlated with surgical findings and outcome. All CT scans were obtained with intravenous contrast; oral contrast was used in 32 patients. Duodenography was analyzed using the 2 x 2 method and Bayes theorem. Results: Indications for duodenography included periduodenal fluid without extravasation (76%), abnormal duodenal wall thickening (16%), and retroperitoneal extraluminal gas (5%). Eighty-six duodenography studies were reported as normal, six were consistent with hematoma, one was indeterminate, and only three revealed extravasation. Two of these three patients with duodenal perforation had retroperitoneal extraluminal air. Only one patient underwent exploration on the basis of duodenography. No blunt duodenal perforation was diagnosed by CT. Overall, duodenography had sensitivity of 54% and specificity of 98%. For BDIs requiring repair, duodenography sensitivity was only 25%; the false-negative rate was also 25%. Retroperitoneal extraluminal air was a useful sign of duodenal perforation, occurring in two of three patients with BDI and only in one without BDI (p < 0.001). Conclusion: Duodenography has a low sensitivity in patients with suspected BDI by CT findings and is of minimal utility in diagnostic evaluation. Retroperitoneal extraluminal air seen on CT is an important sign of BDI requiring surgical repair.

Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.

This study examined a mesh wrap technique that provides effective hepatic tamponade and clinical experience with the technique in 6 patients is reported. Technical feasibility and effectiveness were investigated in 8 miniature swine. The animals were divided into two groups: group A (n = 4), control animals; stellate liver lacerations without mesh wrap or other measures for hemostasis, and group B (n = 4); stellate liver laceration with synthetic absorbable mesh wrap applied for hepatic hemostasis. Except for mesh application, all variables were held constant for both groups. All animals in the control group died within 20 to 120 minutes (mean: 65 minutes). All animals in group B survived (p = 0.029). The livers were harvested for gross and microscopic examinations. No abscess, bile leak, or hematoma was noted. Clinically, total mesh wrapping was attempted in 6 patients with blunt exsanguinating liver injuries. The technique failed intraoperatively in two patients with juxtacaval lacerations and hepatic vein avulsion injuries. One patient with a bilobar gunshot wound died later of sepsis. In three patients with bursting injuries, the technique successfully controlled bleeding and resulted in long-term survival. In conclusion, the total hepatic mesh wrap (1) is geometrically, technically, and mechanically feasible, (2) was not associated with complications in this series, and (3) can effectively secure hemostasis following parenchymal liver injury.