Program Chair’s Message 

Written by: Karen J. Brasel, MD, MPH

Welcome to Las Vegas! This is a special AAST meeting, as it is being held in conjunction with the 7th World Trauma Congress.  We have an amazing program and look forward to the additional opportunities to learn from each other and expand our networking, meet new friends, and mentor the next generation.

Once again we have great science in a variety of venues—oral presentations, quickshots (don’t leave early!), and posters. Taking place on Monday and Tuesday will be the highly-recommended Emergency Surgery Course. We have two fabulous panels on Artificial Intelligence and the value of an Acute Care Surgeon, Military Symposium, three add-on sessions, three pre-sessions, and 13 lunch sessions on a great variety of topics. We will hear from this year’s expert surgeon, Amy Goldberg, MD, Michael Rotondo, MD, our outstanding Fitts Orator, our esteemed president Patrick Reilly, MD,  and YOU—an ever-increasing number of our members who will moderate and discuss at our scientific sessions.  

We will have many opportunities to network and mentor, including but not limited to: WITS, the DEI Networking breakfast, the Welcome Reception, and Banquet/Auction (get ready to bid!), which will all include associate members, students, residents, and fellows.  

I look forward to seeing and talking with you during and outside of the meeting.  As always, please find me to tell you what you like and what you’d like to improve about the meeting.

And remember, what happens in Vegas…is something the AAST wants to share with the world!

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS 

AAST continues to lead in all areas of Acute Care Surgery.  The work in these artilces speaks for itself.  But remember, it is the amplification and dissemination to all colleagues - from Level I to Level V, from full time trauma surgeons to those who cover it in the course of general surgery call to the managers and nurses and registrars who get it done - that need to have access to it.  Share.  Recruit.  Teach. And thank you for all you do! See you in LV...SMF

Research and Education Fund Update

Written by: Andrew C. Bernard, MD

REF will see you in Vegas!

Many of us will be headed to Las Vegas for the 83rd Annual AAST Meeting and the 7th World Trauma Congress. Research and Education Fund (REF) Committee members look forward to seeing everyone there. In fact, some of us will be attending the meetings because of the REF. Contributions to the REF by AAST members and friends directly support travel to the meeting for residents, students and military members. By donating to REF, each of us lends support to our peers and the next generation of trauma surgeons. Thedonation you make, may give someone an opportunity that changes their life or the life of a patient. If you have already donated this year, THANK YOU! Some members wait to donate at the meeting or at the end of the year. And to those members, we say, THANK YOU! But in addition to making cash donations, we will be providing other easy and fun ways to support REF while at the meeting:

1. Trauma Brews on Thursday (8:00 AM – 2:00 PM)-If you have donated in the last year, have a latte on the AAST as a thanks for your support of REF.
2. Silent Auction-Art, handmade items, electronics and other items will be open for bid all week.
3. Live Auction-Travel and experiences donated by members give you the chance to support REF and create lasting memories.
4. Calendars-The new AAST 2025 calendar will be for sale. Look for trauma centers and friends in the U.S. national community. Buy some for your hallway, offices and breakrooms in your trauma centers to let your teams know they are part of something big-the AAST Trauma Community.
5. Clothing-AAST t-shirts, fleeces and other items will be for sale or order. 

Thanks for supporting REF. Look for these REF Committee members at the meeting and throughout the year to learn more about how you can support meeting travel and research scholarships:

Paul Albini (Vice Chair), Jeff Choi, Angie Ingraham, Joe Galante, Susan Evans, Mitu (Suresh) Agarwal, Christine Toevs, Patricia Martinez Quinones, Susan Rowell, Caitlin Anne Fitzgerald, Timothy Pritts, Benjamin Axtman, Anne Stey, Andrew Bernard (Chair).

AAST Congratulates Dr. C. William Schwab on Receiving the 2024 Distinguished Lifetime Military Contribution Award

We are proud to announce that one of our esteemed members, C. William Schwab, MD, FACS, has been selected by the American College of Surgeons (ACS) Board of Regents to receive the 2024 Distinguished Lifetime Military Contribution Award. This prestigious honor will be presented to Dr. Schwab during the Convocation Ceremony at the 2024 Clinical Congress of the American College of Surgeons in San Francisco, California, on Saturday, October 19, 2024.

Dr. Schwab’s remarkable contributions to the field of surgery, particularly in military service, have significantly advanced trauma care and military-civilian partnerships. His dedication to improving combat casualty care and developing trauma systems has left an indelible mark on both military and civilian healthcare.

Please join us in congratulating Dr. Schwab on this well-deserved recognition.

Prevention Committee, Palliative Care Committee, American Trauma Society

Trauma Survivors Network (TSN); How Does it Really Work?

Written by: Thomas K. Duncan, DO, FACS, Glen Tinkoff, MD, FACS, Anna Newcomb, PhD, MSW, LCSW, Pete Anziano, Katherine Joseph, MPH, Anastasia Kunac, MD, FACS

This article is offered with the premise of informing attendees of the 83^rd annual scientific meeting of the upcoming lunch session about the above topic slated to occur on Wednesday, September 11, 2024. It is a collaborative effort between the Prevention Committee, Palliative Care Committee, and the American Trauma Society. The session will focus on the history, development, and patient empowerment of the Trauma Survivors Network (TSN), the importance of collaboration with palliative care teams, and the value of Trauma-informed Care. Furthermore, it will elaborate on the upcoming Advanced Trauma Life Support (ATLS) 11^th edition injury prevention update on the utility of using the three “E’s” framework for developing injury prevention strategies in any domain around the world.

Introduction

When a patient suffers injury, it occurs mostly without foreknowledge and is sometimes unplanned. Hence the term, “injury is NO accident.” As patients and their loved ones find themselves in the abyss of dealing with a multitude of injuries, they are suddenly placed in a circumstance that requires navigating the complex process to recovery. The TSN was organized from grassroots to build a community for survivors and their families to connect and restructure after a physical traumatic injury.¹   

History of the Trauma Survivors Network

The session will start off with a brief description of the TSN’s history, a program of the American Trauma Society (ATS) with intimate linkage to the development and mission of the ATS that dates back to 1966 when the National Academy of Sciences and National Research Council published “Accidental Death and Disability: the Neglected Disease of Modern Society”.² Serving as a national call to action, this report encouraged the trauma world to combat public apathy toward the devastating toll that injury was taking on America by recommending establishment of a National Trauma Association to drive public demand for injury prevention. This culminated in The American Association for the Surgery of Trauma (AAST) heeding that call and founding the ATS in 1968, whose mission to “Save Lives. Improve Care. Empowering Survivors” has a legacy of service to improve trauma care through education, advocacy, and handling the unique needs of trauma survivors. 

Based on a program developed by Inova Fairfax Hospital (IFH) [a level 1 trauma center in northern Virginia] named “Rebuild,” the ATS partnered with them in 2003 to unite trauma survivors and families to support one another by sharing experiences and information about recovery, and helping enhance survivor skills to manage the daily challenges that arise with recovery from injury.  With assistance of the Johns Hopkins School of Public Health (JHSPH), a self-management program for trauma survivors, “NextSteps,” was developed in collaboration with the ATS by convening a multidisciplinary team.³ Development of the TSN was started in 2007 when JHSPH was awarded a national Department of Defense (DOD) grant to establish the Major Extremity Trauma Research Consortium (METRC).⁴ 

After its official launch in 2008, TSN programs were established at IFH and the University of Maryland’s Shock Trauma Center. The ATS subsequently hired a national TSN Coordinator to facilitate site promulgation in 2010. Partnership with JHSPH continued by securing a DOD grant to support six Level 1 trauma centers with full-time TSN coordinators to develop their programs and study outcomes in 2013.⁵ The TSN received its most significant endorsement to date with the release of the American College of Surgeons Committee on Trauma (ACS COT) Optimal Care of the Injured Patient 2022 Standards requiring level 1 and 2 trauma centers to incorporate peer support services.⁶ This has led to unprecedented interest and growth of the TSN which currently supports over 240 sites in the United States (U.S.), and Australia (Figure 1).

Elements of the Trauma Survivors Network

Next will be an elaboration of the TSN’s elements. Implemented and managed by a hospital-based coordinator, the TSN consists of both inpatient and outpatient components. Inpatient services include timely access to information, support and education for family members, peer visiting, and acute and post-traumatic stress disorder (PTSD) screening and referrals. Outpatient services comprise of support groups, a self-management class, peer visitation, and advocacy opportunities. The National TSN also provides online support to survivors lacking access to a local program. During the early stages of the patient’s recovery, a TSN Coordinator or member of the trauma team may round on the patient and family to provide information about the program and offer a Patient and Family Handbook. A locally adapted handbook offers information about traumatic injuries, hospital processes, local resources, and advice from trauma survivors. Such relevant and timely information has been proven to play a significant role in promoting wellbeing, empowerment and autonomy.^8,9

A TSN “Family Class,” facilitates caregiver access to information from staff or other family members; many sites have adapted this supportive resource to a “mobile snack-n-chat,” recognizing that family members may avoid leaving the bedside. A survivor may accompany the TSN Coordinator as they navigate through the unit providing snacks, information, and comfort.

With data from peer-to-peer programs showing a positive impact on depression/feelings of isolation, trained peer visitors provide injured patients the opportunity to meet with fellow survivors and impart a sense of strength, insight, inspiration, and commonality through shared experience.^10,11

Recognizing the mental health screening process recommended by the ACS Verification Review Committee (VRC) in the 2014 and 2022 guides, the ATS includes training for TSN Coordinators to provide PTSD screening and referrals in their trauma centers.^7,12

The TSN offers an online 6-week class, “NextSteps,” which equips learners with tools to become active participants in their recovery for chronic conditions, enabling them to achieve better outcomes as they learn to improve and manage thoughts, feelings, and behaviors.¹³

The highly integrated and coordinated components of the TSN are designed to allow survivors to work toward normalizing the “new reality” by connecting virtually or in-person. It also embodies the ACS COT’s mission to ensure optimal patient outcomes across the continuum of care occurs by developing programs that incorporate advocacy, education, trauma system development, and best practice dissemination.

From Adventure to Resilience: My Journey with a Spinal Cord Injury and the Power of Peer Support

A survivor’s story will be highlighted by Pete Anziano, whose life changed abruptly from being a dedicated father of a 3-year-old and vibrant traveler/adventurer to a paraplegic when he suffered a spinal cord injury (SCI) resulting from a motorcycle crash at the age of 33. Throughout the emotional rollercoaster that developed following Pete’s injury, the focus of his son’s upbringing and life’s outlook was reignited after he met Minna, a Korean immigrant who had suffered an injury like his. He developed a newfound passion for life based on Minna’s positive experiences and approached his rehabilitation from a pragmatic lens. The sense of empowerment renewed his ability to develop a new family, actively partake in important daily activities, and feels that peer support has guided him to the current safe space in life.

Pete’s volunteerism at the Shepherd Center in 2006 ultimately led to employment and subsequent research on the effects of peer mentoring on self-efficacy and readmission after inpatient rehabilitation. He feels that the experiences have given him a unique perspective and drive, proving that peer support leads to personal satisfaction and tangible, positive outcomes. It has been the cornerstone of his resilience and success, exhibiting the power of shared experiences and the human spirit’s capacity for recovery.

Implementation of the TSN (the how; toolkit)

In creating the lunch session, it was felt necessary to provide a toolkit on how to implement the TSN. Four streamlined steps are necessary prior to the start of the program. First, the facility must secure institutional membership with the ATS. Next, it is required to complete a participation agreement, often formalized through a Memorandum of Understanding (MOU). Following this, the center identifies a dedicated individual or team to spearhead the TSN initiatives within the organization. Finally, that individual or team will meet with the TSN staff at the ATS to begin their implementation process (Figure 2).

TSN centers are granted access to a wealth of program support services, including but not limited to comprehensive onboarding and technical assistance, educational webinars, workgroups, and courses. Additionally, TSN coordinators have direct access to secure tools that support ongoing efforts, and benefit from peer support during regularly scheduled networking events.

The ATS has dedicated TSN staff to facilitate the implementation and sustained operation of the network at both the national and local level. Participating centers are coached to build a strong foundational infrastructure to address the specific needs of their trauma community on a local level.

Participation in the TSN offers numerous benefits for trauma centers. Some of these include enhanced care and outcomes for patients and families, increased advocacy for trauma systems and injury prevention, greater opportunities for philanthropic support, and improved patient and family satisfaction.

Palliative Care Collaboration with the TSN:

It goes without saying that the work of the TSN and Palliative Care (PC) teams should not occur in silos. Such partnerships enhance patient empowerment. PC is a specialty focused on improving the quality of life by providing physical, emotional, and spiritual support for patients with serious injury.¹⁴  While most conceive of PC as a specialty directed towards near end of life care, it provides significant benefit across the entire spectrum of illness and injury, regardless of prognosis.¹⁴  Any intervention aimed at easing patient pain and suffering falls under the auspices of PC and is very much in alignment with the goals of the TSN. Recognizing the importance of PC, it is a included as a new chapter in the upcoming ATLS 11^th Edition course update.

PC needs extend beyond the inpatient setting, which makes a case for integrating its practice into the support of trauma survivors in the outpatient realm.  It has been shown to improve patient satisfaction, symptom control, and quality of life by decreasing healthcare utilization, and lengthening survival.¹⁵ While the interdisciplinary care and support provided by survivorship programs yields similar patient satisfaction and healthcare utilization success, there is certainly room to add dedicated PC expertise to such initiatives.¹⁶

Some key opportunities to integrate PC core concepts into the ongoing support of trauma survivors include diligent oversight of symptom management, spiritual support and/or developing a sense of community, and empowering survivors to dictate/revisit their goals and preferences regarding medical care following recovery from injury.   Furthermore, Goals of Care should be revisited at minimum under the following circumstances:

• Advance directive update
• Time-limited post-discharge recovery trial
• Planned complex or highly morbid procedure

When patients with serious traumatic injuries lack decision-making capacity in the acute post-injury state, goals and preferences for medical care are commonly solicited from a surrogate decision-maker in the absence of a written advance directive. Unfortunately, surrogate performance in predicting patient wishes is frequently mediocre or poor.¹⁷ Further, the presence of an advance directive created by the patient substantially reduces the decisional burden of a surrogate decision maker and indirectly lessens severity of depressive symptoms, if the patient has a poor outcome.¹⁸ Goals of care should be revisited and documented if the patient regains decision-making capacity.

Finally, it is important to recognize that trauma survivors frequently require further surgeries or interventions post-discharge.  Part of pre-procedure planning should include anticipation of complications, ICU care, and supportive measures. An honest, shared decision-making discussion of these possibilities should be part of the informed consent process, and revisiting patients’ goals and preferences for treatment is essential. Ultimately, the essence of PC is excellent and patient-centered communication which is already at the foundation of any successful survivorship program.

Advanced Trauma Life Support (ATLS) 11^th Edition - Injury Prevention:

To bring it all together, it has been recognized that injury prevention is an important concept to implement after a patient’s critical injuries have been stabilized, hence its stand-alone chapter in the upcoming ATLS 11^th Edition course update. Trauma care clinicians are in a unique position to help devise and evaluate injury prevention strategies based on information gathered from prehospital personnel and ongoing, locally relevant trends in their community. Though it is acknowledged that contrasting laws and policies may be required in different parts of the world depending on resources and philosophy, the simple frameworks – the “Three E’s” (“Environment/Engineering,” “Education” and “Enforcement”) can be applied to common injury patterns for designing relevant prevention interventions in a multi-pronged fashion.²⁰ Some have advocated for a fourth “E” in the framework, “Equity,” to highlight injuries disproportionately experienced by some individuals.²¹ “Environment/Engineering” refers to modifying factors like improved traffic light timing, scramble crosswalks, or overhead pedestrian bridges if an increased number of pedestrian related injuries are noticed in the same location or intersection. “Education” is the means of raising awareness about the injury pattern and dispersing information. e.g., billboards, pamphlets, townhall meetings, or social media posts. “Enforcement” relays how penalties are implemented for violating laws, like financial sanctions for breaking seatbelt laws, or incarceration for driving under the influence (DUI). “Equity” accounts for assuring disproportionally affected people have appropriate interventions applied fairly.

It is important to consider Social Determinants of Health (SDoH)/Social Drivers of Health because these are often the root cause of both injury risk- and protective factors. These include but are not limited to poverty, structural racism, poor educational access, and lack of healthcare ingress.²⁰ In the same realm, it is key to follow the principles of Trauma-informed Care (TIC) when treating any patient, another new chapter included in the upcoming ATLS 11^th Edition course update. TIC principles are embodied in realizing the widespread impact of injury, recognizing signs/symptoms of trauma, responding to traumatic situations in a comprehensive manner, and aim to avoid re-traumatization. These comprise of safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment of one’s voice and choice, cultural, historical, and gender issues.^22,23 These core principles should be implemented throughout an organization from the top down.²³ 

It is critical to ensure that resources are available to make the appropriate referral if risk factors or evidence of harm is identified during the initial work-up of a trauma patient, such as mental health, absent use of protective gear, intimate partner violence, child abuse and neglect, older adult abuse and neglect, or lacking SDoH. If resources are not available in the facility performing the initial work-up, results should be communicated to the tertiary/receiving institution as part of the sign out process in a transfer checklist. The TSN, in collaboration with palliative care, has created a pathway for assisting patients and their families as they transition to the next stage of recovery, acknowledging that the healing process varies from one individual to another.

Conclusions:

The TSN, though a relatively unknown entity in the past, is now a phenomenal establishment available for trauma centers and related institutions to use as a resource for empowering survivors of trauma to recovery, in collaboration with PC. The three “E’s” should be used in the warm handoff process when relaying injury prevention issues in a patient’s summary to a definitive accepting facility. Remember, “injury is NO accident.”

References:

1. traumasurvivorsnetwork.org. Accessed July 3, 2024
2. Committee on Trauma, and Committee on Shock, Division of Medical Sciences, National Academy of Sciences/National Research Council (US). Accidental Death and Disability: the Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences; 1966.
3. Michetti, C.P. (2019). The American Trauma Society’s 50th anniversary: Saving lives. Improving care. Empowering survivors. Journal of Trauma Acute Care Surgery, 86(3), 489-492. https://doi.org/10.1097/TA.0000000000002153
4. Bradford AN, Castillo RC, Carlini AR, Wegener ST, Teter HJr, Mackenzie EJ.The Trauma Survivors Network: survive connect. rebuild. J Trauma. 2011;70:1557–1560.
5. Wegener, S.T., Pollak, A.N., Frey, K.P., Hymes, A.R., Archer, K.R., Jones, C.B., Seymour, R.B., O’Toole, R.B., Castillo, R.C., Huang, Y., Scharfstein, D.O., MacKenzie, E.J., & Major Extremity Trauma Research Consortium (METRC) (2017). The Trauma Collaborative Care Study (TCCS). Journal of Orthopaedic Trauma, 31(4), S78-S87. https://doi.org/10.1097/BOT.0000000000000792
6. Castillo, R. C. , Wegener, S. T. , Newell, M. Z. , Carlini, A. R. , Bradford, A. N. , Heins, S. E., Wysocki, E. , Pollak, A. N. , Teter, H. & MacKenzie, E. J. (2013). Improving outcomes at Level I trauma centers. Journal of Trauma and Acute Care Surgery, 74 (6), 1534-1540. https://doi.org/10.1097/TA.0b013e3182921606
7. Resources for Optimal Care of the Injured Patient: 2022 Standards. American College of Surgeons. 2022, pg. 106
8. Blöndal K, Sveinsdóttir H, Ingadottir B. Patients' expectations and experiences of provided surgery-related patient education: A descriptive longitudinal
9. Fredericks S, Guruge S, Sidani S. Postoperative patient education: a systematic review. Clin Nurs Res. 2010;19:144 –164. Nurs Open. 2022 Sep;9(5):2495-2505. doi: 10.1002/nop2.1270. Epub 2022 Jun 5. PMID: 35666048; PMCID: PMC9374389
10. Mead S, MacNeil C. Peer support: what makes it unique? Int J Psychosoc Rehabil. 2006;10:29 –37
11. California HealthCare Foundation. Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success. Oakland, CA: California HealthCare Foundation; 2006
12. The Resources for the Optimal Care of the Injured Patient: 2014 Standards. American College of Surgeons. 2014, pgs. 89-90
13. Wegener ST, Pollak AN, Frey KP, Hymes AR, Archer KR, Jones CB, Seymour RB, O’Toole RB, Castillo RC, Huang Y, Scharfstein DO, MacKenzie EJ, and METRC. The Trauma Collaborative Care Study (TCCS). J Orthop Trauma 2017;31(4):S78-S87
14. ACS TQIP Palliative Care Best Practice Guidelines. American College of Surgeons Committee on Trauma. Available online: https://www.facs.org/-/media/files/quality-programs/trauma/tqip/palliative_guidelines.ashx. Accessed 07/23/2024.
15. Rabow M, Kvale E, Barbour L, Cassel JB, Cohen S, Jackson V, Luhrs C, Nguyen V, Rinaldi S, Stevens D, Spragens L, Weissman D. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med. 2013 Dec;16(12):1540-9. doi: 10.1089/jpm.2013.0153. Epub 2013 Nov 13. PMID: 24225013.
16. Livingston DH. Survivorship. J Trauma Acute Care Surg. 2023 Jan 1;94(1):1-7. doi: 10.1097/TA.0000000000003806. Epub 2022 Oct 7. PMID: 36203243.
17. Pope TM. Legal Fundamentals of Surrogate Decision Making. Chest. 2012 Apr; 141(4):1074-1081.
18. Hickman RL Jr, Pinto MD. Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill. J Clin Nurs. 2014 Mar;23(5-6):756-65. doi: 10.1111/jocn.12427. Epub 2013 Dec 14. PMID: 24330417; PMCID: PMC5573593.
19. Falzarano F, Prigerson HG, Maciejewski PK. The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful? Cancers (Basel). 2021 Apr 20;13(8):1977. doi: 10.3390/cancers13081977. PMID: 33924214; PMCID: PMC8074595.
20. Dicker R.A., & Juillard C.J. (2020). Injury prevention. Feliciano D.V., & Mattox K.L., & Moore E.E.(Eds.), Trauma, 9e. McGraw Hill
21. Giles A, Bauer MEE, Jull J. Equity as the fourth 'E' in the '3 E's' approach to injury prevention. Inj Prev. 2020 Feb;26(1):82-84. doi: 10.1136/injuryprev-2019-043407. Epub 2019 Sep 19. PMID: 31537617
22. Bliton JN, Zakrison TL, Vong GD, Johnson DA, Rattan R, Hanos D, Smith R. Ethical Care of the Traumatized: Conceptual Introduction to Trauma-Informed Care for Surgeons and Surgical Residents. JACS. 2022 Jun;234(6):p 1238-1247. DOI:1097/XCS.0000000000000183
23. Substance Abuse and Mental Health Services Administration (SAMHSA). Practical Guide for Implementing a Trauma-Informed Approach.2023

Figure 1. History of TSN

Glossary of undefined abbreviations (all others have been previously defined)

NTSD – National Trauma Survivors Day

TCCI – Trauma Collaborative Care Intervention

Figure 2. Step-by-Step guide for Implementation of TSN 

Diversity, Equity, and Inclusion, Communication, and Education Committees

Creating a More Perfect Union for LGBT Trainees

Written by: Benjamin Pomy, MD

The landscape of diversity, equity, and inclusion (DEI) in medicine, and, to some extent, surgery, has made significant strides in recent years. Yet the experiences of LGBT surgeons and trainees often differ from other underrepresented demographics. While there has been a growing recognition of the unique challenges faced by women and racial/ethnic minorities in surgery, LGBT surgeons, specifically surgical residents, encounter distinct barriers that necessitate tailored approaches for inclusion and support. Recent data highlight the evolving demographics of surgical residents. According to a study by Heiderscheit et al., approximately 4.8% of surgical residents identified as LGBT in 2021, an increase from previous years¹. Population estimates of the prevalence of LGBT people are consistently around 4-6%, so surgical residents seem to self-report at a similar rate as the general population. This change indeed underscores a broader cultural shift towards greater visibility and acceptance within the medical community. However, LGBT residents continue to experience mistreatment, bullying, and harassment at rates significantly higher than their non-LGBT counterparts. In response, there has been growing momentum of support for LGBT surgeons and residents, evidenced by initiatives at the regional and national levels to create a more welcoming workforce.

Regarding mistreatment, Heiderscheit et al. found 59% of LGBT surgical residents reported mistreatment, compared to 42% of their non-LGBT peers.¹ This is unfortunately rather stagnant from approximately 10 years ago, when half of all LGBT trainees were still experiencing mistreatment². Though one may argue that this statistic indicates too frequent mistreatment towards all surgical residents in general, this added pressure is especially harmful in this population. The Trevor Project reports that LGBT youth are more than four times as likely to attempt suicide compared to their heterosexual peers. Within the surgical community, it is estimated that 8% of LGBT surgical residents had seriously considered suicide in the past year, compared to 4% of non-LGBT residents.¹

Furthermore, the desire to leave surgical training due to mistreatment and lack of support is higher among LGBT residents as well. Approximately 20% of LGBT surgical residents considered leaving their training programs, compared to 10% of non-LGBT residents.¹ A recent study found actual attrition from general surgery training between 2001-2018 was 10.03%; altogether, this suggests LGBT residents may be more likely to actually leave their programs, though further investigation in this area is needed.³

To address the above challenges, several initiatives are paving the way for a more inclusive surgical community. The Association of Out Surgeons and Allies (AOSA) is dedicated to creating a supportive network for LGBT surgeons and their allies⁴. By providing resources, mentorship, and advocacy, AOSA aims to foster an environment where all surgeons can thrive. The AOSA also publishes its list of sponsor institutions which can help LGBT applicants, and even potential employees, identify safe workplaces⁵. 

Continuing to push representation within existing national organizations is also critical. The Eastern Association for the Surgery of Trauma (EAST) has initiated #EAST4ALL, a campaign to promote diversity and inclusion within trauma surgery. Similarly, the AAST has sponsored articles in Cutting Edge focused on transgender affirming care, highlighting the importance of inclusive patient care practices⁶. National meetings and conferences are also increasingly recognizing the need for inclusive spaces. Mixers and networking events are being tailored to include LGBT surgeons, such as the DEI networking breakfast at the upcoming AAST annual meeting. The American College of Surgeons has also published statements related to LGBT surgeons in their newsletter The Bulletin and includes LGBT issues in their DEI task force mission⁷. Creating these inclusive spaces at national meetings and within national organizations not only fosters a sense of belonging but also encourages collaboration and innovation. When LGBT surgeons feel supported and valued, they are more likely to contribute to the field's advancement and to mentor future trainees. This mentorship is the key to success when it comes to shepherding in a new generation of surgeons.

While we can study many of the problems facing residents with surveys after the in-training exam, there is little data evaluating current opinions of practicing LGBT surgeons and their peers. This is potentially an area of future study needed to ensure we focus on surgeons in the workforce, as well as surgeons in training.

In conclusion, while significant progress has been made in supporting LGBT surgeons-in-training, continued efforts are essential to ensure a truly inclusive and equitable surgical community. By continuing to address the unique challenges faced by LGBT surgeons and promoting representation and support, we can create a profession that values and respects all its members.

References:

1. Heiderscheit EA, Schlick CJR, Ellis RJ, et al. Experiences of LGBTQ+ residents in US general surgery training programs. JAMA Surg. 2022;157(1):23-32. doi:10.1001/jamasurg.2021.5246.
2. LaBarbera E. Creating an inclusive surgical community: Association of Out Surgeons and Allies. Association of Women Surgeons Blog. Published July 14, 2021. Accessed July 15, 2024. https://blog.womensurgeons.org/women/creating-an-inclusive-surgical-community-association-of-out-surgeons-allies/
3. Haruno LS, Chen X, Metzger M, et al. Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties. JAMA Surg. 2023;158(4):368–376. doi:10.1001/jamasurg.2022.7640
4. St John A, Goulet N. Enhancing Diversity in Surgery: Association of Out Surgeons and Allies, a New Society to Support and Promote Lesbian, Gay, Bisexual, Transgender, and Queer Surgeons. The American SurgeonTM. 2022;88(12):2810-2816. doi:10.1177/00031348221101494
5. Association of Out Surgeons and Allies. AOSA Members. Accessed July 15, 2024. https://www.outsurgeons.org/aosa-members
6. American Association for the Surgery of Trauma. April Cutting Edge. Accessed July 15, 2024. https://www.aast.org/news-letter-detail/april-cutting-edge
7. The doctor is out: supporting inclusion for LGBTQ+ surgeons. Bulletin of the American College of Surgeons. March 2023;108(3). Accessed July 15, 2024. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2023/march-2023-volume-108-issue-3/the-doctor-is-out-supporting-inclusion-for-lgbtqplus-surgeons/

Pediatric Committee

Collaborative Resources for Initial Pediatric Trauma Management: Imaging, MTP, and sTBI

Written by: Aaron R. Jensen, MD, MEd, MS, FACS, FAAP

Most children receive initial post-injury care at hospitals that are not pediatric trauma centers. Emergency Department Pediatric Readiness has been shown to have an independent association with improved risk-adjusted survival and is increasingly being emphasized at trauma centers. While the availability of pediatric-sized supplies and equipment tends to receive the greatest emphasis in pediatric readiness discussions, pediatric-specific management protocols are an equally important aspect of pediatric readiness. A 2021 Delphi analysis identified imaging guidelines, pediatric hemorrhagic shock, and pediatric traumatic brain injury (TBI) as the top priorities for improving quality in pediatric trauma care. To address these needs, the Emergency Medical Services for Children (EMSC) Innovation and Improvement Center (EIIC) has developed standardized one-paged ‘just in time’ resources for use among centers that may not routinely care for children as a part of the Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma (available free at https://bit.ly/PEAKtrauma). These resources include specific guidance on the use of advanced cross-sectional imaging, severe TBI resuscitation, and hemorrhagic shock recognition and management including massive transfusion. This article aims to provide a high-level overview of these resources and promote dissemination among trauma centers for use in collaborative consultation with regional pediatric trauma centers that provide definitive management of injured children. 

Cross-sectional imaging is likely overutilized in children and evidence-based clinical decision rules have previously been developed to safely decrease the use of CT for pediatric trauma evaluation. Avoiding unnecessary CT scanning in children is important, as a significant increase in downstream induced malignancy has been demonstrated in patients with appendicitis diagnosed with CT rather than ultrasound alone.  While whole body CT (WBCT) is routinely utilized in high-mechanism trauma for adults due to lower missed injury rates and faster time to diagnosis of injuries, these benefits are not as great in children. Due to clear anatomy on plain radiographs and the greater risks of radiation in children, WBCT should be reserved for children that have both a high-energy mechanism, an unreliable exam due to severe neurotrauma, and a need for rapid diagnosis of all injuries in children that may need to be in the operating room for craniotomy. Selective body region-specific scanning should be implemented in children based on evidence-based clinical decision rules. The Pediatric Emergency Care Applied Research Network (PECARN) has developed robust clinical decision rules for Head CT, but outside of this rule, clinical decision rules have not been widely adopted and implementation gaps persist. PECARN rules for cervical spine injury have recently been published and provide an evidence-based framework for clinical clearance of the cervical spine in children without the routine use of imaging. These rules, while providing guidance on which children to image, are limited in guidance for how to manage children that do not meet criteria for clinical clearance – specifically when a collar can be removed with negative imaging and persistent symptoms. Formal clinical decision rules have not been proposed for chest CT, but evidence supports reserving chest CT for ruling out mediastinal vascular injury in the presence of an abnormal chest radiograph. Several differing (but complementary) decision rules have been developed for abdominal CT and have been integrated into a single pathway (Figure). Trauma centers can use standardized imaging guidelines to promote communication between centers for quality improvement, and encourage consistent imaging practices across regions and potentially decrease unnecessary CT scans in children.

Figure 1: Pediatric Abdominal CT Clinical Decision Algorithm.  Copyright EMSC Innovation and Improvement Center 2024. Used with permission.

Hemorrhagic shock is a leading cause of preventable mortality in injured children. While the data supporting high-ratio transfusion in children is not as strong as it is in adults, the available evidence does suggest the same benefit. Shock recognition in children can be challenging due to the nonspecific nature of tachycardia (which is often due to pain or fear), the delayed onset of hypotension due to profound compensatory mechanisms in children, and general unfamiliarity of normal vital signs in children. Implementing tools such as the ABC-D score to identify patients with significant hemorrhage can lead to earlier activation of massive transfusion protocols and potentially improved outcomes. Due to the small circulating blood volume of young children, reliance on adult massive transfusion protocols can lead to early unbalanced transfusion (for example, giving a single 300cc ‘unit’ of red blood cells to a 10 kg child is equivalent to giving an adult six units of RBCs to an adult). Many adult massive transfusion protocols start 1:1 transfusion ratios after four units of RBCs, which can lead to early exacerbation of coagulopathy in small children if plasma is not introduced long before the fourth unit of RBCs is started. The EIIC hemorrhagic shock resource includes normal vital signs references, shock identification tools, and an example weight-based pediatric massive transfusion protocol that can be implemented in centers without an existing pediatric protocol.

Timely recognition and treatment of severe TBI is essential for optimization of outcomes for children. Assessing GCS may be challenging if clinicians are unfamiliar with the pediatric GCS scale. Resuscitation algorithms for pediatric sTBI are similar to adults with a few minor differences. The Brain Trauma Foundation recommends 3% saline in children and does not recommend the routine use of mannitol for intracranial hypertension. ATLS principles should be optimized, with early recognition of a patient that exceeds institutional resources a key step in optimizing time to definitive care. Obtaining head CT should not delay transfer out to higher level of care unless it can be obtained while transport assets are being mobilized. CT should be performed in collaboration with a regional pediatric center to ensure appropriate images are obtained and minimize re-scanning after transfer. The EIIC TBI resuscitation algorithm provides just-in-time guidance including calculation of pediatric GCS, prioritization of ATLS principles, indications for endotracheal intubation, and guidance on neuroprotective and osmotic agents.

These resources are intended for primary use at centers that infrequently care for children and do not have the full spectrum of definitive management resources.  They are also intended for pediatric centers to use for education and outreach as a discussion point to improve collaborative care regionally. Standardization of care can decrease variability and potentially improve outcomes. The use of shared resources has the potential to support this standardization and use of these resources should be encouraged to promote collaboration between pediatric trauma centers and their regional partners.

AAST Education Committee

TSACO Patient-Centered Education Collaborative

Written by: Joshua Dilday, DO and Kimberly Hendershot, MD

Imagine the most recent trauma patient you treated. Try to mentally envision the scenario surrounding the event, the initial patient presentation, and the first diagnosis that crossed your mind. Now, think of the next steps you took. Did you whisk the patient away to the operating room to stop the life-threatening hemorrhage? Maybe you escorted the patient to the CT scanner to radiographically identify an enlarging subdural hematoma. Despite your training and experience, some questions might have crept into your mind trying to overstay their welcome like estranged family members over the holidays. Being an expert in your field, you might have quelled this doubt by doing a quick search for a recent article or manuscript on the matter. You could have utilized additional resources – maybe the AAST app was your go-to confirmatory source. Armed with your expertise, gestalt, experience, and literature, you stepped up and did the job you were trained to do.

Now imagine that same scenario but from a different perspective. Try to mentally envision the scenario from the patient’s and family’s perspective. Envision how scary the ambulance sirens must have sounded, how many “big words” the trauma team used when describing the course of action, and how quickly they took you or your loved one away to get a procedure of which you had never heard. Try to imagine how helpless you might feel when the shock, fear, and confusion violently collide in your mind. And then the doctor asks you, “Do you have any questions?”

 If you were in your patient’s shoes, you would have a plethora of questions. If you were the patient’s loved one, the volume of your questions would be overwhelming. But those questions might not be given the mental clearance to come to mind at the moment, as the shock and fear paralyze any capacity for questions. Instead, the questions arise after the medical team leaves to perform surgery, start the ICU admission paperwork, or get that follow-up CT scan.

So where do patients and loved ones turn to get their questions addressed? Where can trauma or emergency general surgery patients go to educate themselves on the scary terminology the doctors just hurled their way? A quick purview of PubMed? The latest acute care surgery textbook? These are not easily available to patients or designed to empower patient-centered education. Feely available, easy-to-find, patient-centered educational resources are lacking in the acute care surgery healthcare community. This, in turn, creates a more distraught, overwhelmed, and hopeless scenario for our patients and their loved ones. We can do better to help our patients and families understand their diseases. The AAST and Trauma Surgery and Acute Care Open (TSACO) and the American Trauma Network Trauma Survivors Network (TSN) seek to provide this assistance.

 The ”Patient Education Series: Understanding Trauma and Emergency Surgery Conditions” is a collaborative effort between the AAST Education Committee, TSN, and TSACO designed to provide a public service to those who need it most: our patients and their loved ones. By joining forces, we will provide freely available, easily found, patient-centered educational resources vetted by both experts in the acute care surgery world and patient advocates. These articles, published monthly in an open-access academic journal, will provide information on common injuries, diseases, and procedures affecting our patients. Each article will be written for patients and their loved ones; health literacy will be augmented as each article will be written at an elementary school reading level.

Trauma is scary enough without the overwhelming assault of questions and misinformation threatening the peace and autonomy of our patients. Patient-centered educational resources are long overdue in the acute care surgery world. Our patients deserve to have free access to vetted information regarding their current ailments. This initiative aims to empower patients with educational resources throughout their medical journey. 

The “Patient Education Series: Understanding Trauma and Emergency Surgery Conditions” initiative kicks off later this fall with expected publication in late September/early October. The first articles will cover rib fractures, appendicitis, and tracheostomy. Additional topics will be published monthly, starting in November. TSACO has created a brand new manuscript category specifically for thi Remember the details below:

The "Patient Education Series: Understanding Trauma and Emergency Surgery Conditions" initiative will begin later this fall, with an expected publication in late September or early October. The first articles will cover rib fractures, appendicitis, and tracheostomy. Additional topics will be published monthly, starting in November. TSACO has even developed a new manuscript category specifically for this initiative. If you have questions or are interested in becoming involved, please get in touch with the team leads, Joshua Dilday ([email protected]) and Kimberly Hendershot ([email protected])

The AAST Associate Membership – 5 years later

Written by: Simin Golestani, MD

The American Association for the Surgery of Trauma (AAST) annual meeting’s Presidents' Dinner features a table referred to in friendly terms as “the kids table”.  This table, made up of the Associate Member Councilors and early career leaders, did not exist for the first 80 years of the AAST. While it is true that the average age of the guests at this table is lower than that of the average AAST guest, the contributions of the council and the seven hundred associate members they represent is anything but small.  

History

In 2016, the idea of The Associate Membership (AM) was first introduced under the presidency of Dr. Raul Coimbra. Until then, membership in the AAST was restricted to surgeons who had at least five years of experience as an attending and represented the values of the AAST through their leadership and scholarly activities. During this time there was a dramatic increase in interest in the surgical critical care and the acute care surgery fellowship by strong, enthusiastic applicants. Dr. David Spain, who served as AAST president in 2019 and oversaw the final creation of the AM, states: “As the organization was evolving and becoming more transparent and merit based, the realization came that it would be a positive move to engage young surgeons interested in acute care surgery (ACS) and trauma from their earliest stages of training.” And as such, the Associate Membership was created.  

Growth and Purpose   

Since it was formed, the growth of the Associate Membership has been rapid and exponential. This expansion highlights the fact that there was a need and interest that hadn’t been filled previously. In its first year, over one hundred applications were received. In 2019, two hundred and eighty-six members were introduced. This number continued to grow each year, with 2023 seeing the largest number of applicants, totaling the Associate Membership to seven hundred and fifty-seven members!

Although attracting members and finding ways to continue growing the Associate Membership was one of the first goals, the focus was then placed on meeting the needs of the Associate Members in a meaningful way. This included addressing the desires of earlier career surgeons, while maintaining alignment with the mission of the greater AAST. In 2019, membership-wide elections were held for three councilor positions and seven officer positions. The Associate Member Council then created a mission statement and bylaws that have served as the compass guiding the development of the Associate Membership. Over time the number and variety of positions has expanded to better serve the needs of the Associate Members in each of the categories of Scholarship and Development, Research and Education, and social media and Communication. Additionally, Vice Chair positions were added as specific needs arose, with specific Vice Chairs assigned to engagement, recruitment, online learning, development, scholarship, and diversity and inclusion.  

The responsibilities of all these committees spans a large spectrum, from providing networking and mentoring opportunities, to advancing scientific achievement of members, and acting as advocates in the trauma world and providing relevant educational discussions.  Some of the initiatives of the Associate Membership have been present since its inception and continue to be quite successful, including educational webinars such as “Turnover Time”, summarizing recent literature in ACS, and “Forks and Things”, discussing protocols and algorithms. A critical care fellow handbook was published with a new fellow handbook in the process of development as well. Some of the newest and most successful initiatives of the Associate Membership in the past years have been the Gun Violence Awareness campaign during the month of June, organizing research training sessions at the AAST meeting and collaborating with both JTACS and TSACO to provide opportunities for involvement, monthly scholarships, and research mentorships to Associate Members.

The Future

With the continued growth and expansion of the Associate Membership has also come new changes and opportunities. One of the most important abilities of any organization is the ability to be introspective and open to hearing the voices of all the members it represents. Acknowledging this, the Associate membership council sent out a survey to all members early this year, and in the spring the council held its first retreat in which actionable plans were made under the guidance of the AAST Board of Managers. The action items directly address the desire for Associate Members to have increased leadership opportunities in an association that values inclusivity. Ryan Dumas, the current chair of the AAST Associate council, states that one of the greatest challenges is continuously developing engaging content and resources that address and meet the needs of young surgeons. Brittany Bankhead, the incoming chair, is looking forward to finding new ways to keep the membership meaningfully engaged.  

In the last five years, the Associate Membership has developed and grown and become an integral part of the trauma world taking on an identify of its own while still functioning under the mission of the AAST to create a network of support and mentorship, provide an opportunity for future leaders to develop skills, promote the dissemination of science and have their academic accomplishments celebrated. The AAST Associate membership will continue to give young leaders in the trauma world, literally and figuratively, a seat at the table.

The Journal of Trauma and Acute Care Surgery

Join us for the JTACS Lunch Session as AAST 2024!

Written by: Raul Coimbra, MD, PhD, Editor-in-Chief

Join us for the Journal of Trauma and Acute Care Surgery (JTACS) journal lunch session at AAST 2024: Case Studies in Publishing and Reviewing for JTACS. The session will be held on Friday, September 13, 12:00 pm–1:15 pm. Register here https://www.xpressreg.net/register/AAST0924/start.asp

In this session, you will have the opportunity to learn how to enhance your peer reviews, improve your JTACS submissions, and refine your biostatistical skills in identifying common flaws in performing and reporting multivariate analysis and propensity scoring. Members of the JTACS editorial board will present:

• Real-life examples of flaws caught by reviewers
• Real-life examples of what not to do when writing and submitting a manuscript
• Types of Multivariate Analyses: When to use them and How to report the model used in the manuscript?
• Types of Propensity Scoring: When to use them and How to report them in the manuscript?

Journal of Trauma 2024 Edition: WTA Algorithms Now Available!

The 2024 edition of the Journal of Trauma (JOT) features algorithms developed by the Western Trauma Association (WTA) selected by Dr. David Livingston. The PDF edition is now available for free online download from the journal site https://journals.lww.com/jtrauma/Documents/2024%20TA%20Online%20Issue%20Proof_V2.pdf . Printed copies of the edition will be available at the JTACS booth at AAST 2024. Stop by and pick up a copy of this valuable resource!2024 Military Supplement Now Available Online and Open Access!

The 2024 Military Supplement is online and free for all to read https://journals.lww.com/jtrauma/toc/2024/08001. Many thanks to the Guest Editors Jay A. Yelon, Valerie G. Sams, and Travis M. Polk for coordinating the issue, and all authors who submitted to this edition.

What You Need to Know Review Series Collection Updated!

Stay on top of the most recently published What You Need to Know Review articles by visiting the online article collection! https://journals.lww.com/jtrauma/pages/collectiondetails.aspx?TopicalCollectionId=18