COMO PREPARAR OS CIRURGÕES PARA O TRAUMA EM CONTEXTO DE POUCA EXPOSIÇÃO?

Carlos Mesquita Coimbra - Portugal

Da faculdade aos cursos de aperfeicoamento • Como preparar os cirurgões para o trauma em contexto de pouca exposição?

Carlos Mesquita Coimbra – Portugal

“O Cirurgião Barbeiro” – Jacobus de Cessolis, séc. XV

HOSPITAIS DA UNIVERSIDADE DE COIMBRA SERVIÇO DE URGÊNCIA

POPULAÇÃO R. CENTRO: > 2000.000 h

URGÊNCIA HUC (ADULTOS):

• Admissões / ano > 200.000 > 500 / d

• Internamentos / ano > 20.000

> 50 / d

• Emergências / ano > 2.000 > 5 / d

INTERVENÇÕES CIRÚRGICAS > 4.000

~ 11 / d

CIRURGIA GERAL 5 / d

Doença Interna 120.286

Quedas 8.790

Outros 7.231

Acidentes de Trabalho 4.663

Acidentes de Trânsito 2.209

Intoxicações 1.241

Agressões 1.150

Acidentes Escolares 829

Acidentes Desportivos 434

Total / ano 18.075 1.241 7.231 120.286 146.833

Total / dia 50 3 20 330 403

12 % 1 % 5 % 82 %

SERVIÇO DE URGÊNCIA– Admissões / ano

CIRURGIA GERAL – 220 camas

• 3 serviços em dois hospitais

• 1 unidade de transplantação hepática

• 1 unidade de cuidados cirúrgicos intermédios

URGÊNCIA CIRÚRGICA

• 2500 internamentos / ano – 7 / dia = ocupação média de 60-70 camas, um terço

• 1800 intervenções/ano – 5 / dia = 30 %, quase um terço da actividade operatória global

CIRURGIA GERAL E CIRURGIA DE URGÊNCIA

EMERGENCY SURGERY

Others 327 - 20 %

Sepsis 869 – 53 %

Trauma 443 - 27 %

CM, n=1639, 34 years (1982 – 2015)

ASPECTOS NEGATIVOS:

• bloco operatório dedicado apenas de manhã (08 -16) e nos dias úteis

• reflexos previsíveis na eficácia dos procedimentos de controlo de dano

• atribuição de significado clínico aos fluxogramas da Triagem de Manchester e delegação de competências em não médicos como forma de contornar a falta de investimento numa triagem médica qualificada

• área cirúrgica transformada num desdobramento da urgência básica

• equipa cirúrgica forçada a dispersar a atenção por um número de doentes mais de 10 vezes superior ao expectável

• consequente quebra de qualidade no atendimento dos doentes cirúrgicos

• internos de Cirurgia Geral no papel de generalistas e recorrentemente impedidos de ir ao bloco operatório, face ao volume de doentes a aguardar uma primeira observação

CIRURGIA GERAL E CIRURGIA DE URGÊNCIA

RESPOSTA HOSPITALAR AO TRAUMA

Como organizar

ou Como é difícil organizar

Artigo 23.º

Comissão de Trauma

À Comissão de Trauma (CT) compete em geral promover a otimização de todos os aspetos relacionados com os cuidados a prestar ao doente traumatizado, segundo o estado da arte e as disposições normativas de boas práticas.

A CT é multidisciplinar e constituída por sete membros, nomeados pelo Conselho de Administração. O seu presidente é o coordenador médico do Centro de Trauma - CHUC.

A CT pode agregar outros elementos sempre que julgue necessário.

• Determina a estrutura do Sistema Integrado de Emergência Médica (SIEM), estabelece padrões mínimos e define o processo de monitorização e avaliação

• Prevê, no que , especificamente, se aplica a adultos e a Centros de Trauma, enquanto polos duma rede nacional de tratamento do politraumatizado grave,

1. que devam ter heliporto ou acesso fácil a um

2. que funcionem numa lógica de centralização de recursos altamente diferenciados, assegurando a prestação de cuidados de saúde no âmbito das seguintes valências, além das obrigatórias para um SUP:

• Radiologia de intervenção

• Cirurgia Cardiotorácica

• Cirurgia Maxilofacial

• Cirurgia Plástica e Reconstrutiva

• Cirurgia Vascular

DESPACHO 10319/2014, DE 11 DE AGOSTO

4. que constituam referência para os doentes a incluir na Via Verde Trauma

5. que a formação e o currículo de 100% dos profissionais em exercício passe a contemplar o suporte avançado de vida em trauma (SAVT)

• que esta formação esteja concluída em três anos

6. que a formação e o currículo de 100% dos profissionais em exercício passe a contemplar o reconhecimento de Competência em Emergência Médica pela OM

• que este reconhecimento esteja concluído em cinco anos

DESPACHO 10319/2014, DE 11 DE AGOSTO

• Tendo em conta, entre outras, as recomendações da DGS e da OM, haverá que compreender o SAVT não apenas como um curso mas, de modo mais abrangente, como um conjunto de modelos de mais do que um nível, orientados para grupos e subgrupos profissionais diferentes, reconhecidos internacionalmente e bem divulgados em Portugal, designadamente

• ATLS, para médicos generalistas

• MRMI, para intervenientes na resposta ao desastre e catástrofe

• ETC, para membros das equipas hospitalares de trauma

• DSTC, MUSEC e EASC, para cirurgiões

• DATC, para anestesistas

• DPNTC, para enfermeiros do bloco operatório

DESPACHO 10319/2014, DE 11 DE AGOSTO

TEAM®

2000

ATLS®

1999

DSTC™

2003 DPNTC™

2005 DATC™

2009

ETC®

2009 / 2014

2013 2013

INVITED FACULTY

2006 – 2007 – 2008 – 2009 – 2011 – 2013 – 2014 – 2015 - 2016

?

? ? ?

? ? • 26 Major Trauma Centres

• Population > 54,000,000

April 2012 UK Government announced creation of major

trauma centres

• Trauma team

• ISS > 15 assessed by consultant within 5 minutes

• CT scan < 30 minutes

• CT scan reported < 60 minutes

• Consultants available on site within 30 minutes when required:

Neurosurgery

Spinal and spinal cord surgery

Vascular surgery

General surgery (adult or child)

Trauma and Orthopaedic surgery

Cardiothoracic surgery

Plastic surgery

Maxillofacial surgery

Ear nose and throat surgery

Anaesthetics

Interventional radiology

Intensive care

Emergency Surgery

Who is practicing what?

In most European countries, a progressive focus on planned activities at the expense of the urgent, has undermined the ability of surgeons in general to intervene in emergency situations outside their area of specialization

• This is even more important when governments and institutions maintain medical missions in theaters marked by underdevelopment, political instability or even war

To bring emergency surgical care into line with the modern world, it is essential to redesign our training curricula

• standards of care for emergency surgical admissions often unsatisfactory

failure to prioritize patients

inadequate senior input

unsatisfactory allocation of infrastructure and manpower

• emergency surgery characterized as the ‘Cinderella Service’

Association of Surgeons of Great Britain and Ireland (2007):

• multicentre audit to measure non-risk-adjusted outcome after emergency laparotomy in order to establish a baseline

• data from 1853 patients were collected from 35 NHS hospitals • mortality rates varied from 3.6% to 41.7%; unadjusted 30 day

mortality was 14.9% for all patients and 24.4% in patients aged 80 or over

• clinicians asked to collect prospective anonymized data for a period of 3 months

• data set included a description of patient characteristics, timing of surgery, grade of clinical personnel in theatre, anatomical site of surgery, operative procedure, postoperative destin- ation, length of stay and 30 day mortality

• analysis of the pooled data returned to contributors, allowing them to identify and reflect upon their own outcomes

Possible solutions

• protocols & pathways

• networks

• non-medical roles

• new training models

Watson R, Crump H, Imison C, Currie C and Gaskins M (2016) Emergency general surgery: challenges and opportunities. Research Report. Nuffield Trust.

• Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures

• a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide

• these 7 procedures were partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy

JAMA Surg. doi:10.1001/jamasurg.2016.0480. Published online April 27, 2016

• the term ‘Emergency General Surgeon’ is now becoming familiar in the UK but, however, EGS remains an unrecognised UK training subspecialty without a separate higher surgical training programme or modular competency based assessment.

• UK higher surgical training programmes have not sought to address potential short falls in emergency general surgical training, and competencies or encouraged trainees to pursue a career in EGS

• EGS training remains acquired during out of hours service provision (limited by European Working Time Directive) on an ad hoc basis, is not standardized and a workforce gap has been created

PROPOSAL TO ESTABLISH A EUROPEAN

QUALIFICATION OF COMPETENCE IN TRAUMA

AND NON-TRAUMA EMERGENCY SURGERY

Carlos Mesquita, Renato Bessa de Melo, Fernando Ferreira, Ricardo Pereira, Jorge Pereira, Luís Filipe Pinheiro, Henrique Alexandrino, Mário Mendes, Pedro Ramos, António Figueiredo, Arnaldo Figueiredo, João Paulo Farias

Working Group for Emergency Surgery of the Portuguese Medical Association (GTFCE-OM)

Ordem dos Médicos GT Cirurgia de Emergência

Ordem dos Médicos – Grupo para a Formação em Cirurgia de Emergência

Sociedade Portuguesa de Cirurgia - Capítulo de Trauma

Associação Lusitana de Trauma e Emergência Cirúrgica

ESTES - Visceral Trauma & Emergency Surgery Sections

IATSIC - National Steering Group for DSTC

WSES – World Society of Emergency Surgery

ACS - American College of Surgeons

1. TRAUMA AND SURGICAL INTENSIVE CARE 06 months

Participation in Trauma Teams

Pre and postoperative treatment of complex surgical conditions, in high dependency

care setting

03 (or 520

hours)

03

1. ELECTIVE AND EMERGENCY SURGERY 18 months

General Surgery 06

Cardiothoracic Surgery 02 (1/3)

Angiology and Vascular Surgery 02 (1/3)

Orthopedics 02 (1/3)

Optional: Transplantation Surgery (including harvesting of abdominal and thoracic

organs), Gastrointestinal endoscopy, Interventional Radiology, Pediatric Surgery, Plastic

Surgery and Burns, Neurosurgery, Urology, Gynecology and Obstetrics and others, or

maximization of time in nuclear traineeships

06 (4/8)

1. COURSES:

Advanced Life Support (ALS, ERC) or equivalent

Essential

Advanced Trauma Life Support (ATLS, ACS) or equivalent Essential

Fundamental Critical Care Support (FCCS, SCCM) or equivalent Desirable

Definitive Surgical Trauma Care (DSTC, DSTS, IATSIC) or equivalent Essential

Emergency Surgery Course (ESC, ESTES) or equivalent Desirable

Modular Ultrasound ESTES Course (MUSEC, ESTES) or equivalent Essential

TRAINEESHIPS AND COURSES Should constitute initial standards the existing training programs in related areas for residents of the various surgical

specialties and the courses listed in this table. However, if the acquisition of specific skills is obtained by other means, including accredited simulation environment, the frequency of the corresponding stages or courses can be dispensed

ANATOMICAL AREA / PROCEDURE ESSENTIAL DESIRABLE

1. AIRWAY

Nasal and oral endotracheal (including rapid sequence) intubation X

Cricothyroidotomy, open and percutaneous X

Tracheostomy, open and percutaneous X

1. SKULL / FACE

ICP monitoring X

Trepanation / Craniotomy X

Nasal packing X

1. NECK

Approach and control of vascular and aerodigestive lesions X

1. THORAX

Damage control techniques, eg aortic clamping X

Approach and control of cardiac lesions and cardiac tamponade X

Approach and control of vascular lesions X

Approach and control of aortic injuries in blunt trauma X

Approach and control of tracheobronchial and pulmonary lesions X

Surgical treatment of infections and empyema X

Surgical treatment of diaphragmatic injuries X

Bronchoscopy: diagnostic and therapeutic X

Approach and control of esophageal lesions X

Video-assisted surgery in relation to the procedures performed X

ACQUISITION OF TECHNICAL COMPETENCES The technical capabilities herein should preferably be obtained in a clinical context. However, simulation training in an

accredited environment, if plausible, can be an alternative

1. ABDOMEN AND PELVIS

Damage control techniques (including pelvic stabilization) X

Approach and control of vascular lesions X

Approach and control of digestive tract and attached organs lesions X

Approach and control of kidneys and urinary tract X

Approach and control of female genital lesions (including pregnancy) X

Approach and control of abdominal sepsis X

Treatment of necrotizing soft tissue lesions X

Approach and control of abdominal compartment syndrome X

Techniques for abdominal wall reconstruction X

Video-assisted surgery in relation to the procedures performed X

1. EXTREMITIES

Imobilization of fractures and dislocations and application of tractions and external fixators

X

On-table angiography X

Approach and control of vascular lesions X

Thromboembolectomies X

Vascular access techniques in context of Extra Corporeal Life Support X

Fasciotomies X

Treatment of necrotizing soft tissue lesions X

Amputations X

1. OTHERS

Plastics and skin grafts (including burns) X

Hypothermia treatment techniques X

Upper and lower gastrointestinal endoscopy X

Diagnostic Ultrasonography X

Therapeutic Ultrasonography X

HONORARY DIPLOMA – EMERGENCY SURGERY

–

BOARD EXAMINATION – EMERGENCY SURGERY

To be considered for the award of an Honorary FEBS(EmSurg) diploma a candidate must:

1. To have been a consultant surgeon (or equivalent) dealing with emergency surgical admissions for a minimum of 10 years

2. To have taught on a nationally or internationally recognised course directly relevant to emergency surgery within the preceding 5 years

3. To have at least one publication in the field of emergency surgery published in a peer reviewed journal during the preceding 2 years

4. To have presented to at least one major national or international meeting in the preceding 2 years

5. To have contributed to the development of emergency surgery at a regional, national or international level

HONORARY DIPLOMA – EMERGENCY SURGERY

BOARD EXAMINATION – EMERGENCY SURGERY

To apply for Eligibility the candidate must fulfill the following requirements:

1. To have been trained in one of the 28 European Union countries, a UEMS country (Iceland, Norway and Switzerland), an associated UEMS country (Armenia, Israel and Turkey) or a country with UEMS observer status (Georgia, Lebanon and Morocco)

2. To have been trained outside the UEMS area provided that the training and qualifications are equivalent

3. To be able to communicate in the English language. Examinations in the local national language(s) may also be provided at the discretion of the executive

4. To have a national Certificate of Completion of Specialist Training

5. To provide a logbook listing the own experience of the required operations and procedures, as published in "Emergency Surgery Curriculum - Skills“. For each procedure the date it was performed, patient's initials (or hospital admission number) and type of independent expert must be provided. Must not contain patients' names

6. All candidates should have successfully completed the Advanced Trauma Life Support (ATLS®) provider course. As an alternative, to provide satisfactory evidence within their logbook of the procedures listed in Category E

7. Candidates should have completed the Definitive Surgical Trauma Care (DSTC®) course or an approved alternative, (i) the Definitive Surgical Trauma Skills (DSTS®) course or (ii) both the Advanced Trauma Operative Management (ATOM®) and the Advanced Surgical Skills for Exposure in Trauma (ASSET®) courses. As an alternative, to provide satisfactory evidence within their logbook of the procedures listed in Category F

8. All candidates must have contributed to a published scientific paper for which they are listed as a co-author

BOARD EXAMINATION – EMERGENCY SURGERY

9. The candidate must have a total of 12 credit points based on the following criteria:

• Participation at recognized international congress (e.g. European Society for Trauma and Emergency Surgery (ESTES) or American Association for the Surgery of Trauma (AAST) (4 points)

• Participation at recognized international congress (e.g. ESTES or AAST) and first authorship of an accepted paper or poster (8 points)

• Participation national congress (2 points) • Participation at national congress and first authorship of an accepted

paper or poster (4 points) • Publication (first authorship) in peer reviewed national surgical journal

(8 points) • Publication (first authorship) in peer reviewed international surgical

journal (12 points) 10. Candidates must be recommended by 2 independent experts, one of which

must not currently work in the same region as the candidate

BOARD EXAMINATION – EMERGENCY SURGERY

The minimum requirement for eligibility for assessment is a certified number of 550 credit points for the listed procedures All the credit points from Category A and at least 150 credit points from Categories B, C and D must be achieved as principal surgeon

EMERGENCY SURGERY SKILLS