Cutting Edge Newsletter
01 Feb 2024
by Prevention Committee, Pediatric Trauma Surgery Committee, Acute Care Surgery Committee, JTACS Editorial Board, TSACO Editorial Board, Communications Committee

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS

Friends and colleagues – 

Punxsutawney Phil did not see his shadow February 2 – early spring is upon us.  For those not familiar with the Pennsylvania tradition or the German lore that frames it – please enjoy some light reading and a piece of modern American history:   Punxsutawney Phil - Wikipedia

An important communications change:  Under the direction of the Executive and Board of Managers, and in the spirit of further cost saving, ease of use, and heightened transparency – print newsletters and mailers are no more!   As a result, the Cutting Edge Newsletter will expand from a quarterly to a bimonthly product to ensure space and wide distribution of all reports, white papers, and other administrative, executive, and committee work products.   Please continue to read, click, and share this important work!   A reminder – while the AAST fire wall mandates a log in/sign in – membership is not required to access this digital resource once a sign in is created – so please share!  Additionally, if you wish to participate in the creation of editorial or other content, please contact me at personal email [email protected] or Erin Lillis at [email protected].

A great issue follows, but I strongly recommend the piece by Dr. Burress on Human Trafficking - it includes the Rapid Appraisal for Trafficking (RAFT) screening tool that should be mandated in our health care centers and other important updates on addressing this societal plague.  

As always, feedback and comments are welcome.  

Thank you for reading!

SMF 

 

Prevention Committee

Human Trafficking: Our Role as Healthcare Providers

Written by: Sigrid Burruss, MD

Human trafficking is the second largest illegal market, just after drug trafficking, and is a form of modern-day slavery (1, 2).  Human trafficking is any form of extreme exploitation of a human being by another for personal or financial gain and involves the use of force, fraud, or coercion to obtain type of labor or sex act (3).  Human trafficking is an international problem with an estimated 12.3 million persons forced into labor  (including forced child labor), sexual servitude and involuntary servitude (4). It is estimated that 600,000-800,000 victims are trafficked annually across and within the United States borders (5).  Women and children make up 70% of trafficking victims with more than 50% of them under the age of 18 (6,7). 

Risk factors that may place them at risk for human trafficking include but are not limited to: substance use, runaway homeless youth, recent relocation, unstable housing and mental health concerns (5,8).  Human trafficking is the most underreported form of child abuse and the national average age at which girls first become exploited through prostitution is 12-14 years (5). The age for boys and transgender youth beginning prostitution is even younger, estimated at 11-13 years old.  Approximately 22% of homeless youth are approached for paid sex within 24 hours of being homeless.   Traffickers prey on those individuals who have few other economic opportunities and coerce victims into being trafficked to address their basic needs of food and shelter.  Traffickers include immediate family, boyfriends, and friends of family more often than employers or strangers (5).  Unfortunately, physical force, threats to self and families as well as emotional manipulation by the traffickers makes it difficult for victims to escape the repeated cycle of abuse, violence, and coercion.

Human trafficking has significant health consequences including urgent and emergent medical needs such as physical injuries resulting in an estimated 50-80% of victims having come into contact with a health care clinician while being trafficked (9,10,11).  Despite the frequency of trafficking victims interacting with healthcare clinicians, there is a general lack of training for recognition and management of said victims.  Amongst surveyed resident physicians, only 20% felt that they understand how to engage and provide support to a victim of human trafficking (12).  Under 50% of healthcare professionals were able to identify sex trafficking victims in a clinical vignette (13).

The first step to supporting victims of human trafficking is identification.  Signs that may indicate a trafficked individual includes, but is not limited to: 1. delays in presentation for medical care, 2. discrepancy between the stated history and the clinical presentation or observed pattern of injury, 3. scripted or mechanically recited history, 4. stated age older than visual appearance, 5. subordinate or fearful demeanor, 6. inability to produce identification documents, 7. documents in possession of an accompanying party, 8. reluctance or inability to speak on one’s own behalf, 9. accompanying individual who answers questions for the patient or otherwise controls the pace and content of the encounter, 10. companion or accompanying individual who insists on providing translation, 11. companion who refuses to leave, 12. evidence of lacking care for previously identified or obviously existing medical conditions, 13. evidence of any kind of physical violence, and 14. tattoos or other marks that may indicate a claim of “ownership” by another (14).  Some tattoos associated with trafficking include symbols of wealth suggesting a victim’s value is tied to the income they can generate (gold bars, currency symbols, crowns, barcodes, money bags) or the name of the trafficker to indicate ownership (14).  Chilsolm-Straker et al developed a screening tool for labor and sex trafficking victims seen in the emergency department (16).  These four Rapid Appraisal for Trafficking (RAFT) questions are  outlined in Table 1.

Once a trafficking victim is identified, clinicians must continue their assessment in a safe and comfortable environment (9,14).  This includes speaking to the patient alone, conducting a complete examination, treating physical injuries and ensuring that follow-up care is established.  Clinicians should use empathetic listening techniques, build trust, and be clear about what services can be offered.  If possible, services should include evaluation by a violence intervention team to assist in navigating the patient through the complex process of obtaining shelter, food, and referral to local organizations that have human trafficking advocates capable of guiding and mentoring trafficking victims, such as trauma recovery and family justice centers.  Documentation in the medical record using ICD-10 codes for human trafficking are available in Table 2 (17).  Laws on mandatory reporting vary by jurisdiction.  There are usually mandatory reporting requirements for child abuse which includes sexual trafficking for anyone under 18 years of age. Information for victims and reporting is found on the National Human Trafficking Hotline 888-373-7888 or https://humantraffickinghotline.org (18). 

Members of healthcare teams have a great opportunity for identifying human trafficking victims presenting to their Emergency Departments and clinics.  This removes victims from the usual environment and potentially from their trafficker.   Healthcare clinicians must have the necessary skills and knowledge to seize the moment for support and change. Raising awareness of this significant problem and providing training to healthcare teams is necessary to curb the worldwide quagmire we face.

Screenshot 2025-08-20 at 3.29.19 PM.png

  

  1. Chisolm-Straker M, Baldwin S, Gaigbe-Togbe B, Ndukew N, Johnson P, Richardson L. Health care and human trafficking: we are seeing the unseen. J of Health Care for the Poor and Underserved. 2016;27:1220-1233.
  2. https://www.globalslaveryindex.org/2018/findings/global-findings/. Accessed 1/14/23
  3. What is Human Trafficking? (humantraffickingsearch.org. Accessed 1/14/23
  4. Statistics on forced labour, modern slavery and human trafficking (Forced labour, modern slavery and human trafficking) (ilo.org). Accessed 1/14/23
  5. Human Trafficking Into and Within the United States: A Review of the Literature | ASPE (hhs.gov). Accessed 1/14/23
  6. Global Slavery Index. International Labour Organization. Walk Free Foundation. Global Slavery Index | Walk Free. Accessed 1/14/24
  7. About Human Trafficking - United States Department of State. Accessed 11/3/22
  8. Polaris-2019-US-National-Human-Trafficking-Hotline-Data-Report.pdf (polarisproject.org). Accessed 1/14/24
  9. Human Trafficking: ACOG COMMITTEE OPINION, Number 787. Obstet Gynecol. 2019 Sep;134(3):e90-e95.
  10. Hainaut M, Thompson K, Ha C, Herzog H, Roberts T, Ades V. Are screening tools for identifying human trafficking victims in health care settings validated? A scoping review. Public Health Reports. 2022, 13:635-725.
  11. Arduizur CarliRichie-Zavaleta, Augusta Villanueva, Ana Martinez-Donate, Renee M. Turchi, Janna Ataiants & Shea M. Rhodes. Sex Trafficking Victims at Their Junction with the Healthcare Setting—A Mixed-Methods Inquiry, Journal of Human Trafficking, 2020, 6:1, 1-29
  12. Garg A, Panda P, Malay S, Rose JA. A Human Trafficking Educational Program and Point-of-Care Reference Tool for Pediatric Residents. MedEdPORTAL. 2021 Sep 13;17:11179.
  13. Beck, M. E., Lineer, M.M., Melzer-Lange, M., Simpson, P., Nugent, M., & Rabbitt, A. Medical providers’ understanding of sex trafficking and their experience with at-risk patients. Pediatrics. 2015, 135(4), e895–e902.
  14. Costa C, McCoy K, Early G, Deckers C. Evidence-based care of the human trafficking patient. Nurs Clin N Am. 2019(54):569-584.
  15. Fang S, Cloverdale J, Nguyen P, Gordon M. Tattoo recognition in screening for victims of human  J Nerv Ment Dis. 2018;206:824-827.
  16. Chisolm-Straker M, Singer E, Strong D, Loo GT, Rothman EF, Clesca C, d'Etienne J, Alanis N, Richardson LD. Validation of a screening tool for labor and sex trafficking among emergency department patients. J Am Coll Emerg Physicians Open. 2021 Oct 12;2(5):e12558.
  17. American Hospital Association ICD-10 Coding for Human Trafficking. AHA-Fact-Sheet-icd-10-code-human-trafficking.updated_1.pdf. Accessed 1/14/24
  18. Human Trafficking Power and Control Wheel | National Human Trafficking Hotline. Accessed 1/14/24.

 

Pediatric Trauma Committee

Optimizing Pediatric Trauma Nutrition: Practical Guidance

Written by: Shannon M. Larabee, MD and Howard I. Pryor II, MD

Introduction

Proper nutrition in critically ill pediatric trauma patients is vital for optimal development and recovery. The significance of close attention to nutrition in managing hypermetabolic states resulting from trauma or major surgical interventions cannot be overstated. By understanding assessment techniques and current best practices, surgeons can enhance outcomes for these patients. 

Nutritional Assessment

Prompt assessment of a patient’s baseline nutritional state, ideally within 48 hours after trauma, is essential. Many trauma patients, including obese patients and those involved in non-accidental trauma, present with inadequate protein stores for optimal injury healing. Screening becomes crucial to identify at-risk populations. For children aged >2 to 18 years, screening should involve z-scores or height-for-weight scores, while infants can be assessed using standard growth curves provided by the WHO. Tools such as the Subjective Global Nutritional Assessment (SGNA) or STRONGkids are based on the patient’s state of physiological stress and assist in evaluating the impact of trauma and critical illness on the patient’s nutritional needs1. While determining patient-specific energy requirements through indirect calorimetry and standard equations is necessary, protein is the most essential nutrient for injury healing. Supplying protein during healing is critical in children because negative protein balance will impair baseline growth and result in loss of critical lean muscle mass1,2. 

Nutritional Requirements

Critically ill pediatric trauma patients require a minimum of 1.5 g/kg/day up to 3.5 g/kg/day of protein. The macronutrient goals for these patients aim to provide all the protein requirements for healing and no more than 70% of the resting energy expenditure. If the nutritional plan is limited by volume, protein should be conserved at the expense of carbohydrates and lipids. In the first week after injury, the goal is to deliver a minimum of 2/3rd of their ideal nutritional requirements1,3. 

Nutritional Delivery

Initiating enteral nutrition is recommended once the patient is hemodynamically stable, not actively being resuscitated, and has no contraindications to enteral feeding. Enteral nutrition should commence within 24-48 hours of assessment, either orally or via nasogastric tube, and titrated to a minimum of 2/3rd of total goal nutrition by the end of the first week. Post-pyloric or jejunal routes can be explored if gastric feeding is not tolerated. Parenteral nutrition is an option if enteral nutrition goals cannot be achieved, but it should not be initiated within the first 48 hours if hemodynamic instability persists1.

Conclusion

Early, adequate, and protein-focused nutrition is crucial for the healing and recovery of pediatric trauma patients. Nutritionists and dietitians are integral care team members, contributing to the assessment, composition, and proper delivery of nutrition. This approach ensures that pediatric trauma patients receive optimal nutritional support, promoting their overall well-being and aiding in the recovery process.

  1. Mehta, N. M. et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. J. Parenter. Enter. Nutr. 41, 706–742 (2017).
  2. Mehta, N. M., Bechard, L. J., Leavitt, K. & Duggan, C. Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry. JPEN. J. Parenter. Enteral Nutr. 33, 336–344 (2009).
  3. Zusman, O. et al. Resting energy expenditure, calorie and protein consumption in critically ill patients: A retrospective cohort study. Crit. Care 20, 1–8 (2016).
Acute Care Surgery Committee

The AAST Acute Care Surgery Fellowship: Inception, Evolution and Current Landscape

Written by: Linda A. Dultz, MD, MPH, FACS

Click Here to Learn More About Acute Care Surgery:
https://www.aast.org/acute-care-surgery-overview  

Introduction

The American Association for the Surgery of Trauma (AAST) has played a pivotal role in advancing the field of trauma surgery through its commitment to education, research, and fellowship programs. Among its notable initiatives, the AAST's Acute Care Surgery (ACS) Fellowship has emerged as a cornerstone for aspiring surgeons seeking advanced training in the management of traumatic injuries, complex emergency general surgery and care of physiologically deranged patients. Here, we explore the background, evolution, and current state of AAST ACS Fellowships, shedding light on the program's origins and changing landscape.

Historical Context

The roots of the AAST ACS Fellowship can be traced back to the early 2000s when the specialty of trauma surgery was in a state of transition. Prior to this period, the trauma surgeon was mostly considered an extension of the general surgeon, with few non-regulated trauma fellowships across the country. The trauma surgeon was touted as the pillar of care for the injured patient, performing countless numbers of exploratory laparotomies and providing 24/7 care for the injured patient. However, by the early 2000s, advancements in imaging and interventional radiology lead to the adoption of non-operative protocol driven treatments, which significantly changed the job description[1]. As a result, only a minority of injured patients now require laparotomies for treatment, with the majority of these being from penetrating trauma.  As this change occurred, leaders in the field recognized the harsh reality that more and more surgeons were not obtaining the operative cases to grow and maintain their skill set. Furthermore, younger surgeons still in training, were often not as comfortable handling complex operative trauma, as the case numbers were dwindling in their own general surgery residencies. This issue was further compounded by the increasing shortage of general surgeons in the workforce and specialization of surgical trainees into other fields. The US population was on the rise, increasing healthcare demands without increasing the number of general surgeons on the call schedule. This left a cohort of emergency general surgical patients in dire need of care. Overall, non-trauma surgeons found themselves overworked from covering elective surgeries during the day and emergencies at night[2, 3]. Ultimately, the care of critically ill trauma and emergency general surgery patients was being compromised. Therefore, leaders and organizations in trauma coined the term “Acute Care Surgery” to describe the next era of trauma surgeons.

The First Iteration of the Fellowship

Prior to the AAST fellowship, several organizations met to discuss the dilemma surrounding the field of trauma. In 2003, a summit meeting was held for members of the American College of Surgeons Committee on Trauma, the Eastern Association for the Surgery of Trauma, the Western Trauma Association and the AAST. The goal at the time was to identify the challenges and propose solutions to rebrand the training and practice of trauma surgery. What came from this meeting was the development of an ad hoc Committee in the AAST tasked to “Reorganize the Specialty of Trauma, Surgical Critical Care and Emergency Surgery”. This committee was led by Dr. Gregory Jurkovich and is now the standing AAST Acute Care Surgery Committee[4]. The committee proposed a new two-year fellowship program combining an ACGME surgical critical care fellowship with an additional non-ACGME year to solidify advanced training in trauma and complex emergency general surgery. The goal was to train surgeons to handle critically ill surgical patients in a time-sensitive manner. The first generation of the AAST ACS fellowship launched in 2008 and was rotation/curriculum based, allowing the fellow exposure to procedures they may not have been exposed to during residency and offering graduated autonomy. As this was a new design, strict requirements surrounding the curriculum were lacking. The goal was to obtain experience in complex acute surgical diseases with exposure in transplant, hepatobiliary, vascular and thoracic surgery[5]. However, after a few years, a review of the operative case logs of these fellowships revealed a large variation in practice. Less than 50% of fellows were meeting the AAST initial standards and there was inadequate exposure to head/neck, thoracic and vascular surgery[6]. Therefore, the next iteration of the fellowship was proposed to help standardize the experience fellows were getting.

The Current Iteration

In 2014, the fellowship was revised to include mandatory thoracic and vascular surgery rotations and outlined a minimum number for operative case requirements[5]. This was followed in 2018 with switching from a rotation-based curriculum to an operative based curriculum. The current iteration focuses on a minimum number of operative cases based on anatomical location and various emergency surgery diseases. This change has allowed programs more flexibility on how to obtain these operative cases based on the local training environment. Additionally, the AAST created an in-training exam and educational modules to assist with standardizing the fellowship and to help minimize the wide variations seen between programs. The in-training exam was initially designed to be given at the start of the ACS fellowship to help program directors identify the gaps in their fellow’s general surgery training and help address them during fellowship. It is now also given at the end of training to assess progress during fellowship. There is currently no minimum score needed for graduation as it is not meant to serve as a board exam, but rather an educational opportunity for both program directors and in-training fellows.

The fellowship also prioritizes the development of leadership skills. As trauma surgeons often find themselves in high-stakes, time-sensitive situations, effective leadership is crucial for optimizing patient outcomes. To assist with this, a lecture series, called “Meet the Mentor”, was developed. This weekly virtual lecture is taught by leaders in Acute Care Surgery. It allows the trainees an opportunity to learn advanced management in trauma and emergency general surgery by experts in the field and gives them an opportunity to discuss controversial topics that may not have clearly defined answers. Although a new component to the fellowship, it has been very well received by trainees, mentors, and program directors.

Looking Ahead

Currently, there are 32 AAST ACS fellowships across the country. This number continues to rise as more training programs are added each year. The future of the fellowship includes sub-tracks in pediatrics and burns to allow sub-specialization based on trainee interest. The goal behind this is to allow additional training in these areas for those fellows that anticipate a practice involving either of these categories. Examples of possible job opportunities would be a career as a pediatric trauma medical director or triaging burn care in a more rural community that does not have readily available access to a burn center. The AAST is working closely with APSA and the ABA to create operative criteria and guidelines for each of these sub-tracks. The goal is to offer these tracks at select AAST ACS programs across the country. 

Additionally, the AAST has launched a new robotic certification training program for both attendings and AAST fellows. Applications for this inaugural program were opened in December 2023 and will be beneficial for those wanting a career in robotic emergency general surgery, which is still a growing field within Acute Care Surgery.

Lastly, it remains unclear whether the AAST ACS fellowship will ever become a separate ACGME fellowship and ABS board certification. However, one thing is clear, the AAST ACS fellowship has only grown and strengthened since inception, and it is here to stay. 

Conclusion

The AAST ACS Fellowship has significantly contributed to the advancement of trauma care by providing specialized training to surgeons dedicated to this field. From humble beginnings rooted in the recognition of trauma surgery as a distinct specialty, these fellowships have evolved into comprehensive programs that prepare surgeons to excel in the complex and fast-paced environment of acute care surgery. With a focus on advanced operative management, time-sensitive treatment of the critically ill, leadership development, and mentorship, ACS Fellowships continue to produce skilled and well-rounded acute care surgeons who contribute not only to the advancement of the specialty but also to improved outcomes for critically ill patients. As the landscape of healthcare evolves, these fellowships have become a standard for those committed to making a difference in the lives of those affected by traumatic injuries.

References: 

  1. Green, S.M., Trauma surgery: discipline in crisis. Ann Emerg Med, 2009. 53(2): p. 198-207.
  2. Davis, K.A. and G.J. Jurkovich, Fellowship training in Acute Care Surgery: from inception to current state. Trauma Surg Acute Care Open, 2016. 1(1): p. e000004.
  3. Jurkovich, G.J., et al., Acute care surgery: An evolving paradigm. Curr Probl Surg, 2017. 54(7): p. 364-395.
  4. Napolitano, L.M., et al., Challenging issues in surgical critical care, trauma, and acute care surgery: a report from the Critical Care Committee of the American Association for the Surgery of Trauma. J Trauma, 2010. 69(6): p. 1619-33.
  5. Davis, K.A., et al., Refining the operative curriculum of the acute care surgery fellowship. J Trauma Acute Care Surg, 2015. 78(1): p. 192-6.
  6. Dente, C.J., et al., How much and what type: Analysis of the first year of the acute care surgery operative case log. Journal of Trauma and Acute Care Surgery, 2014. 76(2): p. 329-339.

 

Journal of Trauma and Acute Care Surgery

JTACS Update

Written By: Raul Coimbra, MD, PhD

Editor in Chief, Journal of Trauma and Acute Care Surgery.

Dear Members of the AAST:

The “What You Need to Know” article series has been a great success. Our readership has given very positive feedback about the quality and usefulness of the reviews, which is exactly what we had in mind when we designed the series.

These articles are FREE TO DOWNLOAD for one year after the date of the publication.

Below is a list with the titles of all articles published so far, including those in the just-out February issue. We hope you use these articles as a reference for your clinical and research work.Keep an eye out for future articles of the series. Great topics are planned for 2024. Please reach out with comments and suggestions; after all, this is YOUR JOURNAL.

February 2024

Trauma-induced coagulopathy: What you need to know

ECMO in trauma care: What you need to know

January 2024

Contemporary management of acute pancreatitis: What you need to know

Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know

December 2023

Common post-bariatric surgery emergencies for the acute care surgeon: What you need to know

Contemporary management of common bile duct stone: What you need to know

November 2023

Damage control surgery in emergency general surgery: What you need to know

Management of traumatic brain injury in older adults: What you need to know

October 2023
Damage control resuscitation in adult trauma patients: What you need to know

Damage-control resuscitation in pediatric trauma: What you need to know

Injury-induced endotheliopathy: What you need to know

 

Trauma Surgery and Acute Care Open 

TSACO Update

Written By: Elliott R. Haut, MD, PhD (Editor-in-Chief) and Jeffry Nahmias, MD (Deputy Editor for Communications)

 Trauma Surgery and Acute Care Open (TSACO) has so many ongoing projects, not all of which can be covered here. For the full breadth of our publishing, please come to our website at https://tsaco.bmj.com

Alongside the broader trauma community, we mourn the recent passing of Dr. David Feliciano. In honor of the life and work of Dr. David Feliciano, TSACO is pleased to present the entirety of Dr. Feliciano’s Case of the Month series. As an Associate Editor for TSACO, Dr. Feliciano brought to the journal his many years of experience in the field. Recognizing Dr. Feliciano’s vast clinical expertise and world-renowned skill as an educator, Dr. Tim Fabian, founding Editor-in-Chief of TSACO, invited him to contribute his most interesting (and unusual) cases to the journal, which he did with a series of over two dozen cases published during the years 2018 to 2022. https://tsacosite-bmj.vercel.app/pages/a-tribute-to-dr-david-feliciano

The TSACO partnerships are growing in number and intensity. The current list and more information is available online at https://tsaco.bmj.com/pages/trauma-surgery-acute-care-open-partnerships . TSACO is excited to grow these collaborations and develop future partnerships that will bring the greatest science possible to our readers. If you have new ideas, please email me at [email protected].

We are excited for the upcoming Mattox Meeting, European Congress of Trauma and Emergency Surgery (ECTES), and the Design for Implementation: Trauma Research and Clinical Guidance Conference. Most recently we published outstanding content from the Hemostatic Resuscitation and Trauma Induced Coagulopathy (HERETIC) meeting https://tsaco.bmj.com/content/9/Suppl_1 . This meeting focused on advances in clinical, basic, and implementation science in transfusion medicine and trauma-induced coagulopathy. Topics ranged from novel and impactful work on therapeutic plasma exchange for severely injured trauma patients to the safety of bioplasma.  Practical and clinically relevant reviews are available regarding use of whole blood in pediatric trauma and use of a walking blood bank. Overall, this represents a substantial collaboration between TSACO and HERETIC to bring forth the highest quality of innovative research and provide education on hot topics throughout trauma and surgical critical care.

And lastly, we named the first winner of the AAST Associate Member TSACO Award. Congrats to Dr. Joshua Dilday for his paper titled “The Disruption of Trauma Research: An Analysis of the Top Cited Versus Disruptive Trauma Research Publications” which can be found on the TSACO website at https://tsaco.bmj.com/content/9/1/e001291

 Please remind all your associate members colleagues about this excellent opportunity. Each monthly winner will get their TSACO publication fees sponsored by the AAST, recognition as an AAST AM Scholarship recipient, and an added one-on-one mentoring session with a AAST and/or TSACO Editorial Board member. The associate member must be (1) either the first author or senior author and (2) the corresponding author. Work should either be either Original Research or a Systematic Review.

 

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