European Journal of Trauma and Emergency Surgery
European Society for Trauma and Emergency Surgery
Presidential Address
Which Future for Traumatology in Europe? The Changing World of Medicine
www.estesonline.org
Contact: President Prof. Dr. Dr. h.c. Pol Maria Rommens Center for Musculoskeletal Surgery University Medical Center Johannes Gutenberg University Langenbeckstrasse 1 55131 Mainz Germany Phone: +49 6131 17 7292 Fax: +49 6131 17 4043 e-mail: [email protected] http://www.klinik.uni-mainz.de
Eur J Trauma Emerg Surg 2010 · No. 2 © URBAN & VOGEL
In the last several decades, a lot has changed in our world, in our societies, in medicine in general, and in our profession specifically. First of all, life expectancy has increased significantly. Thanks to longer lives but due to lower birth rates, demographics show a growing presence of older people, of which many are sick but many are also healthy and still very active. Mobility and consumption of recreational activities have increased for all age and income levels; expectations on quality of life and recovery of functional deficits have changed and continue to evolve. Medical information has become available everywhere; definitions, symptoms, guidelines on treatment, and outcome of diseases and injuries are freely accessible on the Internet. Many patients assume that they know all about their disease and want to discuss treatment alternatives with their doctor of choice. More than before, patients and administration expect a predictable outcome of our medical activities. Medicine and medical research have become popular and are part of everybody’s business, including industry, media, justice, and politics. As medical activities are paid by collective money, many institutions and administrations want to co-decide what we have to do or abandon. Their opinion is based on medical evidence. What is not proven by evidence is not valid anymore. As a consequence, the medical actor is observed from all directions; he or she is becoming less independent and has to explain, defend, or account publicly for his or her decisions or failures. From the central person in medicine, the final decision maker, the doctor, has evolved to one element in a chain of medical and technical directives which are elaborated by others and what we call now case management. Parallel to these immersive changes in our societies, insight into the pathobiomechanics and pathophysiology of injuries and diseases have increased dramatically. The actual fields of medicine reflect a spectrum of knowledge which cannot be covered by one or even several persons anymore. This automatically means that a person with medical responsibility has to restrict him- or herself to a specific field, which bears his or her special interest. This means specialization. Specialization is nothing new; in earlier days, surgery was one specialty, but nowadays it is split up into at least eight sub-specialties. The Union Européene des Médecins Spécialistes (UEMS) has 37 sections, representing actual medical specialties in Europe. The section of surgery, which is only one of these 37, contains divisions of general surgery, coloproctology, hepatopancreatobiliary surgery, surgical oncology, thoracic surgery, transplantation surgery, endocrine surgery, and traumatology. Vascular surgery, cardiothoracic surgery, urology, plastic and reconstructive surgery, neurosurgery, and orthopedic surgery have different sections. We are grateful for the acquisition of knowledge in medicine, as it is of benefit for our patients. But, as a direct consequence, we are confronted with an explosion of specialization and sub-specialization, in which we have to find our way. The section of surgery of the UEMS recognizes the need for sub-specialties to meet the medical needs of the population on a high-quality level. She promotes the training toward medical specialists with a broad competence and experience in
85
European Society for Trauma and Emergency Surgery
surgery but counteracts the production of medical virtuosos of one operation. She is, therefore, against the recognition of an excessive number of surgical sub-specialties. Narrowing the scope of every specialist also means enhancing the need for working in team in case a patient’s problem exceeds the borders of the scope.
Where Does Traumatology Belong to? What is the matter with traumatology? Did this field of activities change as well? Can the general changes in medicine also be felt in our profession? The definition of traumatology did not change over time. Traumatology covers the prevention, recognition, conservative or operative treatment, aftercare, and rehabilitation of all possible lesions in all age categories. With this definition, we immediately discover that there is a major difference with other specialties. Traumatology does not focus on one organ, one system, or even a part of it; its field of activity involves lesions of the whole human body, irrespective of any boundaries. One could wish that the activity of the trauma surgeon be restricted to a limited number of technical acts in the early posttraumatic phase, the trauma surgeon being a kind of acute care physician. But following our definition, this is not the case. Lesions of different complexity and emergency in the brain, the thorax, the abdomen, the spine, the pelvis, or the extremities fall under his or her responsibility. There are only a few other disciplines in a similar situation: pediatric surgery, intensive care, and emergency medicine are among them. Being a discipline that deals with problems of the whole human body, traumatology is often seen as a real specialty, certainly not as a sub-specialty. Medicine is rapidly evolving towards specialization and sub-specialization, but traumatology remains holistic. External and internal opinion makers, so-called professional and political experts, have problems interpreting this phenomenon. They ask: where does traumatology belong? Is it surgery, orthopedic surgery, or emergency surgery, all of this or again something else? In their eyes, the sub-specialist is the super-specialist, the doctor who knows the most of a small medical field. A trauma surgeon can never be a super-specialist, as he or she has to deal with the lung, the spleen, the spine, or the bladder simultaneously. How can he or she compete in excellence and expertise with the thoracic surgeon, the abdominal surgeon, the spine surgeon, or the urologist, who are the surgical specialists in the above-mentioned organs? A discipline with a large scope always competes for the label of quality with disciplines with smaller scopes. The ultimate consequence is that the evidence of the discipline with the larger scope is questioned. Hospitals do not need general surgeons anymore, they need gastrointestinal and hepatopancreatobiliary surgeons, laparoscopists, coloproctologists, or transplantation
86
surgeons. The same is valid for traumatology: why should trauma surgeons do what we super-specialists do as well or even better, is the argument of the opponents? Thereby, they voluntarily forget that the patient actually comes with several urgent problems at the same time, mostly at a moment where the super-specialist has no time or interest to stop his scheduled activities or to subordinate his treatment plans under those of one or several other colleagues. Where is the coordinator?
Traumatology Is a Dynamic Field in Medicine As in other disciplines, medical wisdom has also exploded in traumatology. Thanks to successful fundamental and clinical research on shock and organ failure, thanks to instrument and implant development, to new surgical techniques, thanks to great progression in the detailed visualization of anatomical regions by newest generation computed tomography (CT) scans and with magnetic resonance imaging (MRI), we understand more than ever before how lesions occur, how our balanced organ systems react to the first-hit phenomenon, and how defense systems fail. Treatment protocols significantly changed with these new insights: total-body CT-scan in the resuscitation phase, supra-selective embolization, damage control surgery, minimal invasive surgery, angle-stable plating, and computerassisted surgery are diagnostic and therapeutic procedures, which reflect the integration of recent technical developments and new knowledge. Therefore, the question is allowed if the use of all these new technologies can be mastered by one person? Is it still possible, as in the time of the pioneers, that one surgeon performs thoracotomy for partial lung resection, laparotomy or laparoscopy for blunt abdominal trauma, endoscopic fusion of the ventral thoracolumbar spine, or open reduction and internal fixation of a complex pilon or calcaneal fracture on the highest quality level? How long does the training program of a surgical trainee need to be until he or she is excellent in these different fields? Only in musculoskeletal surgery, one person is hardly able to know all possible operations. In two decades, shoulder surgery has developed to a differentiated and complex entity of activity. The same can be said of spine, elbow, or foot surgery. Sub-specialization is clearly on its way. Look at how orthopedic surgeons organize themselves. Orthopedic surgeons are working together in associations; every single surgeon is responsible for one specific field, such as hip replacement, arthroscopy, and shoulder or hand surgery. Look at our international scientific journals. The Journal of Bone and Joint Surgery or the Journal of Trauma, which cover the whole spectrum of pathology, and journals such as Spine, Journal of Shoulder and Elbow Surgery, Journal of Pediatric Orthopaedics, or the Journal of Foot and Ankle Surgery have similar impact factors, which means that the parts receive more interest than the whole.
Eur J Trauma Emerg Surg 2010 · No. 2
European Society for Trauma and Emergency Surgery
The Trauma Surgeon of the Future Evidence-based medicine, higher expectations on quality of life from the side of the patient as well as from the perspective of the surgeon and his or her family, budget restrictions, explosion of knowledge, trend toward super-specialization, and a holistic view on traumatology—how do we bring all this together into an attractive profession? Is traumatology attractive at all? The answer is clearly yes. Students and young trainees are fascinated by this part of medicine. They feel that it is like looking at a thriller. Something special can happen every minute, there is action, there are surprises, and there are heroes and losers. But fascination dwindles away with time; a thriller is not for every day. When one is getting older and more settled, traumatology is more a burden than a pleasure. Too much stress is not good for healthiness; a regular life is more attractive than an unpredictable one. Moreover, regular surgery is more rewarding than emergency surgery. Traumatology is attractive on the first view, but not on the second. What is the future of traumatology? Trauma patients have always existed; perhaps they were the first surgical patients. They always will exist. Diseases such as gastric ulcer or coronary stenosis will not be treated surgically anymore, but trauma patients will eternally remain surgical patients. The question is not if traumatology will survive, but how it will survive. For the benefit of our patients and especially for the benefit of our young academics, we have to make our profession durable, attractive, well organized, scientific, and focused on our core competence. To achieve this, we have to work hard and simultaneously on several levels. We have to take away the fear of our profession. The trauma surgeon is not anymore the man or woman who is active and energetic day and night, resolving one crisis after the other and feeling well in the middle of blood and tears. How fascinating they were, but the times of dinosaurs are over. The trauma surgeon of tomorrow will be a very dynamic, flexible, committed, and differentiated surgeon with a broad surgical training. Contrary to other colleagues such as surgeons or orthopedic surgeons and their sub-specialists, he or she is able to cope with difficult and challenging problems related to trauma. He or she is the optimal defender of the interests of the injured, especially the severely injured. This does not mean that he or she has to perform all diagnostic and therapeutic procedures of his or her patients himself or herself. He or she has to bring in his or her core competence and be committed to interdisciplinary cooperation and coordination. Today, there is no one-man game anymore. It is all a team game now. This is true in production, commerce, or research, and is especially true in traumatology. Claiming a balanced life between profession and free time, he or she will not be on call every third night and second weekend anymore. He or she is part of a larger group of colleagues who share responsibility and are each other’s substitutes. All partners of the team
Eur J Trauma Emerg Surg 2010 · No. 2
finished training in traumatology, but have their specific field of interest and competence. As skeletal trauma is much more frequent than cavity trauma in our countries, the core competence of most trauma surgeons of the team will lie in this area of activity. To enable such a career, the trauma team deserves a workload that is large enough to spend the whole day on trauma. Therefore, we need trauma centers with larger numbers of injured patients. The creation of trauma centers is a professional and political decision. It is the recognition that expertise goes with quality and that not every hospital is able to offer everything. Already today, this is evident. There is a need for the regionalization of trauma care, of networks around Level I trauma centers, which meet specific logistical and infrastructural requirements and become referral centers for the region. Level II and III trauma centers offer basic and advanced trauma care, but do not maintain the same quantity of personnel, equipment, and supporting departments as in the Level I center.
Traumatology Needs Academic Support Level I trauma centers are training centers as well, in which young and enthusiast academic persons can learn their profession. I underline the word academic, because traumatology needs research and development just as other medical fields. There is still a lot to learn: what is the ideal timing and what are optimal surgical procedures for the polytraumatized patient, how to bridge larger bony defects, why do joints get stiff when immobilized, or how to influence the interaction between biomaterials, tissues, and cells? Without academic pillar, there is no future for any profession. With an academic arm, a profession becomes solid, attractive, and durable. At our universities, we need independent trauma units, headed by clinical and research professors. These chairmen can choose, train, and promote residents to clinical and academic trauma surgeons. The greater the professional excellence, the stronger is the profession. Young people only become attracted by a profession when they can be proud to be part of it. This never will happen when the profession is not visible as an entity which can be distinguished from others. Who closes or subordinates trauma departments instead of supporting them will alienate new candidates to choosing traumatology.
The Role of the ESTES We need a recognized definition of our profession, a description and harmonization of training programs, a description of training centers, regional Level I trauma centers, regional, national, and international networks, quality control, and academic excellence in different fields of trauma care. How do we achieve all of these goals? The European Society for Trauma and Emergency Surgery (ESTES) and the European Journal of Trauma
87
European Society for Trauma and Emergency Surgery
and Emergency Surgery are both important initiatives for this vision. The ESTES is the most important international clinical, scientific, professional, and academic platform of traumatology in Europe today. The Society is a compilation of 23 national societies, which are our institutional members, striving to further the goals of trauma and emergency surgery care in their country. And we have more than 650 individual members. Members do not belong to one specialization such as orthopedic surgery only, but have different mother specialties. All members have in common that they are interested in the quality of care of the injured or emergency surgery patient. Reflecting the different origins of the members and the goals of the ESTES, five different sections have been created: skeletal trauma, visceral trauma, emergency surgery, education, and disaster and military surgery. Especially in the last section, it becomes clear how much we need the expertise of colleagues with a wide surgical armamentarium in special situations such as natural or manmade disasters. Who was the most demanded surgeon in Haiti some weeks ago, who was it in Thailand after the tsunami, or in Italy, Turkey, Iran, China, or Pakistan after the earthquakes some years ago… and who will be needed to help the victims of a catastrophe or conflict in our neighborhood tomorrow? It will not be the sub- or super specialist, but, instead, the trauma surgeon. The five sections of the ESTES focus on different areas of traumatology; they are not competitive but complementary. The sections are represented in the theme issues of our European Journal and offer instructional lecture courses at our annual congress. Thanks to the ATLS courses, thousands of European surgeons have been trained in primary trauma care. Thanks to the ESTES, there will be a first ATLS course in Belgium at the occasion of our Brussels congress. The European Trauma Course (ETC) is another initiative which will be endorsed by the ESTES and give many surgeons of our member societies the chance to gain interdisciplinary training of in-hospital care of the severely injured. The German Polytrauma Registry, which collects data from over 15,000 severely injured patients, has given many of us a deeper insight in the chances of their survival, depending on the effectiveness of pre-hospital support, level of organization of hospitals, and quality of its personnel. Thanks to this registry, there is much more evidence that quality of trauma care saves lives and diminishes disability. This led to a
88
different view on our profession from the side of German politicians, health insurance companies, and medical institutions. It became clear that high-quality trauma care can be accomplished for an acceptable price, but must be structured. It has been accepted that the regionalization of trauma care and classification of hospitals is indispensable. The ESTES wants to benefit from these achievements to go further in this direction. The ESTES wants to make our profession attractive, wants to work on the harmonization of postgraduate training programs in traumatology all over Europe, wants to recommend the participation of trainees in the Board of Surgery Qualification Exam in Traumatology, wants to further the constitution of trauma centers, to promote international exchange, to support research and development in our field, and wants to draw the attention of the decision makers in politics, health care organizations, and hospitals to our work. This is a lot to ask, but we are confident. The ESTES, as a roof organization, is growing rapidly thanks to the efforts of the pioneers. They have given us the foundations on which this institution is expanding. We are standing on the shoulder of giants. Thanks to our predecessors, we have broadened our horizons. We will proceed with the work they have started and travel further and deeper to reach our goals in our hospitals, universities, and university hospitals, all over Europe. Traumatology will further develop into an attractive clinical and scientific field in medicine.
Prof. Dr. Dr. h.c. Pol M. Rommens ESTES President
Eur J Trauma Emerg Surg 2010;36:85–8 DOI 10.1007/s00068-010-9003-6 Published Online: Published Online: April 1, 2010
Eur J Trauma Emerg Surg 2010 · No. 2
European Society for Trauma and Emergency Surgery
Presidential Address
Which Future for Traumatology in Europe? The Changing World of Medicine
www.estesonline.org
Contact: President Prof. Dr. Dr. h.c. Pol Maria Rommens Center for Musculoskeletal Surgery University Medical Center Johannes Gutenberg University Langenbeckstrasse 1 55131 Mainz Germany Phone: +49 6131 17 7292 Fax: +49 6131 17 4043 e-mail: [email protected] http://www.klinik.uni-mainz.de
Eur J Trauma Emerg Surg 2010 · No. 2 © URBAN & VOGEL
In the last several decades, a lot has changed in our world, in our societies, in medicine in general, and in our profession specifically. First of all, life expectancy has increased significantly. Thanks to longer lives but due to lower birth rates, demographics show a growing presence of older people, of which many are sick but many are also healthy and still very active. Mobility and consumption of recreational activities have increased for all age and income levels; expectations on quality of life and recovery of functional deficits have changed and continue to evolve. Medical information has become available everywhere; definitions, symptoms, guidelines on treatment, and outcome of diseases and injuries are freely accessible on the Internet. Many patients assume that they know all about their disease and want to discuss treatment alternatives with their doctor of choice. More than before, patients and administration expect a predictable outcome of our medical activities. Medicine and medical research have become popular and are part of everybody’s business, including industry, media, justice, and politics. As medical activities are paid by collective money, many institutions and administrations want to co-decide what we have to do or abandon. Their opinion is based on medical evidence. What is not proven by evidence is not valid anymore. As a consequence, the medical actor is observed from all directions; he or she is becoming less independent and has to explain, defend, or account publicly for his or her decisions or failures. From the central person in medicine, the final decision maker, the doctor, has evolved to one element in a chain of medical and technical directives which are elaborated by others and what we call now case management. Parallel to these immersive changes in our societies, insight into the pathobiomechanics and pathophysiology of injuries and diseases have increased dramatically. The actual fields of medicine reflect a spectrum of knowledge which cannot be covered by one or even several persons anymore. This automatically means that a person with medical responsibility has to restrict him- or herself to a specific field, which bears his or her special interest. This means specialization. Specialization is nothing new; in earlier days, surgery was one specialty, but nowadays it is split up into at least eight sub-specialties. The Union Européene des Médecins Spécialistes (UEMS) has 37 sections, representing actual medical specialties in Europe. The section of surgery, which is only one of these 37, contains divisions of general surgery, coloproctology, hepatopancreatobiliary surgery, surgical oncology, thoracic surgery, transplantation surgery, endocrine surgery, and traumatology. Vascular surgery, cardiothoracic surgery, urology, plastic and reconstructive surgery, neurosurgery, and orthopedic surgery have different sections. We are grateful for the acquisition of knowledge in medicine, as it is of benefit for our patients. But, as a direct consequence, we are confronted with an explosion of specialization and sub-specialization, in which we have to find our way. The section of surgery of the UEMS recognizes the need for sub-specialties to meet the medical needs of the population on a high-quality level. She promotes the training toward medical specialists with a broad competence and experience in
85
European Society for Trauma and Emergency Surgery
surgery but counteracts the production of medical virtuosos of one operation. She is, therefore, against the recognition of an excessive number of surgical sub-specialties. Narrowing the scope of every specialist also means enhancing the need for working in team in case a patient’s problem exceeds the borders of the scope.
Where Does Traumatology Belong to? What is the matter with traumatology? Did this field of activities change as well? Can the general changes in medicine also be felt in our profession? The definition of traumatology did not change over time. Traumatology covers the prevention, recognition, conservative or operative treatment, aftercare, and rehabilitation of all possible lesions in all age categories. With this definition, we immediately discover that there is a major difference with other specialties. Traumatology does not focus on one organ, one system, or even a part of it; its field of activity involves lesions of the whole human body, irrespective of any boundaries. One could wish that the activity of the trauma surgeon be restricted to a limited number of technical acts in the early posttraumatic phase, the trauma surgeon being a kind of acute care physician. But following our definition, this is not the case. Lesions of different complexity and emergency in the brain, the thorax, the abdomen, the spine, the pelvis, or the extremities fall under his or her responsibility. There are only a few other disciplines in a similar situation: pediatric surgery, intensive care, and emergency medicine are among them. Being a discipline that deals with problems of the whole human body, traumatology is often seen as a real specialty, certainly not as a sub-specialty. Medicine is rapidly evolving towards specialization and sub-specialization, but traumatology remains holistic. External and internal opinion makers, so-called professional and political experts, have problems interpreting this phenomenon. They ask: where does traumatology belong? Is it surgery, orthopedic surgery, or emergency surgery, all of this or again something else? In their eyes, the sub-specialist is the super-specialist, the doctor who knows the most of a small medical field. A trauma surgeon can never be a super-specialist, as he or she has to deal with the lung, the spleen, the spine, or the bladder simultaneously. How can he or she compete in excellence and expertise with the thoracic surgeon, the abdominal surgeon, the spine surgeon, or the urologist, who are the surgical specialists in the above-mentioned organs? A discipline with a large scope always competes for the label of quality with disciplines with smaller scopes. The ultimate consequence is that the evidence of the discipline with the larger scope is questioned. Hospitals do not need general surgeons anymore, they need gastrointestinal and hepatopancreatobiliary surgeons, laparoscopists, coloproctologists, or transplantation
86
surgeons. The same is valid for traumatology: why should trauma surgeons do what we super-specialists do as well or even better, is the argument of the opponents? Thereby, they voluntarily forget that the patient actually comes with several urgent problems at the same time, mostly at a moment where the super-specialist has no time or interest to stop his scheduled activities or to subordinate his treatment plans under those of one or several other colleagues. Where is the coordinator?
Traumatology Is a Dynamic Field in Medicine As in other disciplines, medical wisdom has also exploded in traumatology. Thanks to successful fundamental and clinical research on shock and organ failure, thanks to instrument and implant development, to new surgical techniques, thanks to great progression in the detailed visualization of anatomical regions by newest generation computed tomography (CT) scans and with magnetic resonance imaging (MRI), we understand more than ever before how lesions occur, how our balanced organ systems react to the first-hit phenomenon, and how defense systems fail. Treatment protocols significantly changed with these new insights: total-body CT-scan in the resuscitation phase, supra-selective embolization, damage control surgery, minimal invasive surgery, angle-stable plating, and computerassisted surgery are diagnostic and therapeutic procedures, which reflect the integration of recent technical developments and new knowledge. Therefore, the question is allowed if the use of all these new technologies can be mastered by one person? Is it still possible, as in the time of the pioneers, that one surgeon performs thoracotomy for partial lung resection, laparotomy or laparoscopy for blunt abdominal trauma, endoscopic fusion of the ventral thoracolumbar spine, or open reduction and internal fixation of a complex pilon or calcaneal fracture on the highest quality level? How long does the training program of a surgical trainee need to be until he or she is excellent in these different fields? Only in musculoskeletal surgery, one person is hardly able to know all possible operations. In two decades, shoulder surgery has developed to a differentiated and complex entity of activity. The same can be said of spine, elbow, or foot surgery. Sub-specialization is clearly on its way. Look at how orthopedic surgeons organize themselves. Orthopedic surgeons are working together in associations; every single surgeon is responsible for one specific field, such as hip replacement, arthroscopy, and shoulder or hand surgery. Look at our international scientific journals. The Journal of Bone and Joint Surgery or the Journal of Trauma, which cover the whole spectrum of pathology, and journals such as Spine, Journal of Shoulder and Elbow Surgery, Journal of Pediatric Orthopaedics, or the Journal of Foot and Ankle Surgery have similar impact factors, which means that the parts receive more interest than the whole.
Eur J Trauma Emerg Surg 2010 · No. 2
European Society for Trauma and Emergency Surgery
The Trauma Surgeon of the Future Evidence-based medicine, higher expectations on quality of life from the side of the patient as well as from the perspective of the surgeon and his or her family, budget restrictions, explosion of knowledge, trend toward super-specialization, and a holistic view on traumatology—how do we bring all this together into an attractive profession? Is traumatology attractive at all? The answer is clearly yes. Students and young trainees are fascinated by this part of medicine. They feel that it is like looking at a thriller. Something special can happen every minute, there is action, there are surprises, and there are heroes and losers. But fascination dwindles away with time; a thriller is not for every day. When one is getting older and more settled, traumatology is more a burden than a pleasure. Too much stress is not good for healthiness; a regular life is more attractive than an unpredictable one. Moreover, regular surgery is more rewarding than emergency surgery. Traumatology is attractive on the first view, but not on the second. What is the future of traumatology? Trauma patients have always existed; perhaps they were the first surgical patients. They always will exist. Diseases such as gastric ulcer or coronary stenosis will not be treated surgically anymore, but trauma patients will eternally remain surgical patients. The question is not if traumatology will survive, but how it will survive. For the benefit of our patients and especially for the benefit of our young academics, we have to make our profession durable, attractive, well organized, scientific, and focused on our core competence. To achieve this, we have to work hard and simultaneously on several levels. We have to take away the fear of our profession. The trauma surgeon is not anymore the man or woman who is active and energetic day and night, resolving one crisis after the other and feeling well in the middle of blood and tears. How fascinating they were, but the times of dinosaurs are over. The trauma surgeon of tomorrow will be a very dynamic, flexible, committed, and differentiated surgeon with a broad surgical training. Contrary to other colleagues such as surgeons or orthopedic surgeons and their sub-specialists, he or she is able to cope with difficult and challenging problems related to trauma. He or she is the optimal defender of the interests of the injured, especially the severely injured. This does not mean that he or she has to perform all diagnostic and therapeutic procedures of his or her patients himself or herself. He or she has to bring in his or her core competence and be committed to interdisciplinary cooperation and coordination. Today, there is no one-man game anymore. It is all a team game now. This is true in production, commerce, or research, and is especially true in traumatology. Claiming a balanced life between profession and free time, he or she will not be on call every third night and second weekend anymore. He or she is part of a larger group of colleagues who share responsibility and are each other’s substitutes. All partners of the team
Eur J Trauma Emerg Surg 2010 · No. 2
finished training in traumatology, but have their specific field of interest and competence. As skeletal trauma is much more frequent than cavity trauma in our countries, the core competence of most trauma surgeons of the team will lie in this area of activity. To enable such a career, the trauma team deserves a workload that is large enough to spend the whole day on trauma. Therefore, we need trauma centers with larger numbers of injured patients. The creation of trauma centers is a professional and political decision. It is the recognition that expertise goes with quality and that not every hospital is able to offer everything. Already today, this is evident. There is a need for the regionalization of trauma care, of networks around Level I trauma centers, which meet specific logistical and infrastructural requirements and become referral centers for the region. Level II and III trauma centers offer basic and advanced trauma care, but do not maintain the same quantity of personnel, equipment, and supporting departments as in the Level I center.
Traumatology Needs Academic Support Level I trauma centers are training centers as well, in which young and enthusiast academic persons can learn their profession. I underline the word academic, because traumatology needs research and development just as other medical fields. There is still a lot to learn: what is the ideal timing and what are optimal surgical procedures for the polytraumatized patient, how to bridge larger bony defects, why do joints get stiff when immobilized, or how to influence the interaction between biomaterials, tissues, and cells? Without academic pillar, there is no future for any profession. With an academic arm, a profession becomes solid, attractive, and durable. At our universities, we need independent trauma units, headed by clinical and research professors. These chairmen can choose, train, and promote residents to clinical and academic trauma surgeons. The greater the professional excellence, the stronger is the profession. Young people only become attracted by a profession when they can be proud to be part of it. This never will happen when the profession is not visible as an entity which can be distinguished from others. Who closes or subordinates trauma departments instead of supporting them will alienate new candidates to choosing traumatology.
The Role of the ESTES We need a recognized definition of our profession, a description and harmonization of training programs, a description of training centers, regional Level I trauma centers, regional, national, and international networks, quality control, and academic excellence in different fields of trauma care. How do we achieve all of these goals? The European Society for Trauma and Emergency Surgery (ESTES) and the European Journal of Trauma
87
European Society for Trauma and Emergency Surgery
and Emergency Surgery are both important initiatives for this vision. The ESTES is the most important international clinical, scientific, professional, and academic platform of traumatology in Europe today. The Society is a compilation of 23 national societies, which are our institutional members, striving to further the goals of trauma and emergency surgery care in their country. And we have more than 650 individual members. Members do not belong to one specialization such as orthopedic surgery only, but have different mother specialties. All members have in common that they are interested in the quality of care of the injured or emergency surgery patient. Reflecting the different origins of the members and the goals of the ESTES, five different sections have been created: skeletal trauma, visceral trauma, emergency surgery, education, and disaster and military surgery. Especially in the last section, it becomes clear how much we need the expertise of colleagues with a wide surgical armamentarium in special situations such as natural or manmade disasters. Who was the most demanded surgeon in Haiti some weeks ago, who was it in Thailand after the tsunami, or in Italy, Turkey, Iran, China, or Pakistan after the earthquakes some years ago… and who will be needed to help the victims of a catastrophe or conflict in our neighborhood tomorrow? It will not be the sub- or super specialist, but, instead, the trauma surgeon. The five sections of the ESTES focus on different areas of traumatology; they are not competitive but complementary. The sections are represented in the theme issues of our European Journal and offer instructional lecture courses at our annual congress. Thanks to the ATLS courses, thousands of European surgeons have been trained in primary trauma care. Thanks to the ESTES, there will be a first ATLS course in Belgium at the occasion of our Brussels congress. The European Trauma Course (ETC) is another initiative which will be endorsed by the ESTES and give many surgeons of our member societies the chance to gain interdisciplinary training of in-hospital care of the severely injured. The German Polytrauma Registry, which collects data from over 15,000 severely injured patients, has given many of us a deeper insight in the chances of their survival, depending on the effectiveness of pre-hospital support, level of organization of hospitals, and quality of its personnel. Thanks to this registry, there is much more evidence that quality of trauma care saves lives and diminishes disability. This led to a
88
different view on our profession from the side of German politicians, health insurance companies, and medical institutions. It became clear that high-quality trauma care can be accomplished for an acceptable price, but must be structured. It has been accepted that the regionalization of trauma care and classification of hospitals is indispensable. The ESTES wants to benefit from these achievements to go further in this direction. The ESTES wants to make our profession attractive, wants to work on the harmonization of postgraduate training programs in traumatology all over Europe, wants to recommend the participation of trainees in the Board of Surgery Qualification Exam in Traumatology, wants to further the constitution of trauma centers, to promote international exchange, to support research and development in our field, and wants to draw the attention of the decision makers in politics, health care organizations, and hospitals to our work. This is a lot to ask, but we are confident. The ESTES, as a roof organization, is growing rapidly thanks to the efforts of the pioneers. They have given us the foundations on which this institution is expanding. We are standing on the shoulder of giants. Thanks to our predecessors, we have broadened our horizons. We will proceed with the work they have started and travel further and deeper to reach our goals in our hospitals, universities, and university hospitals, all over Europe. Traumatology will further develop into an attractive clinical and scientific field in medicine.
Prof. Dr. Dr. h.c. Pol M. Rommens ESTES President
Eur J Trauma Emerg Surg 2010;36:85–8 DOI 10.1007/s00068-010-9003-6 Published Online: Published Online: April 1, 2010
Eur J Trauma Emerg Surg 2010 · No. 2
