Trauma surgery often straddles a thin line between organised chaos and catastrophe. Patients on the edge of life, distraught relatives and friends, clinical spectators and maybe even armed assailants invading the ED are not unheard of. With that being the case one could consider any survivor of major trauma to have pulled through with the heaviest of odds stacked against them. Surely, we trauma surgeons deserve a pat on the back every time a life is salvaged, no matter how diminished the quality of that life and whether medical negligence amidst the pandemonium had a part to play in the diminution of good outcomes. Whilst for some it may be comforting to think that you can’t possibly make a trauma patient worse off than when they arrived in extremis, one must be able to justify their actions to survivors and their relatives, and at the very least provide dignity in death.
In surgery, there will always be a level of tolerance for generic and procedure-specific complications such as bleeding, wound infection, anastomotic leak and atelectasis etc. Interestingly, previous studies have shown that trauma surgeons are no more likely to be sued for medical malpractice compared to other specialties. Risk is mitigated through the basic tenets of good communication, rapport-building and careful documentation of rules or guidelines informing clinical decisions. Heightened awareness of high-risk patient groups is also important. A logistical regression analysis of over 11000 trauma patients admitted to the ICU of a US Level 1 trauma center found that non-modifiable factors such as advanced age, female gender, and CNS injury were most strongly associated with the development of complications following surgery.
Even when mistakes are made, perhaps through sloppy practice, there is still the obstacle of proving a direct causative link between this and injury to the patient. This will often hinge on expert witness testimony or whistleblowing. Trauma can be a small world, and many careers may have been saved by the reluctance of fellow surgeons to risk pariah status by testifying against their brethren and sistren.
Not all mistakes are down to the individual. Institutional failings like poor provision of operating capacity, inadequate staffing levels, lack and poor training of support staff clearly play a role. These shortcomings may be symbolic of a wider culture of mismanagement which extends beyond the trauma department alone.
We know historically that race has a huge part to play in health disparities and experiences of medical malpractice across the US. From Tuskagee to the sterilization of ethnic minority women without consent through most of the 20th century. We know that historically black people have had the severity of their pain downplayed or under-treated due to ludicrous misconceptions about skin thickness and nerve-ending sensitivity. We also know that limb amputations rates are higher among black patients than white patients with similar peripheral vascular disease severity. Racial and ethnic minorities are uninsured more often than non-Hispanic whites, a status that frequently results in less than adequate care. Uninsured persons with traumatic injuries are less likely than those with insurance to be admitted to the hospital, receive fewer services if they are admitted, and are more likely to die.
Trauma surgery is often elective surgery done quickly and possibly in stages between stays in the ICU. The surgical principles remain the same and so to should the principles of attention to detail with the aim of achieving the best functional outcome for the patient and their family.