Civilian Forward Surgery

[Veneficus]

I really think there is some disconnect between what "surgery" and especially "field surgery" really entails.

It is often very simple and quick fixes. It is not a 3 hour scrub down with reconstruction.

Flying out to a facility would not create a situation for a "mobile" surgery. It would be the same bedside procedures available in the EDs of trauma centers.

I think it would be rather foolish to think that providing major surgery by some person decending from the air, or ground, or whatever, was suddenly going to start basically setting up a MASH.

However, some very simple skills, which are beyond the ability of EMS, could possibly make a difference.

The city of London has posted some very good numbers on field thoracotomy with penetrating trauma and the Israelis have touted it for years.

Aside from that specific procedure though, from surgical control of wounds, temporizing vascular shunts (I am particularly impressed by ones rigged from IV tubing) retroperitoneal packs, and a host of other "simple skills" I do see some benefit.

Especially maintaining perfusion or stoping bleeding so that resuscitation could be more effective.

I didn't think anyone was going to suggest reproducing a surgical theatre in a remote or mobile capacity.

This type of surgery is demonstrated as both life and limb saving, when you talk about cost, don't forget to factor in long term disability for survivors, life time medical costs, etc.

There is a big difference in lifestyle between a BKA and an AKA. Any idiot with a saw can cut off a limb, but there is benefit to saving as much of it as possible.

There is also a benefit in bringing some blood with you when you go to a major trauma in the field.

 

[EpiEMS]

I really think there is some disconnect between what "surgery" and especially "field surgery" really entails.

It is often very simple and quick fixes. It is not a 3 hour scrub down with reconstruction.

Flying out to a facility would not create a situation for a "mobile" surgery. It would be the same bedside procedures available in the EDs of trauma centers.

I think it would be rather foolish to think that providing major surgery by some person decending from the air, or ground, or whatever, was suddenly going to start basically setting up a MASH.

I think this is going to sound silly, but why not have something along the lines of a smaller version of the USAF's Mobile Field Surgical Teams (ftp://ftp.rta.nato.int/pubfulltext/agard/CP/AGARD-CP-599/31SE4-26.pdf) ready to go at major hospitals for those sorts of mass casualty situations?

 

[Veneficus]

I think this is going to sound silly, but why not have something along the lines of a smaller version of the USAF's Mobile Field Surgical Teams (ftp://ftp.rta.nato.int/pubfulltext/agard/CP/AGARD-CP-599/31SE4-26.pdf) ready to go at major hospitals for those sorts of mass casualty situations?

I was thinking of something smaller, 1 or 2 people.

 

[EpiEMS]

I was thinking of something smaller, 1 or 2 people.

Say, an anesthesiologist and a general surgeon? Or an EM MD and a surgeon?

 

[Veneficus]

Say, an anesthesiologist and a general surgeon? Or an EM MD and a surgeon?

A surgeon and a nurse.

A lot of people don't know that before anesthesia really caught on as a specialty, surgeons were required to provide their own anesthesia. (most were not very good at it)

But like I said, when I posted this, I envisioned something not so grande as setting up a surgical theatre, and really just adding some quick advanced treatments not available to EMS providers.

I would imagine most could be done by an EM, but I figured that due to the nature of trauma, an experienced surgeon would be of more value than somebody who rarely actually does surgery. But that is just based on speculation that most EMs don't crack chests, perform craniotomies, create vascular shunts, pack wounds, etc.

 

[Rialaigh]

A surgeon and a nurse.

A lot of people don't know that before anesthesia really caught on as a specialty, surgeons were required to provide their own anesthesia. (most were not very good at it)

But like I said, when I posted this, I envisioned something not so grande as setting up a surgical theatre, and really just adding some quick advanced treatments not available to EMS providers.

I would imagine most could be done by an EM, but I figured that due to the nature of trauma, an experienced surgeon would be of more value than somebody who rarely actually does surgery. But that is just based on speculation that most EMs don't crack chests, perform craniotomies, create vascular shunts, pack wounds, etc.

I guess I am just missing the point if we are talking about small procedures that make a difference. We should be able to fly a patient from a small ER with no surgical capability to a trauma center close to as fast as we can fly a surgical team to the small ER. There may be a select few field procedures where this could make a very minor difference but again I really don't see this being effective let alone cost effective.

If we are talking about ER docs not packing wounds then...well...we can talk about what EM physicians ought...to be doing...

If we are talking about amputations in the field, then I don't see a need for a team, as they won't be utilized enough. It would have to just be a surgeon and nurse or two willing to pack up some stuff and head out with the fire department the 1 time a year they are truly needed.



I think medicine is over specialized as is, we should be working on improving the basics that would extend and improve hundreds of thousands of lives.


I see the use for this in extremely rural settings, third world countries, and war settings, or large cities with extremely bad crime related trauma issues (see Bogata or other such cities). In these cases I could see a cost effective approach to having a surgeon and nurse or two respond via crash truck on all limb entrapped or other such calls that would require possible surgical intervention, as the safety regulations in those countries and statistics show that many many more limbs are lost in those areas.

 

[Veneficus]

I think medicine is over specialized as is, we should be working on improving the basics that would extend and improve hundreds of thousands of lives.

I definately agree with this, especially the over specialization. But I am of the mind that in order to be most effective, medicine must be brought to people, not locked up out of reach of mere mortals.

 

[Rialaigh]

I definately agree with this, especially the over specialization. But I am of the mind that in order to be most effective, medicine must be brought to people, not locked up out of reach of mere mortals.

And I could see this working if the entire system was changed. If these people going out and doing forward or field procedures would also take the time to manage the diabetes and blood pressure from home as well. If community medicine was implemented in a widespread fashion in the US then running surgeries out to the field would make much more sense. You would already be managing disease in the field instead of treating symptoms so it would make sense to fix basic traumatic problems (or minimize them) in the field as well. Better community nursing and paramedicine programs would improve the effectiveness of field or forward surgery.

 

[EpiEMS]

I definately agree with this, especially the over specialization. But I am of the mind that in order to be most effective, medicine must be brought to people, not locked up out of reach of mere mortals.

Back to the days of the local GP. I so wish that were the case.

 

[Veneficus]

Back to the days of the local GP. I so wish that were the case.

I wouldn't get that extreme.

But I think a lot of the subspecialties could probably be done away with.

I think that will be the natural evolution as specialties continue to move towards being defined by pathology as opposed to procedures or regions of the body.

 

[Dwindlin]

Disagree with the too specialized crowd. There is no way you could have a generalist in the sense that they used to exist. Medical knowledge has advanced to the point that it really is necessary for the highly specialized providers.

 

[Veneficus]

Disagree with the too specialized crowd. There is no way you could have a generalist in the sense that they used to exist. Medical knowledge has advanced to the point that it really is necessary for the highly specialized providers.

I agree that the days of generalist are over for good, but I really do question the need for some of the ultraspecialties still.

 

[Rialaigh]

Disagree with the too specialized crowd. There is no way you could have a generalist in the sense that they used to exist. Medical knowledge has advanced to the point that it really is necessary for the highly specialized providers.

Depends on what sense of the term necessary you are using. If you mean improving patient outcomes then I would argue a lot of specialties could be done away with all together and not even affect the treatment of the patient and the outcome one little bit. Only thing that would affect is the bill...and that would be great

Now if you are talking about necessary from the standpoint of understanding every tiny little thing that is possibly going on in your completely routine patient then I agree, you have to have people who are interested and well paid enough to bother to to it...


Treatment of patients these days has merged with research so much that it has really stifled patient care....

 

[Dwindlin]

Depends on what sense of the term necessary you are using. If you mean improving patient outcomes then I would argue a lot of specialties could be done away with all together and not even affect the treatment of the patient and the outcome one little bit. Only thing that would affect is the bill...and that would be great

Now if you are talking about necessary from the standpoint of understanding every tiny little thing that is possibly going on in your completely routine patient then I agree, you have to have people who are interested and well paid enough to bother to to it...


Treatment of patients these days has merged with research so much that it has really stifled patient care....

I'll bite. Name one specialty you think is unnecessary and why.

 

[Rialaigh]

American board of medical specialties offers these...


Dermatopathology...

Clinical Informatics...

Pain Medicine...

Aerospace Medicine...

Psychosomatic Medicine...

Sports Medicine...

Undersea and Hyperbaric Medicine..

Clinical Cardiac Electrophysiology....I fully expect anyone preforming cardiac procedures to be versed in this, it does not need to be a sub specialty that can be consulted and billed for...

There are quite a few sub-specialties that if they went away, could be picked up easily by others. IMO every ortho surgeon for example should have the basics of sports medicine anyway, no reason to have to "consult" a sports medicine specialist...

 

[Dwindlin]

American board of medical specialties offers these...


Dermatopathology...

Clinical Informatics...

Pain Medicine...

Aerospace Medicine...

Psychosomatic Medicine...

Sports Medicine...

Undersea and Hyperbaric Medicine..

Clinical Cardiac Electrophysiology....I fully expect anyone preforming cardiac procedures to be versed in this, it does not need to be a sub specialty that can be consulted and billed for...

There are quite a few sub-specialties that if they went away, could be picked up easily by others. IMO every ortho surgeon for example should have the basics of sports medicine anyway, no reason to have to "consult" a sports medicine specialist...

Who would pick these up? It's interesting you picked these because for the most part these aren't separate specialties....most of these fall under CAQ's (Certificate of Added Qualification). Derm/Path for example is CAQ many MOH's surgeons acquire so they can read their own biopsies. Pain frankly should be it's own damn residency as opposed to fellowship because pain is handled terribly by MOST providers. Aerospace is unique to the military/NASA...not really sure who would pick this up as not too many physicians deal with the effects of space travel on disease. Not really sure about your point on sports med...they usually are orthopods, so your getting a consult either way (no one sends you to an orthopod who then sends you to a sports med). EP, get out of here, I'm just going to assume you have never seen this done. . .getting access is a monkey skill...that's not why it takes an additional two years AFTER cardiology fellowship to become proficient in this. Clinical Informatics is a non-issue....they don't see patients, they mainly work for EMR companies.

So, that leaves two on your list. I don't know much about them honestly, though I suspect they fall into a similar situation as above. . .

 

[Rialaigh]

Who would pick these up? It's interesting you picked these because for the most part these aren't separate specialties....most of these fall under CAQ's (Certificate of Added Qualification). Derm/Path for example is CAQ many MOH's surgeons acquire so they can read their own biopsies. Pain frankly should be it's own damn residency as opposed to fellowship because pain is handled terribly by MOST providers. Aerospace is unique to the military/NASA...not really sure who would pick this up as not too many physicians deal with the effects of space travel on disease. Not really sure about your point on sports med...they usually are orthopods, so your getting a consult either way (no one sends you to an orthopod who then sends you to a sports med). EP, get out of here, I'm just going to assume you have never seen this done. . .getting access is a monkey skill...that's not why it takes an additional two years AFTER cardiology fellowship to become proficient in this. Clinical Informatics is a non-issue....they don't see patients, they mainly work for EMR companies.

So, that leaves two on your list. I don't know much about them honestly, though I suspect they fall into a similar situation as above. . .

Okay, I'd be okay with eliminating dermatology. And adding that to primary care. Ive never seen a dermatologist do anything involving significant medical care that either

A. a primary care physician couldn't do with ease (or ought to be able to do with ease)

or

B. involved consulting an oncologist and releasing the patient to them.


Rheumatology is another one that could be turned over entirely to Ortho or Cardiology depending on whether the problem involves the joints or the vascular system more. Or hand it over to immunology as that seems to be the increasing cause in Rheuamatoid problems.

 

[JPINFV]

Clinical Cardiac Electrophysiology....I fully expect anyone preforming cardiac procedures to be versed in this, it does not need to be a sub specialty that can be consulted and billed for...

Let's merge interventional and non-interventional cards together then. There's a difference between managing a complicated HTN patient, doing a cardiac cath, and doing an ablation procedure. Hence why there's different levels of cardiology.

There are quite a few sub-specialties that if they went away, could be picked up easily by others. IMO every ortho surgeon for example should have the basics of sports medicine anyway, no reason to have to "consult" a sports medicine specialist...

So sports teams now can only hire orthopedic surgeons now? Also, because sports medicine is just about bones?

 

[Veneficus]

So sports teams now can only hire orthopedic surgeons now? Also, because sports medicine is just about bones?

When did ortho become just about bones?

 

[reaper]

Okay, I'd be okay with eliminating dermatology. And adding that to primary care. Ive never seen a dermatologist do anything involving significant medical care that either

A. a primary care physician couldn't do with ease (or ought to be able to do with ease)

or

B. involved consulting an oncologist and releasing the patient to them.


Rheumatology is another one that could be turned over entirely to Ortho or Cardiology depending on whether the problem involves the joints or the vascular system more. Or hand it over to immunology as that seems to be the increasing cause in Rheuamatoid problems.

When did Rheumatology become just about joints or vascular?