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BenjaminM.Braslow,MD

AssociateProfessorofClinicalSurgery, DivisionofTraumatology,SurgicalCritical CareandEmergencySurgery;SectionChief, EmergencySurgeryService,Departmentof Surgery,PerelmanSchoolofMedicine, UniversityofPennsylvania,Philadelphia, Pennsylvania

L.D.Britt,MD,MPH,FACS HenryFordProfessorandEdwardJ. BrickhouseChairman,Departmentof Surgery,EasternVirginiaMedicalSchool, Norfolk,Virginia

SusanI.Brundage,MD,MPH SectionChief,AcuteCareSurgery, Director,SurgicalCriticalCare,Department ofSurgery,NewYorkUniversitySchool ofMedicine;NYULangoneMedical Center,TischHospital;Departmentof Surgery,BellevueHospital,NewYork, NewYork

ThomasP.Brush,MD Resident,DepartmentofSurgery,Creighton University,Omaha,Nebraska

ClayCothrenBurlew,MD,FACS Director,SurgicalIntensiveCareUnit, ProgramDirector,SCCandTACS Fellowships,DepartmentofSurgery,Denver HealthMedicalCenter;ProfessorofSurgery, UniversityofColoradoSchoolofMedicine, Denver,Colorado

PatriciaMarieByers,MD,FACS Chief,SurgicalNutrition,DivisionofTrauma andSurgicalCriticalCare,TheDeWitt DaughtryFamilyDepartmentofSurgery, UniversityofMiamiMillerSchoolof Medicine,Miami,Florida

KimM.Caban,MD AssistantProfessorofRadiology,University ofMiamiMillerSchoolofMedicine,Jackson MemorialHospital–RyderTraumaCenter, ER-TraumaRadiologyDivision,Miami, Florida

JeremyCannon,MD,SM,FACS,LtCol, USAFMC Chief,TraumaandCriticalCare,San AntonioMilitaryMedicalCenter,San Antonio,Texas;AssociateProfessorof Surgery,UniformedServicesUniversity oftheHealthSciences,Bethesda, Maryland

ShawnM.Cantie,MD

ClinicalInstructorofAnesthesiology,The UniversityatBuffalo,StateUniversityof NewYork,ErieCountyMedicalCenter, Buffalo,NewYork

JoséCeballosEsparragon,MD SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

HowardR.Champion,FRCS,FACS ProfessorofSurgery,UniformedServices UniversityoftheHealthSciences, Bethesda,Maryland

BenjaminChandler,MD

PGY-4Resident,DepartmentofSurgery, RutgersNewJerseyMedicalSchool, UniversityofMedicineandDentistryofNew Jersey;Resident,DepartmentofSurgery, UniversityHospital,Newark,NewJersey

DavidC.Chang,PhD,MPH,MBA

AssociateProfessorofSurgery, MassachusettsGeneralHospital, HarvardMedicalSchool,Boston, Massachusetts

StevenCheung,MD Resident,GeneralSurgery,Creighton UniversityMedicalCenter,Omaha, Nebraska

WilliamC.Chiu,MD,FACS,FCCM AssociateProfessorofSurgery, Director,SurgicalCriticalCareFellowship Program,RAdamsCowleyShock TraumaCenter,UniversityofMaryland SchoolofMedicine,Baltimore, Maryland

A.BrittonChristmas,MD,FACS AssociateProfessorofSurgery,Trauma, SurgicalCriticalCare,andEmergency GeneralSurgery,CarolinasMedicalCenter, Charlotte,NorthCarolina

DavidJ.Ciesla,MD ProfessorofSurgery,DirectorofAcuteCare SurgeryDivision,UniversityofSouth FloridaMorsaniCollegeofMedicine; MedicalDirector,RegionalTrauma Program,TampaGeneralHospital, Tampa,Florida

WilliamG.Cioffi,MD,FACS

J.MurrayBeardsleyProfessorandChairman, AlpertMedicalSchoolofBrownUniversity

DepartmentofSurgery;Surgeon-in-Chief, RhodeIslandHospitalandTheMiriam Hospital,Providence,RhodeIsland

ChristineS.Cocanour,MD, FACS,FCCM

ProfessorofSurgery,UCDavisMedical Center,Sacramento,California

MitchellJ.Cohen,MD AssistantProfessorinResidence, DepartmentofSurgery,Universityof CaliforniaSanFrancisco,SanFrancisco, California

RaulCoimbra,MD,PhD,FACS

TheMonroeE.TroutProfessorofSurgery, Surgeon-in-Chief,ExecutiveVice-Chairman, DepartmentofSurgery,ChiefDivisionof Trauma,SurgicalCriticalCare,Burns,and AcuteCareSurgery,UniversityofCalifornia SanDiegoHealthSystem,SanDiego, California

PeterCollister,MD Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

EdwardE.Cornwell,III,MD,PhD, FACS ChairmanandProfessorofSurgery,Howard University,Washington,D.C.

ThomasB.Cox,BS President,CoxBusinessConsulting,Inc., Beaverton,Oregon

MartinA.Croce,MD Professor,DepartmentofSurgery,University ofTennesseeHealthScienceCenter; ChiefofTraumaandCriticalCare, TraumaDivisionRegionalOneHealth, Memphis,Tennessee

GaryH.Danton,MD,PhD MedicalDirectorofRadiology,Trauma/ER Radiology,JacksonMemorialHospital; Director,RadiologyResidencyTraining Program,AssistantProfessorofClinical Radiology,JacksonHealthSystem,Jackson, Florida;Chief,SectionofImaging Informatics,Trauma/ERRadiology, UniversityofMiami,Miami,Florida

KimberlyA.Davis,MD,MBA ProfessorofSurgery,ViceChairman ofClinicalAffairs,ChiefoftheSectionof Trauma,SurgicalCriticalCare,and

SurgicalEmergencies,YaleUniversity SchoolofMedicine;TraumaMedical Director,SurgicalDirector,Quality andPerformanceImprovement, Yale-NewHavenHospital,NewHaven, Connecticut

EliasDegiannis,MD,PhD,FRCS (Glasg),FCS(SA),FACS ProfessorofSurgery,Universityofthe Witwatersrand;Head,TraumaDirectorate, ChrisHaniBaragwanathAcademicHospital, Johannesburg,SouthAfrica

EdwinA.Deitch,MD

ProfessorandChairman,RutgersNewJersey MedicalSchool,UniversityofMedicine andDentistryofNewJersey;Chiefof Surgery,UniversityHospital,Newark, NewJersey

RichardDenney,MD

ChiefResident,GeneralSurgery,Creighton University,Omaha,Nebraska

ChristopherJ.Dente,MD,FACS AssociateProfessorofSurgery,Emory University;AssociateDirectorofTrauma, GradyMemorialHospital,Atlanta,Georgia

UrmenDesai,MD,MPH

Plastic,Aesthetic,andCosmeticSurgeon, DesaiPlasticSurgeryofBeverlyHills,Beverly Hills,California

RochelleA.Dicker,MD

AssociateProfessorofSurgeryand Anesthesia,UniversityofCalifornia SanFrancisco,SanFranciscoGeneralHospital, SanFrancisco,California

LawrenceN.Diebel,MD,FACS Professor,DepartmentofSurgery, WayneStateUniversity,Detroit, Michigan

KarevDimitryi,MD,FACS Professor,DepartmentofSurgery,Wayne StateUniversity,Detroit,Michigan

AndrewR.Doben,MD

AssociateProfessorofSurgery,Department ofSurgery,TuftsUniversitySchoolof Medicine,Boston,Massachusetts; Director,SurgicalIntensiveCareUnit, DivisionofTraumaandAcuteCare Surgery,DepartmentofSurgery, BaystateMedicalCenter,Springfield, Massachusetts

JayDoucet,MD,MSc,FRCSC, FACS,RDMS

ProfessorofClinicalSurgery,Director, SurgicalIntensiveCareUnit,Director, EmergencyPreparednessandResponse, DivisionofTrauma,SurgicalCriticalCare, andBurns,DepartmentofSurgery, UniversityofCaliforniaSanDiegoHealth System,SanDiego,California

ThereseM.Duane,MD, FACS,FCCM

Vice-Chair,DepartmentofSurgeryfor QualityandSafety,MedicalDirectorfor AcuteCareSurgeryResearch,JohnPeter SmithHealthSystem,FortWorth,Texas

JoeDuBose,MD,FACS

AssociateProfessorofSurgery,Uniformed ServicesUniversityoftheHealthSciences, Baltimore,Maryland;VascularFellow, UniversityofTexasHealthSciences Center–Houston,Houston,Texas

WayneDubov,MD

BoardCertifiedbytheAmericanBoardof PhysicalMedicineandRehabilitation (ABPMR),Subspecialty–SpinalCord InjuryMedicine,Diplomateofthe AmericanBoardofElectrodiagnostic Medicine,LehighValleyHealthNetwork, Allentown,Pennsylvania;Clinical AssistantProfessor,UniversityofSouth Florida,MorsaniCollegeofMedicine, Tampa,Florida

JuanC.Duchesne,MD,FACS, FCCP,FCCM

TraumaMedicalDirector,GMEMedical Director,NorthOaksHealthSystem, Hammond,Louisiana;AssociateProfessorof Surgery,TulaneUniversity,LouisianaState UniversityHealthSciencesCenter; Chairman,LouisianaCommitteeofTrauma, NewOrleans,Louisiana

StanleyJ.Dudrick,MD,FACS, FACN,CNS

ProfessorofSurgery,TheCommonwealth MedicalCollege,Scranton,Pennsylvania; EdwardS.AndersonEndowedChair, ProfessorandMedicalDirectorofPhysician AssistantStudies,SchoolofArtsand Sciences,MisericordiaUniversity,Dallas, Pennsylvania;ProfessorofSurgery,Emeritus, YaleUniversityMedicalSchool,NewHaven, Connecticut

RodneyDurham,MD,FACS

ProfessorofSurgery,UniversityofSouth Florida,Tampa,Florida

AnthonyM.Durso,MD

AssistantProfessorofRadiology, UniversityofMiamiMillerSchoolof Medicine,JacksonMemorialHospital, Miami,Florida

SoumitraR.Eachempati,MD, FACS,FCCM

ProfessorofSurgery,Professorof Medicine,DivisionofMedicalEthics, WeillCornellMedicalCollege,NewYork, NewYork

Colonel(Ret.)BrianEastridge,MD

TraumaandSurgicalCriticalCare, DirectorEmeritus,JointTraumaSystem Program;TraumaConsultant,U.S.Army SurgeonGeneral,InstituteofSurgical Research,Houston,Texas

AileenEbadat,MD

Resident,DepartmentofSurgery,University ofTexasSouthwestern,Austin,University MedicalCenterBrackenridge,Austin,Texas

DavidT.Efron,MD,FACS AssociateProfessorofSurgery, AnesthesiologyandCriticalCareMedicine, EmergencyMedicine,Chief,Divisionof AcuteCareSurgery:Trauma,CriticalCare, Emergency,andGeneralSurgery,Directorof AdultTrauma,DepartmentofSurgery, TheJohnsHopkinsHospital,Baltimore, Maryland

EricElster,MD,FACS,CAPT MCUSN

ProfessorandChairman,NormanM.Rich DepartmentofSurgery,UniformedServices UniversityoftheHealthSciences,Bethesda, Maryland

MichaelEnglehart,MD

BillingsClinic,Billings,Montana

ThomasJ.Esposito,MD,MPH Professor,DepartmentofSurgery,Loyola UniversityChicago,StritchSchoolof Medicine,Chicago,Illinois;Chief,Division ofTrauma,SurgicalCriticalCareand Burns,DepartmentofSurgery,Loyola UniversityMedicalCenter,Maywood, Illinois

GlynEstebanez,MD,MRCS

SurgicalRegistrar,WessexSchoolofSurgery, UnitedKingdom;TraumaResearchFellow, MEDITECH,Neiva,Colombia

SusanEvans,MD,FACS,FCCM

AssociateProfessorofSurgery,Divisionof AcuteCareSurgery,CarolinasMedical Center,Charlotte,NorthCarolina

SamirM.Fakhry,MD,FACS

CharlesF.CrewsProfessorandChief, GeneralSurgery,MedicalUniversityofSouth Carolina,Charleston,SouthCarolina

AnthonyFalvo,DO,FACOS,FACS ClinicalEducator,WayneStateUniversity SchoolofMedicine,Detroit,Michigan

DavidV.Feliciano,MD

BattersbyProfessorandChief,IUDivision ofGeneralSurgery,ChiefofSurgery, IndianaUniversityHospital,Indianapolis, Indiana

LuisG.Fernández,MD,KHS,FACS, FASAS,FCCP,FCCM,FICS

AssistantClinicalProfessorofSurgery/Family Practice,UniversityofTexasHealthScience Center,Tyler,Texas;AdjunctClinical ProfessorofMedicineandNursing, UniversityofTexas,Arlington,Texas; Chairman,DivisionofTraumaSurgery/ SurgicalCriticalCare,ChiefofTrauma SurgicalCriticalCareUnit,TrinityMother FrancesHealthSystem,Tyler,Texas;Brigadier General,PastCommandingGeneral,TXSG MedicalBrigade,(Ret/HR),Austin,Texas

MitchellFink,MD UniversityofPittsburgh,Pittsburgh, Pennsylvania

LewisM.Flint,MD,FACS

Editor-in-Chief,SelectedReadingsinGeneral Surgery,DivisionofEducation,American CollegeofSurgeons,Chicago,Illinois

DonaldE.Fry,MD,FACS

AdjunctProfessorofSurgery,Northwestern UniversityFeinbergSchoolofMedicine, Chicago,Illinois;EmeritusProfessorof Surgery,UniversityofNewMexicoSchool ofMedicine,Albuquerque,NewMexico

TakashiFujita,MD,PhD,FACS AssociateProfessor,Traumaand ResuscitationCenter,TeikyoUniversity Hospital,Tokyo,Japan

JosephM.Galante,MD

AssociateProfessorandViceChair, Education,DepartmentofSurgery, UniversityofCalifornia,Davis;Divisionof Trauma,AcuteCareSurgery,and SurgicalCriticalCare,UCDavis, MedicalCenter,Sacramento,California

RichardL.Gamelli,MD,FACS, FRCSEd(Hon)

Editor-in-Chief,JournalofBurnCareand Research;ProfessorEmeritus,StritchSchool ofMedicine,LoyolaUniversityChicago, Chicago,Illinois

LuisManuelGarcía-Núñez,MD, FACS,FAMSUS

GeneralandTraumaSurgeon,Chief, EmergencyDepartment,MilitaryCentral Hospital,NationalDefenseDepartment, MexicoCity,Mexico

LarryM.Gentilello,MD

ProfessorofSurgery,AdjunctProfessorof Management,Policy,andCommunity Health,DepartmentofSurgery,Universityof Texas,Austin,Texas

RamyarGilani,MD

AssistantProfessor,MichaelE.DeBakey DepartmentofSurgery,DivisionofVascular Surgery,BaylorCollegeofMedicine;Chiefof VascularSurgery,BenTaubGeneral Hospital,Houston,Texas

LaurentG.Glance,MD

Vice-ChairforResearch,Departmentof Anesthesiology,ProfessorofAnesthesiology, ProfessorofPublicHealthSciences,Senior Scientist,RAND(adjunct),Universityof RochesterSchoolofMedicine,Rochester, NewYork

NestorR.Gonzalez,MD

AssistantProfessor,NeurologicalSurgery andRadiologicalSciences,UCLAMedical Center,LosAngeles,California

DanielJ.Grabo,MD

Fellow,DivisionofTraumatology,Surgical CriticalCareandEmergencySurgery, HospitaloftheUniversityofPennsylvania, Philadelphia,Pennsylvania

GeraldGracia,MD

VincenteH.Gracias,MD

InterimDean,CEO,RobertWoodJohnson MedicalGroup;ProfessorandChief, DepartmentofSurgery,RutgersRobert WoodJohnsonMedicalSchool,Robert WoodJohnsonUniversityHospital, NewBrunswick,NewJersey

KirbyR.Gross,MD

Colonel,MedicalCorps,UnitedStatesArmy; Director,JointTraumaSystem,SanAntonio MilitaryMedicalCenter,SanAntonio,Texas; AssociateProfessor,UniformedServices UniversityoftheHealthSciences,Bethesda, Maryland

RonaldI.Gross,MD

AssociateProfessorofSurgery,Tufts UniversitySchoolofMedicine,Boston, Massachusetts;Chief,Divisionof Trauma,AcuteCareSurgery,and SurgicalCriticalCare,BaystateMedical Center,Springfield,Massachusetts

ChrissyGuidry,DO

TraumaandCriticalCare,Tulane UniversitySchoolofMedicine,New Orleans,Louisiana

OliverL.Gunter,Jr.,MD,MPH,FACS VanderbiltUniversitySchoolofMedicine, SectionofSurgicalSciences,Department ofGeneralSurgery,DivisionofTrauma andSurgicalCriticalCare,Nashville, Tennessee

JosephM.Gutmann,MD UniversityofSouthFlorida,Tampa,Florida

ErinHale,MD

Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

S.MoradHameed,MD,MPH AssociateProfessorandChief,Sectionof Trauma,AcuteCareSurgery,andSurgical CriticalCare,DepartmentofSurgery, UniversityofBritishColumbiaTrauma ServicesVGT,Vancouver,BritishColumbia

MollyHartmann,MD

Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

CarlHauser,MD,FACS,FCCM ProfessorofSurgery,HarvardUniversity; AttendingSurgeon,NewEnglandDeaconess MedicalCenter,Boston,Massachusetts

SharonHenry,MD,FACS

AnneScaleaProfessorofTraumaSurgery, UniversityofMarylandSchoolofMedicine, UniversityofMarylandMedicalCenter, RAdamsCowleyShockTraumaCenter, Baltimore,Maryland

MathildaHorst,MD,FACS,FCCM

MedicalDirector,SurgicalCriticalCare; HenryFordHospital;ProfessorofSurgery, WayneStateSchoolofMedicine,Detroit, Michigan

AriHoschander,MD

DepartmentofSurgery,DivisionofPlastic Surgery,UniversityofMiamiHospital, JacksonMemorialHospital,Miami,Florida

HermanP.Houin,MD

SeniorStaffSurgeon,DepartmentofPlastic Surgery,HenryFordHealthSystem,Detroit, Michigan

DavidHoyt,MD,FACS

ExecutiveDirector,AmericanCollegeof Surgeons,Chicago,Illinois

JaredM.Huston,MD

DepartmentofSurgery,DivisionofTrauma andAcuteCareSurgery,NorthShore UniversityHospital,NorthShore-LIJHealth System,Manhasset,NewYork

KyrosIpaktchi,MD

AssociateProfessorofOrthopedicSurgery, ChiefofHand-MicrovascularSurgery, DepartmentofOrthopedicSurgery,Denver HealthMedicalCenter,Universityof Colorado,Denver,Colorado

D’AndreaJoseph,MD,FACS

AssistantProfessorofSurgery,Associate DirectorofTrauma,ProgramDirector ofAcuteCareFellowship,Departmentof Surgery,HartfordHospital/University ofConnecticut,Hartford,Connecticut

GregoryJ.Jurkovich,MD,FACS

ChiefofSurgery,DenverHealthandHospitals; RockwellDistinguishedProfessorofTrauma Surgery,UniversityofColorado,Denver, Colorado

StevenKalandiak,MD

AssistantProfessorofClinicalOrthopedics, UniversityofMiamiMillerSchoolof Medicine,Miami,Florida

RiyadKarmy-Jones,MD

ChiefofTrauma,ThoracicandTrauma Surgery,LegacyEmanuelMedicalCenter, Portland,Oregon

LarryT.Khoo,MD

DirectorofMinimallyInvasiveNeurological SpinalSurgery,LosAngelesSpineClinicat GoodSamaritanHospital,TheLosAngeles SpineClinic,LosAngeles,California

LaszloKiraly,MD,FACS

AssociateProfessor,DepartmentofSurgery, OregonHealthandScienceUniversity, Portland,Oregon

OrlandoC.Kirton,MD,FACS, MCCM,FCCP

ProfessorofSurgery,ViceChair,Department ofSurgery,UniversityofConnecticutSchoolof Medicine,Farmington;LudwigJ.Pyrtek,MD ChairinSurgery,Chief,Departmentof Surgery,Chief,DivisionofGeneralSurgery, InterimDirector,TraumaService,Hartford Hospital,Hartford,Connecticut

MichaelKsycki,DO ChiefofSurgery,BrowningCommunity Hospital,HIS,Billings,Montana

AnastasiaKunac,MD,FACS AssistantProfessorofSurgery,Divisionof TraumaSurgeryandSurgicalCriticalCare, RutgersNewJerseyMedicalSchool,Newark, NewJersey

KulsoomLaeeq,MD Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

AnnaM.Ledgerwood,MD,FACS Professor,MichaelandMarianIlitch DepartmentofSurgery,WayneState University,Detroit,Michigan

BenjaminT.Lemelman,MD UniversityofChicagoMedicalCenter, SectionofPlasticandReconstructive Surgery,Chicago,Illinois

AriLeppäniemi,MD,PhD,MDCC ProfessorofSurgery,ChiefofEmergency Surgery,MeilahtiHospital,Universityof Helsinki,Finland

DavidH.Livingston,MD,FACS WesleyJ.HoweProfessorandChiefof TraumaandSurgicalCriticalCare,Rutgers

NewJerseyMedicalSchool,Newark, NewJersey

JasonLoden,DO DepartmentofSurgery,Creighton University,Omaha,Nebraska

GaryLombardo,MD,FACS AssistantProfessorofSurgery,NewYork MedicalCollege,WestchesterMedical Center,NewYork,NewYork

AndrewLoukas,MD ClinicalAnesthesiologist,South MiamiHospital/BaptistHealth, Miami,Florida

CharlesE.Lucas,MD ProfessorMichaelandMarianIlitch DepartmentofSurgery,WayneState University,Detroit,Michigan

FredA.Luchette,MD,MSc ChiefofSurgicalServices,EdwardHines,Jr. VAMedicalCenter;Vice-Chair,VAAffairs; ProfessorofSurgery,StritchSchoolof Medicine,LoyolaUniversityofChicago, Hines,Illinois

CharlesD.Mabry,MD,FACS AssociateProfessor,Departmentof Surgery,CollegeofMedicine,Universityof ArkansasforMedicalSciences,LittleRock, Arkansas

RobertC.Mackersie,MD,FACS ProfessorofSurgery,UniversityofCalifornia SanFrancisco;DirectorofTraumaServices, SanFranciscoGeneralHospitalandTrauma Center,SanFrancisco,California

PaulM.Maggio,MD,MBA,FACS AssistantProfessorofSurgery,Co-Director, CriticalCareMedicine,StanfordUniversity MedicalCenter,Stanford,California

LouisJ.Magnotti,MD,FACS AssociateProfessor,DepartmentofSurgery, UniversityofTennesseeHealthScience Center,Memphis,Tennessee

JohnW.Mah,MD,FACS AssociateProfessor,DepartmentofSurgery, UniversityofConnecticutSchoolof Medicine,Farmington,Connecticut; AssociateDirector,SurgeryCriticalCare, HartfordHospital,Hartford,Connecticut

AjaiK.Malhotra,MBBS(MD),MS, DNB,FRCSEd,FACS ProfessorofSurgery,VirginiaCommonwealth University,Richmond,Virginia

DarrenMalinoski,MD,FACS AssistantChiefofSurgery–Researchand Education,Chief,SectionofSurgicalCritical Care,VAPortlandHealthCareSystem; AssociateProfessorofSurgery,OregonHealth andScienceUniversity,Portland,Oregon

BrittneyJ.Maloley-Lewis,DO,MBA SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

CorradoPaoloMarini,MD,FACS ChiefofTrauma,SurgicalCriticalCareand EmergencySurgery;DirectorofSurgical CriticalCareFellowship,Departmentof Surgery,WestchesterMedicalCenter, Valhalla,NewYork

ColonelMatthewJ.Martin,MD,FACS TraumaMedicalDirector,MadiganArmy MedicalCenter,Tacoma,Washington; DirectorofTraumaInformatics,Legacy EmanuelMedicalCenter,Portland,Oregon; AssociateProfessorofSurgery,Uniformed ServicesUniversityoftheHealthSciences, Bethesda,Maryland

LeonardMason,MD

PGY-3GeneralSurgeryResident, DepartmentofSurgery,RutgersNewJersey MedicalSchool,Newark,NewJersey

KennethL.Mattox,MD

DistinguishedServiceProfessor,MichaelE. DeBakeyDepartmentofSurgery,Baylor CollegeofMedicine;ChiefofStaffandChief ofSurgery,BenTaubGeneralHospital, Houston,Texas

KimballMaull,MD,FACS AdjunctProfessorofSurgery,Universityof PittsburghMedicalCenter,Pittsburgh, Pennsylvania

JohnC.Mayberry,MD ProfessorofSurgery,DivisionofAcute CareSurgery,OregonHealthand ScienceUniversity,Portland, Oregon

FedericoN.Mazzini,MD SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

ChristopherMcFarren,MD

AssistantProfessorofMedicine,Divisionof NephrologyandHypertension,Department ofInternalMedicine,UniversityofSouth FloridaCollegeofMedicine,Tampa,Florida

NormanE.McSwain,Jr.,MD TraumaandCriticalCare,Tulane UniversitySchoolofMedicine, NewOrleans,Louisiana

MarioA.Meallet,MD ACenterforVisonCare,LACand USCMedicalCenter,LosAngeles,California

J.WayneMeredith,MD,FACS

RichardT.MyersProfessorandChair, DepartmentofSurgery,WakeForest UniversitySchoolofMedicine;Chiefof Surgery,WakeForestUniversityBaptist MedicalCenter,WinstonSalem, NorthCarolina

ChristopherP.Michetti,MD, FACS,FCCM

MedicalDirector,TraumaICU,InovaFairfax Hospital;AssociateProfessorofSurgery, VCUSchoolofMedicine,InovaCampus, FallsChurch,Virginia

KeithR.Miller,MD

AssistantProfessorofSurgery,Universityof Louisville,Louisville,Kentucky

PrestonR.Miller,MD

AssociateProfessor,DepartmentofSurgery, WakeForestUniversity,Winston-Salem, NorthCarolina

RichardS.Miller,MD,FACS VanderbiltUniversitySchoolofMedicine, SectionofSurgicalSciences,Department ofGeneralSurgery,DivisionofTrauma andSurgicalCriticalCare,Nashville, Tennessee

JosephP.Minei,MD,MBA ProfessorandChair,DivisionofBurn, Trauma,andCriticalCare,C.James Carrico,MD,DistinguishedChairin SurgeryforTraumaandCriticalCare, UniversityofTexasSouthwesternMedical Center;Surgeon-in-Chief,ParklandHealth andHospitalSystem,Dallas,Texas

HaarisMir,MD

PlasticandReconstructiveHandSurgery, JosephM.StillBurnCenterandBurnCenters ofFlorida,Miami,Florida

FrankL.Mitchell,MD

MedicalDirector,TraumaandSurgical CriticalCare,St.JohnMedicalCenter,Tulsa, Oklahoma

AliciaM.Mohr,MD,FACS

AssociateProfessorofSurgery,Divisionof AcuteCareSurgery,UniversityofFlorida, Gainesville,Florida

ErnestE.Moore,MD

ProfessorandViceChairmanforResearch, DepartmentofSurgery,Universityof ColoradoDenver;Editor,JournalofTrauma andAcuteCareSurgery,Denver,Colorado

AnneC.Mosenthal,MD,FACS ProfessorandChair,DepartmentofSurgery, RutgersNewJerseyMedicalSchool, Newark,NewJersey

FelipaMunera,MD

AssociateProfessorofRadiology,Chief, DepartmentofRadiology,Universityof MiamiHospital,UniversityofMiami HospitalandClinics,andSylvester ComprehensiveCancerCenter;ER-Trauma RadiologyDivision,UniversityofMiami–MillerSchoolofMedicine,JacksonMemorial Hospital–RyderTraumaCenter,Miami, Florida

AlanD.Murdock,MD

ConsultanttotheSurgeonGeneralfor TraumaandSurgicalCriticalCare, DepartmentofTraumaandGeneralSurgery, UniversityofPittsburghMedicalCenter, Pittsburgh,Pennsylvania;Consultanttothe SurgeonGeneralforSurgicalServices,Air ForceMedicalOperationsAgency,LacklandKellyAirForceBase,Texas

MamounNabri,MD,FRCSI,FACS TraumaSurgery/SurgicalCriticalCare Surgeon,AssistantProfessor,Departmentof Surgery,FacultyofMedicine,Universityof Dammam,Dammam,SaudiArabia

LenaM.Napolitano,MD,FACS,FCCP, FCCM

ProfessorofSurgery,DivisionChief, AcuteCareSurgery(Trauma,Burn, CriticalCare,EmergencySurgery),Associate ChairofSurgery,Director,Traumaand SurgicalCriticalCare,Universityof MichiganHealthSystem,AnnArbor, Michigan

NicholasA.Nash

ScottH.Norwood,MD,FACS

ClinicalProfessorofSurgery,Morsani CollegeofMedicine,UniversityofSouth Florida,Tampa,Florida;TraumaService, RegionalMedicalCenter,BayonetPoint, Hudson,Florida

JohnOeltjen,MD,PhD

AssociateProfessorofSurgery,Universityof Miami,Miami,Florida

ChrisOkwuosa,MD

SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

TurnerM.Osler,MD,MSc,FACS ResearchProfessor,DepartmentofSurgery, UniversityofVermont,Burlington, Vermont

AngelaOsmolak,MD

SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

YasuhiroOtomo,MD,PhD

Director,TraumaandAcuteCriticalCare Center,TokyoMedicalandDental UniversityHospitalofMedicine,Tokyo, Japan

PatrickOwens,MD

AssociateProfessorofClinicalOrthopedics, AssociateProfessorofSurgery,Universityof Miami,Miami,Florida

JohnT.Owings,MD,FACS

DirectorofTraumaServices,University Health,ProfessorofSurgery,Chiefof TraumaandCriticalCare,Louisiana StateUniversitySchoolofMedicine, Shreveport,Louisiana;Professor Emeritus,UniversityofCalifornia Davis,SchoolofMedicine,Sacramento, California

H.LeonPachter,MD,FACS

TheGeorgeDavidStewartProfessorand Chair,DepartmentofSurgery, NewYorkUniversitySchoolofMedicine, NewYork,NewYork

DavidPalange,DS

DoctorofOsteopathicMedicine,University Hospital–UMDNJ,Newark,NewJersey

ZubinJalPanthaki,BEng,MD, CM,FACS

ProfessorofClinicalSurgery,Divisionof PlasticSurgery,ProfessorofClinical Orthopedics,Director,HandSurgery FellowshipProgram,AssociateDirector, PlasticSurgeryResidencyProgram,The UniversityofMiami,LeonardM.Miller SchoolofMedicine;ChiefofPlastic Surgery,ChiefofHandSurgery,Miami VeteransAdministrationHospital; ChiefofPlasticSurgery,Sylvester ComprehensiveCancerCenter;Chiefof HandSurgery,UniversityofMiamiHospital, Miami,Florida

ManishS.Parikh,MD

AssociateProfessorofSurgery,NewYork UniversitySchoolofMedicine,NewYork, NewYork

MichaelD.Pasquale,MD,FACS,FCCM Chair,DepartmentofSurgery,LehighValley HealthNetwork,Allentown,Pennsylvania; ProfessorofSurgery,UniversityofSouth Florida,MorsaniCollegeofMedicine, Tampa,Florida

AndrewB.Peitzman,MD

DistinguishedProfessorofSurgery,MarkM. RavitchProfessorandVice-Chair,VicePresidentforTraumaandSurgicalServices, UniversityofPittsburghSchoolofMedicine, Pittsburgh,Pennsylvania

AlejandroPerez-Alonso,MD,PhD InternationalDoctorinMedicine andSurgery,GeneralandDigestive Surgeon,MasterinTissueEngineering, MasterinTraumaSurgery,Assistant ProfessorofSurgery,SeniorResearcher, DepartmentofExperimentalSurgery, UniversityofGranada;AttendingPhysician, TraumaandGeneralSurgery,Hospital UniversitarioSanCecilio,Granada,Spain

ChristopherH.Perkins,MD

AssistantProfessor,OrthopedicTrauma, BaylorCollegeofMedicine,Houston,Texas

AustinPerson,MD

Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

PatrizioPetrone,MD,MPH, MHA,FACS

DirectorofResearch,ProgramDirector, InternationalVisitingScholars/Research

Fellowship;DivisionofTraumaSurgery, SurgicalCriticalCare,andAcuteCare Surgery,DepartmentofSurgery, NewYorkMedicalCollege;Westchester MedicalCenterUniversityHospital, Valhalla,NewYork

K.ShadPharaon,MD

DivisionofTrauma,CriticalCare,andAcute CareSurgery,DepartmentofSurgery, OregonHealthandScienceUniversity, Portland,Oregon;DivisionofTraumaand AcuteCareSurgery,SurgicalCriticalCare, PeaceHealthSouthwestMedicalCenter, Vancouver,Washington

AllanS.Philp,MD,FACS,FCCM TraumaMedicalDirector,Allegheny GeneralHospital;AssociateProfessorof Surgery,TempleUniversity,Pittsburgh, Pennsylvania

EdgarJ.Pierre,MD

VolunteerAssociateProfessor,Department ofAnesthesiaandSurgery,Universityof MiamiMillerSchoolofMedicine,Miami, Florida

GretaL.Piper,MD

AssistantProfessorofSurgery,NYULangone MedicalCenter,NewYork,NewYork

FrankPlani,MD,FCS(SA),FRACS, TraumaSurgery(SA)

PrincipalSpecialistandDeputyHead, ChrisHaniBaragwanathAcademicHospital TraumaDirectorate,DivisionofSurgery, Soweto;AdjunctProfessor,Departmentof Surgery,ClinicalSchoolofMedicine, UniversityoftheWitwatersrand, Johannesburg,SouthAfrica

PatricioPolanco,MD DepartmentofSurgery,Universityof PittsburghMedicalCenter,Pittsburgh, Pennsylvania

AnthonyPolicastro,MD,FACS DepartmentofSurgery,NewYorkMedical College;AssociateProfessorofSurgery, WestchesterMedicalCenterUniversity Hospital;DivisionofTraumaandSurgical CriticalCare,AssociateDirectorofSurgical CriticalCare,DirectorofSurgicaland TraumaIntensiveCareUnits,Valhalla, NewYork

NathanJ.Powell,DO,FACOS

AttendingSurgeon,Trauma/AcuteCare Surgery,St.FrancisTraumaInstitute,Tulsa, Oklahoma

RiaanPretorius,MBChB(Pta), FCS(SA),Certificateintrauma surgery(SA)

TraumaConsultant,ChrisHani BaragwanathAcademicHospital;Junior Lecturer,UniversityofWitwatersrand, Johannesburg,SouthAfrica

BrandonPropper,MD

G.DanielPust,MD

AssistantProfessorofSurgery,Division ofTraumaandSurgicalCriticalCare, TheDeWittDaughtryFamilyDepartment ofSurgery,RyderTraumaCenter/Jackson MemorialHospital,UniversityofMiami MillerSchoolofMedicine,Miami,Florida Miami,Florida

BradleyS.Putty,LtCol,USAF,MC AssistantProfessor,DepartmentofSurgery, DivisionofTraumaandCriticalCare, St.LouisUniversityHospital,St.Louis, Missouri

JuanCarlosPuyana,MD,FACS

AssociateProfessorofSurgeryandCritical CareMedicine,UniversityofPittsburgh; ChiefMedicalOfficer,InnovativeMedical InformationTechnologiesCenter,University ofPittsburghMedicalCenter,Pittsburgh, Pennsylvania

StephenM.Quinnan UniversityofMiamiMillerSchoolof Medicine,JacksonMemorialHospital, Miami,Florida

DavidJ.Quintana,MD EmoryUniversitySchoolofMedicine, DepartmentofRadiology,Divisionof InterventionalRadiologyandImage-Guided Medicine,Atlanta,Georgia

R.LawrenceReedII,MD,FACS, FCCM ProfessorofSurgery,IndianaUniversity; DirectorofTraumaServices,Indiana UniversityHealthMethodistHospital, Indianapolis,Indiana

BibianaJ.Reiser,MD,MS Children'sHospitalofLosAngeles, UniversityofSouthernCalifornia, LosAngeles,California

PeterRhee,MD,MPH,FACS, FCCM,DMCC

MartinGluckProfessorofSurgery, UniversityofArizona;DirectorofTrauma, CriticalCare,Burns,andEmergencySurgery, UniversityofArizonaMedicalCenter, Tucson,Arizona

MichaelRhodes,MD,FACS,FCCM ProfessorofSurgery,ThomasJefferson University;ValueInstituteSeniorConsultant forAdvancesinMedicine;ChairEmeritus, DepartmentofSurgery,ChristianaCare HealthSystems,Wilmington,Delaware

NormanM.Rich,MD,FACS,DMCC, COL,MC

LeonardHeaton&DavidPackardProfessor, SeniorAdvisortotheChairman,NormanM. RichDepartmentofSurgery,F.Edward HebertSchoolofMedicine,Uniformed ServicesUniversityoftheHealthSciences, Bethesda,Maryland

J.DavidRichardson,MD ProfessorofSurgery,UniversityofLouisville, Louisville,Kentucky

CharlesM.Richart,MD,FACS AssociateProfessor,DepartmentofSurgery, UniversityofMissouri KansasCity; AssociateDirector,TraumaSurgicalCritical Care,Director,SurgicalCriticalCareResearch andSurgicalANHProgram,SaintLuke’ s HospitalofKansasCity,KansasCity,MO

LuisA.Rivas,MD

AssociateProfessorofRadiology,Chief, TraumaandEmergencyRadiology, UniversityofMiami,JacksonMemorial Medical,Miami,Florida

JenniferC.Roberts,MD MarshfieldClinic,Marshfield,Wisconsin

AurelioRodríguez,MD,FACS TraumaandGeneralSurgeon,Associate Director,DivisionofTrauma,SinaiHospital, Baltimore,Maryland;DirectorEmeritus, AlleghenyGeneralHospital,ShockTrauma Center,Pittsburgh,Pennsylvania

JorgeL.Rodríguez,MD UniversityofLouisville,Louisville,Kentucky

ErwinRodriguez-García,MD DepartmentofSurgery,HospitalMilitar Central–UniversidadMilitarNueva Granada,Bogota,Colombia

RosaineRoeder,MD,MPH LaheyHospitalandMedicalCenter, Burlington,Massachusetts

DavidRojas-Tirado,MD

DepartmentofSurgery,HospitalMilitar Central–UniversidadMilitarNueva Granada,Bogota,Colombia

MichaelF.Rotondo,MD,FACS ChiefExecutiveOfficer,UniversityofRochester MedicalFacultyGroup;ViceDeanforClinical Affairs,SchoolofMedicine,Professorof Surgery,DivisionofAcuteCareSurgery,Vice PresidentofAdministration,StrongMemorial Hospital,UniversityofRochesterMedical Center,Rochester,NewYork

SusanRowell,MD,MCR

AssociateProfessorofSurgery,Program Director,SurgicalCriticalCareFellowship, DepartmentofSurgery,DivisionofTrauma, CriticalCare,andAcuteCareSurgery, OregonHealthandScienceUniversity, Portland,Oregon

JerryA.Rubano,MD DepartmentofSurgery,Divisionof Trauma,CriticalCare,andBurns,State UniversityofNewYork,StonyBrook UniversityHealthSciencesCenter, StonyBrook,NewYork

AndrésM.Rubiano,MD,PhD,FACS MedicalandResearchDirector,MEDITECH Foundation;ProfessorofNeurosciences, SouthColombianUniversity;Neurosurgeon, TraumaandEmergencyService,Neiva UniversityHospital,Neiva(Huila), Colombia

AmyRushing,MD

AssistantProfessorofSurgery,Divisionof Trauma,CriticalCare,andBurn,Wexner MedicalCenter,TheOhioStateUniversity, Columbus,Ohio

IronyC.Sade,MD

Resident,3rdYear,GeneralSurgery, WestchesterMedicalCenter,Valhalla, NewYork

ChristopherSalgado,MD

ProfessorofSurgery,DivisionofPlastic Surgery,SectionChief,UniversityofMiami Hospital;EditorinChief,Journalof Anaplastology,Miami,Florida

AliSalim,MD,FACS ProfessorofSurgery,HarvardMedical School;Chief,DivisionofTrauma,Burns, andSurgicalCriticalCare,Boston, Massachusetts

NoelleSalliant,MD

DivisionofTraumatology,Departmentof Surgery,CriticalCareandAcuteCare Surgery,TheTraumaCenteratPenn, UniversityofPennsylvania,Philadelphia, Pennsylvania

JasonSalsamendi,MD

AssistantProfessorofClinicalRadiology, DepartmentofRadiology,Assistant ProfessorofClinicalSurgery,Departmentof Surgery,UniversityofMiamiMillerSchoolof Medicine,Miami,Florida

JamesB.Sampson,MD,FACS DavidGrantMedicalCenter,TravisAir ForceBase,Fairfield,California;Universityof CaliforniaDavis,Sacramento, California

JuanA.Sanchez,MD,MPA, FACS,FACC

AssociateProfessorofSurgery,Johns HopkinsUniversitySchoolofMedicine; Chairman,DepartmentofSurgery, Baltimore,Maryland

WilliamSánchezMaldonado,MD,FACS DepartmentofSurgery,HospitalMilitar Central–UniversidadMilitarNueva Granada,Bogota,Colombia

ThomasM.Scalea,MD PhysicianinChief,RAdamsCowleyShock TraumaCenter,FrancisX.Kelly DistinguishedProfessorofTrauma, UniversityofMarylandSchoolofMedicine, Baltimore,Maryland

WilliamP.Schecter,MD ProfessorofClinicalSurgery,Universityof CaliforniaSanFrancisco,SanFrancisco GeneralHospital,SanFrancisco, California

PaulSchipper,MD,FACS,FACCP ProfessorofSurgeryandProgramDirector, CardiothoracicSurgeryResidency,Oregon HealthandScienceUniversityandPortland VeteransAdministrationMedicalCenter, Portland,Oregon

MartinSchreiber,MD,FACS ProfessorofSurgery,Chief,Divisionof TraumaCriticalCare,andAcuteCare Surgery,DepartmentofSurgery,Oregon HealthandScienceUniversity,Portland, Oregon

JohnT.SchulzIII,MD,PhD MedicalDirector,SumnerRedstoneBurn Center,MassachusettsGeneralHospital, Boston,Massachusetts

C.WilliamSchwab,MD,FACS ProfessorofSurgery,PerelmanSchoolof Medicine,UniversityofPennsylvania; DivisionofTraumatology,SurgicalCritical CareandEmergencySurgery,Hospitalofthe UniversityofPennsylvania,Philadelphia, Pennsylvania

StephenSerio,MD

SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

ParthShah,MD

GeneralSurgeryResident,Departmentof Surgery,CHIHealthAlegentCreighton Clinic,Omaha,Nebraska

MarcJ.Shapiro,MD

ProfessorofSurgeryandAnesthesiology, ChiefofGeneralSurgery,Trauma,Critical Care,andBurns,DepartmentofSurgery, SUNY-StonyBrook,StonyBrook, NewYork

DavidShatz,MD

Professor,DepartmentofSurgery,Division ofTraumaandEmergencySurgery, UniversityofCaliforniaDavis,Sacramento, California

ShreyaShetty,MD

Resident,GeneralSurgery,Creighton University,Omaha,Nebraska

AdamM.Shiroff,MD,FACS ChiefofTrauma,JerseyShoreUniversity MedicalCenter,AssistantProfessorof Surgery,RutgersRobertWoodJohnson MedicalSchool,NewBrunswick, NewJersey

ZiadC.Sifri,MD

AssociateProfessorofSurgery,Divisionof Trauma,RutgersNewJerseyMedicalSchool, Newark,NewJersey

RonaldSing,DO,FACS,FCCM ProfessorofSurgery,DivisionofAcuteCare Surgery,CarolinasMedicalCenter,Charlotte, NorthCarolina;AdjunctProfessorofSurgery, UniversityofNorthCarolinaSchoolof MedicineatChapelHill,ChapelHill,North Carolina

AmyC.Sisley,MD,MPH DivisionChief,AcuteCareSurgery, DepartmentofSurgery,HenryFord Hospital,Detroit,Michigan

R.StephenSmith,MD

SystemChief,DivisionofTrauma,Burn,and AcuteCareSurgery,WestPennAllegheny HealthSystem;ProfessorofSurgery,Temple UniversitySchoolofMedicine,Pittsburgh, Pennsylvania

EduardoSmith-Singares,MD,FACS Chief,DivisionofSurgicalCriticalCare, DepartmentofSurgery,UniversityofIllinoisat ChicagoCollegeofMedicine;Co-Director SICU,UniversityofIllinoisHospitaland HealthSciencesSystem,Chicago,Illinois

DavidA.Spain,MD,FACS

CarolandNedSpiekerProfessorandChiefof AcuteCareSurgery,DepartmentofSurgery, StanfordUniversity,Stanford,California

NicholasSpoerke,MD

SurgicalCriticalCareFellow,Oregon HealthandScienceUniversity,Portland, Oregon

AnanthSrinivasan,MBBS CreightonUniversitySchoolofMedicine, Omaha,Nebraska

DeborahM.Stein,MD,MPH AssociateProfessorofSurgery,Universityof MarylandSchoolofMedicine;Chiefof Trauma,RAdamsCowleyShockTrauma Center,Baltimore,Maryland

JosephJ.Stirparo,MD

Trauma,SurgicalCriticalCare,LehighValley HealthNetwork,Allentown,Pennsylvania; AssistantProfessorofSurgery,Universityof SouthFlorida,MorsaniCollegeofMedicine, Tampa,Florida

LanceE.Stuke,MD,MPH,FACS AssociateProfessorofSurgery,Louisiana StateUniversity,SpiritofCharityTrauma Center,NewOrleans,Lousiana

MithranSukumar,MD

AssistantProfessorofSurgery,Oregon HealthandScienceUniversity;SectionHead, GeneralThoracicSurgery,Divisionof CardiothoracicSurgery,PortlandVeterans AdministrationMedicalCenter,Portland, Oregon

AbhishekSundaram,MD

GeneralSurgeryResident,Department ofSurgery,CreightonUniversity,Omaha, Nebraska

WendyJoSvetanoff,MD HO4,DepartmentofSurgery,Creighton UniversityMedicalCenter,Omaha, Nebraska

wKennethG.Swan,MD

ProfessorofSurgery,Director,ThirdYear SurgicalClerkship,DepartmentofSurgery, NewJerseyMedicalSchool,Universityof MedicineandDentistryofNewJersey, Newark,NewJersey

VartanS.Tashjian,MD,MS ResidentSurgeon,DivisionofNeurological Surgery,UniversityofCalifornia,Los Angeles,LosAngeles,California

ThomasTemplin,MD ResidentPhysician,CreightonUniversity SchoolofMedicine,Creighton UniversityMedicalCenter, Omaha,Nebraska

ErwinThal,MD,FACS,FRACS(Hon.) ProfessorofSurgery,DepartmentofSurgery, UniversityofTexasSouthwesternMedical Hospital;AttendingSurgeon,Departmentof Surgery,ParklandHospital;Attending Surgeon,DepartmentofSurgery,University ofTexasSouthwesternUniversityHospital–St.Paul;AttendingSurgeon,Departmentof Surgery,UniversityofTexasSouthwestern UniversityHospital–ZaleLisphy, Dallas,Texas

SethR.Thaller,MD,DMD,FACS ChiefandProfessor,DivisionofPlastic Surgery,TheDeWittDaughtryFamily DepartmentofSurgery,University OfMiamiHealthSystem,Miami,Florida

GregoryTiesi,MD DepartmentofGeneralSurgery,Rutgers NewJerseyMedicalSchool,Newark, NewJersey

BrandonTieu,MD,FACS

AssistantProfessorofSurgery,Divisionof CardiothoracicSurgery,Departmentof Surgery,OregonHealthandScienceUniversity andPortlandVeteransAdministration MedicalCenter,Portland,Oregon

AretiTillou,MD,FACS,MsEd AssociateProfessor,ViceChairfor Education,UCLADavidGeffenSchool ofMedicine,LosAngeles,California

GlenTinkoff,MD,FACS,FCCM

AssociateViceChair,DepartmentofSurgery, ChristianaCareHealthSystem,Newark, Delaware;ClinicalProfessorofSurgery, JeffersonMedicalCollege,Philadelphia, Pennsylvania

SamuelTisherman,MD, FACS,FCCM

RAdamsCowleyShockTraumaCenter, UniversityofMaryland,Director, SurgicalIntensiveCareUnit,Baltimore, Maryland

S.RobTodd,MD

AssociateProfessorofSurgery,NewYork UniversityLangoneMedicalCenter;Director, BellevueEmergencySurgeryService, DepartmentofSurgery,BellevueHospital Center;Faculty,DepartmentofSurgery,Tisch Hospital,NewYork,NewYork

ZacharyTorgersen,MD

SurgicalResident,CreightonUniversity MedicalCenter,Omaha,Nebraska

PeterG.Trafton,MD,FACS ProfessorandViceChair,Departmentof OrthopedicSurgery,BrownUniversity SchoolofMedicine,Providence, RhodeIsland

MarkTraynham,MD CreightonUniversityMedicalCenter, Omaha,Nebraska

L.R.TresScherer,MD,FACS

VolunteerClinicalProfessorofSurgery, IndianaUniversitySchoolofMedicine, Carmel,Indiana

PeterI.Tsai,MD,MA

AssistantProfessorofSurgery,Divisionof CardiothoracicSurgery,MichaelE.DeBakey DepartmentofSurgery,BaylorCollegeof Medicine/TexasHeartInstitute;Medical Director,DepartmentofCardiothoracic Surgery,BenTaubGeneralHospital, Houston,Texas

DavidW.Tuggle,MD

AssociateTraumaMedicalDirector,Dell Children'sMedicalCenterofCentralTexas, Austin,Texas

AnthonyM.Udekwu,MD,FRCS(C), FACS

AlexB.Valadka,MD,FAANS,FACS ChairmanandChiefExecutiveOfficer, SetonBrainandSpineInstitute, Austin,Texas

NicoleVanDerHeyden,MD,PhD TraumaMedicalDirector,TraumaServices, SalemHospital,Salem,Oregon

ThomasK.Varghese,Jr.,MD

AssistantProfessor,AssociateProgram Director–CardiothoracicSurgeryResidency, UniversityofWashington;Directorof ThoracicSurgery,DepartmentofSurgery, HarborviewMedicalCenter,Seattle, Washington

MichelWagner,MD,FACS AssistantProfessor,DivisionofTrauma, CreightonUniversitySchoolofMedicine, CHI–CreightonUniversityMedicalCenter, Omaha,Nebraska

MatthewJ.Wall,Jr.,MD

Professor,MichaelE.DeBakeyDepartment ofSurgery,BaylorCollegeofMedicine; DeputyChiefofSurgery,Chiefof CardiothoracicSurgery,Departmentof Surgery,BenTaubGeneralHospital, Houston,Texas

AnthonyWatkins,MD ClinicalInstructorinSurgery,Departmentof Transplantation,ColumbiaUniversity/ NewYorkPresbyterianHospital,NewYork, NewYork

JohnWeigelt,MD MedicalCollegeofWisconsin,Milwaukee, Wisconsin wDeceased.

DonaldD.Trunkey,MD,FACS ProfessorEmeritus,DepartmentofSurgery, DivisionofTrauma,OregonHealthand ScienceUniversity,Portland,Oregon

LeonardJ.Weireter,Jr.,MD,FACS

ArthurandMarieKirkFamilyProfessorof Surgery,DepartmentofSurgery,Eastern VirginiaMedicalSchool,Norfolk,Virginia

DavidR.Welling,MD,FACS, FASCRS,DMCC ProfessorofSurgery,UniformedServices UniversityoftheHealthSciences,Walter ReedNationalMilitaryMedicalCenter, Bethesda,Maryland

PaulW.White,MD,FACS LTC,MedicalCorps,UnitedStatesArmy; ProgramDirector,VascularSurgery Fellowship,WalterReedNationalMilitary MedicalCenter;AssociateProfessorof

Surgery,UniformedServicesUniversityof theHealthSciences,Bethesda,Maryland

LucasR.Wiegand,MD

AssistantProfessorofUrology,Universityof SouthFlorida,Tampa,Florida

HarryE.Wilkins,MD

AssociateProfessor,DepartmentofSurgery, UniversityofMissouri–KansasCity;Medical Director,TraumaandSurgicalCriticalCare, SaintLuke'sHospitalofKansasCity,Kansas City,Missouri

RobertF.Wilson,MD,FACS,MCCM ProfessorofSurgery,WayneStateUniversity SchoolofMedicine;Director,Surgical

IntensiveCareUnit,DetroitReceiving Hospital,Detroit,Michigan

DavidH.Wisner,MD

ProfessorandViceChair,Departmentof Surgery,UniversityofCaliforniaDavis;Chief ofSurgery,UCDavisMedicalCenter Sacramento,California

D.DanteYeh,MD,FACS MassachusettsGeneralHospital, HarvardMedicalSchool,Boston, Massachusetts

Traumaticinjuryistheleadingcauseofdeathanddisabilityforyoung adultsandaffectsthelivesofpeopleallovertheworld.Comprehensivetraumasurgicalmanagementmustaddressprevention,the immediateneedsofonevictimorthesuddenarrivalofmasscasualties,aswellasrehabilitationandend-of-lifecare.Thesecondedition ofCurrentTherapyofTraumaandSurgicalCriticalCareisaninvaluableresourceforallwhoparticipateinthecareoftraumapatients, includingmilitarypersonnelandmedicalconsultants.

Notedexpertswhoarepracticingacademictraumasurgeonsauthor thechaptersandaddresscontroversiesinanobjectivemanner. Evidence-basedguidelinesarepresentedanddiscussedasarebestpracticerecommendationsbasedonyearsofbusyclinicalandoperative experience.Thecriticalcaresectionofthebookiswellwrittenandmasterfullybridgesbasicphysiologytothebedsideevaluationofthepatient.

Newchaptersinthiseditionaddressareasofgrowingimportance includingtriageincivilianaswellasmilitaryfacilities,vascularinjuries,difficultandcomplexinjuries,recentlessonslearnedfromthe careofcombatcasualties,braindeath,andorgandonation.

Theeditors,Drs.JuanA.AsensioandDonaldD.Trunkey,are visionaryleaderswhohavespenttheircareerschangingthewaywe viewtraumacare.Theyhaverevisedandexpandedthiseditionof CurrentTherapyofTraumaandSurgicalCriticalCare tohelptrauma systemsmeetnewchallengesinanincreasinglyglobalsociety.

“Ifyougethimtotheoperatingroomwithabloodpressure,Iwill comein”

GrowingupandtrainingontheSouthSideofChicago,Idistinctly rememberthesewordsbeingspokentomebymymentorduring mycardiothoracicsurgeryresidency. Icalledhimtwicein2years. Traumacarehascomealongwaysincethattimeandthoughmanyof theprinciplesofmanagementarethesameandourfocusalways remainsontheinjuryathand,Inowknowthatthereisaneverevolving,complex,andsophisticated “traumasystem” inplacecoordinatingtheeffortsofmanyprofessionalsandnecessarytohavethat patientarriveonmyoperatingtablewitha “bloodpressure.”

As CurrentTherapyofTraumaandSurgicalCriticalCare now entersitssecondedition,itisalreadyoneoftheleadingreferences foranyoneinvolvedintrauma.Thiscurrenteditioncontinuesin thetraditionofthe CurrentTherapy seriesbyupdating,revising andexpandingsections.Therearenewandupdatedsectionsonvascularinjuries,developmentsinimagingtechnology,andup-to-date informationonthenewerventilatorytechniques.EditedbyDr.Juan AsensioandDr.DonaldTrunkey,twoofthemostwellrecognized namesintrauma,itrepresentsacomprehensiveandauthoritativetext thatcoversthecompletecontinuumofcarewithanemphasison operativetechniquesforeventhemostcomplexofinjuries.

Thelistofcontributorsrepresentsavirtual “who’swho” intrauma andcriticalcareandisformattedtogivethepracticingprofessional practical,concise,andupdatedinformationfocusingonorgansystemsandoperativetechniques.Itisacompendiumofwhatisconsideredcommonandacceptedpracticethatisevidencebasedand clinicallyrelevant,expertopinion,anddiscussionofcontroversial areasandchallenges.Thereissomethingforeveryoneinvolvedin traumacare,beginningwiththehistoryoftrauma,thedevelopment oftraumasystems,andthelatestinformationregardingspecificorgan injurymanagement,prevention,ICUcare,masscasualtyevents,palliativecare,rehabilitation,andoutcomes.

CurrentTherapyofTraumaandSurgicalCriticalCare clearlyrepresentsalaborofloveforDr.TrunkeyandnowDr.Asensiowitha visiontocreateacomprehensiveyetpracticalandconcisereference forthetraumacommunity.Iwouldrecommenditasworthwhile readingandavaluablereferenceforanyoneinvolvedinthecareof thetraumapatient

CreightonUniversitySchoolofMedicine CreightonUniversity

Itisnowthedawnofthetwenty-firstcentury,andwhataturbulent centuryitthreatenstobe.Onceagainitisaprivilegeandanhonorto serveastheeditorof CurrentTherapyofTraumaandSurgicalCritical Care.Thisisactuallythesixthedition;however,theeditorshave renumbereditasthesecondeditionbecausewehaveaddedsurgical criticalcaretothisnobletextbook.

Onethingisconstant:ourworldisturbulentanddangerousand willcontinuetobesoformanyfuturegenerations.Aquickscanofthe media,whetheritistelevision,digitalnews,ortheprintedword, revealsthatourworldiscurrentlyexperiencingmultiplearmedconflicts,withalargenumberofcasualtiesfromtheseconflicts.Ourprofession,perhapsthemostgodlyofallprofessions,continuestobe undersiege;economicandmarketforcescontinuetoencroachon theabilityofdoctors,andofcoursesurgeons,todeliverthemostoptimumofcare,especially,asitisoftensaid, “Totheleastofthese , ” whichmeanstothepoorestofourbrethren.

Amidstallofthisturmoil,traumasurgeonsandsurgicalcritical carespecialistshaverisentotheoccasionbyalsotakingontheburden ofthemanagementofacutecaresurgery.Onceagaintraumasurgeonsstandaspillarsofstrength,thequintessential “bandof brothers.” IrisetoquoteShakespeareindescribingtraumasurgeons:

“Thathewhichhathnostomachtothisfight, Lethimdepart.Hispassportshallbemade, Andcrownsforconvoyputintohispurse. Wewouldnotdieinthatman'scompany Thatfearshisfellowshiptodiewithus. Fromthisdaytotheendingoftheworld, Butweinitshallberemembered Wefew,wehappyfew,webandofbrothers; Forhetodaythatshedshisbloodwithme Shallbemybrother.” (HenryV,ActIV,Scene3)

Itismystrongbeliefthatthehonorandtheprivilegeofattempting tosavealifenotonlyinanoperatingroombutalsobycounseling patientsisindeedanobletaskintheefforttoeliminatetraumaas adisease.Wecontinuetoholdontothedreamthatweasleaderswill eventuallyseeaworldinwhichtherewillbenowarsandtherewillbe greaterunderstandingandmoretimeandeffortdedicatedtothe improvementofthehumancondition.Wecontinuetobelievethat withourdedicationwewillmakeadifference,hopingtocreatebridgesbetweenpeople,leadingtogreaterunderstandingandcooperation inhumanrelationsandinthefieldofscientificresearch.Theseideals andgoalsremainlofty,butinspeakingtomycolleagues,thisbeliefis strongandcontinuestomotivateusall.Istronglybelievethatthealleviationofpainandsufferingandthesavingoflivesremainsamost importantcommitmentforthosewhobelongtothiselitefraternity, the “bandofbrothers.”

OnceagainIchallenge,Iurge,Ibeseechallofmycolleaguesin traumasurgerytogobeyondthewallsofacademiatoservethose whomustbeserved,tousethepowerofourprofessionstoexercise ourconsciences,toserveasleadersandadvocatesforhumanrights,to

healthewounded,andtoteachthefuturegenerationsofthosewho willbegiventhegreatgifttoperformtraumasurgery.Wemustbe preparedtotakethechallengetocreatepeaceandtohealwounds becauseitisweandthosewhohavecomebeforeuswhohavebeen there,holdingthehandsofthewoundedandinjured,filledwithpain andcrying,ofteninwardly,whenalifeislost,andcontinuingtostruggletosaveotherlives.

IF—

Ifyoucankeepyourheadwhenallaboutyou Arelosingtheirsandblamingitonyou, Ifyoucantrustyourselfwhenallmendoubtyou, Butmakeallowancefortheirdoubtingtoo; Ifyoucanwaitandnotbetiredbywaiting, Orbeingliedabout,don’tdealinlies, Orbeinghated,don’tgivewaytohating, Andyetdon’tlooktoogood,nortalktoowise:

Ifyoucandream andnotmakedreamsyourmaster; Ifyoucanthink andnotmakethoughtsyouraim; IfyoucanmeetwithTriumphandDisaster Andtreatthosetwoimpostorsjustthesame; Ifyoucanbeartohearthetruthyou’vespoken Twistedbyknavestomakeatrapforfools, Orwatchthethingsyougaveyourlifeto,broken, Andstoopandbuild ’emupwithworn-outtools:

Ifyoucanmakeoneheapofallyourwinnings Andriskitononeturnofpitch-and-toss, Andlose,andstartagainatyourbeginnings Andneverbreatheawordaboutyourloss; Ifyoucanforceyourheartandnerveandsinew Toserveyourturnlongaftertheyaregone, Andsoholdonwhenthereisnothinginyou ExcepttheWillwhichsaystothem: ‘Holdon!’

Ifyoucantalkwithcrowdsandkeepyourvirtue, OrwalkwithKings norlosethecommontouch, Ifneitherfoesnorlovingfriendscanhurtyou, Ifallmencountwithyou,butnonetoomuch; Ifyoucanfilltheunforgivingminute Withsixtyseconds’ worthofdistancerun, YoursistheEarthandeverythingthat’sinit, And whichismore you ’llbeaMan,myson!

From AChoiceofKipling'sVerse (1943)

Contributorsv

Forewordxvii

Prefacexix

PART I.TRAUMA SYSTEMS

DevelopmentofTraumaSystems 1

DonaldD.Trunkey

TraumaCenterOrganizationandVerification(chapteronline at www.ExpertConsult.Inkling.com) 5

BrianEastridgeandErwinThal

InjurySeverityScoring:ItsDefinitionandPracticalApplication (chapteronlineat www.ExpertConsult.Inkling.com) 6

TurnerM.Osler,LaurentG.Glance,andEdwardJ.Bedrick

RoleofAlcoholandOtherDrugsinTrauma(chapteronlineat www.ExpertConsult.Inkling.com) 6

LarryM.GentilelloandThomasJ.Esposito

RoleofTraumaPreventioninReducingInterpersonalViolence (chapteronlineat www.ExpertConsult.Inkling.com) 6

EdwardE.CornwellandDavidC.Chang

TraumaScoring(chapteronlineat www.ExpertConsult. Inkling.com) 6

NicoleVanDerHeydenandThomasB.Cox ResultsoftheMedicalStrategyforMilitaryTraumain Colombia 7

WilliamSánchezMaldonado,ErwinRodriguezGarcía,DavidRojasTirado, andJuanA.Asensio

PART II.PREHOSPITAL TRAUMA CARE

InfluenceofEmergencyMedicalServicesonOutcomeat TraumaCenter 15

DavidShatz

FieldTriageintheMilitaryArena(chapteronlineat www. ExpertConsult.Inkling.com) 17

JeffreyA.BaileyandAlanD.Murdock

FieldTriageintheCivilianArena(chapteronlineat www. ExpertConsult.Inkling.com) 17

KarenBrasel,JohnWeigelt,andJenniferC.Roberts

PrehospitalAirwayManagement:Intubation,Devices, andControversies 18

RaulCoimbra,JayDoucet,andDavidHoyt

PrehospitalFluidResuscitation:WhatType,HowMuch, andControversies 24

AdamM.Shiroff,VincenteH.Gracias,andMichaelF.Rotondo CivilianHospitalResponsetoMassCasualtyEvents 27 RochelleA.DickerandWilliamP.Schecter

InjuriesfromExplosives 33

HowardR.Champion

PrehospitalCareofBiologicAgent–InducedInjuries 38 KennethG.Swan,CharlesD.Mabry,andJuanA.Asensio

WoundBallistics:WhatEveryTraumaSurgeonShould Know 45

LaszloKiraly,JohnC.Mayberry,andDonaldD.Trunkey

CommonPrehospitalComplicationsandPitfallsinthe TraumaPatient 50

FrankL.Mitchell,CharlesM.Richart,andHarryE.Wilkins

PART III.INITIAL ASSESSMENTAND RESUSCITATION

AirwayManagement:WhatEveryTraumaSurgeonShould Know,FromIntubationtoCricothyroidotomy 57 AndrewR.DobenandRonaldI.Gross

ResuscitationFluids 70

RonBarbosa,BrandonTieu,LaszloKiraly,MichaelEnglehart,Martin Schreiber,andSusanRowell

ResuscitativeThoracotomy 76

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso, WendyJoSvetanoff,MollyHartmann,EricElster,G.DanielPust, andMichelWagner

FocusedAssessmentwithSonographyfortheTrauma Patient 88

AndrésM.Rubiano,GlynEstebanez,andAurelioRodríguez RoleofRadiologyinInitialTraumaEvaluation 99

KimM.Caban,GaryH.Danton,AnthonyM.Durso,FelipaMunera, andLuisA.Rivas

InterventionalRadiology:DiagnosticandTherapeuticRoles 116

DavidJ.Quintana,JasonSalsamendi,andFelipaMunera

EndpointsofResuscitation 123

SusanRowell,RonaldBarbosa,MichaelEnglehart,BrandonTieu,and MartinSchreiber

PART IV.HEADAND CENTRAL NERVOUS SYSTEM INJURIES

TraumaticBrainInjury:Pathophysiology,ClinicalDiagnosis, andPrehospitalandEmergencyCenterCare 127

AileenEbadatandAlexB.Valadka

TraumaticBrainInjury:Imaging,OperativeandNonoperative Care,andComplications 133

AileenEbadatandAlexB.Valadka

Spine:SpinalCordInjury,BluntandPenetrating,Neurogenic andSpinalShock 140

VartanS.Tashjian,NestorR.Gonzalez,andLarryT.Khoo

PART V.MAXILLOFACIALAND OCULAR INJURIES

MaxillofacialTrauma 153

UrmenDesai,RosaineRoeder,BenjaminT.Lemelman,andSethR.Thaller

TraumatotheEyeandOrbit 162

MarioA.MealletandBibianaJ.Reiser

PART VI.NECK INJURIES

PenetratingNeckInjuries:DiagnosisandCurrent Management 179

LeonardJ.Weireter,Jr.andL.D.Britt

BluntCerebrovascularInjuries 185 ClayCothrenBurlewandErnestE.Moore

Tracheal,Laryngeal,andOropharyngealInjuries 192

LuisG.Fernández,ScottH.Norwood,andJohnD.Berne

PART VII.THORACIC INJURIES

PertinentSurgicalAnatomyoftheThoraxand Mediastinum 205

BrandonTieu,PaulSchipper,MithranSukumar,andJohnC.Mayberry

ThoracicWallInjuries:Ribs,Sternal,andScapularFractures; HemothoracesandPneumothoraces 229

DavidH.Livingston,CarlHauser,NoelleSalliant,andDevashishJ.Anjaria DiagnosticandTherapeuticRolesofBronchoscopyand Video-AssistedThoracoscopyintheManagementof ThoracicTrauma 238

AjaiK.Malhotra,MichelB.Aboutanos,andThereseM.Duane

PulmonaryContusionandFlailChest 245

CarlHauser,NoelleSaillant,andDavidH.Livingston

OperativeTreatmentofChestWallInjury 254

R.StephenSmithandJuanA.Asensio

TrachealandTracheobronchialTreeInjuries 257

PrestonR.MillerandJ.WayneMeredith

OperativeManagementofPulmonaryInjuries:Lung-Sparing andFormalResections 260

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,Thomas Templin,ShreyaShetty,G.DanielPust,KirbyR.Gross,and MarcusBalters

ComplicationsofPulmonaryandPleuralInjury 274

ThomasK.Varghese,Jr.,RiyadKarmy-Jones,andGregoryJ.Jurkovich CardiacInjuries 281

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso, ZacharyTorgersen,BrianBiggerstaff,BrittneyJ.Maloley-Lewis,Pulkesh Bhatia,JefferyA.Bailey,JuanA.Sanchez,andEliasDegiannis

ThoracicVascularInjury 290

PeterI.Tsai,RamyarGilani,KennethL.Mattox,and MatthewJ.Wall,Jr.

OpenandEndovascularManagementofThoracicAortic Injuries 296

K.ShadPharaonandDonaldD.Trunkey

TreatmentofEsophagealInjury 302

A.BrittonChristmasandJ.DavidRichardson

PART VIII.ABDOMINAL INJURIES

DiaphragmaticInjury 307

CharlesE.LucasandAnnaM.Ledgerwood

SurgicalAnatomyoftheAbdomenand Retroperitoneum 316

JoeDuBoseandThomasM.Scalea

DiagnosticPeritonealLavageandLaparoscopyinthe EvaluationofAbdominalTrauma 323

AmyRushingandDavidT.Efron

NonoperativeManagementofBluntandPenetrating AbdominalInjuries 326

MatthewJ.MartinandPeterRhee

GastricInjuries 336

LawrenceN.Diebel

SmallBowelInjury 339

KimballMaull

DuodenalInjuries 346

GregoryJ.Jurkovich

PancreaticInjuriesandPancreaticoduodenectomy 352

LouisJ.MagnottiandMartinA.Croce

LiverInjury 358

ManishS.Parikh,SusanI.Brundage,andH.LeonPachter

SplenicInjuries 373

JosephM.GalanteandDavidH.Wisner

AbdominalVascularInjury 381

ChristopherJ.DenteandDavidV.Feliciano

ColonandRectalInjuries 391

DavidJ.Ciesla

GenitourinaryTractInjuries 395

LucasR.WiegandandStevenB.Brandes

GynecologicInjuries:TraumatoGravidandNongravid UterusandFemaleGenitalia 401 PatrizioPetroneandAretiTillou

MultidisciplinaryManagementofPelvicFractures:Operative andNonoperativeManagement 407

ThomasM.ScaleaandDeborahM.Stein

PART IX.SPECIAL ISSUESIN MAJOR TORSO TRAUMA

CurrentConceptsintheDiagnosisandManagementof HemorrhagicShock 415

JuanCarlosPuyana,SamuelTisherman,andAndrewB.Peitzman

TheSyndromeofExsanguination:ReliableModelstoIndicate DamageControl 422

JuanA.Asensio,RobertBertelotti,FedericoN.Mazzini,JoséCeballos Esparragon,ChrisOkwuosa,StevenCheung,RiaanPretorius,Luis ManuelGarcía-Núñez,andAliciaM.Mohr

DamageControlResuscitation:AnEvidence-BasedReport 425

JuanC.Duchesne,ChrissyGuidry,LouisA.Aliperti,LanceE.Stuke, andNormanE.McSwain,Jr.

SurgicalTechniquesforThoracic,Abdominal,Pelvic,and ExtremityDamageControl 430

GretaL.Piper,KimberlyA.Davis,andFredA.Luchette

AbdominalCompartmentSyndrome,DamageControl, andtheOpenAbdomen 435

OliverL.Gunter,Jr.,NathanJ.Powell,andRichardS.Miller

TorsoTraumaontheModernBattlefield 446

ColonelMatthewJ.MartinandColonelBrianEastridge

PART X.PERIPHERAL VASCULAR INJURY

VascularAnatomyoftheExtremities 457

NormanM.RichandDavidR.Welling DiagnosisofVascularTrauma 459

JohnT.AndersonandF.WilliamBlaisdell

PenetratingCarotidArtery:UncommonComplexandLethal Injuries 463

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,JoeDuBose, IronyC.Sade,ErinHale,PeterCollister,ThomasP.Brush,andFrankPlani

SubclavianVesselInjuries:DifficultAnatomyandDifficult Territory 469

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,MamounNabri, GeraldGracia,MichaelKsycki,PaulW.White,andRobertF.Wilson

OperativeExposureandManagementofAxillaryVessel Injuries 476

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso, AngelaOsmolak,JasonLoden,GeraldGracia,MichaelKsycki,D’Andrea Joseph,TakashiFujita,andYasuhiroOtomo

BrachialVesselInjuries:HighMorbidityandLowMortality Injuries 481

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,Parth Shah,AustinPerson,AnthonyM.Udekwu,JohnK.Bini,andAriLeppäniemi IliacVesselInjuries:DifficultInjuriesandDifficult ManagementProblems 487

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso, RichardDenney,GeraldGracia,MichaelKsycki,BradleyS.Putty, JamesB.Sampson,andRobertF.Wilson

FemoralVesselInjuries:HighMortalityandLowMorbidity Injuries 494

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,KulsoomLaeeq, AbishekSundaram,MamounNabri,BrandonPropper,andWilliamG.Cioffi PoplitealVesselInjuries:ComplexAnatomyandHigh AmputationRates 504

JuanA.Asensio,PatrizioPetrone,AlejandroPerez-Alonso,MarkTraynham, AnanthSrinivasan,StephenSerio,JeremyCannon,andJohnT.Owings TemporaryVascularShunts 518

DavidV.Feliciano

PART XI.MUSCULOSKELETALAND PERIPHERAL CENTRAL NERVOUS SYSTEM INJURIES

UpperExtremityFractures:Orthopaedic Management 523

StevenKalandiakandStephenM.Quinnan

LowerExtremityandDeglovingInjury 535

PeterG.Trafton,HermanP.Houin,andDonaldD.Trunkey Cervical,Thoracic,andLumbarFractures 540 NicholasSpoerkeandDonaldD.Trunkey

PelvicFractures 544

ChristopherH.PerkinsandStephenM.Quinnan

WristandHandFractures:OrthopaedicManagement ofCurrentTherapyofTraumaandSurgicalCritical Care(chapteronlineat www.ExpertConsult.Inkling. com ) 550

PatrickOwens

ScapulothoracicDissociationandDeglovingInjuriesofthe Extremities(chapteronlineat www.ExpertConsult.Inkling. com) 550

WalterL.BifflandKyrosIpaktchi

ExtremityReplantation:IndicationsandTiming(chapter onlineat www.ExpertConsult.Inkling.com) 550

HaarisMir,MoradAskari,andZubinJalPanthaki

SpecialTechniquesfortheManagementofComplex

MusculoskeletalInjuries:TheRolesofFasciocutaneousand MyocutaneousFlaps(chapteronlineat www.ExpertConsult. Inkling.com) 551

ChristopherSalgado,AriHoschander,andJohnOeltjen

PART XII.SPECIAL ISSUESAND SITUATIONS IN TRAUMA MANAGEMENT

AirwayManagement:WhatEverySurgeonShouldKnow abouttheTraumaticAirway(TheAnesthesiologist’ s Perspective) 553

ShawnM.CantieandEdgarJ.Pierre

PediatricTrauma 556

DavidW.TuggleandL.R.TresScherer

TraumainPregnancy 561

AmyC.SisleyandWilliamC.Chiu

Traumainour “Elders ” 567

DanielJ.Grabo,BenjaminM.Braslow,andC.WilliamSchwab

Burns 571

JohnT.SchulzIII,KimberlyA.Davis,andRichardL.Gamelli

SoftTissueInfections 582

SharonHenry

CommonErrorsinTraumaCare 593

R.StephenSmith,AllanS.Philp,andStephenyD.Berry

CombatTraumaCare:LessonsLearnedfromaDecadeof War 598

MatthewJ.MartinandBrianEastridge

PART XIII.CRITICAL CARE I:MANAGEMENTOF ORGAN FAILURESAND TECHNIQUESFOR SUPPORT

CardiacHemodynamics:ThePulmonaryArteryCatheterand theMeaningofItsReadings 607

D.DanteYeh,MitchellJ.Cohen,andRobertC.Mackersie

OxygenTransport 613

PatricioPolanco,JuanCarlosPuyana,MitchellFink,andAndrewB.Peitzman

PharmacologicSupportofCardiacFailure 616

JohnW.MahandOrlandoC.Kirton

DiagnosisandManagementofCardiacDysrhythmias 621

KareemR.AbdelFattahandJosephP.Minei

FundamentalsofMechanicalVentilation 628

SoumitraR.Eachempati,JerryA.Rubano,JaredM.Huston,PhilipS.Barie, andMarcJ.Shapiro

AdvancedTechniquesinMechanicalVentilation 639

JaredM.Huston,MarcJ.Shapiro,SoumitraR.Eachempati,andPhilipS.Barie

ManagementofRenalFailure:RenalReplacementTherapy andDialysis 644

JosephM.Gutmann,ChristopherMcFarren,LewisM.Flint,andRodney Durham

ManagementofCoagulationDisordersintheSurgical IntensiveCareUnit 650

ChristopherP.MichettiandSamirM.Fakhry

ManagementofEndocrineDisordersintheSurgicalIntensive CareUnit 658

AnthonyFalvoandMathildaHorst

Transfusion:ManagementofBloodandBloodProductsin Trauma 665

LenaM.Napolitano

PART XIV:CRITICAL CARE II:SPECIAL ISSUES AND TREATMENTS

AcuteRespiratoryDistressSyndrome 679

MatthewC.Bozeman,KeithR.Miller,NicholasA.Nash,andJorgeL. Rodríguez

SystemicInflammatoryResponseSyndromeandMultipleOrganDysfunctionSyndrome:Definition,Diagnosis,and Management 683

GregoryTiesi,LeonardMason,BenjaminChandler,AnthonyWatkins, DavidPalange,andEdwinA.Deitch

Sepsis,SepticShock,andItsTreatment 689

MariniCorradoPaolo,GaryLombardo,AnthonyPolicastro,andDimitryi Karev

ImmunologyofTrauma 696

ChristineS.CocanourandS.RobTodd

OverviewofInfectiousDiseasesinTraumaPatients 701

DonaldE.Fry

NosocomialPneumonia 709

PaulM.MaggioandDavidA.Spain

AntibioticUseintheIntensiveCareUnit:TheOldand theNew 715

PhilipS.Barie

FungalColonizationandInfectionDuringCritical Illness 725

MarcJ.Shapiro,EduardoSmith-Singares,SoumitraR.Eachempati,JaredM. Huston,andPhilipS.Barie

PreoperativeandPostoperativeNutritionalSupport:Strategies forEnteralandParenteralTherapies 733

PatriciaMarieByers,S.MoradHameed,andStanleyJ.Dudrick

VenousThromboembolism:DiagnosisandTreatment 742

SusanEvansandRonaldSing

HypothermiaandTrauma 750

LarryM.GentilelloandR.LawrenceReedII

SurgicalProceduresintheSurgicalIntensiveCareUnit (chapteronlineat www.ExpertConsult.Inkling.com ) 755

ZiadC.SifriandAliciaM.Mohr

AnesthesiaintheCriticalCareUnitandPainManagement (chapteronlineat www.ExpertConsult.Inkling.com ) 755

AndrewLoukas,ShawnM.Cantie,andEdgarJ.Pierre

DiagnosticManagementofBrainDeathintheIntensiveCare UnitandOrganDonation(chapteronlineat www. ExpertConsult.Inkling.com) 755

DarrenMalinoskiandAliSalim

PART XV:REHABILITATIONAND QUALITY OF LIFE AFTER TRAUMAAND OTHER ISSUES

PalliativeCareintheTraumaIntensiveCareUnit(chapter onlineat www.ExpertConsult.Inkling.com) 757

AnastasiaKunacandAnneC.Mosenthal

TraumaRehabilitation(chapteronlineat www.ExpertConsult. Inkling.com) 757

WayneDubov,JosephJ.Stirparo,andMichaelD.Pasquale

TraumaOutcomes(chapteronlineat www.ExpertConsult. Inkling.com) 757

GlenTinkoffandMichaelRhodes

Index759

T RAUMA S YSTEMS

D EVELOPMENTOF T RAUMA

S YSTEMS

Moderntraumacareconsistsofthreeprimarycomponents: prehospitalcare,acutesurgicalcareorhospitalcare,and rehabilitation.Ideally,asociety,throughstate(department,province, regional,etc.)government,shouldprovideatraumasystemthat ensuresallthreecomponents.Thepurposeofthischapteristoshow howtraumasystemshaveevolved,todiscusswhetherornotthey work,andtodefinecurrentproblems.

Fromanhistoricalviewpoint,itisanacceptedconceptthattrauma careandtraumasystemsareinextricablylinkedtowar.Whatisnot appreciatedisthattraumasystemsarenotrecentconcepts.Theydate backtocenturiesbeforetheCommonEra.Itisnotknownforcertain whetherthewoundsofprehistorichumansweredueprimarilytoviolenceortoaccident.Thefirstsolidevidenceofwarwoundscamefrom amassgravefoundinEgyptanddatetoapproximately2000 BC.The bodiesof60soldierswerefoundinasufficientlywell-preservedstate toshowmaceinjuries,gapingwounds,andarrowsstillinthebody. TheSmithPapyrusrecordstheclinicaltreatmentof48casesofwar wounds,andisprimarilyatextbookonhowtotreatwounds,mostof whichwerepenetrating.AccordingtoMajno,therewere147 recordedwoundsinHomer’ s Iliad,withanoverallmortalityrate of77.6%.Thirty-onesoldierssustainedwoundstothehead,allof whichwerefatal.ThesurgicalcareforawoundedGreeksoldier wascrudeatbest.However,theGreeksdidrecognizetheneedfor asystemofcombatcare.Thewoundedweregivencareinspecialbarracks(klisiai)orinnearbyships.Woundcarewasprimitive.Barbed arrowheadswereremovedbyenlargingthewoundwithaknifeor pushingthearrowheadthroughthewound.Drugs,usuallyderived fromplants,wereappliedtowounds.Woundswerebound,but accordingtoHomer,hemostasiswastreatedbyan “epaoide, ” that is,someonesangasongorrecitedacharmoverthewound.

TheRomansperfectedthedeliveryofcombatcareandsetupasystemoftraumacentersthroughouttheEmpire.Thesetraumacenters werecalled valetudinaria andwerebuiltduringthefirstandsecond centuries AD.Theremainsof25suchcentershavebeenfound,butsignificantly,nonewerefoundinRomeorotherlargecities.Ofsome interest,therewere11traumacentersinRomanBritannia,morethan currentlyexistinthisarea.Someofthe valetudinaria weredesignedto handleacombatcasualtyrateofupto10%.Therewasaregularmedical corpswithintheRomanlegions,andatleast85armyphysiciansare recorded,mainlybecausetheydiedandearnedanepitaph.

Fromelsewhereintheworldcameotherevidencethattraumasystemswereprovidedforthemilitary.Indiamaywellhavehadasystem oftraumacarethatrivaledthatoftheRomans.The Artasastra,abook writtenduringthereignofAshoka(269–232 BC)documentedthatthe Indianarmyhadanambulanceservice,withwell-equippedsurgeons andwomentopreparefoodandbeverages.Indianmedicinewasspecialized,anditwasthe shalyarara (surgeon)whowouldbecalled upontotreatwounds. Shalyarara literallymeans “ arrowremover, ” asthebowandarrowwasthetraditionalweaponforIndians.

Overthenextmillennium,militarytraumacaredidnotmakeany majoradvancesuntiljustbeforetheRenaissance.TwoFrenchmilitarysurgeons,wholived250milesapart,broughttraumacareinto theAgeofEnlightenment.

AmbroseParé(1510–1590)servedfourFrenchkingsduringthe timeoftheFrench-Spanishcivilandreligiouswars.Hismajorcontributionstotreatingpenetratingtraumaincludedhistreatmentof gunshotwounds,hisuseofligatureinsteadofcautery,andtheuse ofnutritionduringthepostinjuryperiod.Paréwasalsomuchinterestedinprostheticdevices,anddesignedanumberofthemfor amputees.

ItwasDominiqueLarrey,Napoleon’ssurgeon,whoaddressed traumafromasystematicandorganizationalstandpoint.Larrey introducedtheconceptofthe “flyingambulance,” thesolepurpose ofwhichwastoproviderapidremovalofthewoundedfromthebattlefield.Larreyalsointroducedtheconceptofputtingthehospitalas closetothefrontlinesasfeasibleinordertopermitwoundsurgeryas soonaspossible.Hisprimaryintentwastooperateduringtheperiod of “woundshock,” whentherewasanelementofanalgesia,butalsoto reduceinfectioninthepostamputationperiod.

Larreyhadanunderstandingofproblemsthatwereuniquetomilitarysurgery.Someofhiscontributionscanbestbeappreciatedbyhis effortsbeforeNapoleon’sRussiancampaign.Larreydidnotknow whichcountryNapoleonwasplanningtoattack,andtherewaseven conjectureaboutaninvasionofEngland.HeleftParisonFebruary24, 1812,andwasorderedtoMentz,Germany.Shortlythereafter,he wenttoMagdeburgandthenontoBerlin,wherehebeganpreparationsforthecampaign,stillnotknowingpreciselywheretheFrench armywasheaded.Inhisownwords, “Previoustomydeparturefrom thecapital,Iorganizedsixdivisionsofflyingambulances,eachone consistingofeightsurgeons.Thesurgeons-majorexercisedtheirdivisionsdaily,accordingtomyinstructions,intheperformanceofoperations,andtheapplicationofbandages.Thegreatestdegreeof emulation,andthestrictestdiscipline,wereprevalentamongall thesurgeons.”

The19thcenturymaywellbedescribedasthecenturyofenlightenmentforsurgicalcareincombat.Thiswaspartlybecauseofbetter statisticalreporting,butalsobecauseofmajorcontributionstopatient care,includingtheintroductionofanesthesia.DuringtheCrimean War(1853–1856),theEnglishreportedamortalityrateof92.7%in casesofpenetratingwoundsoftheabdomen,andtheFrenchhada

rateof91.7%.DuringtheAmericanWarBetweentheStates,there were3031deathsamongthe3717casesofabdominalpenetrating wounds,amortalityrateof81.5%.

TheCrimeanWarwasnoteworthyinhavingbeentheconflictin whichtheFrenchtestedanumberoflocalantisepticagents.Ferrous chloridewasfoundtobeveryeffectiveagainsthospital-relatedgangrene,buttheEnglishavoidedtheuseofantisepticsinwounds. ItwasalsoduringtheCrimeanWarthattwofurthermajorcontributionstocombatmedicinewereintroducedwhenFlorence Nightingaleemphasizedsanitationandhumanenursingcarefor combatcasualties.

TheuseofantisepticswascontinuedintotheAmericanWar BetweentheStates.Brominereducedthemortalityratefromhospital gangreneto2.6%inareportedseriesof308patients.Thiscontrasted withamortalityrateof43.3%amongpatientsforwhombrominewas notused.Strongnitricacidwasalsousedasanantisepticinhospital gangrene,withamortalityrateof6.6%.Anestheticswereusedbyfederalmilitarysurgeonsin80,000patients.Tragically,mortalityrate fromgunshotwoundstotheextremitiesremainedhigh,paralleling thatreportedbyParéinthe16thcentury.Themortalityratefrom gunshotfracturesofthehumerusandupperarmwas30.7%;those oftheforearm,21.9%;ofthefemur,31.7%;andoftheleg,14.4%. Theoverallmortalityratefromamputationin29,980patientswas 26.3%.

TheFranco-PrussianWar(1870–1874)wasmarkedbyterrible deathsandthereluctanceofsomesurgeonstousethewoundantisepticsadvocatedbyLister.Themortalityrateforfemurfractureswas 65.8%inoneseries,andrangedfrom54.2%to91.7%inotherseries. Lateintheconflict,surgeonsfinallyacceptedLister’srecommendations,andthemortalityratefelldramatically.

DuringtheBoerWar(1899–1902),theBritishadvisedceliotomy inallcasesofpenetratingabdominalwounds.However,earlyresults wereabysmal,andasubsequentBritishmilitaryordercalledforconservativeorexpectanttreatment.

DuringtheearlymonthsofWorldWarI,abdominalinjurieshad anunacceptable85%mortalityrate.Asthewarprogressed,patients werebroughttoclearingstationsandunderwentsurgerynearthe front,withasubsequentdecreaseinmortalityrateto56%.When theAmericansenteredtheconflict,theiroverallmortalityratefrom penetratingabdominalwoundswas45%.OneofthemajorcontributionstotraumacareduringWorldWarIwasbloodtransfusion.

SinceWorldWarII,manycontributionstocombatsurgicalcare haveledtoreductionsinmortalityandmorbidity.Comparativemortalityratesforvariousconflictsarelistedin Table1.Surgicalmortality ratesareshownin Table2.Theintroductionofantibioticsand improvementsinanesthesia,surgicaltechniques,andrapidprehospitaltransportarejustafewoftheinnovationsthathaveledtobetter outcomes.

MODERNTRAUMASYSTEM DEVELOPMENT

Betweenthetwoworldwars,somesignificantadvancesweremadein civiliantraumacare.LorenzBohlerformedthefirstciviliantrauma systeminAustriain1925.Althoughinitiallydirectedatwork-related injuries,iteventuallyexpandedtoincludeallaccidents.Attheonset ofWorldWarII,theBirminghamAccidentHospitalwasfounded.It continuedtoprovideregionaltraumacareuntilrecently.By1975, Germanyhadestablishedanationwidetraumasystem,designedso thatnopatientwasmorethan15to20minutesfromoneofthese regionalcenters.DuetotheworkofHaraldTscherneandcolleagues, thissystemhascontinuedintothepresent,andmortalityratehas decreasedbyover50%(Fig.1).

InNorthAmerica,foundationsformoderntraumasystemswere beingundertaken.In1912,atameetingoftheAmericanSurgical AssociationinMontreal,acommitteeoffivewasappointedto prepareastatementonthemanagementoffractures.Thisledto

TABLE1: PercentageofWoundedAmerican SoldiersWhoDiedfromTheirWounds

War Years

Number of Wounded Soldiers Percentageof Wounded SoldiersWho DiedofWounds

MexicanWar1846–18483,40015

AmericanWar Betweenthe States 1861–1865318,20014 SpanishAmericanWar 1898 1,600

TABLE2: SurgicalMortalityRatesforHead,Chest, andAbdominalWoundsinSoldiersfromU.S.Army HeadThoraxAbdomen

WorldWarI

Numberofsoldiers1891041816 Mortalityrate(%)4037 67

astandingcommittee.Oneyearlater,theAmericanCollegeofSurgeonswasfounded,andinMay1922,theBoardofRegentsofthe AmericanCollegeofSurgeonsstartedthefirstCommitteeonFractureswithCharlesScudder,MD,aschair.Thiseventuallybecame theCommitteeonTrauma.Anotherfunctionbegunbythecollege in1918wastheHospitalStandardizationProgram,whichevolved intotheJointCommissiononAccreditationofHospitals.Onefunctionofthisstandardizationprogramwasanembryonicstartofa traumaregistrywithacquisitionofrecordsofpatientswhoweretreatedforfractures.In1926,theBoardofIndustrialMedicineandTraumaticSurgerywasformed.Thus,itwasthestandardizationprogram bytheAmericanCollegeofSurgeons,theFractureCommittee

TRAUMA DEATHS

Pelvic fractures

Long bone fractures

01 hour3 hours 2 weeks4 weeks Time

FIGURE1 Traumadeathshaveatrimodaldistribution.Thefirst deathpeak(approximately50%)iswithinminutesoftheinjury.The seconddeathpeak(approximately30%)occurswithinafewhours to48hours.Thethirddeathpeak(approximately15%)occurs within1to4weeksandrepresentsthosepatientswhodiefromthe complicationsoftheirinjuryortreatment.Fromapublichealth perspective,thefirstdeathpeakcanbeaddressedonlyby prevention,whichisdifficult,becausepartofthisstrategymeans dealingwithhumanbehavior.Theseconddeathpeakisbest addressedbyhavingatraumasystem,andthethirddeathpeak requirescriticalcareandresearch.

appointedbytheAmericanCollegeofSurgeons,theavailabilityof patientrecordsfromtheHospitalStandardizationProgram,and thenewBoardofIndustrialMedicineandTraumaticSurgerythat providedtheseedsofthetraumasystem.

In1966,thefirsttwotraumacenterswereestablishedinthe UnitedStates:WilliamF.BlaisdellatSanFranciscoGeneralHospital andRobertFreearkatCookCountyHospitalinChicago.Threeyears later,astatewidetraumasystemwasestablishedinMarylandbyR.A. Cowley.In1976,theAmericanCollegeofSurgeonsCommitteeon TraumadevelopedaformaloutlineofinjurycarecalledOptimalCriteriaforCareoftheInjuredPatient.Subsequently,thetaskforceof theAmericanCollegeofSurgeonsCommitteeonTraumamet approximatelyevery4yearsandupdatedtheiroptimalcriteria,which arenowusedextensivelyinestablishingregionalandstatetrauma systemsandhaverecentlybeenexportedtoAustralia.OthercontributionsbytheAmericanCollegeofSurgeonsCommitteeonTrauma includeintroductionoftheAdvancedTraumaLifeSupportcourses, establishmentofanationaltraumaregistry(NationalTraumaData Bank),andanationalverificationprogram.Thelatterisanalogous totheoldhospitalstandardizationprogram,and “verifies” byapeer reviewprocesswhetherahospital’straumacentermeetsAmerican CollegeofSurgeonsguidelines.

ARETRAUMASYSTEMSEFFECTIVE?

Since1984,morethan15articleshavebeenpublishedshowingthat traumasystemsbenefitsocietybyincreasingthechancesofsurvival whenpatientsaretreatedinspecializedcenters.Inaddition,twostudieshaveshownthattraumasystemsalsoreducetraumamorbidity.In 1988,areportcardwasissuedonthecurrentstatusandfuturechallengesoftraumasystems.Atthattime,aninventorywastakenofall stateemergencymedicalservicedirectorsorhealthdepartmentshavingresponsibilityoveremergencyandtraumaplanning.Theywere contactedviatelephonesurveyinFebruary1987,andthenwereasked eightspecificquestionsontheirstatetraumasystems.Oftheeight

criteria,onlytwostates,MarylandandVirginia,wereidentifiedas havingalleightessentialcomponentsofaregionaltraumasystem. NineteenstatesandWashington,D.C.eitherhadincompletestatewidecoverageorlackedessentialcomponents.Notlimitingthenumberoftraumacentersintheregionwasthemostcommondeficient criterion.

In1995,anotherreportcardwasissuedinthe Journalofthe AmericanMedicalAssociation.Thisreportcardwasanupdateon theprogressanddevelopmentoftraumasystemssincethe1988 report.Itwasamoresophisticatedapproach,asitexpandedtheoriginaleightcriteriaandwasmorecomprehensive.Accordingtothe 1995report,fivestates(Florida,Maryland,Nevada,NewYork,and Oregon)hadallthecomponentsnecessaryforastatewidesystem. Virginianolongerlimitedthenumberofdesignatedtraumacenters. Anadditional15statesandWashington,D.C.hadmostofthecomponentsofatraumasystem.

The1995reportcardwasupgradedattheSkamaniaConferencein 1998.Therearenow35statesacrosstheUnitedStatesactively engagedinmeetingtraumasystemcriteria.Inadditiontothereport card,theSkamaniaConferenceevaluatedtheeffectivenessoftrauma systems.Themedicalliteraturewassearchedandallavailableevidencewasdividedintothreecategories:reportsresultingfrompanel studies(autopsystudies),registrycomparisons,andpopulation-based research.Panelstudiessufferedfromwidevariationandpoorinterraterreliability,andtheautopsiesaloneweredeemedinadequate. Thisfindingledtothegeneralconsensusthatpanelstudieswere onlyweakclassIIIevidence.Despitetheselimitations,however, MacKenzieetal.concludedthatwhenallpanelstudiesareconsidered collectively,theydoprovidesomefacevalidityandsupportthe hypothesisthattreatmentinatraumacenterversusanontraumacenterisassociatedwithfewerinappropriatedeathsandpossiblyeven disability.Registryevaluationwasfoundtobeusefulforassessing overalleffectivenessoftraumasystems. JurkovichandMock concludedthedataclearlydidnotmeetclassIevidence.Theircritique oftraumaregistriesincludedthefollowing:thereareoftenmissing data,miscodingsoccur,theremaybeinter-raterreliabilityfactors, thenationalnormsarenotpopulation-based,thereislittledetail aboutthecauseofdeath,andtheydonottakeintoaccountprehospitaldeaths.Despitethesedeficits,conferenceparticipantsreached consensus,concludingthatregistrystudieswerebetterthanpanel studiesbutnotasgoodaspopulationstudies.Finally,populationbasedstudieswereevaluatedandfoundtocompriseclassIIevidence. Anadvantageoverregistrystudiesisattributedtostudyingand evaluatingalargepopulationinallaspectsoftraumacare,including prehospital,hospital,andrehabilitation.Unfortunately,onlyalimited numberofclinicalvariablescanbeevaluated,anditisdifficultto adjustforseverityofinjuryandphysiologicdysfunction.Despitedisadvantageswithallthreestudies,theadvantagesmaybeappliedto variousindividualcommunitiestohelpinfluencepublichealthpolicy withregardtotraumasysteminitiationandevaluation.

Tworecentstudiesdocumenttheeffectivenessoftraumasystems. ThefirstisacomparisonofmortalityratesbetweenLevelItrauma centersandhospitalswithoutatraumacenter.Thein-hospitalmortalityratewassignificantlylowerintraumacentersthaninnontraumacenters(7.6%vs.9.5%).This25%differenceinmortality ratewaspresent1yearafterinjurywitha10.4%mortalityrateconnectedtotraumacentersand13.8%tonontraumacenters.ThesecondstudywasanassessmentoftheStateofFlorida’straumasystem, andthisstudyconfirmeda25%lowermortalityrateindesignated traumacenters.

WHATARETHECURRENTPROBLEMS?

IntheglobalburdenofdiseasestudybyMurrayandLopez,theworld isdividedintodevelopedregionsanddevelopingregions.Theyalso examinevariousstatisticsonagloballevel.Themostusefulstatistic ormeansofmeasuringdisabilityisthedisability-adjustedlifeyear

(DALY).Thisisthesumoflifeyearslostduetoprematuredeathand yearslivedwithdisabilityadjustedforseverity.By2020,roadtraffic accidentswillbethenumber3overallcauseworldwideofDALYs. ThisdoesnotincludeDALYsfromwar,whichisnumber8.Indevelopedcountries,roadtrafficaccidentsarethefifthhighestcauseof DALYs,andindevelopingregions,thesecondhighestcause.One ofthemostdifficultproblemsthatwefaceinthecomingyearsis howtoprovidereasonabletraumacareandtraumasystemdevelopmentinthedevelopingregionsoftheworld.Prehospitalcareiscurrentlynonexistentinmostofthesedevelopingcountries.Thereare few,ifany,traumacentersintheurbanareas,andcertainlynone intheruralareasofthesamecountries.Evenifthereweresuchcentersoratraumasystem,rehabilitationisalmosttotallylacking,and therefore,theinjuredpersonwouldrarelybeabletoreturntowork orproductivityafterasevereinjury.

Asnotedearlier,Europehasinthelastcenturydevelopedsome statewidetraumasystems.However,thereisnoconcertedeffortby theEuropeanUnion(EU)toestablishcriteriafortraumasystems ortocoordinatetraumacareamongcountrieswithintheEU.Similarly,theEUdoesnothavestandardsforprehospitalcare,noristhere anetworkofrehabilitationfacilitiesthathavestandardsandarepeer reviewed.Intheory,surgeonstrainedinoneEUcountryshouldbe abletocrossthevariousnationalbordersandtopracticesurgery, includingtraumacare,withinthesedifferentEUcountries.Again, therearenostandardsforwhatconstitutesatraumasurgeon,and infact,traumasurgeryisapotpourriofdifferentmodels.Onemodel isexemplifiedbyAustria,wheretraumasurgeryisanindependent specialty.Anothermodelincorporatestraumasurgicaltraininginto generalsurgery,andthisincludesFrance,Italy,TheNetherlands, andTurkey.Inathirdmodel,themajorityoftraumatrainingisgiven withorthopedicsurgeryresidencytraining.BelgiumandSwitzerland followthismodel.Thelargestmodelprovidestraumasurgerytraining withinspecificspecialtieswithoutanysinglespecialtyhavingany majorresponsibilityfortraumatraining,andthismodelprevailsin Denmark,Germany,Portugal,Estonia,Iceland,England,Norway, Finland,andSweden.

Someofthemostvexingproblemsintraumasurgeryoccurnowin NorthAmerica,particularlyintheUnitedStates.Thisisinpartdueto changesingeneralsurgery.Itispredictedthattherewillbea major shortageofgeneralsurgeonsintheUnitedStateswithinthenextfew years.Generalsurgeonsarenowolder,andmoreimportantly,general surgeonsarenowsubspecializing.Wenowhaveforegut,hepatobiliary,vascular,breast,andcolorectalsurgeons.Theonethingtheyall haveincommonistheydonotwanttotaketraumacalls.Ourmedical specialtycolleagues’ nightcallisnowintransitionandhospitalsare hiringso-called “hospitalists,” whoaretrainedinfamilymedicineor internalmedicine.Inmanyinstances,thehospitalwillpaytheirsalariestoprovide24/7calls,usuallyona12-hourshiftbasis.Insome instances,possiblyuptoonethird,variouspracticegroupswillpay thesehospitaliststotaketheircallsinhospital.Anothertrendaffectinggeneralsurgeryistherapidtransitiontonondiscrimination regardinggender.Atleast50%ofenteringmedicalstudentsare nowfemale,butonly7%(approximately500individuals)applyto surgery.Thereasonsgivenarelonghoursandpoorlifestyle,asthese womenwishtocombineprofessionalcareerswithparentingresponsibilities.Thereisanoveralldecreaseinapplicationstogeneralsurgery,andthereasonsforthisarecomplexandmultifaceted.One importantreasonisthatgeneralsurgeons’ incomesareapproximately 50%lessthanthoseofsomespecialtysurgeons.Amoreconcerning reason,however,islifestyleperceptions.Youngermedicalstudents andphysicianstendtooptoutofsurgery,andtheyparticularlyabhor traumasurgery,becauseofthetimecommitmentandrelatedlifestyle issues.Anotherproblem,whichmaybeuniquetotheUnitedStates,is thedecreaseinoperativecasesintrauma.Therehasbeenashiftfrom penetratingtraumatoblunttraumaandanothershifttononoperative management,particularlyofliverandspleeninjuries.Generalsurgeonshavecompoundedtheproblembyreferringcasestosurgeons whospecializeinvascularsurgeryorchestsurgery.Interventional

radiologistsalsoparticipateinmanagementofcertaintraumatic injuries.

AnothervexingproblemintraumacareintheUnitedStatesisthe currentdemandforon-callpaybyspecialtysurgeons.Thisisparticularlytrueinorthopedicsandneurosurgery.Thison-callpayranges from $1000to $7000anight.Onaverage,aneurosurgeoninaLevelI hospitalwouldonlybecalledin33timesinthecourseofayear.In contrast,orthopedicsurgeonsaverageapproximately275emergency casesduringtheyear.Obviously,thisresponsibilitycouldbeshared betweengroups.Nevertheless,hospitalsarebeingaskedtopayon-call stipendstoneurosurgeonsthatarequitelarge,consideringtherelativelylowprobabilityofbeingcalledin.

Otherfactorsaffectingtraumaavailabilitybyspecialtysurgeons arefreestandingambulatorysurgerycenterswherethesurgeons canoftenavoidgovernmentregulations,donothavetotakecalls, andhavehospitalistscarefortheirpatientsatnight.

Theseproblemswillbeaccentuatedinthenextfewyearsasthe elderlypopulation(aged65andolder)reaches30%ofthetotalpopulation.StudiesintheUnitedStatesshowthatthemortalityratefor peopleaged65andolderintheintensivecareunitis3.5timesgreater thanthatofyoungerpeople,andlengthofstayislonger.Unfortunately,themajorityoftheseelderlypatientswhoareseriouslyinjured donotreturntoindependentlifestylesfollowingacutecare.

SOLUTIONS

Correctingtheproblemsindevelopingcountriesmaybethemostdifficult.Mostofthesecountriesaretotallylackingintheinfrastructure forprovisionofatraumasystem,includingprehospitalcare,sufficientadequatelytrainedsurgeons,andrehabilitationservices.InternationalinstitutionssuchastheWorldBankandWorldHealth Organizationwouldhavetotakealeadingroleinprovidingfinancial resourcesandtrainingforprehospitalcare.Thiswouldbeapotentiallyhugesum,becauseitwouldrequirecreatinganddevelopingadequatecommunications,ambulances,andproperlytrainedprehospital personnel.Similarly,provisionofappropriatelytrainedsurgeonsis equallyproblematic.BringingsurgeonstoWesterncountriesfortraininghasbeenaproblembecausemanyofthemdonotreturntotheir countriesoforigin.Inmyopinion,theoptimalwaytotraintheseindividualswouldbeforsurgicaleducatorsfromcountrieswithmature traumasystemstospendtimeeducatingsurgeonsintheappropriate medicalschoolsintheirhomecountries.Thisisalsoproblematic, becausethequalityofmedicalschoolsvariestremendouslyindevelopingnations.Furthermore,inadditiontosurgeons,anesthesiologists, criticalcarephysicians,andnurseswouldhavetobeeducatedaswell. Thethirdcomponentofatraumasystem,rehabilitation,isalmost totallylackingindevelopingcountries.Thiselementmaynotbeas resource-dependentorcostlyasothercomponents,butitwouldhave tobedevelopedconcomitantlywithprehospitalandacutecare.

Thefundamentalproblemindevelopingregionsissettingpriorities. IfweacceptthatDALYsareareasonableapproachtodeveloping soundhealthcarepolicy,thenwecanexaminethe10mostcommon causesofDALYs.Arankorderofthe10mostfrequentDALYsin developingcountriesare:(1)unipolarmajordepression,(2)roadtraffic accidents,(3)ischemicheartdisease,(4)chronicobstructivepulmonarydisease,(5)cerebrovasculardisease,(6)tuberculosis,(7)lower respiratoryinfections,(8)war,(9)diarrhealdiseases,and(10)HIV (humanimmunodeficiencyvirus)infection.Iambiased,butIbelieve thatroadtrafficaccidentsmaybethemostcost-effectiveDALYtotry toaddress.Preventionwouldclearlyplayamajorroleinchronic obstructivepulmonarydisease,ischemicheartdisease,andcerebrovasculardisease,iftheUnitedStates(amongothers)simplyquitmaking andexportingcigarettes.Iwouldalsoarguethatastheworldeconomy becomesmoreglobalizedanddevelopingcountriesbecomeeconomic powersintheirownright,itisimportantforustobeinvolvedearlyon inprovidingtheinfrastructureformanaginghealthcareingeneraland traumacareinparticular.

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