June 2024 Cutting Edge Newsletter

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS 

Friends and Colleagues: 

We enter the month of WEAR ORANGE and a series of coordinated programs to raise awareness and advocate for prevention of the gun violence epidemic in our country.  The AAST is proud to have so many members and partners deeply embedded in this necessary and challenging work.  As you have seen in these pages previously, I strongly believe understanding origin and evolution should influence the decisions and actions of today – do you know why we WEAR ORANGE in June?

“On January 21, 2013, Hadiya Pendleton marched in President Obama’s second inaugural parade. One week later, Hadiya was shot and killed on a playground in Chicago. Soon after this tragedy, Hadiya’s friends commemorated her life by wearing orange, the color hunters wear in the woods to protect themselves and others.”  (source Wear Orange link below) She was 15.  She was not the intended target.  This occurred less than a mile from the Obama’s Chicago home residence.   June 2, 2015 was her 18^th birthday – her friends and family created a platform leading to the consolidation of multiple efforts to combat the tide of gun violence and mass shootings in this county.  And this effort transformed and solidified a national movement.

The movement expands:  it is now a specified period of three days a year: National Gun Violence Awareness Day (the first Friday in June), Wear Orange Weekend (the following weekend), and an entire month full of programs, events, and local, regional, national efforts to raise awareness of gun safety, reduce gun violence and save lives.   Please participate and loudly advocate. 

Thank you to those who purchased and support the AAST campaign!

Thank you to those in AAST who lead the movement.

Additional resources: 

Murder of Hadiya Pendleton - Wikipedia

Wear Orange | Wear Orange

Wear Orange | Brady (bradyunited.org)

Respectfully and with gratitude,

Shannon

Now Introducing

The Cutting Edge Podcast!

Dive into the dynamic world of trauma, acute care, and emergency general surgery with 'The Cutting Edge,' a podcast created by surgeons, for surgeons. 

Brought to you by the American Association for the Surgery of Trauma, join us as we explore interviews with industry experts, dissect cutting-edge technologies, and uncover the human side of life beyond the operating room. Stay ahead of the curve with The Cutting Edge, where every episode equips surgeons with essential knowledge for the modern medical landscape.​​

Tune In to Episode 1: Trauma Tales with Patrick M. Reilly, MD
In this episode, Patrick M. Reilly, MD shares his expertise and experiences in trauma surgery. The conversation covers topics such as mindset and preparation in the operating room, the importance of trajectory determination in penetrating trauma cases, the use of checklists, and the mental skills of surgery. 

President's Message

Written by: Patrick Reilly, MD

Just back from waving the AAST flag at both ECTES in Lisbon, Portugal and the Royal Australasian College of Surgeons meeting in Christchurch, New Zealand.  Both meetings were exceptional with healthy doses of Acute Care Surgery content.   Our organization’s international role as a leader in this arena seems quite strong, thanks in large part to the expansive output from our many committees.  They are doing great work, and I encourage you to get involved and contribute.  Please take the time to get involved in one of our many committees.  Dr. Stewart will be making new appointments this fall…now is a perfect time to complete a volunteer form and submit it through the website at the link below:
https://www.aast.org/committee-volunteer-form

Dr. Brasel and the Program Committee have put together a great program for our annual meeting this September in Las Vegas, held in conjunction with the World Trauma Congress. The scientific content is top notch and the additional pre- and add-on and lunch sessions will highlight much of the output from our committees.  Amy Goldberg will be delivering the Expert Surgeon Lecture, and Michael Rotondo will be serving as the 2024 Fitts Lecturer.  And of course, there will be ample opportunity for networking and other social offerings.  There should be something for everyone.  I hope you’ll plan on attending.  More details of the meeting can be found in this issue of the Cutting Edge.

Finally, the Board of Managers continues to work through an 18 – month long strategic planning initiative.  The first two sessions focused on member engagement and emergency general surgery.  The third and final session in April focused on research initiatives and was be led by Rosemary Kozar and Ram Nirula.  Lots of intriguing ideas were discussed by the group and a punch list of priorities developed.  We are developing our overarching plan for the next few years and will share it with the AAST community in the upcoming months.  

As always, thanks to Sharon Gautschy and the entire AAST staff whom work tirelessly behind the scenes to keep everything moving forward.  All those involved in committee work know we couldn’t do it without them!  Please make an effort to thank them on your next committee call!

Executive Director's Message

Written by: Sharon Gautschy

It’s here – Summer!  And in the Midwest we are inundated with Cicadas!  Millions of Cicadas!  That is the bad news – the good news is that the program for the 83^rd Annual Meeting of AAST and Clinical Congress of Acute Care Surgery will be available soon – very soon.  Along with the program, registration will open this month (June).  So if you have not already starting planning your trip, please start planning.  AAST is looking forward to seeing you.  

The 7^th World Trauma Congress program should be available soon also.  Registration for the World Trauma Congress is included in the regular registration fee for AAST.  Stay tuned for both educational programs!

The AAST membership application deadline is fast approaching!  If you are writing letters for a prospective member, please make sure you have it completed by the deadline.  If you have a partner, resident, or in-training fellow that qualifies for the Associate Member category, encourage them to apply.  If you have questions on the application process, please send an email to [email protected] OR [email protected].

I look forward to seeing you in Las Vegas in September! 

Acute Care Surgery Committee and Educational Development Committee​

Launch of the Inaugural AAST ROBOtic TRaining for Acute Care Surgeons (ROBO-TRACS) Program!

Written by: Matthew Martin, MD, FACS

Trauma and Acute Care Surgery as a specialty has been relatively slow to adopt advanced minimally invasive surgery approaches and techniques, an area which has now become a focus for improvement of the AAST Acute Care Surgery Fellowship program. This includes both advanced laparoscopic techniques as well as modern robotic surgical platforms.

We are proud to announce a new hands-on robotic surgery training program for current ACS fellows and attending surgeons, the ROBOtics TRaining for Acute Care Surgeons or ROBO-TRACS program. This program was developed by the AAST Acute Care Surgery and Educational Development Committees in partnership with Intuitive Surgical, Inc. This 6-month program includes a series of monthly live webinars led by national leaders in ACS robotics, simulation exercises, and funding to attend a live hands-on ACS robotics course at an Intuitive training facility. The inaugural class of ROBO-TRACS students includes eight current ACS fellows and seven attending-level AAST members who were selected via a competitive application process.

The core faculty for ROBO-TRACS includes Matthew Martin (course director), Bruce Crookes, Andrea Pakula, Joseph Sakran, Leah Tatebe. To date the students have completed five of the seven scheduled webinars, and attended a highly successful hands-on training day at the Intuitive facility in Atlanta, Georgia on April 29, 2024 (see photo). As the first year of this program comes to an end, we expect to continue the program with an expanded class size for the 2024 to 2025 academic year. Keep an eye out for a call for applications in July/August. Candidates must be either 1) a current fellow in an AAST approved ACS fellowship program with at least one ACS attending credentialed in robotics and performing robotic procedures or 2) an AAST member who is attending surgeon with current robotic credentials at their home institution.

Pediatric Surgery Committee

AAST Needle tip – Americans’ mental health is in crisis: Utilizing Trauma Informed Care to Optimize Patient Care and Team Performance.

Written by: Lillian Liao, MD MPH and Deidre Wyrick, MD

• American youth mental health is a public health issue.
• Violence and other ACEs perpetuate the cycle of inequity in health/health care.
• Traumatic injuries serve as a gateway for Trauma Centers to engage in the high-risk group of children who are socially disadvantaged.
• Implementation of ISAVE workgroup strategies will decrease burden of injury in the long-run: Trauma-Informed-Care (TIC), Integration of social care into trauma care, investing in at-risk communities, advocacy.
• Optimizing our team performance – TIC can benefit clinicians and non-clinical team members in our hectic emergency care environment.

Addressing mental health care in children as a group of trauma surgeons seems farfetched. Yet, we cannot ignore the growing reports of mental health disorders affecting the population which contributes to the injuries sustained by our patients as well as the consequences of being injured and the impact it has on the lives of not only the patients but their families. Our collected goal for optimal care of the injured patients must propel us to focus on psychological injuries and preexisting mental disorder. Up to 1 in 5 children and adolescents aged 3 to 17 years in the United States have reported mental, emotional, developmental, or behavioral disorder. Studies have suggested that the average delay between onset of mental health symptoms and treatment is as long as 11 years. The Pandemic also created an unfathomable sense of uncertainty and fear within this vulnerable population which further affects outcomes. Recent surveys also demonstrated that the stress and fear which resulted from the pandemic disproportionally affected racial and ethnic minority as well as marginalized populations as they are more likely to experience grief and suffer loss of family members compared to non-Hispanic white peers. 

* NOTE: Analysis of CDC WONDER underlying cause of death data, 2011 to 2021. Suicide deaths were identified using ICD-10 113 Cause List, Intentional self-harm (U03, X60-X84, Y87.0). Rates are age-adjusted for all demographics except age groups. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Data were insufficient to allow for analysis of other racial groups. 

Initial data from 2022 CDC WONDER showed the highest recorded number of firearm related suicide deaths. During the pandemic years, firearm related suicide has increased by 8% from 2020 to 2021 and another 3% from 2021 to 2022. While availability of firearms is an issue related to the high firearm suicide rate, the increase in overall suicide deaths speaks to the underlying decay of the population mental health and wellness. Additionally, suicide deaths account for more than 55% of all deaths involving firearms in 2021.
 

NOTE: Analysis of CDC WONDER underlying cause of death data, 2011 to 2021. Suicide deaths were identified using ICD-10 113 Cause List, Intentional self-harm (U03, X60-X84, Y87.0). Rates are age-adjusted for all demographics except age groups. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Data were insufficient to allow for analysis of other racial groups.

The US suicide death in children ages 5-18 has steadily increased over the last decade. The recent CDC data suggest that there is almost a 48% increase in suicide deaths in the age group of children 12-17 years old. Firearm is the leading means of suicide based on CDC data in 2022. Which is consistent with other age groups as firearm related suicide deaths have surpassed all other means of firearm deaths. Trauma centers are seeing an increasing number of firearm related injuries and deaths in the pediatric population. Prevention of firearm related injuries should be multidimensional. While firearm availability and accessibility are popular and politically charged topics, other root causes of violence which result in firearm injuries and deaths should not be ignored. These statistics shows that both firearm injuries/deaths as well as mental health of our children are in crisis, a public health crisis. As trauma centers, we must address the mental health of our patients while we discuss firearm injury prevention. Both firearm and mental health warrant our full attention if we believe that our north star is optimal patient care. 

The ISAVE workgroup of the American College of Surgeons Committee on Trauma has worked diligently to promote the Trauma Informed Care approach to care by developing transparency and trust with our patients. The ISAVE framework empowers collaborative approaches to care by understanding where our patients come from. In its most simple terms, it is humanism in medicine defined by understanding that the collective experiences in childhood have a great effect on future health outcomes and human actions.

Adverse childhood experiences (ACEs) have been shown to worsen overall outcomes in a person’s lifelong health and well-being. Studies have shown that mental health problems are more likely to develop from emotional trauma than physical abuse. Yet, due to the relative invisibility of emotional trauma, it is often overlooked. Both positive and negative childhood experiences have extraordinary impact on the future physical and mental health of an individual. Adults who have experienced childhood trauma are more likely to attempt suicide, come an alcoholic, use drugs, experience depression, and smoke. Thus, early childhood experiences are an important public health issue. To understand ACEs, we must understand the social determinants of health (SDH). The fact that nature and nurture both play a role in our health is best exemplified in recent years as we see the lives of Black and Hispanic Americans experience far worst outcomes compared to non-Hispanic White and Asian Americans during the COVID19 Pandemic. In the area of violence and firearm related deaths, black men are 14x more likely to die from firearm injuries than white men. The pandemic resulted in more ACEs in an already vulnerable population as children experience caregiver loss, illness, parental job loss, and increasing reports of emotional/physical abuse during this time.  

Studies show that those with pre-existing mental health disorders are more likely to develop PTSD. A survey of trauma centers across the country showed that only 25-30% of Level 1 and 2 centers have a screening process for PTSD. In a national study of 69 trauma centers, PTSD and depression was an independent predictor of survivor’s inability to return to work after injury hospitalization. There is a paucity of literature related to children and their families. Yet we know that chronically ill children and those who have had hospitalizations are more likely to have a mental health diagnosis. 

Our trauma centers exist as a gateway for health care for many the vulnerable patient population. Given that trauma disproportionally affects minorities and socially disadvantaged populations, there is a tremendous opportunity for all of us in the field to contribute to improving the health of the population by improving mental health alongside the physical trauma we are so use to treating. Our work in the area of mental health care, reducing adverse childhood experiences, and improving social determinants of health may not have the immediate impact that surgeons crave. However, this is important work that we, as leaders in trauma must embark upon so that in 10-20 years, we will see a gradual decline in the death of children and adults by means of suicide.

Reference:

1. National Center for Mental Health Promotion and Youth Violence Prevention, "Childhood Trauma and Its Effect on Healthy Development," July 2012(http://sshs.promoteprevent.org/sites/default/files/trauma_brief_in_final.pdf) 
2. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services (http://www.samhsa.gov/children/social_media_apr2011.asp)
3. The National Child Traumatic Stress Network: https://www.nctsn.org
4. Felitti, V. J., Anda, R. F., Nordenberg, D, et. al (1998). Relationship of Childhood Abuse andHousehold Dysfunction to Many Leading Causes of Death in Adulthood. American Journal of Preventative Medicine, 14(4), 245-258. Retrieved April 17, 2017.
5. Kiyimba, N. (2016). Developmental trauma and the role of epigenetics.Healthcare Counseling & Psychotherapy Journal, 16(4), 18-21.
6. Reece, R. M., & Hanson, R. F. (Eds.). (2014). Treatment of Child Abuse: Common Ground forMental Health, Medical, and Legal Practitioners (2nd Edition). Johns Hopkins University  Retrieved April 17, 2017.
7. Rees, C. (2009). Understanding Emotional Abuse. Archives of Disease in Childhood, 95(1)59-67. Retrieved April 17, 2017.
8. Salazar A, Haggerty K, Lansing M, et al (2014). Using communities that care for communitychild maltreatment prevention. American Journal Of Orthopsychiatry, 86(2):144-155. Retrieved April 14, 2017.
9. Sterling, J., & Amaya- Jackson, L. (2008). Understanding Behavioral and EmotionalConsequences of child abuse. Pediatrics, 122, 3rd ser., 667-673. Retrieved April 16, 2017.
10. Timmer, S., & Urquiza, A. J. (2014). Evidence-based approaches for the treatment of maltreatedchildren: Considering core components and treatment effectiveness. Dordrecht, NY:  Retrieved April 14, 2017.
11. Toth, S. L., & Manly, J. T. (2011). Bridging research and practice: Challenges and successes inimplementing evidence- based preventative intervention strategies for child maltreatment. Child Abuse and Neglect, 35(8), 633-636. Retrieved April 14, 2017.
12. Van der Kolk, B., (2014). What’s love got to do with it? InThe body keeps score: the brain, mind, and body in the healing of trauma (pp. 139-170). New York City, NY: Penguin Books.
13. Amaro H., Chernoff M., Brown V., Arevalo S., Gatz M. (2007). Does integrated trauma-informed substance abuse treatment increase treatment retention?Journal of Community Psychology, 35, 845–862.
14. American College of Surgeons. Dateline DC—STOP THE BLEED demonstrates how advocacy has the power to effect change.Bull Am Coll Surg. June 1, 2019. Available at: https://bulletin.facs.org/2019/06/dateline-dc-stop- the-bleed-demonstrates-how-advocacy-has-the-power-to-effect-change. Accessed September 5, 2021.
15. Bulger EM, Kuhls DA, Campbell BT, et al. Proceedings from the Medical Summit on Firearm Injury Prevention: A public health approach to reduce death and disability in the US.J Am Coll Surg. 2019 Oct;229(4):415-430.
16. Bulger EM, Rasmussen TE, Jurkovich GJ, et al. Implementation of a National Trauma Research Action Plan (NTRAP).J Trauma Acute Care Surg. 2018;84(6):1012-1016.
17. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma.Prehosp Emerg Care. 2014;18(2):163-173.
18. Dicker RA, Thomas A, Bulger EM, et al; ISAVE Workgroup; Members of the ISAVE Workgroup. Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma.J Am Coll Sur 2021 Sep;233(3):471-478.
19. Jacobs LM, McSwain NE, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus.J Trauma Acute Care Surg. 2013;74(6):1399-1400.
20. Jacobs LM. Implementation of The Hartford Consensus initiative to increase survival from active shooter and intentional mass casualty events and to enhance the resilience of citizens.Bull Am Coll Surg. 2015;100(1Suppl):83-86.
21. National Academies of Science, Engineering, and Medicine.A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press; 2016.
22. Price MA, Kozar RA, Bulger EM, et al. Building the future for national trauma research.Trauma Surg Acute Care Open. 2020;5(1):e000421.
23. Stewart RM, Kuhls DA, Rotondo MF, Bulger EM. Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death, and Disability from Firearm Violence. J Am Coll Surg. 2018 Aug;227(2):28
24. Talley CL, Campbell BT, Jenkins DH, et al. Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I.J Am Coll Surg. 2019 Feb;228(2):198-206.
25. Winchell RJ, Eastridge BJ, Moore MM, et al. Developing a national trauma system: Proposed governance and essential elements.J Trauma Acute Care Surg. 2018;85(3):637-641.

Diversity, Equity, and Inclusion Committee

Mentorship: An update on the AAST DEI Outreach Subcommittee Longitudinal Mentoring Program

Written by: Megan Quintana, MD

Many definitions of mentorship abound, but generally mentorship can be seen as “a professional, working alliance in which individuals work together over time to support the personal and professional growth, development, and success of the relational partners through the provision of career and psychosocial support.” (Byars-Winston and Dahlberg 2019) Under the guidance of Dr. Cherisse Berry as the chair of the AAST DEI Committee, Dr. Sharon Henry, Chair of the Outreach Subcommittee, and Dr. Bethany Strong, Vice Chair of the Outreach Subcommittee, grant funding from the American College of Surgeons, AAST, and Pediatric Trauma Society were used to create a longitudinal mentoring program for high school students interested in a career in healthcare and surgery that started in 2022. Part of the pipeline program includes a one-day workshop at our national meeting every year. Local underrepresented high school students are accepted by an application process and are paired with a local trauma surgeon as their mentor. We are coming up on two years of this longitudinal mentoring program and wanted to share one pair’s experience over the past year.

Diya Luthra is a high school student at Oxford Academy in Cypress, California. She was paired with Dr. Reza Kermani, a trauma surgeon nearby in Palmdale, California. They have been working together and meeting for the past year, and Diya very much appreciates, “Dr. Kermani’s patient explanations and encouragement” when she was learning “complex concepts that felt overwhelming.” He helped her to “break down [the concepts] and persevere.” She notes specifically that “his belief in me made a huge difference in my confidence approaching new challenges in STEM.” Although she has time to decide what career path to take, Dr. Kermani’s “guidance made [her] realize the importance of a strong academic foundation to reach [her] goal” of a career in STEM. And the pair have “explored different areas of STEM research together.” This has excited a passion for trauma surgery in Diya and she notes that “Dr. Kermani emphasized the realistic side of things, explaining that teamwork and critical thinking skills are essential in trauma surgery.”

Dr. Kermani and Diya have worked on several projects together, but the most impactful for Diya was making an academic roadmap to help her pursue a potential career in trauma surgery. “This plan ensures a strong foundation in science, relevant coursework, and research experience that align with trauma surgery.” Dr. Kermani’s “dedication and the impact this field has on patients” has been a main inspiration for Diya when considering a career as a trauma surgeon. Both Diya and Dr. Kermani really appreciated the mentorship meeting at the one-day workshop in Anaheim. “It served as a great launching pad for the mentorship going forward.”

Dr. Kermani makes a point of working with Diya not only on the academic side of things, but also in “dealing with the stress of teenage life.” His goal in this partnership has been to “support her and to help her continue on her journey to obtain a high school education and become a doctor, and hopefully a trauma surgeon in the future.” He notes that he is specifically “impressed by the maturity and the work ethic” he sees in Diya.

Diya states that “research skills I’ve developed working with Dr. Kermani have been invaluable. But beyond that, his mentorship has also instilled in me the importance of perseverance, curiosity, collaboration. These qualities, I know, will be crucial for my success in STEM and beyond!” If mentorship is an alliance to promote professional and personal development, it seems as though Diya and Dr. Kermani exemplify this partnership. This longitudinal mentoring program is clearly integral in our commitment to enhancing racial diversity in surgery and making surgery a truly inclusive field of medicine.

References

Byars-Winston A, and Dahlberg ML. (2019). The science of effective mentorship, A consensus study report of The National Academies of Sciences, Engineering, Medicine. Washington, DC: The National Academies Press.

Henry, S and Strong, B. (2022). Fixing the Leaky Pipeline to Careers in Surgery: A Longitudinal Mentoring Program for High Sc

Violence & Injury Prevention Committee

Celebrate Pride 2024 by Uncovering Hidden Bias and Addressing Inequities

Written by: Alexis Moren MD, MPH, FACS, Christine Castater MD, FACS, and Shelbie Kirkendoll D.O., M.S., M.S.

June 1^st kicks off Pride Month every year which celebrates the resilience, diversity, and ongoing struggle for equality within the LGBTQ+ community. Pride Month celebrations began in 1962 with the decriminalization of same-sex activity in Illinois, and each year this celebratory month embodies a spirit of acceptance and advocacy that reverberates worldwide. In the past 62 years, the United States appears on face value to have made commendable strides in recognizing the rights of the LGBTQ+ community. Unfortunately, beneath this vision of progress lies a disturbing reality; a rising epidemic of violence targeting LGBTQ+ individuals and allies. Although violence affects people of every race, gender, class, and age there is a disproportionate amount of violence towards members of the LGBTQ+ community. Disproportionate violence increases healthcare disparities in a community which often has less access to safety nets like shelters or law enforcement.

Causes

As of April 2024, there were 816 bills introduced in the United States regarding the LGBTQ+ populace of which the majority (78%) were anti-LGBTQ+ bills.¹ It is not surprising that this growing climate of discrimination has led to an increase in violent acts against this community. These bills span across all areas of social welfare but relate predominately to education and healthcare. The majority provide support towards banning gender-affirming care for transgender youth and regulating public school curriculum. Examples include restricting and banning gender affirming care; refusing to insure certain LGBTQ+ groups such as those who are trans-gender; banning LGBTQ+ books; censoring discussions; forcing staff to out LGBTQ+ students; and punishing parents who are supporting their LGBTQ+ children by enforcing criminal charges and potential prison sentences.² Many of these bills amplify and perpetuate the hostile environment that has led to an increase in violence against the LGBTQ+ community.

Legislative action is only part of the problem. Root causes of LGBTQ+ violence are complex and multifactorial, stemming from a combination of societal prejudice, systemic discrimination, and individual biases. Homophobia, transphobia, and biphobia contribute to the hostile environment that perpetuates violence and marginalization against LGBTQ+ individuals. Structural inequalities, including lack of legal protections, socioeconomic disparities, and barriers to accessing healthcare perpetuate this hostile environment. Specific examples are numerous, but a common theme is a cycle of inequity with higher rates of poverty, stigma, and marginalization putting the LGBTQ+ community at greater risk for sexual assault and hate-motivated violence. Additionally, LGBTQ+ people are often hyper-sexualized even within their relationships which can lead to intimate partner violence stemming from internalized homophobia and shame.²  
 

Statistics

 Studies have consistently shown that LGBTQ+ individuals experience higher rates of violence compared to their heterosexual and cisgender counterparts. This violence adopts many forms, including physical assault, verbal harassment, sexual violence, and hate-motivated crimes. Compared to non-LGBTQ+ people, LGBTQ+ people experience 71.1 victimizations per 1,000 people compared to 19 per 1,000 non-LGBTQ individuals. For those over the age of 16, LGBTQ+ individuals are nearly 4 times more likely to experience violent assault.^4,5 Even though these numbers are staggering, interpersonal violence and harassment has continued to increase among this minority population in recent years. This populace has been the subject of spontaneous attacks, violent mobs, and targeting by law enforcement and extremists.⁶ In 2024 alone over 200 anti-LGBTQ+ incidents have been reported and acts of LGBTQ+ political violence have tripled compared to 2021.⁶

According to the National Coalition of Anti-Violence Programs, LGBTQ+ people are disproportionately affected by hate crimes, with transgender women of color facing the highest risk of violence and homicide.² Sexual violence begins early, often during childhood. Bisexual women are at particularly heightened risk of sexual violence with 61% of bisexual women experiencing rape, physical violence or stalking by an intimate partner compared to 44% of lesbians and 35% of heterosexual women.² In the 2011 National Transgender Discrimination Survey, 19% of respondents reported having experienced domestic violence from a family member, with higher rates among those who identify as American Indian (45%), Asian (36%), Black (35%) and Latinx (35%).² Over 39.2% of LGBTQ+ women who had cohabitated with a female partner at some point in their lifetime had experienced rape, physical assault or stalking by an intimate partner.¹ LGBTQ+ people are 6 times more likely to experience violence by someone who is well known to them and 2.5 times more likely to have a violent assault at the hands of a stranger compared to non-LGBTQ+ people. Lesbian, bisexual, and transgender women are 5 times more likely than cisgender women to experience violent assault. Similarly, the risk of violence for gay, bisexual, and transgender men is more than twice that of cisgender men.⁴

Healthcare

Further exacerbating issues for the LGBTQ+ community include lack of acceptance and access to healthcare. In 2016, the National Coalition of Anti-Violence Programs found that 44% of LGBTQ+ survivors of violence seeking help with housing insecurity were denied shelter services due to being LGBTQ+.⁵ Populations with increased vulnerability regarding both housing and medical care include transgender, non-binary, and gender non-conforming survivors as they are often turned away, mistreated, and/or deadnamed/misgendered in shelters or blatantly denied services that are segregated by sex.⁵ Violence against LGBTQ+ individuals is also profoundly underreported for many reasons including; hesitation to report out of fear of encountering anti-LGBTQ+ stigma, prior negative and discriminatory experiences with health care providers and institutions, and fear of stigma or prior experience with the police and judicial system.⁵ Moreover, LGBTQ+ individuals may face internalized stigma, shame, and self-blame as a result of their victimization, leading to decreased self-esteem and an increase in mental health conditions including depression and anxiety. Socially, LGBTQ+ violence contributes to feelings of isolation, mistrust, and alienation from mainstream society all of which perpetuate cycles of violence and victimization.

Action Items

Awareness and identification of issues are both a large part of creating change. Clinicians should educate themselves on the unique issues faced by the LGBTQ+ community and by survivors of LGBTQ+ violence. Research and data collection on injury and violence prevention should include sexual orientation, gender identity and gender expression, as each is necessary to treat patients holistically. Data should specifically target understudied and underserved populations including transgender and bisexual people in a culturally competent manner. We must also work to reduce the overarching societal stigma against LGBTQ+ people that hinders LGBTQ+ trauma survivors from seeking help.

Addressing LGBTQ+ violence requires a comprehensive and multi-pronged approach encompassing legal, social, and cultural dimensions. First and foremost, any efforts to prevent LGBTQ+ violence must include the implementation and enforcement of anti-discrimination laws and hate crime legislation to protect LGBTQ+ individuals from violence and harassment. Further, education and awareness-raising initiatives that challenge stereotypes, promote acceptance, and foster empathy towards LGBTQ+ people should be implemented in both medical and non-medical arenas. Resources and support services must specifically be tailored to fit the needs of the LGBTQ+ community, and must be broad reaching. More specifically, the provision of LGBTQ+ affirming support services, such as community centers, crisis intervention hotlines, counseling, support organizations, and advocacy, can help mitigate the impact of violence and empower survivors to seek help and support. These resources should be advertised and available to all patients. It is also crucial to ensure equitable access to healthcare services including mental health support and the adoption and implementation of trauma-informed care by healthcare providers. Successful LGBTQ+ violence prevention requires a cultural shift— a shift towards greater acceptance, inclusion, and celebration of LGBTQ+ identities.

Allyship

Allyship in the medical community for LGBTQ+ individuals is crucial in ensuring equitable, compassionate, and competent care. This requires healthcare professionals to actively work to understand the unique health needs and disparities faced by LGBTQ+ patients.  Anyone can be an ally, but it is imperative that we provide affirming care. Affirming care goes beyond passive acceptance and involves educating oneself about the challenges faced by the LGBTQ+ community, challenging discriminatory behaviors and systems, and amplifying LGBTQ+ issues and addressing needs. This includes using inclusive language, respecting pronouns, and creating a safe and supportive environment. Examples of an accepting space include having the Pride flag or a Pride sticker on a badge or in an office, accessible pamphlets for resources available in clinic or upon discharge and creating a relationship between provider and patient where the patient can speak freely. By embodying these principles, medical professionals can build trust, improve health outcomes, and ensure that all patients receive the dignity and care they deserve.

References

1. The Trevor Project. Lesbian, Gay, Bisexual, and Transgender Studies. Library of Congress, Washington, D.C. Accessed April 10, 2024. https://www.thetrevorproject.org/bill-tracker/?post=11486&activeView=map&activeLegislationType=bill&activeState=all&activeSort=%5B%22state%3Aascending%22%5D&activeCategories=%5B%22all%22%5D&id=bcf89f1a-53cd-46c1-845d-61c31211693c.
2. University of California, Merced. Violence Against LGBTQ People. April 15, 2024. Accessed April 15, 2024. https://care.ucmerced.edu/advocacy/violence-against-lgbtq-people.
3. American Civil Liberties Union. 2024 Legislation. Access April 8, 2024. https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2024
4. UCLA Williams Institute School of Law. LGBT people nearly four times more likely than non-LGBT people to be victims of violent crimes. October 2, 2020. Accessed April 8, 2024. https://williamsinstitute.law.ucla.edu/press/ncvs-lgbt-violence-press-release/
5. Human Rights Campaign. Understanding Intimate Partner Violence in the LGBTQ+ Community. November 4, 2022. Accessed April 15, 2024. https://www.hrc.org/resources/sexual-assault-and-the-lgbt-community
6. The Armed Conflict Location & Event Data Project. Fact Sheet: Anti-LGBTQ+ Mobilization on the Rise in the United States. November 23, 2022. Accessed 11, 2024. https://acleddata.com/2022/11/23/update-fact-sheet-anti-lgbt-mobilization-in-the-united-states/

AAST International Relations Committee

International Relations Committee Update

Written by: Jose L. Pascual L. MD, PhD, FRCS(C), FACS, NCC (UCNS), FCCM

After over a year of discussions, in April 2023, the AAST International Relations Committee (IRC) Chair, Dr. Rochelle Dickers presented to the AAST Board an initiative to join with the Pan-American Trauma Society (PTS) and co-organize one of their four monthly International Trauma Tele-Grand Rounds.  The existing PTS Tele-Grand Rounds had been and remain highly successful on their own, having existed for over a decade and led by Dr. Antonio Marttos of the Miami Miller School of Medicine.  Shortly thereafter, past president Dr. Eileen Bulger signed a memorandum of agreement with the PTS to co-host monthly joint PTS/AAST international trauma case conferences.  This one-hour long virtual joint venture would involve 2 trauma case presentations by a trauma hospital from anywhere in the world discussing how management was innovative, unusual, controversial or unique, using local resources, and addressing multiple competing priorities highlighted in the trauma bay, the operating room or the ICU. Three senior, expert trauma surgeons serve as panelists, commenting on points of management and debating alternative options, controversial and unusual approaches, bringing their personal experiences and quoting published literature related to the care discussed.

The inaugural joint session occurred in person at a lunch session in Anaheim during the 82^nd Annual Meeting of the AAST in September 2023. Distinguished expert panelists included Professors William Schwab (Penn), David Feliciano (Grady, Shock Trauma) and Damian Clarke (Pietermaritzburg, South Africa).  Presenting a set of formidable cases were Professors Christina Gaarder (Oslo) and Francisco Collet e Silva (São Paulo).

Since then, monthly virtual sessions have continued, co-hosted online and organized by the AAST IRC and PTS. Average audiences range between 40 to 60 virtual attendees registering from all continents. (See figure). Since then, these monthly one-hour, virtual, co-moderated sessions that provide CME, have involved USA participants from Los Angeles, Philadelphia, Cleveland, Las Vegas, Boston, New York, Sacramento, Seattle, Baltimore, Chicago and Pittsburgh.  International conference participants have joined from Johannesburg, Taipei, London, Hong Kong, Montreal, Doha, São Paulo, Panama City, Mexico City, Cape Town, Lund, Helsinki, Madrid, Bangkok, Wellington, Nottingham, Abu Dhabi, Coimbra, Jerusalem and Milan. Particularly captivating was a case presentation by Professor Francisco Colet e Silva, from the University of São Paulo Medical School in Brazil, describing the management of a 30-year-old pregnant pedestrian involved in a city bus collision. Participants routinely present imaging including x-rays and CT scans as well as echocardiography footage, flanked by operative and non-operative photographs and videos to better situate the audience on the often difficult and challenging management decisions and patient trajectories.

This joint AAST/PTS initiative has begun discussions with Trauma Surgery & Acute Care Open (TSACO) and EIC, Professor Elliott Haut to consolidate the best presenter cases and panelist comments to be summarized and potentially published in TSACO under Challenges in Trauma and Acute Care Surgery. Furthermore, other national and international trauma and injury societies have asked to join the AAST and PTS initiative to conduct joint trauma case conferences with them as well. If you have a difficult, unusual, trauma case that was managed innovatively, operatively or non-operatively, with notable aspects in the prehospital setting, emergency department/trauma bay, operating room or intensive care unit, please reach out to Jose Pascual ([email protected]) or Antonio Marttos ([email protected]) to present at this wonderful joint international educational experience.
 

AAST Multicenter Trials Committee

AAST Multicenter Trials Committee Update

Written by: Joseph DuBose, MD

The AAST MCT continues to review and support the implementation of high-quality multicenter research efforts designed and led by our membership.  Several great efforts are being developed that are open to enrollment and support from fellow AAST members.  Below we highlight ongoing activities of your Multicenter Trials Committee and highlight studies for involvement.

Study highlight: A multi-institutional, prospective observational study on impact of pre-hospital whole blood on mortality in severely injured trauma patients

Hemorrhage is a major source of morbidity and mortality for trauma patients. Nearly 30% of pre-hospital trauma deaths and over 20% of in-hospital trauma deaths are due to hemorrhagic shock. Blood product transfusion until hemorrhage control is achieved has been shown to improve mortality. Trauma resuscitation in hemorrhagic shock has progressed from use of crystalloid fluids (CF), to balanced component transfusion therapy (BCT), and most recently toward the administration of whole blood (WB). Transfusion of WB or BCT restores the oxygen-carrying capacity of the circulating volume by maintaining oncotic pressure and hemoglobin concentrations, while decreasing the risk of trauma induced coagulopathy. WB was the mainstay of resuscitation in the military setting until the 1970’s, at which point blood component storage and crystalloids evolved as an inexpensive alternative to increase circulating volume. However, lessons learned in the military setting have fueled, in part, the resurgence of WB use in civilian trauma. Optimizing both the product offered as well as the timing of administration could dramatically reduce mortality and the associated morbidity of trauma patients, diminishing a key preventable cause of death.

In a randomized control trial, Guyette et al demonstrated lower red blood cell transfusion requirement at 24 hours and improved hemostatic characteristics in those who received pre-hospital WB as compared to component therapy. Similarly, a single institution study by Braverman et al demonstrated improvement in shock index and ED mortality in those who received pre-hospital WB. However, large prospective studies examining the impact of pre-hospital WB on transfusion requirements and mortality is lacking.

The aim of this study is to investigate use of pre hospital WB + ED WB combined with component transfusions versus in-hospital WB combined with component transfusions alone, with specific attention to intensive care unit (ICU) length of stay (LOS), 4-hour and 24-hour packed red blood cells (pRBCs) transfusion volumes, and in-hospital mortality in adult civilian trauma patients sustaining injuries severe enough to merit administration of an MTP within the first 4 hours of arrival to the hospital. To our knowledge, there are presently no studies addressing this specific question.

If interested in participation in this study, please contact Dr. Asanthi Ratnasekera at [email protected]

Trauma Surgery and Acute Care Open 

TSACO Update

Written by: Elliott R. Haut, MD, PhD, Editor-in-Chief

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

For this edition, I am focusing on two specific asks of the broad AAST membership to help grow the TSACO editorial team with suggestions (including self-nominations) for open positions on our editorial board and for 2 open spots for social media interns.

Editorial Board Positions

Are you interested in joining the Trauma Surgery & Acute Care Open editorial team? Do you want to be involved in publishing, research, communication, and global outreach in all aspects of acute care surgery? Have you always been interested in the academic publishing process, but didn’t know how to get more involved? Will you bring knowledge, skills, energy, ideas, dedication, and diversity of thought to the editorial team? In order to promote diversity, equity, and inclusion, Trauma Surgery & Acute Care Open (TSACO) is announcing an open call for volunteers and nominations (including self-nominations) to join the editorial board.

Trauma Surgery & Acute Care Open is the American Association for the Surgery of Trauma’s open access journal dedicated to the rapid publication of peer-reviewed, high-quality trauma and acute care research. TSACO provides an interdisciplinary forum for global issues in trauma and acute care surgery and is dedicated to covering epidemiological, educational, and socioeconomic facets of trauma management and injury prevention. The journal’s vision is to provide the global trauma & acute care surgery community with free access to top-notch scientific information.

TSACO is seeking to grow our cadre of associate editors and editorial board members (with a strong focus on the need for global members from outside the US. Roles and responsibilities will include helping to review high-quality research, managing manuscripts through the peer-review process, overseeing journal operations, and enhancing global communication.

To apply:

Interested applicants should email the following to Sharon Gautschy, [email protected], with the email header:  TSACO Editorial Board

• A statement of interest (maximum 250 words) that explains the applicant’s overall interest in becoming a member of the editorial board which specific areas of focus (as listed above) would be your strength and why
• CV (curriculum vitae)

Social Media Interns

TSACO is seeking two new social media interns, to start July 1, 2024. The initial appointment will be for one year, with a renewable option for a second year. The goal of this position is to assist the TSACO social media editors with disseminating TSACO publications to increase the journal’s influence and readership by sharing publications, creating visual abstracts, and devising creative ways to increase reach through social media. The applicant should already be facile with social media (e.g., Twitter). The position is ideal for a current ACS/surgical critical care fellow or a surgical resident in a non-clinical academic/research time.

The intern will:

• Work directly with senior editorial staff
• Participate in the peer-review process of select papers
• Be invited to produce at least one co-authored commentary
• Be listed on the journal’s editorial board webpage
• Participate in biannual editorial board meetings
• Receive free registration for annual AAST meeting

Expectations:

• Work with authors to prepare one social media post for every article published
• Work with authors to create a visual abstract for selected manuscripts
• Devise creative posts highlighting past TSACO articles on social media
• Approximately 3-4 hours per week time commitment

Interested applicants should email the following to [email protected] by June 10, 2024.

1. A statement of interest (maximum 250 words) which explains the applicant’s interest in trauma/ ACS/critical care and highlights how this position fits within their career goals.
2. CV (curriculum vitae)
3. Provide your Twitter handle

Selection Process

Interns will be selected by the current TSACO social media editors and interns with approval from the TSACO Editor-in-Chief. AAST and TSACO are committed to the mission of diversity, equity and inclusion.

For questions, contact TSACO Deputy Editor for Communications Jeff Nahmias (@jnahmias1), Associate Editors of Social Media Caroline Park (@cPark_MD) or Ron Barbosa (@rbarbosa91) or current Social Media Interns Julia Coleman (@JuliaColemanMD) or Lucia Nguyen (@Lucywhatisee) or email [email protected] .