My journey as the 2018 American College of Surgeons (ACS) Traveling Fellow to Australia and New Zealand (ANZ) began at the ACS Clinical Congress 2017 in San Diego, CA, where I met with Prof. Julian A. Smith, MB, BS, MS, MSurgEd, FACS, FRACS, FFSTRCSEd, FCSANZ, FAICD, head of the departments of cardiothoracic surgery and surgery, Monash University, Melbourne, Australia, and President, ANZ Chapter of the ACS. He connected with me throughout Australia’s trauma centers in Sydney and Melbourne, as well as with Prof. Ian Civil, BSc, MB, ChB, FACS, FRACS, co-director, trauma services, Auckland City Hospital, New Zealand, and past-president, Royal Australasian College of Surgeons (RACS).
The RACS also engaged me with Jeremy Hsu, MB, BS, FACS, the 2018 trauma program convener and director of trauma, Westmead Hospital; as well as Prof. Richard M. Hanney, MB, BS, FACS, FRACS, chair, Developing a Career and skills in Academic Surgery (DCAS) course, and clinical senior lecturer, University of Sydney. All four surgeons were central to my academic activities, networking, and travel planning.
Surgeon-scientists in Sydney
Annelise M. Cocco, MB, BS, a graduating surgical resident interested in trauma, greeted me and Prof. Timothy Pritts, MD, PhD, chief, section of surgery, University of Cincinnati, OH, at Darling Harbour. She accompanied us to the Westmead Hospital International Professorial Symposium, organized by Dr. Hanney; chaired by Prof. Henry Pleass, MD, FRACS, surgical head of the Australian National Transplant Unit; and moderated by Danny O’Connor, BSOCSTOC(Hon), MSW, chief executive, Western Sydney Local Health District. Speakers included Profs. Arthur J. Richardson, MB, BS, DClinSurg, FACS, FRACS, head, upper gastrointestinal and hepatobiliary surgery at Westmead; Marc Gladman, MB, BS, PhD, DRCOG, DFFP, MRCS, MRCOG, FRCS, FRACS, DCAS co-chair, University of Adelaide; and senior U.S. surgeon health services researchers, including Amir A. Ghaferi, MD, MS, FACS, associate professor, University of Michigan, Ann Arbor; Caprice C. Greenberg, MD, MPH, FACS, vice-chair, research, and professor of surgery, University of Wisconsin, Madison; and Lillian S. Kao, MD, FACS, professor of surgery, The University of Texas Health Science Center (UTHealth), and chief, division of acute care surgery, McGovern Medical School, UTHealth, Houston.
Drs. Pritts, Hsu, and I led a trauma hands-on session, during which I enjoyed discussing mentorship in trauma and facilitating ballistics and penetrating trauma cases, which are uncommon mechanisms of injury in Australia due to steady legislative efforts since 1996. Despite the infrequency of these scenarios, the knowledge base, cognitive skills, and creativity of the Westmead trainees and faculty in caring for the injured patient afflicted by penetrating trauma were impressive.
Professor Hanney arranged a rooftop dinner at the Cafe Sydney with Westmead anesthesiology and surgery faculty and topped this off with a day trip to the Hunter Valley Wine Country. Joining the Westmead DCAS contingent were young Australian academic surgeons and U.S. DCAS and Association of Academic Surgery (AAS) members, as well as many families and other friends. At the Thomas Allen Winery, we tasted wine, learned about Australian viticulture, finished with a hearty meal at Blaxton Inn, and concluded with a fortuitous wallaby sighting.
First ASSET Course in Australasia
It was an honor to participate in the inaugural ACS Advanced Surgical Skills for Exposure in Trauma (ASSET) course in Australia and New Zealand at Macquarie University, New South Wales. Mark W. Bowyer, MD, FACS, professor, surgical director of simulation, and chief, division of trauma and combat surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, led the development of the day-long ASSET course with the ACS Committee on Trauma (COT) and its education committee. Dr. Hsu, aided by New Zealand surgeon Ashish Taneja, MD, head, acute surgical unit, Auckland City Hospital; Dr. Pritts; and I directed the course. The ASSET course participants comprised preeminent surgical residents and faculty from both Australia and New Zealand. Michael Muller, MB, BS, MMEDSCI, FRACS, founding director of trauma, Royal Brisbane and Women’s Hospital and a course participant, reminisced about his wife, Karen, and her time as a Vanderbilt nurse practitioner, as well as about the trials and tribulations faced by our Vanderbilt trauma medical director Oscar Guillamondegui, MD, FACS, as a Galveston medical student. Overall, all who participated felt this interactive ACS trauma course facilitated bidirectional learning, and we anticipate these experiences will drive future course deployments throughout Australasia and New Zealand.
RACS ASC: Reflecting on what really matters
Taking advantage of the integrated social program built into the RACS Annual Scientific Conference (ASC), I joined the breathtaking and beautiful BridgeClimb Sydney and was grateful to meet Prof. Stephen Deane, MB, BS, FACS, associate dean, clinical partnerships, Macquarie University, trauma surgeon, and internationally recognized trauma educator. He brought the ACS COT Advanced Trauma Life Support® (ATLS®) course to Australia, created the Definitive Surgical Trauma Care course, and received the Member of the Order of Australia for his lasting contributions. His wife, Anne, was equally impressive with her expansive knowledge of Sydney history, which matched that of our BridgeClimb tour guide. She joined Dr. Guillamondegui and myself for a breakfast with koalas at the Wild Life Sydney Zoo and was excellent company during many RACS ASC dinners.
The RACS ASC was a fabulous interdisciplinary and educational event with the Australian and New Zealand College of Anaesthetists (ANZCA). One of the meeting highlights was the unveiling of a joint emergency laparotomy binational pilot study intended to improve quality and reduce costs in acute care surgery. I enjoyed presenting Insights into Intensive Care Unit (ICU) Survivorship in the ASC keynote lecture, chaired by Professor Smith and graciously acknowledged by the 47th RACS president and orthopaedic surgeon John Batten, MBBS(Hons), FRACS, FAOrthA. I participated in a session on postacute trauma issues and delivered Spinal Clearance and Mobility—Do We Really Need Collars, Spine Boards and Bed Rest?, moderated by Dr. Civil. Trauma surgeon and international ATLS expert Scott D’Amours, MDCM, FRCS, FRACS, moderated a fun, interactive session on Standardization to Improve Outcomes—Bundles of Care in Trauma & Critical Care. Whereas Vanderbilt’s Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center is leading ongoing randomized clinical trials in critical care (NCT012115221, NCT017399332), it was exhilarating to see the results from the ANZCA Clinical Trials Network and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group investigation, the REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery: RELIEF Study (NCT01424150). Published in the New England Journal of Medicine (NEJM) during the RACS ASC, the work showed no difference in the rate of one-year disability-free survival after randomization to a restrictive or liberal fluid strategy for 24 hours after major abdominal surgery.3
After the RACS ASC, I enjoyed a home-cooked meal with Dr. Hsu; ACS President-Elect Ronald V. Maier, MD, FACS, FRCSEd, FCSHK(Hon); and their spouses. I spent additional time at Westmead Hospital with Dr. Hsu and joined their trauma rounds to learn more about their clinical approach. In many ways, the U.S. and Australia/New Zealand trauma care systems are similar. Westmead uses a team-based and shift-based approach, such that a mountain of clinical, imaging, laboratory, and operative information passes at the daily check-out using heavy and creative abbreviations that U.S. residents would appreciate (TF means transfer; HSMVA means high-speed motor vehicle accident; BIBA means brought in by ambulance, and so on).
In other ways, our critical care training and care models are different. In a U.S. ICU, critical care is an extension of perioperative and trauma care, staffed by surgical intensivists, as well as anesthesiology intensivists. However, in Australia and New Zealand, ICU care is led by talented medical intensivists who often extend themselves even to emergency room environments and trauma resuscitations.
My final foray at Westmead focused on oral examination preparation for graduating surgery residents, which felt more intensive than the American Board of Surgery Certifying Exam, in that trainees are expected to explain surgical pathophysiology, as well as demonstrate the history and physical of actual patients waiting for surgery, over a multi-day testing period marked by higher failure rates. These were outstanding young surgeons,and I am proud to report that Dr. Cocco passed her exam and is embarking on a career in trauma.
Trauma, critical care, and clinical trials in Melbourne
Upon my arrival in Melbourne, my new colleague from the inaugural ANZ ASSET course, Dr. Jithoo, and his anesthetist friend took me to dinner and showed me the beautiful South Wharf. Then, I visited The Alfred and Royal Melbourne Hospitals (RMH), and their respective trauma centers led by Profs. Mark Fitzgerald, MBBS, MD, and Rodney Judson, MBBS, FRACS, FRCS. At The Alfred, I enjoyed rounding with Dr. Fitzgerald, engaging trainees in discussions about penetrating trauma cases coordinated by ASSET colleague Dr. Martin, and witnessing their collaborative webcast, the Victorian Trauma Grand Rounds.
Subsequently, I connected with the acclaimed clinical trialist and researcher Prof. Jamie Cooper, AO, BMBS, MD, FRACP, FCICM, FAHMS, participated in their journal club on extracorporeal membrane oxygenation, and rounded in their ICUs. At RMH, after rounding with Dr. Rezvaneh (Rose) Shakerian’s Trauma Service, I witnessed the 2018 National Tribute & Awards Ceremony for Clinical Trials of the Year, where Dr. Cooper’s TRANSFUSE study (NEJM 2017)4 was a finalist. It was incredible to see the multifaceted support for “public-good” clinical trials by patients, government (National Health and Medical Research Council [NHMRC], Department of Industry, Innovation and Science), clinical researchers (ACTA), and health care.
Kia Ora from Auckland
I closed my academic journey by visiting Auckland City Hospital and its trauma program under Drs. Civil and Taneja. I joined both trauma and emergency general surgery services, as well as their multidisciplinary trauma audit, partook in mid-morning tea, and enjoyed meeting Prof. Li Hsee, MB, BCh, BAO, FRACS, co-director, trauma services; clinical director, general surgery; and chair, New Zealand Trauma Committee of the RACS. Afterward, my family and I continued onto Rangitoto and Waiheke Islands, before further adventures in Queenstown and Christchurch. The ACS/ANZ Traveling Fellowship facilitated friendship, ties to the RACS, DCAS, AAS, and ANZICS organizations, and an unforgettable journey.
I am forever indebted to my family; the trauma division and surgery leadership at Vanderbilt University Medical Center; the AAS; the ACS and its International Liaison Section consummately coordinated by Kate Early; the RACS and its ASC; the ANZCA; Westmead Hospital, Macquarie University, The Alfred Hospital, The Royal Melbourne Hospital, and Auckland City Hospital; Australian Clinical Trials Alliance (ACTA), Department of Industry, Innovation and Science, and the NHMRC. All of these entities facilitated my wonderful experiences serving for the 2018 ACS Traveling Fellowship to ANZ.
- ClinicalTrials.gov. The Modifying the Impact of ICU-Associated Neurological Dysfunction-USA (MIND-USA) Study (MIND-USA). Identifier: NCT01211522. Updated September 12, 2018. Accessed October 1, 2018.
- ClinicalTrals.gov. The MENDSII Study, Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients With Acute Respiratory Failure (MENDSII). Identifier: NCT01739933. Updated January 23, 2018. Access October 1, 2018.
- Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018;378:2263-2274. Accessed October 1, 2018.
- Cooper DJ, McQuilten ZK, Nichol A, et al. Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults. N Engl J Med. 2017;377:1858-1897. Accessed October 1, 2018.