ACUTE CARE SURGERY: A new concept about an old need

George C. Velmahos, MD, FACS, FRCS, FRCPS, FCCM

Massachusetts General Hospital

Harvard Medical School


            Emergency care is at a breaking point. Patients overpower the capacity of Emergency Rooms (ER) to provide adequate care for all. Failed social health systems oblige patients to wait endlessly for elective visits, forcing them essentially to seek their routine care through an ER. Systems based on private insurance have contributed to the problem in a different way; since health insurance is not affordable by all, those without it have no other choice but to receive care in an ER. In developed countries up to 30% of the population is uninsured, a percentage that approaches 100% in the underdeveloped world. In the United States, one of the most advanced health care systems in the world has left over 30 million Americans without insurance. Even when insurance coverage is not a problem (as it occurs in many European countries), patients swarm in ER’s to receive urgent care. The real magnitude of the problem can only be experienced on a busy Saturday evening in an overcrowded ER.

            Surgical emergencies are a primary example. Patients and physicians suffer alike, as they struggle to provide or receive care in chaotic environments. Trauma surgeons have made a laudable effort to allow timely access of most trauma patients to centers of excellence. In the U.S. trauma systems and trauma centers were founded approximately 30 years ago and quickly created new standards of care. Trauma patients were rapidly transferred to specialized hospitals and managed by dedicated teams. Trauma systems and trauma centers were developed. Quality indicators, standards of care, educational course, and powerful research advanced the field of trauma care to a new level. Trauma patients were managed expeditiously and expertly, and outcomes improved.

            Unfortunately, the same level of urgency and organization was not offered to non-traumatic surgical emergencies. Patients who have emergent problems (e.g. perforated viscus, bleeding ulcer, obstructed bowel, inflamed organ, necrotizing infection, etc) frequently experience unacceptable delays in diagnosis and care. The lack of dedicated surgical teams to take care of these patients is a major flaw in the existing medical infrastructure.

            The American Association for the Surgery of Trauma in collaboration with multiple other societies around the world has created a new subspecialty, Acute Care Surgery. The scope of its practice includes most surgical emergencies of traumatic or non-traumatic etiology. Care is provided by committed and specially trained surgical teams, which offer a safety net for the hospital and the community around the clock. The Acute Care Surgeon of the future is a natural continuation of the Trauma Surgeon but treats all surgical emergencies and preferably has also a foot in the Intensive Care Unit. The resuscitation and management of these very sick patients require physicians who are in tune with complex human physiology and critical care needs.

            In the U.S. the concept has been discussed since the early 2000’s but came into fruition in 2006 with the creation of the AAST Committee for Acute Care Surgery, the establishment of a 2-year Acute Care Surgery fellowship (that includes trauma, emergency surgery, and surgical critical care), and the application of the concept in selected large academic institutions. The Massachusetts General Hospital was one of the first that espoused the concept and converted its 1-year trauma/critical care fellowship into a 2-year Acute Care Surgery fellowship. Within a minimal amount of time the ACS concept spread throughout the country in academic and community hospitals alike. Currently, only 7 years later most institutions around the country have or are striving to have Acute Care Surgery teams. The lightning-speed with which the concept was adopted in the U.S. proves the validity of the argument in favor of Acute Care Surgery.

            The early experience has shown that one size does not fit all. Clearly, there are overarching guidelines about the function, scope of practice, and limitations of an Acute Care Surgery team. Coverage 24/7, close relationship with Emergency Medicine physicians, fast response to surgical emergencies, and an organized approach that obeys the principles set long ago by trauma teams are the undisputed elements of the new specialty. On the other hand different institutions have different needs, and flexibility should exist on issues related to in-house versus out-of-house coverage, size and depth of the team, involvement versus no involvement in elective surgical practice, etc. One of the most challenging concepts is the definition of the practice boundaries for an Acute Care Surgeon. Clearly, this should be tailored to local needs but in general it is accepted that an ACS should be comfortable in treating abdominal surgical emergencies related to: bleeding, perforation, acute obstruction, acute inflammation. Other extra-abdominal diseases that constitute an emergency (e.g. necrotizing fasciitis, extremity compartment syndrome, etc) should also be part of the ACS’s expertise. Additional extra-abdominal procedures, which are often managed by subspecialists (e.g. vascular embolism, tracheal or esophageal perforation, etc), may or may not be within the ACS’s scope of practice, depending on local needs and resources.

            Numerous articles have examined the financial impact of the creation of an ACS team. All of them conclude that there is a financial benefit to the institution and/or the surgical teams. Of note, the general surgeons do not experience a financial hit if an ACS team is established in their institution. Furthermore, one cannot underestimate the effect of the ACS concept in the new generation of physicians. Medical students, who often perceived trauma surgery as a specialty with unfavorable working hours and decreasing surgical involvement, are now reporting in published surveys that they rank ACS as one of their top choices for surgical training. Clearly, there are numerous hurdles to be overcome, as this new concept is gaining steam, but there is confidence that Acute Care Surgery will substantially improve the care of patients with emergent surgical diseases.