ACS ANZ Traveling Fellow reports on experience at Australian trauma centers

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Dr. Burlew (left) in Auckland with Professor and Mrs. Civil

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Dr. Burlew, post-Auckland visit, at Lake Rotorua in New Zealand

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Dr. Burlew with Professor Civil (left) and Dr. Townsend

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Dr. Burlew with her husband and daughter at Circular Quay in Sydney

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Morning rounds with the trauma service at Liverpool Hospital in Sydney

Two countries, eight cities, four hospital visits, nine talks, one Royal Australasian College of Surgeons (RACS) Congress, a meeting with a former patient, numerous kind hosts, and countless kangaroo sightings—that description does not come close to summing up my amazing experience as the American College of Surgeons (ACS) Australia and New Zealand (ANZ) Traveling Fellow. I am truly honored to have had this experience and I enjoyed the hospitality of so many surgeons.

Arrival in Auckland

My husband Paul and I arrived and were greeted at the airport by our hosts Prof. Ian Civil, MB, BCh, FACS, and his wife Denise; they were kind enough to meet us after our more-than 12-hour flight out of San Francisco, CA, landed at 5:50 am. That night at a team dinner with Professor Civil’s trauma faculty, I began to learn about everything from the surgical structure of ANZ residency (registrar) training to trauma system development.

I spent the following day at Auckland City Hospital with Professor Civil. We started the day with morning rounds with the trauma team, including the trauma fellow, second-year house staff, and a trauma nurse coordinator. We saw myriad conditions, including elderly patients with rib fractures and pulmonary embarrassment, a patient with left lobar hepatic necrosis after angioembolization, and a patient with a complex pelvic fracture with an associated perineal laceration, which required diverting colostomy. I saw many parallels between the U.S. and ANZ trauma systems (patient-centered care, trauma team and nursing coordination, imaging review) and a few differences (closed intensive care unit [ICU], patient care run by intensivists because there are no surgically trained critical care specialists, different dosages of standard medications). I was struck by the minimal number of penetrating trauma (approximately 5 percent), and those such patients we did see had stab wounds rather than gunshot wounds. The effect of graduated autonomy afforded to residents during their six-month rotations was a notable contrast to our much shorter rotation length of one to three months. The faculty noted that these longer rotations really allow them to get to know and mentor the residents.

“Kiwis” are known for their love of coffee, and a mid-morning Flat White was a mandatory part of my hospital experience. What could have been a routine beverage break actually served as an opportunity for a collegial interaction between medical specialists in the open atrium; one could easily catch up with any consultant who was involved in the care of your patient.

Given my interest in blunt cerebrovascular injuries (BCVI), we then met with one of the chief radiologists and interventionists to discuss several recent cases and their screening algorithm for BCVI. Rather than the trauma surgeon driving the decision for computed tomography angiogram (CTA) imaging of the vasculature, the radiologist determines whether the patient has an injury pattern that triggers BCVI screening during their initial trauma CT scans. If such an injury is identified, CTA to evaluate for a BCVI is done while the patient is still on the CT scanner. With the implementation of a radiology-driven screening process, the identification of injuries has markedly increased.

I rounded out the day with a lecture at a noontime conference. The trauma group, emergency medicine physicians, intensivists, house staff, and registrars were in attendance.

RACS Annual Scientific Congress

The 2017 RACS Annual Scientific Congress took place in Adelaide. I attended the convocation of the Congress at the opening of the meeting, and sitting between RACS Past-Presidents Profs. Civil and Bruce Barraclough, MB, BS, FACS, FRACS, I learned of the interesting history of RACS. The RACS is particularly focused on surgical education and training and emphasizes a varied training experience that provides exposure to a range of patient populations, hospital environments, and locales. Many in the RACS leadership spoke about the importance of mentorship and educating the next generation, particularly in the area of professionalism. As mentioned previously, I think RACS surgeons are particularly effective in this regard given the length of resident rotations, which afford trainees an in-depth experience.

The themes of collaboration, respect, and professionalism were echoed in the address by RACS President Prof. Philip Truskett, MB, BS, FACS, FRACS. He reminded us that, as surgeons, we should be willing both to ask for help and to answer the call for help, emphasizing that there is more to being a surgeon than technical skill.

Before performing my official duties at the RACS Congress, I spent a morning with the trauma service at the Royal Adelaide Hospital (RAH). Cases from the trauma service for the last week were presented, and we discussed the indications for resuscitative thoracotomy, the role of resuscitative endovascular balloon occlusion of the aorta, and the utility of laparotomy in the trauma bay. The RAH serves as the Level I trauma center for the state of South Australia (one of seven states in Australia). The trauma team described the transport process used to move trauma patients to the hospital. Under this tiered response system, regular ambulance/paramedic teams carry out most transfers, but a MEDStar team, which is composed of both paramedics and physicians, is used for high-level trauma transfers. Interestingly, paramedics are equipped to initiate red blood cell transfusions in the field. I spoke at the morning conference about pelvic trauma and discussed the Denver Health trauma team’s algorithm of care for multiply injured patients.

My host at RAH, Christopher Dobbins, MB, BS, FRACS, arranged my trauma surgery program visit at the RACS. On the first full day of the conference, I gave a lecture on Management of the Open Abdomen in 2017 as part of the Trauma on the Cutting Edge session. My talk included the topics of temporary abdominal closure, enteral nutrition in the open abdomen, peritoneal resuscitation, and sequential fascial closure techniques. Other speakers discussed rib fracture fixation, junctional trauma, and the Adelaide experience with resuscitative thoracotomy. That evening I attended the Women in Surgery networking event and had a delightful conversation with the current leader, Melissa Bochner, MB, BS, MS, FRACS, and the incoming leader, Pecky De Silva, MB, BS, FRACS.

On successive days of the Congress, I gave two additional lectures. First, I delivered the ACS lecture on Hemorrhage Control in Complex Pelvic Fractures. ACS President Courtney M. Townsend, Jr., MD, FACS, attended the lecture, and Professor Civil introduced me. My final lecture of the Congress, Blunt Cerebrovascular Injuries, was presented during the joint Trauma and Vascular Surgery session. Following my talk, incoming RACS president John Batten, FRACS, graciously acknowledged my contributions to the Congress meeting.

On to Sydney

Following the week in Adelaide for the RACS Congress, we enjoyed some sightseeing en route to Sydney. We drove along the southern coastline of Australia to Melbourne, stopping along the Great Ocean Road to admire different limestone formations, including The Twelve Apostles, The Loch Ard Gorge, The Bay of Martyrs, and London Bridge.

Arriving in Sydney was joyous for two reasons. First, I had never before been to Sydney. It is simply a wondrous city filled with the iconic Sydney Opera House, Circular Quay, and many other fascinating sights. Second, my parents and our daughter arrived to join us for the final portion of our trip.

While my family was recovering from a bit of jet lag, I continued my tour of ANZ trauma centers. My first stop was the famed Liverpool Hospital, where my host, Scott D’Amours, MDCM, FRACS, FRCSC, organized a delightful day. I spent the morning with the residents and trauma fellows, making rounds and discussing patients. During rounds, a trauma activation was issued. I accompanied the team to the trauma bay to care for a patient who was crushed by a steer. Team coordination was one of the critical elements I noted. All members of the resuscitation team have self-stickered tags that identify their respective roles: trauma surgeon, airway physician, circulation nurse, emergency department (ED) registrar, anaesthetist, procedure physician, orthopaedic specialist, and scribe. The team efficiently evaluated the patient with the intensivist managing the airway, the trauma fellow calling out physical findings, the trauma nurse performing the FAST (focused abdominal sonography for trauma) exam, and the ED registrar reviewing bedside imaging. The day concluded with an afternoon televised trauma symposium, during which I gave three lectures: Acute Care Surgery: The American Training Experience; Chest Tube Debacles; and Pelvic Trauma. The following morning I visited Westmead Hospital at the invitation of Jeremy Hsu, MB, BS. I again discovered that much of trauma care is universal—from protocols, system development, and patient conundrums, to training perspectives.

One of the most memorable days of the entire trip was traveling by train north to Gosford to visit a former patient, Scott Parry-Jones, and his wife Kim. Scott had suffered significant trauma after a ski accident in the Rocky Mountains and had been flown to Denver Health for care. Admittedly, I almost didn’t recognize him compared with his weeks in the hospital. It was wonderful to spend a day with them and see his ongoing recuperation.

We concluded our ANZ adventure with snorkeling at the Great Barrier Reef and exploring the Daintree Rainforest.

The investment and collaboration of the ACS and RACS on this Traveling Fellowship are to be commended. I feel incredibly fortunate to have had this opportunity and I thank everyone for a magnificent trip. It was truly a once-in-a-lifetime experience, and I hope to visit again soon.

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