Critical Care Surgeon
Definition
Surgical critical care is one of three components of acute care surgery, the other two being trauma surgery and emergency general surgery. Acute care surgery is a relatively new specialty. It was brought about by a lack of specialists trained in responding to patients with time-sensitive and highly acute conditions.
Surgical critical care, in particular, refers to the timely management of non-trauma cases that present, or are likely to result in, organ system dysfunction. Its history and its practitioners’ roles and contributions are tied closely to the critical care team, a multidisciplinary team of physicians and nurses, and the intensive care unit, or ICU.
Education
Aspiring acute care surgeons must first receive a pre-medical bachelor’s degree. Courses in Biology, Chemistry and Physics are commonly taken as a pre-medical degree. After that, the aspiring surgeon must complete four years of medical school. Medical school generally consists of two years of class and laboratory work, followed by two years of clinical duty. Once completed, the aspiring surgeon must pass a licensure exam to receive a medical license and earn a doctor of medicine.
A three to five-year residency program would then follow to allow the aspiring acute care surgeon to expand their knowledge of clinical practice in trauma care, critical care, and emergency response. Upon completing the required residency rotation hours, further licensure exams are required to allow aspiring acute care surgeons to become board-certified.
These exams differ from country to country. In America, for example, residents may take the General Surgery Qualifying Examination and the General Surgery Certifying Examination. Upon passing both, the resident becomes qualified to take the Surgical Critical Care Certifying Examination, which allows the resident to become a board-certified acute care surgeon.
Following licensure is membership in a fellowship, which will generally last one to two years. A fellowship provides acute care surgeons further training in the treatment of blunt and/or penetrating traumas, single or multi-organ injuries, as well as critical organ support, organ transplant and other high-risk procedures. Fellowships also provide opportunities to perform clinical research in trauma and critical care surgery or to teach other residents.
Roles & Responsibilities
Surgical critical care practitioners work in a critical care team, which is a team of multidisciplinary physicians and nurses, depending on availability. As a multidisciplinary team, it is capable of providing a broad system of care to patients of varying illnesses and organ dysfunctions. This care is characterized by constant vital sign monitoring combined with immediate responses to any change in organ function.
The team’s overall goal is to maintain homeostasis and reduce primary and secondary injury, as well as reduce the risk of illness caused by treatment or examination.
Here are some common conditions a critical care surgeon would treat:
Sepsis
Sepsis is the body’s life threatening response to infection. While the body’s inflammatory responses to infection are usually localized in the infected area, sepsis is a systemic response, meaning it affects the entire body. When combined with organ failure or reduced blood flow, severe sepsis occurs and may lead to septic shock. This is characterized by critically low blood pressure due to sepsis.
Sepsis occurs when bacteria enters the bloodstream and the body usually responds to an infection with inflammation, which aids in the healing process of the source of the infection. Inflammation also causes blood vessels to widen, thus decreasing blood pressure. When this response is spread throughout the entire body, blood flow to vital organs decreases. To respond to the lack of blood, the heart pumps faster and harder, thus increasing the rate at which the bacteria which caused the inflammation spreads its toxins throughout the body. These two factors further tax the heart, causing it to weaken. Vital organs receive even less blood and therefore begin to release waste products into the bloodstream, making it acidic. All of these cause multiple organ failure and death within hours.
Having a weakened immune system considerably increases the risk of sepsis. Newborns, the elderly and pregnant women all have weakened immune systems. Patients that are treated with drugs that suppress the immune system, such as chemotherapy drugs, or those who have AIDS are also at risk of sepsis. Other risk factors include artificial joints, catheters or breathing tubes. These devices allow bacteria to move into the body through its insertion point.
When sepsis is detected, immediate source control significantly reduces the chance of death. A study from 2014 has shown that survival rate for patients who received source control surgery within the first two hours of admission to the hospital is at 98%. Patients who received the same treatment after 6 hours had a 0% survival rate.
Hypothermia
Modern medicine has significantly improved survival rates for patients with hypothermia due to environmental factors. Patients who suffered from hypothermia between 28°C and 32°C have a survival rate of 80%. However, survival rates for hypothermia for patients who are injured are significantly different. In a large study, no patient survived with an initial core body temperature of less than 32°C. Hypothermia often impairs the blood’s ability to form clots, which then results in an increase in blood acidity. The combination of hypothermia, an increase in blood acidity and the failure of blood to coagulate increases the risk factor for death in injured patients.
Hypothermia is common in patients who suffer from extreme traumatic injury. Researches show that hypothermia can happen to patients with traumatic injuries regardless of the time of the year. The longer the environmental exposure of a patient is, the higher the risk of hypothermia. Elderly patients are also at a higher risk of hypothermia, as their bodies are less capable of maintaining their core body temperature. The environment of the injured also affects the risk factors of hypothermia. Heat loss in water is significantly higher compared to heat loss in air. Anesthesia also increases the risk of hypothermia, as it reduces the body’s ability to maintain its core body temperature.
The minimum threshold for survival for injured patients with hypothermia is 34°C. At temperatures above this, the body is still able to increase its core temperature with various responses. Shivering produces up to five times the regular metabolic heat compared to regular processes. The heart and the respiratory systems are both stimulated and confusion will generally occur. However, when the body temperature reaches lower than 34°C, these functions are further impaired. The body will then be less able to fight off hypothermia. Specifically, the breathing drive will be reduced, a comatose state may be expected and resuscitation may prove to be impossible.
Injured patients who suffer from hypothermia should be rewarmed as soon as possible. While such a patient’s body is capable of preventing further heat loss, it is incapable of increasing its temperature. Patients with mild injuries and have a core body temperature of more than 35°C may undergo passive warming. Patients are placed in a warm room with blankets to prevent heat loss. Patients who have more serious injuries or have a core body temperature of less than 35°C while injured should undergo active warming. The most basic form of active rewarming is the introduction of warmed intravenous fluid in the body. This method is invasive, and thus is associated with higher risk, but warm the body more rapidly. Forced air surface warming is a noninvasive, easy to use and readily available form of active warming. It involves an interface of paper or plastic that circulates heated air over a patient, providing heating by convection. Multiple trials have shown that forced air surface warming is a better form of warming compared to blankets. Forced air surface warming has also shown to be successful in the warming of patients with severe hypothermia. However, this method should not be used for severely hypothermic patients who are also bleeding, as they require faster forms of rewarming.
Organ Transplantation
As the success of modern transplant surgery is attributed to the suppression of the immune system, the acute care surgeon needs to be present before, during, and long after the surgery to ensure that risks of side effects or rejections are minimized. By suppressing the receiver’s immune system, the receiver becomes at risk of infection and sepsis, as mentioned above. An infectious complication affects up to 63% of organ transplant receivers within the first year of the operation. Because the treatment for immunosuppression is increased between 6 to 12 months of organ transplant operations, this time also puts organ transplant receivers at the highest risk of infection. A delicate balance must therefore be maintained between the risk of rejection and the risk of infection.
Acute care surgeons are also uniquely qualified to assist in the determination of death for potential organ donors. Death has been defined in the Uniform Determination of Death Act as the irreversible cessation of circulatory or respiratory functions or all brain functions. Extensive tests must be performed prior to the harvesting of organs from the donor. In the case of brain death, patients must be in a deep, unresponsive coma, have a core temperature of less than 32°C, not be intoxicated or poisoned, not have any conditions that might confound the assessment of brain death, pass an apnea test, and have specific cranial nerve reflexes and responses. Two physicians independently determine the brain death and accomplish the forms for the declaration of death separately. The two physicians who assess the death cannot participate in the harvesting or transplanting procedures. The definition of brain death was defined in 1968 by the Ad Hoc Committee of Harvard Medical School. Due to the gap between organ donor supply and organ recipient demand, the list of potential donors has been expanded to those who have died after cardiac death, living donors and expanded criteria donors.
Cardiac death means that the heart cannot be spontaneously restarted or the patient has signed a do-not-resuscitate order, which prevents physicians from resuscitating the patient. This defines the patient’s cardiac cessation as legally irreversible. While the timing for declaring the irreversible cessation of circulatory and respiratory functions vary between different transplant programs, the United Network for Organ Sharing has presented minimum requirements for the withdrawal of life-sustaining measures. A time-out is recommended before the withdrawal of life-sustaining measures to verify patient and personnel identification and responsibilities. No member of the transplant team will be present for the withdrawal of life-sustaining measures and no member of the organ recovery team may participate during the declaration of death. There must be a determination of the location and process for the withdrawal of life-sustaining measures as a component of patient management. These minimum requirements were finalized in March 2007 and became effective on July 1, 2007.
Palliative Care
Acute care surgeons will be regularly faced with conflicts related to end of life care, as their patients are commonly highly acute. In the most ideal case, planning for such care begins as the patient declares their end of life choices prior to becoming ill. However, palliative care is commonly considered only after the patient is considered terminal. With this in mind, relief from the symptoms and stress of a critical illness should be considered a constant in critical care. The shift in between curative care and palliative care therefore becomes not a change in therapy. Rather, it becomes a change in the goals of therapy.
There are significant ethical considerations in the shift from curative care to palliative care. These considerations generally revolve around autonomy, beneficence, dignity, honesty and non-maleficence. Autonomy is the patient’s right to determine his or her care. Beneficence is the physician’s pledge to act in the best interest of the patient. Dignity is the patient’s right to respectful, ethical, and empathetic treatment. Honesty is the patient’s right to know the truth about their condition, the planned treatment and its associated outcomes and risks. Non-maleficence is the physician’s pledge to never harm the patient. Disagreements in the goals of therapy can often be resolved with a discussion between the patient and the physician. The physician should make the ethical frameworks and considerations, the facts of the case, the probabilistic nature of medical study, and his/her possible biases clear to him/herself.
The American College of Surgeons Committee on Ethics has provided guiding principles in palliative care. The physician must respect the dignity of both patient and caregivers, be sensitive to and respectful of the patient’s and family’s wishes, use the most appropriate measures that are consistent with the choices of the patient, ensure alleviation of pain and management of other symptoms, recognize, assess and address psychological, social and spiritual concerns, ensure the continuity of care by the patient’s primary or specialist physician, provide access to therapies that may realistically be expected to improve the patient’s quality of life, provide access to appropriate palliative care and hospice care, respect the patient’s right to refuse treatment and recognize the physician’s responsibility to forego futile treatment.
The provision of palliative care revolves around the relief of pain and stress as well as the provision of psycho-social support. Palliative care may also extend towards spiritualism and existentialism in the approach to life after death. An effective tool in the provision of effective palliative care is the PEACE Tool. PEACE Tool is an acronym which stands for pain, emotion, autonomy, closure, economic burden, and transcendentalism. Relief from pain and the discomfort from symptoms can be addressed by a surgeon, but palliative care specialists may be needed when discomfort is not completely relieved. On the management of emotions, delirium, depression and anxiety often occur in patients. Once detected, it is important to keep a positive relationship between the patient, the family and the physician. Autonomy allows the patient a level of control over their treatment. This is often a cause of conflict between patients and physicians, where disagreements over the level of treatment may arise. The patient’s desire for autonomy should always be respected, but a patient’s decisions may not always be logical. In cases like these, a clear discussion of the medical decisions, its projected outcomes and risks must be performed to guide the patient towards a more rational choice. Closure for patients and their families is integral to ensure that death will occur without regrets. Closure may also become a tactic for organ donation, as some families may find meaning in sudden death in the chance to preserve another patient’s life. Economic concerns consider the fact that the costs of being critically ill may be a cause of stress for the patient. Assistance in insurance applications or simply discussing options with the family may relieve some of the stress. Transcendentalism is often important to critically ill patients. The provision of faith-based support for patients often serves as a support for the first four domains.
History
Acute care surgery is a fairly new specialty with a comparatively short history. The first documented application of critical care is credited to Florence Nightingale. As a nurse during the Crimean War in 1853, she arranged injured soldiers by the severity of their conditions, with the most severe conditions closest to the nurse’s station. This can be considered as an early form of the Intensive Care Unit. Her innovations in the treatment of wounded soldiers reduced mortality rates from 40% to 2%. Her knowledge in applied statistics also paved the way for modern hospital care. Her observations in the relationship between hospital sanitary conditions and patient mortality changed the organization of British military health care and became an early standard for hospitals all over the world.
The establishment of the first actual hospital ICU is credited to Dr. Walter Dandy. During a time of large hospital wards and lesser private beds in the early 20th century, Dandy, a neurosurgeon, arranged for a 3-bed private area for the postoperative care of his patients in the Johns Hopkins Hospital in Baltimore. The poliomyelitis epidemics of the 1950s made his format for the ICU spread throughout the United States. By the 1970s, nearly every large hospital in the United States had an ICU.
The poliomyelitis epidemics also led to the development of mechanical ventilation systems, an early form of single organ support, and the creation of Intensive Therapy Units, hospital areas which provided devices and techniques for organ support. Ventilation for patients with respiratory paralysis was done in Drinker-Shaw negative pressure ventilators, commonly known as iron lungs. When hospitals became overwhelmed by patients who needed ventilation during the poliomyelitis epidemics, medical students performed manual ventilation on patients. Several other inventions were later invented, like the Mueller Morch Piston Respirator and the Intermittent Positive Pressure Breathing ventilators. Support systems for other organs were also developed, like the Dr. Willem Kolff’s dialysis machine for kidney failure in 1943. The dialysis machine saw widespread use during the Korean War in 1952, where a rat borne virus infected soldiers and civilians and caused kidney failure.
The development of intensive care medicine as a specialty on its own came in the late 20th century. Research showed that specially trained and qualified intensive care physicians and nurses provided better care for ICU patients. Prior to this, ICUs were staffed primarily by anesthesiologists or specialists in internal medicine. In 2005, the American College of Emergency Physicians conducted a survey which showed that nearly three-fourths of emergency department directors in America believe that they lacked on-call specialty coverage. A similar survey conducted by the Institute of Medicine of the National Academies showed a similar conclusion in 2006. In 2007, the American Association for the Surgery of Trauma started to develop the curriculum for a new specialty, which resulted in the first formal Acute Care Surgery fellowship in July 2008.
Surgical Critical Care and the Critical Care Team
While the composition of critical care teams is different for each team, there are common therapies for the acutely ill. These are early resuscitation, appropriate antibiotic therapy and timely and effective source control for threats. The significance of time is always clear in the performance of the acute care surgeon, acting within the critical care team. Early resuscitation is proven to improve outcomes in patients. Patients who have infections have shown significantly better results when given antibiotic therapies as early as possible. Particular emphasis must be given to the detection of the specifics of infection, such as the specific kind of threat and its resistances to antibiotics as well as the source of the threat. The incorrect identification of the specifics of infection has shown to lead to a significantly higher risk of mortality. Thus, “as early as possible” means “after the threat has been adequately identified”. Aside from antibiotic therapy, source control must be performed immediately to reduce the risk of the infection spreading throughout the body or the hospital area. If an infection is left untreated, a patient’s body may respond with sepsis, which can quickly cause tissue damage, organ failure and death.
References
Azuhata, T., Kinoshita, et al. (2014, May 02). Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. Retrieved from https://ccforum.biomedcentral.com/articles/10.1186/cc13854
Britt, L. D. (2012). Acute care surgery. Philadelphia, PA: Lippincott Williams & Wilkins.
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Sepsis. (2017, August 25). Retrieved from https://www.cdc.gov/sepsis/basic/index.html
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Vincent, J. (2013, March 12). Where have we been and where are we going? Retrieved from https://ccforum.biomedcentral.com/articles/10.1186/cc11500
Wallace, D. J., & Kahn, J. M. (2015, November). Florence Nightingale and the Conundrum of Counting ICU Beds. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610246/
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